All contents of this presentation remain the cannot be used for any purpose in the absence of Dr. Barth s specific authorization.

(1)

The nature of

back pain

Robert J. Barth, Ph.D. Robert J. Barth, Ph.D.

Chattanooga, TN and Birmingham, AL Chattanooga, TN and Birmingham, AL Parkridge Hospital Plaza Two, Suite 202 Parkridge Hospital Plaza Two, Suite 202 2339 McCallie Av. 2339 McCallie Av. Chattanooga, TN 37404 Chattanooga, TN 37404 423/624 423/624--20002000 rjbarth@barthneuroscience.org rjbarth@barthneuroscience.org General Disclaimer

(learned from Dr. Melhorn)

All contents of this

presentation remain the

property of Dr Barth and

property of Dr. Barth, and

cannot be used for any

purpose in the absence of

Dr. Barth’s specific

authorization.

The nature of back pain

Back pain is normal

(just like headaches, stomach

aches and fatigue are

aches, and fatigue are

normal)

Significant episodes of back

pain are experienced by

80% of Americans

(2)

Back pain is normal

Hadler NM.

Hadler NM. Occupational

Occupational

Musculoskeletal Disorders, 3

rdrd

Edition.

Edition. 2004.

2004.

Edition.

Edition. 2004.

2004.

AMA’s

AMA’s Guides to the Evaluation

Guides to the Evaluation

of Disease and Injury

Causation.

Causation. Melhorn and

Melhorn and

Ackerman, 2008.

Back pain

We are not yet talking about

chronic pain

What about complaints of new,

recent onset back pain?

What about the

What about the filing of a medical

filing of a

medical--legal claim

legal claim for new, recent onset

for new, recent onset

back pain?

Back pain

What is the best predictor of new, What is the best predictor of new,

recent onset back pain? recent onset back pain? (this is not limited to medical legal (this is not limited to medical legal

claims) claims)

Depression

Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ,

Deyo RA. Three

Deyo RA. Three--year incidence of low back pain in an initially year incidence of low back pain in an initially asymptomatic cohort: clinical and imaging risk factors. Spine. asymptomatic cohort: clinical and imaging risk factors. Spine. 2005 Jul 1;30(13):1541

(3)

Back pain

Bigos SJ, et al. Bigos SJ, et al.

A prospective study of work perceptions and psychological A prospective study of work perceptions and psychological

factors affecting the report of back injury. factors affecting the report of back injury.

Spine, 1991, 16, 1 Spine, 1991, 16, 1--6.6.

What are the best predictors of

p

the

filing of a new workers

compensation claim

for back

pain?

1.

Job Dissatisfaction

2.

Scale 3 from the MMPI

Back pain

Scale 3 of the Minnesota Scale 3 of the Minnesota Multiphasic Personality Multiphasic Personality Inventory (MMPI)??? Inventory (MMPI)??? This scale was constructed This scale was constructed This scale was constructed This scale was constructed using patients who exhibited using patients who exhibited some

some physical complaints for physical complaints for which no general medical which no general medical

explanation could be explanation could be

established. established. MMPI

MMPI--2 Manual2 Manual

Back pain

Scale 3 of the Minnesota Multiphasic Scale 3 of the Minnesota Multiphasic Personality Inventory (MMPI)??? Personality Inventory (MMPI)???

In other words, the In other words, the

t it f i j t it f i j extreme opposite of injury extreme opposite of injury

is the best predictor of a is the best predictor of a workers compensation workers compensation

claim being filed!!!! claim being filed!!!!

(4)

The nature of

chronic

back pain

Chronic back pain

For 85

For 85--90% of chronic

90% of chronic

back pain cases,

th

i

th

i

there is

no general medical

diagnosis

that explains the pain…

For 85

For 85--90% of back pain cases, 90% of back pain cases, there is

there is no general medical diagnosisno general medical diagnosis that that explains the pain…

explains the pain…

This means…

The overwhelming

j

it

f b

k l i

j

it

f b

k l i

majority of back claims

are not injury

are not injury--related

(and, therefore, not

work

(5)

For 85

For 85--90% of back pain cases, 90% of back pain cases, there is no general medical diagnosis that there is no general medical diagnosis that

explains the pain… explains the pain…

Deyo RA, et al.

