Articles by JCS

Bogus Science

Bogus Science

 

Medical Meddling in Research

By

JCS

Just as the federal court found that the chiropractic management of back pain was supported by many medical witnesses, just a few years later similar findings of the effectiveness of SMT and the ineffectiveness of the medical management of low back pain—drugs, shots, and surgery—have been supported by recent research into the epidemic of low back pain.

Some politicians alleged there is a vast right wing conspiracy about political events in this country, I can say for a proven fact that there has been a vast medical conspiracy that has kept the public misinformed about the benefits of chiropractic spinal care. This essay will tell you more about this conspiracy and everything else you’ve never known about chiropractors.

In 1994, the US Public Health Service’s Agency for Health Care Policy and Research (AHCPR) conducted a two year investigation of over 4000 articles and it concluded that spinal manipulation was a “proven treatment” for acute low back pain in adults.[1]

The AHCPR made history when it concluded that spinal manipulative therapy is the most effective and cost-effective treatment for low back pain.  The 1994 guidelines for acute low back pain developed by AHCPR concluded that spinal manipulation hastens recovery from acute low back pain and recommended that this therapy be used in combination with or as an alternative to nonsteroidal anti-inflammatory drugs. 

At the same time, AHCPR concluded that various traditional methods, such as bed rest, traction, and other physical and pharmaceutical therapies were less effective than spinal manipulation and cautioned against lumbar surgery except in the most severe cases.  Perhaps most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief and functional improvement.  But for acute low back pain not caused by fracture, tumor, infection, or cauda equina syndrome, spinal manipulation is the treatment of choice.

Because acute low back pain is the most prevalent ailment and most frequent cause of disability for persons younger than 45 years of age in the United States, adherence to these practice guidelines would have substantially increase the numbers of patients referred for spinal manipulation.  Chiropractors provide 94% of spinal manipulation; limited numbers of physical therapists and traditional osteopathic physicians provide the remainder.[2] However, the stats have shown that the number of patients referred to DCs for back pain actually decreased.

When you suffer with back pain, don’t be mistaken to believe your primary care physician knows much about spinal problems or treatments. The delivery of musculoskeletal care is spread across a spectrum of practitioners, including not only orthopaedic surgeons but also internists, family physicians, and pediatricians, among others. Moreover, under the so-called gatekeeper model that is prevalent in managed-care systems, physicians other than orthopaedic surgeons will provide an expanding share of this musculoskeletal care. However, most MDs have little if any training in MSDs, yet they appear to patients as experts as they dispense drugs, shots or surgeries that have been deemed ineffective.

The "obstinacy of the medical directors and the insulting conduct toward the chiropractors" displayed by medical physicians who sit on the policymaking boards have shown the inherent, institutional bias against chiropractors according to attorney George 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.”[3]

A good example of medical meddling occurred with the destruction of the Agency for Health Care Policy and Research (AHCPR). This agency of the US Public Health Service was to be an ongoing partner in an effort to improve US medicine. This agency was charged by Congress with being a federal arbiter of evidence and a setter of guidelines. This Congressional empowerment of the AHCPR was part of the growing national movement to begin evidence-based care through linking practitioner choices to scientific evidence.

The AHCPR's process was to choose conditions, focusing on high-cost, high-use conditions like back surgery for low back pain. The AHCPR would convene multi-disciplinary panels of 18-25 highly-regarded researchers who would chair the panels.

These guidelines would be updated as new evidence was produced. The AHCPR would be an ongoing partner in the betterment of US medicine. Great idea to improve ineffective treatments, but little did this agency understand the power of the medical profession to thwart this noble goal.

The most shocking recommendation in this federal guideline focused on back surgery. This expert panel found back surgeries to be costly, based on misleading tests, and were generally ineffective. Basically, the underlying disc derangement theory was deemed inaccurate since many people with abnormal discs had no pain while many with healthy discs were in pain. Thousands of MRI scans were deemed unnecessary and most spinal fusions were deemed ineffective.

These back surgeons just couldn’t stomach the thought that their spine surgeries were deemed ineffective and the recommendation for chiropractic spinal manipulation was too much for them to swallow. It simply stuck in their craw that the US Public Health Service would recommend spinal manipulation over medical methods.

Despite the permanent injunction order from the federal court to stop interfering with chiropractors, the medical demagogues launched another scheme to destroy the AHCPR. When the findings of this study were leaked, the North American Spine Society (NASS) filed an injunction to stop its public release that took over six months before another federal court allowed its dissemination on December 8, 1994.

Unable to accept expert criticism of spinal surgery, NASS protested the AHCPR research team’s alleged bias and ineptitude despite the fact that this team was headed by Stanley Bigos, an orthopedic surgeon, and it harshly criticized one of the preferred forms of therapy (spinal manipulation). Furthermore, they took their attack on the AHCPR to Capitol Hill.  A NASS board member/surgeon created a bogus patient lobbying group called the Center for Patient Advocacy that deluged Congress with misinformation about AHCPR.

This effort led the House of Representatives to pass a 1996 budget with zero funding for the AHCPR. Only after great efforts in the Senate to expose the reasons for the attacks was it possible to salvage some funding for the AHCPR. Ironically, its guideline development work was curtailed, even though it was originally ordered to do so by a 1989 Congressional mandate. Obviously, the wishes of special interests like AMA’s political action committee supersedes Congress’ wish to determine the best treatments for common ailments.

This bogus advocacy group then sued many of the researchers themselves to intimidate present and future critics by eliminating these messengers who report the many ineffective and costly medical procedures that have driven up health care costs to the two trillion-dollar range. A member of the AHCPR panel, Richard Deyo, MD, co-authored in The New England Journal of Medicine an article, “The Messenger Under Attack--Intimidation of Researchers by Special Interest Groups.” He wrote, “The huge financial implications of many research studies invite vigorous attack... Intimidation of investigators and funding agencies by powerful constituencies may inhibit important research on health risks and rational approaches to cost-effective health care.”[4]

Sadly, the AHCPR endorsement was the most significant recognition to date of manipulative therapy for the epidemic of low back pain, and instead of being heralded as the champions of this treatment, chiropractors got short shrift by the medical experts in the media that virtually ignored this landmark study or distorted its findings.

