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Stabbed in the back: Moving the knife out of back pain

1 Feb, 15 | by BJSM

By Jørgen Jevne @jevnehelse

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Low back pain (LBP) is an enormous socioeconomic and emotional burden. In spite of vast efforts the number of LBP sufferers remain stagnant [1] and back pain endures as a clinical conundrum.

Despite being increasingly recognized as a complex condition demanding a biopsychosocial framework [2], alarming trends are evident in the medical literature [3]. Care is becoming progressively discordant with clinical guidelines; we are prescribing more MRI, strong pain-medication, injection therapy and surgery [4-6]. Some factors may drive this negative spiral:

  • Patients’ illusions of ‘quick fixes’ yields more imaging, injections and surgery
  • Practitioners’ actual, or self-perceived incompetence, leads to poor, guideline discordant decisions
  • Clinicians’ willingness to comply with patient preferences drives an on-going illusion of ‘magic bullets’ among the general population
  • Health systems reward interventions and examinations not supported by evidence (i.e. early imaging modalities)

For decades we have scanned, screened and tested. We have treated short, weak and tight muscles. We have ‘stabilized’ and performed movement screenings. Joints have been popped, cracked and allegedly realigned. We have prescribed pills, needled taut bands and injected steroids into nerve roots. Spines have been cut, carved and fixated.

But on our disillusioned journey to find the pathoanatomical ‘Holy Grail’ of pain, we seem to be forgetting something:

Our patients are not cars. And we are not mechanics.

Reconceptualization

Stress and lifestyle factors’ influence on heart disease is an undisputed fact. Ironically, it seems as though many clinicians are reluctant to recognize the same mechanisms in LBP, which is still largely considered as an ‘injury’.

To move this field forward there is need for reconceptualization. The picture of our bodies as reductionist objects is antiquated. We cannot reasonably expect centuries of evolution to be marginalized into misaligned joints, weak muscles or degenerated discs [7]. We need to assess and treat the human body less like a machine and more like an ecosystem.

An ecosystem where multiple factors will influence patient presentations and outcomes. Fear, lack of self-efficacy, lack of confidence, fear-avoidance behavior, poor sleep, frustrations, insecurities and other stressors all influence the delicate balance in our patients’ ecosystem.

Catalyzers for the paradigm shift

The ultimate cure for the LBP epidemic remains elusive, but please consider these catalysts for a paradigm shift:

  1. The need to reconceptualize people`s notion of pain [8].

Medical professionals up to date with the current literature will no longer consider LBP, especially in the persistent and recurrent phase, to be caused by tissue injury and noxious inputs to the nervous system. In contrast, pain is considered to be an output from the brain [2,9]. Structure, biomechanics and nociception will continue to play a role in back pain management, but they can no longer be the cornerstones of our interventions. We must cater to the more fundamental needs of our patients, not their ‘short muscles’ or ‘worn out’ disks.

This communication must pervade professions and educational institutions. It must extend from stakeholders and politicians at the very top to the devoted clinicians seeing the patients every day. The public deserves to learn that there are no quick fixes. No magic bullets. As clinicians we need to abandon narrowly focused professional shelters and move towards interprofessional understanding and respect and encourage multidisciplinary research and clinical practice.

  1. The immense gap between academia and clinical practice [10].

The shear volume of research is incomprehensible in day-to-day practice, and tools for easy and structured implementation are strongly needed. The overwhelming amounts of research possibly leads to reduced implementation, which in turn might lead to guideline discordance and ultimately results in suboptimal patient management [11].

  1. The need to rethink the front line of care for back pain [12].

We must ensure that messages to patients are delivered consistently and precisely and that this communication remains guideline concordant across health professions. Health care is currently imbued with vested interests. Many systems reward procedures and services not supported by evidence. This likely fuels a seemingly never-ending hunt for mechanistic pathoanatomical explanations for LBP, with expensive scans and invasive interventions that have questionable health benefits.

Patients with back pain should consult practitioners who primarily deal with musculoskeletal conditions to ensure that care is delivered from evidence-informed clinicians competent within this field [13,14]. This is highlighted by recent work indicating many primary care practitioners provide guideline discordant management [15-17]. Thus, we need to leave our professional sanctuaries. We need to taste the cognitive dissonance and dare to admit we might be wrong. We need to stop playing Gods and start playing by the rules. The rules of science and evidence-based practice.