Low back pain.

o

bac pa

JAMA

2001 Feb 1;344(5):363

2001 Feb

1;344(5):363--70.

70.

For 85

For 85--90% of back pain cases, 90% of back pain cases, there is no general medical diagnosis that there is no general medical diagnosis that

explains the pain… explains the pain…



AMA Guides, 5

thth

_Edition

_Edition..



AMA’s

s

Physician’s Guide

ys c a s Gu de

to Return to Work.

Talmage and Melhorn,

2005

Chronic Pain claims

American Psychiatric Publishing Textbook of Psychiatry, 4 American Psychiatric Publishing Textbook of Psychiatry, 4thth

Edition Edition..

“there is little correlation

between the level of pain

and

general medical findings”

(6)

Chronic Pain claims

AMA Guides, 5th ed.

“Thus, pain can exist

ith

t ti

d

ith

t ti

d

without tissue damage,

and tissue damage can

exist without pain.”

Imaging???

Spine imaging almost

never provides an

explanation for back

pain…

Spine imaging almost never provides an Spine imaging almost never provides an

explanation for back pain… explanation for back pain…

Carragee E, et al. Carragee E, et al. Are first

Are first--time episodes of serious LBP associated with new MRI time episodes of serious LBP associated with new MRI findings?

findings? Spine J. 2006 Nov

Spine J. 2006 Nov--Dec;6(6):624Dec;6(6):624--35. 35.

84% f

b

k

i



84% of

84% of new

new back pain cases

back pain cases

had either unchanged or

improved

improved MRIs compared to

MRIs compared to

pre

(7)

explanation for back pain… explanation for back pain… Hadler NM.

Hadler NM.

MRI for regional back pain: need for less imaging, MRI for regional back pain: need for less imaging,

better understanding. better understanding.

JAMA

JAMA. 2003 Jun 4;289(21):2863. 2003 Jun 4;289(21):2863--5. 5.



MRI findings are an example of the general MRI findings are an example of the general problematic trend toward over

problematic trend toward over--testing andtesting and problematic trend toward over

problematic trend toward over testing and testing and over

over--treatmenttreatment



No currently available general medical test No currently available general medical test actually explains back pain complaints actually explains back pain complaints



No currently available general medical No currently available general medical treatment provides demonstrable benefit treatment provides demonstrable benefit



Back pain sufferers would be better off if they Back pain sufferers would be better off if they stayed away from doctors

stayed away from doctors

explanation for back pain… explanation for back pain…

Chou R et al. Imaging strategies for low back Chou R et al. Imaging strategies for low back

pain. Lancet,

pain. Lancet, 20092009, 463, 463--72. 72.



MRI for low back pain does not lead to MRI for low back pain does not lead to any identifiable benefits

any identifiable benefits

MRI i t d ith t d



MRI was associated with a trend MRI was associated with a trend toward

toward worseworseoutcomes (maybe outcomes (maybe because the irrelevant “findings” scare because the irrelevant “findings” scare patients, and prompt them to avoid patients, and prompt them to avoid exercise and other activity

exercise and other activity –– which are which are the best things that one can do to the best things that one can do to recover from back pain).

recover from back pain).

Work

Work--relatedness????

relatedness????

The nature of one’s

work does not change

g

the risk of developing

back pain.

(8)

The nature of one’s work does not change The nature of one’s work does not change

the risk of developing back pain. the risk of developing back pain.

Bigos SJ, et al.

A prospective study of work

perceptions and psychological

factors affecting the report of

back injury.

Spine, 1991, 16, 1

Spine, 1991, 16, 1--6.

6.

The nature of one’s work does not change The nature of one’s work does not change

the risk of developing back pain. the risk of developing back pain.

AMA’s Physician’s Guide

to Return to Work

to Return to Work.

Talmage and Melhorn,

2005

Chronic Pain claims

So if chronic pain does

not come from injury,

i

fi di

i

fi di

spine imaging findings,

general medical issues,

or work,

where does it come from?

