Misinformed Consent? What not to tell a patient with back pain

We just came across a fancy patient information form that was given to a patient after an assessment by a clinician. The form just blew our minds (but not in a good way) because it seemed to be the perfect clinical tool for generating ongoing pain and disability, and all by the simple process of ramping up the fear. So, just for fun, we thought we’d take you through it….(we wanted to show you pictures but issues of copyright gave us the heebie-jeebies – however if you would like to see a blank version of the form you will find it on sale here.)

Page 1 “Examination findings and recommendations for care”.

This page shows a diagram of the spine that the clinician has highlighted in a number of places. Comments are added related to the specific problems of the patient including “curvature of the spine”, “degenerative changes in the spine” and “subluxation complex at the pelvis, L4, L3, T6, T1, C5”. We are starting to build a picture of a rather unwell spine. Unhappy curvatures, degenerative changes and multiple “subluxations”. Actual bona fide spinal malalignments? This sounds bad. No wonder it looks like this will need extensive treatment. In fact the notes assert that the patient will need to be seen twice a week for 3-4 weeks and then once a week for a further 5 weeks (and as we will later learn maybe many, many more times).

Page 2 “Your nervous system controls everything”. The terrifying consequences of subluxations

We are presented with another diagram of the spine, and at each vertebral level the organs/ systems that are associated with (I guess controlled from?) each vertebral level are outlined. For example T6 (the 6th thoracic vertebrae – right in the middle) apparently controls the pancreas, spleen, stomach, oesophagus, middle back (logically – no problem with that!) and duodenum. Our rusty anatomy can’t recall a precise anatomical basis for many of these pathways but it must be true because it just looks so glossy. For our unlucky patient it is amazing that they are still with us. Their identified subluxations suggest possible problems with their half their physiological systems. Our helpful clinician has taken the trouble to highlight the adrenal glands and the liver. So it’s not just the back that is at risk. Already I can feel my pituitary gland and liver begin to ache….

The “Spinal Decay Report” Oh my goodness my spine is crumbling!

Perhaps the most impressive piece of fear-mongering in the document is the “Spinal Decay Report”. This elegant graphic demonstrates a beautiful normal spine alongside images of the process of degeneration and draws a clear causal link between spinal dysfunction and wear and tear. It’s a bit like those horror posters you used to see at the dentist when you were a kid. Helpfully the clinician has highlighted where the patient’s spine is at on this continuum of misery, where they are headed to, and the patient can clearly see that without help they are looking at a permanent problem with “severe bone remodelling”, “irreversible joint fusion” and “permanent loss of function”.

What is wrong with giving patients detailed information? Absolutely nothing but ultimately information should be accurate and empower the patient to make good decisions. The problems here are legion. The patient is lead to consider their pain as the result of serious spinal malalignments (subluxations). Subluxations are a common focus of some chiropractic practice. However the evidence that such subluxations exist and are clinically important phenomena does not stand up to close scrutiny.  Amazingly there is strong evidence that that even clear and unambiguous structural spinal subluxations such as spondylolisis and spondylolisthesis as identified by MRI scans do not seem to relate strongly to back pain symptoms. There is also the implication that these subluxations may be causing disease of other biological systems (once again in the absence of evidence or a clear and plausible mechanism). The spinal decay report weaves a horror story of crumbling degenerating spines, but there is a wealth of evidence telling us that the association between the findings of spinal imaging and pain is weak to non-existent as is the predictive value of spinal imaging for the prognosis of back pain ( e.g. see here, here and here).

Ultimately by perpetuating these myths about back pain the patient is given good reason to fear the pain as a marker of serious disease; to somatize, catastrophise and alter their behaviour to protect their spine unnecessarily. If we consider pain to be “an output of the brain that is produced whenever the brain concludes that body tissue is in danger and action is required” then this information sheet appears to us to be a pretty good pain generating input. Of course we have no evidence that this information did have this effect but we feel it is a reasonable risk to highlight.

What could possibly drive such an approach to therapy? The final page of the report seems to offer some clues. “When you’re feeling better, you’ll have a decision to make. Will you continue with the care necessary to fully heal soft tissues? Or will you abandon the investment that you’ve made so far?”  A colourful graph shows us two possible courses of symptoms. One malignant red line tells a miserable tale of reduced function peppered with regular flare ups. The other cheerful green line demonstrates what happens when the patient invests in continued care. It is a friendly cuddle of an upward curve of improved ligament stability, biomechanics and “doing and being your best”. This of course can be achieved through “monthly checkings”.

Epilogue

Our concerns about this information sheet are related to how it could promote false and unhelpful illness beliefs and a reliance on unnecessary therapy in patients with normal benign back pain. However there is a more sinister side. The patient that this form was handed to presented as a late middle aged, thin lady with a history of rheumatoid arthritis. She was a smoker, had endured long term steroid use and complained of unremitting central mid thoracic pain. These are clear clinical signs to suspect a variety of possible serious pathologies including osteoporotic fractures (she had already had investigations that confirmed reduce bone mineral density in her spine and hips) and yet of the basis of the above assessment her spine was manipulated on 2 occasions. Of course the possible presence of osteoporosis is a contraindication for spinal manipulation. Errors occur in all areas of clinical endeavour and good and bad practitioners can be found wherever you look. However it is worth pondering whether basing an assessment on imaginary or scientifically bankrupt diagnoses might be a barrier to spotting real and serious ones. Later scans of this patient demonstrated thoracic burst fractures. This is not a happy tale.

About Neil

Neil O’Connell is one of the BiM collaborators and a researcher in the Centre for Research in Rehabilitation, Brunel University, West London, UK. He also tweets! @NeilOConnell.

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BWand

About Ben

Benedict Wand is Associate Professor at the School of Health Sciences, The University of Notre Dame

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References:

ResearchBlogging.org

Beattie PF, Meyers SP, Stratford P, Millard RW, & Hollenberg GM (2000). Associations between patient report of symptoms and anatomic impairment visible on lumbar magnetic resonance imaging. Spine, 25 (7), 819-28 PMID: 10751293

Borenstein DG, O’Mara JW Jr, Boden SD, Lauerman WC, Jacobson A, Platenberg C, Schellinger D, & Wiesel SW (2001). The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study. The Journal of bone and joint surgery. American volume, 83-A (9), 1306-11 PMID: 11568190

Kalichman L, Li L, Kim DH, Guermazi A, Berkin V, O’Donnell CJ, Hoffmann U, Cole R, & Hunter DJ (2008). Facet joint osteoarthritis and low back pain in the community-based population. Spine, 33 (23), 2560-5 PMID: 18923337

Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, & Hunter DJ (2009). Spondylolysis and spondylolisthesis: prevalence and association with low back pain in the adult community-based population. Spine, 34 (2), 199-205 PMID: 19139672

Mirtz TA, Morgan L, Wyatt LH, & Greene L (2009). An epidemiological examination of the subluxation construct using Hill’s criteria of causation. Chiropractic & osteopathy, 17 PMID: 19954544

Moseley GL (2003). A pain neuromatrix approach to patients with chronic pain. Manual therapy, 8 (3), 130-40 PMID: 12909433

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