A NICE approach to treating low back pain

NICE which is the UK's National Institute for Clinical Excellence has just released guidelines for treating low back pain (LBP).

The first recommendation is to promote self-management. This means to suggest to patients with LBP to exercise and try to continuing doing ones normal activity, as possible. The next one is pain medication - first acetaminophen. The final recommendation is exercise or manual therapy (i.e. spinal manipulation) or acupuncture.

Another interesting feature is what the guidelines proscribe. All of the following are treatments/diagnostic tests that are NOT allowed (because they either don't work or aren't needed):
Medical/Surgical treatments

• SSRIs for pain management
• Facet injections
• Radiofrequency facet joint denervation
• IDET (Intradiscal Electrothermal Annuloplasty)
• PIRFT (Percutaneous Intradiscal Radiofrequency Thermocoagulation)
  

Physical therapy

• Laser therapy (AKA Cold Laser)
• Interferential electrical stimulation
• Therapeutic ultrasound
• TENS (another kind of electical stimulation)
• Lumbar supports or belts - back braces
• Traction

Diagnostic tests

• Plain film x-ray under any circumstances
• MRI to be offered only to rule out red flags or for surgical referral
• I think of an MRI for a a back pain patient, a road map for a surgeon. Keep that in mind if you are pushing your doctor to get one.
• Red Flags are signs of:

• Spinal cancer
• Cauda equina syndrome
• Infection
• Ankylosing spondylitis or another inflammatory disorder
• Fracture

Of course as I noted in previous blogs, it is likely that your health care provider will ignore these recommendations and do what they have always done, even if the scientific evidence is that it is not effective.

See:

• Treatments that don't work
• Resistance to using the best treatement
• Ultracrepidarian Doctors and Back Pain
  

These new guidelines are is not particularly new but nice to see.

SMP

Ultracrepidarian Doctors and Back Pain

An ultracrepidarian is a person who professes expertise the they do not posses. This is an epithet not often used but I am fond of and have used in presentations and my ethics column. Some might say that fondness is because it should be applied to me. Nevertheless, I like it because I find so many experts who pontificate on that which they know so little. Think of my earlier blog entry about Katz.

There is a classic paper that sort of tested the prevalence of this disorder amongst very smart college students. The title says it all, "Unskilled and unaware of it: How difficulties in recognizing one's own incompetence lead to inflated self-assessments". (The link goes to free full text)

A new study, published in today's Spine by Buchbinder et al could be called ultracrepidarian doctors and back pain. The paper, "Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain" details a study that surveyed general practitioners about their interest and knowledge regarding how to treat back pain. The results are counter-intuitive because those with the greatest interest in treating back pain had the poorest knowledge of the current best evidence of how to treat it. Thus, they were ultracrepidarians.

It was almost comical but the doctors with a special interest in back pain thought that guidelines are very helpful in determining how to treat patients with back pain, yet they choose treatments, such as bed rest, that are clearly bad for patients. Bed rest in particular has been known to be harmful for a long time.

This paper is very similar to one published quite a while ago also showing that doctors choose treatments that are ineffective and avoid ones that are effective such as spinal manipulation.

Buchbinder and colleagues previously published studies that showed that public education reduces disability from workers compensation type claims. Sometimes the public is teachable and their doctors aren't. I wish I could give patients hope that the doctor they go to really is up-to-date but clearly if the doctor says they are does not mean that they actually are.

SMP

Resistance to using the best treatment

The NYTimes reports on the battle against the use of the best evidence in health care. Once again it is reported that one of the biggest problems in getting good health care is the resistance of health care providers to changing the voodoo that they do to treatment that actually works.

This article talks about the Agency for Health Care Policy and Research's guidelines on treating lower back pain. (1) Spine surgeons were so upset that it excluded their favorite treatment - surgery - that they tried to kill the agency. As the Times article reports the reason that surgery was not recommended: research didn't show it was effective but it did show that spinal manipulation was effective.

But as Max Planck said: "A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it."