 

The Medical Media Mess

Once again the AMA did its best to keep this revelation quiet and actually fought to invalidate the research. After the Wilk Antitrust trial, the AMA’s smear campaigns against chiropractors change to covert tactics instead of overt methods since the court gave a permanent restraining order against the AMA.

During the 1980’s the AMA limited its anti-chiropractic tactics to obstructing legislative matters in Congress like the expansion of chiropractic services in Medicare and the Military Health Services, Veteran’s Affairs, and workers’ compensation programs. While it was publicly quiet, the AMA still worked hard to restrain the chiropractic profession making in-roads into the mainstream healthcare system.

However, with the increasing cost of back pain treatments, more and more government and private researchers looked more closely at medical treatments and found disturbing facts, such as the inconsistency of spine surgery, the contradictory findings of disc abnormalities on MRIs, and the fact that conservative chiropractic care seemed most effective.

During the 1990s, the AMA greased the palms of its many friends in the media and once again we saw an upsurge of anti-chiropractic articles. Most interesting is that these articles completely ignored the Wilk Trial verdict and they ignored the cascading research showing chiropractic’s effectiveness.

Starting in 1990 when the first MRI study by Dr. Scott Boden emerged showing that disc abnormalities were incidental, and in 1994 when the US Public Health Service’s Agency on Health Care Policy and Reform recommended spinal manipulation as a “proven treatment,” the AMA had to do something to squelch this changing paradigm in spine care from medical care to conservative methods like chiropractic.

Since it couldn’t attack the chiropractic profession as it once did before the Wilk trial, the AMA goon squad turned to its friends in the media who gladly toed the line with misinformation to the public. Columnists like Ann Landers, magazines and newspapers, and even TV medical experts all gave a collective “thumbs down” to chiropractors despite the overwhelming evidence to the contrary.

Text Box: Art Ulene, MD After the AHCPR guideline on low back pain was released, The Today Show featured its in-house medical expert, Art Ulene, MD, presenting this report. After he detailed the findings accurately, the host, Matt Lauer, concluded that “So, if you have a back problem, then you should see a chiropractor first.”

“Oh, no,” said Ulene, “I would never recommend a chiropractor. Go see an osteopath instead.”

In one fell swoop, Ulene invalidated our profession in the minds of millions of viewers. 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. It was the courage of chiropractors taking pot shots across their bows from medical detractors and being labeled as “rabid dogs” that saved this healing art from extinction. 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? My plea fell on deaf ears, of course, and I received no reply. His goal was accomplished— to undermine the damn chiropractors and distort the truth to save the medical monopoly from embarrassment and the potential loss of income.

Consumer Beware

So, when you wonder why more isn’t known about the chiropractic profession, ask yourself how many times you’ve seen an objective report in the media. Indeed, DCs are the black sheep of the medical world and get nil attention by the medical experts on television news programs. The medical bias against chiropractors still runs amok throughout the health care delivery system, and that includes the medical media.

As an avid news program junkie, for example, I’ve not once heard NPR’s excellent program, All Things Considered, speak of my profession—the third largest health profession in the world. Nor have I ever heard FOX News or MSNBC or CNN tell a “fair and balanced” story about chiropractors. If anything is said, it always has a medically-tainted slant reported by medical experts leaving the viewers with a rather jaundiced opinion, and with me screaming.

And it’s a story worth hearing not only from the perspective of medical politics shaping this country’s failing health care system with antiquated, expensive, and ineffective treatments for the epidemic of spinal disorders, but also from a humane perspective of denying access to millions of suffering people who need chiropractic spinal care. Imagine if only 10% of the public ever visited a dentist how bad our oral health would be, that’s the present situation for chiropractors and may explain why back ailments are the leading cause of disability in the workplace.

As a patient and practitioner alike, I weep knowing that millions of patients are wasted on drugs, shots, and surgery by MDs using ineffective treatments who by now should know chiropractic spinal care ranks amongst the best treatment for most neck/back pain cases, but they’re willing to sacrifice their patients’ health in order to appease their gods of power and money.  I cringed at the realization of the millions of unnecessary back surgeries, addictive pain medications, expensive epidural shots, and worthless muscle relaxers that mostly impair rather than help as the latest research now reveals.

Sadly, the only time the public is informed about the chiropractic profession seems to be when something terrible occurs. A few years ago allegations that manipulative therapy caused strokes surfaced in the press when a lawsuit in Canada was filed. Although researchers proved it was virtually impossible for this to happen, and the chiropractor was found innocent at trial, in the court of public opinion, the medically-biased press had all but convicted chiropractors of murder.

To this day, I still have the occasional patient who is scared to death of being manipulated after getting what I call the voodoo diagnosis from their MD: “If you’re stupid enough to go to a chiropractor, don’t come crawling back to me when you’re paralyzed.” If I had a nickel for every time I’ve heard this, I’d be rich.

Fortunately, the facts belie this falsehood. As I tell these frightened souls, the malpractice insurance companies know who’s hurting who. While rates vary by location, brain surgeons in Brooklyn currently pay $267,000 annually for malpractice insurance, while general surgeons in Manhattan pay $123,120 and obstetricians in Queens pay $180,490.

Last year I paid only $1,600 for malpractice insurance. In 30 years I’ve never been sued because spinal manipulation is incredibly safe in skilled hands. While adverse effects like soreness or the occasional broken rib might occur in patients with osteoporosis, in general manipulation is safe and effective. Obviously the malpractice insurance companies know who’s hurting who, and we chiropractors are remarkably safe. Plus, a good spinal adjustment is the second-best feeling there is!

Not only did the U.S. Public Health Service recommend SMT, its guideline also warns that “It should only be done by a professional with experience in manipulation.”[5] Since chiropractors do 94% of all SMT in this country according to the RAND Corporation study on acute low back pain, one must acknowledge that DCs are the leaders in this form of treatment.[6]

Clinical iatrogenesis for chiropractors usually consists of broken ribs, occasional strokes or supposed disc aggravation, to name but a few. Of course, the rate of accidents is 1-2 per million for all SMT and, excluding the 40% of problems caused by the 6% of non-DCs who do manipulation, this rate actually drops to 1 in 3 million for neck manipulation. Considering the rate for cervical surgery is 15,600 accidents per million, I can live with our very low rates.

