The following is a reader take by Ronald Donelson.
I am an orthopedic surgeon who has specialized in and researched the evaluation and non-operative care of low back and neck pain, first in private practice and then for ten years in an academic tertiary spine institute.
For you clinicians who treat patients with acute low back pain (LBP), do you follow clinical guideline recommendations to simply encourage patients to remain active while reassuring them that their pain will likely go away soon? Or do you find most patients seek more care than that and you want/need to provide more?
Meanwhile, most clinicians are unaware of the disparity between what LBP clinical guidelines recommend and what has actually been published in the peer-review literature. Despite claiming to be evidence-based, most guidelines are developed by consensus using a literature review limited to what seems most relevant to panelists’ collective understanding of LBP. The resulting guideline is based on an incomplete literature review resulting in substantial clinician non-compliance and highly variable, often ineffective, sometimes harmful, and frequently very expensive care.
One of the more glaring guideline omissions is the evidence that establishes that most LBP is actually rapidly reversible, i.e. it recovers quickly, and turns out to be fairly simple to treat. Learning how to identify this large reversible subgroup is the first step in helping these individuals speed their recovery/reversal. A unique form of clinical evaluation reveals characteristics of the reversible pain source that guides patients in successfully self-treating by using pain-eliminating exercises and posture modifications.
Unmentioned by guidelines are the multiple studies reporting high inter-examiner reliability for both conducting and interpreting this unique clinical examination and at least eight cohort studies and four randomized clinical trials that all report that these recoveries in this large subgroup occur much faster and more frequently using these patient-specific treatments. This rapidly reversible LBP subgroup is very large, including 70-89% of acute, 50% of chronic LBP, as well as 50% of those with LBP-only or sciatica, even with neural deficits.
Also overlooked are three studies of those determined to be candidates for disc surgery who only then underwent this unique evaluation. Rapidly reversible LBP was found in 32-52%. One study of patients with sciatica and neural deficits who were felt to be disc surgery candidates reported that 52% (N=67) turned out to have a rapidly reversible problem. Every patient (N=34) completely recovered within five days using pain-eliminating exercises identified by their examination findings.
So it is likely that 50% of today’s lumbar disc surgeries (discectomies, fusions, disc replacements) are not only unnecessary, but rapid recoveries are likely, easy, and inexpensive. This only happens however if clinicians and payers are informed about rapidly reversible LBP how easy and inexpensively it can be identified and treated.
Unfortunately, most researchers and guidelines continue to focus on the nearly useless research question: “What is the best treatment for non-specific LBP?” …. an unvalidated diagnosis. We don’t have guidelines focused on chest pain or abdominal, elbow or ankle pain. So how do we justify our persistent focus on non-specific LBP and one-size-fits-all treatments when we can reliably identify subgroups that then have superior outcomes using subgroup-specific treatments?
Meanwhile, millions undergo unnecessary, even detrimental, tests and treatments that push the U.S. LBP cost to an estimated $80-90 billion per year.
Although the context and politics of this topic are complex, the scientific evidence validating rapidly reversible low back pain is substantial and the economic and quality of care implications are immense.
Ronald Donelson is an orthopedic surgeon and author of Rapidly Reversible Back Pain.
