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October 2006, Vol. 16, No. 4
Table of Contents
Do 90% of Acute Low Back Pain Episodes Resolve Within Two Months Regardless of Treatment Rendered? • Blues Already Using CCGPP to Cut Claims! • CBP® Annual Awards • Chiropractic, Disease, Adjustments and Other Voodoo! • Effective Initial Exam • It's Don's Opinion • Letters to the Editor • Neurosurgeon Heralds Posture Pump® MRI Study • New PCCRP X-ray Guidelines Will Protect Your Rights • Association of NJ Chiropractors OPEN LETTER to the CCGPP • PosturePrint® Head Manuscript Accepted by JMPT • Research Corner • The Benefits of Short Duration Whole Body Vibration • Triano and CCGPPs Will Give You Six Visits Part II • PostureRay™: Digital X-ray Digitization and Analysis has Finally Arrived
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Soft Tissue Research
Do 90% of Patients with an Acute Episode of Low Back Pain Resolve Within Two Months, Regardless of the Treatment (If Any) Rendered?
by Daniel J. Murphy, DC, FACO
Vice President of ICA
Dan Murphy graduated magna cum laude from Western States Chiropractic College in 1978, and has more than 20 years of practice experience. 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.
Dr. Murphy is on the post-graduate faculty of several chiropractic colleges. His post-graduate continuing education classes include “Whiplash and Spinal Trauma” and “Pain Neurology.” Dr. Murphy is the coordinator of a year-long certification program in “Chiropractic Spinal Trauma,” now (2000) in its twelfth year of being offered. This year, the program is being offered through the International Chiropractors Association of California. He has taught more than 700 post-graduate continuing education seminars.
Dr. Murphy is a contributing author to the book Motor Vehicle Collision Injuries, published by Aspen, 1996; and to the book Pediatric Chiropractic, published by Williams & Wilkins, 1998. He writes a quarterly column in the Journal of Clinical Chiropractic.
In 1987, 1991 and 1995 Dr. Murphy received the Post-graduate Educator of the Year award, given by the International Chiropractic Association. In 1997, he received The Carl S. Cleveland, Jr., Educator of the Year award, given by the International Chiropractic Association of California.
I began full-time chiropractic clinical practice in 1978. That same year, I purchased and read the new book Clinical Biomechanics of the Spine. The second edition of Clinical Biomechanics of the Spine was published in 1990. The authors are:
Clinical Biomechanics of the Spine
Augustus A. White, MD, DMed Sci
Professor of Orthopedic Surgery at Harvard Medical School
Orthopedic Surgeon-in-Chief at Beth Israel Hospital in Boston
Manohar M. Panjabi, PhD
Professor of Orthopedics and Rehabilitation and Mechanical Engineering
Director of Biomechanics Research
Yale University School of Medicine
J.B. Lippincott Company
1990
This text is quite authoritative, perhaps the most authoritative text on spinal clinical biomechanics. Importantly, a comment made on page 424 of this text is often used against our patients with an acute episode of low back pain; this comment is often used by insurance companies or their representatives:
“There are few diseases [low back pain] in which one is assured improvement of 70% of the patients three weeks and 90% of the patients in two months, regardless of the type of treatment employed.”
Therefore, “it is possible to build an argument for withholding treatment.”
FIRST IMPORTANT QUESTION:
from where is this statement, (printed in a most authoritative reference text), derived? White and Panjabi give a single reference:
Alf Nachemson, MD
The Lumbar Spine,
An Orthopedic Challenge
SPINE
Volume 1, Number 1
March 1976
Pages 59-71
Concerning this reference by Nachemson, White and Panjabi state:
“An outstanding, well-written review of all aspects of the state of knowledge in 1976.”
The exact quote from Nachemson, in SPINE, 1976, is:
“Irrespective of treatment given, 70% of [back pain] patients get well within three weeks, 90% within two months.”
This 1976 quote by Nachemson is essentially identical in percentages, time, concept and language as used by White and Panjabi in 1990. This concept regarding the natural history of an episode of back pain is being expressed by the best individuals (Nachemson in SPINE, White & Panjabi in Clinical Biomechanics of the Spine) in the best of publications.
