One of the overarching themes of this blog, if not the overarching theme, is to expose and combat the infiltration of quackery into medicine. What I'm referring to, of course, is the phenomenon that's risen over the last 25 years or so in which various pseudoscientific alternative medicine therapies (but I repeat myself) have found increasing acceptance, thanks largely to a major lack of critical thinking skills among both patients and, worse, the physicians who have embraced modalities such as acupuncture, naturopathy, chiropractic, and the like. In fairness, it's not just a lack of critical thinking skills, but rather a defect in the very concept of evidence-based medicine, which fetishizes clinical trial evidence über alles and ignores incredibly compelling evidence from the basic sciences that various prescientific modalities, such as much of traditional Chinese medicine, or quackery based in vitalism, such as homeopathy, cannot possibly work. In the case of homeopathy, for instance, many of the remedies are diluted far beyond the point where there is likely to be even a single molecule left.
Such treatments first wormed their way into medicine under the guise of "complementary and alternative medicine" (CAM), which was later renamed "integrative medicine," mainly because its advocates didn't like the subsidiary position relative to real medicine implied by the term "complementary." Unfortunately, a whole cottage industry within medical academia has developed to study such incredibly implausible treatments, all with the idea of validating them, a phenomenon I like to refer to as quackademic medicine.
Given this background, you knew I'd be very unhappy to see this news story last night on NBC Nightly News, Overcoming Back Pain: New Doctor Recommendations:
Basically, the American College of Physicians has issued new guidelines for the treatment of low back pain, as announced yesterday in this press release:
The American College of Physicians (ACP) recommends in an evidence-based clinical practice guideline published today in Annals of Internal Medicine that physicians and patients should treat acute or subacute low back pain with non-drug therapies such as superficial heat, massage, acupuncture, or spinal manipulation. If drug therapy is desired, physicians and patients should select nonsteroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxants.
And:
For patients with chronic low back pain, ACP recommends that physicians and patients initially select non-drug therapy with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (MCE), progressive relaxation, electromyography biofeedback, low level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation.
Acupuncture? And the ACP started out so well. Yes, it is advisable to start out treating acute and subacute low back pain with nonpharmacological therapies. That's nothing new. What is new—and unwelcome—is the ACP's inclusion of acupuncture as one of its suggested first line "non-drug" therapies.
Now go back and watch the news report above, if you haven't already. It's only a minute and a half; so go ahead. Notice how it starts out with a yoga class, where, the correspondent Kristen Dhalgren intones, most of the people in the class are there to overcome "often crippling" back pain, and the caption says, "Back pain relief without drugs or surgery." We meet a woman who used to get cortisone injections but is now doing well with yoga, after which the recommendations. Now, as I've said before, there's nothing special about yoga or Tai Chi when it comes to back pain or anything else. Stripped of its underpinnings in Eastern mysticism, yoga is nothing more than a system of exercise that emphasizes mobility, and the same is true of Tai Chi.
The segment on acupuncture is even worse, though. It's so credulous, so downright atrocious, that it might as well have been a commercial for the acupuncturist, Dr. Houman Danesh, a physical medicine and rehabilitation physician, as well as a pain specialist, at Mt. Sinai Medical Center, who is shown administering acupuncture to a patient and then later saying that there is a "lot of benefit to it" and that acupuncture is "based in science." (No, it's not. The evidence is overwhelming that acupuncture is nothing more than a theatrical placebo. It doesn't work.) Not surprisingly, this patient is very happy and satisfied with acupuncture. He's asked where he would be if not for alternative medicine and responds that he probably would have been considering surgery. His assessment? "Amazing!"
That's what's so infuriating about the ACP recommendations. Several of them are perfectly reasonable. Then there's the quackery, and it's all "integrated," just as "integrative medicine" preaches.
