Articles by JCS

Chiropractic Waterloo

The Chiropractic Waterloo

Last year at the closing banquet of the DC2017 conference, Dr. David Herd, the ACA president, proudly announced the imminent ‘new’ ACA. However, as we’ve witnessed with our new president in the White House, sometimes change isn’t for the better despite high hopes and big promises.

As a longtime ACA member myself for over 30 years, including as a former member of the ACA’s Governors’ Advisory Cabinet and as a recipient of the ACA’s 2002 Chairman’s Award, I was delighted to hear changes were impending. Indeed, it’s been a long uphill battle to bring our profession together and to increase our brand as America’s leading nondrug spine care provider.

Little did I know the changes were not as I expected.

Recent events have revealed rather than bringing chiropractors together, the ACA’s ‘new’ Choosing Wisely program will most likely alienate thousands of field practitioners with controversial clinical guidelines and prohibitions causing denied payments for services and thereby decrease the ACA’s membership.

Indeed, this may become the ACA’s Waterloo in a political battle they may live to regret. Time will certainly tell, but early indications are not good.

This is not the first attempt to reform the ACA. In the Jan/Feb 2003 edition of ACA Today, then-president Dr. Daryl Wills asked in his column: “What is our message?” Dr. Wills concluded the ACA’s focus groups sadly confirmed: “a lack of knowledge regarding the new ACA message…”

“I am convinced that in spite of all we do, say or print, the majority of our profession does not know what a viable, pro-chiropractic, member-driven organization we have in the ACA. It is our responsibility to help the non-members and uninformed to understand why ACA is the organization to represent this profession in the future.”

I daresay the same dilemma exists for the ‘new’ ACA, but in its quest, methinks the ACA’s leadership has shot itself in the foot.

Since his views in 2003, today even Dr. Wills has questions about the ‘new’ ACA representing the profession in the future. Recently Dr. Wills offered his opinion of the ‘new’ ACA’s Choosing Wisely policy:

“No, I do not like the direction nor do I approve of the intention of current leadership and their ‘own’ agenda instead of doing what is best for chiropractic and the association.”[1]

His comments came about after the release of five controversial prohibitions in the ‘new’ ACA policy:

  1. In the absence of red flags, do not obtain spinal imaging (X-rays) for patients with acute low-back pain during the six weeks after the onset of pain. 
  2. Do not perform repeat spinal imaging to monitor patients’ progress. 
  3. Avoid prolonged or ongoing use of passive or palliative physical therapy treatments (such as heat, cold, electrical stimulation and ultrasound) for low-back pain unless they support the goal(s) of an active treatment plan. 
  4. Do not provide long-term pain management without psychosocial screening or assessment for possible related psychological disorders, most notably depression and anxiety.  
  5. Do not prescribe lumbar supports or braces for the long-term treatment or prevention of low-back pain.

Obviously the ACA’s Choosing Wisely guideline is a minimalist program that will anger the majority of field doctors. Instead of taking steps forward to improve our understanding of spinal healthcare and correction of vertebral subluxations, it appears the ‘new’ ACA has taken a step backward.

To sell its injudicious policy, the ACA has assembled a group of five DCs at the upcoming 2018 National Chiropractic Leadership Conference to speak on this policy:  Am I Choosing Wisely? How to Implement Choosing Wisely in Your Practice. They will discuss the background and the development of the ‘new’ ACA policy and attendees will hear how the panelists are implementing these recommendations into their practices.

Is this an academic debate or a political pitch to present this policy that was never voted upon by the ACA’s membership?

Although I am not a participant (no, not me), let me respond to each recommendation with dissenting evidence:

  1. “Do not obtain spinal imaging (X-rays) for patients with acute low-back pain” (does this mean cervical xrays are okay?)

First of all, these proponents insist imaging is not necessary to adjust a patient. These advocates cite two papers by Triano and Haldeman:

·         Review of methods used by chiropractors to determine the site for applying manipulation by John J Triano, et al. One interesting note: the authors were equivocal on the use of xrays, “The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays.” Let me add “unclear” is not the same as “unnecessary” as some might allege.

Here are selected comments from Triano’s paper:
The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays.