SECOND IMPORTANT QUESTION:
from where is this statement, (printed in SPINE), derived? Nachemson gives two references:
FIRST REFERENCE:
A St. J Dixon
Progress and Problems
in Back Pain Research
Rheumatology and Rehabilitation
Volume 12, Number 4
November 1973
Pages 165-175
I have obtained this reference by Dixon. This Dixon reference is not a study of any sort. Rather it is
“From a paper read at the Annual Meeting of the British Association for Rheumatology and Rehabilitation, London, March 1973.” (p. 165)
The first two sentences of the article are:
“It is a great honor to be invited to talk to my own Medical School, but I am not noted for my contribution to back pain research nor for my startling observations into the biochemistry of the human intervertebral disc. My only contribution has been to show that patients with non-specific back pain more often do better in a rabbit-wool body belt than in a rigid spinal corset which they are more frequently prescribed.”
(p. 165)
The bulk of this article pertains to current and future directions for back pain research. The end of the article transcribes an informal question and answer session between the author and the audience. Dixon’s discussion includes comments such as: “Discs contain no pain nerve endings, so cannot hurt.” (p. 170) Obviously, much has changed since Dixon delivered this speech in 1973, as it is now firmly established that the disc is innervated1, 2 and is a very common (if not the most common) producer of chronic low back pain.3, 4, 5, 6, 7
It is quite clear, from Dixon’s own opening admission, he is not an expert on back pain, nor is he a back pain researcher.
Dixon does reference the following statistics:
“Of those who seek advice [for back pain] from their family doctors, 44% are better in one week irrespective of treatment and 86% are better in one month. Only 14% drag on longer than this. It takes little imagination to see that any treatment for acute back pain will have a high proportion of rapid successes. Manipulation, whether by osteopaths, chiropractors, registered medical practitioners, or physiotherapists, has to be judged against this background.”
Note the following table:
Note what we have so far:
Two very authoritative authors (White & Panbjabi, Nachemson) in two very authoritative publications (Clinical Biomechanics of the Spine, SPINE, respectively), often utilized by insurance companies and their representatives to reduce or deny the treatment of patients with back pain, is based upon a lecture given by an individual (Dixon) who self admits is no authority or researcher in spinal problems or back pain. And, astonishingly, Nachemson references Dixon quite poorly.
Dixon states that 44% of the patients are “better” in 1 week, while Nachemson states that 70% of the patients are “well” within three weeks. Not only are the numbers and time frames substantially different, the word “better” used by Dixon can imply any degree of improvement, while the word “well” used by Nachemson implies that the issue has completely resolved. In addition, the 86% number used by Dixon in one month became 90% within two months by Nachemson. Obviously, the editors of SPINE in 1976 did not check or read the Dixon reference quoted by Nachemson, nor did White & Panjabi when they referenced Nachemson and quoted his error exactly.
Also, I believe that it is relevant to know that the journal used by Dixon, Rheumatology and Rehabilitation, Volume 12, Number 4, 1973, is not indexed by PubMed as of the time that I am writing this article. PubMed searches the indexed articles in the National Library of Medicine. Therefore, this often quoted article by Dixon cannot easily be found by doing a PubMed data base search, by using either the journal (Rheumatology and Rehabilitation) or the author (Dixon). Because this article is difficult to find, and because those who reference it do so badly, it appears that few who reference Dixon are actually reading his article. It appears more likely that an individual (Nachemson) read the article by Dixon, misquoted Dixon, published the error, and others are reading the error and repeating it. Additionally, the Nachemson article is in the very first issue of SPINE, Volume 1, Number 1, March 1976. As of this writing, in 1976, SPINE was also not indexed in PubMed, and one cannot find this article by Nachemson by searching PubMed using either the journal (SPINE) nor the author (Nachemson). SPINE was not indexed by PubMed until two years later, beginning in March of 1978.
As noted above, Nachemson used two references, using a reference other than Dixon:
SECOND REFERENCE:
Penntti M. Rissanen
The Surgical Anatomy and Pathology of the Supraspinous and Interspinous Ligaments of the Lumbar Spine With Special Reference to
Ligament Ruputres
ACTA ORTHOPAEDICA
SCANDINAVICA
Supplement Number 46
1960
Pages 1-100
This second reference by Nachemson is 100 pages long. As the title suggests, this article does not appear to be related to the topic of the natural history of back pain, and I can assure you, it is not. I have read the entire article, and astonishingly, no place in the article is there any discussion of the natural history of back pain. There are no numbers related to the percentages and time frame for back pain improvement, becoming better, or becoming well. This article is a study of 306 cadavers evaluating ligament histology, fatty degeneration as a function of age, and incidence of adult rupture of the interspinous ligaments. This revelation should be quite an embarrassment to Dr. Nachemson, Dr. White, Dr. Panjabi, the editors of SPINE, the publisher of Clinical Biomechanics of the Spine (Lippincott), and by anyone else who quotes them.