I always like to go straight to the source when discussing guidelines like this. So I had to go immediately to the source, the actual guidlines themselves, published in the Annals of Internal Medicine. Interestingly, the way the recommendations are discussed in the actual guidelines is belied by the news reports. Take a look at the first two recommendations:
Recommendation 1: Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)
Recommendation 2: For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)
The main two recommendations are hard to argue with. For example, most patients with acute and subacute back pain do get better, regardless of treatment (or lack thereof). Almost anything that is done will appear to result in improvement. Of course, that's the very same reason why pretty much any quackery used to treat acute back pain seems to "work." The patient gets better because it is the natural history of the condition to get better, not because it is necessarily effective. That's also the reason why it is difficult to do randomized clinical trials for acute low back pain, because the placebo group will get better. The question is whether whatever intervention is being used results in faster improvement, at least in most patients. Similarly, given the often intractable, long term nature of chronic back pain, it is certainly preferably to avoid drugs at first if possible.
The devil, of course, is always in the details. Look at the levels of evidence for each of the individual interventions. When examining levels of evidence, it is, of course, always a good idea to see exactly what sort of scale is being used to assess the evidence. In this case, here is the standard:
Diving into the details, I immediately noticed one thing. Although the strength of the overall recommendation for Recommendations 1 and 2 is "strong," when you dive into the weeds you quickly will see that, in general, the quality of evidence for for individual interventions is disappointingly low. That doesn't just include the acupuncture, but a lot of the other interventions for back pain as well. However, for acupuncture, you'd never get the feeling that the evidence for acupuncture and yoga is so poor. For example, notice how the only intervention for acute back pain with even moderate quality evidence is heat. Massage, acupuncture, and spinal manipulation all have low quality evidence for benefit. On the other hand, notice the almost ringing endorsement for nonsteroidal antiinflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs), comparatively speaking, where the recommendation states that the evidence is of moderate quality if pharmacological intervention is desired.
Looking at this, I had to wonder. For acute back pain, given that it will get better over time anyway, what's wrong with using a short course of NSAIDs and/or SMRs to manage the acute pain while waiting for recovery? I understand why one would want to avoid opioids, if at all possible. I understand why, for chronic pain, one might wish to avoid drugs for as long as possible. After all, long term use of NSAIDs is not without potentially serious complications, but short term use is generally pretty safe.
I also couldn't help but note the actual studies used to justify the recommendations. For example, this study showed that there was no difference between "true" acupuncture and sham acupuncture (which is what pretty much all well-designed acupuncture studies show). In other words, it showed that acupuncture is a placebo intervention. This study tested a sort of "scalp acupuncture" that I've never heard of before. Another study was from China, and, as has been discussed before, pretty much all acupuncture studies out of China are positive.
What about chronic low back pain? Take a look:
Low-quality evidence showed that acupuncture was associated with moderate improvement in pain relief immediately after treatment and up to 12 weeks later compared with sham acupuncture, but there was no improvement in function (125–130). Moderate-quality evidence showed that acupuncture was associated with moderately lower pain intensity and improved function compared with no acupuncture at the end of treatment (125). Low-quality evidence showed a small improvement in pain relief and function compared with medications (NSAIDs, muscle relaxants, or analgesics) (125).
I laughed. At least, I laughed when I looked over the list of references. The authors actually included the GERAC study in its list, which basically showed that acupuncture does not work, given that sham acupuncture was indistinguishable from acupuncture. Another study was a "bait and switch" in that it studied "electroacupuncture," which is in reality TENS. We're talking thin gruel indeed.
Of course, I have no problem with massage or exercise for low back pain, be it acute or chronic. So I really don't have a problem with recommending massage, Tai Chi, or yoga for back pain. I really don't. What I do have a problem with is representing such interventions as somehow being "alternative" or "integrative." Tai Chi and yoga are, at their hearts, little different than motor control exercise (MCS), which is a form of exercise that aims to restore coordinated and efficient use of the muscles that control and support the spine. Patients are initially guided by a therapist to practice normal use of the muscles during simple tasks. Then, as the patient's skill increases the exercises are progressed to more complex and functional tasks involving the muscles of the trunk and limbs. There is low to moderate quality evidence, according to the Cochrane Collaborative, that MCS has a clinically important effect compared with a minimal intervention for chronic low back pain. There is, of course, no evidence that MCS is superior to other forms of exercise—pretty much a lot like Tai Chi and yoga.
