Articles by JCS

Bones & Flaws

Bones & Flaws

“Chiropractic…vaulted from last to first place…”

by

JCS

Introduction

The late Robert Mendelshon, MD, renowned author and self-proclaimed medical heretic, once wrote, “Anyone who has a back surgery without seeing a chiropractor first should also have his head examined.”[1] His admonition back in the 1980s was prophetic and a forewarning of today’s back pain dilemma.

Just in the past few years, if not months, more evidence has emerged that critiques the medical model of back pain diagnosis, treatment, and management. Evidently, in this era of evidence-based medicine (EBM), the typical medical diagnosis for back/neck pain consisting primarily of “slipped discs” and “pulled muscles” have not proven true, nor has their remedies of drugs, shots, and spine surgery withstood the test of time or research. Yet the mainstream medical profession and media continue with this expensive ruse and refuse to say what Dr. Mendelshon and many worldwide researchers agree—those damn chiropractors, for the most part, were right all along!

Dr. James Weinstein, orthopedist and lead author of the SPORT study[2], said the rapid growth in surgical procedures, coupled with the lack of hard evidence, points to the need to spell out all the risks and benefits for patients and let them choose—in other words, to end the medical stranglehold on the back pain business.

“As in most of medicine, there isn't as much evidence as we would like," said Weinstein, director of the Dartmouth Institute for Health Policy and Clinical Practice. “We need to be clear that there is a choice of treatments,” he said, and "that one isn't necessarily better than the other."[3] Quite an admission from an orthopedist undoubtedly tormented that the profitable standard medical methods can’t be substantiated in this era of EBM.

Regrettably, his advice has fallen on deaf ears inasmuch as the rate of increase in spine surgeries has escalated leaving a wake of impairment and disability as well as huge costs, while the growth of conservative treatments like chiropractic care have not seen the same increase in usage. Indeed, in most cases patients have been mislead about the cause of their back pain, treated with unproven or ineffective treatments, misled about the likelihood of success from surgery and reoperations, and the most glaring omission concerns one alternative treatment in particular—chiropractic spinal manipulation.

Why? Foremost, institutionalized medical ideological bias toward anything to do with chiropractors is the biggest reason why spinal manipulative therapy (SMT) has been ignored despite the abundance of evidence showing the clinical and cost-effectiveness of SMT.

Paul Goodley, MD, orthopedic physician, in his book, Release from Pain,[4] writes of this medical bias and the ethical dilemma it poses for physicians. He coined a term to describe this blind eye toward manipulative therapy as the Fundamental Flaw of medicine. I contend there are other Fundamental Flaws in medicine that have led to this pandemic of pain, not just the medical bias as Dr. Goodley suggests.

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

This medical bias is deeply rooted in most physicians and nurses, a medical catechism taught from day one in medical school. Sadly, this prejudice has not only hurt chiropractors but the millions of patients who suffer from back/neck pain.

Secondly, money is a huge factor considering the cost for spinal treatment is astronomical—$36 billion for treatments[5] and up to $100 billion annually for total costs—the lion’s share of the cost of back pain comes from expenses related to work loss, disability claims, early retirement, and lost productivity. Spine surgery is the second largest money maker behind heart surgeries, so there is little interest by hospitals to change tracks despite what the evidence and ethics might indicate.

Thirdly, outdated medical diagnosis of back pain, based primarily on disc abnormalities as the main focus, has been contraindicated by recent EB research, yet the medical profession has turned a blind eye upon this latest research.

Fourthly, numerous analyses of medical training for musculo-skeletal conditions have shown consistently low scores in Basic Competency Exams by medical students, recent medical graduates, non-orthopedic staff physicians, osteopathic students, and physical therapy students. Chiropractic clinicians with postgraduate training showed considerably better results than chiropractic interns.[6] Despite these failings, primary care physicians hold themselves out to be competent diagnosticians to patients for spinal disorders when, in fact, a dentist would be just as competent, yet, just as uninformed.

These are the Fundamental Flaws in this war on back pain and the medical profession is unwilling to admit, for the most part that their paradigm has been wrong and those damn chiropractors may have been right all along. There’s just too much money and pride at stake to let the evidence cloud their actions.

This silent epidemic has certainly not gotten the attention it deserves in the past compared to other epidemics like heart disease and cancer because it’s not fatal, but its reach is just as significant considering these facts about low back pain (LBP):

  • LPB is the leading workers’ compensation injury,
  • LPB is the leading cause of disability for people under the age of 45,
  • LBP is the second-leading cause of visits to doctors’ offices,
  • LBP is the third-leading cause for hospital admissions,
  • LPB the second-leading cause of surgery other than heart surgeries.[7]

Richard Deyo, MD, MPH, et al.[8] from the Center for Cost and Outcomes Research compiled staggering statistics regarding the volume and rates of spine surgeries.

  • Lumbar Spine Fusion Volumes: 122,316 lumbar fusions for degenerative conditions in 2001. This represents an increase in fusions from 1990–2001 of 220%
  • Primary Diagnosis associated with lumbar fusion: Rate of fusion surgery increased fastest among oldest patients: 230% for age greater than 60, 180% for age 40-59, 120% for age less than 40. For patients with primary diagnosis of degenerative change, instability, or stenosis, the percent of operations involving a fusion increased from 25% in 1988-89 to 51% in 2000 – 2001.
  • Lumbar fusion volume by primary diagnosis: Proportion of operations involving fusion by diagnosis in 2001: Degenerative Changes: 70% Possible instability: 93% Spinal Stenosis: 26%.
  • Spinal fusion surgery was the most rapidly increasing type of lumbar spine surgery during the 1980s. It has been suggested that advances in technology, including pedicle screw and plate systems, may have contributed to this rise, along with improvements in preoperative care, expanded training of spine surgeons, and reimbursement incentives. Spinal fusion rates appear to vary among geographic areas even more dramatically than rates of other types of back surgery. International rates of spinal fusion vary more than rates of other types of back surgeries.

EBM from Europe and America now suggests major changes to the management of patients with low back pain including those diagnosed with disc herniation. Studies in the US [9], UK [10], Canada [11], Denmark [12], to name a few major studies, have all concluded the same—back surgeries are out and conservative care such as spinal manipulative therapy is the best approach to the vast majority of LBP problems. Yet this evidence continues to fall on deaf ears.

The BACKPage editors summarized the present dilemma and admitted its failure: “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.”[13]

According to Pran Manga, PhD, medical economist, “There is an overwhelming body of evidence indicating that chiropractic management of LBP is more cost-effective than medical management.” [14] There is now broad agreement internationally that surgery should not generally be considered until there has been a trial of conservative non-surgical care.[15],[16],[17]

For the most part, however, this evidence has been ignored due to Fundamental Flaws in for-profit medicine in America. Rather than evidence as the guiding light, the medical attitude in regards to back pain appears to be “Don’t confuse us with the facts.” Indeed, there is simply too much money and too much pride involved to change the present medical system in the USA.

Not Much Bang for the Bucks

In fact, Americans are spending more money than ever to treat spine problems, but their backs aren’t getting any better according to a recent report in the Journal of the American Medical Association.[18] This study by Martin et al. found that United States alone spent nearly $86 billion in 2005 on spine treatments, a rise of 65 percent from 1997, after adjusting for inflation. Despite this huge amount of money, the proportion of people with impaired function due to spine problems actually increased during the period, even after controlling for an aging population.

“You’d think if you’re putting a lot of money into a problem, you’d see some improvements in health status,’’ said lead author Brook I. Martin, research scientist at the University of Washington’s department of orthopedics and sports medicine. “We’re putting a lot of money into this problem, and it’s a big investment in health care
expenditures, but we’re not seeing health status commensurate with those investments.’’[19]

Researchers found no improvement whatsoever over the eight-year period. Moreover, people actually got slightly worse during the period. Patients reported more disability from back and neck pain, including more depression and physical limitations.

The report is the latest to suggest that America is losing its battle against back pain, and that many popular treatments may be ineffective or overused. As far back as 1994 the Agency for Health Care Policy and Research, under the US Public Health Service, conducted at that time the most comprehensive meta-analysis of acute low back pain in adults and came to the same conclusions as the more recent studies, but it also was virtually ignored by the medical profession.[20]

Professional pride not withstanding, more and more doctors now questioned whether surgical treatments, epidural steroid injections, and narcotic pain medications are being used appropriately in many patients. In this light, others question why alternative treatments such as chiropractic care aren’t recommended in light of studies showing its effectiveness. Indeed, this suggests the medical profession is still operating under Fundamental Flaws in its approach to this epidemic of back pain.

“I think the truth is we have perhaps oversold what we have to offer,’’ said Dr. Richard A. Deyo, a physician at the Oregon Health &  Science University in Portland and a coauthor of the report. “All the imaging we do, all the drug treatments, all the injections, all the operations have some benefit for some patients. But I think in each of those situations we’ve begun using those tests or treatments more widely than science would really support.’’[21]

According to the Martin study, in 2005, Americans spent an estimated $20 billion on drug treatments for back and neck problems, an increase of 171 percent from 1997. The biggest jump was for narcotic pain relievers, such as OxyContin and Vicadin, which increased more than 400 percent, even though their use for chronic pain is controversial.

"We still don't know much about their long-term efficacy and safety for chronic back pain. Patients need to understand that if they take these (opioid) medications long term, after a few months it will be difficult to stop. And there is pretty good evidence that long-term use may actually increase sensitivity to pain." Deyo told WebMD.[22]

S. K. Mirza, MD, MPH, in a commentary in Spine, raised concern about supposed success cases that were still using opioids in 64-84% of cases.[23]

“Another concern is the meager success rate observed in both the artificial disc and the lumbar fusion groups. Only 57% of the patients with disc replacement and only 46% of those with interbody fusion met all 4 criteria for success. While evaluating a device designed to treat back pain, the definition of success did not consider pain relief or opioid medication use. Even among the patients classified as having a successful result, most were still using narcotic medications at the 2-year follow-up, including 64% of the successful-result patients in the disc replacement group and 84% in the fusion group.

“These are results in ideal patients, how many patients will accept an improvement chance no better than a coin toss? Furthermore, an artificial joint can only deteriorate with time, and some patients in either group may have adjacent level disease develop, so the longer-term results in both groups can be anticipated to get worse.”

Imagine the inappropriate use of $20 billion for dangerous drugs that have temporary results at best despite, toxic side-effects, and the belief that narcotics have no effect upon the underlying cause of LBP. As well, spending for surgical procedures and other inpatient costs grew by 25 percent to about $24 billion despite many researchers who believe spine surgeries are ineffective and overused according to the Martin study.

“I do worry there is a combination of side effects and unnecessary treatments,’’ Dr. Deyo said. “The combination of those kinds of things may actually be in some cases doing more harm than good.’’

Despite the growth in treatment of back problems, the data show that the percentage of people with serious spine problems hasn’t improved; in fact, it appears to have gotten worse. Despite the worldwide research showing the ineffectiveness of the medical management of back problems, in the US the medical profession has shown a huge resistance to limiting one of their biggest money makers—back surgeries.

These researchers estimated that in 1997, about 21 percent of the adult population suffered from back or neck problems that limited their function. By 2005, that number grew to about 26 percent, after adjusting the numbers for age and sex. It’s not clear to Martin et al. why more people appear to be suffering from back and neck pain. They suggest it could be that rising obesity rates are taking an added toll on the spine. Or it could be that excessive treatment of back problems is leading to more problems. Or could it be that the medical paradigm is incorrect in that back pain is not primarily a function of pulled muscles or disc abnormalities—the basis of the medical model for LBP?

Remarkably, the medical paradigm of back pain as the real source of this epidemic has gone unchallenged. Combined with a suspect disc theory that suggests disc abnormalities are the basis of back pain is the medical bias that has plagued the diagnosis and treatment of back pain treatment for over one hundred years. Avoidance of EBM is another problem that plagues for-profit healthcare when profits supersede doing what’s best for patients. Indeed, the American healthcare delivery system is failing, costly, and intransigent to improvement.

Another recent seven-year, international study by The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders published in the journal Spine finds that some alternative therapies such as acupuncture, neck manipulation and massage are better choices for managing most common neck pain than many current practices.[24] The study also found that corticosteroid injections and surgery should only be considered if there is associated pain, weakness or numbness in the arm, fracture or serious disease.

“Neck pain is not a trivial condition for many people,” says Task Force president Dr. Scott Haldeman, clinical professor, department of neurology at the University of California, Irvine; and adjunct professor, department of epidemiology at UCLA.  “It can be associated with headaches, arm and upper back pain and depression.  Whether it arises from sports injuries, car collisions, workplace issues or stress, it can be incapacitating.  Understanding the best way to diagnose and manage this problem is of high importance for those who are suffering and for those who manage and pay for its care.”