(9)

Chronic Pain claims

Primary issue:

Chronic pain is always a

psychological issue,

but it is not always a

general medical

*

issue

>>>

Chronic Pain claims

IASP Classification of

Chronic Pain, 2

ndnd

_Edition.

“…(pain) is always a

psychological

state…” >>>

Chronic Pain claims

American Psychiatric Publishing Textbook of American Psychiatric Publishing Textbook of

Psychiatry, 4

Psychiatry, 4thth_Edition_Edition..

“The literature supports the

importance of

importance of psychosocial

psychosocial factors

factors

rather than general medical variables

in determining whether a person will

recover from his or her pain.”

(10)

Chronic Pain claims

AMA Guides 5th ed.

Prospective studies have

consistently shown that the

onset and chronicity of

disabling pain is contingent

upon a variety of

psychosocial

issues.

The nature of chronic pain.

AMA Guides 5th ed.

“The role of

“The role of thoughts, behavior,

thoughts, behavior,

and/or environmental

contingencies

contingencies have been

have been

compellingly demonstrated for

chronic pain presentations”

Classic reference…

Dr. Alf Dr. Alf Nachemson Nachemson

His book reviewed His book reviewed

by by Dr. Andersson, in Dr. Andersson, in the NEJM, as “by the NEJM, as “by far the best” book far the best” book ever written on the ever written on the

subject. subject.

(11)

Back

Back AND

AND Neck Pain

Neck Pain

Textbook review:

Nachemson AL, Jonsson E.

Nachemson AL, Jonsson E. Neck and Back PainNeck and Back Pain. Philadelphia, Pa: . Philadelphia, Pa: Lippincott, Williams, and Wilkins; 2000.

Lippincott, Williams, and Wilkins; 2000.

“There is strong evidence that

g

psychosocial variables

generally

have more impact than

biomedical or biomechanical

factors”.

(continued) (continued)

Back

Back AND

AND Neck Pain

Neck Pain

psychosocial variables generally have more impact: psychosocial variables generally have more impact:



 passive attitude; passive attitude;



a tendency to think catastrophically about a tendency to think catastrophically about the pain complaints;

the pain complaints; the pain complaints; the pain complaints;



depression; depression;



anxiety; anxiety;



any other form of emotional distress; any other form of emotional distress;



a history of sexual and/or physical abuse; a history of sexual and/or physical abuse;



a perception of poor health in general.a perception of poor health in general.

Back pain

American Pain Society review:

Sanders, S. H. (2000). Risk factors for chronic, Sanders, S. H. (2000). Risk factors for chronic, disabling low back pain: an update for 2000. disabling low back pain: an update for 2000. American Pain Society Bulletin

American Pain Society Bulletin, March/April., March/April.

Scientifically established

risk factors for chronic

disabling low back

pain…

(12)

Risk factors for chronic disabling low back pain

*



PrePre--existing existing somatization somatization tendencies, tendencies,



PrePre--existingexisting



Blue collar Blue collar employment, employment,  History of History of childhood abuse childhood abuse Pre

Pre existing existing depressive depressive tendencies, tendencies,



Low activity Low activity levels, levels,  Job Job dissatisfaction, dissatisfaction, childhood abuse, childhood abuse,  History of History of substance abuse, substance abuse, 

Claims context of Claims context of presentation, presentation, 

Unemployment.Unemployment.

Chronic disabling back pain

medical

medical--legal claims

legal claims

The primary

i

t

f

i

t

f

importance of

personality

disorders

Personality Disorders

Definition (DSM

Definition (DSM--IVIV--TR): “A personality TR): “A personality disorder is an enduring pattern of disorder is an enduring pattern of inner experience and behavior that inner experience and behavior that

d i t k dl f th

deviates markedly from the deviates markedly from the expectations of the individual’s expectations of the individual’s culture, is

culture, is pervasivepervasiveand inflexible, and inflexible, has an

has an onset in adolescence or early onset in adolescence or early adulthood

adulthood, is stable over time, and , is stable over time, and

leads to distress or impairment leads to distress or impairment.”.”