Despite the evidence of the efficacy of conservative, chiropractic treatment of disc herniation, many MDs still do not generally include referral to DCs for manipulation. One reason may be the presumed lack of safety and fear that joint manipulation may cause further injury to an already weakened disc. Yet published medical experts in manipulation such as Bourdillon and Day in Canada,[7] Lewit in the Czech Republic,[8] and Maigne in France,[9] agree with the chiropractic and osteopathic professions that skilled manipulation is safe and appropriate for the great majority of patients with disc herniation and should be considered a first option for conservative care.

In a comprehensive literature review in 1992, assessing all the studies internationally in English, French and German that reported adverse effects of lumbar spinal manipulation, Terrett and Kleynhans found a total of 65 cases in which disc-related complications were alleged.[10] Nearly half (44%) were medical manipulation under anesthesia. Oliphant provides a best estimate of the risk of spinal manipulation causing a clinically worsened disc herniation of “less than one in 3.7 million treatments.”[11]

A generation ago some researchers, such as Farfan, suggested that rotational stress (torsion) for manipulation might cause disc failure.24 However, Cassidy et al. conclude that in general “it is hard to comprehend how the small amount of rotation introduced during side-posture manipulation could damage or irritate a healthy or herniated disc.”[12]

More recently other extensive studies have concluded that spinal manipulation is as effective if not more so than anything the medical world has to offer. The Decade of Bone and Joint Disorders studied chronic low back pain treatments consisting over 200+ different types and also suggested SMT is as effective as anything in the medical arsenal. It also suggested there were too many drugs, shots and surgery, just like the AHCPR study concluded in 1994.

Text Box: Anthony Rosner, PhD Indeed, the public wants improvement in the American healthcare delivery system. People understand by now that no one health care profession holds the key to every aspect of health care in this epidemic of back pain with escalating surgical costs and disability, and with the emerging evidence-based research and international guidelines now showing the efficacy of manual manipulation for both acute and chronic low back pain, people are clamoring for options to medical care.

As Tony Rosner, PhD, said in 2003, “Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.”[13] It’s time the public learned this too.

Imagine the validity chiropractors could gain if the press and public knew  multidisciplinary groups of MDs now work alongside DCs, such as the Texas Back Institute, the Rehab Institute of Chicago, the Rhode Island Spine Center at Brown University, to name but a few in the private sector and, in the military health services, the Department of Veterans Affairs Medical Centers now has 30 clinics with MDs and DCs working cooperatively, as well as the  DoD that has multidisciplinary services in more than 50 clinics throughout the US including the Bethesda Naval Hospital.

Rather than outcasts as chiropractors are now perceived by many, instead DCs should be seen as overlooked heroes who brought a new non-drug, non-surgical vision of health along with effective tools to help this epidemic of neck/back pain.

I often liken chiropractors to the black aviator heroes of the . Fifty years after the war ended and racism abated in the military, these unsung heroes finally were honored for their bravery.

More recently, the AMA passed a resolution that announced a formal apology for its historical racism toward African American medical doctors. [14] While black MDs were forced to sit in the back of the medical bus for too long, chiropractors were thrown under the same bus. Few people realize that chiropractors were jailed over 15,000 times in the first half of the last century for allegedly practicing medicine without a license when, in fact, the real crime was practicing health care without drugs and surgery.

While this may be well known by most DCs, it is not common knowledge among the press or public. To this day, while many realize the medical profession has a bad attitude about chiropractic, they have no idea of its origins or its ugliness. As far as public perception goes, the Wilk antitrust trial never existed and the damage done to the chiropractic profession was never explained.

In one sense, it’s as if the chiropractic holocaust never existed and continues unabated despite the legal victory.  That’s why I thought when the AMA issued a public apology to its black members for years of discrimination, it would be an excellent time also to seek an apology to the chiropractic profession for its persecution.  Alas, no such contrition is forthcoming from the medical profession.

Apparently the AMA is willing to apologize to its own black members who suffered from prejudice within its own ranks, but to apologize for its documented genocidal program against chiropractors is asking too much, illustrating the demagoguery, bias, and prejudice that still exist within the medical profession.

I can only  imagine the public’s reaction if it were aware of the AMA’s Committee on Quackery established by its Board of Trustees for the sole purpose "to study the chiropractic problem and whose prime mission was to be, first, the containment of Chiropractic and, ultimately, the elimination of Chiropractic.

In this day of public condemnation of all things sexist or racist, imagine the public’s anger when told the AMA referred to chiropractors as “killers and rabid dogs,” and conspired with the ARA, AHA, and other medical groups to eventually “see them wither on the vine.” If this wouldn’t spark reactions among the public, what would?

Little does the public remember that even ethical MDs who referred to DCs were threatened with the loss of licensure and ostracized from the medical fraternity for consulting with “cultists and quacks.” MDs couldn’t even join the same social club for fear of being branded as unethical by their own medical society.

Nor does the public realize the many medical researchers who now admit that the medical management of this epidemic has added to the problem with unnecessary drugs and ineffective back surgery, and admit that chiropractic spinal manipulation may be the best solution for the majority of these LBP problems. This guideline states: “This treatment (using the hands to apply force to the back to ‘adjust’ the spine) can be helpful for some people in the first month of low back symptoms. It should only be done by a professional with experience in manipulation [chiropractors].”[15]

Gordon Waddell, M.D., renowned orthopedist and spine researcher, states,

“Low back pain has been a 20th century health care disaster …Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem… Medical care for low back pain in the United States is specialist-oriented, of high technology, and of high cost, but 40% of American patients seek chiropractic care for low back pain instead.” [16]

Sadly, this honesty is not well known by most people and what most people know about chiropractic care is just foolishness learned from medical bigots. I’m not suggesting that every MD is prejudiced against chiropractors, but most are adamantly biased, not unlike a white person growing up in the Old South. The history of this sordid situation is well documented but remains unknown by nearly everyone.

As any type of prejudice slowly erodes as the light of truth shines upon it, many Americans today now realize they have been the victims of this medical racism, if you will, from ineffective and unnecessary drugs, shots, and surgery. Back treatments like pain pills, muscle relaxers, epidural steroid injections and spine surgeries are now considered by worldwide research as mostly unnecessary, ineffective, costly, and based on a failed disc theory.  This message has not reached the public although chiropractors have been the torchbearers of this caution for over 110 years now but, for the most part, getting short shrift by the media that is strongly influenced by the medical profession.