  1. In the era of physical inactivity [18], there is a desperate need for movement.

Not expensive exercise machines or special shoes, but natural movement. Pleasurable movement. In all its simplistic complexity. As the burden of physical inactivity continues to rise, so too does the demand for competence to accommodate the sequelae of this development. This calls for more collaboration between disciplines including general practitioners, chiropractors, physiotherapists, strength and conditioning coaches and personal trainers. Physical activity will not solve the pandemic of LBP, but it seems more than obvious that it will reduce its burden.

  1. Clinicians need to change their role.

For decades we have claimed magical powers and appointed ourselves in charge of patients’ health and well-being. The time has come to change this role from operator to interactor. We must be team players, not captains. We need to listen, not speak. Empathize, not moralize.

In short, we need to bring the care back into health care. While implementation of evidence-based practice has been an indisputable success for modern medicine, our search for ‘best practice’ might have focused too much on scientific methodology and our clinical repertoire. Let us get back to why we all do this: the patients [19].

  1. We need to confront the ‘guruism’ within back pain care.

Whereas a considerable demand exists for pioneers to lead research and clinical practice, there is certainly no shortage of supply from self-proclaimed experts attempting to fill these roles. Unfortunately, their statements are often based upon anecdotes with little or no substantiating evidence. Some are welcomed into colleges and universities, which may provide artificial credibility rather than scientific scrutiny. This professional indolence has led to survival of many fossilized diagnoses and technique systems invented in a time where evidence-based practice was mere a wishful prospect and not the archetype of medicine [20].

  1. Embrace stratified models of care.

Subgrouping different low back pain patients is quickly becoming the zeitgeist in modern LBP management and several publications are showing promising results [21-24]. While vast amounts of work remain, the future of different stratification models certainly holds potential for the millions of people suffering from LBP. The Achilles heel in this process might very well turn out to be the actual implementation of this ongoing research and not the quality of the evidence itself.

In all its brutal honesty, we must admit it. We have stabbed our patients in the back. We have not lived up to the ancient philosophy of ‘primum non nocere’.

The time for change is long past due. The time is now.

Let us move patients away from simplistic models of injury and faults. Away from pathologic scans and shiny scalpels. We can gravitate towards a new dawn for back pain management.

Researchers can drive the change. Clinicians can be the change. And the patients deserve the change.

**********************************

Jørgen Jevne is a dedicated musculoskeletal clinician with a degree in physiotherapy and chiropractic, practicing in a private clinic in Hønefoss Norway. He is also a writer, lecturer and part-time researcher. 