(13)

Personality Disorders

Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Narcissistic Personality Disorder Avoidant Personality Disorder Dependent Personality yp Personality Disorder Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Disorder Obsessive-Compulsive Personality Disorder Personality Disorder Not Otherwise

Specified (e.g. Passive Aggressive;

Depressive)

What is the rate of personality

disorders in the general population?

10%

10% -- 13%

13%

Hales, R. E., Yudofsky, S. C., (2002).

Hales, R. E., Yudofsky, S. C., (2002). The The

American Psychiatric Publishing Textbook American Psychiatric Publishing Textbook

of Clinical Psychiatry, Fourth Edition

of Clinical Psychiatry, Fourth Edition. .

American Psychiatric Publishing. American Psychiatric Publishing.

How many

chronic pain patients

have a personality disorder?

31%

31% -- 64%

64%

Gatchel and Weisberg (2000)

Gatchel and Weisberg (2000).

Personality Characteristics

of Patients With Pain

of Patients With Pain.

.

American Psychological

Association.

(14)

Chronic disabling back pain

in workers comp

When actually investigated

When actually investigated,

,

how many

chronic disabling spine pain

patients in workers’ comp

are discovered to have a

personality disorder?

How many

How many chronic disabling spine pain chronic disabling spine pain patients in workers’ comp

patients in workers’ comphave a personality have a personality disorder? disorder?

70%

Dersh J, et al. Dersh J, et al.

Prevalence of psychiatric disorders in patients Prevalence of psychiatric disorders in patients with chronic disabling occupational spinal with chronic disabling occupational spinal

disorders. disorders. Spine

Spine. 2006 May 1;31(10):1156. 2006 May 1;31(10):1156--62.62.

The primary importance of

personality disorders

1.

1. General medical investigation of General medical investigation of low back pain claims will produce low back pain claims will produce significant findings 10

significant findings 10--15% of the 15% of the ti ( t th t) b t

ti ( t th t) b t time (at the most), but… time (at the most), but…

2.

2. Investigating for a personality Investigating for a personality disorder will produce significant disorder will produce significant results 70% of the time for medical results 70% of the time for

medical--legal claims of chronic low back legal claims of chronic low back

pain… pain…

(15)

The primary importance of

personality disorders

1.

1. General medical investigation of low back pain claims will General medical investigation of low back pain claims will produce significant findings 10

produce significant findings 10--15% of the time (at the most), 15% of the time (at the most), but…

but…

2.

2. Investigating for a personality disorder will produce Investigating for a personality disorder will produce significant results 70% of the time for medical

significant results 70% of the time for medical--legal claims of legal claims of chronic low back pain

chronic low back pain chronic low back pain… chronic low back pain…

Rhetorical question: Rhetorical question:

Why are we always doing MRIs and other Why are we always doing MRIs and other general medical investigations, while we general medical investigations, while we almost never respond to back claims by almost never respond to back claims by

evaluating for personality disorders? evaluating for personality disorders?

Mental illnesses

that are commonly

associated with

complaints of pain:

Mental illnesses commonly

associated with complaints of pain:

Somatoform Disorders Somatoform Disorders Mood Disorders Mood Disorders Anxiety Disorders Anxiety Disordersyy Personality Disorders Personality Disorders Psychotic Disorders Psychotic Disorders Factitious Disorders Factitious Disorders Substance

(16)

Bottom line in regard to medical Bottom line in regard to medical--legal legal

claims of “back injury” claims of “back injury”

They usually

ll

aren’t really

“injuries”…

They usually aren’t really

“injuries”

Hadler NM, Tait RC, Chibnall JT. Hadler NM, Tait RC, Chibnall JT. Back pain in the workplace. Back pain in the workplace.

JAMA

JAMA. 2007 Apr 11;297(14):1594. 2007 Apr 11;297(14):1594--6.6.

JAMA

JAMA. 2007 Apr 11;297(14):1594. 2007 Apr 11;297(14):1594 6.6.



Back pain is not an injury



The injury

The injury--model for back

model for back

pain is doing more harm than

good.

They usually aren’t really

“injuries”



A history lesson in how

backache (something like a

headache) transformed into the

concept of back injury.

Allan DB

Allan DB, , Waddell GWaddell G. .

An historical perspective on low back pain and An historical perspective on low back pain and

disability. disability.