Hopefully soon public opinion of back surgeries will join the ranks of once considered routine but now regarded as unnecessary surgeries like appendectomies, tonsillectomies, pacemaker implants, coronary bypass surgery, hysterectomies, Caesarean section, prostate surgery, radical mastectomy, laparoscopy, or surgery for sleep apnea and jaw pain.[17]

Many experts believe up to 60% of all surgeries are unnecessary, and some suggest 50% to 90% of back surgeries are deemed the same. Most Americans don’t know that the rate of back surgery in the United States is at least 40% higher than any other country and was more than 5 times those in England and Scotland. [18]

This epidemic of back injuries is fueled in part by unnecessary, ineffective, and expensive back surgeries that could have been avoided by the use of chiropractic care and active rehab measures. Dr. Hubert L. Rosomoff, MD, from the University of Miami, called a moratorium on back surgeries when he realized, after two weeks of rehabilitation, his back patients no longer required surgery. “Following this kind of concept, you can eliminate 99% of the surgical cases. In fact, the incidence of surgery if one really looks at this appropriately is one in 500.”[19]

Unfortunately in the USA, money motivates many surgeons instead of doing what is in the best interest of the patient. When the profit motive is gone, so are 90% of surgeries. Certainly the subject of unnecessary back surgeries becomes an ethical issue in light of the numerous medical experts who criticize the basic theory of spine surgery.

Money is a great motivator, especially in the spine surgery business. As Dr. Jerry Groopman wrote in The New Yorker magazine by, "Knife in the Back,” (April 8, 2002), "If I don't do them, they'll go around the corner and the other surgeon will.”

In the Norway Spine Study, Dr. JI Brox mentioned a moratorium on spine fusions since they found them ineffective and difficult to diagnose.

“These surgeons refuse to have fusion surgery or recommend fusion surgery for their family members. So the question is: why should we recommend these procedures for our patients?”[20]

 

Surgery No Better Than Waiting or Conservative Care

Text Box: JN Weinstein, DO, MS A large study of 2,000 patients with low back and leg pain, typically called sciatica, led by James N. Weinstein, DO, MS, Chair of the Department of Orthopaedic Surgery at Dartmouth, reported in JAMA showed that patients with low back and leg pain who underwent spinal surgery fared no better two years later than those who used non-invasive therapy. Dr. Weinstein reported an estimated 300,000 Americans a year have surgery to relieve the symptoms. [21]

As many as a million Americans suffer from sciatica, characterized by an often agonizing pain in the buttocks or leg or weakness in a leg, but when faced with severe back/leg pain, patients are rarely informed of their options, nor are they told of recent research that confirms spine surgery is no better than waiting. As a chiropractor, I find it odd that this comparison didn’t include chiropractic care, the leading green treatment for low back pain; it’s obvious the researchers are avoiding a direct comparison for fear of the public learning what ACHPR and other studies confirm. Indeed, comparing surgery with waiting is ridiculous, but in the end, though, neither waiting nor surgery was a clear winner.

Text Box: Steven R. Garfin, MD After two years, about 70 percent of the patients in the two groups said they had a ''major improvement'' in their symptoms. No one who waited had serious consequences, and no one who had surgery had a disastrous result.

Many surgeons had long feared that waiting would cause severe harm, but those fears were proved unfounded. ''It says you don't have to rush in for surgery. Time is usually your ally, not your enemy,'' said Dr. Steven R. Garfin, chairman of the department of orthopedic surgery at the University of California, San Diego.

Patients are often told that if they delay surgery they may risk permanent nerve damage, perhaps a weakened leg or even losing bowel or bladder control. But nothing like that occurred in the two-year study comparing surgery with waiting in nearly 2,000 patients. Fear that delaying an operation could be dangerous ''was the 800-pound gorilla in the room,'' said Dr. Eugene J. Carragee, professor of orthopedic surgery at Stanford. Dr. Carragee said that he had never believed it himself, but that the concern was widespread among patients and doctors. ''The worry was not knowing,'' he added. ''If someone had a big herniated disk, can you just say, 'Well, if it's not bothering you that much, you can wait?' It's kind of like walking on eggshells. What if something terrible did happen?'' [22]

Text Box: Eugene J. Carragee, MD Not surprisingly, back surgery is very lucrative with the average cost approaching $50,000, there are nearly 500,000 back surgery cases as rates increase almost linearly with the per capita supply of orthopedic and neurosurgeons in the country, with increased risk of complications, higher medical costs and no difference in quality of life at 2 years after surgery.[23]

While not as big as cancer, diabetes or heart disease, musculoskeletal problems are huge in both costs and disability rates that could be greatly helped by chiropractors if given a fair chance to access these patients before the medial world devours them. Worldwide, musculoskeletal conditions are the most common causes of severe long-term pain and physical disability and account for half of all chronic conditions in people more than 50 years of age in developed countries. In the United States, musculoskeletal conditions cost our society an estimated $269.3 billion every year.[24] That’s a huge amount of money that could be drastically reduced in half if the green technology of chiropractic was used first instead of drugs, shots and surgery.

Text Box: Scott Haldeman, MD, DC, PhD However, it’s tough for any treatment to emerge in the supermarket of treatments available today due to tradition and bias. For medical treatments that ultimately proved to be valuable, there is a time lag of 17 years between discovery and scientific validation according to Dr. Scott Haldeman. Scientists refer to the time lag as the “valley of death,” according to an article in Newsweek.[25]

I might add, for chiropractic spinal care, the valley of death and lag time has been over 110 years! Indeed, it’s a sordid story that affects the vast majority of Americans who suffer with the silent epidemic of back pain. If the electronic industry were like the medical profession, it’d still be in the vacuum tube era.

Text Box: WC Peul, MD, PhD The supermarket of care for spinal disorders just got more confusing with the release of a random controlled trial by WC  Peul et al. [26] Dr. Peul is Director of the Spine Intervention Prognostic Study Group at Leiden University Medical Center. Since 2004, he has been a full time spinal neurosurgeon in The Hague and Chairman of the Spine Center in The Netherlands.

In the lead article of the June edition of The BACK LETTER, Balancing Costs and Benefits: Is Disc Surgery Cost-Effective?”[27] Peul and his associates clouded the treatment of sciatica with a study that is filled with dumbfounding comparisons, glaring omissions, and obvious bias. Sadly, this flawed study may be used against conservative treatments despite its obvious shortcomings that only a professional versed in conservative care and manual medicine would notice.