“One thing that became very clear to us is that the classic model we use in clinical practice doesn’t work. We tend as clinicians to see a person with neck pain, try to diagnose the cause of the problem, prescribe treatment, and hope the patient has no more pain. What we found is that this model just doesn’t fit the evidence,” said Haldeman. Given the existing evidence, management models based on the effective diagnosis and treatment of neck pain are simply “doomed to failure,” Haldeman suggested. [25]

“This is an important body of research that will help to improve the quality of patient care by incorporating the best evidence into practice and patient education,” says Dr. Linda Carroll.  “Neck pain can be a stubborn problem - we hope this comprehensive analysis of the evidence will help both sufferers and health care providers better manage this widespread complaint.” [26]

The Task Force admitted that surgery has a role to play in the treatment of neck problems, but there are huge gaps in the evidence on surgery. There is some evidence that surgery can lead to substantial relief of pain and disability over the short-term in the treatment of cervical radiculopathy. But there is no compelling evidence from high-quality clinical trials that surgery is superior to nonsurgical care or that any form of surgery is clearly superior to others in the treatment of radiculopathy. And there is currently very little compelling evidence that surgery is an effective treatment for axial neck pain in the absence of radicular symptoms.[27]

Back Pain Supermarket

Back pain treatment is like opening a box of chocolates, you just never know what you’ll get. In the words of Dr. Seth Waldman, a New York doctor who heads a referral center for chronic pain, “Each approach to diagnosis and treatment is essentially a franchise, and there are too many franchises battling for control.”[28]

Considering 90% of adults will suffer an acute low back episode that often leads to a chronic problem, the various treatments available only compound their misery. To make matters worse, often surgeons have a conflict of interest, many doctors ignore evidence-based guidelines, some physicians practice outdated methods, and many still hold a bias against what’s proven to be effective—spinal manipulative therapy.

In a recent article in The Spine Journal, acclaimed multi-dimensional spine spokesman, Scott Haldeman, DC, MD, PhD, mentions this quandary for patients and practitioners in regards to treatment for chronic LBP.

“Patients with chronic low back pain (CLBP) are finding it increasingly difficult to make sense of the growing list of treatment approaches promoted as solutions to this widespread problem...The current approach to the management of CLBP makes this goal virtually unobtainable.

“When a new treatment approach is being considered in fields as cardiology, infectious diseases, acute trauma, or neurology, there is a general expectation that adequate research will support its effectiveness, safety, and cost effectiveness before it is endorsed as a viable treatment option. With CLBP, however, treatment options appear virtually endless and increasing every year, have strong and vocal advocates, and often limited scientific evidence… Conversely, approaches that have demonstrated only minimal benefit in clinical trials continue to be recommended by proponents who allege that such studies were flawed and do not accurately represent current clinical practice.”

A good example of this myopia came from Dr. Richard Fessler, a professor of neurosurgery at Northwestern University regarding the recent Martin study, who called the study “fatally flawed.” He offered no studies to support his stance, he merely gave his own opinion, one heavily influenced by his own self-interests.

“The methodologies in the paper are atrocious. I can’t imagine how this got published,” he wrote in an e-mail to Reuters.[29] Fessler said the study fails to mention recent clinical trials that, in his opinion, showed certain patients undergoing spinal surgery improved significantly. “Some people are so afraid to have surgery [after reading] these type of articles that they choose to continue suffering” rather than do a simple procedure that can fix the problem, he says. It’s perplexing how Fessler contends invasive spine surgery is a “simple procedure” in light of non-invasive SMT that has been shown to be as effective in the numerous studies. Indeed, does Fessler give his patients options to his surgery that includes chiropractic care? Okay, stop laughing!

According to Dr. Haldeman, “Decades spent listening to presentations at scientific meetings, reading textbooks, discussing the problem with clinicians and patients, listening to advertisements on the television or radio, and browsing the internet, could lead one to conclude that the classical method of making healthcare decisions based on scientific evidence and expert consensus appears to have been replaced with a commercial and competitive model akin to shopping at a supermarket.”[30] He might also have included what is most profitable to the practitioner’s franchise.

According to Dr. Haldeman, the choices for treatment are exhausting for the patients:

  • over 60 pharmaceutical products
  • 32 different manual therapies; this is only a partial list as there are well over 100 named techniques in chiropractic, physical therapy, osteopathy, and massage therapy.
  • 20 different exercise programs,
  • 26 different passive physical modalities,
  • 9 educational and psychological therapies
  • over 20 different injections therapies and minimally invasive interventions widely promoted as alternatives to surgery.
  • 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, which are used by a large and apparently growing number of patients.

“This simplified, partial inventory of treatment options available to a person with CLBP includes over 200 different medications, therapies, injections, products, or procedures. It is a challenge for anyone involved in the management of CLBP to memorize this list, let alone understand the relative benefits and harms of each intervention at a level that is sufficient to provide advice to their patients. Although true informed consent requires a discussion of available alternatives, it would be impossible—or at least unfeasible—for a clinician to do so fully and accurately when it comes to CLBP.”

When one of the most astute spine professionals in the world admits confusion about back pain treatments, you know we have a big problem. But one thing is for certain, in the for-profit American healthcare system, everyone agrees there is too much spine surgery. Despite the media image of surgeons as saviors to patients, in fact, many spine surgeons may be ripping off the majority of their patients as the recent research indicates.

Dr. Richard Deyo, another leading spine researcher, concurred 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 ‘over-medicalized.’” [31]

Despite the increasing calls questioning the validity of spine surgery in prestigious professional journals like Spine and THE BACKLETTER, the annual number of spinal fusion operations rose by 77% between 1996 and 2001 and continue to rise. Drs. Deyo and Cherkin mentioned that the rate of back surgery in the United States was at least 40% higher than in 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 the country.[32]

A 15-member Spine Care Advisory Committee was formed in 2005 to investigate this growing problem. Margaret E. O'Kane, National Committee for Quality Assurance president, also agrees with Haldeman and Deyo:

“In many cases, back pain is treated with unnecessary surgery that still leaves the patient in pain. This program will steer people to doctors who not only know how to diagnose back problems, but who also explain the pros and cons of treatment options, help them manage their condition and get well again.”[33]

Despite the admonitions from experts, their message is not getting to the public in the popular press. Consequently, the dilemma for consumers remains—conflicting diagnosis, divergent treatment paradigms, huge surgical costs, insurance non-coverage for alternative treatments, serious side-effects, lack of informed consent, and common treatments unsupported by current research.

Compounding these problems is a biased medical profession still averse to referring patients to chiropractors despite the overwhelming research supporting active rehab, including spinal manipulative therapy, for mechanical low back pain. 26, 27 The huge money involved with spine surgery has tainted the ethics of surgeons, made accomplices of  hospital administrators and perverse insurance companies who prefer expensive surgery over cheap SMT because there’s more money for everyone! Where else can American doctors, hospitals and insurance companies profit so easily off the backs of unassuming patients who mistakenly think their best interests are at the heart of this epidemic of back surgery? Only in America does this medical scam persist due to the perverse for-profit system and the lack of evidence to support the massive amounts of spine surgeries.

"If we stopped paying for everything that had no evidence of benefit, we would be a very unpopular organization," said Dr. Steve Phurrough, director of Medicare's coverage and analysis group. "Back pain is an increasing problem in our country and people . . . want something done."[34] It appears managed care organizations are willing to pay for expensive procedures that lack evidence, but refrain from non-medical methods like SMT that have proven effective because they more they pay, the more they profit.

Although the perverse motivation remains in managed care organizations, hospitals are now under pressure from large private insurers, state governments and Medicare, hospitals around the country not to charge when they make medical mistakes, also called "never events" because they shouldn't happen, such as patients who had surgery on the wrong body part or were disabled from the wrong medication. This is major revolution in the hospital world.

"Asking hospitals to commit to normal customer-service principles should not be radical, but it is," said Rachel Weissburg of The Leapfrog Group, a nonprofit organization that pushed for the move. "We have a very strange system in the U.S., where you don't pay for quality, you pay for service."[35]

Perhaps unnecessary and ineffective spine surgeries should be added to this list of “never events,” especially if conservative care is not done beforehand as many of the international guidelines recommend. Considering the high percentage of ineffective spine surgeries and the fact that 20% of spine surgeries have re-operations, how can hospitals and surgeons charge for these failed surgeries? Only in medicine are services charged despite poor results. Imagine if hospitals were required to offer guarantees or warranties to patients, just as other product manufacturers are required to do.

Aside from the perverse motivation by surgeons, hospitals, and insurance executives, other stakeholders in the back pain business also exhibit perverse motivations. Certainly some DCs can be accused of over-treating some patients, but these costs are miniscule compared to the costs of unnecessary spine surgery considering researchers state disc abnormalities are not the primary problem in LBP.

  • According to WH Kirkaldy-Willis, MD and David Cassidy, DC, discs are involved in fewer than 10% of back pain cases.[36]
  • According to Nikolai Bogduk, MD, PhD, discs are involved in fewer than 5% of these cases.[37]
  • According to V. Mooney, MD, discs problems account for less than 1% of these cases.[38]
  • According to Dr. Scott Boden, orthopedist/researcher, “the disc might not be the cause of pain. And if so, fixing it is a waste.” [39]

This points out the single-most prevalent cause of misdiagnosis in low back pain problems—that is, the use of costly MRI images to show disc abnormalities to convince patients that some sort of disc problem is the cause of their pain. In fact, as Dr. Deyo, the U.S. guideline, and other researchers have repeatedly shown, disc abnormalities are not the cause of most back pain, often appear in perfectly pain-free patients, and continue as the largest segment of “false positives” in the diagnosis of most back pain problems.

As Dr. Deyo mentioned, “Detecting a herniated disc on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”[40] He concludes that 97% of back pain is “mechanical” in nature, and disk abnormalities account for only 1% of back problems. Concerning herniated intervertebral discs, Dr. Deyo believes,

“In the absence of the cauda equina syndrome or progressive neurologic deficit, patients with suspected disc herniation should be treated non-surgically for at least a month.”[41]

Sage advice that is mostly ignored nowadays by surgeons and other stakeholders involved in the escalating costs of back pain. As a 30-year practitioner working near the largest single-sight employer in the state of Georgia, Robins Air Force Base, I can count on one hand the number of workers’ comp. cases I’ve gotten. Sadly, physicians on base are instructed to refer all back pain cases to the surgeons, which certainly add to the costs and explains why Macon is supposedly the capital of back surgeries per capita in the state and ranks fourth on the list nationally. Knowing the ease to having spine surgery, many employees opt for surgery in order to become disabled and be awarded compensation. Is this not perverse or what?

Another case came to me after 5 spine fusions with metal screws failed him. My analysis found the source of his LBP came from his sacroiliac, and after only 3 treatments with SMT, his pain was gone. When I asked why he hadn’t seen a DC first, he told me he requested a referral, but was denied by the base doctors who also gave him the voodoo diagnosis to implant fear of being adjusted. Sadly, this man was misdiagnosed, mistreated, misinformed, and will live with interminable back pain for the rest of his life.

Another similar mismanaged case comes to mind when a woman was slighted injured in a rear-end MVA. She complained only of a slight sprain/strain in her neck and after 12 treatments with SMT, was dismissed with flying colors. Indeed, the last time I saw this attractive 50-year old, she was in her tennis skirt outfit ready to play and looking like she was 30. Apparently this small case wasn’t enough for her PI attorney who sent her to a local Macon surgeon who committed 3 spine fusions on her—one in her low back even though she had no complaints.

Over a year later I participated in a deposition in her case, contending she was a victim of unnecessary surgery. Her attorney was suing for over a $250,000 and due to my testimony, settled for only $90,000. A third went to her attorney, a third went toward her medical bills, and the other $30,000 was taken by her husband who bought himself a new pickup truck. All this lady got out of this deal was 3 unnecessary back surgeries.

By happenstance, I saw her shortly afterwards in the local grocery store. At first I failed to recognize her since she wasn’t the youthful woman I had last seen ready to play tennis. Instead, she was dressed in a bathroom robe and needed a walker to move about. She explained to me the three surgeries, but when I asked why she had a lumbar fusion when she had no LBP complaints, she told me the surgeon said she had “degenerative disc disease” as if it were some infection that would spread if he didn’t remove it. What a con-job!

The very next day I phoned her attorney to ask why he subjected her to this awful ordeal. His response was classic for an unethical PI attorney: “Do you want a third of $10,000 or a third of a quarter of a million?” Obviously this unscrupulous scalawag and an unethical, knife-happy surgeon ganged up on this unsuspecting woman to exploit her only as a lawyer and surgeon can do.

Don’t think this is a sole case on a local level since this has become institutionalized in the Georgia state worker’s comp business too. As many studies have shown access for injured workers' comp cases to chiropractic care should be increased, to bring about significant direct and indirect cost savings, we are witnessing precisely the opposite. Chiropractic care seems to be getting squeezed out of the system considering cost recoveries were just 0.8 percent of the benefits disbursed to physicians in 1997 and 1998.[42]

In view of the increasing costs of workers’ comp injuries, the past governor of Georgia assembled the stakeholders in this area for a conference to lower cost and improve outcomes. I was asked by my state association to attend and to present a paper on the then-recent AHCPR and Manga Reports showing SMT was cheaper, safer and more effective for common LBP cases. Of course, the MDs and CEOs didn’t want to hear how chiropractic care can take profits away from their businesses. At one point in my 45-minute presentation, an MD suddenly stood up and told the audience that “we don’t need chiropractors who think they can cure diabetes,” getting a big laugh in an effort to discredit my talk.

I responded calmly by indicating that diabetes is not a workers’ comp. injury nor was I talking about the impact SMT may have upon organic disorders. I was simply demonstrating that SMT was effective for LBP cases. After another snide remark from someone in the audience who also didn’t want to be confused with the facts, finally a huge African-American man, a labor rep from Atlanta, stood up and asked if he could speak.