Considering this information, in discussing the natural history of low back pain, it would be inappropriate to reference White & Panjabi in Clinical Biomechanics of the Spine, Nachemson in SPINE 1976, or Dixon in Rheumatology and Rehabilitation 1973. The above shows that the natural history of low back pain statistics used in these references are erroneous, quoting of a non-existent study from a non-expert on the topic that was published in a non-PubMed indexed journal. Yet, sadly, Dixon in particular, continues to be referenced on the topic of the natural history of low back pain. As an example, the 2006 draft copy of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) states:
“As much as 90% of cases [of low back pain] have been estimated to resolve without intervention (Dixon).” Pg. 14
“Even more, Dixon demonstrated that perhaps as much as 90% of low back pain will resolve on its own, without any intervention whatsoever.” Pg. 72
In both sections of the CCGPP draft document (pages 14 and 72), the authors are clearly not endorsing their referenced statistic from Dixon and they present rebuttal references. However, I believe that the above information shows that Dixon should never be cited as being authoritative on the topic of the natural history of low back pain. It appears clear that the authors of the CCGPP draft document did not actually read the Dixon article that they are referencing.
Although Dixon is the most often end reference of the natural history of back pain, a review of Dixon’s article finds that Dixon actually quotes another:
J Fry
Advisory Services Colloquia
“Back Pain and Soft Tissue
Rheumatism”
Advisory Services
(Clinical & General) Ltd., London
Number 1
1972
Page 8
A COLLOQUIUM is “a gathering of scholars to discuss a given topic over a period of a few hours to a few days.” Thirteen individuals took part in this colloquium. Dr. J Fry, MD, is listed as a general practitioner from London. Dr. Fry’s published contribution to this colloquium includes:
In an average [general practitioner] practice each year 125 patients could be expected for soft tissue rheumatism or acute back pain.
“Of these 125 patients, 50 would be likely to be suffering from acute back pain and 25 from acute neck pain.”
“44% of the patients with acute low back pain lost their symptoms in less than one week and 82% in less than 4 weeks.”
Dr. Fry makes it clear that these numbers are from a retrospective review of his general practitioner practice of acute low back pain patients. There is no information presented on how Dr. Fry evaluated his patients or even on how many patients he used to establish these statistics. Consequently, these statistics by Dr. Fry are meaningless and should never be referenced as being authoritative of the natural history of low back pain. Interestingly, the same short section by Dr. Fry in this colloquium states:
“It was agreed that it was the patients whose symptoms did not rapidly clear up who often formed part of the osteopath’s clientele.”
My interpretation of this comment, consistent with my extensive clinical experience, is that osteopaths (and chiropractors) are more likely to treat patients who are chronic, not acute; patients who did not respond to symptomatic general practitioner medical management; patients who are the most difficult to manage and resolve.
Lastly, another group of researchers, led by professor Peter Croft, have evaluated the statistics on the natural history of low back pain that they attribute to Dixon, and they show Dixon’s statistics to be false. Once again, because they also misquote Dixon, it is clear that the Croft group did not actually read the Dixon article. The Croft group study is reviewed below:
Outcome of low back pain in general practice: a prospective study
British Medical Journal
May 2, 1998
Vol. 316, pp. 1356-1359
Peter R Croft, Gary J Macfarlane, Ann C Papageorgiou, Elaine Thomas, Alan J Silman
KEY MESSAGES FROM AUTHORS:
1) It is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month.
2) While 90% of subjects consulting general practice with low back pain ceased to consult about the symptoms within three months, most still had substantial low back pain and related disability.
3) Only 25% of the patients who consulted about low back pain had fully recovered 12 months later.
KEY POINTS FROM DAN MURPHY:
1) This prospective study of 463 patients with an acute episode of low back pain agrees with numerous other studies that indicate that approximately 90% of such patients will stop consulting their doctor about their back within three months. In this study, the number was actually 92%.
2) However, this study is adamant that NOT seeing a doctor for a back problem does NOT mean that the back problem has resolved. This study showed that 75% of the patients with a new episode of low back pain have continued pain and disability a year later, even though most are not continuing to go to the doctor.