Acta Orthop Scand Suppl. 1989;234:1 Acta Orthop Scand Suppl. 1989;234:1--23. 23.

(17)

Strategy for addressing most back claims, and Strategy for addressing most back claims, and

getting the healthcare on the right track getting the healthcare on the right track



Apply science to the general medical Apply science to the general medical details of this one case to show that details of this one case to show that there there is NOT a general medical explanation for is NOT a general medical explanation for the pain

the pain the pain the pain 

Apply science to the psychosocial details Apply science to the psychosocial details of the case to demonstrate that

of the case to demonstrate that there there ARE ARE non

non--injuryinjury--related factors that account for related factors that account for the pain complaints

the pain complaints

Strategy for addressing most back claims, and Strategy for addressing most back claims, and

getting the healthcare on the right track getting the healthcare on the right track

AAOS model

AAOS model -- Putting psychological Putting psychological tests in the offices of the general tests in the offices of the general medical doctor and relying on a medical doctor and relying on a medical doctor, and relying on a medical doctor, and relying on a psychologist to explain the psychologist to explain the significance of the results significance of the results

Credible

treatment for

back pain

(18)

Credible treatment for

back pain

ODG

ODG –– Treatment in Workers CompensationTreatment in Workers Compensation “

“

Graded

Graded activity

activity (including

(including

modified duty) is

modified duty) is more

y)

more

effective than usual care

effective than usual care in

in

reducing the number of days

of absence from work because

of low back pain.”

Credible treatment for

back pain

AMA’s

AMA’s Physician’s Guide to Return to Physician’s Guide to Return to Work.

Work. Talmage and Melhorn, 2005.Talmage and Melhorn, 2005.

Progressively increasing

exercise and work

exercise and work activity

activity

are recommended as

treatment

treatment..

Today’s detailed discussions:



Bulging disks

D

ti

D

ti



Degenerative

disk disease

(19)

Bulging

disks

Bulging Disks



Disc bulges are normal



They are not an

explanation for pain

complaints



They are not justification

for surgery (or for any

other treatments).

Bulging Disks

References that you

t

i

t

i

can start using

right away…

(20)

Bulging Disks

Jensen MC, Brant

Jensen MC, Brant--Zawadzki MN,

Zawadzki MN,

Obuchowski N, et al.

Magnetic resonance imaging of

the lumbar spine in people

without back pain.

New England Journal of Medicine.

1994 Jul 14;331(2):69

1994 Jul 14;331(2):69--73.

73. Bulging Disks

Bulging Disks

Jensen MC, et al. NEJM, 1994. Jensen MC, et al. NEJM, 1994.



Specifies the

Specifies the controversial

controversial

nature of claims that spine

imaging is relevant to back

pain complaints.



Studied spine MRIs of

Studied spine MRIs of people

people

who do not have back pain

who do not have back pain…

…

Bulging Disks



“Normal” spine MRI results

were found for a

were found for a MINORITY

MINORITY

were found for a

were found for a MINORITY

MINORITY

of the people who had no

back pain

 Only 36% of the people Only 36% of the people

without back pain had normal without back pain had normal spine imaging findings… spine imaging findings…

(21)

Bulging Disks



Most

Most of the people who

of the people who

were

free from any pain

were

free from any pain

had at least one disc bulge



52% of the people without

back pain had disc

bulges…

Bulging Disks



 The authors warn:The authors warn:



 Back pain is commonBack pain is commonpp



 Disk bulges are commonDisk bulges are common 

 When someone with back pain is When someone with back pain is found to have disk bulges, this found to have disk bulges, this might be nothing but a

might be nothing but a coincidence

coincidence

Bulging Disks

Jarvik JJ, Hollingworth W, Heagerty P, Jarvik JJ, Hollingworth W, Heagerty P,

Haynor DR,

Haynor DR, Deyo RADeyo RA..

The Longitudinal Assessment of The Longitudinal Assessment of

Imaging and Disability of the Back Imaging and Disability of the Back (LAIDBack) Study: baseline data. (LAIDBack) Study: baseline data. Spine. 2001 May 15;26(10):1158 Spine. 2001 May 15;26(10):1158--66. 66.