References

  1. Hoy, D., March, L., Brooks, P., Blyth, F., Woolf, A., et al.: The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis, 2014.
  2. O’Sullivan, P.: It’s time for change with the management of non-specific chronic low back pain. Br J Sports Med, 2012. 46(4): p. 224-7.
  3. Mafi, J.N., McCarthy, E.P., Davis, R.B., Landon, B.E.: Worsening trends in the management and treatment of back pain. JAMA Intern Med, 2013. 173(17): p. 1573-81.
  4. Deyo, R.A., Mirza, S.K., Turner, J.A., Martin, B.I.: Overtreating chronic back pain: time to back off? J Am Board Fam Med, 2009. 22(1): p. 62-8.
  5. Deyo, R.A., Von Korff, M., Duhrkoop, D.: Opioids for low back pain. BMJ, 2015. 350: p. g6380.
  6. Martin, B.I., Turner, J.A., Mirza, S.K., Lee, M.J., Comstock, B.A., et al.: Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997-2006. Spine (Phila Pa 1976), 2009. 34(19): p. 2077-84.
  7. Brinjikji, W., Luetmer, P.H., Comstock, B., Bresnahan, B.W., Chen, L.E., et al.: Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol, 2014.
  8. Melzack, R. , Katz, J.: Pain. WIREs Cogn Sci, 2013. 4: p. 1-15.
  9. O’Sullivan, P. , Lin, I.: Acute low back pain: beyond drug therapy. Pain management Today, 2014. 1(1): p. 1-13.
  10. Greenhalgh, T., Howick, J., Maskrey, N., Evidence Based Medicine Renaissance, G.: Evidence based medicine: a movement in crisis? BMJ, 2014. 348: p. g3725.
  11. Westfall, J.M., Mold, J., Fagnan, L.: Practice-based research–“Blue Highways” on the NIH roadmap. JAMA, 2007. 297(4): p. 403-6.
  12. Hartvigsen, J., Foster, N.E., Croft, P.R.: We need to rethink front line care for back pain. BMJ, 2011. 342: p. d3260.
  13. Briggs, A.M., Slater, H., Smith, A.J., Parkin-Smith, G.F., Watkins, K., et al.: Low back pain-related beliefs and likely practice behaviours among final-year cross-discipline health students. Eur J Pain, 2013. 17(5): p. 766-75.
  14. Fritz, J.M., Childs, J.D., Wainner, R.S., Flynn, T.W.: Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine (Phila Pa 1976), 2012. 37(25): p. 2114-21.
  15. Fullen, B.M., Baxter, G.D., O’Donovan, B.G., Doody, C., Daly, L., et al.: Doctors’ attitudes and beliefs regarding acute low back pain management: A systematic review. Pain, 2008. 136(3): p. 388-96.
  16. Fullen, B.M., Baxter, G.D., O’Donovan, B.G., Doody, C., Daly, L.E., et al.: Factors impacting on doctors’ management of acute low back pain: a systematic review. Eur J Pain, 2009. 13(9): p. 908-14.
  17. Buchbinder, R., Staples, M., Jolley, D.: Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine (Phila Pa 1976), 2009. 34(11): p. 1218-26; discussion 1227.
  18. Blair, S.N.: Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med, 2009. 43(1): p. 1-2.
  19. Sackett, D.L., Rosenberg, W.M., Gray, J.A., Haynes, R.B., Richardson, W.S.: Evidence based medicine: what it is and what it isn’t. BMJ, 1996. 312(7023): p. 71-2.
  20. Zusman, M.: Belief reinforcement: one reason why costs for low back pain have not decreased. J Multidiscip Healthc, 2013. 6: p. 197-204.
  21. Hill, J.C., Whitehurst, D.G., Lewis, M., Bryan, S., Dunn, K.M., et al.: Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet, 2011. 378(9802): p. 1560-71.
  22. Vibe Fersum, K., O’Sullivan, P., Skouen, J.S., Smith, A., Kvale, A.: Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial. Eur J Pain, 2013. 17(6): p. 916-28.
  23. Foster, N.E., Hill, J.C., O’Sullivan, P., Hancock, M.: Stratified models of care. Best Pract Res Clin Rheumatol, 2013. 27(5): p. 649-61.
  24. Childs, J.D. , Flynn, T.W.: Clinical decision making for low back pain: a step in the right direction. J Orthop Sports Phys Ther, 2014. 44(1): p. 1-2.

 

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  • Thanks for an important and great post Jørgen. Kudos!

  • Great post Jorgen, but i fear there will be apathy and lack of support in some parts , which is of course what you were talking about! .I personally subscribe to stratified care, but acknowledge the results are modest but a step in the right direction

  • Phil

    A very interesting post Jorgen and I agree with much/most of its content, in particular the non-existence of the miracle cure! A couple of points though. Whilst I think it is important to highlight the role of efferent pathways in LBP (and other musculoskeletal pain), I think there is a danger of overlooking the role of afferent/nociceptive pathways which are likely to be significant in the acute stages of pain. You also point towards the importance of evidence based medicine and I would wholeheartedly agree with the desirability of EBM. However, whilst I also agree with you about the importance of movement in the prevention and treatment of LBP, is there much in the way of STRONG evidence to support this? I suspect not. So in our support and belief in the importance of movement, are we both not guilty of that greatest of crimes, unsubstantiated hypothesizing and clinical instinct!?

  • tim

    Sorry if I am underwhelmed by the “importance” of this obvious post. This is a redundant recasting of he last decades’ movement in back care which has lead to very little change other than more writing, more talking, more injections, more surgeries, more “care” and less owner responsibility.