Peul’s study suggests discectomies for sciatica are preferable/cost effective over conservative care in the short term (6 weeks), but admitted not in the long term (6 months). “The advantage was discernible six weeks after surgery but vanished by six months. And there were no significant differences between treatment groups in pain or disability beyond that follow-up point.”

Failed Disc Theory

The correlation of disc abnormalities to back pain despite the weak evidence is a mistaken assumption that has led to unnecessary surgery, high costs, and poor outcomes. Researchers have found some people with disc abnormalities are perfectly pain free while some people with healthy discs are in bad pain, so doing disc surgery for back pain is considered unwarranted.

Leading spine experts like Dr. Richard Deyo confirm the idea that MRI scans to detect a suspected disc abnormality as justification for back surgery is mistaken. In fact, he refers to these as “false positives” and jokingly calls them “incidentalomas”:

Early or frequent use of these tests [CT and MRI] is discouraged because disc and other abnormalities are common among asymptomatic adults. Degenerated, bulging, and herniated disks are frequently incidental…Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”[28]

Text Box: NM Hadler, MD            

Yet thousands of patients daily are routinely misdiagnosed by their MD who presents these false positives as justification for back surgery. “See, I can prove it to you that you need surgery because you have a herniated disc (or a degenerative disc, or a bulging disc, arthritis, or whatever abnormality he finds).”

Dr. NM Hadler, author and medical professor at UNC, is also highly critical of the use of MRI to sell back surgery.

“Whatever we see on the MRI is likely to have been present when the person heals. The discal hypothesis—the idea promulgated seventy years ago that the ‘ruptured disc’ is the culprit—has not withstood scientific scrutiny well. It is largely untenable for axial pain, and marginal for radicular pain…Magnetic resonance imaging cannot be used to predict back pain.” [29]

How much more straightforward can it be said that MRI scans to detect the source of your back pain is wrong. Patients are never told that these leading medical experts scoff at the use of MRI to sell back surgery, which is also a legal issue as well as an ethical issue called informed consent. After diagnostic tests and before treatment commences, the law states that patients must be informed of all possible alternatives to treatment, the risks involved, and not be railroaded into one scheme. Sadly, patients are rarely told the truth or that chiropractors may be the best choice. There’s just too much money at stake to be truthful.

The standard medical procedure for anyone complaining of back pain invariably includes initially pain pills and muscle relaxers and, when that fails, they are sent in for epidural shots in the spine and, when that fails, they are sent off for MRI scan to detect some abnormality to justify back surgery. Rarely, if ever, are these patients told the truth about the failure of this medical model and told to seek the care of a chiropractor before drugs, shots or surgery as the guidelines now suggest. As I said, there’s just too much money at stake to be truthful.

“Back pain is one of the most common and expensive causes of disability in the U.S.,” according to Richard Deyo, MD, professor at the University of Washington School of Medicine. “Yet millions of Americans get substandard care for back pain; there's tremendous potential for improving outcomes and controlling costs by helping doctors and patients make more informed choices in this area."[30]

 

The Failure of Back Surgery

Text Box: Lynn Johnson, MD According to Dr. Lynn Johnson, director of the Center for Pain Medicine of North Carolina, while back surgery has a place, there are too many surgeries being done, and that most doctors fail to apply conservative measures such as chiropractic, physical therapy, and minimally invasive surgical techniques before suggesting surgery.[31]

Yet, most public and private hospitals still deny staff privileges to doctors of chiropractic, many health insurance programs like the Blues still deny or severely limit access to and treatment by chiropractors, and many workers’ compensation programs also limit chiropractic care to injured workers despite the overwhelming evidence supporting spinal manipulative therapy as well as evidence indicating the ineffectiveness of spinal surgery.

 “Just about any approach is better than having surgery because all the studies have shown that, if you take a surgical population and non-surgical population, they all seem to do the same in five years,” Dr. Lynn Johnson believes.[32]

Another study confirmed that patients were more satisfied with chiropractic care than other treatments for low back pain.  T.W. Meade, M.D., of the Wolfson Institute of Preventive Medicine, London, UK, surveyed patients at three years and found that “significantly more of those patients who were treated by chiropractic expressed satisfaction with their outcome at three years than those treated in hospitals—84.7% vs. 65.5%.” [33]

Text Box: E. Berger, MD Research repeatedly has shown the poor results from back surgery, including a recent study by Dr. E. Berger published in Surgical Neurology that showed the high rates of permanent disability from spinal fusions.

One thousand workers’ compensation patients who had undergone lumbar spinal surgery were divided into two groups: one group consisted of 600 patients with single operations, evaluated on average 51 months after surgery; and the second group consisted of 400 with multiple operations, evaluated 38 months postoperatively. The results were stunning, to say the least. 71% of the single-operation group had not returned to work more than 4 years after the operation, and 95% of the multiple-operations had not returned to work. In none of these cases was there a neurological deficit that precluded gainful employment—the failure to return to work being blamed on chronic postoperative pain.[34][13]

Text Box: HL Rosomoff, MD Other medical researchers have also concluded that spinal surgery is ineffective and costly. At the University of Miami Comprehensive Pain and Rehabilitation Center, Dr. H.L. Rosomoff concluded:

 “Further, low back pain in the population at large is not usually a surgical problem, and the chances of there being significant pathology requiring surgical or other forms of intervention may be less than 1% of those affected… Low back pain per se is in the majority not a neurologic problem, an orthopedic problem, or a neurosurgical problem, so that consultation with these groups, unless there are strong suspicions otherwise, has limited value.”[35][14]

 

The ethical experts couldn’t be clearer on the failure of back surgery, an ethos that escapes unethical MDs who are biased against chiropractors.

