Taking Charge of Back Pain

review by Jule Klotter

Watch Your Back! by Richard A. Deyo, MD

ILR Press, Cornell University Press, Sage House, 512 East State Street, Ithaca, NY 14850

© 2014; $21.95; hardback; 212 pp.

When I came upon Watch Your Back! by Richard A. Deyo, MD, I anticipated a well-researched book revealing the little-discussed shortcomings of back pain treatment. I wasn’t disappointed. Deyo coauthored the provocative exposé Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises. In Watch Your Back!, Deyo examines the back pain industry and questions the increased use of scans and the effectiveness of many interventions. He also educates readers about the nature of pain and about informed decision-making.

Contrary to expectations, abnormalities found on MRI scans or X-rays are not necessarily the cause of pain. Deyo cites studies that show a sizeable percentage of people who never experience pain or sciatica exhibit vertebral abnormalities. In one study, a herniated disc was found in about one-fourth of these pain-free folk, degenerated discs in over half, and bulging discs in about 60%. He says, “… the percentage of ‘abnormal’ findings in ‘normal’ people is pretty consistent.”

Moreover, scans fail to predict who will experience back pain in the future. When neuroradiologist Jerry Jarvik performed a second MRI three years after first scanning pain-free adults, he found very few new abnormalities. Furthermore, he could not find a correlation between the initial scans and the development of pain. Interestingly, depression at baseline “was a stronger predictor of who would get back pain that the MRI results were,” writes Deyo.

MRI scans provide more detail (finding more abnormalities) than X-rays and are more likely to lead to surgery, but more surgery does not mean better results. The patients who were randomly assigned to receive an MRI in another study led by Jarvik were twice as likely to have back surgery within a year, compared to those who were X-rayed only. Yet, both the MRI group and the X-ray group improved to the same degree. The MRI patients, however, were more satisfied with their care – reflecting the cultural belief that technology gives the best results. Deyo recommends avoiding scans unless back pain is accompanied by overt clinical symptoms, such as weakness in a leg or foot, or other factors including unexplained fever, a history of cancer, a history of injection drug abuse, or unexplained weight loss. “Surgery works best when there’s a clear-cut anatomical abnormality [such as severe curvature] that explains clear-cut findings on an office examination,” says Deyo.

In many cases, the actual cause of pain – despite the finding of common abnormalities – is unclear. Deyo gives examples of people who underwent surgery in the belief that it would end their pain – most notably President John F. Kennedy and Jerome Groopman, author of The Anatomy of Hope. Both experienced years of severe pain and limited activity after having surgery. Both found relief with rehabilitative exercise programs. Exercise, combined with cognitive behavior therapy, provides the most successful treatment for back pain.

Pain, explains Deyo, is extremely complex: “When nerve impulses arrive in the brain, they don’t stimulate just one spot. Instead, they tickle a complex network that involves many parts of the brain. Memories, anticipations, and moods get linked up with the pain.” Stress, fatigue, anxiety, and frustration increase pain. As pain escalates, people limit activity. Cognitive behavior therapy give people tools for managing factors that increase pain so that they can regain function and stay active. Deyo writes, “It appears that this combination of cognitive-behavioral therapy and exercise can literally change your brain. It appears to ‘re-program’ the pain circuitry, perhaps like rebooting your computer when it acts up. Only this is a slower process, and requires more work.” Work that only the patient can do.

Watch Your Back! is a highly useful decision-making aid for people with back pain. It explains the complexity of cause and treatment and offers a noninvasive method for retaining and improving quality of life. This is a must-read book for anyone with back pain.

Quote: “You can’t stand by passively while you wait for a doctor or other health profession to bestow The Cure upon you.”