Contemporary Perspective on Back Pain
At this juncture, I suspect I am "preaching to the
choir" because if you have accessed this information,
it is most likely due to a personal experience with back
pain or knowing someone close to you who can't be faking
that much discomfort so convincingly and consistently. Therefore,
you probably know enough to understand that very little
help can be expected from the current medical practices
widely available to the back pain sufferer.
After all, if you were largely satisfied with how you were
treated, you wouldn't have felt the need to acquire this
information in the first place.
Not only myself, but other physicians categorize
the current state of affairs as nothing less than "monstrous
ignorance." Dr. Paul Altrocchi, a neurologist in private
practice told the Washington Academy of Family Physicians
in 1987:
"In any group of people, we may find
that 80% have had back pain at one time or another...yet
few fields in medicine abound with such a monstrous amount
of ignorance and lack of understanding." The belief
that the condition is a surgical disease is at the core
of the myths surrounding back pain. This idea has come about
because primary care physicians have for years, abdicated
responsibility for these patients to others, he charged.
"Back pain does not titillate our diagnostic minds,
and it gives us complaining patients whose exams don't lead
to a wonderful sense of exhilaration.(17)
It's odd how back pain has
gotten the "short shrift" in terms of the devotion
of effort on behalf of the medical profession to analyze
it to the degree necessary to properly manage it. I am constantly
frustrated by how much pseudo-science is applied to the
making of inaccurate diagnoses and prescriptions for illogical
therapy. This is not solely my criticism but emanates from
numerous other sources capable of publishing their objectivity.
For instance, the medical journal, Emergency Medicine, anonymously
reveals an attempt to rationalize a decision to abandon
the time-honored requirement demanding that the physician
make an accurate diagnosis before initiating treatment.
The article, "BACK PAIN, Is
a Definitive Diagnosis Necessary?" begins:
"Vague associations between symptoms,
pathologic changes and the results of history-taking leave
primary care physicians no choice but to send patients with
lower back pain home with no specific diagnosis. Many attempt
to plug the clinical gaps with a progression of imaging
studies. That route, however, is costly and sometimes misleading.
But is an exact diagnosis really necessary in all cases
of lower back pain? A Seattle physician thinks not. He believes
that the goals of the history and physical examination should
be somewhat less ambitious, aimed more toward the identification
of more serious problems and the practical disposition (emphasis
mine) of the patient."
"The essential issues can be approached
with the history and physical examination alone," says
Dr. Richard A Deyo, professor in the departments of medicine
and health services at the University of Washington School
of Medicine. "Only a minority of patients require further
diagnostic testing.(18)"
Sounds more like pragmatic disposal of patients
to me. My wager is that the author has never suffered from
a bad back, or he would be less likely to advocate diagnostic
ignorance in order to search for a potential means to "dispose"
of those who do.
Antithetically, the sagacious William Osler,
M.D., in 1902, presciently answered this attitude by stating:
"In the fight which we have to wage incessantly
against ignorance and quackery among the masses and follies
of all sorts among the classes, diagnosis, not drugging,
is our chief weapon of offense. Lack of systematic personal
training in the methods of recognition of disease leads
to the misapplication of remedies, to long courses of treatment
when treatment is useless, and so directly to that lack
of confidence in our methods which is apt to place us in
the eyes of the public on a level with empirics and quacks."
Whether originating from frustration, incompetence,
or a desire to reduce medical expenditures, a willingness
to abandon the necessity for a diagnosis reveals better
than any other the current decision by medical intelligentsia
to deviate from previous, held to be inviolate, standards.
By way of comparison, if a patient with swollen ankles and
shortness of breath asked a doctor precisely what was happening
on a pathophysiological level, the doctor would, most likely,
insist upon a battery of tests to make the diagnosis and
justify its necessity with elaborate explanations involving
sodium retention, serum renin levels, pulmonary wedge pressures,
etc.; but just ask the doctor why, when you simply wake
up in the morning, with no apparent trauma you have immobilizing
neck stiffness or stabbing back pain, he
will more than likely not give you a direct, competent,
or anatomically sensible answer because it is as much a
mystery to him as it is to you. The reality is that medical
science has not really directed the equivalent amount of
scrutiny to the back pain problem as has been devoted to
other human diseases. When physicians attempt to educate
patients as to the nature and means to a resolution of back
pain in the absence of a diagnosis, they seemingly must
be indulging in self-serving obfuscation apparently more
illusional than realistically helpful.
