Doctor Doom

George Washington's doctors couldn't save him - they might even have killed him

On Dec. 14, 1799, doctors attending to George Washington bled the first president of the United States five different times, extracting, depending on which account you believe, 1.7 to 3.75 liters of blood in a failed attempt to cure him from a severe throat infection.

The invasive practice of bloodletting, which had been carried out by healers for more than 2,000 years, was disparaged by Dr. James Brickell, who criticized the practice six weeks after Washington’s death.

“Very few of the most robust young men in the world could survive such a loss of blood; but the body of an aged person must be so exhausted, and all his power so weakened by it as to make his death speedy and inevitable,” Brickell wrote.

More than 200 years later, medical science has progressed to a point where such a “cure” would be considered truly cringe-worthy by most physicians and patients alike, particularly when held up against the medical triumphs of the polio vaccine or the discovery of penicillin.

Yet every day in the U.S. and in developed countries around the world, at hospitals and high-tech outpatient surgery centers, hundreds of similarly invasive – and often, unfortunately, similarly unsuccessful – procedures are carried out on willing patients hoping to get relief from back, knee, or shoulder pain.

Surgeons slice through muscles and nerves, cleat together bones with metal, replace aging joints with mechanical ones and reattach ligaments to bone.

Sometimes the results are spectacularly good – aging weekend warriors who spent their cartilage have a new lease on life, skiing again for the first time in years or even running marathons after stints of serious debility.

But sometimes they’re just as spectacularly bad, causing more pain, paralysis, infection or even death and often leading patients to undergo numerous other surgeries in attempts to rid themselves of pain. Doctors even have a name for this downward spiral, it’s called Failed _____Surgery Syndrome (fill in the blank with back, knee – you get the picture.)

What most patients don’t know is that many orthopedic surgeries are proposed and conducted despite the fact that their efficacy, or their capacity to produce a beneficial change in the patient’s condition, is relatively unproven against alternative, more conservative treatments. That’s because designing a randomized clinical trial (the gold standard of medical research) comparing surgery to alternatives requires that surgeons conduct “fake” surgeries – procedures that many would consider an ethical breach of the oath to not harm patients unecessarily.

When it comes to back surgery, this cut-first mentality is harming patients. According to this 2004 study, which looks at 18,325 patients with back pain, “previous back surgery is associated with significantly worse general health status than those without surgery.”

Studies like these and others that emphasize psychological factors as an important element in many kinds of chronic pain, make it clear to me that surgeons often don’t know if their invasive treatment is going to relieve their patients’ pain. Worse yet, they’re absolutely playing with fire when they start cutting into healthy tissue. Consider this report, in which nine percent of more than 8,000 surgeons surveyed reported they had made a “major medical error” in the last three months.

I believe more research is sorely needed into how emotional and psychological factors can impact or even cause chronic pain. After all, if counseling, group therapy or other non-invasive treatments like exercise or biofeedback can help, we’re risking a hell of a lot less than the patient who agrees to get cut on under anesthesia.

This report, presented at a major conference called Orthopedics Today Hawaii 2010, signals that some doctors are moving in the right direction. Dr. John Bergfeld, of the The Complex Patellofemoral Pain Clinic in Cleveland, spoke of 150 patients treated at the clinic – all of which had previous failed surgical treatment to correct either instability or pain in the knee (patients, 87 percent of which were women, had an average of 3 unsuccessful surgeries and one had 32 procedures on her knee.)

Bergfeld reported that 42 percent of those 150 patients were victims of childhood abuse – 23 percent of that was physical, verbal or neglect and 19 percent was sexual. Therefore, he added, “malalignment does not mean pain, and realignment [read surgery] does not guarantee the relief of pain.”

He went on to urge those doctors attending the conference to listen to their patients – not to presuppose that surgery was the cure for their problems.

“Listen to what they are telling you,” Bergfeld said. “Do a physical exam without bias; do not have your mind made up about what you are going to do before you even start.”

Walkin’

This guy's back feels GREAT!

My back didn’t have a very good December. It got really cold in Salt Lake City, I abandoned my eight-mile-round-trip bike ride to work every day and I’m pretty sure I strained it bowling three games on the Friday after Thanksgiving. The result: an irritating dose of sciatica on the left side that lingered through two sessions of deep-tissue massage, my regular core routine and my twice-weekly weight lifting routine (low weight, high reps).

