Back pain; why the evidence does not support most treatments being sold to patients and how you can find care that works.
Evidence based care is the current buzz word in healthcare, yet the costs of care continue to rise and as the evidence of what we do and how we practice is often a contradiction. As a result, we are doing fewer mammograms, fewer pap screen, fewer knee surgeries and appendix problems are now being taken care of with antibiotics.
In the world of back pain, it seems that everyone has an answer, yet many of these solution have little scientific basis and often fail to relieve the problem. Perhaps the problem is the structural approach to back pain being taught in most schools of medicine and physical therapy. The idea is that the symptom is the problem and we need to do things to it.
If those things do not work, we do expensive tests and wait for the aha moment and then if we find a lesion, these patients will often find themselves either on drugs, or getting injections or having surgery that often does not solve the problem.
Is back pain a mental problem, a physical problem, an mechanical problem or a problem with movement, and what is the best way to figure out what will work best.
Certainly, it is not what we as most healthcare providers have been doing. Most doctors simply send patients for therapy, yet they do not get better. If you have doubts, ask the doctors staff and they will tell you that, yet because of ingrained referral habits, most doctors send their patients blindly to therapy that cannot possibly work.
Patients who visit chiropractors have the highest levels of satisfaction yet even chiropractors have many patients who do not improve as well. Since back pain often is a problem with movement patterns, and chiropractic manipulation restores movement, it is likely the reason for manipulations effectiveness, yet manipulation alone often does not solve the problem, likely due to the problem of tight fascia which guides and controls movement in the body.
The most effective and consistent way of improving a lower back problem is using active evaluation which looks at movement and movement patterns as well as strength and how you can perform certain actions against gravity. Sometimes, a treadmill evaluation holds the key to the best result, since we will see things that the evaluation alone often does not. Then, by using myofascial release, instrument assisted soft tissue and exercises, we can treat the tightness and movement issues and then retest the patient on the same visit to see if what we did was effective. If the patient can perform those tests and by the follow-up visit, continue to maintain this improvement, a predictable functional improvement and reduction of pain is commonly seen. This right now is the only scientifically valid approach to care, and it is still in its infancy.
The evidence of what does not work in back pain treatment is growing, yet most people are often experiencing what does not work. Also, since we are all built differently, a one size fits all approach to care is wasteful and not patient centered. An effective practitioner will used an evidenced based treat-test-treat approach to help the patient get the best outcome. An effective practitioner will also try to get the patient to be independent of them and the need for constant monitoring.
Check out this blog post. It is an eye opener
The Problem with a (Entirely) Structural Based Approach to Low Back Pain
Date: December 9, 2016
The problem with a (entirely) structural based approach to low back pain”¦.
Is there may actually be no problem.
This sounds like channeling the girl from the Matrix proclaiming there is no spoon, but it”™s not far off. Before a finding can be called a problem the base rate of the finding needs to be established. Or put another way, what is the incidence of that finding in the normal, asymptomatic population? Too often radiology reports are read as death sentences to patients when in fact it is natural progression of aging or highly present in the general, pain free population. Recently my intern and I set out to see what those rates are in hopes of further demystifying issues to both patients and practitioners. Here, in wonderful blog format, are our findings.
Henscke 2013 would say there is no sufficient red flag to screen for malignancy, but history of prior cancer was the most likely (I know you”™re all surprised by that). Dowie 2013, when screening for fracture, states there is no strong association but old age, corticosteroid use, severe trauma, and presence of contusion should all increase the probability. The normal bowel/bladder dysfunction and progressive neuro symptoms or upper motor neuron signs are still included.
The point of this being many of the pathologies don”™t really hold up and there are large flaws within the structuralist model. Koes 2006 would argue that up to 90% of low back pain is nonspecific, or said better”¦we don”™t really know what is causing the pain. If established anatomical abnormalities do not really correlate, then it is even more difficult to state that non established things like innominate rotation (even though they don”™t rotate), tight hip flexors (which we first have to decide what is “œtight”) or trigger points (which still have no evidence) are correlated with their onset.