An interesting study was recently done in
which researchers educated physicians as to the state-of-the-art
of back pain management; then, by telephone interviews of
the patients these physicians subsequently treated, the
researchers attempted to determine the success these physicians
had in satisfying their patients desire to have their back
pain "fixed." The results were devastatingly dismal.
The education program did not measurably affect outcome
among any of the patients, including that subset of patients
whose physicians had perceived themselves to have had the
greatest benefit from the educational intervention!(19),(20)
I think this 1991 study, more than any other,
exposes the failure of current medical management for low
back pain. It would be comical if it were not underwritten
in so much agony. Here, we are relying upon the most up-to-date
minds in back pain management, educating society's supposedly
best and brightest, only to learn that, despite 62% of the
providers believing that they had "acquired increased
confidence" that they could help patients and 50% believing
that they had "learned more" about the scientific
and psychosocial aspects of back pain management, as well
as 50% "feeling more comfortable" treating patients
with low back pain, none of the patients got any better
than they would have otherwise. One has to just shake one's
head and ask: "What is wrong with this picture?"
It's almost reminiscent of the finest and best-educated
doctors in the 18th Century priding themselves upon having
attended educational seminars on purging and bleeding and
believing themselves to have arrived at the definitive state-of-the-art.
To be fair, there are other factors contributing
to this complicated equation. There is also a great deal
of physician trepidation in tampering with the spinal column
in these days of litigation. If a doctor were to stray too
far from the standard therapies and a paralysis were to
occur, the next person he might be talking to would be that
patient's lawyer. Leaving well-enough alone and adopting
a policy of "Less is More" (which is how the back
pain gurus have interpreted and applied the overall message
of the government's guidelines discussed below) doesn't
appear so likely to result in nerve damage or paralysis
for which an intervening physician can theoretically or
legally be found culpable. No intervention, in that regard,
is superior to one that might end the doctor in court when
the outcome appears to be the same regardless of what any
physician chooses to do. This philosophy updates the age-old
physician's precept, "first do no harm," to the
more contemporary, "don't do anything outside of the
guidelines and you won't get sued." This attitude appears
to be well-received by doctors and insurance companies;
unfortunately, it leaves patients suffering--a condition
which seems to result every time bureaucrats try to practice
medicine.
I intentionally delayed putting the book together
until the definitive "state-of-the-art" was formalized
in writing by way of the government's new encroachment into
medical arts referred to as Clinical Practice Guidelines:
Acute Low Back Problems in Adults: Assessment and Treatment.
Every physician in the country, one way or another, was
going to be influenced by this promise to codify and justify
back pain management (or better, "mis-management");
and I wanted to be sure that the state-of-the-art had been
ultimately defined before I presented my method. I was not
surprised to learn that nothing new is being really offered
to the back pain sufferer by the government's incursion
(or academia's dangerous collusion with same) into the realm
of disease treatment.
Certainly, there was some advantage gained
by assembling the country's leading experts in an attempt
to define the way a patient should be routed through the
medical system; and I would encourage the reader to obtain
the Agency for Health Care Policy and Research's free publications
related to: Acute Low Back Problems in Adults: Assessment
and Treatment, by calling the information clearing house
at 1-800-358-9295.
There are physician versions and consumer
versions. They do at least a good job at defining dangerous
back symptoms and signs as "Red Flags" indicative
of a potential need for surgical intervention and differentiating
these conditions from those amenable to "conservative
treatment" (which, in truth, amounts to something more
akin to neglect if one follows their advice). Nevertheless,
the guidelines do serve an excellent function for my purposes.
Their availability makes it unnecessary for me to reproduce
all the work necessary to compile the existing literature
or describe in detail the state-of-the-art in back
pain management so that the readers may assess
for themselves the available alternative methodologies.
The reader can easily turn to those guidelines to determine
what constitutes a potentially serious spinal condition.
Any person satisfying those "Red Flag" criteria
should probably not rely too rapidly or readily upon this
methodology for their salvation until they have been reassured
that they do not have a serious surgical condition. If so,
they should insure that they present themselves to the most
appropriate physician for evaluation before proceeding with
any therapy. After exhausting all of the remedies outlined
in the government pamphlets and provided through the current
medical system, then, the reader may feel free to return
to this website for advice and relief.
In delineating the current thinking on back
pain, the guidelines prove, if only to my satisfaction,
that no current literature seems to have arrived at as well-founded
an explanation for the origins and solutions of spinal pain
than is engendered in The O'Connor Technique (tm). The careful
reader of the government guidelines will note that in all
their recommendations in favor of or recommendations against
specific alternative methodologies, not a single one follows
from "strong research-based evidence." Therefore,
it would seem unlikely that anyone could criticize myself
for advocating my method; since the justification inherent
in the government's currently recommended modalities has
arguably equivalent research-based scientific support as
my own.
