Articles written by JCS.

15 Minutes of Fame

15 Minutes of Fame

By

JCS

Andy Worhall popularized the notion that most everyone will have his 15 minutes of fame (or infamy). Indeed, we’ve seen on the news some rather obscure or outlandish claims to fame, such as the Paris Hilton or Anna Nicole Smith absurdities. Yet with the abundance of news media in the print, electronic, and internet, I have yet to see where the chiropractic profession has had its 15 minutes of fame in its 110+ year history.

It’s as if the medical media reporters’ bias is so strong they cannot bring themselves to admit that chiro care may, in fact, be effective despite the medical research of late. Certainly it would mean eating a lot of crow for these medically-biased reporters after years of telling the public how dangerous DCs are.

Indeed, we remain the Mystery Science Profession despite the recent research studies that have shown our effectiveness with the epidemic of low back pain, such as:

  • Manga Part I & II [1]
  • AHCPR guideline on acute LBP in adults[2]
  • The recent study comparing surgery with conservative care by Peul WC, et al.[3]
  • Norway Spine Study

Brox JI, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A, Ingebrigtsen T, Eriksen HR, Holm I, Koller AK, Riise R, Reikeras O. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine. 2003 Sep 1;28(17):1913-21

  • Swedish Lumbar Spine Study

Fritzell P, Hagg O, Jonsson D, Nordwall A; Swedish Lumbar Spine Study Group , Cost-effectiveness of lumbar fusion and nonsurgical treatment for chronic low back pain in the Swedish Lumbar Spine Study: a multicenter, randomized, controlled trial from the Swedish Lumbar Spine Study Group.. Department of Orthopedic Surgery, Falun Hospital, Falun, Sweden.  Spine. 2004 Feb 15;29(4):421-34

  • UK Spine Stabilisation Trial Group

Fairbank J, Frost H, Wilson-MacDonald J, Ly-Mee Yu, Barker K, Collins R,  Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ  2005;330:1233 (28 May), doi:10.1136/bmj.38441.620417.8F (published 23 May 2005)

These are just a few of the many studies that have shown conservative care is superior or equivalent to medical care in the treatment of acute or chronic LBP; certainly SMT is less risky and less expensive as well as clinically effective. Yet the word of this revelation has never reached the public nor has the medical profession admitted the fact that their longtime nemesis—those damn quack chiropractors—may have been right all the time.

In reading these studies and the subsequent analysis, it also never ceases to amaze me how the medical spokesmen always seem to twist the results in the public media. Certainly there is a strong bias in the medical profession to never give credit where credit is due outside their profession, especially when it’s those damn chiropractors, acupuncturists, nutritionists, herbalists or any of the non-allopathic practitioners.

I’ve concluded that we cannot expect any MD to be completely objective and honest in the area where one of their treatments is compared to any non-MD treatment. Imagine if a prominent MD were to go public with admiration for DCs—he would be crucified and probably have his membership revoked at his local country club or Rotary Club.

Undoubtedly the most blatant example of medical bias occurred when the AHCPR study on acute low back pain in adults was released on December 8, 1994. All the morning news shows carried this report, including NBC’s Today Show. I still recall when the host, Matt Lauer, interviewed their in-house MD.

To my surprise, this Harvard-educated, uppity MD, Art Ulene, with an ego so big you could drive a truck through it, explained the study and the results in a fair manner. But when Lauer summarized his analysis by saying, “So, if you have a back problem, you should see a chiropractor first.”

It was the reasonable conclusion considering the AHCPR guideline listed SMT as a Proven Method and mentioned that back surgery was helpful in only 1 in 100 cases of LBP. The MD almost had a heart attack and replied, “No, I would never suggest that. I recommend going to an osteopath instead.” That’s when I fell out of my breakfast chair, gagging on my English muffin.