Since he was 6’7” tall and weighed over 350 pounds, I said he could talk about anything he wanted. I was delighted to hear his testimony when he said, “When I played football for the Atlanta Falcons and the Detroit Lions, it was chiropractors who kept us playing, not you medical doctors with your drugs, shots and surgeries. I suggest you get off his back and let him tell us how he can help.” His admission broke the ice and opened up a flood of other positive comments about chiropractic care helping injured workers and some negative comments how WC tries to limit access to DCs too. “I have plenty of clients who want to go to chiropractors, but their WC adjuster won’t let them go,” said one attorney although chiropractic care is legally available to them.

Afterwards, a plaintiffs’ attorney told me that I was talking to the wrong crowd. “These are the for-profit guys who want to see rising costs because,” he explained, “the more they pay out, the more they can charge in premiums to invest, so there’s more money for everyone when they send patients for surgery rather than to chiropractors.” Obviously a cheaper mousetrap is not good for the back pain business in workers’ compensation.

Obviously the unnecessary spine surgery business is good for some, but bad for many. Indeed, these are the Fundamental Flaws in medicine, especially orthopedics, in regards to the growing epidemic of low back pain and ineffectual treatments. If these scenarios make you mad with disbelief, the following evidence should make you wonder how anyone can trust any surgeon, adjuster, attorney or anyone who still routinely railroad patient into spine surgeries without recommending first using a chiropractor. Just like hysterectomies, tonsillectomies, and appendectomies, in the near future hopefully back surgeries will rank highest among these once common but unnecessary money-making surgeries.

 Although Robert Mendelshon advised that “Anyone who has a back surgery without seeing a chiropractor first should also have his head examined,” perhaps today he would include ethical exams for surgeons, administrators, insurance executives, attorneys, and greedy patients too.

Bones of Contention

Regrettably, the advice from EBM has fallen on deaf ears for many reasons. After 30 years considering the antipathy toward chiropractors and SMT, there seem to be 3 main issues on the open agenda: the safety, scope and efficacy of chiropractic care. The hidden agenda that until only recently has gotten any public press remains the turf war focusing principally on professional bias and money—lots of money.

Bone #1: Safety of SMT: The Voodoo Diagnosis

“If you go to a chiropractor, don’t come crawling back to me after you’re paralyzed,” is a comment some patients are still told by their spine surgeons. Obviously this is a scare tactic—the voodoo diagnosis—that ignores the recent plethora of research about SMT and its safety. It is difficult to believe these surgeons are unaware of these research findings considering their immense publicity in professional journals and in the national media.

The safety and danger of spinal manipulation remains paramount in the patients’ minds after years of hearing from the media and medical professionals that chiropractors may cause strokes or paralysis. After the Lana Lewis lawsuit in Canada brought international media attention to her death from a stroke weeks after being manipulated by her chiropractor who was found not negligent in this case, researchers have brought to light many interesting facts about SMT and stroke.

Dr. Adrian Upton, Head of the Department of Neurology at McMaster Health Sciences Centre testified at the inquest into the death of Lana Lewis that, based on all of the evidence he has reviewed, Ms. Lewis died of a stroke caused by advanced atherosclerosis. During examination, he stated that a chiropractic neck adjustment she received not long before her stroke was at best “a remote possibility at the bottom of the list of probabilities” for causation. Ms. Lewis was extremely hypertensive, off her meds, and a heavy tobacco smoker at the time of her death—as Dr. Upton put it, “she was a time bomb ready to explode.”

According to Terret et al., the rate of iatrogenic problems associated with spinal manipulative therapy as rendered by doctors of chiropractic is only 1 in 5.85 million cases, which is less than the chance of stroke in a hair salon or being hit by lightning (one in 600,000). It equated to one occurrence in 48 chiropractic careers.[43]

A recent Canadian study by The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders indicates there is no increased risk related to chiropractic treatment in the debate about whether neck adjustments can trigger a rare type of stroke. Researchers found patients are no more likely to suffer a stroke following a visit to a chiropractor than they would after stepping into their family doctor's office.

The findings, recently published in the journal Spine,[44] help shed light on earlier studies that had cast a cloud on the chiropractic profession and suggested that their actions resulted in some patients suffering a stroke after treatment. In fact, the findings support the chiropractic position of its extreme safety when compared with drugs and surgery.

“We didn't see any increased association between chiropractic care and usual family physician care, and the stroke,” said Frank Silver, one of the researchers and also a professor of medicine at the University of Toronto and director of the University Health Network stroke program.

“The association occurs because patients tend to seek care when they're having neck pain or headache, and sometimes they go to a chiropractor, sometimes they go to a physician. But we didn't see an increased likelihood of them having this type of stroke after seeing a chiropractor.”

SMT can be associated with relatively benign temporary side effects including mild localized soreness or pain, which typically does not interfere with activities of daily living. A large, prospective observational study of 1,058 patients who received 4,712 sessions of SMT from 102 DCs in Norway reported the following common adverse events (AEs): local discomfort (53%), headache (12%), tiredness (11%), radiating discomfort (10%), and dizziness (5%). Most of these AEs occurred within 4 hours of SMT (64%), were of mild-to-moderate severity (85%), and disappeared the same day (74%). It should be noted that this study included AEs from SMT applied to the cervical, thoracic, or lumbar areas, and was not restricted to CLBP.[45]

Gert Bronfort, DC, PhD, et al. conclude that the “preponderance of the evidence for efficacy, including recent high-quality trials, and the estimated very low risk of serious AEs support SMT and mobilization (MOB) as viable options for the treatment of CLBP. SMT and MOB are at least as effective as other efficacious and commonly used interventions.”

All published medical experts in manipulation such as Bourdillon and Day in Canada,[46] Lewit in the Czech Republic,[47] and Maigne in France,[48] agree with the chiropractic and osteopathic professionals 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. It should be noted that all of them practice in not-for-profit healthcare systems where EBM is more apt to be used.

Bone #2: The Scope of Chiropractic : The Jury is In; the Jury is Out.

The antipathy toward chiropractic’s scope of treatment prevails in part to claims by some chiropractors to help organic disorders that remain unclear, a dilemma and source of internal argument within the chiropractic mainstream. Regrettably, while progressive evidence-based DCs look to research for guidance, some ol’ time chiropractors cling to the past vitalism despite their lack of evidence other than anecdotal case studies. Indeed, the Big Idea of BJ Palmer that chiropractic adjustments cure via the innate healing power of the CNS has become the Big Problem for the profession. While anecdotal evidence exists, scant research proves this adequately.

NM Hadler wrote about the purview of chiropractic in his book, The Last Well Person. “What is less defined, somewhat contentious within chiropractic, and very contentious for mainstream medicine is the purview of chiropractic. Is it solely the regional musculoskeletal disorders? That is not the stance of many chiropractors or many schools of chiropractic. These advocates and practitioners are willing to ‘reduce subluxations’ for a range of ailments from headaches to asthma…Subluxations are the chiropractic diagnosis that implies spinal malalignment. They are imaginary; no such specific skeletal changes correlate with symptoms…how anyone can imagine that such an event can salve asthma or diabetes or the like is a testimony to the tenacity of vitalistic theories.”

            Obviously the medical mindset has rejected any link between organic disorders and spinal problems except for lumbar disc herniations causing cauda equina syndrome and bowel and bladder incontinence.           While Dr. Hadler scoffs at the idea of helping asthma with SMT, research has shown, in fact, there has been some relief for some disorders according to a study by Hawk et al.[49] to evaluate the published evidence on the effect of chiropractic care on patients with nonmusculoskeletal conditions. The search yielded a total of 276 papers. Applying the exclusion criteria resulted in 179 papers. There were 14 RCTs targeting 10 different conditions. They concluded:

  • Evidence from both controlled studies and usual practice is adequate to support the “total package” of chiropractic care, including SMT, other procedures, and unmeasured qualities such as belief and attention, as providing benefit to patients with asthma, cervicogenic vertigo, and infantile colic.
  • Evidence was promising for the potential benefit of manual procedures for children with otitis media and for hospitalized elderly patients with pneumonia.
  • Evidence did not appear to support chiropractic care for the broad population of patients with hypertension, although it did not rule out the possibility that there may be subpopulations of hypertensive patients who might benefit.
  • Evidence was equivocal regarding chiropractic care for dysmenorrhea and premenstrual syndrome; it is not clear what level of biomechanical force is most appropriate for patients with these related conditions. It does appear that an extended duration of care, over at least 3 menstrual cycles, is more likely to be beneficial.
  • There is insufficient evidence to make conclusions about chiropractic care for patients with other conditions.

Dr. Gerry Clum, president of Life-West Chiropractic College, suggests the chiropractic profession has evolved from a “free-wheeling out-of-control profession to a highly regulated and insured one welded into the low back pain model. Researchers have followed the money trail in LBP,” he noted, adding with a bit of chagrin. “What we have now is two fleas arguing over who owns the dog.”[50]

“I am offended by those who snicker at the notion that subluxation addresses organic conditions.” He mentioned his own case as a child when he was told either a tumor at the optic chiasm or MS would render him blind by the age of 12, but as a result of chiropractic care, he still sees today. Another nice anecdote, but no RCT to prove its overall validity.

This paradox has become the bane of leading chiropractic spokesmen. Ironically, many evidence-based chiropractors agree with Dr. Hadler’s sentiments, but also point out that the possibility of SMT to help may still exist.

“Regretfully, in 2007, ‘subluxation’ remains a topic of contention,” according to David Seaman, DC, MS, and instructor at Palmer College.  “This truly is surprising, as we have no objective measurement of ‘subluxation here’ before adjustment and ‘subluxation gone’ after the adjustment. In the modern day, this lack of objective evidence should make us question the importance of subluxation and cause our focus to be directed at various potential outcomes of the spinal manipulation. It certainly is possible that spinal manipulation has beneficial effects that have nothing to do with joint mechanics, and much more to do with the modulation of segmental and supra-segmental neuronal activity that can reduce pain and visceral symptoms in certain patients.” [51]

Scott Haldeman, MD, DC, PhD, perhaps the most respected chiropractic statesman, mentions this dilemma: “What must be avoided at this stage of understanding of the neurologic effects of the adjustment is the unreasonable extrapolation of current knowledge into speculation and presentation of theory as fact.”[52]

This contentious debate as to the scope of treatment has been a main stumbling block for over a century. It’s past time for the chiropractic profession to prove its Big Idea or else accept its limited role for MSDs as the evidence shows. This challenge is also echoed by George Lundberg, MD, Medscape Editor in Chief, editor-in-chief of JAMA from 1982 to 1999:

“If some influential individual or group in chiropractic would follow your thesis, and would loudly and openly embrace EBM, let the chips fall where they may, and, if I may push further, openly repudiate the “vertebral subluxation and resulting nerve pressure is the root of all diseases” (presumably the Palmer belief structure), then I and many other physicians could openly and without fear and derision look at what 2005 EBM chiropractors actually do and go forward together.”[53]

 

The prudent choice now is to put aside the scope of SMT as a treatment for a myriad of organic disorders until more research verifies the possible affects of SMT and to accept its role in the epidemic of MSDs. As for now, however, the preponderance of research shows that SMT is a “proven method” for LBP as recommended by the AHCPR.[54] While the jury is still out as to the extent SMT may help organic disorders, certainly the jury is in concerning SMT and LBP and neck pain.

Perle et al.[55] proposed that the most appropriate role for the chiropractor is that of a direct-access, conservative and minimalist, neuromusculoskeletal specialist fully integrated in the current health care system and contributing to the evidence-based health care movement.

The call for scientific research and professional reform within chiropractic has gained a stronger voice over the past few decades, albeit a problem for the chiropractic reformists who are vilified by the ol’ time vitalists and demagogues who refuse to accept that BJ Palmer’s Big Idea may not be as big as they would like to believe.

Dr. Louis Sportelli, a leading chiropractic spokesman and past chairman of the American Chiropractic Association, warned of this need to reach to the future with research rather than clinging to the past vitalistic ideology:

“Thus, a new era of professional ethics is emerging, and the chiropractic profession must recognize the challenge to meet the expectations, or suffer the consequences…There is no other way to insure chiropractic in this marketplace than to be able to back up our claims with credible data, our outcomes with supportable evidence, and our patient’s satisfaction based on our service.”[56]

 

 

Bone #3: Efficacy of SMT: “Don’t confuse me with the facts”

Despite the international call in EB guidelines for a paradigm shift in the management of back pain from drugs, shots and surgery to a comprehensive conservative program, little change has transpired in the average physician’s office in the USA. The notion that back pain care is like a supermarket of franchises is too true considering the fact that many MDs and spine surgeons have ignored the recent research findings showing the efficacy of spinal manipulative therapy. Indeed, “don’t confuse me with the facts” seems to characterize the present state of affairs for some physicians and surgeons.

A prime example of this professional contempt toward EBM came after the landmark 1994 US Public Health Service’s Agency for Health Care Practice and Research (AHCPR) extensive two-year study on acute low back pain that recommended spinal manipulation as a “proven method.”[57]

The most shocking conclusion in the US federal guideline by the US Public Health Services panel found back surgeries to be costly, based on misleading tests, and were generally ineffective.