    The categorization of LBP patients is a noble and appropriate switch but it is far from the holy grail and the only category validated was the manipulation/mobilization group for short term gains. The directional preference groupings are useful but over utilized with the majority of the patients being excluded from all studies, and the majority of those who are deemed “non responders” are delegated to the sticking, then stabbing, then screwing algorithm. The “stabilization” group is ridiculously simplified when compared to the real population of patients who seek guidance for their dysfunction and instead get a recipe for all backs which are apparently created & damaged equally. In addition one would think that all back patients need this and of course need to train a muscle that was utterly ignored until a standardized instrument was needed to have a reliable measure in an isolated research project. The correlation with human function remains unstudied, I defy you to push a heavy object with only TA contraction. The mechanical traction group need not be mentioned. The explain pain group is marvelous for us, certainly better than Sodoku, but useless for those who would rather eliminate the pain and not understand how than understand why they are suffering.

    It strikes me that we have lost the willingness to think aloud even if we are wrong. The guru age was long overdrawn but we seem to have replaced it with the evidence driven age where the new guru in town is the evidence. This dawn of binary thinking in a non-dualistic entity (life) will surely be looked back upon as a needed stepping stone but where are the practitioners who should be calling this for what it is? Everyone is secure about not belonging to a common think group. This is failure to think and recognize that complex problems are exactly that and we cannot will them into a median point on a gaussian curve. Prius vita cam doctrina.

    Amongst the more obvious things that we do not speak about is that all pathology has a natural history including life itself. Various spinal pathologies occur more commonly at various stages of life including the simplest of all the loss of cell density over time. Do we really think that all pathologies and age groups should be treated in a similar fashion? The more sedentary society becomes the more failure tag we will see in spinal columns. The more complicated life becomes and the further the owner of that life distances themselves from the responsibility of caring for the body and the mind (to say nothing of the soul) the discordant life experiences we will see.

  • Humanity has always known why human beings have back pain, it is in the muscles.

    Let’s deconstruct the most likely place for pain: Bone, cartilage, disc, ligaments, tendons, bursae, muscles, vessels and nerves.

    Nerves and vessels are naturally quiet structures? So NO! Unless there’s blood test detectable inflammation.

    Lets ask marathoners who pound out 26.2 miles which applies tons of energy into the body?
    Joints, cartilage or meniscus or disc? NO!
    Tendons and ligament would be frayed? NO!
    Muscles? YES!

    What other organ system aggravates humanity on a daily basis?? Muscles? YES!

    Lets ask bricklayers, roofers, carpenters or ball players? Muscles? YES!
    Weightlifters? Muscles? YES!

    Why are researchers and physicians overlooking this obvious fact?
    Misinformation from a shallow research that does not include >50 years.
    Misguided by the investments made my the business of medicine.
    Mislead by short sighted academic.
    Misdirected by provocateurs.
    Is this effort covert? It is definitely a concerted effort to deny these common sense facts.

    How do you treat back pain? Just like we have always have since we diverged from the Neanderthals ~ 1ma year ago.

    The Chinese deduced the same and perfected the most profound tool in medicine, a steel needle. I’ll bet they were not swayed by profits and technology as easily as modern man.

    My suggestion would be to go backwards in time not 1 ma but 60 yrs to learn from these scientist, then formulate your own conclusions: Gunn, Travell & Simons’, Rachlin, Baldry, Seems, Helms, Starlanyl, Hackett, Craig, Gokavi, Lennard, Burke, DiFabio and Pybus, B.J./D.D. Palmer, Wyburn-Mason,and Chaitow.

    Here is a synopsis of all the ideas of the above scientist, I think it is mandatory to treat MF pain within a 2 stage recipe concept:

    The Holistic Healing Recipe-Self: Daily self-care with a wholesome diet, extra vitamins and Magnesium supplements, exercise, stretching, yoga, heating with pads or hot tubs, Epsom soaking, massage, chiropractic spinal adjustments and most importantly sleep hygiene.

    The Holistic Healing Recipe-Assisted: If you get too far behind or do not seem to be able to complete restore to wellness, then you must seek out the “most profound igniter of healing” needles. I’ve witnessed the healing power which can only be ignited with needles; myofascial acupuncture, dry needling and Travell’s TrP injections and various other Bio/Prolo/Neural hypodermic injections.