The problem is that people have a hard time changing. Most hate change. Personally I thrive on it. Most don't like finding out they were wrong. I used to be like that. I think the change was when I read the first study that suggested that spinal manipulation might be effective for treating some people's symptoms who have spinal stenosis (2)

This paper came out 2 years after I had told a patient who came in with CT showing the stenosis (he'd been symptomatic for ~10 years) that I couldn't help him and he should have the surgery he had scheduled. The study isn't what I'd call compelling evidence of clinical effectiveness of spinal manipulation but IF it had been published two years earlier I could have told this man he might have a 36% chance of getting better after two weeks of care. Given the fact he'd lived with the pain for 10 years he might have been willing to try two weeks of care instead of "going under the knife". For a while I beat myself up over this and then I realized, you can't know what isn't known. That liberated me to be comfortable with saying that was wrong. As W.V. Quine and J. S. Ullian wrote in The Web of Belief (Random House, New York, 2nd edition, 1978, p. 133) my favorite quote:

The desire to be right and the desire to have been right are two desires, and the sooner we separate them the better off we are. The desire to be right is the thirst for truth. On all accounts, both practical and theoretical, there is nothing but good to be said for it. The desire to have been right, on the other hand, is the pride that goeth before a fall. It stands in the way of our seeing we were wrong, and thus blocks the progress of our knowledge.

The Times article suggests that most doctors are more interested in having been right, rather than being right.

SMP

1. Bigos S, Bowyer R, Braen R, et al. Acute Low Back Problems in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; 1994.
2. Kirkaldy-Willis WH, Cassidy JD. Spinal manipulation in the treatment of low-back pain. Can Fam Phys. 1985;31:535-40.
   

Ye Of Little Faith - In Chiropractic That Is

My last blog entry Swine Flu & Chiropractic is stirring up a hornets nest. Of course you wouldn't know that by looking at my blog because no one has posted any comments, so far. I have received quite a few emails. All of the emails sent to me directly by the person commenting have been complimentary.

I haven't yet received any anonymous hate mail, such as when my colleague Randy Ferrance, DC, MD and I co-authored one of my ethics columns for Dynamic Chiropractic on vaccinations, entitled What's Good for the Goose Is ... Ethics and Vaccinations. (BTW I think we would write this differently now due to a change in the evidence on stroke and chiropractic.)

That column resulted in such an outpouring of venom directed at Dr. Ferrance and me that I wrote a column about Argumentum Ad Hominem (ad hom for short) - which is to attack the person not their argument. For some reason, I do not completely understand, many people in my profession will resort to ad hom rather than find the flaws in an argument they think is wrong. To quote from my Dynamic Chiropractic article: "This is the most feeble reply one can make and generally reflects poorly upon the person who does it. Those who are not biased see this as having no probative value in the argument, and it signals that the person using that reply has no valid counterpoint and is not acting professionally."

Lack of Faith

Some think that my last blog entry shows I lack "faith" in chiropractic. Well clearly I do lack faith in chiropractic, just as I lack faith in medicine, physics, mathematics...

I think that faith is not an appropriate word to describe ones association with ones profession. No one would ask a mathematician, "do you have faith in math?" However, one might ask a member of the clergy do you have faith in your religion. This is because one is obligated to have faith in a religion. There is no other method for one to accept the tenets of a religion, as there is no method to determine the validity or lack of validity of those tenets. Faith is a belief that does not rest on logical proof or material evidence.

I do have faith in the epistemology (a subset of philosophy) inherent in science (i.e., skepticism, empiricism and determinism). Science is an epistemological theory about how one acquires knowledge and cannot be validated using the scientific method. Using science to validate science is a tautology. Thus one must have faith that science is a good method to discover how things function. So far it has worked out pretty well. You are reading this because of thousands of scientific discoveries that ultimately lead to blogging (not sure this is science's best day).

Chiropractic is a health care science and thus starting with my faith in science, I am forced not to have faith in chiropractic but to conclude, based on the available science that chiropractic is or is not a useful method for the care and prevention of human illnesses or maladies.

Given the above, I have found evidence that I find to be compelling to make me conclude that chiropractic is an extremely valuable method for the care and prevention of human illnesses or maladies. I will not blindly have faith in chiropractic or anything else, I will question it constantly, that I believe is my job as an academic.