“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.” [58]

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…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.”[59]

After its release in December, 1994, the North American Spine Society successfully lobbied Congress to revoke the ability of the Agency on Health Care Policy and Research to do its mandated job to investigate medical procedures and to recommend treatment guidelines with the goal to lower costs and improve outcomes. Its ire stemmed from the criticism levied at spinal fusions, especially those involving pedicle screws due to the findings that fusions had few scientifically validated indications and was associated with higher costs and complications rates than other types of back surgery.[60]

NASS also formed a so-called grassroots movement dubbed “Center for Patient Advocacy” to make it appear its objections were from consumers, not special interests. A manufacturer of pedicle screws, Sofamor Danek, unsuccessfully sought a court injunction to prevent publication of the AHCPR guideline on acute low back pain. Not only were they successful in gutting the AHCPR, these angry orthopedists even sued the researchers involved to discourage any other attempts to change the medical status quo.

Dr. Richard Deyo, in his book, “Hope or Hype: The obsessions with medical advances and the high cost of false promises,” mentions the sentiments of ethical spine surgeons:

“Some surgeons, like Dr. Edward Benzel at the Cleveland Clinic Spine Institute, believe that too much spine fusion surgery is being performed. Benzel estimated to the New York Times that less than half the spinal fusions being performed were appropriate. ‘The reality of it is, we all cave in to market and economic forces,’ he was quoted as saying, adding that the current system of paying doctors is ‘totally perverted.’ Dr. Zoher Ghogawala, a Yale neurosurgeon, agreed that too much fusion surgery is done, saying, ‘I see too many patients who are recommended for fusion that absolutely do not need it.’”[61]

As a member of the AHCPR panel on acute low back pain in adults, Richard Deyo, MD, subsequently co-authored in The New England Journal of Medicine an article in response to this intimidation, "The Messenger Under Attack--Intimidation of Researchers by Special Interest Groups."[62] He alluded to the for-profit mindset of some surgeons supersedes the value of research: "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."

This resistance to new guidelines in for-profit systems comes as no surprise to many researchers. According to a recent article, “Market-Based Failure,” in the NEJM by Robert Kuttner, “Comprehensive, government-organized, universal health insurance systems are far better equipped to realize these efficiencies because everyone is covered and there are no incentives to pursue the most profitable treatments rather than those dictated by medical need.”[63] Certainly in the for-profit healthcare system in the US, back surgeons have little interest in following EB guidelines and referring to DCs when huge fees are involved and insurance companies readily pay for them.

“The extreme failure of the United States to contain medical costs results primarily from our unique, pervasive commercialization,” according to Dr. Kuttner. “The dominance of for-profit insurance and pharmaceutical companies, a new wave of investor-owned specialty hospitals, and profit-maximizing behavior even by nonprofit players raise costs and distort resource allocation. Profits, billing, marketing, and the gratuitous costs of private bureaucracies siphon off $400 billion to $500 billion of the $2.1 trillion spent, but the more serious and less appreciated syndrome is the set of perverse incentives produced by commercial dominance of the system.”[64]

As once told to me by an attorney working for a workers’ compensation insurance company when I pressed him on why they boycott chiropractic care but willing to pay for spine surgeries despite the poor results and high costs: “The more the surgeons and hospitals charge, the more the insurance companies can charge in premiums and the more they have to invest, so there’s more money for everyone.” This is the perverse motivation Kuttner mentions and the main motivation in American healthcare against implementing any less expensive methods.

To illustrate the vast difference between for-profit and non-profit healthcare systems, Medicare now covers about 40 million seniors, gets high marks for customer satisfaction and whips the private sector on efficiency by allocating approximately 5% toward administrative costs. Private insurers spend six times as much on administration, proportionally—mostly to weed out costly customers or fight payment, according to Richard Coniff.[65]

And I might add, to pay their officers ungodly sums of money—the true goal of this perverse system. Dr. William McGuire is a good example of the perverse nature of for-profit healthcare. He’s the past chief executive officer of UnitedHealth Group Inc., one of the nation's largest health-care companies. He earned $8 million a year in salary plus bonus, enjoying perks such as personal use of the company jet. His total compensation in 2004 was $124.8 million as he amassed one of the largest stock-options fortunes of all time. Dr. McGuire's cache of unexercised options was valued at $1.78 billion, a sum far greater than any other U.S. corporate chieftain.[66]

In a scathing commentary in the Washington Post, [67] columnist Steven Pearlstein wrote,

“Isn't it odd that a company could be so persnickety when it comes to pinching pennies from doctors and patients, and so cavalier when it comes to lavishing executives with hundreds of millions of dollars of shareholders' money?

“Or maybe it's not. Maybe what we have here is the most outrageous corporate scandal since Enron and WorldCom.”

The perverse motivation in healthcare is not new. In 2001 the National Academy of Sciences report admitted that applying evidence-based research to health care delivery is a huge gap that must be crossed.

“In the current health care system, scientific knowledge about best care is not applied systematically or expeditiously to clinical practice. An average of about 17 years is required for new knowledge generated by randomized controlled trials to be incorporated into practice, and even then application is highly uneven…and that there are insufficient tools and incentives to promote rapid adoption of best practices.”[68]

Fundamental Flaw #1: Suspect Treatments: Overused, Ineffective

Although these bones of contention may exacerbate the inclusion of chiropractors into the mainstream, the fundamental flaws of the medical world also remain paramount problems that must be addressed if this pandemic of back pain is to improve.

As a consequence of this intimidation, indifference, greed, and time-lag between research and best practices, the public and some within the medical community itself remain unaware of the recent discoveries by international researchers that conclude that standard medical treatment consisting of pain pills, muscle relaxers, epidural shots, MRI scans leading to disc surgery has now been shown to be expensive, risky, and often clinically ineffective.

Gordon Waddell, MD, orthopedist, spine researcher, and author of The Back Pain Revolution, sums it best:

“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.”[69]

To treat back pain, doctors often prescribe a range of medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants and analgesics. Muscle relaxants are the second most common type of drug used to treat low back pain; a 1998 study found that on average, 35 percent of people with LBP are prescribed some type of muscle relaxant.[70]

Today EBM questions this approach. Ostensibly the most common LBP diagnosis is “pulled muscles” by PCPs and the routine treatment is NSAIDs and muscle relaxants in 63% of cases. Carey et al.[71] published in Spine a study that found patients with severe acute LBP, muscle relaxant use was associated with a statistically significant increase in time to recovery -- 32.4 days compared to 16.2 days in the placebo group, due to the sedative effect upon patients. The researchers concluded there was “no demonstrable effect from muscle relaxant use.”

Franklin et al.[72] found nearly 14% of the ailing workers were still receiving disability compensation a year later. They suggest that early prescription of opioids may be a risk factor for long-term disability among workers with back pain claims. They recommend that physicians exercise caution in the prescription of these painkillers. “Consistent with existing evidence-based guidelines and in the absence of other data bearing on effectiveness and risks, opioid use might most prudently be reserved for only the most severe cases,” they point out.

Aside from extending disability, many patients become addicted to pain medications. This is because the painkillers (e.g. Vicadin, OxyContin, Norco, Hydrocodone) -- commonly prescribed by physicians to treat pain -- cause a change in brain chemistry. Dr. Clifford Bernstein, a pain management physician and author on Spine-health.com[73], clearly outlines how these pain medications physically affect the body:

  • The brain responds to the pain medicine by increasing the number of receptors for the drug, and the nerve cells in the brain stop functioning
  • The body stops producing endorphins (the body's natural painkillers) because it is receiving opiates instead
  • The degeneration of the nerve cells in the brain causes a physical dependency on an external supply of opiates, and reducing or not taking the pain killers causes a painful series of physical changes, known as withdrawal.

At this point many people (an estimated 7% who are prescribed narcotic analgesics) continue taking the pain medication to avoid the withdrawal symptoms rather than to treat the original pain. When this occurs the person is dependent on or addicted to the prescription pain medicine. Most people do not know that taking painkillers over a long period of time may in fact increase a patient’s sensitivity to pain (hyperalgesia). This happens because long term use of opiate painkillers causes a decrease in the ability to tolerate pain, and an increased sensitivity to pain. When the pain increases, people are often led to believe they need to take higher doses of pain medication than they were on initially. For those who are addicted to narcotic pain medications, a detoxification program is often needed. Pain killer addiction is a chemical, physical disease, one that requires expert medical treatment in a safe, humane environment.

In many respects, the prescription of opioids for acute low back pain appears to be overkill. The recent clinical guidelines by the American College of Physicians and the American Pain Society on medications for acute and chronic low back pain suggested that opioids should be reserved for the minority of individuals with severe, disabling pain. Roger Chou, MD, and Laurie Huffman, MS, pointed out that each analgesic

employed in the treatment of low back pain has a distinctive risk-benefit profile that must be aligned with the needs and values of each individual patient.[74]

“For mild or moderate pain, a trial of acetaminophen might be a reasonable first option because it may offer a more favorable safety profile than NSAIDs ... For more severe pain, a small increase in cardiovascular or gastrointestinal risk with NSAIDs in exchange for greater pain relief could be an acceptable tradeoff for some patients ...For very severe, disabling pain, a trial of opioids in appropriately selected patients may be a reasonable option to achieve adequate pain relief and improve function, despite the potential risks for abuse, addiction, and other adverse events...” according to Chou and Huffman.

According to Steven H. Sanders, PhD, epidural steroid injections also have proven to be of low value for LBP despite the high costs, ranging from $1,068 to $1,272 for the doctor’s fee and hospital charges:

“From the current review, we must conclude that lumbar epidural steroid injections and sympathetic nerve blocks produce a large amount of money, with very little science to support their application. Does this mean they are useless? Obviously not; these techniques have some value in acute pain management and should not be completely abandoned. However, their use as a mainstream (almost knee-jerk) intervention for acute or chronic low back pain does not appear to be at all justifiable at the scientific level.[75]

In a literature review by Novak et al.[76] to determine the current evidence to support guidelines for frequency and timing of epidural steroid injections (ESIs), to help determine what sort of response should occur to repeat an injection, and to outline specific research needs in these areas, the authors determined, “There does not appear to be any evidence to support the current common practice of a series of injections.”

Deyo et al. found a disturbing trend in the use of ESIs: Between 1994 and 2001, there was a 271% increase in lumbar epidural steroid injections and a 231% increase in facet injections among Medicare recipients.[77]

In another literature review by Edgar Ross, MD, Director, Pain Management Center, Brigham and Women’s Hospital, and Assistant Professor of Anesthesia, Harvard Medical School, he concludes that, in general, epidural steroid injection for radicular lumbosacral pain "does not impact average impairment of function, need for surgery, or provide long-term pain relief beyond 3 months." In addition, they found insufficient evidence to recommend either cervical epidural steroid injections or radiographic guidance of injections.[78]

Old theories die hard as seen with the criticism of opioids and ESIs and now the main reason for spine surgery—disc abnormalities—as the source of back pain has also come under extreme criticism. The use of MRIs to show patients a disc abnormality has led to many mis-diagnoses as many researchers now admit.

NM Hadler, MD, professor at UNC medical school and author of The Last Well Person, opines that the disc theory is suspect as the primary cause of LBP. 

“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…‘Ruptured discs’ and ‘bad back’ are terms that deserve to be relegated to the historical archives.”[79]

Other orthopedic researchers confirm Dr. Hadler’s belief. Most notably, the AHCPR noted: "Studies of asymptomatic adults commonly demonstrate intervertebral disc herniations that apparently do not entrap a nerve root or cause symptoms."[80]

“It should be emphasized that back pain is not necessarily correlated or associated with morphologic or biomechanical changes in the disc. The vast majority of people with back pain aren't candidates for disc surgery,” according to Scott Boden, MD, Director of The Emory Spine Center.[81] His Center has taken a progressive outlook on treatments for back pain as his webpage states, “We try to emphasize non-operative solutions first before considering surgery. When surgery is necessary, we use the latest discoveries to make our treatments less invasive and more successful.”

Instead of diagnosing back ailments from a pathological point of view—disc abnormalities—most astute practitioners and researchers now look at LBP from a functional point of view. This transformation began when the early MRI studies by Dr. Boden at Emory in 1990 showed repeatedly that some patients without disc abnormalities had back pain and many patients with disc problems had no pain. Many orthopedists now jokingly call disc abnormalities “incidentalomas”—they’re like finding grey hair—everyone has it, but it’s just incidental to the underlying structure of the spine. [82]

In The Spine Journal, Don S. Angus, FRACS and Eugene Carragee, MD, from Stanford University Medical Center explain this situation:

“The problem remains that the overwhelming majority of patients with chronic LBP have nonspecific findings on imaging studies, rather than serious pathology at which surgery may be directed. Structural findings of disc degeneration, annular disruption, and end plate changes are commonly seen in patients with CLBP in clinical studies. However, such findings are also common in cross-sectional studies of asymptomatic populations. It is therefore impossible to draw conclusions between findings of common degenerative changes on imaging and patient complaints of CLBP. Imaging findings are also not able to identify those at risk of developing CLBP because DDD on MRI in asymptomatic subjects is not predictive of experiencing LBP in the future. Similarly, subjects with new episodes of severe LBP and previous MRI scans are unlikely to detect changes in disc protrusion, annular fissures, high-intensity zones, or end plate signal changes with repeated MRI.”[83]

More evidence of the fallacy of the disc theory comes from prominent researcher, Richard Deyo, MD, MPH.

