As if we didn't have enough examples, here is another one that shows how much unnecessary surgery is being performed. Yes, I know this is for non-traumatic shoulder pain and for non-traumatic spinal and knee injuries, but since in many areas the overwhelming majority of surgery of this type, is performed due to non-traumatic "injuries" (or merely degenerative changes), the point remains the same.
CPG: Surgery for Shoulder Pain? Think Twice.
Authors of a new clinical practice guideline (CPG) on treatment of shoulder pain took a hard look at the advisability of surgery and came to a conclusion that can be boiled down to 3 words: don't do it.
Published in BMJ, a new Clinical Practice Guideline (CPG) focuses on adults with atraumatic shoulder pain lasting for 3 months or more (diagnosed as subacromial pain syndrome, or SAPS), and examines the effectiveness of arthroscopic surgery versus nonsurgical treatment approaches including exercise therapy, analgesics, and injections.
Surgery resulted in no significant differences from other approaches—including placebo surgery. The lack of difference remained at 6-month, 2-year, and 5-year follow ups. Since the conclusion that was reached indicated surgery isn't any more effective than sham surgery or other treatment approaches, the CPG authors next analyzed the benefits and harms of the procedure. And, again, surgery did not do well.
Since the surgery carried significant risks and lacked superiority in terms of effectiveness, "the panel concluded that almost all well informed patients would decline surgery and therefore made a strong recommendation against subacromial decompression surgery," authors write. "Clinicians should not offer patients subacromial decompression surgery unprompted, and others should make efforts to educate the public regarding the ineffectiveness of surgery."
A recent research article (see reference below) touts the benefits of reducing carbohydrate intake for the treatment of Type 2 Diabetes. Type 2 Diabetes is sometimes known as acquired diabetes, meaning it is not a disease that you are born with, but rather it is a condition that is acquired during a person’s lifetime, usually due to their lifestyle/eating habits. It is strongly associated with obesity and chronic high blood sugar.
The article lists some truly spectacular results achieved by a large group of diabetic patients by way of the mere reduction of carbohydrate intake: 94% reduction in insulin use, a 100% reduction in the use of these patient’s diabetes medications and a 12% reduction in body weight !
The overlooked, but most important, point:
But the most important lesson of the study, by my point of view, is not the wonderful results achieved by these diabetic patients. The most important lesson, from a cautionary-tale perspective, becomes clear when you compare these wonderful results with the results of a second group of diabetic patients who were provided instead with the "usual" medical care. This second group saw NO reduction in medication use, NO reduction in blood sugar levels and NO reduction in body weight! This was after a full 12 months of the “usual” medical care.
You have to wonder what kind of care is being provided to the millions of patients across the country with Type 2 Diabetes. If they are being provided with the “usual” care (as, by definition, they most certainly are) then they are clearly being provided with care that is wholly inadequate and ineffective. In fact, I would take it even further to say that it is possible that a significant percentage of Type 2 Diabetics are actually being worsened by the “usual” medical care, since it is reasonable to expect at least some patients with Type 2 Diabetes to actually improve on their own, if they were provided no formal medical treatment. However, since the patients in this research study that were in the group that were provided with “usual” did not improve at all, it appears that the “usual” care is harming more people than it is helping.
I have personally treated a great many patients with Type 2 Diabetes who were attempting to follow the dietary advice of their physician and using the nutritional supplement drinks recommended or prescribed by their physician. In most cases, the advice of their physician and these dietary supplements (pushed by their physicians) appeared to be, at best, perpetuating the eating habits and lifestyles that led to their diabetic condition in the first place. At worst, these “usual care” therapies, appeared to me to be making these patients worse, at an accelerated pace.
Just one more addition to the long list of spectacular failures presided over by the entrenched medical establishment.
