THE MYTH

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THE MYTH


Chiropractic has been plagued for over 30 years by the following quote:

"Irrespective of treatment given, 70% of back pain patients get well within three weeks, 90% within two months."

This erroneous quote morphed into the following mantra, beginning in the early 90's: "All back pain patients are fully recovered within 6-8 weeks whether or not they received any kind of treatment by any doctor."

themythThis then is THE MYTH. Read on and find out the truth behind this "junk science" atrocity.

Not surprisingly, insurance companies and their legion of IME doctors (aka IE, see my IME Monitors page) have continually seized upon this phrase as a means to abridge care to needy patients. In a breathtaking forensic examination of this MYTH, chiropractor Dan Murphy researched this issue and established the entire time-line for this abomination and tells us how it all got started. His original article can be found at this citation: Murphy D, "Do 90% of Patients with an Acute Episode of Low Back Pain Resolve Within Two Months, Regardless of the Treatment (if Any) Rendered?" J of Clin Chiro, Oct, 2006, Vol. 16(4). www.danmurphydc.com

>Dr. John Haberstroh (Boston Spine Clinics) summarizes Dr. Murphy's eight page thesis here:  Basically, a well known and authoritative text reiterates this quote and it continues to reflect badly on the chiropractic profession. The book is called "Clinical Biomechanics of the Spine," by Augustus White, MD, Professor of Orthopedic Surgery at Harvard Medical School/Orthopedic Surgeon-in-Chief at Beth Israel Hospital in Boston. The other author is Manohar Panjabi, Ph.D., Professor of Orthopedics and Rehab and Mechanical Engineering/Dir. of Biomechanical Research at Yale University School of Medicine. The 2nd Ed. of this book was published in 1990 by Lippincott Co.

Needless to say, the book is considered extremely authoritative in clinical biomechanics. On page 424, this quote can be found: "There are few diseases (low back pain) in which one is assured improvement of 70% of the patients in three weeks and 90% of the patients in two months, regardless of the type of treatment employed." This is the quote often used by insurance companies and/or their representatives to deny or withhold treatment.

QUESTION #1: From where did Panjabi and White obtain this "information?"

>ANSWER #1: Their textbook gives a single reference: Alf Nachemson, MD, "The Lumbar Spine-an Orthopedic Challenge," SPINE, Vol. 1 (1), March, 1976, pp: 59-71.

>DISCUSSION #1:  With reference to Nachemson, Panjabi & White say this, "An outstanding, well-written review of all aspects of the state of knowledge in 1976." Hmmm, interesting. As we shall see, it was not outstanding nor was it well written. The exact quote from Nachemson, in SPINE, 1976 was this: "Irrespective of treatment given, 70% of back pain patients get well within three weeks, 90% within two months." So what we have is ostensibly the best thinking on the subject by the best individuals in the arena in the best publication. But this leads to another question . . .

QUESTION #2:  Where did Nachemson get his information? He didn't actually discuss any studies he himself undertook nor any in depth review of much of the literature back then.

>Answer #2: Nachemson gave us two references. 1) A St. J. Dixon, "Progress and Problems in Back Pain Research," Rheumatology and Rehabilitation, Vol. 12 (4), Dec. 1973, pp:165-175.

>Discussion #2: The so-called Dixon "study" was not a study at all. Bizarrely, it was "From a paper read at the Annual Meeting of the British Assoc. for Rheumatology and Rehabilitation, London, March, 1973." Dixon was quoted verbatim at this meeting and it was reproduced in the article. He stated, "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). Dixon went on to regale the crowd that day with statements like this, "Discs contain no pain nerve endings, so cannot hurt." (p. 170). Clearly, much has changed since Dixon gave that mistake ridden speech in 1973. We now know that discs are indeed richly innervated by pain receptors and what's more, discs can and do lead to chronic pain. Dixon thus admitted that he was not an expert in back pain nor was he even a researcher. Dixon did reference the following stats: "Of those who seek advice for back pain from their family doctors, 44% are better on one week irrespective of treatment and 86% are better in one month. Only 14% drag on longer that 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 judged against this background."

