According to JAMA, the proportion of patients who left their doctors’ appointments with orders for MRIs increased from 7.2 percent in 1999 to 11.3 percent in 2010. As a result, the percentage of patients who were referred for back surgery or other interventions more than doubled, rising from 6.9 percent to 14 percent in the same period.
However, in 2014 researchers at the Mayo Clinic found that disc degeneration was normal at all ages. It was present in more than a third of asymptomatic twenty-year-old subjects and in 96 percent of eighty-year-old subjects. “Black” discs, often employed as one of the indications for a diagnosis of degenerative disc disease, were found in more than half of normal subjects over forty and in nearly 90 percent of those over sixty. Bone spurs were common in pain-free subjects as well. Mayo Clinic scientists concluded that such changes were not “part of a pathologic process requiring intervention.”
Yet MRI orders were still creeping upward in 2015. A significant number of practitioners acknowledged that they ordered all those scans defensively, attempting to avoid malpractice liability.
In a 2015 review of the medical literature, the Agency for Healthcare Research and Quality found no evidence that epidural steroid injections were effective in treating symptoms of spinal stenosis or typical low-back pain. Even in the presence of a recent disc herniation and ensuing sciatica, the benefits of injections were small and not sustained over time. That news followed on the heels of an FDA statement warning that injection of the active medication in these shots, glucocorticoids—a class of corticosteroids—into the epidural space of the spine could result in rare but serious neurological problems, including loss of vision, stroke, paralysis, and death. Based on those and other findings, the Journal of the American Medical Association (JAMA) advised physicians to refrain from recommending injection therapy to patients with any kind of chronic back pain.
There are several healthcare providers who perform spinal manipulation, including Doctors of Osteopathic Medicine (DOs), Physical Therapists, and Chiropractors.
In Trick or Treatment, a must-read book about fallacies in alternative medicine, science reporter Simon Singh and his coauthor, scientist Edward Ernst, describe an experiment conducted by psychiatrist Stephen Barrett, one of the most fervent naysayers regarding chiropractic. To see what they might advise, Barrett arranged for a twenty-nine-year-old woman to make four visits to different chiropractors. The first chiropractor “diagnosed ‘atlas subluxation’ [an improperly situated vertebra at the top of the spine] and predicted ‘paralysis in 15 years’ if the problem was not treated. The second practitioner found not just one but many vertebrae ‘out of alignment’ and one hip ‘higher’ than the other. The third said that the woman’s neck was ‘tight.’ The fourth said that misaligned vertebrae indicated the presence of ‘stomach problems.’” Despite the disparity in diagnoses, all four recommended long-term regular adjustments.
Recent Research in the form of Systematic Reviews indicates that spinal manipulation is effective when performed within the first 15 days of acute onset back pain without any pain, numbness, or tingling traveling down the leg. This same study indicated that, on average, 8 treatments were effective, but any more treatments after 8 were not effective. If you have had back pain longer than 15 days and/or you have pain traveling down your leg, spinal adjustments probably won’t be effective for you.
Spine surgeons, who are typically trained as orthopedic surgeons or neurosurgeons, do essential things. They repair traumatic injuries. They excise spinal tumors. They fix congenital abnormalities. But, except for top-tier physicians who usually work at academic medical centers, such procedures are not their main-stay. About 60 percent of patients who walk into a spine surgeon’s clinic have back pain that will be diagnosed as “ordinary,” “axial,” “mechanical,” “degenerative,” “functional,” or “nonspecific.” Those terms describe flattened discs, black discs, bulging discs, herniated discs (described as “prolapsed discs” in the United Kingdom), and the bony outgrowths known as osteophytes. Too often, surgeons point to these commonplace artifacts on an MRI and diagnose “degenerative disc disease,” recommending lumbar spinal fusion surgery as the best option.
But there’s a problem with this very common procedure in which the intervertebral disc is excised and adjacent vertebrae are connected with cages, screws, plates, rods, and other medical devices. Studies show that lumbar fusion succeeds in barely 40 percent of patients. In this context, the word “success” does not mean much. In one study, two years after spinal fusion, in “successful” procedures, pain had barely been reduced by half, and most patients continued to use painkillers. In another study, two years after surgery, about one third of the patients reported that their pain was as bad as it had been before they’d had the operation, and 14 percent believed that they were in worse shape after spinal fusion than before the surgery.
Most primary care providers have little or no training in musculoskeletal (back pain) management beyond prescribing medications to treat symptoms, ordering expensive and too often unnecessary tests, and referring to orthopedic surgeons when only 10 percent of the exams are surgical. The problem is compounding by a projected shortage of 20,000-30,000 primary care physicians by 2025. Ineffective treatment is the standard of care nationally for musculoskeletal disorders, and related opioid addiction is an emergent crisis.
Studies indicate that, by seeing a Physical Therapist to initiate care for any musculoskeletal disorder, you will save on average 50 percent of the money that you would normally spend on expensive images, medications, injections, and surgeries.
The bottom line is that seeing a physical therapist when it hurts to move will get you in the hands of an expert who can offer you a natural solution to your pain and save you a ton of money at the same time.
The back pain experts at Superior Physical Therapy have an intimate understanding of how the entire body is connected and know that you must look above and below the painful back in order to find a solution. Call one today at 231.944.6541 or sign-up to attend a Free Back Pain Workshop! SIGN UP
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