Stabbed in the back: Confronting back pain in an overtreated society.
Article Type: Book review
Subject: Books (Book reviews)
Author: Chhabra, H.S.
Pub Date: 07/01/2010
Publication: Name: Indian Journal of Medical Research Publisher: Indian Council of Medical Research Audience: Academic Format: Magazine/Journal Subject: Biological sciences; Health Copyright: COPYRIGHT 2010 Indian Council of Medical Research ISSN: 0971-5916
Issue: Date: July, 2010 Source Volume: 132 Source Issue: 1
Topic: NamedWork: Stabbed in the Back: Confronting Back Pain in an Overtreated Society, 1st ed. (Nonfiction work)
Persons: Reviewee: Hadler, Nortin M.
Accession Number: 237135666
Full Text: Stabbed in the back: Confronting back pain in an overtreated society, 1st ed., N.M. Hadler (The University of North Carolina Press, USA) 2009. 224 pages. Price: US$ 25.00 ISBN 978-0-8078-3348-3

In this book Nortin M. Hadler gives an insight into the very common problem of backache. As per the author "To live a year without a backache is abnormal. It is an intermittent predicament in life."

The initial chapters deal with the history of regional back pain, causes and some of its more frequent complications, particularly nerve compression. The author tries to bring out how we are still uncertain of our understanding of the causes and treatment of back pain and how legacies from the past influence our clinical thinking and public health policies. Community epidemiology provides insight into the contribution of psychosocial confounders in chronic back pain and the role of coping in management. As per the author fibromyalgia, better termed as chronic widespread pain, is a social construction. It is the suffering consequent to uncertainties due to the pain, rather than the pain itself, that leads such people to seek medical care. Hence the suffering demands recognition and care.

Clinical aspects of regional low back pain and the various treatments are discussed in the central chapters. The author analyses that there is no point in routinely trying to find a patho-anatomical cause of regional back pain. Every patient should not be subjected to imaging studies since changes are often found in normal individuals of that age and most often it is not possible to ascribe a certain finding to be responsible for the cause of that episode of back pain. The perception of pain, includes an important element of cognition, particularly the suffering that overlays the pain. Allopathy has still not found a cure for back pain. Neither complementary and alternative medicine, nor surgical procedures like Chymopapain like injection, IDET, discectomy and fusion have withstood scientific testing for their effectiveness. He feels that surgeons have become very aggressive and tries to bring out the nexus between the industry and the surgeon.

In the final chapters, the author dissects the ergonomic fallacy as well as the flaws in the American health care system and suggests some measures for reform. He challenges the notion that backache is an injury and feels that convergence of Mixter's concept of discal rupture and the worker's compensation insurance scheme has transformed backache at work into a surrogate complaint. It is more common for a worker dissatisfied with his working conditions to portray back pain as an injury.

However, the consequences are unlikely to be the worker's advantage. The author feels that the worker's compensation system is spending the majority of its resources on treatments that are ineffective as well as lack scientific support. He points out the shortcomings and disparities of the existing US health care system which relies on the health insurance industry and talks about the need for reform. Before it is put to use, effectiveness of a drug or a device should have been clearly demonstrated by a randomised controlled trial in which the drug or device should have been compared with an established gold standard of treatment. He proposes a state based system of Health Assurance & Disease Insurance to come out of these problems.

The book is meant for those suffering or likely to suffer from back pain. Since this would encompass a large proportion of the population, one could say that the book is meant for the society in general. The author perhaps also intends to carry a message for health professionals and the industry. He proposes health care policy reforms, and thus may have intended it for policy makers as well.

Rather than publishing a medical textbook or a self help manual, the author has written the book with the aim of educating those suffering or likely to suffer from back pain about the advancements in our understanding of back pain so that they could interpret professional opinion in a proper manner, not be misled by industry and take appropriate decisions. The author hopes to change attitudes and entrenched practices and attempts to change the way we think about and react to low back pain.

The book brings out the supreme talent of the author with the language and his in depth knowledge of back pain. It is a thought provoking book and there may be a lot of truth in the basic message that the author may be trying to convey. However, he may have been a bit overzealous in his attempt to make "an assault on the backache industry", with the result that it does not seem to reflect a very balanced view of the prevailing scenario. It is true that imaging is often overused, procedures overperformed and devices overused in the management of backache leading to overdiagnosis and mismanagement. It is also true that there have been increasing reports of unethical practices and the influence of industry on the medical community. However, this cannot be used to make a generalized statement to indict all service providers, as a significant proportion of the common lay person readers is likely to interpret, and should not undermine the role of a judicious use of imaging as well as conservative and surgical management of backache for which there is a reasonable scientific evidence. Also the book may have relevance for America and other countries with similar health care policy and not for countries like India and China where worker's compensation insurance scheme is not effective, where fusion surgeries for backache are not common and overall incidence of spine surgeries is far lower.

The book is recommended to patients, lay persons and professionals. They should however keep in mind that the author may have resorted to exaggeration at places in order to drive his message home and should be able to interpret the book accordingly.

H.S. Chhabra

Indian Spine Injuries Centre

Vasant Kunj

New Delhi 110 070, India

drhschhabra@isiconline.org
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