If you have low back pain (and if you don’t, you probably will, for four of five of us develop an achy lower back at some point in our lives), you’ll be interested to learn that three alternative therapies — acupuncture, manual therapy (massage and/or spinal manipulation) and exercise — are now the officially recommended first line of treatment in the United Kingdom.
The recommendations, which raised a few doubting eyebrows among some of Britain’s more staid physicians (more about that in a second), were issued late last month by the U.K.’s National Institute for Health and Clinical Excellence (NICE). This is the group that evaluates the evidence for various medical practices, determines which ones actually work, performs a cost-benefit analysis, and then decides if the practices should be offered through Britain’s National Health Service (NHS).
According to The Guardian newspaper, which offers a thorough summary of the evidence for and against the recommendations here, this is the first time NICE has given a positive thumbs up to alternative treatments.
First, do no harm
What this trio of alternative therapies share is a relatively inexpensive price tag as well as some evidence (perhaps a bit lukewarm) that they provide some symptom relief. Also, they’re unlikely to cause harm.
That last factor is important, for most nonspecific low back pain (defined as stiffness, pain and tension in the lower back for which no specific cause can be pinpointed) gets resolved within a month or so on its own.
What’s also interesting, however, is what the recommendations tell doctors not to do when a patient has non-specific low back pain: no X-rays of the lumbar spine and no MRIs (magnetic resonance imaging) unless something more sinister is suspected, such as a spinal malignancy, infection or fracture.
The recommendations also nix laser or ultrasound therapy and transcutaneous electrical nerve simulation (TENS).
Doubting Thomases
According to reports in the British press, doubts about these recommendations seem to be coming from two main sources.
Some doctors are adamant that corticosteroid injections are the way to go (despite the lack of any good studies). Other doctors are concerned that spinal manipulation poses more risks than benefits.
The steroid advocates seem particularly angry about the NICE recommendations. “I have never known so many pain medicine specialists to be so furious,” a doctor told The Daily Mail. “More patients will end up having more expensive surgery, which is unnecessary, risky and has worse results.”
Coming to a medical clinic near you?
NICE estimated that stopping the use of steroid injections will by itself save $53 million. But the alternative therapies don’t come cheap. NICE also estimated NHS will spend $39 million extra on acupuncture, for example.
If we get some kind of national health care here in the United States, we’ll have a similar group figuring out our best medical practices. As President Obama stated last week, reforming health care includes “promoting best practices, not just the most expensive practice.”
Get ready for the pushback.
Writing in the June issue of US News and World Report, Bernadine Healy, MD, lays bare the murderous Nazi intent of the Obama plans, using the question of hospital readmissions, an issue singled out by Obama in his budget. There she laid out a plan to limit Medicare reimbursements if a patient is re-admitted within 30 days of discharge, “saving” $26 billion of “wasted money” over 10 years. Dennis Rivera of the Soros-linked SEIU union has been especially vocal on this point.
The real reason for the increasing rate of re-admissions is not that doctors are gaming the system to make money, but that the elderly are living longer with serious infirmities. A study of 2 million Medicare patients who were re-admitted to hospitals showed, number one, that “the patients are really, really sick,” in Dr. Healy’s words. Ninety percent of re-admissions in the first 30 days were emergencies, led by heart failure, emphysema, pneumonia, and psychotic breakdown.
“A sudden struggle for breath in someone with serious heart or lung disease can mean an acute deterioration that, left unattended, would lead to an imminent and needlessly cruel demise. It’s a call that can only be made by the medical team caring for the patient. Checking the chart to see if the patient has been hospitalized for the same problem recently is routine; such an event indicates a more intractable condition and might even encourage re-admission. If that chart check instead results in a decision not to re-admit, because of fears of financial penalties or bad performance marks, we’ve created an ethical monster….
“If doctors and hospitals stop re-admitting these patients, what happens to them? One suggestion that’s been knocked around, which sounds ghoulish the more you think about it, flicks at a better use of palliative care. But palliative or hospice care is not for those who are treatable. In fact, 93% of those 2 million Medicare re-admits were alive a year later — despite, or probably because of, having had two or more hospital re-admissions in the course of that year.
“So, before we start counting the savings, imagine what those treatment penalties would mean for your mom or dad, or grandma or gramps. They all started paying into Medicare when they were young and robust so it would be there for them when they grew old and sick. Do we change their social contract?”
What Healy is describing is the very process of thinking that led to Hitler’s T4 program. Healy’s title is, “When Healthcare Reform Hits Grandma.”
I am wondering how an inflammatory comment describing “the murderous Nazi intent of the Obama plans” gets posted on this site.
I’m not even going to venture into the mudbath generated by the first comment, but I’d like to remark on the article itself.
My brother is a specialist in occupational medicine and sees many bad backs and other types of chronic pain. He finds that a lot of the pain can indeed be healed with massage therapy, postural adjustments, or exercise.
He’s had patients come in who have actually had surgery and are still in pain. A couple of carefully targeted non-invasive procedures can sometimes fix the problem for much less than the cost of surgery.
“Stiffness, pain and tension,” as noted above, often cause lower back pain and should logically be addressed before expensive or invasive options.
Bending and stretching exercises and a heating pad can help ease both stiffness and tension, and therefore pain. Walking strengthens the lower back muscles and can help prevent future episodes.
There was an interesting study about low back pain published in the New England Journal of Medicine in about 1995 or so which prospectively compared both cost and outcomes for people with low back pain who saw a family practitioner, an orthopedist, or a chiropracter. The orthopod was most expensive, predictably, but the chiropracter was a close second. The FP was the best deal. And guess what? Outcomes were about the same.