Seeing Dr. Danesh in that NBC News report piqued my curiosity. I couldn't help but look at Mt. Sinai's integrative medicine offerings. Of course, there's acupuncture. (Isn't there always?) There's yoga. And, of course, there's "energy medicine," which is the ultimate form of quackery. There's even something that Mt. Sinai calls the Holistic Preparation for Surgery Program:
This program helps patients prepare for surgery using the following techniques:
- Centering and Grounding
- Aromatherapy
- Guided Imagery
- Biofeedback
- Energy Healing (Therapeutic Touch, Reiki)
The program has been so successful in helping patients feel more comfortable and reduce medication use following surgery that Ms. Ortiz educated and trained nurses throughout surgical units at the hospital to teach patients breath control techniques and clinical imagery for pain management.
Argh! More "energy healing"!
That little detour aside, the ACP recommendations for back pain management are the epitome of what is "integrative medicine." They integrate quackery with real medicine. Depressingly, when that happens, people don't notice the part about how weak the evidence is for therapies like acupuncture. They only hear how great it is. The ACP really should have (and could have) done better. It's just a measure of how far quackery has insinuated itself into medicine that the ACP chose not to do so.
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I can hear the sound of the loons wafting from Lake Stupid now: "The American College of Physicians recommends" [enter one or one or more of the quack modalities here; whichever you want to promote] without so much of a mention of back pain, or the lack of evidence in support, cited and not. But the American College of Physicians?! Is it just a matter of wanting to profit from the unwitting unwashed or did they figure Hippocrates would approve, so why not?
Maybe their time has past. Perhaps the time is overdue for new college with "Science-Based Medicine" in the name. ACSBM anyone?
At great risk I will comment on personal experience of myself and my wife. Both of us have had significant "physical" impairment to an arm in my case and a shoulder injured because of a fall in her case. She went to Chiropractor recommended by a friend and in 6 weeks without surgery has had total movement of her shoulder. In my case it felt that my left arm had no strength and again after good old Mike it has worked perfectly. Maybe one should listen to what people say and not be so certain that YOU KNOW ALL the answers. Peace
PS The evidence for explosives is overwhelming and yet you ......
@Thomas Spellman - physical therapy, which is what competent chiropractic therapy is, sounds perfectly reasonable for a shoulder injury.
Exactly. As I like to say, chiropractors are incompetent physical therapists with delusions of grandeur.
The ACP lists a number of things for patients to do, or at least try to do, and a couple of things that might be done to patients; the latter being acupuncture and spinal manipulation. I suggest that all these things for patients to do, or be done to, simply fill in the time necessary for the back to heal itself.
The very fact that so many very different modes of therapy are proffered, a veritable smorgasbord of choices, brings to mind the word "placebo".
I periodically have trouble with my back. I gently - oh so gently! - exercise, with yoga-ish type twists and stretches. Or maybe they aren't even yoga-ish; just natural enough movements which I would not normally do, in a systematic way. I don't kid myself that it's doing much more than provide me with a sense of mental relief - at least I am doing something which maybe - who knows? - might help.
Isn't the reality that everyone who suffers with occasional back pain knows that it will get better in time, and that one simply has to wait it out.
The alternative medicine world prides itself on being all about the whole person. What this really means, I believe, is that if one cannot heal the body then one should try to heal the unhappiness. It's psychotherapy (psycho-sympathy) by another name. That's what the ACP list is really all about.
Do my eyes deceive me, or does the strength of the ACP recommendation (as indicated in the above table) depend only on the relative degree of risks and benefits, not on the strength of the evidence? Because certainly I would prefer interventions with a stronger evidence base over those with a weaker evidence base, other things being equal. I can understand reluctance to recommend something risky, no matter how strong the supporting evidence, but shouldn't the strength of evidence have some influence on the strength of the recommendation?
