There is a back problem epidemic in the world because often these pains have been diagnosed on X-rays where we see things irrelevant to the patient’s problem.
Research confirms this observation and in addition states that minor traumas, sudden movements or efforts have no relation to back pain.
Two recent studies (which won the Volvo Awards = like the Oscar for low back pain research) by Carragee et al. have refuted two extremely common practices in the world of spine care:
- the widespread tendency to find diagnostic answers in MRI abnormalities of uncertain age and significance.
2. the reflexive linking of back pain to trauma;
They concluded that most findings on a MRI scan or X-rays are of uncertain significance and have no obvious connection to recent back pain episodes, because most people with those abnormalities are symptom free ( osteoporosis, annular tears, disc degenerations, scoliosis, spondylolysis, spondylolisthesis, congenital anomalies, etc. are common among both symptomatic and asymptomatic individuals).
New episodes of serious low back pain rarely have a relationship to new abnormalities on MRI scans (except in new disc herniations ) .
The study blew also a large hole in the injury model of low back pain by demonstrating that serious back pain and disability do not stem from minor trauma, structural malformations, or a combination of the two.
Attributions of disc herniations are often blamed on discrete events like a fall, a slip or lifting at work (I would add an adjustment) and often take on substantial medico-legal importance, but according to the research by King et al. they are almost never accurate.
Their extensive literature review showed that under normal compressive loading, in upright or bent postures, it takes thousands of cycles of loading to rupture a disc. Therefore a traumatic event that occurred immediately before a sciatica should be viewed as “the straw that broke the camel’s back”.
So most attributions of discrete events as a blame for disc herniations are unscientific and perpetuate an injury model that doesn’t exist under normal human loading conditions.
Often, also sometimes to please patients, doctors prescribe X-rays that are absolutely irrelevant. This tendency to trust technology for symptoms such as headache, neck- or back pain is useless because most of the time it does not help cure patients.
These findings confirm largely what we have seen over the years at the Sanrocco chiropractic clinic, that X-Rays and MRI’s are more useful for finding contraindications to the use of certain chiropractic techniques than finding indications of what to treat. We also observed that X-rays are many times used by health professionals as an excuse for lack of knowledge and to prescribe drugs or useless surgery.
Already years ago spinal research pioneer Nachemson once remarked, “THE GREATEST PROBLEM IN SPINE CARE IS THAT PHYSICIANS TREAT X-RAYS AND MRI SCANS RATHER THAN THE WHOLE PERSON”.
In other words, normal disc degeneration (i.e. normal spinal anatomy) has been turned by many “spine specialists” into a degenerative disc DISEASE and therefore used as a treatment indication. (If disc degeneration is a disease than you have a lot of sick people in the world.)
Now finally a new clinical guideline from the American College of Physicians published in the beginning of 2011 says that routine spinal imaging literally has no value – and should be eliminated from modern back care. They not only found strong evidence that routine imaging for low back pain by using X-Rays or NMR’s is not associated with a clinically meaningful effect on patient outcomes, but also that it often leads to a long and expensive cascade of unnecessary referrals, nonsurgical treatments, interventional pain procedures, and useless surgery. (Bauer et al.: Spine 32 oct. 2013)
Recently another large hole has been shot in finding diagnostic answers on imaging scans: The so called visual evidence of spinal stenosis on MRI, CT, do not have any consistent relationship with pain and symptoms in patients. Spinal stenosis is the most common surgical indication among people older than 65 years and just think that often this patients are routed toward surgery on the basis of imaging scans. (Burgstaller JM et al., Spine, 2017; 41(7):E1053-62.)
It is important to know that most back exercises are NOT the answer to low back pain.
This was confirmed by the new findings, published in the American Journal of Public Health, where researchers followed for 18 months 700 patients with low back pain. Those who walked and got other forms of “recreational” exercise like brisk walking or swimming had a lower risk of pain over time. In contrast, those who performed exercises specifically for their backs appeared to make matters worse.
Also sitting is not beneficial for people with low-back pain. Being sedentary delays recovery and makes the back more prone to (pain) recurrence.
Mc Beth et al. found that exercises designed to increase cardio-respiratory fitness instead of specific back exercises improved the health status of patients with chronic pain by 35% in a period of 6 months.
That is why we don’t give many exercises at Sanrocco, except brisk walking, swimming or any physical activity as long as the patient likes it and does not damage his back. Even small adjustments in daily life, such as the proper way to bend, sit and lift weights can be of great help.