  • If you see my prior post you can begin to comprehend how simple and natural pain can be. On the flipside you can see how human beings with our gift of imagery and deception can cloak over what is an innate protective mechanism of the human body.

    There are a lot of people in the world who have taken it upon themselves to be corrupters and provocateurs. In the case of long-term pain or myofascial pain and dysfunction this becomes a lot easier.

    Myofascial pain is a function of life, and in life each individual is responsible for maintaining his body. Self-care body maintenance is vital and relatively straightforward. It is what humans have inherited from our DNA. Staying ahead of these needs are profoundly human. We know these things, perceive them around us we prepare for disaster.

    So why have modern man decided that self-care is unnecessary or can be ignored and disregarded?

    We have been trained to ignore the needs of our body.

    We have been told and it has been promoted that a pill will heal you as long as you take the pill.

    We have been placed in boxes, cars and in cubes offices where we are not able to move and exercise.

    We are fed tainted ideas of what to eat, how to act, what to appreciate, what to believe and not think for ourselves.

    We have been fooled by sports medicine to believe that an injury requires an MRI and surgery. Not that mother nature will heal every injury automatically.

    We have been fooled to believe that a surgeon can see and fix the pain seen on an x-ray. [You cannot see pain on an x-ray or MRI, this is a fallacy that gets confirmed by every failed procedure for the treatment of pain.]

    We have been fooled to believe that arthritis, degeneration of disc and cartilage, spurs and narrowing spaces are the cause of pain. NO! This is the most egregious lie in medicine.

    We’ve also been fooled to believe that muscles are so innocent and insignificant that muscles cannot cause misery and muscles can not lead to secondary and tertiary problems. This is fallacy. Physicians in the last century discovered this and promoted these ideas but a group of physicians decided that it was not in their financial best interest to allow these ideas to be promoted.

    On the same token the AMA launched a campaign to disparage and disavow chiropractic medicine. The AMA and NIH have found it necessary to downplay the benefits of acupuncture, spinal adjustments, massage, traction and other hands on muscle therapies.

    Somehow the same group of profiteers, provocateurs, naysayers and their followers removed certain benefits from insurance policies thus allowing for patients to suffer without the proper care and feeding of their myofascial pain.

    The most egregious deception is that in some cases of myofascial pain and dysfunction the cellular structure of the associated cells degrade. These degraded myofascial cells act like cancer cells and they spread and seed into other parts of the body to cause a long list of complicated long-term pain problems. Most notable are trigeminal neuralgia, migraines, RSD, complex regional pain syndromes, all types of neuropathies, neuropathic pain syndromes all of which if not treated properly will destroy the well-being of the patient leading them to overdose on pain pills or commit suicide.

  • I can tell you what does NOT work for LBP and that is surgery, epidurals, rhizotomies and facet injections. They do not work because they are misguided, illogical, unreasonable, unnatural, not grounded in reality, too dangerous, failure rates are too high, the results are too haphazard.

    SBM and EBM are a farce, because the tenants of the scientific method demands that a patient, a witness or I as a professional can report back to the AMA, HHS, Medical board to report all of the failures so that the original premiss can be modified for accuracy. This is not the case!!

    These failures go unrealized so do the errors. In my office, these errors are REAL PEOPLE who are miserable, who have been dumped back into society with no further options. All were promised to have a better quality of life. All were never given full disclosure as to the risk. ALL were never offered what providers had used in the 80s, intensive full force PT.

    All are an example of a healthcare system that has lost it’s integrity. Be it in the UK, US or Australia which all use the same set of policies and procedures.

  • Johninpa

    Forgive me, Dr. Rodrigues, if I have misunderstood your comment, but I feel compelled to respond. I am of sufficient age to have practiced “full force, intensive” PT in the 1980’s – actually ever since 1980. Primarily, we used a lot of modalities, perhaps some mobilization, maybe manipulation if we had studied Cyriax (as I had), along with a sympathetic tone in our voice and a pat on the back as our patient left our department or office. We tended to treat for a very long time (3 days per week, maybe for 2-3 months), and many recovered in that time, and I suspect it was not because of our treatment but rather in spite of it. As you know, most get well in 4-6 weeks regardless.

