MD Primary Care for LBP: End of the Road?

It's hard to say whether the amount of ink that has been spilled in this space measures up to the blood that has been spilled by unnecessary surgeries¹ and other sequelae of the primary care in orthodox medicine that have fallen woefully short of resolving low back pain issues. (Problematic safety² and expense³ issues have been amply dealt with elsewhere.) And the mantra that "most issues of low back pain resolve spontaneously" has been shattered by the reports that onsets of pain in chronic low back pain recur again and again over an extended period of time.^4-5

The misappropriated belief that back pain "just goes away" may actually due to the fact that patients, rather than the pain, have left the building. In other words, back pain sufferers have just not gone back to their primary care physicians for further help, sensing that the latter have nothing further to offer.

A little over a year ago, a scathing report card on primary care research on low back pain emerged from the 2011 International Forum on Primary Care Research on Low Back Pain.⁶ The report opens with the finding from the forum the year prior that evidence-based guidelines and systematic reviews, while plentiful, have in fact had little impact upon actual primary care practices.⁷ Despite a copious amount of research, the actual situation has deteriorated:

• A population-based study from North Carolina demonstrated a fivefold increase in the prevalence of chronic, disabling low back pain over a 15-year period, as well as increases in associated medical care.
• There is a growing recognition that low back pain is often intermittent, varying in its presentation and severity, and persisting in many primary care patients.6
• Risk factors include an adverse working place, pain and being "distressed," overwhelmed by pain and functional limitations.
• High-dose opioids are often prescribed, in contrast to recommendations of most guidelines for only short-term use.

From the 2011 forum emerged a number of recommendations for improving outcomes, including the following:

• Nonspecific (placebo) treatment effects may be of some value.⁸
• A low-back-pain visit should focus on improving function, rather than eliminating pain. This entails shifting the locus of control from medical and rehabilitation providers to patients and their employers, recognizing consumer choice, demedicalization, and the rapid return to work.6 It also finds that coping and adaptation rather than medical treatments are more successful in achieving key employment outcomes.⁹
• Health care needs to recognize the genesis and impact of patient expectations on treatment outcomes.
• Qualitative and mixed-method studies that focus upon patients' perspectives, preferences and priorities need to be encouraged, as well as longitudinal and cross-sectional studies.
• Randomized, controlled trials conducted in rarefied settings with highly selected patients may not be generalizable and are especially problematic for workplace interventions for low back pain. (This particular problem has been discussed in depth elsewhere.)¹⁰
• Future studies should include specific preintervention strategies, including communication, discussion, or more formal cognitive approaches.

Add to this the horrifying recent Case of the Tainted Steroid Spinal Injections, the news story first having broken as an outbreak of spinal meningitis in October 2012 and in late December, having been supplemented as a further infestation of black mold in patients given steroids via injection to alleviate spinal pain. With this modality routinely used as a medical option in the management of spinal pain, we have now had to face at least 39 deaths and 555 cases of back infection and/or meningitis, excruciating pain and abscesses caused by the contamination of steroid preparations prepared by the New England Compounding Center and distributed across a multiplicity of states. On top of this comes the report that in one hospital, the use of amphotericin to treat such infections has led to kidney damage in several patients. To sum up, In the words of the ironically named John Perfect of Duke University, the medical profession is "flying by the seat" of its pants.¹²

The situation could almost be called farcical if it weren't so tragic. Is this the optimal, evidence-based health care that has been virtually mandated by the mainstream medical establishment? Oh, please. The answer is clearly in the negative. There has to be a clear alternative, and that would be chiropractic.

With all that chiropractors have to offer low back pain patients, and for which they are most clearly recognized, there is a huge cognitive dissonance. Specifically, one of the latest estimates of chiropractic use in the U.S. adult population from the compelling Medical Expenditure Panel Survey puts the prevalence of use in 2008 at a numbing 5.2 percent,¹² a significant drop from the 10-11 percent estimates provided in the mid 1990s^13-14 when it was both thought and hoped that the percentages of chiropractic users would continue to increase. This disturbing turn of events clearly indicates that 95 percent of the population did not avail themselves of chiropractic services in 2008, and it is unclear whether that level of usage has changed significantly since then.

Clearly, a change in collective thinking is needed here. A cultural revolution that in many ways could be argued to resemble how smoking – once fashionable and considered an alluring trademark of almost every movie star – has now been recognized as a major health risk even to the extent of secondhand smoke. Accordingly, we've witnessed its being banned from a large percentage of public establishments nationwide.

With exercise and workout rooms becoming freely available nationwide, it should not be too much of a stretch to imagine that the cost-effective and safe, selective and even preventive back care alternative provided by chiropractors should likewise become more apparent and approachable by the American public. The challenge upon us is to point out in bolder detail what the consequences will be for at least musculoskeletal issues if the conventional primary care route, as Robert Frost once put it, becomes the road not taken.

References

1. Leape LL. Unnecessary surgery. Annual Review of Public Health, 1992;13:363-383.
2. Rome PL. Perspectives: An overview of comparative considerations of cerebrovascular accidents. Chiropractic Journal of Australia, 1999;29(3):87-102.
3. Rosner A. "Worker's Comp Costs Call for Chiropractic." Dynamic Chiropractic July 29, 2012.
4. Croft PR, Lewis M, Papageorgious AC, Thomas E, Jayson MIV, Macfarlane GJ, Silman AJ. Risk factors for neck pain: a longitudinal study in the general population. Pain, 2001;93:317-325.
5. Hestbaek L, Leboeuf-Yde C, Engberg M, Lauritzen T, Bruun NH, Manniche C. The course of low back pain in a general population: results from a 5-year prospective study. Journal of Manipulative and Physiological Therapeutics, 2003;26(4):213-219.
6. Pransky G, Borkan JM, Young AE, Cherkin DC. Are we making progress? The Tenth International Forum for Primary Care Research on Low Back Pain. Spine, 2011;36(19):1608-1614.
7. Cherkin D, Kovacs FM, Croft P, et al. The Ninth International Forum for Primary Care Research on Low Back Pain: International Organizing Committee of the Ninth International Forum for Primary Care Research on Low Back Pain and all the participants. Spine, 2009;34:304-307.
8. Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Archives of Internal Medicine, 2009;169:858-866.
9. Lamb SE, Lall R, Hansen Z et al, Back Skills Training Trial [BeST]: Design considerations in a clinical trial of a cognitive behavioural intervention for the management of low back pain in primary care: Back Skills Training Trial. BMC Musculoskeletal Disorders, 2007;8:14.
10. Rosner A. Evidence-based medicine: revisiting the pyramid or priorities. Journal of Bodywork and Movement Therapies 2012;16(1):42-29.
11. Kowalczyk L. "Tainted Steroids Found to Cause Spinal Infections." Boston Globe, Dec. 21, 2012.
12. Zodet MW, Stevans JM. The 2008 prevalence of chiropractic use in the U.S. adult population. Journal of Manipulative and Physiological Therapeutics, 2012;35(8):580-586.
13. Eisenberg DM, Kessler RC, Foster C, Norbeck FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States: prevalence, costs, and patterns of use. New England Journal of Medicine, 1993;328:246-252.
14. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wiley S, Van RM, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. Journal of the American Medical Association, 1998;280:1569-1575.