In 1993 one of the most complete studies on the effectiveness and cost-effectiveness of management of low back-pain by Manga et al., funded by the Ontario Ministry of Health and therefore not manipulated by private interests, demonstrated already that:
– Many medical therapies are of questionable validity or are clearly inadequate. That has been confirmed later on by Deyo, Carette et al., Staal, Chou, Carragee, Elshaug et al. and Manchikani , whom demonstrated that many medical standard approaches, i.e. bedrest, massage, “tens” or other forms of electrotherapy, steroid injections into the articular facets and almost all surgical interventions are inefficient or are clearly inferior to chiropractic treatment.
– There is an overwhelming body of evidence indicating that spinal manipulations applied by chiropractors are safer than medical approaches and more effective than any other treatment for LBP.
Moreover in work-related nonspecific LBP the use of chiropractic services, which generally cost less than services from other providers, have a significantly lower risk of recurrent disability than when the care is provided by physical therapists, physicians or when there is no treatment at all. (Cifuentes et al.).
Astin J.A. et al., Mind-body medicine : State of the science, implications for practice ;The journal of the American Board of Family Practice, 16: 131-147, 2003.
Barsky A.L., et al., Nonspecific medication side effects and the nocebo phenomenon ; Journal of the American Medical Association, 287(5): 622-627, 2002.
Bekelman JE et al., Scope and impact of financial conflicts of interest in biomedical research: A systematic review, JAMA, 2002; 289:454-65.
Berman B., Ezzo J. Et al.; Reviewing the reviews: Intern. J. Technol. Assessment in Health Care, 17.4, 457-466, 2001.
Bishop Pb et al., The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) part I: A randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain, presented at the annual meeting of the International Society for the Study of the Lumbar Spine, Hong Kong, 2007; and the North American Spine Society, Austin, Texas. Spine 2007 ( in Press)
Blanchflower DG and Oswald AJ, Is wellbeing U-shaped over the life cycle? In press, Social Science & Medicine, 2008.
Boyle E et al., Examining VBA stroke in two Canadian provinces, Spine,; 33(4S):S170-175, 2008.
Cacioppo J. Et al., Alone in the crowd: The structure and spread of loneliness in a large social network.; 2009 ; Journ. of Personality and Social Psychology in Press.
Carragee E et al.,: Are first-time episodes of low back pain associated with new MRI findings? Presented at the annual meeting of the North American Spine Society, Seattle, 2006; (as yet unpublished).
Carragee E et al.; Does minor trauma cause serious low back pain illness?; presented at the annual meeting of the International Society for Study of the Lumbar Spine, Bergen, Norway, 2006; and The Back Letter Vol.21, No. 10, October 2006.
Carragee EJ., Validity of self-reported history in patients with acute back and neck pain after vehicle accidents; advance access, The Spine Journal, 2007.
Carragee EJ et al., treatment of neck pain: injections and surgical interventions: results of the bone and joint decade, 2000-2010 task force on neck pain and associated disorders, Spine 33 (4 Suppl): S 153-S169. , 2008.
Cassidy JD et al; Risk of vertebrobasilar stroke and chiropractic care, Spine,; 33(4S):S176-S183, 2008.
Chou R et al., Interventional therapies, surgery and interdisciplinary rehabilitation for low back pain, Spine,; 34: 1066- 1077. 2009.
De Crean A.J., et al., Placebo effect in the acute treatment of migraine : subcutaneous placebos are better than oral placebos ; Journal of Neurology 247: 183-166, 2000.
Deyo et al., How many days of bedrest for acute low back pain: a randomized clinical trial; N.Engl. J. Med., 315 : 1064-70, 1986.
Deyo R. A., Low-back pain; Scientific American, 49-53, 1998.
Deyo et al., A controlled trial of tens and exercise for chronic low back pain; N. Engl. J. Med.; 322 : 1002-7 1991.
Deyo R.A., Fads in the treatment of low back pain. N. Engl. J. Med.; 325 : 1039-40, 1991.
Deyo R.A., Gaps, tensions, and conflicts in the FDA approval process: Implications for clinical practice; Journal of the American Board of Family Practice, 17: 142-9, 2004.
Deyo R.A. and Patrick D.L.; Hope or Hype: The obsession with medical advances and the high cost of false promises. New York: Amacom; 2005.
Elshaug et al., New Engl. J. of Med.; 2009; 361(6): 557-68;569-79. New Engl. J. of Med.; 2011; 364(15: 1390- 3).
Diblasi Z., et al., Influence of context effects on health outcomes: A systematic review; Lancet, 357: 757-762, 2001.
Dionne C et al., Does low back pain prevalence really decrease with age? A systematic review, Age and Ageing, 35:229-34, 2006.
