This document summarizes key points from the book "Watch Your Back!" by Richard A. Deyo. It discusses the overtreatment of back pain in recent decades, with a 300% increase in MRI scans and 100% increase in narcotic painkiller use from 1994-2005. While many "cures" exist, functional limitations continue to rise. Bed rest was once the standard treatment but exercise is now recognized as more effective. Patients should be actively involved in decisions by understanding treatment options, benefits, risks, and the implications of no treatment. Unnecessary medical tests often lead to incorrect treatments and extra costs without benefits. Drug companies have influenced medical organizations through marketing and sponsorship, potentially contributing to rising opioid overdose deaths.

1. CORNELL UNIVERSITY PRESS
512 East State Street • Ithaca, NY 14850 • www.cornellpress.cornell.edu
WATCH YOUR
BACK!
RICHARD A. DEYO, MD
PUB DATE: OCT 21, 2014
220 Pages
Cloth ISBN 978-0-8014-5324-3
$21.95 / £13.50
FOR INTERVIEWS CONTACT:
RICHARD A. DEYO, MD
E • DEYOR@OHSU
FOR ADDITIONAL INFO:
JONATHAN HALL
E • JLH98@CORNELL.EDU
With nearly-two thirds of all adults reporting back pain at some time in their lives, it is no
surprise that there has been an exponential growth in back pain treatment over the last
twenty years. According to author Dr. Richard A. Deyo and his research team at the Univer-
sity of Washington, from 1994 to 2005 there was a 300 percent increase in MRI scans of the
lower back for Medicare patients, a 100 percent increase in the use of narcotic painkillers
for back pain, and a 200 percent increase in spinal fusion surgery. Deyo asks us to confront
the fact that we have a surplus of approved “cures” for back pain (over 200 options avail-
able, not including surgeries), yet annual surveys of people with back pain report steadily
worse functional limitations and work disability.
Putting Bed Rest to Bed
Deyo describes the standard treatment for back pain when he first began his medical
career in the 1980s as such: “Strict bed rest. You were not to get out of bed for meals. You
were not to sit up in bed. We debated whether it was okay to go to bathroom or whether
a bedside commode was necessary.” Seems a bit extreme, doesn’t it? But the fact of the
matter is, in recent history the most common treatment for back pain was bed rest. This
was the case for John F. Kennedy, who was regularly condemned to bed rest for up to
weeks at a time for his back pain. Kennedy also underwent multiple surgeries and regu-
lar spinal injections. But it wasn’t until Dr. Hans Kraus provided President Kennedy with a
rigorous exercise routine that the President was able to lift his own son and return to play-
ing his favorite sports. College football star, Green Beret and Deputy Commander of the
nation’s Special Forces, David Fridovich is another American leader who battled with back
pain. He too found relief in exercise. In fact, physical activity has become such a successful
alternative to bed rest that rehabilitation doctors like Jim Rainville of Boston have been
able to create careers out of helping even those who have suffered through unsuccessful
back operations and severe activity limitation for years simply through rigorous exercise.
Active Versus Passive Treatment
Arguably the worst thing someone can do for their back pain is sit back and let a doctor or
someone else try and fix it for them. As Deyo puts it, “passively expecting a pill, procedure,
or program to cure back pain is unrealistic. Instead, patients need to become actively in-
volved in their own care and decisions about it.” But involvement only goes so far if you’re
not informed about what exactly you’re getting involved in. Luckily, there is a growing
~over~
DESPITE COUNTLESS BACK PAIN “CURES,”
PHYSICAL EXERCISE MOST EFFECTIVE TREATMENT

2. interest among doctors in facilitating a process of shared decision making with their pa-
tients. Deyo encourages patients to know the answers to these four questions before mak-
ing any decision: What are your other options? What are the likely benefits of each, and
how big are those benefits? What are the most common and serious risks of each option?
What will happen if you don’t have the treatment?
Less Is More
The US health care system wastes one-third of all spending (approximately $900 billion)
on errors, waste and inefficient care. Deyo explains how we as people are programmed to
want more tests to ease our anxiety, because “an extra test, ‘just to be sure,’ seems prefer-
able to missing something.” And doctors are providing them, despite the fact that clinical
guidelines recommend doing MRI or CT scans on only the unusual patient with extenuat-
ing circumstances. Government or insurance spending aside, unnecessary testing leads to
more problems for the patients themselves as well. There is no definite way to see how a
scan correlates to the patient’s pain. It’s an issue of correlation versus causation. Deyo ex-
plains that this fact can be proved through those who have no back pain but have horrible
looking spines on an MRI. So, scans often lead to incorrect treatments, unnecessary addi-
tional tests and dozens of extra doctor visits.
Drug Companies’ Influence
If you scratch my back, I’ll scratch yours. That’s exactly what drug companies said to the
American Academy of Pain Medicine when they started allowing the drug companies to
hold sponsored seminars at their conferences and education programs. Companies like Pur-
due Pharma, Abbott Laboratories, and Endo Pharmaceuticals are known to have “premiere
status” at AAPM’s Annual Meeting and other networking events. These three companies
in particular also happen to be the makers of OxyContin, Vicodin and Percodan. As Deyo
describes in his chapter on painkillers and the marketing of pain, recent events have raised
concern about companies’ influence on medical organizations and doctors’ prescribing
habits. In 2011, AAPM made $1.3 million off the drug industry. Aside from misleading doc-
tors and patients alike, aggressive marketing may contribute to prescription opioid-related
deaths which have quadrupled since 1999; there were 16,651 deaths in 2010 alone. That
figure far surpasses the number of deaths from heroin and cocaine combined.
How Ineffective Treatment “Works”
So as more and more treatments for back pain are being proven ineffective, why do some
people continue to swear by them? Deyo claims there are four main factors that exag-
gerate the real effectiveness of therapy: natural history, regression to the mean, placebo
effects, and caring attention. Natural history refers to the natural healing process and the
idea that your body really does know how to take care of itself. “Regression to the mean”
can be translated to “returning to the average.” This is the idea that pain is not consistent,
and you’re likely to see a doctor when it is at its worst. But extreme symptoms are likely
to return to their average level over time, making you think that whatever treatment you
tried in the process worked. The placebo effect is a widely-understood concept that applies
to treatments for anything from back pain to depression. In a collection of studies done
using placebos, up to 85 percent of subjects experienced placebo effects. One idea behind
this is the effect of expectations: “If you expect that treatment is going to reduce your
pain, that alone may reduce anxiety, fear and the severity of pain. Things may seem more
controllable, and you may be even more likely to notice small improvements and dismiss
negative events.” Finally, caring attention refers to the idea that a doctor’s friendliness,
interest, empathy and attentiveness all may enhance the effects of ineffective therapy.