Diabetes Therapy (2018) 9:583-612 Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study
During a recent presentation in Salt Lake City, I was surprised to see that the attendees were largely made up of people who appeared to be young (primarily between age 25-35) and in above average physical condition. The presentation focused on the demonstration and teaching of Self-Mobilization techniques to employees and employers so they can treat their own back injuries. However, probably due to my background in bodybuilding and the fitness level of the attendees, many of the questions I received afterward in the Q and A centered around improving strength/muscle size, nutrition, protein intake, weight training frequency, how to get “cut”, the best bodybuilding routines, etc
Because so many of the questions were related to this issue, let me be very clear about one basic fact: In order for a muscle to increase in size, it must also increase in strength. Additionally, if a muscle increases in strength, it must also increase in size. There is no such thing as a differentiation in training between “training for strength” or “training for size”. One will produce the other. To a casual observer, this seems counterintuitive since anyone who has frequented a gym has seen people who do not in any way appear to be very muscular, but yet they are able to use more weight, or lift more in certain exercises than someone who appears more muscular or is larger. This can lead you to believe that there is a basic difference in training methods, with regard to number of repetitions, sets and exercises, when we are “training for strength” as opposed to “training for size”. It appears that one of the methods will produce increases in muscle size and altogether a different method will produce increases in muscle strength. However, there is a very fundamental error in this type of comparison because we are comparing one person to another person. This requires an explanation:
There are many factors that contribute to any one individual’s ability to lift a certain amount of weight for a certain number of repetitions. One of the factors in the muscle’s cross-sectional area or simply put; the size of their muscles. That’s the part we can see. Other factors, that are not as readily visible include muscle fiber type, tendon attachment points, neuromuscular efficiency/recruitment, bone/leverage length, percentage of subcutaneous fat, etc. A person with visibly larger muscles may well be beaten by someone with visibly smaller muscles, if the smaller man has enhanced fiber type or any of a host of additional advantages that are simply not visible and usually genetically determined. However, this does not negate the reality that, within a single individual, in order for that individual to increase his/her muscle size, they must increase their strength. If you succeed in lifting more weight or lifting the same weight for a greater number of repetitions (demonstrating an increase in strength), then an increase in muscle size will surely (and rapidly) follow. (I am assuming that the increase in weight lifted or the increase in number of repetitions performed, was in fact, performed in perfect strict form, relatively slowly, without cheating/hitching, and at the same speed and angle as the previous performance to which it is being compared.) In short, if your muscle has increased it’s strength, then it has also increased in size.
The question now becomes; What’s the best way to train for strength/size? I receive this question invariably, not from the novice, but usually from someone who has been weight training/bodybuilding for several months to several years. They have meticulously logged their workouts and when they look back 6 months to a year, they realize that their records show that their strength has not improved in many months (or years). They also now begin to realize they have plateaued or reached what is sometimes called a “sticking point”. When this happens, it is usually because they have not taken into account the reality that “things have changed” and the thing that has changed the most is their body. What I mean by this is that the basic routine that worked for them initially, (and virtually any routine will work for anyone, when they first start bodybuilding/weight training), will not work for them as they increase in strength and size. When the strength/size of a muscle increases, the continued training of this (now stronger) muscle demands a greater and greater portion of your recovery ability, in order to grow. As a result, the volume and frequency of your workout must decrease, in order to make further progress. Unfortunately, when most people hit a “sticking point”, they do exactly the opposite--they increase both the volume and the frequency of their workouts. The results of this is that their progress stops completely and they may even regress.
When I state that your workouts must decrease in volume and frequency, I do not mean to imply that they must become easier. Far from it! Initially, many people, for a period of anywhere from 6 weeks to 6 months, will make good, steady progress on a typical routine of working every bodypart, in each of 3 workouts per week, performing anywhere from 1 to 5 sets per body part. However, they will quickly reach a plateau/sticking point after the aforementioned time. As already mentioned, when muscles increase in strength and size, they demand a greater and greater portion of your recovery ability, in order to grow. However, although the muscles have increased in size, the “size” of your recovery ability does not increase to nearly the degree that the muscles have increased in strength/size. As a result, as the muscles grow, they drain a greater and greater percentage of your recovery ability. Ultimately the demand on your recovery ability exceeds your ability to recover, and a plateau results.
When you decrease the volume and frequency of workouts, a lower demand is made on your ability to recover. This again allows growth to take place. However, what must now increase, is the intensity of effort of each and every set performed. Each set must be taken to failure (in ultra-strict form, no swinging, cheating, hitching and no partial range repetitions. Only full, pain free ROM for each repetition. Not only is this done to prevent injury, but also to promote muscle growth.) Reduce sets to a bare minimum, preferably to one set per body part and reduce frequency to one or two workouts per week.
Yes, I know there are a lot of unanswered questions; What exercise are the best ?, How many exercises per body part?, How many reps per set?, How much weight to use?. But these are all relatively minor details that I will flesh out in another blog post. In the meantime, the basic premise I want to convey is this: reduce the volume of your bodybuilding workouts by approximately one half and reduce the frequency of your workouts by half and watch you progress begin, in earnest, again. That is the best way to continue to build muscle size/strength.
