When I was in active practice I was often asked, and now working with clients that I train individually, I continue to be asked, a recurrent question.

“Doctor Fudala… What is the best treatment for low back pain?”

For those of you surfing at warp speed, with the attention span of a hummingbird, and want to get right to the point… here is the answer.

There is no such thing as a “best” treatment. And, if your clinician tells you that a certain treatment has been shown to be clearly better than others, they are “cherry picking” the scientific literature, or giving you their own biased opinion, to support the type of treatment they most likely earn their living providing.

For those of you who have followed my posts over the years, you have heard, or read, me making these statements many times. But, for the sake of this article, I will do so again.

There are over 250 different treatments for low back pain.
There are at least 23 different types of clinical professionals who treat it.
Science has never clearly shown one treatment as proven to be better than any other.
Science has never clearly shown one type of clinician as proven to be better than another.

In fact, here is the most honest thing that can be said about the treatments, and clinicians who provide them.

Everything works for someone, nothing works for everyone, and it is impossible to predict with a high degree of certainty how well anything will work for anyone. (I have the scientific references to prove this, but don’t want to bore you with them right now. Send me an email if you want them and I will get them to you.)

The point I am making here is NOT that any treatment is inherently bad, and NOT that the clinicians who provide treatment are doing so solely for financial self-gratification.

My point is that there are SO many treatment and SO many professionals offering treatment that it can be confusing, if not entirely chaotic, trying to decide what you should do.

I have found that, for me at least, when faced with the need to make a decision when the “optimal choice” is not clear-cut, having a frame of reference for comparison is helpful.

In such situations the frame of reference I use is to usually compare my options against what I would consider to be an “optimal choice”

So, lets now look at what I would consider the “perfect” treatment for back pain based upon the experiences I have had.

If there were such a thing as a “perfect” treatment (which as I have said, there is not), that low back pain treatment would do the following things:

Completely relieve your pain.
Relieve your pain by healing the problem that caused the pain and returning you to “normal.”
It would do the above quickly and affordably.
The treatment would be consistently predictable in the type of results produced and the type of person or condition who would get those good results.
It would be painless.
There would be minimal if any risks or adverse side effects.
The results of treatment would make is so that condition would NEVER return again.

Now, you may decide to undergo (or have undergone) a certain type of treatment and experienced a complete relief of pain, with minimal or no side effects, and feel like your function has been restored to completely normal.

Again, I don’t discount that this can happen.

My point is, that someone else, whose lifestyle and condition is similar to yours, in almost every way possible, could have that same treatment and get entirely different results.

So… knowing that there is no treatment that is consistently “right” or “best” for everyone, how do you go about choosing a treatment that is “right”…FOR YOU?

When working with clients who need treatment (and many find that they don’t after putting the lessons in SpineCamp to work for them) I suggest that they consider the following 3 part formula.

Know what’s REAL
Understand how to assess your personal RISK (s)
And once you know what’s real and the level of your individual risk (s), you will then be able to make a well-informed decision about what is most RELEVANT to your situation.

Lets take a closer look at those 3 “R’s+ (Reality, Risk, Relevance)

REALITY involves knowing how to keep the right type of clinical score (and most of you have never been shown how to do this) so that you can do several important things.

Have realistic expectations of what is meant by treatment “success'“ (most research has shown clearly that people’s expectations are unrealistic, often because of what they have been told by their treating clinician)
Be able to monitor your own progress to see if a change in treatment approach is needed.
Knowing how to keep the right type of score (the way clinicians do.. and it’s not difficult) also lets you make accurate and reliable comparisons between different types of treatment.

Additionally, reality means knowing what your treatments do, the effect they have on your body, the time involved to receive them, and any potential risks or drawbacks they present, and how much they cost (both in time and money)

RISK involves giving consideration to the SAME 3 RISKS that each of us have, although in differing degrees. Those risks are:

Time
Money
Health

It’s also important recognize that risk not only applies to what may happen when/if you do something, but also what could happen if NOTHING is done and you just try to wait the situation out. (this can often the best approach, but is something that many of you are unaware of because of what you have been told)

Here are 2 examples of the variability of risk in different individuals.

Example 1: Bob is a very wealthy and successful businessman and money is no concern to him. Since he owns his own business, he enjoys the freedom to come and go as he pleases without it costing him money, and without him having to answer to anyone. Bob has been struggling with chronic low back pain and several surgeons have suggested a lumbar spinal fusion. Although he has heard of some doing well with surgery, he has also seen those who have done poorly and had to give up many of their activities. Bob is also an active, athletic, man, and although his activities cause him pain, he hasn’t had to give up anything because of his back pain.

