Overtreating Back Pain

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                        Overtreating Back Pain

                        Written by Dr. Daniel J. Murphy D.C., D.A.B.C.O.
                        TAC, Research Review , Volume 31, Issue 7
                        Published:
                              

 

                        Key Points from Dr. Dan Murphy
                         
                        1.     “Pain complaints are a leading reason for medical
                        visits. The most common pain complaints are
                        musculoskeletal, and back pain is the most common of
                        these.”
                         
                        2.    “The prevalence and impact of back pain have led
                        to an expanding array of tests and treatments, including
                        injections, surgical procedures, implantable devices,
                        and medications. Each is valuable for some patients, but
                        use may be expanding beyond scientifically validated
                        indications, driven by professional concern, patient
                        advocacy, marketing, and the media.”
                         
                        3.     Although approximately 25% of US adults reported
                        back pain during the past 3 months, this percentage has
                        not changed for decades.
                         
                        4.    Expanded testing and treatment for back pain have
                        not improved outcomes, but have increased complications,
                        including deaths.
                         
                        5.       “Chronic back pain is among the most common
                        patient complaints.”
                         
                        6.    There are increases in Medicare expenditures for
                        back pain diagnostics and treatments, as follows:
                                            a.  A 629% increase for epidural
                        steroid injections
                                            b. A 423% increase in expenditures
                        for opioids for back pain
                         c. A 307% increase in the number of lumbar magnetic
                        resonance images
                                            d. A 231% increase in facet joint
                        injections
                                            e. A 220% increase in spinal fusion
                        surgery rates
                         
                        7.       These increases have not improved in patient
                        outcomes or disability rates.
                        8.     Manufacturers aggressively promote new drugs and
                        devices for the treatment of back pain, yet there is
                        evidence of misleading advertising, kickbacks to
                        physicians, and major investments by surgeons in the
                        products they are promoting.
                        9.    The use of lumbar magnetic resonance imaging (MRI)
                        has increased dramatically, and spinal surgery rates are
                        highest where imaging rates are highest.
                        10.    Approximately 33–66% of spinal computed
                        tomography (CT) imaging and MRI may be inappropriate.
                        11.   “Many factors probably underlie the growth of
                        imaging, including patient demand, the compelling nature
                        of visual evidence, fear of lawsuits, and financial
                        incentives.”
                        12.   “One problem with inappropriate imaging is that it
                        may result in findings that are irrelevant but
                        alarming.”
                        13.    “Positive findings, such as herniated disks, are
                        common in asymptomatic people.”
                        14.   Positive imaging findings result in more surgery
                        and higher costs than those receiving plain X-rays, but
                        the clinical outcomes are no better, including
                        subsequent pain, function, quality of life, or overall
                        improvement.
                        15.   Prescription opioid use is steadily increasing,
                        especially for musculoskeletal conditions. Emergency
                        department reports of opioid overdose parallel the
                        numbers of prescriptions. Deaths related to prescription
                        opioids are greater than the combined total involving
                        cocaine and heroin.
                        16.   Cancer patients tend not to take opioids for long
                        periods of time because they die. In contrast, patients
                        taking opioids for back pain can do so for decades. More
                        than half of the prescriptions for opioids are for back
                        pain and, consequently, they constitute a major portion
                        of those with opioid consumption complications.
                        17. The benefit of opioids drugs in clinical practice
                        for the long-term management of chronic low back pain is
                        questionable. 
                        18.    Ironically, “Opioid use may paradoxically
                        increase sensitivity to pain.”
                        19.  Chronic use of opioid drugs may also cause
                        hypogonadism, reduced testosterone levels, diminished
                        libido, and erectile dysfunction.
                        20.  “Epidural corticosteroid injections may offer
                        temporary relief of sciatica, but both European and
                        American guidelines, based on systematic reviews
                        conclude they do not reduce the rate of subsequent
                        surgery.”
                        21.  “Facet joint injections with corticosteroids seem
                        no more effective than saline injections.”
                        22. “For patients with axial back pain without sciatica,
                        there is no evidence of benefit from spinal injections.”

                        23. Spine fusion surgery is limited when treating
                        degenerative discs with back pain with no sciatica, yet
                        they have increased 220% from 1990 to 2001 in the United
                        States.
                        24.   “Higher spine surgery rates are sometimes
                        associated with worse outcomes.”
                        25.   New and improved fusion techniques and devices,
                        such as implants, increase the risk of nerve injury,
                        blood loss, overall complications, operative time, and
                        repeat surgery, but do not result in improved disability
                        or reoperation rates.
                        26.  Increases in the rates of imaging, opioid
                        prescriptions, injections, and fusion surgery might be
                        justified if there were substantial improvements in
                        patient outcomes; unfortunately, they are not. In fact,
                        statistics indicate that disability from musculoskeletal
                        disorders is rising, not falling.
                        27.    “Prescribing yet more imaging, opioids,
                        injections, and operations is not likely to improve
                        outcomes for patients with chronic back pain.”
                        28.    “There are no “magic bullets” for chronic back
                        pain, and expecting a cure from a drug, injection, or
                        operation is generally wishful thinking.”
                        29.    “Chronic back pain, like diabetes or asthma, is a
                        condition we can treat but rarely cure,” and its
                        management may “benefit from sustained commitment from
                        health care providers; involvement of patients as
                        partners in their care; education in self-care
                        strategies; coordination of care; and involvement of
                        community resources to promote exercise, provide social
                        support, and facilitate a return to work.”
                         
                        COMMENT FROM DAN MURPHY
                        In the 10 years that I have been doing my Article
                        Reviews, we have seen a number of studies that show that
                        spinal adjusting is highly effective, safe, cost
                        effective, and results in long-termed stable outcomes in
                        the treatment of chronic low back pain.
                         
                        Dr. Daniel J. Murphy D.C., D.A.B.C.O. graduated magna
                        cum laude from Western States Chiropractic College in
                        1978. He received Diplomat status in Chiropractic
                        Orthopedics in 1986. Since 1982, Dr. Murphy has served
                        part-time as undergraduate faculty at Life Chiropractic
                        College West, currently teaching classes to seniors in
                        the management of spinal disorders. He has taught more
                        than 2000 postgraduate continuing education seminars.
                        Dr. Murphy is a contributing author to both editions of
                        the book Motor Vehicle Collision Injuries and to the
                        book Pediatric Chiropractic. Hundreds of detailed
                        Article Reviews, pertinent to chiropractors and their
                        patients, are available at Dr. Murphy’s web page,
                        www.danmurphydc.com