In one fell swoop, Ulene invalidated our profession in the minds of millions of viewers even when the US Public Health Service recommended it. I wrote an angry letter to Ulene to vent my frustration, asking him why he couldn’t give credit where credit is due. I explained that if spinal manipulative therapy had been left in the hands of osteopaths, it would be a lost art today. I told him it was the courage of chiropractors taking pot shots across their bows from medical detractors that saved this healing art. After the US Public Health Service finally concluded in their definitive study that SMT was preferable to drugs or surgery, why couldn’t he acknowledge that? Of course, I received no reply. His goal was accomplished—invalidate the damn chiropractors and distort the truth to save the medical monopoly. Ugh!

Considering DCs do 94% of SMT in this country, I found it rather disingenuous of this so-called expert to slam chiros and endorse a profession that has virtually excluded manipulative therapy from its portfolio. Here was an opportunity to inform millions of viewers that chiro care for LBP was effective, yet this medical SOB didn’t have the intellectual honesty to admit it.

Medical bias continues today by virtue of the opinions of the back experts like Richard Deyo, MD, MPH, University of Washington Medical School. On one hand, he’s been critical of the medical mess in the treatment of LBP. Deyo has written many articles dealing with the ineffectiveness of spinal surgeries, especially spinal fusions.

 “Old concepts supported only by weak evidence” and the reliance on MRI exams to infer disc abnormalities as the universal cause of back pain. In The New England Journal of Medicine, he debunks the disc theory that often leads to a “false positive” misdiagnosis:

“Early or frequent use of these tests [CT and MRI] is discouraged, however, because disc and other abnormalities are common among asymptomatic adults. Degenerated, bulging, and herniated disks are frequently incidental findings, even among patients with low back pain, and may be misleading. Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”[4]

Dr. Deyo mentioned in the NEJM article that chiropractic is a popular solution, but seems tongue-tied to tell the popular press the same.

“Chiropractic is the most common choice, and evidence accumulates that spinal manipulation may indeed be an effective short-term pain remedy for patients with recent back problems.”[5]

In the AHCPR’s Clinical Practice Guideline, the section on Spinal Fusion clearly summarizes the research:

“There appears to be no good evidence from controlled trials that spinal fusion alone is effective for treatment of any type of acute low back problems in the absence of spinal fractures or dislocation.... Moreover, there is no good evidence that patients who undergo fusion will return to their prior functional level.”[6]

Despite his admission that the disc abnormality explanation for LBP may be weak and incidental, he has an inability to admit that conservative care may work well if not better than the standard medical care of drugs, shots, and surgery. I imagine the word “chiropractic” must stick in his craw; instead opting to use “conservative care.” God forbid the public realizes that the crazy chiropractors may be as effective or better than the esteemed spine surgeons for the majority of LBP!

Here’s an article on CNN.com that illustrates the misinformation that is still fed to an unsuspecting public.

Surgery can fix back problems, but time works too [what about chiro care working too?]

POSTED: 4:58 p.m. EDT, June 1, 2007

• Study: Surgery works for slipped, misaligned disk, but often is not necessary
• 1.5 million disk operations done worldwide each year.
• 95 percent in study reported recovery after one year, with or without surgery

BOSTON, Massachusetts (Reuters) -- Surgery works [According to research by Berger, 71% of lumbar fusions failed for those with one surgery; for multiple surgeries, 95% never returned to work, but this info failed to be mentioned. [7]] for people with a slipped or misaligned disk [I didn’t know discs slipped or misaligned did you? Why does the medical media perpetuate a misnomer?], but often is not necessary if patients can muster enough patience, according to two studies in the New England Journal of Medicine.

Back problems are a difficult challenge for doctors in part because it is difficult to know when to operate. [Why not follow the AHCPR guideline and send these LBP patients for SMT before pills, shots, and surgery—none of which were recommended as first line treatments by the federal guideline?[8]]

Consider sciatica, where a leg becomes numb or pain shoots down a leg because a nerve is pinched. In 75 percent of patients, the problem improves without surgery within three months. [So, waiting out the pain is proper medical care? Do they tell this to patients with chest pains too?]