Back in 1994, the Agency for Health Care Policy and Research (AHCPR), a 23-member panel headed by orthopedist Stanley Bigos, MD, confirmed the rare need for surgery:

“Even having a lot of back pain does not by itself mean you need surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.”[36]

Ten years later in 2004, The BackLetter, a compilation of articles about spine care and surgery written by MDs, contains the following indictment:

"The world of spinal medicine, unfortunately, is producing patients with failed back surgery syndrome at an alarming rate…Despite a steady stream of technological innovations over the past 15 years—from pedical screws to fusion cages to artificial discs—there is little evidence that patient outcomes have improved.” [37]

Do you need more evidence that back surgeries are out and conservative care like chiropractic is in? Spine experts also conclude “Lumbar fusion for common degenerative changes appears to offer limited relative benefits, if any, over intensive nonoperative management.”[38]

Jens Ivar Brox, MD, department of orthopaedics at National Hospital in Oslo, Norway, believes that spinal fusion should be an uncommon option for patients with chronic disabling low back pain. Some of the orthopaedic surgeons in his department have recurrent back pain and disc degeneration, but these surgeons refuse to have fusion surgery or recommend fusion surgery for their family members.

Text Box: JI Brox, MD Dr. Brox asks, “So the question is: why should we recommend these procedures for our patients?”[39]

Not only are spine fusions unnecessary, they are a huge expense. Fortune 500 companies spend over $500 million a year on avoidable back surgeries for their workers and lose as much as $1.5 billion in indirect costs associated with these procedures in the form of missed work and lost productivity, according to a two-year study by Consumer's Medical Resource (CMR).

The Voodoo

Despite the growing realization that the medical approach to back pain treatments—drugs, shots, and surgery—have not withstood the scrutiny of international researchers, the public remains confused by the persistent inability of the medical profession to admit its limitations or admit to its historical prejudice against chiropractors.

Indeed, the seeds of this dispute were sown decades ago on mistrust and deceit. Instead of admitting back surgeries don’t work and those damn chiropractors may be right all along, many MDs continue to lie to their own patients and ridicule them when they ask about chiropractic care.

“If you go to a chiropractor, don’t come crawling back to me after you’re paralyzed,” is the voodoo diagnosis I’ve heard often enough to realize the deceitfulness and intellectual dishonesty of misguided MDs and surgeons.  Whether patients are subjected to unnecessary drugs, shots or surgeries, or denied chiropractic care, the present situation on spine care in America is appalling as you’ll read for yourself.

Text Box: Paul Goodley, MD Dr. Paul Goodley, author of Release from Pain and a leading orthopedic physician and champion of manual medicine/spinal manipulation among the medical profession, has also experienced the bias that has deterred the integration of manual medicine into the mainstream, an attitude he’s termed the Fundamental Flaw of medicine:

“Eventually, the prejudice against manipulation self-perpetuated and evidence was always available to justify this attitude. There have always been [chiropractic] charlatans.

Admittedly, Dr. Goodley is right in that there has always been a small percentage of unethical chiropractors who can be viewed as charlatans—those DCs who overstep the research with outrageous claims of cure, those who commit fraud and deceit, and those who are very unprofessional in their practices. I’ll be the first to admit the chiropractic profession has had its share of shady characters, but they are dwindling in numbers as the licensing boards become stronger and the chiropractic colleges matriculate better students. Indeed, sometimes the chiropractors have shot themselves in the foot by their own unethical actions, only adding fuel to the fire of medical bias.

As Dr. Goodely laments:

“So, instead of the manipulative fundamental dynamically developing as a cohesive, trustworthy guide within traditional medicine, it was discredited as the synonymous derelict symbol of its most despised competitor - chiropractic.

 

He’s also painfully aware of the damage this medical bias has done to suffering patients. Many spine experts like Dr. Richard Deyo admit the inability of MDs to accurately diagnose and treat the cause of back pain, but they fail to admit their own medical bias against manipulative therapy is also a big reason for their dismal results.

“Up to 85% of patients cannot be given a definitive diagnosis because of weak associations among symptoms, pathological changes, and imaging results. We assume that many of these cases are related to musculo-ligamentous injury or degenerative changes.” [40]

Dr. Goodley answers Dr. Deyo’s admission with his belief that the Fundamental Flaw against manipulative therapy is a large reason for this pandemic of pain.

“I accuse that a big slice of the 85% ignorance is accountable to the                  rejection of the thinking involved in manipulative approaches. The conflict remains so near unimaginable that future historians may well describe the past century as a time of unnecessarily perpetuated pain.”

I admire Dr. Goodley’s strong backbone to admit his orthopedic profession has turned a blind eye toward manipulative therapy as an answer to this back pain epidemic. The boycott of chiropractic care, for whatever reason, has led to denying to the suffering one of the best methods to control this pandemic of pain.

The Fundamental Flaw of MDs toward chiropractors stems not only from economic rivalry, but from academic ignorance. While the medical model focuses on discs, the chiropractic model and justification for manipulation focuses on joints. Most people fail to know that there are 206 bones in the body that have 360 joints. The spine alone has 137 joints that can misalign, buckle, twist, wrench or become stiff thus causing pain as well.

Joint dysfunction is the major source of back pain and chiropractors diagnose these joint problems and skillfully adjust them to improve joint play/motion. In fact, some MDs believe that disc problems are secondary to joint problems, which suggests adjusting misaligned joints can circumvent the need for disc surgery. According to orthopedist JL Shaw, MD and noted lecturer:

“Joint dysfunctions are the major cause of LBP as well as the primary factor causing disc space degeneration and ultimate herniation of disc material.” [41]

Dr. Shaw suggests that before lumbar discs herniate, the forgotten sacroiliac joints become dysfunctional. These SI joints are gliding type of joints that do not have the discs seen in the lumbar spine, but when these SI joints twist out of alignment, patients experience severe pain in their buttocks. This initial misalignment may cause the entire pelvis to twist out of balance and lead to disc problems elsewhere. But the main cause of the disc problems stems from the SI problem.

Dr. Shaw noted in his research 98% of 1000 patients had a mechanical dysfunction of the SI joints as the cause of their LBP. Treatment by restoration of full SI joint motion led to relief of symptoms in almost all cases. Most remarkable was the absence of need for surgery—only 2 patients needed surgery for protruded discs.

While most adults suffer with a few bouts of back pain, most don’t know that this is pandemic. In 1998, the Journal of Bone and Joint Surgery reported that back pain and musculoskeletal disorders (MSDs) were “second only to upper respiratory illness, musculoskeletal symptoms are the most common reason that patients seek medical attention, accounting for approximately 20 percent of both primary-care and emergency-room visits. Musculoskeletal problems were reported as the reason for 23 percent of visits by patients to a family physician, and musculoskeletal injuries accounted for 20 percent of visits to the emergency room.  As well, many back pain patients don’t go to a doctor for care or they self-treat themselves at home.