Healthy and appropriate posture and movement can eliminate back pain. Unhealthy posture and movement can and will create back pain. I teach the Gokhale Method, which is primal posture based on anthropological research. This teaches natural healthy human architecture, and was created by scientist Esther Gokhale to eliminate her own back pain after her first back surgery failed. Without knowledge of healthy structure people are creating their own back problems. The ACP guidelines are important and good news but I was disappointed that posture improvement was not featured.
Posture improvement should have been featured on the ACP list of alternatives to surgery and medication. People create their own back problems if they have bad postural habits. The Gokhale Method which I teach is based on anthropological research of healthy human architecture, and is created to eliminate back pain.
@Margaret Haight: I always knew that someone would benefit by teaching correct posture and slapping their name on it. By the way - her website is VERY wrong in the picture of someone apparently lifting a box by bending over. That's a good way to have back pain.
By the way...I stand and walk with a retroverted pelvis, due to lordosis. I've had it all my life. The only time I experience back pain is when I do something stupid and over-use my muscles or - slam my head into the bottom of an overhanging cabinet when straightening up (that one caused severe pain for a few days, thanks to the jolt.)
And yay for the racism of "cultures that don't experience back pain". Is that like the Noble Savage?
Anthropology is not biology. The former is the study of current and historical cultures. There is absolutely zero reason to suspect that ancient humans didn't have back pain or other ailments, let alone that those were the result of how they stood as opposed to modern humans.
One of the occasional hazards of a hunter-gatherer society would have been how to transport a successfully hunted big game animal (with a mass of hundreds of kilograms) back to the camp. The only reason this might have helped with back pain issues is that the ones more prone to severe episodes would not be able to return with the kill and therefore be less likely to reproduce. But of course it still would have happened sometimes.
Then humans invented agriculture, and that undoubtedly made things a great deal worse. Breaking the ground and weeding are activities that can be hard on the back. (I know this from firsthand experience as an amateur gardener, and I do much less of this stuff than subsistence farmers would have to do.) And you don't get to rest during growing season, as you would for a few days after bringing home a large kill.
Hmm mmm, theres all these alternative physical therapies (little of which works) just to keep the patients away from the opioids.
It is a shame that more people don't have access to or don't understand that cannabis is safe and highly effective for spasms, spastic colon, cramps, and back pain -- now they're going after kratom just as millions are discovering that it is outstanding pain relief.
Cannabis takes away the pain and leaves the user with a grin, again and again. Certain pharmaceutical companies are developing psuedo-cannabinoid substances sans grin.
Great column. I've got almost 30 years in clinical medicine. For the vast majority of acute back pain, I spend a fair amount of time with the patient explaining what to expect. The gist of my information is: your pain will get better. It might be a week, or two weeks, or four weeks or six weeks, but it will get better. It really doesn't matter what you do during that time. People love their chiropractor and acupuncturists, so I try not to belittle patients for seeing them. I do tell them not to allow X-rays; we will do them in our clinic if they are indicated. If we don't order them, then they don't need them. If they really want, they can see a chiropractor and they may feel better while there getting "adjusted and manipulated," and maybe better later that day. But by the next day it wil be as if you hadn't gone at all. Same effect for acupuncture; same if I send you to see a physical therapist and get massage and heat and stretching exercises. Better that day, no effect the next, and absolutely no effect on the overall duration of discomfort. If no contraindications, I may suggest nonsterioidal antiinflamatories (think naproxen) and low dose muscle relaxants (primary to help with sleep). I explain that these won't speed their healing either, but might make them more comfortable while the week or two or six passes until they're better. Ice or heat, whichever feels better; patient's call. I offer tips on surviving the discomfort, ways to get up and down using arms on stable surfaces, suggest they allot extra time for tasks such as getting to the bathroom, encourage activity to reduce stiffness. Sometimes I'll suggest writing a note on their calendar six weeks in the future say, "My back pain is better." More often then not, it will be true. Of course, I always mention symptoms of serious illness that should prompt immediate follow up. Finally I mention something an ER doc told me years ago, that often bending and twisting to the side is the original trigger for back pain.
@ Gilbert
Just because something is natural, it doesn't mean it is safe. Canabis also has side-effects and I don't know if it really serves as a painkiller. Of krakom I know next to nothing, but I think others have commented on that.