Nonetheless, 1.5 million disk operations are done worldwide each year. Typically, doctors remove part of the disk to take the pressure off the nerve. [Considering medical experts believe up to 99% of all disc surgeries are unnecessary, I find it odd that this author failed to mention this obvious problem. Here’s a short list of international spine researchers who conclude that disk abnormalities are not the primary problem.

  • According to WH Kirkaldy-Willis, MD and David Cassidy, DC, discs are involved in fewer than 10% of back pain cases.[9]
  • According to Nikolai Bogduk, MD, PhD, discs are involved in fewer than 5% of these cases.[10]
  • According to V. Mooney, MD, discs problems account for less than 1% of these cases.[11]
  • According to Dr. Scott Boden, orthopedist/researcher, “the disc might not be the cause of pain. And if so, fixing it is a waste.” [12]

One new study, led by Wilco Peul of the Leiden University Medical Center in the Netherlands, looked at 283 patients who had suffered with the problem for at least six weeks. They found that 95 percent reported recovery after one year, whether or not they had surgery.

However, 39 percent assigned to conservative care opted for surgery anyway, typically after about five months, and surgery relieved the symptoms twice as quickly. [I’d like to know what protocols they used in the conservative care treatments inasmuch as most practitioners of all types rarely offer comprehensive care for LBP cases. As the Director of the Texas Back Institute said at ACC-RAC this last year, whatever initial intervention is used, if it’s not followed by active rehab and ADLs, it will most likely relapse.]

"Thus, for patients with persistent sciatica, there seems to be a reasonable choice between surgical and nonsurgical treatment, which may be influenced by aversion to surgical risks, the severity of symptoms, and willingness to wait for spontaneous healing," Richard Deyo of the University of Washington in Seattle said in a Journal editorial. [I’d like to adjust or decompress followed by active rehab these cases to see if it might accelerate the “spontaneous healing.”]

The second study looked at a very different problem where degeneration in the spine bones causes one to slip too far forward.

A team led by James Weinstein of Dartmouth Medical School in New Hampshire found that fusing the bones to treat this degenerative spondylolisthesis typically works better than nonsurgical treatment.

Nearly half the 145 people assigned to nonsurgical care ended up having the operation anyway because their problem was so bad. [But what constitutes “nonsurgical care”? Does this mean doing passive modalities, mobilization methods, or dynamic spinal manipulative therapy followed by active rehab?]

"Surgery patients did a lot better," Weinstein said in a telephone interview. [Yet two years down the road these surgical patients were no better than non-surgical patients according to the same report.]

But when patients were allowed to choose for themselves, the outcome was a bit different. When 303 were offered either option, 130 initially decided against surgery and of those, 75 percent were able to stick with that decision after two years.

This is the first sizable study to compare surgery with non-surgery and it allows patients to better understand their options, he said. "These are quality of life decisions." [Does he suggest that MDs actually give patients informed consent information that objectively shows conservative care is equivalent to surgery? Okay, stop laughing since we field docs know that surgeons typically give patients the voodoo diagnosis when they ask about chiro care, “If you’re stupid enough to go to a quack to let him crack your back (implying fracture), don’t come crawling back to me when you’re paralyzed.”]

About 300,000 spinal fusions are performed in the United States every year. [Of which 90% are deemed unnecessary by most researchers I’ve already noted above. How can any investigative journalist forget to mention the huge numbers of unnecessary back surgeries in such a report? Perhaps this writer’s bias precluded him from mentioning this important point.]

Deyo said while it is clear that people with major motor problems require back surgery, the new studies suggest that "patients with herniated disks, degenerative spondylolisthesis, or spinal stenosis do not need surgery, but the appropriate surgical procedures may provide valuable pain relief." [So, why doesn’t Deyo also add that “appropriate non-surgical care may also provide valuable relief”? Why does he fail to state that the AHCPR guidelines that he was intimately involved in also recommend SMT before drugs or surgery? Has he become tongue-tied or what?]