Currently, there is no consensus on the mechanism(s) or identity of the pain generators of non-specific spinal pain. Even the validity and impact on care delivery of recent clinical prediction rules remain uncertain. Consequently, there is no gold standard for diagnosis, in the traditional sense.

·         In response to Triano’s article, O’Dane Brady and Scott Haldeman wrote, Commentary: we can tell where it hurts, but can we tell where the pain is coming from or where we should manipulate?

Although this paper is also used to debunk xrays and VSC, the authors clearly did not state that:

What this paper does not inform us on is the nature of the lesion causing the pain or where the manipulation should be applied to obtain the best outcome… Furthermore, in the absence of any gold standard there is no means of determining the sensitivity or specificity of the tests in assessing the patient’s complaint.”

“The assumption in this article by Triano et al. is that the manipulation will be applied to the manipulable lesion identified in the testing.”

Scott Cuthbert, DC, author and master Applied Kinesiologist, disagreed with Triano's conclusion — “basically, their science says 'adjust them where it hurts'.”[2] And stop adjusting them when the pain diminishes.

In regards to spinal imaging for diagnostic value and developing a treatment plan, The International Chiropractors Association (ICA) states:

"Radiography is a scientifically proven, clinically valid and appropriate method to evaluate multiple aspects of human spinal anatomy, identify vertebral subluxations, altered spinal biomechanics, postural misalignments, pathology and in providing information and safeguards in rendering chiropractic care in clinical practice."

The ICA also states evidence supports:

"…an extensive list of clinical indications for taking an x-ray image of the patient such as suspected subluxation, history of trauma, including birth trauma, motor vehicle accidents, falls, postural and for the procedure by chiropractic profession to identify multiple clinical components including fractures, congenital, developmental, postural biomechanical and degenerative conditions, ruling out pathologies, assess the indications for appropriate options in performing a chiropractic spinal adjustment for both the acute and non-acute patient.” 

Secondly, the issue of excessive radiation is a concern cited by the anti-xray advocates although this notion has been disputed by many investigations:

·         Should Chiropractic Follow the American Chiropractic Association / American Board of Internal Medicine’s Recommendations on X-Ray?

“Based upon the literature, radiation is not cumulative and has rendered no evidence of long term effects. Therefore, the doctor of chiropractic must weigh the risk of treating blindly in the presence of clear biomechanical markers. Treating blindly is often done at the expense of our patients and the malpractice carriers, especially in a scenario where little risk exists.”

·         Radiation Study Finds Little Risk

“The researchers found that the workers exposed had lower overall death rates, and lower numbers of lung, lymphatic and blood cancers than those who had not been exposed.”

·         A Rebuttal to Chiropractic Radiologists’ View of the 50-year-old, Linear-No-Threshold Radiation Risk Model

“…their main arguments against routine use of radiography in common practice, radiation risks and lack of clinical usefulness are without scientific support”.

·         Subjecting Radiologic Imaging to the Linear No-Threshold Hypothesis:  A  Non  Sequitur of Non-Trivial Proportion, debunking this “radiophobia”:

“On the contrary, low-dose radiation does not cause, but more likely helps prevent, cancer.”

·         The Birth of the Illegitimate Linear No-Threshold Model: An Invalid Paradigm for Estimating Risk Following Low-dose Radiation Exposure.

They suggest “no associated health effects have been documented to date anywhere in the world.”

·         Time to Terminate LNT: Radiation Regulators Should Adopt LT

The public needs protection from radiophobia, rather than from low-dose radiation exposure.”

·         Is Diagnostic Medical Radiation Safe?

“Nevertheless, a large volume of circumstantial evidence suggests that diagnostic levels of radiation probably are associated with a low level of risk for inducing disease many years after exposure. Such an event would be very infrequent. Benefits to patients who are sick or injured are so substantial that the radiation risk becomes a minor factor in their healthcare.”

  1.  “Do not perform repeat spinal imaging to monitor patients’ progress.” 

 

Let me ask: Is pain the only criteria we should monitor?