    Now, that doesn’t mean I disagree with all the comments, as well as the blog post. I do think we like to make complicated matters out of simple problems. I’m not convinced that we must go the neuroscience route for more chronic patients. I would propose that many chronic patients have just not been managed well, even with the multiple physicians, PT’s, chiro’s, gurus and all the rest they have seen.

    So, where does that leave me (us)? The evidence doesn’t support a lot of common treatments for back pain. So, what is supported? Two very simple concepts have significant evidence behind them – directional preference (even though discredited in the comment above) and centralization. Using those simple concepts, many back pain sufferers improve – acute through chronic. While I know I can expect great criticism (generally from those unfamiliar with the approach), mechanical diagnosis and treatment offers much to that patient, allows for classification, and treatment becomes the responsibility of the patient, not the care giver. Not all patients will benefit, but a significant percentage will, they will respond quickly and will know how to care for themselves now and in the future. If you are interested, Dr. Rodriques, I would suggest you obtain a copy of “Rapidly Reversible Back Pain” by Donelson. It is not a scientific text, but rather an overview of that approach, with references to support his claims. Then find a McKenzie credentialed therapist in your area and have a discussion.

    So, as one of those “full force” PT’s of the 1980’s, and now a less forceful and hopefully wiser PT in 2015, we have a lot to learn. I’ve been much more effective using MDT, and would suggest it is a useful base to initiate care for the low back.

  • WOW!!! Thank you. Dr. Cyriax was is now included my author list. His name escaped my research, but his concepts are deeply embedded in the true, straight and narrow natural path to peace, harmony, health and wellness. I will study his concepts tonight!! His admonitions are my admonitions that I had to uncover or rediscovered on my own. These concepts are based on mathematics, reason, logic and common sense.

    I’m always learning new concepts that have been hidden away for my training. From 1979-1997 it was all classic. In the past 15 years, I have retooled to be ALL inclusive so I have gone back 5000 years to tap into some of our ancient wisdom.

    If the therapy is natural, holistic, safe and nontoxic and gives results that are positive, restorative, auto-reparative and curative? I keep it. I’m also obligated to promote these therapies to the public so that they will be more educated and informed consumers.

    If the treatments are unnatural, not holistic, treats patients like mechanical objects, toxic, does not restore to wholeness, dismantling, amputates, attempt to fix with results that are haphazard or does harm? It is junked. I’m also obligated by my oath to aggressive publicize these poor, harmful, crippling and detrimental evidence.

    These are my gurus or the Masters of Medicine that I have studied over the 15 yrs: Gunn, Travell & Simons’, Rachlin, Baldry, Seems, Helms, Starlanyl, Hackett, Craig, Gokavi, Lennard, Burke, DiFabio and Pybus, B.J./D.D. Palmer, Wyburn-Mason,and Chaitow.

    We must talk!

  • Sean Lester

    Ok your post is both great and terribly disturbing at points
    Diet: ok, fair enough. Supplements? Not evidence based or necessary.
    Exercise, stretching, yoga: Great!
    Heating: Great, pain management without invasion.
    Epsom soaking and chiro “adjustments” refers to the exact kind of guru-ism we need to step away from. You can’t “adjust” a spinal joint “back into place”, and inferring that you can is detrimental to your patient’s and their relationship with you.
    Sleep hygeiene: again, fantastic holistic standpoint.
    Needling, “Travell’s TrP injections”: Again, take a look at what you’re promoting and whether its helping.

  • I have for over 30 yrs in medicine and I can see with mush better clarity.
    Your comments are disturbingly biased and agenda based. You sir are mistaken and should read the history of medicine to grasp what has been known.
    Who are you?
    Who put you up to making such ignorant statements?
    Do you really know what the definition of pain?

    I have hundreds of references if you are serious about what matters.

  • Sean Lester

    I’m a physiotherapist who makes a habit of keeping current with evidence so I can discuss points like this. I see a lot of personal attacks in your post, which would seem to indicate that you’re happy to lower yourself. I would love for you to not attack me with ad hominem and discuss your points as a scientist and a practitioner, please indulge me.