Freeman L.W. , Lawlis G.F., Mosly’s Complementary & alternative medicine: A research-based approach; Mosly St Louis, 2001.
Friedman B.W., et al., Systemic steroids ineffective for back pain; Journal of emergency Medicine, 4: 365-370, 2006.
Haldeman, S., DC, Ph. D. MD, Modern Developments in the Principles and practice of Chiropractic, 1979. Appleton-Century-Crofts/Norwalk. Connecticut.
Hogg-Johnson S et al., The burden and determinants of neck pain in the general population, Spine, 33(45).S39, 2008.
Hurwitz,E..Effects of Recreational Physical Activity and Back Exercises on Low Back Pain and Psychological Distress: American Journal of Public Health, October 2005.
Jonas W.B. , Levin J.S., Essentials of complementary and alternative medicine ; Ed. Philadelphia: Lippincott Williams & Wilkins, 1999.
Jones G. Et al., Adverse events in childhood and chronic widespread pain in adult life: results from the 1958 British Cohort study,; Pain 143; 92-96, 2009.
Kasch H. et al., Development in pain and neurologic complaints after whiplash; Neurology, 60: 743-761, 2003.
King et al.; Don’t blame disc herniations on recent trauma; The annual meeting of the International Society for the study of the lumbar spine, Bergen, Norway, 2006, Backletter, Vol.21, No 10, 120, 2006.
Kirkaldy-Willis W.H., Orthopaedics and chiropractic: a close relationship; Journal of the Canadian Chiropractic Association; 48(2): 113-116, 2004.
Lexchin J., et al., Pharmaceutical industry sponsorship and research outcome and quality: systematic review; BMJ, 326: 1167-1170, 2003.
Lexchin J., Light D.W., Commercial influence and the content of medical journals; BMJ., 332: 1444-1447, 2006..
Manga P. Et al., The Ontario Ministry of health, Ottawa, Ontario, Canada, August 1993: Executive summary, Dynamic Chiropractic vol. 11 ; no. 22 Oct. 1993.
Manchikanti L. et al., Explosive growth in facet joint interventions in the Medicare population in the US: a comparative evaluation of 1997, 2002, and 2006 data, BMC Health Services Research, 2010.
Messias E. Et al., Bearing grudges and physical health. Soc. Psychiat. Epidemol.: 45, 2, Feb.2010.
Morter, M.T., DC., Your Health Your Choice, 1990, Fell Publishers. Inc., Hollywood, Florida, USA.
Moynihan R., Cassels A., Selling sickness: How the worlds biggest pharmaceutical companies are
turning us all into patients; Nation books, New York, 2005.
Nachemson A., Newest knowledge of low back pain. Clin. Ortho and related research. 297: 9-21, 1992.
Pick M.G., The subluxation complex and its potential effect on the central integrated state of the nervous system; A.I.C., Milan, Nov. 12-13, 2004.
Garjajev Pjotr et al., Scientist prove DNA can be reprogrammed by words and frequencies. http.//wakeup-world.com/2011/07/12.
Rief W., et al., Medication-attributed adverse effects in placebo groups: Implications for assessment of adverse effects; Archives of Internal Medicine 166(2): 155-160, 2006.
Rubenstein SM et al., A systematic review of risk factors for cervical artery dissection, Stroke;; 36:1575, 2005.
Schoene ML et al.; Does minor trauma trigger serious low back pain? Is the injury model valid?; Backletter, 11: 121,131, 2005.
Seru, P.P., D.C., Guida Alla Chiropratica, De Vecchi Editore, Milano, 1993, II° Ediz.
Seru, P.P., D.C., A practical approach for patient care, ,Asociaciòn Espaňola de quiropràctica, 27-28 May : 2000 Madrid, Spain. Privately published.
Seru, P.P., D.C., A practical approach for patient care, protocol for the first visit, 6,7-8 June 2008 and 18, 19 – 20 Feb. 2010 : Ivry-sur–Seine. Paris, France Privately published.
Staal JB et al., Injection therapy for sub acute and chronic low back pain: an updated Cochrane review, Spine, , 34:49-59, 2009.
Turtle M.J. ,M.D.: Huge gap in medical knowledge about back pain; Backletter, Vol.21, No 9, Sept.: 108, 2006. and BMJ, 332: 1430-4, 2006.
Walther, D.S., DC., Applied Kinesiology – head, neck and jaw pain and dysfunction – the stomatognatic system, Vol. II, System D.C., Pueblo, Colorado, U.S.A., 1983, pp. 260-268