Monday, February 6, 2012

Spreading the unwelcome news about back pain

The best thing to do behind a man’s back is to pat it.
                    Lisa Jane McInnes-Smith

At the beginning of my quest, as I call it, I was a much more conservative doctor than I am now. Perhaps naively, I decided I was going to do things by the book and not unnecessarily step on the toes of my medical peers – if I could help it. I knew I was on to something, and the temptation to go public with my story via the media was a strong one despite the ethical risks over advertising.  However, I decided to go through the official channels to begin publicising the procedure. I knew it would not be easy because of the power of the backlash the procedure had generated some twenty years before.
I tested the water by sending an article about my results, taken from my follow-up with patients twelve months after treatment, to the Medical Journal of Australia.
Although the article was rejected, without reason, the editor kindly asked me to write a letter about my work which she undertook to publish in the letters to the editor section. It was duly published in May 1990, but failed to arouse much comment from readers.

Percutaneous rhizolysis: why does it work?
(Copyright ©the Medical Journal of Australia.  1990; 152: 500. Reprinted with permission)
To the editor:
Percutaneous rhizolysis was first described by Rees in 1971 1. Since then many articles have been published demonstrating its efficacy, 2,3,4 and yet it is still offered to relatively few back pain sufferers.
I recently completed a 12 month follow-up of 95 of my first 110 consecutive cases of back pain treated by rhizolysis. In the series the average patient age was 57.6 years (range 17 – 84) and the average pain duration was 13.6 years (range 0.5 – 42 years). The most common diagnosis to explain the pain was osteoarthritis. Every patient had tried (unsuccessfully) some or all of the following treatment modalities; non-steroidal anti-inflammatory drugs, physiotherapy, chiropractic, acupuncture, massage, injection, epidural corticosteroid therapy and operation. In most cases, physical examination yielded unremarkable findings except for the almost universal presence of myofascial trigger points in the vicinity of the pain, regardless of the underlying diagnosis.
At the follow-up examination, patients were asked to allocate their current pain and disability status into one of six groups:
  • Worse
  • No change
  • Mild improvement
  • Moderate improvement
  • Marked improvement
  • Total resolution
as compared with pre-treatment pain levels. A good result was considered as moderate, marked improvement or total resolution. By these criteria, 66.1% of cases achieved a good result. This series reaffirms the findings of previous studies that rhizolysis has a high degree of success in selected people with chronic back pain.

The original explanation for this success was that rhizolysis cuts the medial branch of the posterior ramus of the segmental nerve thus denervating the zygapophyseal joint 5. The theory was disputed because: an incision 2 cm from the midline would cut the lateral branch of the posterior ramus; in obese people the blade is not long enough to cut either nerve6, and trigger points often do not lie over zygapophyseal joints.
One explanation for the genesis of myofascial pain is that trigger points can be established by a wide variety of stimuli and that pain perception is transmitted centrally from these points by the Ad nerve fibres and the C slow conducting (group IV) nerve fibres7. Many different methods have been used to deactivate these points, usually with only temporary success.

An alternative theory to explain the success of rhizolysis would be that it divides these afferent or pain conducting nerve fibres thus effecting much longer relief.

For whatever reason rhizolysis works it should be offered to more people with chronic back pain before expensive and invasive instigations and operations are embarked upon.

                    Richard H Stuckey, MB BS

1.    Rees S Multiple bilateral sub-cutaneous rhizolysis in the treatment of the slipped disc syndrome. Ann Gen Pract 1971; 16: 126-127
2.    Toakley JG. Subcutaneous lumbar ‘rhizolysis’ – an assessment of 200 cases. Med J Aust 1973; 2: 490-492.
3.    Francis J. Subcutaneous lumbar ‘rhizolysis’ – an assessment of 200 cases. Med J Aust 1973; 2: 749-750.
4.    Rees WS. Multiple bilateral percutaneous rhizolysis. Med J Aust 1975; 1: 536-537.
5.    King JS. Randomised computerised trials of the Rees and Shealy methods for the treatment of low back pain. In: Morely TP ed. Current Controversies in Neurosurgery. Toronto. Saunders Press, 1976: 89-93
6.    Cyriax J. Treatment of intractable back-ache. In: Cyriax J ed. Textbook of Orthopaedic Medicine.  Vol 1. London: Bailliere Tindall. 1982: 353-355
7.    Travell J, Simons D. Myofascial pain and dysfunction: the trigger point manual. Baltimore: Williams & Wilkins, 1983: 13-17

Encouraged, I wrote to the editor of a leading Australian medical journal in May 1990 asking his advice about writing a paper on the treatment, which I then called percutaneous rhizolysis, with a view to informing other doctors about it. He replied:

Dear Doctor Stuckey,

Thank you for your letter of 28.5.90. Percutaneous rhizolysis has been around for some time now and is a proper subject for discussion. I suggest you write a short article for us – in the order of 2,000 words – which I shall publish under the heading “Point of View”. As you say, no doubt others will wish to criticise what you say, but I see no harm in controversy.
Yours sincerely,

So far, so good. I wrote the article and sent it off with high hopes. As is usual, the article was given to two specialists to act as referees in judging the suitability of the article for publication.
A few weeks later, the editor wrote back saying that, regretfully, the articles had been declined for publication. He included the unsigned comments of the two referees.

The first was bad enough:
In summary, this paper is wholly without scientific merit. In my opinion it is not of sufficient standard for publication to be considered and its fundamental faults are such that no amount of editing would render it so.

But the second more or less traumatised me.
This is a totally unsuitable article about a largely discredited procedure. There are great dangers in the widespread use of tenotomy or similar knives being plunged into buttocks or para vertebral areas. Many of this age group – 60.4 years – can be expected to respond to any treatment that involves interest and follow-up.