  • This topic is too critical for indulging.

    Everyone is current which seems to be the problem. No one is looking back in time.

    If being currant was the best way to restore patients than we should a pain free and healthy society. But we don’t. Modern scientist have been taught to look to the future and told to negate and ignore past accomplishments. The past has been shelved and archived into dusty libraries. This is why pain management and therapy is pathetic.

    Our prior physicians, were not dummies, they were as dedicated as you are. What we need is an unbiased and critical review of the archives and the history of pain medicine. Collect was was valid to help to restore the foundation of modern pain medicine.

    Ok your post is both great and “terribly disturbing” To whom? If the points disturbed you than ask for clarity.

    “Supplements? Not evidence based or necessary.” Your advice is incorrect, long-term pain is muscular and magnesium is a key mineral. (you did not ask specifics but copper, zinc and selenium are also vital.)

    Exercise, stretching, yoga: Great!

    Heating: Great, pain management without invasion.

    guru-ism we need to step away from. Your name calling is not needed, if you go back in time you will pick up all those historical points from the archives.

    “You can’t “adjust” a spinal joint “back into place”,”

    Different types of spinal adjustments hands-on and manipulative medicine has been a part of human pain therapy for millennia. The words you used to describe what a chiropractor does are erroneous. It is about stretching the small rotator muscles of the spine, like a runner would stretch her/his quadriceps to restore them to optimal function.

    “detrimental to your patient’s and their relationship”

    Thanks for your concern about my practice, but IMO, the proper concern is what the AMA has done to medicine. It’s easy to poke at me, harder to poke at such a large and dominating entity.

    “Needling, “Travell’s TrP injections”: Again, take a look at what you’re promoting and whether its helping.”

    Your disposal of needling and Travell are exactly why we are here. Travell/Simons, Gunn, Rachlin, Hackett and many others used different types of needling to restore. They may not have known the exact mechanism of action but they had the perfect set of tools to accomplish the restoration of diseased muscles.

  • Sean Lester

    Clearly you misunderstood my comment. I was asking for peer reviewed evidence, which, if you’re familiar with the strata of evidence based practice, is held in a much higher regard than “expert” opinion.

    So I tried to do your job for you, but couldn’t find any articles about magnesium, copper or any other metal supplements for chronic pain. Nor any which claimed that chronic pain is muscular, more so that it is a pathophysiological response by central systems.

    I’m aware of the origins of manipulation, I use it in clinical practise. Again though, there are no reports of manipulation having anything other than a modulatory effect on central pain responses.

    And lastly, dry needling cannot restore a damaged muscle, and there have been no reports of this. I’m sure that as a distinguished practitioner you have read pieces such as this: http://bjsm.bmj.com/content/49/6/348.extract (full text here: https://thesportsphysio.wordpress.com/2014/09/14/soft-tissue-sore-spots-of-an-unknown-origin/), or this article: http://www.ncbi.nlm.nih.gov/pubmed/1404132 where it was discovered that trained leading experts cannot reliably identify “trigger points”, so how do you propose we treat something which can’t reliably be found 80% of the time?

    Fred Wolfe, a colleague of Travell and Simons wrote this excellent piece: http://www.fmperplex.com/2013/02/14/travell-simons-and-cargo-cult-science/ which summarises why your current treatment philosophies are a mess. As a 22 year old physiotherapist, I find it highly disturbing that my knowledge of chronic pain is greater than that of an experienced doctor, and I highly recommend some CPD via any number of sources (other than trigger point and MFR gurus).

  • John Austin

    Which modalities are you attacking?

    I am also apposed to “guruism” with questionable processes and little scientific evidence- a prime example being the “Posture Guru of Silicon Valley” http://gokhalemethod.com/

    However, blanketing everything not taught in medical school as unhelpful or placebo is ridiculous. The Alexander Technique, for example, has existed for over 100 years and has significant research backing it’s results- both in the form of clinical testing by the (including a study by the BMJ) and extensive case studies. I have personally seen dozens of people with RSI and other chronic pain rehabilitated from these issues AND the treatments and surgeries from so-called experts on chronic pain (both MDs and otherwise).