I have one small observation I made about my own back pain --yeah, it was chronic, for years and all the Tai Chi in the world failed to help. Kinda crazy, but I discovered that if I drink an extra half-glass of liquid in the morning with breakfast over what I used to drink, the pain just disappeared. Like a light switch! I speculate that maybe the discs in my spine expand and contract based on my hydration state --I have no idea if this is actually true or whether it applies to anyone else, but it's such a simple correction for such constant, long-term misery. I often wonder if all this pain people feel is because they don't mind the simple things, like how much water they should be drinking; all the money spent toking up on drugs, all the time in Yoga or Tai Chi... is all that really as needful as anyone believes?
@viggen: I can see why yoga or tai chi would have little direct effect on back pain. But being forms of light exercise, they have other benefits, such as improving your cardiovascular condition and in some cases helping to keep excess weight off. A former officemate of mine has long suspected that the weight gain accompanying his sedentary lifestyle (most of our work is done at desks, or sitting somewhere with an open laptop) contributed to his back problems. I don't know how solid the evidence is to support that idea, but it is a physically plausible causal mechanism: excess weight means extra stress on the joints and muscles. Furthermore, if you are getting this exercise through classes, you have additional human contact which you are unlikely to get while lying in bed feeling miserable.
Same thing with NSAIDs: they may not help directly, but if you sleep better because they reduce your acute pain level, that helps you in other ways.
Of course, if you have found that upping your fluid intake helps you, then by all means continue. But just because light exercise or NSAIDs don't do much for your typical acute back pain patient doesn't mean they don't help in other ways.
[citation needed]
OK, it's not your fault that the necessary studies haven't been done. For that, we can blame this country's insane drug laws (e.g., that tobacco is legal but marijuana is not). But if you use the search box in the upper right corner, you will find that Orac has discussed this topic in the past, and pointed out that we don't actually have solid evidence of the supposed benefits of medical marijuana.
Furthermore, the active ingredient in cannabis, THC, is a mind-altering substance. I wouldn't want somebody driving under the influence of any such substance, for the same reason drunk driving is illegal. (For similar reasons, I think that people taking prescription painkillers of any kind should not drive.) Just because the dangers have been overblown does not mean there are none.
Actually, much of the efficationess comes from CBD which is non-psycoative.
http://www.foxnews.com/health/2016/12/20/now-schedule-1-drug-cbd-hemp-o…
Gilbert @12: The same thing could be, and has been, said about gin.
and maybe you can get through your day baked out of your brain, but most people have jobs to do, heavy machinery to operate and lives to live, which can't be done in a total "grinning" stupor.
"can't be done." It's done all the time. There was a particular saying, "a drunk driver goes 100 mph not having a clue what they are doing. A stoned driver goes 50 mph and knows exactly what they're doing.
There are many. Could you just visualize the monotonous grind of those operating backhoes, digging dirt, without the empathy for safety and attentiveness derived from cannabis?
Nb4 "this post is not about cannabis".
In related news, State Rep for Lenox (and surrounding communities) Smitty Pignatelli has introduced another round of legislation that would require insurers to cover acupuncture as if it were a proven medical procedure.
I have explained to him at some length, we being old schoolyard chums, how this not the case - but he is a politician not a scientist and he has chosen to go after the votes.
Which leaves us in the reality based community with the age old question of what can we do differently to get our point across? Clearly we are not reaching these people.
@18
There's still no evidence for that. Like the earlier post said it is not your fault there is no evidence. But the statement that CBD does more than THC is not mentioned at all in your reference material. I even checked the reference material of that article and it's all just legislation. If there is a study or evidence out there please cite it. I only spent a couple minutes looking but I could not find any legitimate evidence differentiating the two as active ingredients. Anecdotal evidence does not count here. If you do find some please let me know I would love to read it
Ahh; The 'no studies to show' gambit. Mostly, the studies have not been alowed.That is convenient for those who see cannabis as competition. Some studies are being allowed so that pharma doesn't miss the boat.