In fact, Dr. Deyo has previously mentioned this: “Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”[13] He concludes that 97% of back pain is “mechanical” in nature, and disk abnormalities account for only 1% of back problems.

According to JL Shaw, MD and orthopedic researcher, “Joint dysfunctions are the major cause of LBP as well as the primary factor causing disk space degeneration and ultimate herniation of disc material.”[14] Why hasn’t his opinion been studied or promoted in the media?

Concerning herniated intervertebral disks, Dr. Deyo recommended non-surgical methods, but once again can’t bring himself to mention chiropractic care:

“In the absence of the cauda equina syndrome or progressive neurologic deficit, patients with suspected disk herniation should be treated non-surgically for at least a month.”[15]

Dr. Deyo admits in his report on low back pain in the NEJM:

“There are wide variations in care, a fact that suggests there is professional uncertainty about the optimal approach. In addition, there is evidence of excessive imaging and surgery for low back pain in the United States, and many experts believe the problem has been ‘overmedicalized.’”[16]

Researchers have noted this epidemic of failed back surgery with very poignant comments. Dr. Gordon Waddell mentions that the high disability rate is actually caused by medical methods and admits that chiro care is effective:

 “Sadly, we must conclude that much low back disability is iatrogenic [doctor-caused]…It [back surgery] has been accused of leaving more tragic human wreckage in its wake than any other operation in history…There is now considerable evidence that manipulation can be an effective method of providing symptomatic relief for some patients with acute LBP.”[17]

The AHCPR guideline also mentions the low success rate of back surgery and fusion in particular.

Moreover, surgery increases the chance of future procedures with higher complication rates.”[18]

   “There appears to be no good evidence from controlled trails that spinal fusion alone is effective for treatment of any type of acute low back problems in the absence of spinal fracture or dislocations…Moreover, there is no good evidence that patients who undergo fusion will return to their prior functional level.”[19]

Noted medical author, Dr. Ruth Jackson, formerly chief of orthopedic surgery and instructor at Baylor University College of Medicine in Dallas, wrote the mainstay of textbooks on neck problems summarized the true indications for fusion:

“When, then, should fusion be done? Certain fracture-dislocations with marked instability may need fusion. Marked ligamentous instability with spinal cord irritation, or if there is danger of cord involvement, may indicate the necessity for fusion…Surgery should be avoided unless there are absolute and definite indications for it, otherwise the results from operative procedures will be disappointing and the symptoms may be worse than they were before surgery was done.”[20]

Another study conducted in 1994 by Drs. D.C. Cherkin, R.A. Deyo, J.D. Loeser, T. Bush, and G. Waddell compared international rates of back surgeries and found the startling fact that American surgeons are unusually excessive.

The rate of back surgery in the United States was at least 40% higher than any other country and was more than five-times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopedic and neurosurgeons in that country.”[21]

Pran Manga, PhD, medical economist, and Doug Angus, Director of Masters Program in Health Administration at the University of Ottawa, concluded in their report on back pain in the Canadian medical system that the exclusion of chiropractic services from mainstream medical services has caused increase costs to taxpayers and patients alike. 

“Chiropractic care is a cost-effective alternative to the management of neuromusculoskeletal conditions by other professions. It is also safer and increasingly accepted by the public, as reflected in the growing use and high patient retention rates. There is much and repeated evidence that patients prefer chiropractic care over other forms of care for the more common musculoskeletal conditions… The integration of chiropractic care into the health care system should serve to reduce health care costs, improve accessibility to needed care, and improve health outcomes.”