    Also, “Subgrouping different low back pain patients is quickly becoming the zeitgeist in modern LBP management and several publications are showing promising results”

    Is this not going the route of further testing and classification; how is this substantially different?

  • Sean you do not hear the grasshopper at your feet.

    ”I was asking for peer reviewed evidence”

    Be careful of what you read, reading what men has written will lead you to do tremendous harm.

    As a young hands-on specialist, I would suggest reviewing vetted sources such as:

    http://www.amazon.com/Gunn-Approach-Treatment-Chronic-Pain/dp/0443054223/ref=la_B0034OMF7A_1_1/176-0295073-4391501?s=books&ie=UTF8&qid=1425821648&sr=1-1

    http://www.amazon.com/Myofacial-Pain-Dysfunction-Trigger-Manual/dp/0683083651/ref=sr_1_11?s=books&ie=UTF8&qid=1425821677&sr=1-11&keywords=janet+travell+books

    I will take you a few years to read, process and practice what you have learned. Talk to an advanced practitioner who has touched and restored aching souls, not academics who have not. Their perspectives will be dramatically different. If you have any question ask. I have spent 15 yrs and had tens of thousands of patient encounters, so I’m a little ahead of you.

    “evidence based practice, is held in a much higher regard than “expert” opinion.”

    The most profound evidence comes from the lips of an aching soul who states, “That treatment is already helping me to feel better, thank you Doc, I will see you next week.”

    The value of evidence is relative to knowledge + experiences applied to help the people in your office.

    “So I tried to do your job for you,”

    Thank you for trying. As a return favor, I will try to help you.

    “couldn’t find any articles about magnesium, copper or any other metal supplements for chronic pain.”

    Expand or broaden your search and you should pickup the articles you missed.

    “pathophysiological response by central systems.”

    What does this mean?

    “there are no reports of manipulation having anything other than a modulatory effect on central pain responses.”

    What is central pain responses and how does this translate into a patient encounter?

    And lastly, dry needling cannot restore a damaged muscle, and there have been no reports of this.

    You missed the point! Needling is a way to “re-injure” a segment of muscle that did not repair properly for whatever reason.

    The articles your linked fail to understand the premise of a tender point, trigger point, a sore spot, and ah she point, so they are VOIDED.

    Fred Wolfe and John Quintner are geniuses. Their combined intellect is staggering. Their logic and prose is astounding. They are renowned around the world. They have published many papers. They have an interesting concepts and options. Unfortunately they both are tragically practically, reasonably, scientifically, morally and ethically WRONG.

    …22 year old physiotherapist, I find it highly disturbing that my knowledge of chronic pain is greater than that of an experienced doctor, …I highly … CPD via any number of sources (other than trigger point and MFR gurus).

    Young Grasshopper listen, read, learn, feel and think for yourself.

  • Sean Lester

    I don’t enjoy having to ask a third time, but I find myself still wanting. Pretty words are not peer reviewed evidence, and have no place in guiding clinical practise. As for the books, I am familiar with both, and there is a reason that neither are used for the mainstream training of health professionals. Please make an attempt at linking me to articles supporting any of your points, this is quickly turning into a display of circular reasoning.

  • Familiare does not cut the mustard. You owe it to your clients to read what is in the history of medicine. This aspect, I can not help you.

    Once your get a few hundred complex cases to manage, you should understand the need to discover what your predecessors used.

    Keep reading, researching and think for yourself. We are done. Thank you.

  • Mike Wade

    Your post mentions how to help back pain through visiting clinics, getting exercise, easing stress, etc. Another thing that really works is having a seat supporter. My sister had spinal surgery recently and she uses a seat supporter all the time. She says it really helps and she won’t go without it. If you’re interested, she got hers from this website: http://www.healthyback.com/landing-pages/Seat-supports/58

  • Adam

    I hope the victim doesn’t to drugs which cause a lot of harm and people try to cover it up. They should resort him to chiropractic treatment Chiropractor Frenchs Forest. I hope you all know about Chiropractor Frenchs Forest. Way better than those magic pills.

  • nice effort

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  • very useful post Jørgen. am clearly agreed with your post its really important. all points clear explaining about the things. i will wait your next post and recommended other.

  • Sandness Peak

    very helpful blog to get relief from Back Pain.

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