If I had had any doubts about the existence of a backlash against the procedure, I held none after reading those comments. At that point, I concluded there was little point in making further efforts to be published in mainstream Australian medical journals.

A short time later, after receiving a little guidance in the matter from another doctor, I sent the article to the Academy of Neurological and Orthopaedic Surgeons in the United States and asked them to consider it for publication. Imagine my delight a short time later to receive the following reply dated 4 November 1990 which reads in part:

Dear Doctor Stuckey,
Your excellent article has been accepted for publication into our Journal.....

The same organisation then accepted a second article for publication in its journal both of which are included in the latter part of this book.

I was invited to attend and present an address at the convention in Las Vegas in September 1991 of the Academy of Neurological and Orthopaedic Surgeons. I accepted. I was quite nervous about this. Here was I, a general practitioner from Australia, about to address a gathering of leading orthopaedic and neurological surgeons from throughout America; it was intimidating to say the least. I had put together a short video and slide display to present during my address as well as some carefully written notes. By the time it came for me to speak I had become quite relaxed about the whole thing because I felt that I had come better prepared than some of the speakers before me.

I went ahead and addressed about seventy specialists in a conference room at the Bally’s Las Vegas Hotel and at the end of it, I am pleased to report that I was rushed by quite a number of them. The six spare copies of my videotape were gone within a few moments and I found myself busy for quite some time afterwards answering questions about my procedure. It was a gratifying moment in my life as a doctor and one I am proud of. I felt somehow vindicated in the knowledge that at least in the USA there were open minds prepared to listen to what I had to say.

Back in Australia, invigorated and encouraged by my American experience, I entered a hypothesis about Nesfield’s Treatment, entitled “Percutaneous Neurotomy (which I now called it medically because I believed rhizolysis was an inaccurate description); Why Does It Work? For a research grant for general practitioners sponsored by a pharmaceutical company under the auspices of a medical body.
It was rejected on several grounds. First, that the results were not achieved from a controlled* trial, second, that the statistics were questionable and third, that there would be bruising. Neither did they accept my hypothesis as to why it worked, i.e. separating sensory fibres, or trigger points. They did not say why.
I was not overly surprised at the rejection, but it added to my frustration, knowing of the thousands of back pain sufferers still being denied knowledge of a procedure that worked.
*(A controlled trial is one where half of the experiment group receive the active treatment and the other half a sham treatment. No patient knows which they have received. An independent observer (who does not know who has had the active or sham procedure) assesses the results after a specified time interval. A successful result would be where the active treatment produced significantly better results than the sham treatment.)

In 1992, I applied to present on the subject at the world body of musculoskeletal medicine (the International Federation of Manual Medicine) triennial conference in Brussels. My paper was one out of 350 submissions made worldwide and became one of seventy actually accepted and given by me at the conference in September of that year.

Again, I was met with a deeply positive, even enthusiastic, reaction to my address and again, I came away feeling satisfied that outside Australia at least, I was dealing with genuinely open minds.
In November 1991, I lent my assistance to a professional freelance television documentary team who were trying to make a film about Nesfield’s Treatment. I gave them interviews with myself and with a dozen patients. I also allowed them to film the procedure while I performed it. In Sydney, Dr Rees had similarly accommodated them. Although both the British Broadcasting Corporation and Australian Broadcasting Commission in Australia were at first deeply interested in the excellent sample material sent in by the producers, neither was prepared to fund the film. Later, the producers kindly gave me a copy of the material they had put together and allowed me to send it to most of the popular current affairs programs. All rejected the story but did not say why. Three years later (May 1993) one of these programs asked to run the story. I am not sure why they had a change of heart but they produced a segment highlighting opinions for and opinions against Nesfield’s Treatment. The programme drew unprecedented public response with literally thousands of listeners phoning in their opinion or request for further information. I was told it was the biggest response they had had to any story they had ever run.

In 1972, the prestigious ABC program “Four Corners” unit, Mr Gordon Bick, who initially wondered if the show had made a mistake producing such a program, says now that the public reaction to the segment was the greatest in all his ten years working on “Four Corners”; it was astonishing. The ABC phones were still ringing months later with people calling in, eager to find out more about the treatment Dr Rees had demonstrated.

I believe it is reasonable to conclude that there is still powerful resistance to Nesfield’s Treatment here in Australia, despite a deep public interest in it. For obvious reasons, I also believe it is a great tragedy that it has not been commonly available to back pain sufferers for the last twenty years.

This book has discussed a different method of treating back and neck pain. It is particularly aimed at long-term sufferers. I repeat that it is not put forward as an answer to all back pain. Nor is it designed to replace any of the currently accepted treatment methods. It is written primarily to inform people about Nesfield’s Treatment, a misunderstood and under-utilised procedure.

The book has outlined a different method of treating back pain based on a different theory about the causes of pain. Because this method and theory are not discussed or taught in medical schools, chiropractic colleges or physiotherapy schools, very few practitioners know about this procedure and even fewer perform it. Very few patients are ever likely to hear about it. If they do, it will usually be from someone who has successfully undergone the treatment.

Nesfield’s Treatment appears to be totally risk free, is simple and quick to perform, easily learned, cheap to administer, does not require drugs or hospitalisation or expensive equipment and, most importantly of all, on certain patients works better than any other method of back pain treatment.

Old habits die hard and accepted medical dogma is difficult to change. But progress and change can only ever be made when someone is prepared to question established ideas and put forward new ones.
To all back pain sufferers, therefore, when someone next tells you that you have to live with your pain, don’t believe them.

1 comment:

  1. Hi, You have post an important Pain Treatment service. Thanks for the great Treatment.
    Alicia Lara

    "Carl Balog"