Actually, I should be content with that state
of affairs. If all the answers were already available, there
would have been little need for my book/website. No new
revelations would be possible if the mysteries had been
previously elaborated and the puzzle solved by someone else.
One nice outcome of the government's compilation of information
is that manipulation therapy during the first month of symptoms
was given some semblance of credibility by categorizing
it as being justified with support by "moderate research-based
evidence." Since no mention was made of self-manipulation
(which, if one were to characterize The O'Connor Technique
(tm) in its application by lay persons to their own back
pain, it undoubtedly should be classified), it must, therefore,
constitute a novel and unique classification.
Unfortunately, the manner in which these sort
of governmentally-sanctioned pronouncements are received
by the medical community tends to lend them an aura of "the
final word" or becoming "written in stone,"
leaving little or no room for innovation and an excellent
means for a third party payor to refuse to pay for alternative
medical strategies. One must understand that when the government
decides to accomplish something, the impetus is politically
motivated and controlled. With back pain, it appears to
have gone something like this: The politically powerful
and influential insurance companies would like to see less
money spent on back pain. They monetarily support and acquire
politicians who can control bureaucrats who then selectively
employ and seat on committees only those professionals who
espouse the desired medical philosophy that coincides with
their monetary strategy. That way, the resultant conclusion
appears to have been arrived at in an unbiased manner by
objective experts. It's an excellent societal management
technique used by the ruling class for centuries to give
the illusion that the very best is being done for the masses.
I fear that this current, government-sanctioned,
justification for doing little or nothing for the majority
of back pain sufferers a majority of the time will prevail;
since, already, "The new thinking" on low-back
pain concluding that "less is more" is severely
limiting the use of needed imaging techniques by giving
third party payers an elegantly documented means of denying
approval for those modalities. I happen to especially advocate
the use of imaging studies to document the reality of disc
disease for diagnostic purposes, to ascertain the position
of a displaced disc fragment, and to insure safety prior
to ordering exercise-based physical therapy or active forceful
manipulation. None of these governmental inquiries bothered
to count all the people who got worse when they were sent
out for manipulation or "work-hardening" exercise
training in advance of a competent diagnosis.
Contrary to the prevailing recommendations,
I have found imaging studies prove very self-helpful for
insurance purposes. Immediately after an accident or other
forcefully damaging event, I believe it behooves the sufferer
to gain as accurate a piece of injury evidence as possible,
since often, the only means of proof that can be obtained
to justify a claim must be gathered while the damage is
fresh before the disc migrates back into its central location
either as a consequence of manipulation or random activity.
On this issue, I heartily disagree with their findings and
recommendations based upon the knowledge I have acquired
through my own, albeit independent, experience.
The fact of the matter is, The O'Connor Technique
(tm) can be equally as effectively applied by an office-based
physician to carefully but non-forcefully immediately alleviate
acute as well as chronic back pain by a hands-on manipulative
re-positioning of displaced, protruding or herniated disc
material. Even after I teach them and they have shown successful
ability, some patients nevertheless require intermittent
assisted manipulation when they cannot get their own disc
material back in place with The O'Connor Technique (tm),
requiring the repeated services of a trained practitioner.
However, the government's Clinical Practice Guidelines "recommend
against" a "prolonged course of manipulation."
Does this give third party payers the justification they
need to deny these services after an arbitrary period of
time has elapsed? Does this imply that even prolonged courses
of self-manipulation are not recommended? The originality
of The O'Connor Technique (tm) calls some of the most "modern"
thinking into question. Principally, does what the government
certifies as "ok" exclude all else and legitimize
a denial of services or reimbursement?
I have been performing the type of manipulations
arising from my unique understanding of back pain mechanics
for several years now and have also arrived at a very simple
assistant-mediated method which applies the principles of
The O'Connor Technique (tm) and may be practiced by any
trained person to whom a back pain suffer turns for relief.
This should probably be relegated to physicians or chiropractors
so long as they are sufficiently educated to determine which
patients are candidates for the technique and which ones
should be referred to surgeons for last resort management.
Article Contents:
You are not alone
The Pain
Contemporary
Perspective on Back Pain
Historical
Perspective of Back Pain
Science and Art
Alternative
Therapeutic Modalities
Back Surgery
Comparative Programs
Not an Excercise
Program
Dismissing
the "Psychological" Contribution To Spinal Pain
Getting Better
as a Process
Become your own
Chiropractor
Hope
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