]]]]]]]]]]]]]]]]]]]]]           BACK PAINS       [[[[[[[[[[[[[[[[[[[[[
              By T.A. Dorman, M.D. (Freeman 93401DORM)     (12/8/1989)    
                        (From his newsletter)

       The American Back Society has just concluded its seventh 
annual meeting. Each year the society has grown in membership, 
exhibitors, faculty and participants. This year was your doctor's 
first attendance. He was invited to put on a workshop on prolotherapy. 
I was a little hesitant and shy. But happily I found the group open 
minded and accepting of the fact that the problems with back pain are 
a scourge in our society and the answer is not in yet. My workshop was 
well accepted and is to be presented again at the annual meeting for 
1990 in Chicago. It is encouraging that national organizations are 
accepting prolotherapy as an important form of treatment. I will do my 
best to represent it objectively. The scientific basis for 
prolotherapy with injections will also be a podium subject your doctor 
has been asked to address for the American Association of Orthopedic 
Medicine P a much smaller group meeting in Boston in April. I will 
also direct two and a half days of systematic teaching. At press time 
Dr. M J Ongley, the developer of many of the methods I advocate in
orthopedic medicine and Dr. Bjorn Eek from the Sansum Clinic in Santa 
Barbara have agreed to serve as faculty. It seems that 1990 is going 
to present an exciting challange.