This back pain epidemic is a huge problem that has been investigated internationally to help solve this problem. Here is a short list of the most notable scientific investigations that have endorsed spinal manipulative therapy as a proven method for low back pain (LBP):

  • 1979:  Royal Commission of Inquiry on Chiropractic in New Zealand
  • 1994: AHCPR on Acute Low Back Pain in Adults
  • 2003: Ontario Workers’ Safety and Insurance Board
  • 2004: European Back Pain Guidelines.
  • 2004: UK BEAM 
  • 2007: Guideline on Back Pain: American College of Physicians
  • 2008: Decade of Bone & Joint Disorders for Chronic LBP

Despite the worldwide research, the sad fact remains chiropractors are still on the fringe of the back pain professions for no other reason than the Fundamental Flaw among biased MDs and surgeons who continue to push their drugs, shots and surgery despite the evidence to the contrary. “Don’t confuse us with the facts” remains their motto.

Dr. Scott Haldeman, co-chair of the study on chronic LBP by the Decade of Bone & Joint Disorders commented on what have we learned about the evidence-informed management of chronic low back pain?

“Although potentially heartening to the many clinicians who have adopted aspects of this approach, it is somewhat disappointing to note that 14 years after dozens of highly promoted new interventions, thousand of studies, millions of lost work days, and billions of dollars spent on its care, so little has changed in the evidence available to guide stakeholders and support treatments for CLBP.” [42]

Obviously the time has come for the public, press and politicians to correct this medical abuse. With the plethora of worldwide research staring at them with indisputable facts, and combined with our failing healthcare delivery system, the public must come to realize they cannot trust their health matters to men and women in the medical world who remain bias and ignore the new research and guidelines.

Just as Americans were ripped off by the greedy bankers on Wall Street, the time has come to admit patients with acute or chronic LBP have been exploited by their own doctor on Main Street.   

After 30 years, I’m now determined to right this listing ship by telling the chiropractic side of this disgrace. I flinch whenever I hear people repeat the medical drivel just as I cringe whenever I hear any bigoted statement against blacks, women or any minority. I know some people speak with malice in their hearts while others speak who are simply misinformed. To this group I write this rebuttal to the century of slander perpetuated by our antagonists in the medical and media industries.

Smorgasbord of Treatments

Not only are many MDs still very prejudiced in their attitude about chiropractors, also confusing matters for the public is the fact there are now over 200 different medications, therapies, injections, products, or procedures for chronic low back pain (CLBP) treatment, most of which researchers believe are worthless.

 

This smorgasbord of treatments for low back pain includes:

  • 60+ pharmaceutical products
  • 32 different manual therapies;
  • 20 different exercise programs,
  • 26 different passive physical modalities;
  • 9 educational and psychological therapies
  • 20+ different injections therapies
  • 11 more traditional and newer surgical approaches.
  • Extensive lifestyle products sold for CLBP, including braces, beds, chairs, and ergonomic aides.
  • Complementary and alternative medical approaches to CLBP.

As I’ve often told my patients (with thanks to Forrest Gump), spine care is like a box of chocolates, you just never know what you’ll get and you’ll faint when you have to pay for it.

In fact, some experts now believe that spine care in America is getting worse, not better. “Nationally, the annual expenditures attributable to spine problems rose 65% from 1997 to 2005. During this period the health status of those with spine problems did not improve,” said lead authors BI Martin and Richard Deyo from the Department of Orthopaedics and Sports Medicine, University of Washington.[43]

These spine experts also admitted the huge costs of this epidemic. Outpatient visits accounted for $30.8 billion—36%--of spine related problems...result of such factors as medical imaging, diagnostic tests, spinal injections and spinal fusion surgery.

 

This back pain epidemic while not deadly is certainly a huge expense and source of disability. Worldwide, musculoskeletal conditions are the most common causes of severe long-term pain and physical disability and account for half of all chronic conditions in people more than 50 years of age in developed countries. In the United States, musculoskeletal conditions cost our society an estimated $269.3 billion every year.[44]

According to a leading spine authority, Scott Haldeman DC, MD, PhD, “navigating this selection without an informed guide is analogous to shopping in a foreign supermarket without understanding the product labels…with chronic low back pain treatment options appear virtually endless and increasing every year, have strong and vocal advocates, and often limited scientific evidence.”[45]

A recent study reported that the prevalence of LBP in the general adult population is estimated at 37%, whereas the 1-year prevalence is 76% and the lifetime prevalence is 85%; approximately 20% of sufferers describe their pain as severe or disabling. [46]

So, where does the modern chiropractic profession stand in this epidemic of back pain treatments according to our best analysts, Dr. Bill Meeker and Dr. Scott Haldeman?

  • “Chiropractic has survived, and it has begun to embrace the values and behaviors of a mainstream health profession.  In the past few decades, chiropractic has strengthened its educational system; initiated research that has validated spinal manipulation; increased its market share of satisfied patients; initiated collaborations with other disciplines in practice, research, and professional settings; and effectively used political, legislative, and legal measures to secure a role.  Nevertheless, significant attitudinal and structural barriers to mainstream status still hinder chiropractic, and the advances of recent years may not be enough to ensure continuing progress in this direction.
  • “Chiropractic still maintains some vestiges of an alternative health care profession in image, attitude, and practice.  The profession has not resolved questions of professional and social identity, and it has not come to a consensus on the implications of integration into mainstream health care delivery systems and processes.  In today’s dynamic health care milieu, chiropractic stands at the crossroads of mainstream and alternative medicine.  Its future role will probably be determined by its commitment to interdisciplinary cooperation and science-based practice.”[47]   

Dr. Villanueva-Russell agrees: “Chiropractic cannot survive totally outside the realm of science. . . . For the sake of quality patient care, for protection from interlopers, for legitimacy against third party payers and malpractice suits, chiropractic needs to define for itself what the parameters of the profession are, and how to legitimate and validate these knowledge claims.  Unfortunately, this does not seem imminently possible with the host of forces mitigating these efforts from both within and outside the profession.”[48]

Above the din of this confusion on back pain treatment stands chiropractic care; as one prominent spokesman, Tony Rosner, PhD, testified before The Institute of Medicine: Committee on Use of CAM by the American Public on Feb. 27, 2003:

“Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.”