In this situation, Bob has several options. Surgery is probably NOT at the top of the list. Even though there is the possibility that such a surgery could result in significant relief, there is also the possibility that the surgery wouldn’t be successful, leading to more pain and less function. Colloquially speaking, “the climb is not worth the possible fall.” By this I mean that because Bob is already still able to do most of what brings him value in his life, he possibly has as much to lose from surgery (if it doesn’t work) as he does to gain if it does (pain relief).

Regenerative medicine treatments, such as stem cell, PRP, prolotherapy, etc may be another option for Bob, and possibly a good one. As with most other treatments, the results of regenerative medicine methods cannot be predicted and are not universally successful. However their biggest downside (risk) if they DON’T work is the money spent to get them (very expensive) and the time it takes to wait and see if there is benefit (their benefit is often not seen for several months). In Bob’s case, he has the money to spend without it significantly compromising his lifestyle and he has the time to see if they work because he is still able to do most of the things that bring value to his life (even though they may cause increased pain.)

Example 2: Mary has not been able to work (desk job) for several months due to severe low back pain. It is a struggle to get out of bed in the morning and driving makes her pain markedly worse (she needs to drive 45 minutes each way to work). She used to exercise a lot, but has NOT been able to do anything since her pain worsened. Her inactivity and inability to work and care for her family (2 younger children) has led to increasing depression, anger, and weight gain. Even though Mary has a good job, she only earns enough money to make ends meet and her employer is becoming increasingly frustrated about her inability to work and her sick pay will only last for another 3 months.

In contrast to example 1, Mary differs from Bob in several ways. 1. She is unable to work, care for her family or exercise. 2. She has little money to spend on “experimental” treatments that are NOT covered by her insurance. 3. She is running out of time (and sick pay benefits) and if she cannot return to work she will lose her job.

In this situation, stronger consideration of low back surgery is warranted. Although not a “perfect” option, it may be her best because.. 1. It will be covered by her insurance. 2. She needs to do something to get back to work as quickly as possible or she will lose her job. 3. Even though there are potential risks to surgery, she seems to have as much (or more) to gain if it works out. (returning to work, being able to exercise and care for her family again, etc). In Mary’s case, the risk of surgery needs to be weighed against the risk of spending the out of pocket money (she doesn’t have) for “safer” treatments as well as the risk of losing her job, insurance, etc.

The above scenarios represent just a fraction of the many possibilities that exist and need to be considered when making treatment decisions. And, as with the above examples, for most of you these important factors are more related to life-style and individual circumstances than they are to medical or clinical factors. Unfortunately, this is something that is commonly misunderstood and rarely discussed when treatment decisions are being made.

Now, lets summarize the above 2 examples from a REALITY, RISK, RELEVANCE standpoint comparing Bob’s situation to Mary’s:

REALITY:

Bob and Mary shared a similarity in that neither of them could predict what type of treatment would work or how well it would work. But..
Bob had the out of pocket money to spend on “investigational” treatments and Mary did NOT.
Bob was still able to most of the things that were important to his life and Mary was NOT.
Bob had the time to wait and see if his Regenerative treatments would work and Mary did NOT.
Mary was becoming increasingly frustrated and angry and Bob was NOT.

RISK:

Mary was at risk of losing her job and Bob was NOT.
Mary was at risk of losing her insurance and Bob was NOT.
Bob would be at risk (if surgery didn’t work) of losing the ability to do the important things he was still able to do and Mary was NOT. (she was unable to do most of the things that were important to her life)

RELEVANCE:

For Bob, you can see how Regenerative treatment may be the most relevant to his situation. He had time, money, and the ability to still do the stuff he wanted to do. He was not at risk of losing his job or insurance as he waited things out. He didn’t want to accept the risk (even if it was small) that his physical abilities would be compromised if something like surgery didn’t go as well as anticipated.
For Mary, it is clear that Regenerative treatments were NOT relevant because of her having no time, little money, and she risked losing her job (and insurance) if she wasn’t able to return to work fairly soon. Surgery also seems to be the better option because Mary was NOT at much risk of physical loss because she was already NOT able to do the stuff she wanted to do.

In closing, there is much more than pure science when it comes to making decisions about treatment.

The only “BEST” treatment is the one that is most relevant to YOUR life and your current situation.

Sign up for my blog below and you will also be sent (FREE) my three part series that goes over the following topics.

Know Your Score
Know What’s Real
Know Your Strategy

Once you know these 3 things you will be in a better place to determine what is RELEVANT to your current situation.

Thanks,

Dr. RDF (rdf-10)

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