“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 findings…Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.” He concludes that 97% of back pain is “mechanical” in nature, and disk abnormalities account for only 1% of back problems. [84]

Dr. Deyo also believes that the majority of spine fusions are unwarranted. “I think fusion for degenerative disc disease and back pain should be considered experimental…a treatment of marginal efficacy at best.”[85]

Similar suspicions about the efficacy of spinal fusion have arisen. According to a recent study by Mohit Bhandari et al. from the Division of Orthopaedic Surgery, Department of Surgery; McMaster University:

“Lumbar fusion surgery in patients with chronic low-back pain does not appear to offer any major benefit in outcomes over conservative rehabilitation programs incorporating physical activity and cognitive–behavioral therapy. Patients undergoing lumbar fusion may have a slightly lower but clinically unimportant decrease in disability scores in exchange for an increased risk of complications, higher medical costs and no difference in quality of life at 2 years after surgery.”[86]

Dr. E. Berger published in Surgical Neurology the shocking results in postoperative spine surgery patients[87]:

  • 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.
  • Perineural fibrosis was seen at the time of the second operation in 47% of these patients.
  • 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.

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 and 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.”[88]

The Cochrane Collaboration in the US, dedicated to evidence-based medicine, also concluded: “Ninety percent of acute attacks of sciatica settle with conservative management. Absolute indications for surgery include progressive leg muscle weakness and altered bladder function, but these are rare.”[89]

As well as surgery, standard forms of care by physical therapists were also not recommended for LBP. Again, to quote from the Patient Guide, Understanding Acute Low Back Problems, published by the U.S. Public Health Service: “A number of other treatments are sometimes used for low back symptoms. While these treatments may give relief for a short time, none have been found to speed recovery or keep acute back problems from returning. They may also be expensive. Such treatments include: Traction, TENS, massage, biofeedback, acupuncture, injections into the back, back corsets, ultrasound.” [90]

Despite these calls from medical experts in evidence-based research, spine surgeries continue to increase in America. Obviously research is not the guiding light in scientific medicine as many would expect. Incredibly, as much as 85% of current health care practices remain scientifically invalid despite the claim of medicine to scientific superiority.[91]

So, if not research, what guides modern medicine in America?

Fundamental Flaw #2: EBM: Economic-based Medicine—the Gravy Train

Despite the call for restraint on spinal fusions and the endorsement of SMT as safe and effective in the battle against back pain, the low utilization of SMT and referrals to DCs remains a paradox in today’s evidence-based healthcare. Sadly, some medical experts believe EBM is more accurately “economic-based medicine” inasmuch as this lucrative marketplace has been a cash cow for many surgeons and hospitals alike.

“The surgeons themselves are guilty of being insufficiently critical of products and techniques they are developing,” said Dr. Richard A. Deyo, a medical professor now at Oregon Health and Science University. “More people are interested in getting on the gravy train than on stopping the gravy train.”

“Close relationships between surgeons and device companies can affect more than the potential quality of an individual clinical trial,” said Dr. Drummond Rennie, a professor of medicine at the University of California, San Francisco who has studied conflicts of interest among physicians. Because the entanglements are so common, Dr. Rennie said, it is unlikely another surgeon will speak out about any potential misgivings they have about any device. “The absolute ideal from a drug or device company is everyone is covered,” he said. “And what they have it covered with is money.”

Spinal-fusion surgery is one of the most lucrative areas of medicine. An estimated half-million Americans had the operation this year, generating billions of dollars for hospitals and doctors at an average cost of $50,000 for fusion and $100,000+ for disc replacements.

But there have been serious questions about how much surgery actually helps patients with back pain and whether surgeons' generous fees might motivate them to overuse the procedure. Those concerns are now heightened by a growing trend among some surgeons to profit in yet another way—by investing in companies that make screws and other hardware they install.[92]

Such doctors face "an awfully pernicious conflict of interest," said Dr.  
Richard A. Deyo.
“The hype for artificial discs has attracted thousands of spine surgeons into taking introductory courses…Why does this situation continue to exist, given the fact that there are about 500,000 spine surgeries performed in the United States each year? Frankly, it is beyond the comprehension of this online journal, but the existence of hidden agendas and personal gain appear to be important reasons behind this problem.” 

According to Reed Abelson, NY Times medical writer, spine surgeons at about half of the 17 centers evaluating the Prodisc in one FDA trial had a financial interest in the success or failure of this product. The alleged conflicts of interests that Abelson described are legal but unseemly from a research perspective. The attitudes of treating physicians, conscious and unconscious, can potentially influence patients’ response to new treatments and products. The professional judgment of the physicians may also be affected by the financial interests.

“The way the Prodisc was tested and approved provides a stark example of conflicts of interest among clinical researchers—conflicts that are seldom evident to doctors and patients trying to weigh the value of a new device or drug,” according to Abelson. “Instead of serving as objective gatekeepers who can screen out potential harmful or ineffective new devices or drugs, some medical experts say, clinical researchers may have incentives to overstate the value of a new product for patients.”[93]

"These are, I believe, unethical and bias the doctors' choice for what is best for the patient," said Dr. Charles D. Rosen, a spine surgeon at the University of California
at Irvine, who is the president of the newly formed Association of Ethical Spine Surgeons. The group has about 75 members so far, who have agreed not to invest in companies whose devices they use.

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.”[94]

Nelson et al.[95] measured over a 4-year period the effects of a managed chiropractic benefit on the rates of specific diagnostic and therapeutic procedures for the treatment of back pain and neck pain. They concluded for the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis. The results in reduction of imaging and surgery were astounding.

For patients with low back pain, the use rates of all 4 studied procedures were lower in the group with chiropractic coverage. On a per-episode basis, the rates in the group with coverage were reduced by the following: surgery (−32.1%); computed tomography (CT)/magnetic resonance imaging (MRI) (−37.2%); plain-film radiography (−23.1%); and inpatient care (−40.1%). On a per-patient basis, the rates were reduced by the following: surgery (−13.7%); CT/MRI (−20.3%); plain-film radiography (−2.2%); and inpatient care (−24.8%). For patients with neck pain, the use rates were reduced per episode in the group with chiropractic coverage as follows: surgery (−49.4%); CT/MRI (−45.6%); plain-film radiography (−36.0%); and inpatient care (−49.5%). Per patient, the rates were surgery (−31.1%); CT/MRI (−25.7%); plain-film radiography (−12.5%); and inpatient care (31.1%). All group differences were statistically significant.

In today’s cost-effectiveness healthcare programs, an important concern for spine treatments should focus on the clinical costs, utilities and advantages of chiropractic, PT, pharmacological, or surgical management?

“All CE studies involve an economic analysis superimposed on an RCT,” according to Dr. Nelson. Costs may include all medical costs—physician fees, hospital, drugs equipment, and downstream costs like disability. The results of a CE study are expressed in terms of dollar amounts to produce one unit of clinical benefit.

All health benefits are measured in Quality Adjusted Life Years, aka, QALY, which allows decision makers to compare different treatments for different conditions. As Dr. Nelson explained, “the QALY number is a measure of its efficiency in buying health. The lower the number the more health you can buy with a dollar. The virtue of this method is that it allows comparisons across different treatments and different conditions.”

A few studies have shown that SMT to be more cost-effective than PT, PCP care, and surgery. Ingeborg et al.[96] noted that manual therapy is dominant over physiotherapy—that is, manual therapy is associated with a larger improvement in pain and lower costs. The cost effectiveness planes showed similar dominance of manual therapy over physiotherapy on recovery and quality of life (with most bootstrapped ratios, 85% and 87%, respectively). Also, a similar dominance was shown for the cost effectiveness planes for manual therapy over general practitioner care on perceived recovery and quality of life (96% and 97%, respectively, of bootstrapped ratios).

Herman et al.[97] compared manual therapy to general practitioner care in regards to neck pain. Manual therapy had a lower one-year cost ($402, US$) than general practitioner care ($1241). The QALYs were 0.82 for manual therapy and 0.77 for general practitioner care. Since the costs were lower and the QALYs higher for manual therapy as compared to usual care, manual therapy is said to dominate general practitioner care and no cost-utility ratio is calculated.

Fairbank et al.[98] in the UK revealed “The mean total cost per patient was estimated to be £7830 (SD £5202) in the surgery group and £4526 (SD £4155) in the intensive rehabilitation arm, a significant difference of £3304 (95% confidence interval £2317 to £4291)…Conclusion: Two year follow-up data show that surgical stabilisation of the spine may not be a cost effective use of scarce healthcare resources.”

The editors of the BMJ concluded:

“Surgical stabilisation of the spine for treating chronic low back pain is not cost effective when compared with an intensive rehabilitation programme from the perspective of health providers and patients…the potential risk and additional cost of surgery also need to be considered. No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation.”

Additionally, the benchmark CE study for LBP by Skargren in the UK BEAM study (Back pain, exercise, and SMT) had an ICER score of $17,000/QALY.[99]

Oddly, there are few Incremental Cost Effectiveness Ratio (ICER) scores for spinal fusion. The Swedish Lumbar Spine Study group that concluded societal total cost per patient (standard deviations) in the surgical group was significantly higher than in the non-surgical group: Swedish kroner (SEK) 704,000 (254,000) vs. SEK 636,000 (208,000).[100]

This study also asked probing questions:

 Surgical issues: “Surgeons were allowed their own choice of operation to improve the chance of clinical success. The Swedish trial showed no difference between three surgical techniques of fusion. These results call into question what lumbar fusion is actually doing to patients with chronic back pain.” 

Another economic consideration concerning spine surgery is the rate of reoperation.  Deyo et al.[101] from the Center for Cost and Outcomes Research spoke of this growing problem.

“Because reoperation is generally regarded as an unfavorable outcome, such a finding may have important implications for patient selection or technical quality of care… If reoperation rates are indeed increasing, it may suggest that advances in surgical technique are creating more problems (e.g., the need to remove hardware) or that increasing technical ease of surgery is resulting in less careful patient selection, and worse overall outcomes.

“Our previous work described higher rates of reoperation among patients receiving certain types of surgery and for certain diagnoses. For example, among patients having surgery for degenerative disc disease, those who had spinal fusion surgery had nearly twice the rate of reoperations compared to those who did not have fusion surgery, even after adjusting for age, gender, prior surgery, comorbidity, and coverage by Workers’ Compensation. In contrast, patients undergoing spinal fusion in association with discectomy for a herniated disc had no differences in reoperation rates.”

According to a study by Martin et al.[102] re-operation rates post spinal fusion are over 20%. The Agency for Healthcare Research and Quality, and colleagues from the University of Washington in Seattle, found that about one in five patients who had lumbar spine surgery for degenerative spine disorders underwent another back surgery procedure within the next 11 years. This is higher than commonly reported rates for hip or knee replacement, where 10 percent of patients have a second procedure within 10 years.

Repeat lumbar spine operations are generally undesirable, implying persistent symptoms, progression of degenerative changes, or treatment complications. Compared to decompression alone, spine fusion is commonly viewed as a stabilizing treatment that may reduce the need for additional surgery. However, indications for fusion surgery in degenerative spine disorders remain controversial, and the effects of fusion on reoperation rates are unclear.

After fusion surgery, 62.5% of reoperations were associated with a diagnosis suggesting device complication or pseudarthrosis. The authors conclude that patients should be informed that the likelihood of reoperation following a lumbar spine operation is substantial. For other degenerative spine conditions, the cumulative incidence of reoperation is higher or unimproved after a fusion procedure compared to decompression alone.

North et al.[103] calculated the cost effectiveness of reoperation for FBSS to be staggering-- The mean cost per success was US $117,901 for crossovers to Spinal Cord Stimulation. No crossovers to reoperation achieved success despite a mean per-patient expenditure of US $260,584. The mean per-patient costs were US $38,160 for reoperation (intention to treat), US $105,928 for reoperation (treated as intended), and US $36,341 for reoperation (final treatment).

Ironically, after a few failed back fusion surgeries, often the spine surgeon will opt to an artificial disc implant at twice the cost.

In a letter to the editors of the North American Spine Society publication SpineLine, spine surgeon André van Ooij of the Netherlands expressed his concern as someone who has observed significant numbers of post-artificial disc implants.

“These patients represent the most disabled group of patients that I have personally seen in 24 years of spine practice.”  Dr. Ooij also expressed concern regarding “the overload of the facet joints as a consequence of removal of the anterior longitudinal ligament and annulus fibrosis producing axial rotational instability and related progressive degeneration of the facet joints.”[104]

Dr. Deyo remarked on this obvious dilemma, “People say, ‘I'm not going to put up with it,’ and we in the medical profession have turned to ever more aggressive medication, narcotic medication, surgery, more invasive surgery.” [105]

It’s dumbfounding to think the medical professionals are not listening to patients, the researchers, or their own critics when they continue to assault the public with risky and ineffective methods. Indeed, the sound of money rings louder than science or ethics in medicine. "If I don't do them, they'll go around the corner and the other surgeon will,”[106] admits Dr. Jerry Groopman in his article, “Knife in the Back.”

Another consideration why spine fusions fail is the alignment factor. Indeed, if a straight spine with normal lateral curves is considered ideal as a weight bearing unit, obviously many spine surgeons have ignored this factor. As a 30-year chiropractic practitioner who has treated hundreds of cases of failed back surgery syndromes, I can attest more often than not the patients’ spinal unit was fused in a misaligned position.

Text Box: Ex. 3 Left lateral kink (18 degrees) at C5/6 Text Box: Ex: 1: Kyphotic post-surgical view at C5/6 on lateral cervical Text Box: Ex. 2 Normal lateral cervical (+17cm.) As the photo (Ex.1) below on the left shows, this lateral cervical plain film radiology shows a kyphotic alignment on a post-surgical patient. The normal lateral curve in the cervical spine is considered to be a +17cm. radius as in Example 2. In this example, the post-surgical alignment is measured as -28 cm. radius, a complete reversal from the normal lordotic curve.