Mark Payne, DC, President of Matlin Mfg. Inc., concedes xrays are not only for the detection of VSC:  

I do, however, support the use of pre and post care radiography to assess spinal structure. Radiography remains the single best tool available to visualize and measure the spine and determine the efficacy of any care program attempting to improve the patient’s posture. That’s important stuff if you are a clinician seriously interested in spinal structure. Not so important if you just want to know where to pop the spine. Trust me, when something better comes along I will jump on the bandwagon.  Just haven’t seen it yet![3]

The ICA Best Practices & Practice Guidelines also support comparison x-ray studies in order to:

“…effectively utilize certain techniques as it provides valuable information detailing the effects of the chiropractic adjustment and to assess and anticipate the patient's response to care and future progress."

  1. “Avoid prolonged or ongoing use of passive or palliative physical therapy treatments.”

Is this recommendation based on clinical necessity or economics to save money for ASHN? If people with acute pain feel better after treatment, why would passive modalities or physical therapeutics be taboo for chronic pain relief too? Does chronic pain not warrant equivalent clinical treatment?

The studies listed below in PubMed support multimodal treatments for neck and low back pain:

·         Evidence-based guidelines for the chiropractic treatment of adults with neck pain.

CONCLUSIONS:

Interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain. Increased benefit has been shown in several instances where a multimodal approach to neck pain has been used.

·         Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash.

REPORTED BENEFITS, HARMS AND COSTS: The benefits from the recommendations include more rapid recovery from pain, impairment and disability (improved pain and ROM)

·         Implementation interventions to improve the management of non-specific low back pain: a systematic review.

CONCLUSIONS:

Single intervention or one-off implementation interventions may seem attractive but are largely unsuccessful in effecting meaningful change in clinical practice for NSLBP. Increasing frequency and duration of implementation interventions seems to lead to greater success and the most successful implementation interventions used consistently sustained strategies.

  1. “Do not provide long-term pain management...”

This recommendation is particularly annoying to me as a clinician and as a patient with life-long spinal impairment. To discourage maintenance care for chronic LBP flies in the face of preventative care by multiple research studies, and may force patients to take opioid painkillers from pill mills instead if denied access to chiropractors.

Take a look at these supportive articles in PubMed:

CONCLUSIONS:

Intensive spinal manipulation is effective for the treatment of chronic low back pain. This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective post-intensive treatment disability levels.

CONCLUSION:

SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.

CONCLUSION:

The patient appeared to experience improvement in quality of life while showing signs suggestive of improved spinal function

CONCLUSIONS:

There is relatively high consensus on when maintenance (MC) should and should not be used. A history of prior low back pain combined with a positive response to treatment encourages the use of MC, whereas no previous history of back pain or a worsening of symptoms discourages the use of MC. There seems to be a difference in the proportional use of MC between chiropractors with more experience educated in North America and those with less experience educated in Denmark.

CONCLUSION:

The vast majority of our respondents believe that chiropractic treatment can prevent relapses of back pain. When recommending secondary preventive care, past frequency of the problem is considered. For tertiary preventive care, the patient needs to improve considerably before a recommendation of maintenance care is made.

·         A survey of practice patterns and the health promotion and prevention attitudes of US chiropractors. Maintenance care: part I.

CONCLUSIONS:

Despite educational, philosophic, and political differences, US chiropractors come to a consensus about the purpose and composition of MC. Not withstanding the absence of scientific support, they believe that it is of value to all age groups and a variety of conditions from stress to musculoskeletal and visceral conditions. This strong belief in the preventive and health promotion value of MC motivates them to recommend this care to most patients. This, in turn, results in a high level of preventive services and income averaging an estimated $50,000 per chiropractic practice in 1994. The data suggest that the amount of services and income generated by preventive and health-promoting services may be second only to those from the treatment of low-back pain. The response from this survey also suggests that the level of primary care, health promotion and prevention activities of chiropractors surpasses that of other physicians.

CONCLUSIONS:

On the basis of the response of participating chiropractors, this study describes the therapeutic components of MC for the elderly patient. For these patients, MC does not simply consist solely of periodic visits for joint manipulation, but it involves an eclectic host of interventions (e.g., exercise, nutrition, relaxation, physical therapy, and manipulation) that are directed at both musculoskeletal and visceral conditions.