>Summation Thus Far: Three well known and highly respected medical authors and self-proclaimed experts on back pain (White, Panjabi, Nachemson) publish, in two very highly regarded and authoritative publications ("Clinical Biomechanics of the Spine"{textbook} and SPINE-{Journal}) information that has been used for decades by insurance companies to deny or abridge care for needy patients; all based on a quoted lecture by a man (Dixon) who admited he was not an authority or researcher on spinal problems or back pain. And to boot, in a "study" that was no more than a random speech conjuring mere conjecture on Dixon's part.  Incredibly, Nachemson couldn't even quote Dixon accurately.

>Discussion #2(a): Dixon stated that 44% of the patients were "better" in one week, while Nachemson stated that 70% of the patients were "well" within three weeks. Numbers and time lines are completely different. As well, Nachemson opted to use the term "well" instead of "better." This inflects a whole different meaning. "Better" means somewhat improved. "Well" suggests recovered. Add to all of this the fact that Dixon's "86% better in one month" morphed into "90% well after two months" in Nachemson's quote. Neither the editors of SPINE, nor Panjabi and White bothered to check any of this information before they published.

>Discussion #2 (b): As if this all wasn't haphazard enough, note that Dixon's journal, Rheumatology and Rehabilitation, Vol. 12(4), 1973 is not indexed at this time (early 2007) by PubMed. PubMed searches the indexed article in the National Library of Medicine, Therefore, this oft quoted article by Dixon cannot easily be found by doing standard medical searches through standard search engines either by the author's name (Dixon) or the article title or the journal. Thus, because this article is so difficult to locate and those that do reference it, do it so badly, it is reasonable to assume that these authors aren't actually reading the original article. It is far more reasonable to assume that Nachemson may have actually glanced at the original article by Dixon, misquoted him in his own article that was published and others have just been repeating the error ever since. Interestingly, SPINE was not added to the PubMed data base until its third year of publication. Nachemson's article in which he misquoted Dixon appeared in the very first issue of SPINE, Vol 1 (1) in 1976.

>Answer 2 (continued): As stated, Nachemson gave two references. Dixon was the first, this was the second: "Rissanen P, "The Surgical Anatomy and Pathology of the Supraspinous and Interspinous Ligaments of the Lumbar Spine with Special Reference to Ligament Ruptures," Acta Orthopedic Scandinavica, Supp. #46, 1960. This article is 100 pages long and has absolutely nothing to do with the history and treatment of back pain. The article discussed 306 cadavers evaluating ligament histology, fatty degeneration as a function of age and incidence of adult rupture of the interspinous ligaments.

QUESTION #3: Finally, did Dixon himself quote anyone?

Answer #3: Yes. Fry J, "Advisory Services Colloquia: Back Pain and Soft Tissue Rheumatism," Advisory Services, Ltd., London, (1), 1972.

Discussion #3: A "Colloquium" is "a gathering of scholars to discuss a given topic over a period of a few hours to a few days." 13 individuals took part in this colloquium. Dr. Fry, MD is listed as a general practitioner from London. Dr. Fry's published contribution is thus: "In an average (GP) 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 patient with acute LBP lost their symptoms in less than one week and 82% in less than 4 weeks."

Dr. Fry makes it very clear that these numbers were conjured from simple observation of his own private practice. There simply was no scientific method used. There was no mention of what type of treatment was rendered or any kind of blinded, statistical methodology used. Obviously, these numbers are utterly meaningless and should never be used or quoted as being authoritative with regard to the history of low back pain.

FINAL SUMMATION:

The entire lineage in the "THE MYTH," from Fry to Dixon to Nachemson to White/Panjabi is based on nothing more than simple, uninfomred conjecture and observation. The whole "90% are well in two months no matter what" mantra is a "junk science" hoax and should not be given any scientific weight whatsoever. Chiropractors and their patients should be made aware of this and not put up with or be constrained by this unprofessional medical hokum.

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