Treating Back Pain: “Where’s the Beef?”

Written By:  Ronald D. Fudala, DC | Board Certified Chiropractic Neurologist.

A tiny piece of meat engulfed by a massive bun caused the frail, grey haired grannie to loudly exclaim:

“WHERE’S THE BEEF?”

The now iconic statement first appeared over 30 years ago in a Wendy’s commercial as actress Clara Peller, portraying the hamburger-eating grannie, lamented a lack of substance to her meal.

Back pain treatment today has too much bun for the beef!

Commercialization and hype obscure the fact that our success rates with back pain are inadequate for the amount of money that is being spent and the number of treatments that are promoted.

“WHERE IS THE BEEF?”–Consider just a few of these alarming statistics on back pain:

• More people are experiencing more back pain and it is lasting longer. The incidence of back pain has increased 29% between 2000-2007. Chronic low back pain has increased by 64%. (1)
• Spending on spine treatments totaled nearly 86 billion (yes that’s BILLION) dollars in 2005, a rise of 65% compared to 1997. Despite this spending, the % of people with impaired spine function has continued to increase. (2)
• Over a 2-year period, medical costs for chronic low back pain patients average $38,817 MORE than those without back pain. (3)
• Per person spine-related expenses in the US is 73% GREATER than for individuals in other countries, yet with no difference in the success rates of treatment (1)
• The % of people seeking social security disability for low back pain is increasing. (4)
• As many as 45% of individuals with their first episode of back pain have a chance of a less than favorable treatment result. (5)
• Floridians should be especially concerned. The cost of spinal fusions nearly tripled from $40,996 per case in 1992 to $111,662 in 2012. Along with the costs, the number of spinal fusions performed increased 16-fold during the same time frame. (6)

The statistics above, as alarming as they are astounding, caused researchers Dr. Janna Friedly et al to pose a critically important question:

“Are spine problems worsening over time, or are we simply using an increasing number of costly treatments that are not effective?”(4)

In other words, she is basically asking; WHY DO WE HAVE MORE BUN (Treatments-Procedures-Expense) THAN BEEF (Results)?

As far back as 2001, researchers had noted, “There are wide variations in spine care, a fact that suggests there is professional uncertainty about the optimal approach.” (7) Illustrating this uncertainly more poignantly was an article pointing out the over 200 different forms of “back care” that could be provided by over 23 different clinical professionals. (8).

Do your own research. Just “GOOGLE” treatment for back, spine, sciatica, pinched nerves, neck, disc, etc. You get the idea… And you will also get an idea of some additional “devices” or “miracle cures” that were not even mentioned in the article noted above discussing the “200 different forms of care.”

So, why are there so many “BUNS” and so little “BEEF”? Lacking a single answer to explain this, a few of the more obvious reasons are:

• In most cases, the source of back pain cannot reliably be determined. (9,10)
• In most cases, one cannot accurately predict the response a patient will obtain from any given form of care. (11,12)
• Many treatments that have never undergone thorough scientific study often find their way to “market” and are promoted as cures to unsuspecting patients. (8)
• Treatment promotional materials often over-state benefits and very rarely present the scientific evidence of effectiveness or discuss potential harms. (8)
• Even supposedly “valid” scientific research can be tainted by commercial interests and entrepreneurialism. (13,14,15)
• Territoriality and professional bias can preclude cooperative effort for the benefit of the patient. (16,17,18)
• And as a final example; there is currently a lack clinicians, appropriately trained in the subtleties of spine-related care, who function to “guide” a patient, rather that “treat” a patient. (19,20,21)

In the 1996 movie “Jerry Maguire”; Arizona wide receiver Rod Tidwall (played by Cuba Gooding) popularized the exhortation “Show me the money!” by demanding that his agent do more to obtain a high-dollar contract. Admonishing his client, Jerry’s retort was “Help me, help you”

In other words, Jerry was saying; “Give me performance. Show me the beef. Then… I will show you the money.”

Improved results in spine-related care will only begin to occur when we discard commercialism, hype, and territoriality and focus on performance, outcomes, and what is in the best interest of our individual patients.

This, and other factors to consider in spine-related care, will be discussed further in future posts.

References:

1. Smith M, et al. Aging baby boomers and the rising cost of chronic back pain: secular trend analysis of longitudinal Medical Expenditures Survey data for years 2000-2007. JMPT, 2013;36(1)

2. JAMA, February 13, 2008—Vol 299, No. 6

3. Hitesh Suresh Chandwani, Ph.D. The Economic Burden of Chronic Low Back

Pain in The United States: A Societal Perspective. The University of Texas, Austin, 2013

1. Janna Friedly, MD,a,* Christopher Standaert, MD,b and Leighton Chan, MD, MPH. Epidemiology of Spine Care: The Back Pain Dilemma.       Phys Med Rehabil Clin N Am. Nov 2010; 21(4): 659–677.

2. Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: Identifying patient subgroups for initial treatment. Arthritis Rheum. 2008;59:632–641.

3. A Florida case study in surgical necessity.       Washington Post Oct. 2013. http://www.washingtonpost.com/business/economy/a-florida-case-study-in-surgical-necessity/2013/10/27/5cb52864-3ce5-11e3-b6a9-da62c264f40e_graphic.html

4. RA Deyo and DO Weinstein. New England Journal of Medicine, Feb. 2001

5. Scott Haldeman, DC, MD, PhD, FRCP(C)*, Simon Dagenais, DC, PhD. A supermarket approach to the evidence-informed management of chronic low back pain.   The Spine Journal 8 (2008) 1–7

6. Deyo, RA, RAinville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992;288:760

7. Federico Balagué, Anne F Mannion, Ferran Pellisé, Christine Cedraschi Non-specifi c low back pain. Lancet 2012; 379: 482–91

8. Haskins R, Rivett DA, Osmotherly PG. Clinical prediction rules in the physiotherapy management of low back pain: A systematic review. Man. Ther. 2012 Feb;17(1)

1. Peter O’Sullivan. It’s time for change with the management of non-specific chronic low back pain.       Br J Sports Med March 2012 Vol 46 No 4

2. Abelson R. Medtronic will settle accusations on kickbacks. The New York Times, July 19,     2006:C4

3. Abelson R. Financial ties are cited as issue in spine study. The New York Times, January 30,   2008.

4. Dr. Nortin Hadler. Stabbed in the back: Confronting Back Pain in an Overtreated Society.   http://www.amazon.com/Stabbed-Back-Confronting-Overtreated-Society/dp/0807833487

1. Bate P. Changing the culture of a hospital: from hierarchy to networked community. Public Adm. 2000;78(3)

2. Axelsson SB, Axelsson R. From territoriality to altruism in interprofessional collaboration and leadership. J Interprof Care. 2009;23(4)

3. Chadwick L. R. Chung, DC, Jasmin Manga, DC, Marion McGregor, DC, PhD, Christos Michailidis, DC,

4. Donald R Murphy, Brian D Justice, Ian C Paskowski, Stephen M Perle5 and Michael J Schneider, The establishment of a primary spine care practitioner and its benefits to health care reform in the United States. Murphy et al. Chiropractic & Manual Therapies 2011, 19:17

5. Matthew Mintz, MD, FACP. Medical Economics. http://medicaleconomics.modernmedicine.com/medical-economics/news/modernmedicine/modern-medicine-feature-articles/practice-models-primary-care-       May 25, 2011

6. Jen Christensen. Doctor shortage, increased demand could crash health care system. CNN Health.       http://www.cnn.com/2013/10/02/health/obamacare-doctor-shortage. Oct 2, 2013.

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