But today, as I type, I’m going on more than a week of no pain whatesoever. And I’m convinced its due to walking – the oldest, most trusted weapon in my chronic pain arsenal.

I walked about 25 miles this week, getting most of the miles in on four-mile one-way trips to work. Each trip takes about an hour of brisk walking that really gives my legs a workout. This mode of transportation has its advantages – it’s free and it’s a gives me time to myself to think and relax.

It’s also carbon-neutral which is a huge bonus in this town, which this winter has hosted worse air quality than L.A. for several days thanks to a weather quirk called an inversion that traps pollution and drapes the valley in a nasty brown cloud.

Commuting to work on foot  is a bonus because I’m using time that I would have spent just sitting on the bus or driving – so I don’t have to set aside much extra time for workouts. While I’m lucky enough to live close enough to work to be able to walk the whole way, even those who live farther can easily build in a walk to the bus stop or park-and-ride.

But the best thing about walking is its absolute simplicity – there’s no gear, no getting in the car to drive to the gym, no throwing the bike up on the rack for the drive to the trailhead. It’s as easy as putting one foot in front of the other.

“Completely Researched and Scientifically Proven”

Laser Treatment "Heals" Damaged Backs? In What Universe?

Newspaper advertisements really have changed, haven’t they? Where before the big, full-color front-section ads pitched department store purses and clothing or car tires, now they are selling full-blown medical cures. In Sunday’s Salt Lake Tribune, Utah Spine and Disc exhorts: “Live Pain Free, Free Yourself From Chronic Pain, Whether it’s Back Pain or Arthritis, Dr. Meadors Can Help You.”

The ad goes on to say: “Completely researched and scientifically proven to be effective, the Newlife Signature Laser provides soothing relief from many kinds of chronic pain, from Lower Lumbar and Sciatic Pain to the treatment of painful Arthritis. The research is conclusive: Laser treatment heals damaged tissue in the back.”1

The “1” footnote on the half-page advertisement presumably refers to proof outlining how Laser Treatment “heals” damaged back tissues. Only problem is, there is no corresponding footnote explaining the truth of this statement.

Maybe that’s because – just an educated guess here – there actually is no proof that this surely expensive therapy does what the ad claims it does?

It’s unclear just what particular kind of laser Utah Spine and Disc is promoting. The ad mentions “LLT Approved” devices. Perhaps they meant “LLLT (Low Level Laser Therapy), instead? If so:

A 2007  study encompassing six different randomized clinical trials found that “there was no difference between LLLT and comparison groups for pain-related disability”. Unless Dr. Meadows and company has a new trial showing drastically different results, why would he be allowed to advertise this “clinically researched and scientifically proven” method of back pain treatment?

Here’s what the FDA says about LLLT, also known as Biostimulation Lasers (note the emphasis on “temporary” pain relief’):

Biostimulation lasers, also called low level laser therapy (LLLT), cold lasers, soft lasers, or laser acupuncture devices, were cleared for marketing by FDA through the Premarket Notification/510(k) process as adjunctive devices for the temporary relief of pain. These clearances were based on the presentation of clinical data to support such claims. FDA will consider similar applications for these and other claims with the decision to require clinical data being made on an individual basis, taking into consideration both the device and the claim.

The controversial 510(k) process is used for products that the FDA determines to be a lower risk to consumers because they’re similar to devices that have already been approved. This speeds up the approval process – typically to just 90 days – getting devices to market quicker while sometimes foregoing requirements for thorough clinical trials. But the program has been under fire by critics who say the accelerated FDA approval timeframe can compromise patient safety.

My guess – and it’s just a guess, I’ve never tried laser therapy for back pain – is that these patients would be be better served by employing exercise and/or behavioral counseling than they would be paying Utah Spine and Disc for treatment that the FDA says only leads to temporary pain relief (contrary to the unbelievably misleading ad, which claims to “heal damaged tissues in the back.”)

Relaxation Response

Fight Fight-or-Flight: Herbert Benson Says Relax!

Most chronic back pain sufferers will try anything for relief, from costly, often-addictive drugs to surgeries to unproven alternative therapies. But what if each of us had a magic button we could push to sharply decrease pain? And what if this button was free, easy to access and proven to also improve symptoms of other illnesses ranging from hypertension to insomnia?