(22)

Bulging Disks

Jarvik JJ, et al. Spine. 2001. Jarvik JJ, et al. Spine. 2001.

Studied spine MRIs of

Studied spine MRIs of people

people

Studied spine MRIs of

Studied spine MRIs of people

people

who do not have back pain

who do not have back pain…

…

Bulging Disks

Jarvik JJ, et al. Spine. 2001. Jarvik JJ, et al. Spine. 2001.



Most

Most of the people who

of the people who

were free from any pain

had at least one disc bulge



64% of the people without

back pain had disc

bulges…

Bulging Disks

Stadnik TW, et al. Stadnik TW, et al.

Annular tears and disk herniation: Annular tears and disk herniation: Annular tears and disk herniation: Annular tears and disk herniation:

prevalence and contrast prevalence and contrast

enhancement on MR images in the enhancement on MR images in the absence of low back pain or

absence of low back pain or sciatica.

sciatica.

Radiology. 1998 Jan;206(1):49 Radiology. 1998 Jan;206(1):49--55.55.

(23)

Bulging Disks

Stadnik TW, et al. Radiology. 1998 Stadnik TW, et al. Radiology. 1998

Studied spine MRIs of

Studied spine MRIs of people

people

Stud ed sp e

s o

Stud ed sp e

s o peop e

peop e

who do not have back pain

who do not have back pain…

…

Bulging Disks

Stadnik TW, et al. Radiology. 1998 Stadnik TW, et al. Radiology. 1998

Most

Most of the people who

of the people who

were free from any pain

had at least one disc bulge



81%

of the people without

back pain had disc

bulges…

Bulging Disks

ACOEM Guidelines (2

ndnd

_Edition

Revised 2007):

“

bulging is thought to

“

…bulging is thought to

bulging is thought to

be asymptomatic in

nearly all patients”.

(24)

Bulging Disks



Implications:



Disc bulges are normal

Th

t

l

ti

Th

t

l

ti



They are not an explanation

for pain complaints



They are not justification

for surgery (or for any

other treatments).

Degenerative

Disk

Disease

Degenerative Disk Disease

Key

y

Points…

(25)

Degenerative Disk Disease



DDD is not work

DDD is not

work--related



DDD does not have a

demonstrable

relationship to pain

Degenerative Disk Disease



 Surgery is not credible treatment Surgery is not credible treatment for DDD

for DDD



 Claims that an accident caused Claims that an accident caused DDD to become symptomatic DDD to become symptomatic



 are not credible generically, and are not credible generically, and 

 are usually created in a manner are usually created in a manner

that is non

that is non--credible at several credible at several different levels

different levels

Degenerative Disk Disease

References that you

t

i

t

i

can start using

right away…

(26)

Degenerative Disk Disease

Battié MC, Videman T, et al.

The Twin Spine Study:

contributions to a

changing view of disc

degeneration.

Spine J. 2009 Jan

Spine J. 2009

Jan--Feb;9(1):47

Feb;9(1):47--59.

59. Battié MC, et al. Spine J. 2009

Battié MC, et al. Spine J. 2009

DDD is not

work

work--related or

related or

injury

injury--related

Battié MC, et al. Spine J. 2009

Twin

Twin Spine

Spine

p

Study

(27)

Battié MC, et al. Spine J. 2009

Disk degeneration is

Disk degeneration is not

not

correlated with:



"wear and tear"



wear and tear



mechanical insults



Injuries



Vibration (e.g., motor

vehicles)

Battié MC, et al. Spine J. 2009

“In fact, some

indications were found

th t

ti

l

di

th t

ti

l

di

that routine loading

may actually have

some benefits to the

disc.”

Battié MC, et al. Spine J. 2009

Disk degeneration

Disk degeneration is

is

correlated with:



Genetics



Smoking



(28)

Degenerative Disk Disease



Savage RA, et al.



The relationship between the

magnetic resonance imaging

appearance of the lumbar

spine and low back pain, age

and occupation in males.



Eur Spine J. 1997;6(2):106

Eur Spine J. 1997;6(2):106--14.