Perhaps, it is not so much that CBD does more than THC as they treat different conditions. So, what is the promise of CBD? It is a superior anti-seizure med and the only one shown to effectively treat Dravet's syndrome.
http://labiotech.eu/uk-cannabis-drug-epilepsy-gw-pharmaceuticals-dravet…
https://en.wikipedia.org/wiki/Charlotte%27s_web_%28cannabis%29
Ok. I guessTHC does seem more useful for pain,
https://www.sciencedaily.com/releases/2017/01/170112130145.htm
Combined CBD and THC for cancer,
https://www.leafly.com/news/health/cannabis-drug-extend-lives-brain-can…
http://fortune.com/2017/02/07/gw-pharmaceuticals-marijuana-brain-cancer/
But the anecdotal 'evidence' is overwhelming. Gee. I wonder why this is mostly all the evidence there is? It's almost, as if, something is hindering the research. If I were a researcher, I'd certainly not just discount this evidence; I would, if allowed, be more yearning to study it.
Glibert @20: I'm going to need some citations that stoned people are more attentive than sober people, because *my* anecdotal evidence disagrees.
Gilbert makes a good point. Stoned drivers are paranoid and paranoid drivers are more careful.
Have you ever driven without a driver's licence? I have. And guess what, as soon as I got my licence I became a more reckless driver.
I was a better driver without a licence.
Matt Perl #13. Your last statement about lifting and twisting is spot on, I've never heard a doctor acknowledge that before. I spent a few years as the medical cover for a team who took part in what was listed in the Guinness Book of Records as; 'The Toughest Team Sport in the World'.
All the injuries were acute and I learned all I know from physios, the twisting and lifting was an early lesson because it would also cause thoracic spinal injury. The real secret, which hasn't really been mentioned, is to treat early. i.e. within 12-24hrs.
After that, guarding sets in and makes the treatment a whole lot longer.
I'm surprised nobody has mentioned the use of Diazepam (5mg tds/tid for a couple of days).
Margaret Haight #7 and 8:
A few years ago I went to a presentation by Esther Gokhale; I asked her what evidence supports selling this treatment for back pain. She denied it was a treatment, said there was research in progress, but continued to maintain that this would "help" with back pain. Plenty of time has gone by, but like all quacks the research never happened, or was never published; at least, she doesn't mention it on her website.
Is there really good evidence that bad posture causes back pain, or is it just another way of blaming the victim? Does she even notice when people stop taking her classes because they make the back pain worse? Probably not. If she only sees the people who say they are better, and ignores the dropouts, she can easily achieve a 100 percent success rate.
I have no doubt that the people Gokhale takes money from often get better--so do most people who have problems with back pain. A friend of mine went through their elaborate instruction of how to walk, sit, etc.. They even offered (for more money) to come and watch her swim, but happily my friend realized that they knew nothing about swimming so declined their offer. None of this is covered by insurance. I just wish people would need to show that what they are doing actually works before making a career out of selling it.
Another friend has become an Alexander Technique instructor. She has long been prone to woo, and now she's selling it. She says it helps with back pain, but it's not a treatment, and actually believes there is science to support it. Alexander Technique has been around a long time, but again they don't test it before making claims about its efficacy.
#18 Gilbert
Actually, much of the efficationess comes from CBD which is non-psycoative.
I have prescribed cannabis to over 100 people and remain totally un impressed by the results that I have seen so far. I do not like prescribing the THC component because you never know for sure, if the persons statement that it works is true, especially when they tell me that they tried street marijuana and it worked wonderfully. So far, of all the patients that I have prescribed cannabis for, maybe 10% have had benefit from Cannabis CBD. The vast majority that used the CBD stopped the drug after the first month. The cost for Cannabis Oil 1:20 which contains 1 part THC and 20 parts CBD, is $160 for a 60ml bottle. The people that received the Cannabis CBD were mainly the elderly seeking relief from chronic non cancer pain. I may prescribe Cannabis THC in the future, when I see some people with terminal cancer and who request cannabis for anxiety, insomnia and appetite loss.