Narrow view of chiropractic

One chiropractors suggested that my blog entry shows that I have a narrow view of chiropractic and that I implied we should stick to headaches, low back and neck pain. I wrote:

There is a growing body of good scientific evidence that spinal manipulation can be an effective treatment method for neck pain, headaches and low back pain.

Tell me where does it say that we should "stick to headaches, low back and neck pain"? It doesn't. It says that there is a growing body of good scientific evidence on three conditions. That's all. I didn't mention any others.

If one wants to see a good review of what evidence there is take a look at the Council on Chiropractic Guidelines and Practice Parameters (CCGPP)'s web site. One could also look at the Cochrane Collaboration and search for manipulation or chiropractic. Then there are some conditions that there is a complete lack of evidence. Such as preventing the flu.

As you can see from my long list of quotes on this blog, I am a fan of quotes. Two from Carl Sagan are illuminating in this regard.

"Absence of evidence is not evidence of absence"
- "The Dragons of Eden"

This one is often cited by members of my profession about those things we have no evidence for. For example using chiropractic care to prevent or treat swine flu. While this is true I think what is also important is another quote from Sagan:

"I believe that the extraordinary should certainly be pursued. But extraordinary claims require extraordinary evidence"
- " Broca's Brain"

The claim that spinal manipulation will improve immune function to the extent that it can be used to prevent or help treat the flu is clearly an extraordinary claim. I absolutely believe that it should be researched, just it is not my area of research interest. Some might say why not no harm. Well that is true as long as the public isn't lead to believe that this is a validated treatment. Until the evidence is found, we, the chiropractic profession, have to stop making the claim that chiropractic care will help prevent or treat the flu, which is what the blogger I was responding to wrote. He said that one of the "Sure-fire Strategies to help you and your family respond to the threat of the flu" is chiropractic.

As I wrote before it only serves to marginalize our profession by making us look like we are unscientific.

What I Was Taught In School

Another comment was about how a doctor wanted to believe what he was taught in chiropractic school about an adjustment improving immune function. As I tell my students often do not believe what I tell you. Go to the scientific literature yourself and find the evidence. And if you find that the evidence shows. I would be happy to eat my words that an adjustment will help prevent the flu so show me the scientific evidence.

CDC

One comment about my blog entry was that I suggested that people look at the CDC's web site for advice about the swine flu. The problem with that is supposed to be that "the first thing that website site [CDC's] says is to get the flu vaccine to prevent the flu. We all know that the flu shot is a shot in the dark and far from an exact science"

The problem with this statement is that the CDC does not recommend a flu vaccine for the H1N1 but for seasonal flu. In fact, they say that there isn't a vaccine for the H1N1 flu. Here is what they recommend:

1. Avoid close contact - Avoid close contact with people who are sick. When you are sick, keep your distance from others to protect them from getting sick too.
2. Stay home when you are sick - If possible, stay home from work, school, and errands when you are sick. You will help prevent others from catching your illness.
3. Cover your mouth and nose - Cover your mouth and nose with a tissue when coughing or sneezing. It may prevent those around you from getting sick.
4. Clean your hands - Washing your hands often will help protect you from germs.
5. Avoid touching your eyes, nose or mouth - Germs are often spread when a person touches something that is contaminated with germs and then touches his or her eyes, nose, or mouth.
6. Practice other good health habits - Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.

I know that no chiropractor would have a problem with these recommendations. What does this tell us with the complaint about my suggesting use the CDC for information. It tells us that the person who was criticizing me never even clicked on the links to the CDC to see what the CDC actually recommended. Just as they inferred I had a narrow view of chiropractic, without reading carefully what I wrote, they assumed that the CDC would recommend the flu shot.

As I wrote in the swine flu blog: "Overstating what we know only serves to decrease our credibility." In this case making pronouncements that, all easily available evidence, refutes doesn't do great things for ones credibility either.

