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Amusing back pain patients with “evidence-based” garbage

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

An updated JAMA Patient Page on back pain is mostly an admission of defeat: medicine doesn’t have much to offer to most back pain patients beyond awareness of red flags.

The “options to consider” are a rogues’ gallery of trivial and dubious treatments that are technically evidence-based, but only according to extremely underwhelming “positive” trials and reviews that expert critics have been rolling their eyes at for years: heating, NSAIDs, massage therapy, acupuncture, mindfulness, muscle relaxants, yoga and t’ai chi, motor control exercises, spinal manipulation, laser therapy, cognitive behavioural therapy… ugh! (Yes, I have written about all of those topics to some degree, many of them quite a lot: every one of those links goes to a relevant article.)

This is a great example of really terrible “evidence-based” medicine, based only on weak cherry-picked evidence that ignores the broader and more nuanced view we might get from “science-based” medicine (or just better EBM, as you like, different strokes; see Why “Science”-Based Instead of “Evidence”-Based?).

How back pain should be managed is a tricky question (understatement), but the options suggested here are mainly a list of ways to “amuse the patient while nature cures the disease.” And waste their time and money, too! As Jim Eubanks, MD, put it more diplomatically, “We need guidelines for common musculoskeletal conditions to reflect sensible, science-based strategies to mitigate negative lifestyle effects, not a supermarket approach to natural history management.” Guidelines like these are such a joke that it is easy to make fun of them, as did years ago: “anything but opioids!” Such as “backgammon, yodeling, tickling matches…”

I don’t claim my back pain book has The Answers — it absolutely does not — but it definitely has a lot of education and perspective in the same spirit as this post. Just a lot more of it.

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