3) The belief that “90% of episodes of low back pain seen in general practice resolve within one month” is false, and based primarily upon one flawed study published in 1973 by Dixon. [Again, importantly, as noted above, Dixon is NOT a study, and should never be referred to as such.]
4) It is generally believed that most low back pain episodes will be “short lived and that ‘80-90% of attacks of low back pain recover in about six weeks, irrespective of the administration or type of treatment.’” This belief is untrue, false.
5) Many patients seeing their general practitioner for the first time in an episode of back pain will still have pain or disability 12 months later but not be consulting their doctor about it. [Very Important]
6) Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences.
7) 90% of episodes of low back pain DO NOT end in complete recovery within a few months.
Important quotes from this article include:
“It is generally believed that most of these episodes [of low back pain] will be short lived and that ‘80-90% of attacks of low back pain recover in about six weeks, irrespective of the administration or type of treatment.’”
These authors “investigated the claim that 90% of episodes [of low back pain] resolve within a month.”
“By three months after the [initial] consultation with their general practitioner, only a minority of patients with low back pain had recovered.”
“There was little increase in the proportion who reported recovery by 12 months, emphasizing the recurrent and persistent nature of this [low back pain] problem.”
“The findings of our interview study are in sharp contrast to the frequently repeated assumption that 90% of episodes of low back pain seen in primary care will have resolved within a month.”
“However, the results of our consultation figures are consistent with the interpretation that 90% of patients presenting in primary care with an episode of low back pain will have stopped consulting about this problem within three months of their initial visit. The original article to which the statement of ‘90% recovery’ can be traced drew on a record review in one general practice.” [Dixon AStJ. Progress and problems in back pain research. Rheumatol Rehabil 1973; 12(4): 165-175.]
“The inference that the patients have completely recovered [because they have stopped going to the doctor] is clearly not supported by our data.”
“We should stop characterising low back pain in terms of a multiplicity of acute problems, most of which get better, and a small number of chronic long term problems. Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences. This takes account of two consistent observations about low back pain: firstly, a previous episode of low back pain is the strongest risk factor for a new episode, and, secondly, by the age of 30 years almost half the population will have experienced a substantive episode of low back pain. These figures simply do not fit with claims that 90% of episodes of low back pain end in complete recovery.”
My conclusion is that it is time for all credible publications to stop referencing White and Panjabi in Clinical Biomechanics of the Spine 1990, Nachemson in Spine 1976, and Dixon in Rheumatology and Rehabilitation 1973, as to the natural history of low back pain. The 90% “recovery” rate as the natural history of low back pain in these references is erroneous and the byproduct of misquoting of a non-existent study from a non-expert on the topic that was published in a non-PubMed indexed journal. In addition, the 90% recovery myth has subsequently been proven to be false.
ACKNOWLEDGEMENTS
Retrieving the references used in this article would not have been possible without the help of Michelle Schaer, DC (private practice, Mesa, AZ) and Barbara DelliGatti (reference librarian, Life Chiropractic College-West).
REFERENCES
1) Bogduk N, Tynan W, Wilson AS. The nerve supply to the human lumbar intervertebral discs. J Anat. 1981 Jan;132(Pt 1):39-56.
2) Bogduk N. The innervation of the lumbar spine. Spine. 1983 Apr;8(3):286-93.
3) Kuslich SD, Ulstrom CL, Michael CJ. Orthop Clin North Am. 1991 Apr;22(2):181-7.
The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia.
4) Freemont AJ, Peacock TE, Goupille P, Hoyland JA, O’Brien J, Jayson MI. Nerve ingrowth into diseased intervertebral disc in chronic back pain. Lancet. 1997 Jul 19;350(9072):178-81.
5) Coppes MH, Marani E, Thomeer RT, Groen GJ. Innervation of “painful” lumbar discs. Spine. 1997 Oct 15;22(20):2342-9.
6) Freemont AJ, Watkins A, Le Maitre C, Baird P, Jeziorska M, Knight MT, Ross ER, O’Brien JP, Hoyland JA. Nerve growth factor expression and innervation of the painful intervertebral disc. J Pathol. 2002 Jul;197(3):286-92.
7) Peng B, Wu W, Hou S, Li P, Zhang C, Yang Y. The pathogenesis of discogenic low back pain. J Bone Joint Surg Br. Jan;87(1):62-7.
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