SMP

Swine Flu & Chiropractic

I recently saw a blog that suggests that the second best of the "Sure-fire Strategies to help you and your family respond to the threat of the flu." is chiropractic. Now don't get me wrong, I'd love to be able to say with a straight face and the research to back it up that going to see a chiropractor would help you prevent or even get better from the swine flu, er I mean Influenza A(H1N1) (surely we don't want to insult swines). But honestly I think it is intellectually dishonest and a public disservice to imply that a chiropractor has unique therapeutic tools that will help prevent or treat the flu.

Let's look at the argument in favor of chiropractic as part of how ones family should "respond to the threat of the flu."

Supposedly Ronald W. Pero, Ph.D. performed one of the most important studies that showed the positive effect chiropractic care has on immune function and general health. First the link in the blog leads to an article about the 1917-8 flu epidemic. I'd like to see the original data rather than the owner of that web sites excerpts. Nevertheless it might be true that chiropractic care was better than medical care for the flu in 1917-8. There is a world of difference in the field of medicine between then and now. I hate to say it but I do not think there has been an equally large increase in the effectiveness of an adjustment. In fact I think most traditionalists in my profession would suggest it was as good as it was going to get way back when and we've only screwed stuff up since then.

I searched the National Library of Medicine's online database search system, PubMed to find any published paper by Dr. Pero on chiropractic. I can't find it. Here is that search. Here is another search of just what R Pero published. I read the title of all 183 papers and none appear to be about chiropractic. If anyone can find me the paper, rather than an article in a chiropractic newspaper talking about the research I really would be grateful to find the paper and read it.

Next the blogger discusses a study done at the National College of Chiropractic (now National Health Sciences University) by their then research director, Patricia Brennan. Brennan’s study, if anyone actually reads it, is not really about immune function. It was an attempt to find a physiological marker of active manipulation. The intent was to see if they could differentiate between a sham and real manipulation.

Lots of folks want to use this study to show how chiropractic improves immune function. What is stated: “phagocytic respiratory burst of polymorphonuclear neutrophils (PMN) and monocytes were enhanced in adults that had been adjusted by chiropractors.” is true. So to the true believer in the unlimited wonders of the adjustment this is “proof” that an adjustment improves immune function. Unfortunately, one cannot conclude this from that study. First of all the subjects were healthy normal individuals. We do not know if the response will happen to those who are ill. Maybe when one is ill the response is blunted or eliminated because the PMN’s are already “enhanced” by the need to fight an infection. Conversely, it is possible that the response is enhanced even to a greater degree in the person fighting an infection. We just do not know. Also the response was transient; it was found at 15 minutes but dissipated by 30 minutes after the manipulation. The true believer’s response would be, "so adjust the patient every 15 minutes." That seems logical, except we don’t know if the response is repeatable or if it fatigues. And again it could be more profound as it is repeated, we don’t know. Also we do not know if the increased phagocytic respiratory burst will actually work in any appreciable way to make one better able to defend against an infection or to help the individual get better faster or have reduced effects of the infection that one might have.

The blogger mentions a study done at Life Chiropractic University. There is no such educational institution in the US. The name of the institution is Life University which was Life Chiropractic College. For some reason there are a lot of people who make this mistake. If one googles "life chiropractic university" one finds many chiropractors web pages say they graduated from there. I suggest they take a look at their diplomas.

Regarding this study, I can not comment about any specifics, I haven't read the paper. My only comment is that good research requires replication and if the best we can do is a paper in a defunct journal that is more than 10 years old...

The blog goes on to say that chiropractic improves "And chiropractic care improves the function of the nerve [sic] system through improving the movement of the spinal bones that encase and protect the spinal cord." This is an interesting theory that has been espoused by some in my profession for years. I am aware of no valid research that supports this statement. There is a growing body of good scientific evidence that spinal manipulation can be an effective treatment method for neck pain, headaches and low back pain. Overstating what we know only serves to decrease our credibility.

For information on prevention and treatment of influenza A(H1N1) (swine flu) see the CDC or CDC's flu pandemic web site or MedLine Plus (great consumer oriented health information). Hopefully your chiropractor will recommend these sources of information rather then suggesting that a sure-fire strategy is getting a chiropractic adjustment.

SMP