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Belluz talks about back pain research Date: 12/01/17

Julia Belluz

By Tara Haelle

Nearly all people experience back pain at some point, and it’s the second most common disability in the US, costing an estimated $90 billion annually. It’s also the kind of chronic pain that can lead to long-term opioid use, which has exploded in the epidemic Americans read about daily in health news. But does long-term opioid use even help back pain? What about chiropractic care? Or yoga?

Vox reporter Julia Belluz took a dive into the evidence to find out what actually causes it and what can — and can’t — treat it. In this Q&A, she describes how she approached and executed the Show Me the Evidence piece on back pain.

Q: Tell me about the Show Me the Evidence series at Vox? How did it come about?

It's the antidote to the single study stories that often distort what we know in science. You know, stories that suggest 'red wine is good for you' one day and it'll kill you quicker the next day. I wanted to start something that got really nerdy about what the totality of the evidence, not just single studies, can tell us about the health questions that matter to us. And I was lucky because Ezra Klein, Vox's founding editor, is also quite obsessed with research and was eager to help me and our former science editor, Brad Plumer, think through how we might approach this format at Vox. We came up with Show Me the Evidence, which launched with a feature about e-cigarettes in 2015.

Since then, we've used the format to cover everything from the health benefits of yoga to the medical potential of psychedelic drugs, and whether exercise really works for weight loss. Every installment has been complemented by great visuals from Vox's graphics team, and some have turned into Vox videos.

 Q: What led you to begin reporting on"A comprehensive guide to the new science of treating lower back pain"?

It started as many features do: with a smaller related story. When I was writing an initial piece about low back pain, I was reminded what a giant burden to society this problem is – one of the top reasons people go to the doctor and it costs the U.S. some $90 billion per year. We thought it would be a service to a lot of people if we could comb through what the research had to say on treatments for the problem. We were originally going to give the Show Me the Evidence treatment to chiropractics only, and had a wonderful medical student and research intern, Mohsin Ali, helping to search for evidence on that angle. Vox’s science editor, Eliza Barclay, encouraged me to go much broader and delve into all the most popular treatments on offer. So the story grew and grew over time. 

There were also interesting conversations happening in the medical and research communities about how many the most often-used treatments for low-back pain (opioids, surgeries, injections) fail most people, while evidence for some alternative and psychological therapies was mounting. The question about what to do about this pervasive pain problem was also more urgent in the context of America's prescription painkiller epidemic.

Q: What was the biggest challenge as you got started and how did you overcome it?

When I started to search the literature, I was overwhelmed: unlike some of the other topics we had tackled using the Show Me The Evidence format, there were thousands and thousands of studies about back pain. So I had to come up with a process to streamline my search, and called up a friendly researcher, Hilda Bastian at NIH, for help in thinking that through. 

Q: What was your process in identifying and filtering out what research you would rely on?

I wrote a methods section in the story. Here it is: "There’s a mountain of research on low back pain. (Entering the term in the PubMed search engine turned up more than 31,000 results.) So I zeroed in on the highest-quality evidence: systematic reviews. (These are syntheses of the research evidence that bring together all the highest-quality studies to come to more fully supported conclusions.)

I found the Agency for Healthcare Research and Quality (AHRQ), a federal agency that crunches the best available data on the effectiveness of health care interventions and had recently (February 2016) published a comprehensive 800-page systematic review of research on noninvasive treatments for low back pain. The AHRQ review covered 156 of the best back pain studies from 2008 to April 2015. I then searched for low back pain–related systematic reviews on PubMed Health, the government search engine that specializes in systematic reviews and meta-analyses, to cover the recent period left out of the AHRQ review (from May 2015 to the present, July 2017).

To make sure I wasn’t missing anything, I consulted the chronic and acute low back pain articles on UpToDate, (a service that synthesizes the best available research for clinicians), the Cochrane Library of systematic reviews, and, and sometimes followed the footnotes in these reviews to other studies. Ramin’s book Crooked was also an excellent source for thinking on back pain. Finally, I conducted interviews with nine back pain doctors and researchers, including authors of many of the systematic reviews referenced here." 

Q: What red flags in back pain research did you come across that revealed bias in the studies or were inadequately addressed in the studies?

Most back pain interventions are by definition heterogeneous and tricky to study. If you talk about the effects of massage, what type of massage do you mean? Are all practitioners of that style of massage really doing the same thing to patients? If you talk about yoga, what style of practice? And if the yoga helped, was it the yoga or the experience of going to a class with other people and a friendly teacher that made your back feel better. 

We addressed these issues in two ways: I stated the limitations of the research outright, and also relied on systematic reviews that look at the totality of the research evidence and are therefore less prone to bias than individual studies. 

Q: Did you encounter any other noteworthy obstacles in the midst of reporting that you can discuss?

Doing these types of evidence searches can be painstaking. They require days or weeks of concentrated work. In this very busy news cycle, it’s been difficult to carve out time to read through and make sense of studies. There are so many daily stories to respond to. But the early summer news cycle was a little slower, and I had some space for focused work.

Q: Did you encounter any difficulties in understanding the studies you used? How had you prepared yourself to be able to make sense of them?

Nothing jumps out as being particularly difficult for this story. But in general, whenever I hit these kinds of roadblocks in understanding a study, I usually call up the authors of related, high-quality systematic reviews — who have a good overview of the research literature in their area and how studies are done — and talk my questions through with them. 

Q: What advice would you have for other reporters interested in writing a story that delves so deeply into the research of a current and controversial topic where the evidence base is still incomplete or shifting?

Ask researchers what the big meta debates in their area of study are: what are the uncertainties and disagreements, the things they squabble with their colleagues about. This will sensitizes you to areas where the research has accumulated and there's more knowledge, and areas that aren't as firm, where there's a lot of uncertainty. I try to then communicate these meta debates — we know, how we know it, what we don’t know — to my readers. 

Q: Any other challenges or rewards of reporting the story you want to mention? 

We got dozens of letters about this story from grateful readers, and it was very widely read. The same has been true for all the Show Me the Evidence features we've run -- and I think it's because readers are smart and appreciate when you take the time to do the work of reading through the science for them and clearly communicating what it says. As a reporter, these stories give me a firmer grasp on the subjects I'm covering, and often generate more story ideas. Combing through all the research can be painstaking and time consuming, but it's always worthwhile and readers definitely appreciate it. 

Julia Belluz (@juliaoftoronto) is Vox's senior health correspondent, focused on medicine, science, and public health. In 2015, Belluz launched Vox’s Show Me the Evidence series, which goes beyond daily headlines to look at the state of the science behind pressing health questions.