In my last blog I explained what is called the “natural history” of back pain and elaborated on how the overwhelming majority of all back pain will be significantly better or fully resolved in 6 weeks or less---if you do nothing. In other words, it most oftentimes gets better on its own. I also mentioned that the problem is, the pains usually recur. That is to say, the pains come back, usually repeatedly and over the course of months or years the episodes of pain can become progressively worse.
As a result, the best course of action is to embark on a treatment plan that places a heavy emphasis on the prevention of recurrence. The good news is, this can be done and very successfully. OK, so if this is the best way to go, why doesn’t everybody do it? The reasons fall into two broad categories:
Let’s assume your pain began early in the day, and by evening, not only has your lower back gotten no better, but you are now beginning to experience an increasing pain going from your lower back down your right leg. Any attempts to bend either forward or to straighten up are met with additional sharp pains. When you stand slightly bent forward, this seems to be the position that very slightly reduces your pain, but lying down is your best position for now.
What I’ve just described is a very common clinical scenario for someone with acute lower back pain. In a case like this, it would be highly counter-intuitive for you to make repeated attempts to straighten up or bend backward. After all, attempting to straighten up increases your pain. Additionally, when attempting to straighten up or bend backward, you feel like something inside your lower back is "blocking" you from going in that direction. But yet, this may well be exactly what is needed for you to not only decrease the pain, but to abolish it altogether and in a rapid manner. Most importantly this may well the first step with regard to successfully preventing future episodes. And prevention of future episodes of pain is, after all, what we are after.
What you need at this point is a coach. Someone with training and experience who can confidently, clearly, and yes, repeatedly explain and demonstrate to you that beginning the process of bending backward and straightening up, although initially painful in the lower back, will decrease the pain in your leg. This coach will also repeatedly and diplomatically explain to you that increases in the center of your lower back are a good sign and should be taken as an indicator that the exercises and position prescribed are taking you down the correct path to fully resolving your pains. Fully convincing a patient of all this, a patient that is already anxious, in pain, frightened and probably agitated is not easy, to say the least. It requires patience, persistence, repetition, repeated demonstrations and resolve---on the part of the coach. In short what you need is a good physical therapist. And a good physical therapist, with all of the above qualities, is rare indeed.
Much more likely is the chance that you will receive a therapist that will provide some low-grade palliative treatment such as some form of heat, therapeutic ultrasound, low level traction, electrical stimulation, massage, manual mobilization and instructions to assume positions of least pain, positions which you have already intuitively discovered to provide you with some minimal pain relief. This type of treatment will be given for several sessions as the passage of time provides its reductions of your pain (the natural history). In a few weeks to a few months your pain will, in all likelihood, return, and the whole cycle will be repeated.
Now let’s move on to what I meant when I said, “It’s difficult.” I meant "it's difficult", not just for the patient experiencing the pain, but also for the therapist. To tolerantly explain to a patient that straightening-up and beginning the process of bending backward is the best therapeutic approach, with some patients, can be very time consuming, tedious, frustrating, stressful and understandably met with some resistance and hesitation on the part of the patient. After all, broadly speaking, the therapist is now trying to convince the patient that an increase in pain is a good thing. Keep in mind, the patient has sought out professional help, is paying a fee and has taken the time and effort to come into a clinic to get one thing and one thing only: pain relief, not pain increases.
The process of reducing pain in the leg, at the expense of (temporarily) increasing pain in the lower back is definitely a good sign and is, in fact, one of the best indicators with regard to determining the correct movements and exercises. Additionally, there are now good scientific studies showing that if your pain moves toward the center of your spine (even at the expenses of temporarily increasing central back pain), and the pain decreases in the leg, your chances for a full recovery are excellent. Nevertheless, this can be a “tough sell” to a patient already in pain and desiring quick relief.
For the therapist providing care in a busy clinic, where the therapist is under the pressure of productivity quotas and ratings, in a clinic where other therapists are providing only temporary, palliative treatments, easy-to-apply treatments that are met with minimal, if any, resistance by the patient and doing so in a much less stressful environment, with less time commitment, it can be very tempting for the therapist to take the path of least resistance and begin treating patients with a less labor intensive approach.