Mind-body pioneer Dr. Herbert Benson calls that magic button The Relaxation Response. When Benson published his book with the same name in 1975, it quickly became a bestseller and helped to launch a medical movement that is still delving into the healing power of the mind.

Benson, a Harvard Medical School doctor and researcher, presents a science-based case for a kind of meditation-light without all of the whistles and bells (or gurus), which takes only 20-40 minutes a day to succeed in lessening the symptoms of a host of common ailments – including chronic pain. The technique, which involves emptying the mind of everyday thoughts by repeating a word, or mantra, over and over, reduces the body’s consumption of oxygen and leads to drops in the level of blood lactate – a known contributor to anxiety.

Together, these physiological changes counteract the negative effects of the so-called Fight-or-Flight Response, which we all elicit wrongly in response to everyday work and family stress, Benson says. Fight-or-Flight is a human response to perceived threats which quickly increases blood pressure and breathing rate and the flow of blood to muscles. Over time, repeated experience of this response can lead to hypertension, and an increased risk for heart attack and stroke.

One thing I thought was particularly interesting about Benson’s book was his documentation of religious and spiritual ceremonies that effectively have elicited a similar “relaxation response” for hundreds of years. Without discounting those proven techniques, Benson successfully demystifies the practice of meditation and prayer through repeated scientific explanation and reporting of rigorous study.

I think many people with long-term back pain understand or at least suspect that outside stress makes pain worse. These folks should put Benson’s Relaxation Response – as well as exercise, other stress management tools and good nutrition into their toolboxes.

“Catastrophizing” Back Pain

You think you got it bad? A little perspective, please!

This image is a good analogy for how I’ve felt at my absolute lowest – when back pain took over my life and I had zero hope for the future. Absolutely overwhelmed, I spent hours lying on the floor, refusing to attend social events, whacked out on muscle relaxants and wondering if my life was worth living.

I’ve been in that boat twice – the first time when severe leg pain returned shortly after my first surgery and the second in 2005 when a bad job, bad relationship, poor physical conditioning and absolute terror of my spine left me totally debilitated.

For those reading who feel like that now, know that I recovered. I went on to ride miles of single track mountain bike trails, travel to Mexico and Hawaii and France virtually pain free – I got married to someone wonderful.

Also know that as I write this I’m dealing with some pretty sharp pain – a knife of sciatica deep inside my left hamstring, likely brought on by some ill-advised bowling, a touch of holiday stress and cold weather that led me to cut 25 miles per week of bike commuting out of my fitness schedule (I’ve since resumed riding on my stationary bike to compensate for the loss.)

The difference between then and now is I’m not climbing down to the floor to wait this pain out. Knowing that it will go away eventually and I’ll be as good as new, I’m hastening its departure with smart exercise and positive thinking.

As a result, I’m still participating in life: I lifted weights at the gym twice this week, rode indoors for 16 miles (I plan another 8 tonight before dinner), walked 5 miles, picked out a Christmas tree with my wife and hauled all seven feet of it into our house (my wife helped – which turned out to be a smart decision!)

As I’ve delved into the back pain research project that is this blog, I keep coming across this “catrostrophizing” word, which frankly rubbed me the wrong way at first because it strikes me as clinical and made up. But I’ve come around – now I think it’s a perfect description for how I have hobbled myself with fear over the course of my 20-year battle with back pain.

Pain researchers are starting to investigate as well. This interesting study of Danish healthcare workers found those who feared job-related pain were more likely to experience that pain- a self-fulfilling prophesy that I have personally experienced more than once.

That stress is negatively associated with cardiac disease is no longer debateable;  it’s a fact that’s been proven by multiple clinical studies. I’m a firm believer that this insidious process is at work in back pain as well. And if you think about it, what’s more stressful than thinking you’re facing a tsunami of unending pain?

“If you have to prove you are ill, you can’t get well.”

Watch Your Back: Worker's Compensation Makes Us Sicker?

As both a patient and student of the back injury treatment industry, I have used this blog to discuss what I believe to be major impediments to recovery.

These include surgery, which, particulary for a diagnosis of “regional back pain”, is over-prescribed, rarely helps more than conservative treatment and in some cases makes the problem worse.

The psyche of the patient also hinders recovery, in my opinion, because patients “catastrophize” their injuries, leading them to protect them and furthering the cycle of pain and disability. I would add stress into this category as well, because I believe mind-body connection advocates who conclude that internalizing pscychological pain can cause physical pain, particularly in the lower and upper back.