The sad fact that many Americans don’t share Dr. Rosner’s learned opinion doesn’t stem from the lack of need, the lack of proof, or the lack of chiropractors trying to tell their story for over 110 years now. Principally it comes from the medical misinformation that has overwhelmed the media with clatter that continues to cloud the chiropractic story.

 

 



[1] 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.

[2] 1998 (July): Annals of Internal Medicine, Dr. Jerry McAndrews, 2002/SAGA: pp. 65-6.

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

[4] Deyo RA, Psaty BM, et al. The Messenger under Attack--Intimidation of Researchers by Special    Interest Groups, NEJM, vol. 336, No. 16, pp. 1176-79, April 17, 1997.

[5] S. Bigos, ibid.

[6] P. Shekelle, et al, “The Appropriateness of Spinal Manipulation for Low Back Pain.” RAND Corporation Report, Santa Monica, Calif., 1992.

[7] Bourdillon JF, Day EA (1987) Spinal manipulation, 4th edition, William Heineman medical books, London, 216-217.

[8] Lewit K (1985) Manipulative therapy and rehabilitation of the locomotor system; Butterworths, London and Boston, 178.

[9] Maigne R (1972) Orthopedic medicine: A new approach to vertebral manipulations trans and ed by Liberson WT, 300.

[10]Terrett AJ, Kleynhans AM (1992) Complications from manipulation of the low back, Chiropr J Aust 27:129-140

[11] Oliphant D (2004) Safety of spinal manipulation in the treatment of lumbar disk herniations: A systematic review and risk assessment, J Manipulative Physiol Ther 27:197-210

[12] Cassidy JC, Thiel HW, Kirkaldy-Willis KW (1993) Side posture manipulation for lumbar intervertebral disk herniation, J Manipulative Physiol Ther 16(2):96-103.

[13] Testifimony before The Institute of Medicine: Committee on Use of CAM by the American Public on Feb. 27, 2003

[14] AMA apologizes to black doctors for past racism, by Lindsey Tanner, AP Medical Writer Thu July 10.

 

[16]Waddell G. Low back pain: a twentieth century health care enigma. Spine 1996 Dec 15; 21 (24):2820-5

[17]Unnecessary Surgery by James Barron; Published: April 16, 1989, NY Times.

[18] Cherkin DC, Deyo RA, An international comparison of back surgery rates et al. Spine. 1994 Jun 1;19(11):1201-6.

[19] Widen, M. “Back specialists are discouraging the use of surgery.” American Academy of Pain Medicine, 17th annual meeting, Miami Beach, Fl. Feb. 14-18, 2001.

[20] Brox JI, Sørensen R, Friis A, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913–1921

[21] Weinstein JN et al., Surgical vs. non-operative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) observational cohort, JAMA, 2006; 296:2451–9.

[22]Surgery Need Is Questioned In Disk Injury   By GINA KOLATA , NY Times, Wednesday, November 12, 2008.

[23] Mohit Bhandari, Brad Petrisor, Jason W. Busse and Brian Drew Division of Orthopaedic Surgery, Department of Surgery; McMaster University;  Spine Unit, Hamilton Health Sciences–General Hospital, Hamilton, Ont., CMAJ • August 16, 2005; 173 (4). doi:10.1503/cmaj.050884.

[24] Yelin E, Cisternas MG, Pasta DJ, Trupin L, Murphy L, Helmick CG. Medical care expenditures and earnings losses of persons with arthritis and other rheumatic conditions in the United States in 1997: total and incremental estimates. Arthritis Rheum. 2004;50:2317–2326.

[25] Begley, Sharon, Where are the cures? November 10, 2008, pp. 56, Newsweek.

[26] Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: Two-year results of a randomized controlled trial, BMJ, 2008.  

[27] vol. 23, no. 6, 2008.

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

[29] JAMA, Need for less imaging, better understanding June 4, 2003 vol. 289 no. 21

[30] “National Spine Care Advisory Committee Formed,” Dynamic  Chiropractic September 14, 2005, Volume 23, Issue 19.

[31] Widen, M. ibid.

[32] Widen, M. ibid.

 

 

 

[36] Bigos S. et al. US Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guideline, Number 14: Acute Low Back Problems in Adults AHCPR Publication No. 95-0642, December 1994.

[37] The BackLetter, Vol. 12, No. 7, pp.79, July, 2004.

[38] A brief overview of evidence-informed management of chronic low back pain with surgery, Angus S. Don FRACS and Eugene Carragee MD, The Spine Journal, Volume 8, Issue 1, January-February 2008, Pages 258-265

[39] Brox JI, Sørensen R, Friis A, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913–1921.

 

[40] Conservative Therapy for Low Back Pain: Distinguishing useful from useless therapy. JAMA 1983: 250;1057 - 62.

[41] 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

 

[42] What have we learned about the evidence-informed management of chronic low back pain? Scott Haldeman DC, MD, PhD, FRCP(C) and Simon Dagenais DC, PhD The Spine Journal Volume 8, Issue 1, January-February 2008, Pages 266-277.

[43] Martin BI et al., Expenditures and health status among adults with back and neck problems, AMA, 2008; 299:656–64. 

[44] Yelin E, Cisternas MG, Pasta DJ, Trupin L, Murphy L, Helmick CG. Medical care expenditures and earnings losses of persons with arthritis and other rheumatic conditions in the United States in 1997: total and incremental estimates. Arthritis Rheum. 2004;50:2317–2326.

[45] Scott Haldeman DC, MD, PhD, FRCP(C) and Simon Dagenais DC, PhD. A supermarket approach to the evidence-informed management of chronic low back pain. The Spine Journal, vol. 8, Issue 1, January-February 2008, Pages 1-7.

[46] Scott Haldeman DC, MD, PhD, FRCP(C) and Simon Dagenais DC, PhD. A supermarket approach to the evidence-informed management of chronic low back pain. The Spine Journal, vol. 8, Issue 1, January-February 2008, Pages 1-7.

 

[47] Meeker WC, Haldeman S.  Chiropractic: A profession at the crossroads of mainstream and alternative medicine. Annals Int Met 2002; 136: 216-227.

[48] Villaneuva-Russell Y. Evidence-based medicine and its implications for the profession of chiropractic. Soc Sci Med 2005; 60: 559

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