Combine 1)Human Nature and 2)the Inherent Difficulty in providing better quality care and it is understandable why “not everyone does it”.
There is one additional issue I want to mention: The reward that comes from doing the right thing. (And yes, many patients do in fact appreciate it.) There is also the satisfaction that comes from being able to successfully treat a patient using your intellectual skills and knowledge rather than simply doing what is “easy”. The choice for a physical therapist, as to which treatment approach to select, is still, red pill or blue pill. I made my choice many years ago.
I want to start this blog by acknowledging something that for obvious reasons, I virtually never see even mentioned in any advertisements, websites and various other marketing efforts directed at
treatments/prevention of back pain. I am referring to what is sometimes called the “natural history” of back pain. The natural history refers to the fact that the overwhelming majority of all back pain gets better by itself, without any treatment whatsoever. (The catch is, it oftentimes continues to recur). But let me start at the beginning:
It is astonishing, but in the last half-century, a time when we have seen some almost unbelievably
exciting advances in medical science, we have not advanced with regard to reducing the incidence of what is one of the most expensive problem in all of health care: spinal pain. Along with diabetes and ischemic heart disease, back/spinal pain comes in as the 3rd member of what I call the “Big 3”. These are the three most expensive health related issues in the entire country.
Here’s the not-so-dirty little secret about lower back pain that few chiropractors or physical therapists will openly reveal: well over 90% of all back pain, even the sharpest of pains, will be significantly better or fully abolished in 6 weeks or less if you do nothing. That’s right, if you seek no formal treatment, just “take it easy” for a few days to a few weeks, and …voila! Your back pain will, in all likelihood, be gone or nearly so, in relatively short order. The mere passage of time is enough to oftentimes have a dramatic pain relieving effect.
Here’s the dirty part of the secret that nary a physical therapist, chiropractor or anyone else who makes a significant portion of their living from treating back pain patients (count me as one of them) will divulge: Virtually any treatment, be it any of the various forms of traction, heat, cold, ultrasound,
electrical stimulation, decompression, injections, medications, massage, manipulation, surgery (laser-surgery or any other kind), yoga, weight training, tai-chi, myofascial treatments, trigger point
therapy, core strengthening, stretching, spinal stabilization, pain management or any of the hundreds of pills, potions and lotions that are available over-the-counter---any and all of these treatments will almost assuredly make the patient better or “cure” them.
This puts a back care practitioner like myself in a great position; as long as I don’t do anything too
aggressive with a patient, as long as I don’t do anything to the patient that even temporarily or slightly increases their pain, I am assured of a success rate with my patients that will be well in excess of 90%. That’s a great success rate by anyone’s judgement. In fact, it gets even better for me; although the patient’s pain has, in reality, been relieved simply by the passage of time alone, most patients will give me and my treatments the credit for relieving their suffering. Not only is this gratifying for my ego, but it also enhances my bottom line. Here’s how: I have, by way of my treatments (any treatment) of the patient (treatments which were worthless but harmless), now set up a powerful Pavlovian response in the patient: The next time this patient experiences a bout of back pain, they will instantly remember what they believed to be the course of action which previously relived their pain, i.e. they need to come and see me…and ching, ching. I have now, in effect, created the most sought after commodity for any spinal clinic patient: The repeat customer. After all, it only makes sense; I’m in pain now, so my brain automatically recalls what it believes relieved my pain the last time around. Meld this powerful conditioned response to the current culturally reinforced belief concerning healthcare, namely that any time we are in pain, there should be someone else who will fix it for me. This provides the back-care specialist the perfect combination of conditioning and dependency to assure a continual flow of patients and dollars.
Oh, I know you’ve heard from many physical therapists that they strive, above all else, to educate the patient thus making the patient self-reliant, free from the need for a physical therapist, physician or chiropractor for the treatment of future painful episodes. But in reality, the overwhelming majority of clinics want patients to keep coming back over and over, ad infinitum. The last thing they want is self-reliant patients who have been effectively educated to the point where they are able to treat subsequent episodes of pain independently. What all too many healthcare practitioners really want is a long line of patients who have a strong sense of dependency on them and the “treatments” they provide. They want patients who are highly conditioned to seek them out each and every time their pain recurs.
Yes, there is a better way. I will address this in another post, as well as the ultimate question: If there is another way and it’s so effective, why isn’t everyone doing it?