Finally, I would say inactivity obviously hampers recovery, as does being overweight and excessive reliance on pain medications.

Dr. Nortin Hadler, in his fascinating book, Stabbed in the Back: Confronting Back Pain in an Overtreated Society, adds a counterintuitive item to the list: the worker’s compensation system. While he credits the indemnity program – used in the U.S. and other countries under different names – for successly reintegrating victims of traumatic work injuries back into the workforce, he holds it up as an abject failure when it comes to back injuries.

That’s because the status of those unfortunate enough to injure their backs at work immediately shifts from patient to claimant, Hadler observes. This designation can send patients on a years-long search to determine the degree of their injury – a journey that can lead to sometimes unnecessary surgeries because “refusal of treatment taints the claimant with innuendo that he or she does not really want to get well and return to work.”

“If you have to prove you are ill, you can’t get well,” Hadler writes. “Being challenged naturally causes anyone to focus on his or her symptoms, to recall the waxing more than the waning of symptoms, to be less inventive in circumventing activities that might aggravate them, and to consider any coincidental regional musculoskeletal disorder as yet another setback.”

This self-defeating, litigious downward spiral is creating legions of back pain sufferers stuck in a horrible limbo – unable to work and unable to heal, Hadler writes. And it’s an extremely expensive conundrum, as well.

While 80 percent of U.S. workers compensation claims are related to tramatic injuries such as dismemberment, Hadler writes, 80 percent of medical and indemnity payouts relate to the other 20 percent – claims that involve “regional musculoskeletal disorders, regional low back “injury” in particular,” he adds.

Pandora’s Box

If this was your knee, wouldn't you want an actual doctor looking at this x-ray?

If this film depicted your knee, I’d say it’s fair to assume you’d want a doctor to diagnose whatever problem you might be having with it. But if you were a patient x-rayed at one of several hospitals in the Southeastern U.S. from May 2007 through January 2008, there’s a good chance a non-doctor called a Radiology Practice Assistant looked at it instead.

To add insult to surgery (perhaps), the remote imaging company likely then sent it back (electronically) to where it was taken along with a diagnosis of your problem “written” by a “doctor” who actually never saw your film.  

This disturbing scenario – an electronically-enabled potential surgery factory faciliated by people without adequate medical training – is detailed in the recent indictment of Dr. Rajashakher P. Reddy, owner of Atlanta-based Reddy Solutions, according to the U.S. Department of Justice. 

What’s disturbing about it to me is the imaging aspect I’ve written about before on this blog (see “The Surgery Factory”, which discussed higher incidences of back surgery in areas with higher concentrations of MRI machines). Are we really taking so many images that it’s necessary to outsource radiology to private companies? And if that’s the case, are we really truly helping to heal these patients? 

I suspect not – instead we’re caving to special interests who advocate espensive medical imaging for everything for breast cancer screening for younger women (a very controversial subject right now) to people like me with regional back pain or sciatica who would likely benefit just as much from a conservative prescription of light exercise as they would from a laminectomy. (Don’t believe me? Check this study out.) 

Without delving too deeply into the breast cancer screening issue, I think it’s an instructive example that sheds light on the failure of back pain treatment in this country. 

To recap: the U.S. Preventive Services Task Force recently recommended that women in their 40s not get routine breast cancer screening – which goes against longstanding previous policy. The reason? Overall, it likely does more harm than good, leading to unnecessary anxiety or major surgery that may not be needed.

The imaging lobby – with the help of journalists who unfailingly painted sympathetic pictures of women saved by early detection – declared an absolute  jihad on the task force and anyone who dared to espouse its recommendation.

Gary Schwitzer, author of the excellent Schwitzer health news blog, called them out in this post , which detailed the inherent conflicts of interests of beneficiently-labeled groups like the American Cancer Society Cancer Action Network, (donors include Hologic, which makes breast imaging products, and Johnson and Johnson, maker of an image-guided breast biopsy product) and the American College of Radiology Imaging Network Fund for Imaging Innovation, whose donors include Siemens, GE Healthcare, Phillips, Hologic, and many others that make mammography machines or related products.

This experience is worth taking note of as the drive toward U.S. health care reform gathers momentum. It’s clear that vested interests like the medical imaging lobby and Big Pharma will fight like hell to keep Pandora’s Box open, even if it means patients suffer as a result.