The other photo of the anterior to posterior cervical spine (Example 3) shows a lateral kink of 18 degrees at the site of the fusion rather than a straight line as the two plumb lines indicate. As far as the chiropractic structural hypothesis is concerned, this patient was fused in a very serious misaligned position. Incredulously, her main complaint was headaches, not radiculitis as one would think with a C5/6 fusion, which begs to question why this fusion was done in the first place.

Indeed, how many spine surgeries have done the same considering the fact that most spine surgeons fail to consider the alignment of the spine as an important factor other than for scoliosis cases. In this case, this patient will forever have an unstable neck due to the fusion in a misaligned position, which undoubtedly will lead to future degeneration above and below the fusion as well as more symptoms. My observations of fusion cases suggests that those with greater misalignments are the most likely to fail in
terms of patient-reported pain. This hypothesis could and should be tested.

Not only do patients have to face the reality of a 20% reoperations rate and continued usage of narcotics for pain control, they also need to be told that the fusion may leave them permanently in a misaligned position that may also cause future pain and degeneration.

The ethics of spine surgery has come to the forefront of concern due to the huge costs and ineffectiveness of this medical management. The Journal of the AMA[107] has called for a reconsideration of the present conflicts of interest by some physicians.

“Conflicts of interest between physicians' commitment to patient care and the desire of pharmaceutical companies and their representatives to sell their products pose challenges to the principles of medical professionalism. These conflicts occur when physicians have motives or are in situations for which reasonable observers could conclude that the moral requirements of the physician's roles are or will be compromised. Although physician groups, the manufacturers, and the federal government have instituted self-regulation of marketing, research in the psychology and social science of gift receipt and giving indicates that current controls will not satisfactorily protect the interests of patients. More stringent regulation is necessary, including the elimination or modification of common practices related to small gifts, pharmaceutical samples, continuing medical education, funds for physician travel, speakers bureaus, ghostwriting, and consulting and research contracts. We propose a policy under which academic medical centers would take the lead in eliminating the conflicts of interest that still characterize the relationship between physicians and the health care industry.”

Indeed, if spine surgeons were to follow the advice of international researchers, there would probably be 90% fewer spine surgeries done, which is unfathomable in today’s for-profit healthcare industry. Not only is greed a huge factor in this billion dollar industry, but the public has been convinced disc surgery is the final solution to back pain despite the poor statistics. Until conservative care is mandated as the first avenue of treatment as the AHCPR guideline on acute low back pain recommended, little will change to decrease the numbers of spine surgeries and their failures.

Fundamental Flaw #3: Medical Bias and Poor Training for MSDs

Although most LBP patients enter via their primary care physician, research has shown these portal of entry physicians are among the least educated to diagnose musculoskeletal problems despite the fact conditions affecting the musculoskeletal system are the primary reason patients seek medical care from physicians, accounting for nearly 100 million office visits per year.[108] Musculoskeletal conditions are the most common cause of long-term pain and physical disability.[109]

“A disease like back pain can have a lot of variability in the ways medical professionals approach patient care,” according to Scott Boden, MD, director of the Emory Orthopaedic and Spine Center in Atlanta. “Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders.”[110]

In 1998, Freedman and Bernstein published a landmark study in the Journal of Bone and Joint Surgery, wherein they administered a validated musculoskeletal competency examination to 85 recent medical graduates who had begun their hospital residency. Of these medical doctors, 82 percent failed to demonstrate basic competency on the examination, leading the authors to conclude, “We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.”[111]

In their 2004 review published in Physician and Sportsmedicine, Joy and Van Hala describe the musculoskeletal training of allopathic physicians as “woefully inadequate,” and note that among a sample of 85 recent medical graduates, “the average time spent in rotations or courses devoted to orthopedics during medical school was only 2.1 weeks. One third of these examinees graduated without any formal training in orthopedics.”[112]

As would be expected, these data suggest that limited educational experience contributes to poor performance. Clawson et al.[113] surveyed nearly 2,000 second-year residents in US allopathic and osteopathic residency programs. They found that up to 60% of allopathic residents felt poorly to very poorly prepared to conduct a musculoskeletal examination of the foot.

Matheny et al.[114] surveyed 351 graduating family practice residents about their confidence in the management of musculoskeletal conditions. They found that the residents were far more confident in making a diagnosis of acute myocardial infarction or treating hypertension than they were in diagnosing musculoskeletal conditions. In the same survey, residents ranked their overall musculoskeletal and orthopedic training as a 5.4 on a 10-point scale of least adequate to most adequate.

In early 2007, Humphreys, et al. [115], administered the previously utilized standardized competency examination to a sample of 123 senior chiropractic students from a single college to find that 51 percent of these students were competent in musculoskeletal care by this standard. Remarkably, the pass rate for a group of 10 chiropractic doctors was 100 percent on this same examination that was consistently failed by allopathic students, doctors and, according to a small study, osteopathic students.

A study by Childs et al.[116] on the physical therapists’ knowledge in managing MSD conditions found that only 21% of students working on their master’s degree in physical therapy and 25% of students working on their doctorate degree in physical therapy achieved a passing mark on the Basic Competency Exam.

            Not only do most MDs suffer bias toward DCs, they also have proven to be the least competent to diagnose or treat MSDs. The best available current evidence indicates that generally, only 20 percent to 30 percent of allopathic seniors and graduates are competent in musculoskeletal medicine, while the comparable rate of competence among chiropractic seniors and clinicians ranges from 52 percent to 100 percent.

Klein et all published their findings in Spine concerning primary care physician education regarding evidence-based low back pain management in an HMO setting can reduce use of imaging and specialty referrals without reductions in patient satisfaction, and implementation of a non-surgical spine clinic for complex or chronic spine patients can significantly reduce spine surgery consultations and spine surgery rates.[117]

            Yet the average non-EBM PCP today still poses as an expert to patients as he hands out ineffectual meds, orders expensive MRIs looking for “incidentalomas,” only to refer to a back surgeon. If and when patients ask for an opinion on SMT or chiropractic care, they are usually given the voodoo scare job. Typically, the usual encounter is one of a mis-diagnosis, mis-treatment, and mis-information about options to medical care.

Some admit their incompetence to diagnose MSDs according to Dr. Deyo, 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.” [118]

 I accuse that a big slice of the 85% ignorance is accountable to the rejection of manipulative approaches…The conflict remains so near unimaginable that future historians may well describe the past century as a time of unnecessarily perpetuated pain,” states Paul Goodley, orthopedic physician.

The dilemma this incompetence and bias creates for consumers seeking back pain treatment is obvious: on one hand they have been discouraged from using chiropractors despite the research and guidelines recommending non-invasive conservative care first and, on the other hand, they are forced into the medical treatments—drugs, shots, surgery—that are expensive, risky, often ineffective, and based on a suspect disc theory.

Even medical experts aware of the emerging support for conservative care remain wary of an endorsement for manipulative therapy due to the Fundamental Flaw. According to Dr. Hadler, “I am a rheumatologist, a mainstream physician with an MD, schooled in and committed to the care of patients with musculo-skeletal disorders… Do I have to learn manual medicine? Should I seek such a salve for my own next predicament of a regional musculo-skeletal disorder? Should I refer my patients to such practitioners?”[119]

As a hands-on chiropractor, my answers to his questions are No, Yes and Yes.

Perhaps, even reasonably, he doesn’t have to become competent in manual therapy, but as a specialist in this area of medicine he should be encouraged to learn how to examine properly for joint dysfunction so he can refer more comfortably and be able to make his own assessments. Otherwise manipulative therapy will remain a suspected black box and he’ll feel at the mercy and resentful of the DC for not having any idea what’s going on.

Fortunately, more spine experts are emerging from the medical closets to express their support for SMT. William Lauerman, MD, chief of spine surgery,  professor of orthopedic surgery at Georgetown University Hospital states: "I'm an orthopedic spine surgeon, so I treat all sorts of back problems, and I'm a big believer in chiropractic.”[120]

Dr. Goodley is presently a columnist for Medscape, an online orthopedic newsletter published by WebMD. In his February, 2007 column he wrote:

“I have been accepted as the only MD to participate in a select chiropractic group that periodically erupts with emails…I am being exposed to some of the best that chiropractic can produce, and I increasingly see the reality that my dream about the development of orthopaedic medicine is so trapped in mire that it will be major triumph in medicine if only some of its principles achieve some degree of understanding in the general medical community.

“From all this, I conclude that the association of ethical physicians and chiropractors offers the only possibility today for noticeably improving this vital area of medicine in the foreseeable future…it's already happening, of course. It couldn't be otherwise.

“But, particularly concerning chiropractic, it is being resisted for reasons kin to why orthopaedic surgeons wouldn't look at a non-surgeon's work or would feel resentful at having a non-surgeon teach them something. This has obviously been a central theme in my professional life. From all this, I'm unambiguously articulating this now.”[121]

This is an ethical question that every MD faces today: Will medical bias stand in the way of using SMT that has been shown to be very effective for musculoskeletal disorders because it is the professional domain principally of chiropractors? Indeed, after many osteopaths gave up manipulative therapy to become allopathic physicians in the early 1960s, and PTs to this day shy away for fear of guilt by association to the ostracized DCs, if it weren’t for the unheralded tenacity of hands-on chiropractors, SMT would, for the most part, be a lost art today. Indeed, just when will credit be given to those damn chiropractors?

Fundamental Flaw #4: Slipped Discs or Slipped Joints?

The unwavering commitment to traditional medical diagnosis and treatments as disc abnormalities dissuade many MDs to realize that joint dysfunction and mechanical issues may be the primary problems causing back pain. Certainly a disc doesn’t herniate or degenerate on its own, but only when bio-mechanical forces cause it to react.

According to Joseph Shaw, MD, orthopedist:

“The conventional wisdom is that herniated discs are responsible for low back pain, and that sacroiliac joints do not move significantly and do not cause low back pain or dysfunction. The ironic reality may well be that sacroiliac joint dysfunctions are the major cause of low back pain, as well as the primary factor causing disc space degeneration, and ultimate herniation of disc material.” [122]

 

Dr. John McMillan Mennell, orthopedist and author, testified in 1987 at the chiropractic v. AMA antitrust trial (Wilk case) about the nature of joint play, joint dysfunction, and manipulative therapy as the logical solution to this problem.[123] The basic dilemma for many physicians may rest with their lack of understanding of manipulative therapy. While the suspect disc theory remains alive, forgotten is the role of the 137 spinal joints in this epidemic of back pain.

“When you are dealing with manipulative therapy in the spine…your objective is to try to restore the proper motion joint play, which is prerequisite to the normal function in the spine,” according to John McMillan Mennell, MD, author, and medical professor.

If you don’t manipulate to relieve the symptoms from this condition of joint dysfunction, then you are depriving the patient of the one thing that is likely to relieve them of their suffering.”[124]

Other notable MDs have expressed similar opinions about the role of joint play in spinal health.

“The sacroiliac joint appears to be the single greatest cause of back pain...when the normal joint play is lost, agonizing pain can be precipitated,” according to Dr. JF Bourdillion, a leading orthopedic researcher and author.[125]

Dr. JL Shaw spoke before the World Congress on Low Back Pain in 1992 with a similar message of the loss of joint play as the cause of LBP[126]: 

  • 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.

 “Joint dysfunctions are the major cause of LBP as well as the primary factor causing disc space degeneration and ultimate herniation of disc material,”  according to Dr. Shaw.

Not only can joint dysfunctions cause axial pain and disc abnormalities, new research has shown that joint dysfunction alone may also cause radiculopathy like sciatica, a condition long equated to disc herniation, according to a recent study by H. Tachihara et al. in Spine.

“When inflammation was induced in a facet joint, inflammatory
reactions spread to nerve roots, and leg symptoms were induced by chemical
factors. These results support the possibility that facet joint inflammation
induces radiculopathy.”[127]

Obviously more and more evidence has emerged challenging the disc as the primary clinical basis of LBP. The research now shows a shift from disc abnormalities as a primary cause and spine surgery as the foremost treatment. The overlooked joint paradigm as a result of the Fundamental Flaw has now emerged as a primary causation of back pain, yet the chiropractic message has remained quiet on this important factor for some time due to the scant media attention. Regrettably, the public remains unaware that chiropractors may have been right all along, despite the Fundamental Flaw and media misrepresentation of the chiropractic profession. Indeed, SMT may be the best kept secret in the American medical system.

The most obvious oversight of a medical analysis of back pain is the lack of a comprehensive, dynamic diagnosis rather than merely looking for static disc abnormalities to justify the yearning for surgery. Indeed, a disc, acting like a shock absorber, does nothing until the mechanics of the spine force it to become deranged, and even when disc abnormalities exist, they often have little to do with pain as the evidence shows. In fact, to overlook joint play and alignment and to focus on the secondary effect of spinal pathology is putting the proverbial cart before the horse.

The accumulative effect from traumatic injuries during childhood compounded in adulthood by the effects from gravity and obesity increasing spinal compression aggravated by prolonged sitting/standing, improper lifting, accidents, will develop a functional spinal lesion that causes a “segmental buckling effect,” according to research by Jay Triano, DC, PhD, et al. at the Texas Back Institute, an interdisciplinary clinic of MDs, DCs, and PTs offering comprehensive spinal care.[128]

Once the joints buckle, neurologic problems commence, such as proprioceptors, nociceptors, and mechanoceptors all fire causing the pain, inflammation, and spasm associated with LBP. [129] Spinal manipulative therapy to restore joint play and improve alignment relieves these neurologic issues to decrease disc herniation, nerve root compromise, muscle spasm and pain.