The ACA’s lead attorney, Mr. George McAndrews sought to prove that Trigon "funnels business to the medical world" by putting a $500 cap on all chiropractic treatment during the year. Patients are then encouraged to go to MDs for their back problems. The MDs have no such cap despite the poor outcomes of spinal surgery. The "obstinacy of the medical directors, and the insulting conduct toward the chiropractors" displayed by Trigon and the medical physicians who sit on the policymaking boards will also be shown. According to Mr. McAndrews:

"That is a funneling of business from the most-skilled to the least-skilled providers. We have a wealth of documents and studies that we'll be able to rely on to prove that those patients are prejudiced when they are forced to take their health problems from a chiropractor to a medical physician who isn't skilled in that area.

"If you look at their advisory boards, their policymaking boards, and their medical directors, they utilize the medical doctor with the medical doctor’s narrowly focused, restricted in health education, to determine whether or not chiropractic care should be given or is appropriate. We're going to have that aired out with this case." [22]

I believe it’s time to go on the offensive with an all-out assault on spine surgeries. The facts are clear—there are too many fusions, they are risky, expensive and have low success rates, often leaving a wake of disability behind them. Despite the pitiful endorsement of “conservative care” by our medically biased researchers, there’s enough support to make our case that for the vast majority of “garden variety” LBP cases, our methods (SMT with active rehab) have proven most clinically and cost-effective.

But we need to state our case to the public and the media. As long as the likes of Deyo refuse to give any credit to chiropractic care, even to the point of refusing to mention our profession in his public comments, we’ll continue to sit in the back of the bus.

Indeed, just when will chiropractic get its 15 minutes of fame?

 

 

 



[1] Manga, P and Angus, D. “Enhanced chiropractic coverage under OHIP as a means of reducing health care costs, attaining better health outcomes and achieving equitable access to select health services.” Working paper, University of Ottawa, 98-02

[2] Bigos S et al. (1994) Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14, AHCAPR Publ. No., 95-0642, Rockville MD; Agency for Health Care Policy and Research, Public Health Service, US

[3] Peul WC, et al. in The New England Journal of Medicine May 31, 2007; Vol. 356, No. 22, pp. 2245-2256.

[4] Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001 Feb 1;344(5):363-70.

[5] Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001 Feb 1;344(5):363-70.

[6] Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publ. No 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, December 1994, pp. 90.

[7] Berger E. Later postoperative results in 1000 work related lumbar spine conditions. Surg. Neurol 2000 Aug:54 (2)101-6.

[8] Bigos S et al. (1994) Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14, AHCAPR Publ. No., 95-0642, Rockville MD; Agency for Health Care Policy and Research, Public Health Service, US

[9] Kirkaldy-Willis WH and D. Cassidy, Can. Fam. Phys. 31 (1985): 535-40.

[10] Bogduk N. Clinical anatomy of the lumbar spine, pp. 170.

[11] Mooney V, Spine 12(6):754-59 (1987).

[12] S.D. Boden et al., “Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects,” J. Bone Joint Surgery (AM) 72(3):403-8 (1990).

[13] Deyo, RA, ibid.

[14] Shaw JL, “The role of the sacroiliac joints as a cause of low back pain and dysfunction,” speech before the World Congress on Low Back Pain, University of California, San Diego, Nov. 5-6, 1992

[15] Richard A. Deyo, James N. Weinstein, Primary Care: Low Back Pain The New England Journal of Medicine, Feb. 1, 2001, vol. 344, no. 5

[16] Deyo RA, Weinstein JN, ibid.

[17] Waddell G. and OB Allan, “A historical perspective on low back pain and disability, “Acta Orthop Scand 60 (suppl 234), 1989,.

[18] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[19] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[20] Jackson, R. “The Cervical Syndrome.”

[21] Cherkin, DC et al., “International comparison of back surgery rates, “ Spine 19 (11): 1201-1206 (1994).

[22] Judge Rules on Trigon's Motion to Dismiss ACA Lawsuit, Dynamic Chiropractic, August 6, 2001

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