The Role of Ligaments.
       Though prolotherapy has received all the news it should be 
kept in mind that ligaments and fascia, which are like the supporting 
layers of the lining of a garment, are really the subject at issue. It 
is not surprising that injuries, particularly 
accelerationPdeceleration injuries, are apt to strain, harm and even 
rupture these binding parts of the body. When these layers are 
disrupted and new strains are applied in the normal course of work and 
exercise, abnormal tension develops at the points of weakness and 
sometimes at `wrinkle points' which may be at some distance from the 
original injury. These concentrations of stress in the binding layers 
are the sites of pain. One of the mysteries of pain in the body is 
that it is often felt at a place far away from the original injury. 
The cause may be a remote strain in the fascia, just as a wrinkle in a 
sheet over a bed can cause a tear at the other end from the one being 
pulled on. Another might be the body's habit of `feeling' an injury 
further down a leg or other part. The business of interpreting these 
referred pains and treating them is a subject which has intrigued your 
doctor for many years. This has been the basis for the research he has 
taken part in.
The Art of Medicine.
       It has become part of our cultural norm to think in terms of 
The Science of Medicine. The large houses where the sick were kept 
received the name RhospitalsS from their hospitality. The infirmaries 
and the hospitals of the past are being replaced by Health Science 
Centers and Acute Care Facilities. Although hasty name changes smack 
of sleight of hand, the polishing of a corporate image before take 
over, they are also symbolic of a subtle change between two ages. 
Sickness is becoming a taboo. The art of healing and charity for the 
suffering is waning. In its place we find the `state religion' of the 
science of health. It is hard when living within an age of change to 
find words to express the contrast between notions, ideas and mores 
which are rapidly becoming the past to those which seemingly are 
becoming the norms of the future.
The Coming Revolution.
       Northcote Parkinson, (1980) gets credit for recognizing that 
when ideas become formalized in institutions, are subject to 
legislation and have large buildings erected in their names, they 
forfeit the dynamic qualities which make them relevant. Nation states, 
individual freedom and responsibility, privacy and private ownership 
will all meet the challenge Carthage faced in Rome, and who knows if 
we will have an Hannibal (218 BC). It seems to me that establishment 
medicine is preparing its own nemesis.
The Obstinacy of Dogma.
       There is a large investment in time and mental effort in 
becoming a doctor. A large portion of this effort is in jumping 
various hoops of exams, degrees, licences, so that the M.D. who has 
arrived has little inclination to continuously doubt and re-evaluate 
all the dogma of the establishment, let alone challenge. Dealing with 
day to day problems is enough. The categories of illnesses and 
branches of medicine for dealing with them were defined some time ago. 
The then-young Andrew Carnegie Foundation gave Abraham Flexner (1910)
the task of recommending and then organizing scientific medicine in 
this country. The framework has not changed since. The increasing 
power of the Eastern establishment foundations behind the scenes, as 
well as the entrenched bureaucracy in academia and later in various 
federal and state offices, is not easily altered. In the case of 
orthopedic medicine a need for change has come about because of the 
advent of soft tissue injuries. It is almost certain that the 
frequency of soft tissue injuries, such as chronic neck sprains and 
back pain, was not as high in the day of the horse and buggy, which 
were also the days of physical work. The human frame was subject to 
more physical exercise and less jolting by accelerationPdeceleration 
injuries, either in sport or travel. It is almost certainly these two 
factors which are responsible for the epidemic of back injuries and 
the like. The empiric method, that is to say recognizing the symptoms 
and signs of these injuries, is in your doctor's opinion, not very 
different in kind from recognizing illness in other parts of the body. 
Unfortunately these symptoms and signs were not worked out by Sydenham 
(1676) or Osler (1892). These were the doctors who brought the empiric 
method to medicine after rather painfully discarding the dogma of two 
thousand years which had been laid out by Aristotele (322BC) and Galen 
(157AD), which had literally acquired the authority of religion. 
Things move faster in modern times and it might be hoped that the 
dogma of the last two hundred years can be challenged without waiting 
another two millennia. Not only is death an inherent feature of the 
human species, but so is illness. Institutionalizing the idea that 
perfect health is everyone's right might have the effect of hiding 
disease. This is particularly so for illnesses which don't meet the 
present scientific mold. It seems to be an article of faith in this 
new religion of ours that an abnormal test is needed to make an 
illness legitimate. Organ systems in the body, as well as groups of 
illnesses which we still don't understand, the chronic fatigue 
syndrome for instance, don't get recognition. I for one don't mind 
taking the position that I simply don't understand these things. The 
poor patients who have these problems are denied the formality of a 
diagnosis, the formality of being legitimately ill. They become 
pariahs. 
The Problem with Compensation for Illness.
       In the past the ill were treated privately or through charity, 
the very sick in hospitals. Now that society has formalized the 
payment of your tax money to the sick, (workman compensation, social 
security) the science of medicine has been given the formal task of 
deciding who is RsickS, so that the unfortunate people with illnesses, 
which our two hundred year old medical science has not yet defined, 
become the new outcasts. I wonder if the lot of the Jew in the middle 
ages was much worse than the person with chronic back pain in our own 
time. 
       Back pain is better than fatigue syndrome. In the case of 
chronic back pain the patients do at least have local characteristic 
symptoms and some physical signs. Although these have not been defined 
by the fathers of medicine, they are coming to be recognized. No test 
is yet available for ligament injuries, but something in the way of 
curative help is probably available with prolotherapy.
       In respect to the illnesses which are somehow outside the 
molecular chemistry and anatomy, illnesses which seem to have 
something to do with the overall programming of the body, which 
haven't been defined genetically P their prospect for official 
recognition seems hopeless. 
The Worsening Impasse.
       As an observer of the medical scene, one notes that the 
worsening mismatch between help, charity and cure for the sick, on the 
one hand and the amount of effort which goes into the field of health 
on the other, is growing. I attribute this disparity to thoughtless 
continuation of trends which were good three generations ago but are 
becoming less applicable in changing circumstances. Learned articles 
appear periodically about these problems, expressed either in monetary 
terms or measuring the magnitude of iatrogenic disease. More 
impressive is the groundswell of the public's dissatisfaction with 
establishment medicine and the rapid multiplication of alternative 
practitioners.
       What will become of the healing arts after the inevitable 
revolution our civilization is facing? Will we allow the enquiring 
mind of the healing artisan to explore all avenues in a free for all, 
or are we going to lock in what we know now? Will we have a 
bureaucratically controlled scientific religion and relegate the 
unknown to a pariah status for two millennia? I am humble in 
recognizing there is so much we don't know. To me medicine is an art. 
Science smacks too much of religion. The empiric method which has come 
to us from the Age of the Renaissance is the greatest boon to the 
thinking species. We should preserve it live not as a fossil.
Back Treatments with Prolotherapy.
       The use of manipulation and injection techniques for chronic 
pain in the neck and back has been increasing in the practice in the 
last five years. Your doctor's enthusiasm for a technique now called 
Ongley's technique was studied by a double blind protocol in 1986 
jointly by Bjorn Eek, an orthopedic surgeon, Robert Klein, a 
rheumatologist, and your own doctor under supervision of the inventor, 
Milne Ongley. The study confined itself to cases of chronic back pain 
due to ligament insufficiency. It showed 90% improvement while studied 
under a strict scientific protocol over six months (double blind) and 
the treated patients were followed for a whole year. There were eighty 
patients in the study. In our practice we have now surveyed the last 
eighty patients treated by the same routine for the low back and 
similar ones for mid back and neck pain. Randii Harstad RN has 
surveyed all the cases by telephone and the results are similar, but 
the follow up has been possible for up to five years in some cases. 

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