A study by Descarreaux et al.[130] appears to confirm previous reports showing that LBP and disability scores are reduced after spinal manipulation.[131] It also shows the positive effects of preventive chiropractic treatment in maintaining functional capacities and reducing the number and intensity of pain episodes after an acute phase of treatment. Maintenance chiropractic care involving spinal manipulation combined with other treatment modalities (exercises, pain management program) should be investigated. Such combined interventions may have a critical influence on pain, disability, and return to work.

Moreover, this study confirms previous reports showing that pain and disability scores related to chronic LBP conditions are reduced after SMTs.[132] Stig et al.[133] showed that 75% of the chronic LBP patients receiving chiropractic treatments reported improvements (pain and global improvement) after 12 visits. Meade et al.[134] showed significant decrease of Oswestry scores after 10 chiropractic treatments (mainly manipulative treatment) in patients with chronic and severe LBP.

Many researchers now question the medical model to view low back pain primarily as disc pathology. As the evidence has shown, some people with disc abnormalities are perfectly pain-free while others with healthy spines suffer with back pain. Obviously there’s more to the diagnosis of back pain than merely disc abnormalities, spinal arthritis or most common-held beliefs that pathology alone is the root cause of most LBP.

Rather than looking at LBP as a static problem caused primarily by degeneration or pathologies, another approach is to view the spine as a dynamic, mechanical, weight-bearing column susceptible to overloads, injuries, repetitive stress, prolonged compression and leverage issues. Altered bio-physics such as joint dysfunction and disc compression rather than pathologies alone may be the key to understanding LBP and treatment.

The debate on the effectiveness of SMT affecting organ function remains unclear, but the debate on the effectiveness of SMT for musculo-skeletal disorders is very clear. In fact, recent European research supports the conservative approach as the most clinical and cost-effective.

“No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation,” according to Jeremy Fairbank, MD, lead investigator, British Spine Study,  UK BEAM. “And spine care providers should offer intensive rehabilitation enthusiastically, as it finds clear support in the scientific literature, and will prevent unnecessary surgery in a substantial proportion of patients.”[135]

Dr. JI Brox, lead investigator of the Norway Spine Study, states similar conclusions: “Lumbar fusion did not differ from cognitive therapy plus exercise for reducing disability and pain in chronic low back pain.” Dr. Brox says that he and his colleagues “no longer perform spinal fusion specifically for ‘degenerative disc disease’ because they do not regard it as a clearly diagnosable entity.”[136]

“Today, our departments’ first choice for the treatment of patients with chronic low back pain is a cognitive intervention [to change attitudes and beliefs about back pain] and exercises. Although pain receptors in degenerated discs may produce severe pain, we have gradually recognized that abnormal findings and positive discography are common even in asymptomatic individuals…The concept of highly selected patients is not evidence-based…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?

Another recent study in JAMA by Weinstein et al. shows that patients with low back and leg pain who underwent spinal discectomy surgery fared no better two years later than those who used non-invasive therapies.[137]

Dr. Scott Boden from Emory also participated with Weinstein in the SPORT study. He noted:

“The least successful is back surgery done for axial (non-radiating low back pain).  That has nothing to do with the SPORT study which was on discectomy patients with leg pain. You cannot lump all spine surgery together.  In the axial back pain population, many of those patients remain on narcotics after surgery - although by modern criteria that would not be considered a successful surgery.[138]

“In fact, if a patient’s severe leg pain has lasted 6 weeks and they can afford/tolerate waiting another 6 weeks, then continued non-operative care is reasonable.  On the other hand, if the patient feels the pain is too severe to bear for an additional 6 weeks, then surgery is the appropriate treatment.  What the study did not address is that patients with persistent leg pain for 12 weeks (less than 10 percent of those with HNP) most likely would benefit from surgery because the natural history for spontaneous improvement suggests that if it has not happened by 12 weeks then there is a small chance that it will happen.

 “For the majority of the HNP population, they will get better without surgery.  However, for those with persistent pain at 6 weeks (SPORT study) or at 12+ weeks (prior natural history studies), in fact surgery would be the preferred treatment for persistent leg pain.”[139]

Despite the consensus among researchers and orthopedic physicians that recommend conservative, active rehab before medical interventions—drugs, shots, MRIs, surgery—this has fallen mostly upon deaf ears of surgeons in the USA.

The BACKLETTER recently reports the intransigence of physicians to implement the new guidelines for LBP. “Numerous international guidelines have endorsed the use spinal manipulation as a treatment for acute back pain—as part of an evidence-based treatment algorithm. But researchers have been slow to examine the impact of guidelines-based care in rigorous clinical trials— to see if an evidence-based approach actually works in real-world clinical settings.”[140]

In the Bishop et al. study published in Spine, they recorded and scored the content of the family physician-directed care and again found it to “highly guideline-discordant.” “Typically, the family physician-based care involved excessive use of passive therapies such as massage and passive physical therapy, excessive bed rest, and excessive use of narcotic analgesics,” added Paul B. Bishop, DC, MD, PhD, Clinical Associate Professor in the Department of Orthopaedics at U.B.C.. The three studies by Bishop et al. provide an excellent illustration of the slow pace of implementation of evidence-based spinal care into primary care settings.[141]

According to the comprehensive Canadian meta-analysis on back pain by Pran Manga, Ph.D, “The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain,” this evidence-based study concluded:

“In our view, the constellation of the evidence shows:

1)     the effectiveness and cost-effectiveness of chiropractic management of low-back pain.

2)    the untested, questionable or harmful nature of many current medical therapies.

3)    the economic efficiency of chiropractic care for low-back pain compared with medical care.

4)    the safety of chiropractic care.

5)    the higher satisfaction levels expressed by patients of chiropractors.

Dr. Manga was very realistic about the turf warfare in the healthcare business:

 “There should be a shift in policy now to encourage the utilization of chiropractic services for the management of LBP, given the impressive body of evidence on the effectiveness and comparative cost-effectiveness of these services, and on the high levels of patient satisfaction.

“The shift in utilization from physician to chiropractic care should lead to significant savings in healthcare expenditures judging from evidence in Canada, the US, the UK and Australia, and even larger savings if a more comprehensive view of the economic costs of low back pain is taken.

“Unnecessary or failed surgery is not only wasteful and costly but, ipso factor, low quality medical care. The opportunity for consultations, second opinions and wider treatment options are significant advantages we foresee from this initiative which has been employed with success in a clinical research setting at the University Hospital, Saskatoon.

“A prominent medical organization, the North American Spine Society, has recently concluded that spinal manipulation, and specifically chiropractic adjustment, is an acceptable and effective treatment for most patients with lumbosacral disorders. This review, when coupled with more thorough analysis by prestigious institutions such as RAND Corporation, adds measurably to the growing credence in spinal manipulation as a therapy of choice for most low back pain.”

“However, the desired change in the healthcare delivery system will not occur by itself, by accommodation between the professions, or by actions on the part of Workers’ Compensation boards or the private sector generally. The government will have to instigate the reform and monitor the progress of the desired changes called for by our overall conclusion.”[142]

The trend today toward evidence-based and value-based procedures may be a hard pill to swallow in a culture previously convinced of the “slipped disc” as the main cause of LBP, but the evidence has shown that spinal manipulation, [143],[144],[145],[146],[147],[148],[149],[150],[151],[152],[153]  spinal flexion/distraction, [154] decompression,[155],[156] and active rehab29 methods combined may be the best value for most mechanical LBP  and neck pain cases before spinal surgery of any sort is required.

Fundamental Flaw #5: Lack of Informed Consent

The advent of EBM has created new problems for practitioners. Not only has the evidence cast suspicion upon long-time methods for the treatment of back pain, legal advances such as Informed Consent have compounded the dilemma for physicians to explain the options of alternative treatments to their patients. No longer can “just trust me” suffice in this day and age of accountability.

Kevin Patterson, MD wrote a revealing article in The New York Times Magazine, “What Doctors Don’t Know (Almost Everything).” [157]  The article states in a subtitle: “Until recently, medicine was governed by the educated guess. But a new emphasis on data is challenging that tradition – with profound implications for both doctors and patients.” 

A key paragraph in the article states: “But people, doctors included, have a tendency to see what they expect to see.  It’s the premise of every sleight-of-hand game.  If it makes sense that a treatment will work – or if one stands to make money if a treatment works – then a doctor will, with alarming and disheartening reliability, perceive that it does in fact work.  What is surprising is that a profession that dresses itself up in the garb of science has taken so long to acknowledge a principle that every small-town carny understands. 

“A chain of command has existed since the profession (of medicine) found its modern face – doctor’s orders – with the most senior and academic physician experts directing the decisions of specialists, family physicians and ultimately the patients.  This order is now in the throes of a revolution known as evidence-based medicine, which asserts the supremacy of data over authority and tradition.” 

“The instant the practitioner stops saying, ‘I think you should take this therapy,’ and starts  saying, ‘The evidence is that this therapy will work this percent of the time,  with these complications, this frequently; what do you want to do?’ then the power hierarchy of doctor over patient is collapsed, and  autonomy is assigned to the patient… Just as the idea of authority within medicine is rejected, so too, the idea of the profession of medicine itself having authority over the patient is rejected.  Giving authority to the data, instead of other people, empowers everyone, the movement (of evidence-based medicine) holds.” 

Not only has EBM brought new ethics into the doctor-patient relationship, a legal consideration known as Informed Consent also demands that physicians share all known alternatives and risks to the patient.

According to a case Jean Matthies v. Edward D. Mastromonaco, DO, argued before the Supreme Court of New Jersey on February 19, 1999, a unanimous decision was handed down when a doctor was sued for lack of informed consent.[158] This decision extended the rights of the patient with regards to alternative medical treatment in general. “Like the deviation from the standard of care, the doctor’s failure to obtain informed consent is a form of medical negligence. Recognition of a separate duty emphasizes the doctor’s obligation to inform, as well as treat, the patient.”

Obviously a new era has emerged from EBM in the treatment of LBP. The scientific validity of SMT has finally emerged, a call for new ethics among practitioners to follow the data rather than their pocketbook, and a legal precedent to inform patients of their alternatives have created a demand for a new management of this epidemic of back pain.

Dr. James Weinstein, an orthopedist, said the rapid growth in the procedures, coupled with the lack of hard evidence, points to the need to spell out all the risks and benefits for patients and let them choose. "As in most of medicine, there isn't as much evidence as we would like," said Weinstein, director of the Dartmouth Institute for Health Policy and Clinical Practice. "We need to be clear that there is a choice" of treatments, he said, and "that one isn't necessarily better than the other."[159]

Social Iatrogenesis: How the Healthcare System Makes You Sick
Ivan Illich, author of The Medical Nemesis,[160] coined a few terms that apply in this situation. “Clinical iatrogenesis” means physician-induced problems, and it’s painfully obvious that drugs, shots and back surgeries are wrought with clinical problems compared to conservative care like SMT. Indeed, when researchers tell us that more people died from NSAIDs than HIV annually, when back surgeries have a 20% reoperation rate, and when 71% to 95% of single and multiple lumbar spine fusions patients never return to work, the medical methods are bleak.

            But Illich took this iatrogenic notion to two higher levels—the concept of “social” iatrogenesis in which health systems made people sick or caused more problems, and “cultural” iatrogenesis where attitudes make people sick.

In regards to social iatrogenesis, DCs can easily relate to this when we see MCOs, Medicare, and group health insurance exclude or grossly limit chiropractic care, forcing patients into the medical world of drugs and surgery. Also, when PI attorneys prefer sending MVA patients to surgeons in order to increase their payoffs, the “system” is the culprit. When hospitals exclude DCs because they can make more money by doing surgery instead, the “system” is to blame. When a workers’ comp patient relates to me that her claim adjuster says “Chiropractors are no-no’s” and “they do more harm than good,” without any supportive evidence, something is terribly amiss. In these cases, the “system” is making patients suffer due to their discriminatory policies toward chiropractors.

Dr. Pran Manga discussed how increasing patient access to chiropractic care would save money and better help patients, thus preventing social iatrogenesis. I might add that in Canada, they operate in a not-for-profit setting, which drastically changes their motivation to discover what methods work best, not necessarily which methods make the most profit. “In order for the Ministry of Health to maximize the savings in health care costs, it should maximize the flow of patients to chiropractors for NMS conditions and injuries.”[161]

Obviously railroading back pain patients into the medical model has only been successful in making surgeons very wealthy at the expense of patients’ well-being. Social iatrogenesis not only denies patients their freedom of choice concerning their own bodies and health care providers, it denies DCs their right to compete on a level playing field. Obviously, the reason for excluding chiropractors from hospitals is due simply to this economic decision to make more money from surgery than from SMT, despite the facts that have shown SMT to be safer, cheaper, more effective, longer-lasting, and with three times the patient satisfaction rates.[162] In this day of outrageous medical costs, to deny any method that is superior clinically and less costly is unethical to stakeholders and immoral to patients.