14. Savage RA, et al. Eur Spine J. 1997

Savage RA, et al. Eur Spine J. 1997

DDD is not

related to pain

(or to work)

Savage RA, et al. Eur Spine J. 1997

Compared spine MRIs of

--

workers who

workers who did not

did not

have back pain

--workers who

workers who did

did have

have

back pain

(29)

Savage RA, et al. Eur Spine J. 1997

“there was

no relationship

between LBP and

disc degeneration”

DDD is not related to pain

AMA’s

Guides to the Evaluation of

Disease and Injury

Causation

. Melhorn and

Ackerman, 2008.

DDD is not related to pain

AMA’s

AMA’s Guides to the Evaluation

Guides to the Evaluation

of Disease and Injury Causation

of Disease and Injury Causation..

j

y

Degenerative discs and

arthritis are not predictive of

pain or disability.

(30)

Degenerative Disk Disease

Gibson JN, Waddell G.

Surgery for degenerative

l

b

d l

i

l

b

d l

i

lumbar spondylosis.

Cochrane Database

Syst

Rev. 2005 Oct

19;(4):CD001352.

Gibson JN, Waddell G.

Cochrane Database

Cochrane Database 2005

2005

Surgery is not a

credible

treatment for

DDD

Gibson JN, Waddell G.

Cochrane Database

Cochrane Database 2005

2005



1999: There is no scientific evidence on the 1999: There is no scientific evidence on the effectiveness of any form of surgical effectiveness of any form of surgical

decompression or fusion for degenerative lumbar decompression or fusion for degenerative lumbar spondylosis compared with natural history, spondylosis compared with natural history, placebo, or conservative management. placebo, or conservative management. 

2000: There is no scientific evidence about the2000: There is no scientific evidence about the 

2000: There is no scientific evidence about the 2000: There is no scientific evidence about the effectiveness of any form of surgical

effectiveness of any form of surgical

decompression or fusion for degenerative lumbar decompression or fusion for degenerative lumbar spondylosis compared with natural history, spondylosis compared with natural history, placebo, or conservative treatment. placebo, or conservative treatment. 

2003: There is no scientific evidence about the 2003: There is no scientific evidence about the effectiveness of any form of surgical

effectiveness of any form of surgical

decompression or fusion for degenerative lumbar decompression or fusion for degenerative lumbar spondylosis compared with natural history, spondylosis compared with natural history, placebo, or conservative treatment. placebo, or conservative treatment.

(31)

Gibson JN, Waddell G.

Cochrane Database

Cochrane Database 2005

2005



There is moderate evidence that There is moderate evidence that instrumentation can increase the instrumentation can increase the fusionfusion

rate, but

rate, butany improvement in clinical any improvement in clinical outcomes is probably marginal. outcomes is probably marginal. outcomes is probably marginal. outcomes is probably marginal.



The effectiveness of intraThe effectiveness of intra--discal discal electrotherapy (

electrotherapy (IDETIDET) remains ) remains unprovenunproven..



Only preliminary results are available on Only preliminary results are available on disc replacement

disc replacementand it is and it is not possible not possible to draw any conclusions

to draw any conclusionson this subjecton this subject. .

Fusion is not a credible

treatment for low back pain

Richard Deyo, Alf Nachemson, Sohail Mirza

Spinal

Spinal--Fusion Surgery Fusion Surgery —— The Case for Restraint. The Case for Restraint.

NEJM

NEJM, 350;7, February 12, 2004., 350;7, February 12, 2004.



DDD is among the most common DDD is among the most common

it d f f i

reasons cited for performing a reasons cited for performing a fusion

fusion



But the effectiveness of fusion But the effectiveness of fusion for any pain complaints in the for any pain complaints in the context of DDD has not been context of DDD has not been established

established

Fusion is not a credible

treatment for low back pain

Mirza SK, Deyo RA.

Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine. 2007 Apr 1;32(7):816-23.

The results of

The results of threethree scientific trials scientific trials indicated that fusion is not more indicated that fusion is not more effective than

effective than

3 weeks of cognitive

3 weeks of cognitive--behavioral behavioral psychotherapy addressing fears psychotherapy addressing fears about back injury.