Cultural Iatrogenesis: Misleading Diagnosis on LBP
Illich also coined another phrase that hits at the core of our nation’s healthcare disaster—“cultural” iatrogenesis. In this instance, he noted how bad habits and wrong-headed attitudes made people sick. The junk phood epidemic and tobacco addiction are good examples of this. The reliance upon medications, the proverbial “wonder” drugs to mask symptoms, also has contributed to demise in Americans’ health. Is it really any wonder why Americans lead the world in every category of chronic degenerative disease when you consider our leisurely lifestyles devoid of physical activity and reliance on junk phoods? In this case, patients are becoming ill not because of clinical mistakes or system bias, but due to prevailing unhealthy attitudes in our society.

I might add another overlook reason why Americans are so prone to back pain—the avoidance of supportive spinal care as we see with supportive or preventative dental care due to the fundamental bias against DCs. As chiropractors, we still face cultural attitudes that go unresolved, such as the medical slander that still exists. The fact that our profession has not successfully initiated a PR program to counteract the decades of propaganda has allowed these misconceptions to continue unabated.

I might include that the chiropractic profession has also been lacking in any reform movement to deal with the charlatans that Dr. Goodley mentioned were one source of the medical bias. As attorney George McAndrews, lead counsel of the American Chiropractic Association, said, “I believe this is the era of image. It is time for the 'deweirdization' of the profession...It is time to isolate the rascals...5% of you are cultists, 5% of you are freaks, and the rest of you keep your mouths shut!”[163]

In regards to proper spinal care, it’s painfully obvious that 90% of Americans don’t know how to manage their backs. Plus, we have the medical society pushing their useless drugs or their back surgeries to no avail. Despite the many guideline which recommend SMT and discounts the entire medical approach of physical therapy, drugs and surgery, nonetheless the "slipped disc" or "pulled muscle" paradigm remains paramount in the public’s mind despite MRI research that disproves both.

Until they learn you don’t slip discs, but you do slip spinal joints, the medical model will remain the source of cultural iatrogenesis. As the researchers recommend, most back problem treatment should start with conservative chiropractic care. After 4 weeks of treatment, re-evaluation should determine if referral for MRI exams and a possible surgical consultation be arranged for those few cases who fail to respond to SMT. As the AHCPR Patient Guide suggests: “But you most likely will find out that your symptoms are not being caused by a dangerous medical condition [that requires surgery]. Very few people (about 1 in 200) have low back symptoms caused by such conditions.” [164]

It may take three generations of Americans before this paradigm shift occurs. The research alone won’t change the public’s conception of proper spinal care, as we now can see. Until public consciousness changes, the current political and economic forces of the medical cartel will suppress any research that it fears, such as the AHCPR guideline.

A recent population-based survey by Gross et al.[165] to assess the back pain
beliefs, attitudes, and recovery expectations to determine prevailing public opinions in two Canadian provinces found that a high prevalence of back pain was reported, with a lifetime prevalence of 83.8%, and 1-week prevalence of 34.2%. Generally, a pessimistic view of back pain was held. Most agreed that back pain makes everything in life worse, will eventually stop one from working, and will become progressively worse with age. Mixed opinions were observed regarding the importance of rest and staying active. A significant minority (12.3%) reported taking time off from work for their last back pain episode. Those individuals taking time off from work held more negative back pain beliefs, including the belief that back pain should be rested until it gets better. The authors concluded that “public back pain beliefs in the two Canadian provinces sampled are not in harmony with current scientific evidence for this highly prevalent condition. Given the mismatch between public beliefs and current evidence, strategies for reeducating the public are needed.”

Conclusion: Remnants of the Medical Monopoly

These Fundamental Flaws of medicine toward the management of back pain and chiropractic care cannot be explained as mere oversights or ignorance. Physicians and surgeons read these same journals and are well aware of the changing paradigms in LBP care. What we see now with the medical intransigence to change is undoubtedly the remnants of the medical monopoly—restriction of the marketplace, monopolization of public hospitals, obnoxious salaries for surgeons, hospital administrators, and insurance executives, and a limited market that prohibits the growth of competitors with the best mousetrap.

Despite the antitrust victory by the chiropractic profession in 1987 against the AMA et al. for their illegal boycott of chiropractors in public hospitals, [166] it’s obvious this boycott continues covertly to limit the growth of chiropractic care despite the support in evidence-based research and meta-analyses. Indeed, it certainly must stick in the craw of the AMA to admit after decades of slander and prejudice that those damn chiropractors were right all along.

As Paul Goodley, orthopedic physician/author, states, “The conflict remains so near unimaginable that future historians may well describe the past century as a time of unnecessarily perpetuated pain.” As I’ve found often in my 30-years of practicing, there are “right” ways to get well and “wrong” ways, depending upon who profits. It now appears in regards to the epidemic of back pain, many MDs prefer the “right” ways that have proven ineffective, costly, and dangerous. Of course, the “wrong” way to get well is conservative care like chiropractic care despite the overwhelming evidence. As Dr. Goodley mentions, it appears many MDs have forgotten their Hippocratic Oath and would rather perpetuate their patients’ pain with ineffective medical treatments than to refer to those damn chiropractors.

Pran Manga, PhD, opined on the intransigence to change in the care of this silent epidemic. "You don't win an argument on paper, or in books or monographs -- even the type that we've written. Ultimately, you have to make a battle of it, and political reform doesn't come easily…you win or lose this battle in a political arena and not because you have very convincing studies and an eminent health economist says it should be done this way." As Dr. Manga complained, “distributive injustice” is very much a part of the medical industry and DCs are the best example of the cheaper mousetrap being ignored and abused by third party payers.[167]

Depending upon the government for parity in healthcare hasn’t worked. Although the Wilk v. AMA antitrust trial found in favor of the chiropractors, pitifully few DCs are on hospital staffs. Both state and federal workers’ comp programs allow chiropractors on panels, yet WC insurance companies have a virtual boycott, again due to the perverse motivation. The military health services allow for DCs now, but few bases have followed the federal law to have DCs in their infirmaries. The VA now allows DCs on staff, but few are employed and patients are still asked to jump through medical hoops before the VA hospitalists will refer to a DC. While federal insurance programs now include chiropractors, the number of office visits allowed is pitifully limited unlike any other provider, as is Medicare services for senior citizens. At every turn, DCs are relegated to the margins of the medical mainstream.

Is it possible to legislate parity in healthcare? Not as long as biased medical professionals are in charge of these systems. No longer can the medical profession say there’s a lack of research since EBM has shown the efficacy of SMT for LBP and neck pain. Indeed, prejudice, pride and power are the root problems now.

Just as civil rights legislation did not immediately change racist or sexist attitudes, neither can legislation create a level playing field in healthcare. In fact, under George W. Bush, healthcare reform and patients’ bill of rights legislation were dead in the water upon his arrival in the White House. Monopoly cartels presently run American healthcare for their profit as the statistics have shown and political power has more say in healthcare than evidence-based research.

With America looking at health care costs projected to reach $4.3 trillion by 2017,[168] any and all methods to decrease this should be done as Pran Manga suggested with his notion of distributive justice. “The shift in utilization from physician to chiropractic care should lead to significant savings in healthcare expenditures judging from evidence in Canada, the US, the UK and Australia, and even larger savings if a more comprehensive view of the economic costs of low back pain is taken.”[169]

These questions remain:

  • Will individual physicians overcome their Fundamental Flaws and follow the EBM trend and relegate spine fusions to the “historical archives” as Dr. Hadler suggests?
  • Will patients have to wait another 17 years before spine surgeries are preceded by SMT?
  • When will patients’ needs supersede the bias of physicians or the profits of managed care organizations?
  • When will chiropractors have the unfettered ability to offer patients manual therapy, not only for back/neck pain, but for many peripheral joint problems for temporomandibular joints, carpal tunnel syndrome, shoulders, elbows, knees and ankles?[170]
  • When will the medical media admit those damn chiropractors were right all along when it comes to treatment for LBP?

 

When these questions are answered positively, only then can we be assured the patient is receiving the proper care based on the correct diagnosis without any hidden agendas, bias, or Fundamental Flaws. Undoubtedly a call from a chiropractor will have no impact upon the medical profession to do the right thing about back pain treatment since it has resisted all demands for changes from noteworthy medical critics in the past.

While many MDs and their congressmen erroneously state, “Americans have the best health care delivery system in the world.” Although we do have the most expensive medical system, any claim to have the “best health care delivery system” is blatantly untrue as the WHO report mentioned in 2001. After surveying 191 countries, the US ranked first in cost, 72nd in population health, and 37th in overall healthcare delivery itself, allthewhile approximately 47 million Americans cannot get into the healthcare system for lack of coverage.

Also in March 2001, the Institute of Medicine, a part of the National Academy of Sciences, a private organization chartered by Congress to advise the government on scientific matters, release its report, “Crossing the Quality Chasm: A New Health System for the 21st Century.”[171]

“Despite the major advances in medical research and disease treatment, the American healthcare system is failing to improve the care of patients,” according to their experts. This report also states that most troubling is that proven methods that can save lives and improve patient outcomes are not being used in everyday practice. I daresay this is too true regarding the ninth most expensive ailment—back pain—according to AHRQ.[172]

This publication courageously concluded that "the American health care system is in need of a fundamental change," especially because "what is perhaps most disturbing is the absence of real progress toward restructuring health care systems to address both quality and cost concerns."

We now know that superficial makeovers will not suffice. The IOM indicated that entirely new patterns of thinking will be necessary to escape this dilemma. "Our present efforts," suggested Mark Chassin in another 1998 article published in JAMA, "resemble a team of engineers trying to break the sound barrier by tinkering with a Model-T Ford. We need a new vehicle, or perhaps many new vehicles. The only unacceptable alternative is not to change."[173]

Never before in the history of back pain research has so much evidence shown the need for a new paradigm for back pain treatment. Never before has so many medical experts themselves criticized the medical management, excessive surgeries, outrageous costs, and poor outcomes of this epidemic of back pain. Never before has the chiropractic profession had the proof it needs to make its case in the public arena that despite the Fundamental Flaws and contentious bones to pick, that those damn chiropractors were right all along.

Tony Rosner, PhD, formerly Director of Research at FCER, spoke of this proof in 2003 concerning the evolution of the research supporting chiropractic care in his testimony before The Institute of Medicine: Committee on Use of CAM by the American Public:[174]

“Despite the fact that chiropractic has existed as a formal profession worldwide for over a century, most of what we consider to be rigorous, systematic research in support of this form of health care has emerged only in the past two-and-a-half decades. In 1975, Murray Goldstein of the National Institute of Neurological Diseases and Stroke concluded that there was insufficient research to either support or refute chiropractic intervention for back pain and other musculoskeletal disorders.[175] Nearly 30 years later, we now can review with great satisfaction how back pain management has been assessed by government agencies in the U.S.;[176] Canada;[177] Great Britain;[178] Sweden;[179] Denmark;[180] Australia;[181] and New Zealand.[182] All of these reports are highly positive with respect to spinal manipulation. 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.”

 



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[3] Dembner, Alice Spine tuning, Innovative surgeries raise hope, concern, Boston Globe Staff ,  September 3, 2007.

[4] Goodly, PH, Release from Pain, Don’t be a victim of  the pain pandemic, 2005. www.Dr.Goodley.com 

[5] See AHRQ, MEPS, Total expenditures for conditions by site of service, United States, 2005;

[6] B. Kim Humphreys, DC, PhD, Andrew Sulkowski, DC, Kevin McIntyre, DC, Mark Kasiban, DC and A. Neil Patrick, DC; AN EXAMINATION OF MUSCULOSKELETAL COGNITIVE COMPETENCY IN  CHIROPRACTIC INTERNS; Journal of Manipulative and Physiological Therapeutics, Volume 30, Number 1.

[7] Bigos et al.

[8] Richard A Deyo, MD, MPH Principal Investigator; Co-Investigators. Darryl T.Gray, Sohail Mirza, William Kreuter, Brook Martin, Bryan Comstock; Epidemiology of Spinal Surgery: Rates and Trends; Center for Cost and Outcomes Research, Univ. of Washington, School of Public Health and Community Medicine http://depts.washington.edu/ccor/studies/SpineSurgEpi.shtml

[9] Bigos et al.

[10] Her Majesty’s Stationery Office in London in its Report of a Clinical Standards Advisory Group Committee on Back Pain, 1994

[11] 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.

[12] Manniche C et al. Low-back pain: Frequency, management and prevention from an HDA perspective. Danish Health Technology Assessment 1999: 1(1).

[13] The BackPage editorial, The BackLetter, pp. 84, vol. 20, No. 7, 2005

[14] Manga et al.

[15] Weber H (1994) The natural history of disc herniation and the influence of intervention, Spine 19:2234-2238.

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[18]Brook I. Martin, MPH; Richard A. Deyo, MD, MPH; Sohail K. Mirza, MD, MPH; Judith A. Turner, PhD; Bryan A. Comstock, MS; William Hollingworth, PhD; Sean D. Sullivan, PhD: Expenditures and Health Status Among Adults With Back and Neck Problems; JAMA. 2008;299(6):656-664. 

[19] Parker-Pope, Tara; Back Pain Spending Surge Shows No Benefit; NY Times, Feb. 12, 2008.

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[25] The Bone and Joint Decade Task Force Questions Common Assumptions About Neck Pain; THE BACKLetter; Published by Lippincott Williams & Wilkins Vol. 23, No. 2, February 2008

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[42] www.ganet.org/sbwc/about

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[53] Lundberg, private communication, November 2, 2005.

[54] Bigos et al.

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