Our results indicate that a substantial proportion of the US chiropractors and students who completed our survey, as well as a number of key faculty, have a positive attitude toward providing clinical preventive services, particularly those related to physical activity and diet. However, the results also suggest that there may be areas where chiropractic training is not consistently meeting the newly established national guidelines for clinical preventive services.

  1. “Do not prescribe lumbar supports or braces for the long-term treatment or prevention of low-back pain.”

While back supports are not curative (similar to crutches do not cure a sprained ankle), they temporarily do relieve pain and axial compression, vital in circumstances of prolong sitting and standing. Also, I wonder why the ACA would be opposed to the “prevention of low-back pain.” There were equivocal studies:

·         Lumbar supports for prevention and treatment of low back pain.

·         There was moderate evidence that lumbar supports are not more effective than no intervention or training in preventing low-back pain, and conflicting evidence whether lumbar supports are effective supplements to other preventive interventions. It is still unclear if lumbar supports are more effective than no or other interventions for the treatment of low-back pain.

·         Mechanisms of action of lumbar supports: a systematic review.

·         CONCLUSION:

·         There is evidence that lumbar supports reduce trunk motion for flexion-extension and lateral bending. More research is needed on the separate outcome measures for trunk motion before definite conclusions can be drawn about the work conditions in which lumbar supports may be most effective. Studies of trunk motion at the workplace or during specified lifting tasks would be especially useful in this regard.

·         Lumbar supports for prevention and treatment of low back pain: a systematic review within the framework of the Cochrane Back Review Group.

CONCLUSIONS:

There continues to be a need for high quality randomized trials on the effectiveness of lumbar supports. One of the most essential issues to tackle in these future trials seems to be the realization of adequate compliance.

·          Lumbar supports for prevention and treatment of low-back pain.

The systematic review of therapeutic trials showed that there is limited evidence that lumbar supports are more effective than no treatment, while it is still unclear if lumbar supports are more effective than other interventions for treatment of low back pain.

Perhaps one reason why lumbar supports were marginally effective in these studies may be due to the possibility most patients were incorrectly instructed how to put on a lumbar support. Preferably, the patient should lie down to decompress the spine before putting on the support from the tip of the sacrum upwards.

I have discovered most patients were instructed by MDs/PTs to stand up first before fitting the support. Doing so compresses their spine defeating the purpose of axial decompression. They also wrap the support too high above their waistline with the bottom of the support at L5/sacrum; as such, the support only acts like a girdle to hold in the patient’s belly and restrict trunk motion, but does not help to alleviate axial compression. Obviously any tool used incorrectly will perform poorly as these studies suggest.

I wonder if the ACA also would discourage patients from using a crutch or cane as well for ambulatory relief. According to the NBCE, 83% of DCs prescribe lumbar or cervical supports. For those of us who also personally use lumbar supports, they are a blessing if used properly.

As you can see, there is adequate research to refute this Choosing Wisely program that minimizes our care to a brief exam and minimal acute care—what I refer to as the ‘pop and pray’ modus operandi. Perhaps this explains why Medicare limits chiropractors to 10 or less codes for SMT when the ACA’s minimalist policy suggests we don’t need any more services for acute care nor are chiropractors allowed to give chronic care, structural rehab or preventative maintenance care. Indeed, we’ve painted ourselves into a corner with the Choosing Wisely program.

Bigger Fish to Fry

Moreover, this Choosing Wisely program dumbfounds me as a priority issue for the ACA. Methinks there are bigger battles to fight to improve our profession than clinical procedures that have been established parts of our profession for over a century working very well.

May I recommend the ACA bigwigs focus on more important issues that would unite our profession instead of dividing it? I urge the ACA to drop its five prohibitions and, instead, take on the following five recommendations long ignored:

1.                  Increasing Our Market Share:

What has the ACA done to increase patient access to chiropractors in group health insurances, Medicare, TRICARE, and workers’ comp programs? I’ve not seen any increase in access by patients to our services although many recent guidelines admit access to care remains an obstacle to nondrug alternatives to opioids. Instead of worrying about the use of xrays, perhaps the ACA should focus as its primary concern on strategies to increase our market share by using the new guidelines as leverage to publicly shame payors who limit chiro care. Perhaps we need to hitch-hike on the #MeToo social movement with one of our own, #ChiropractorsMatter or #AvoidBackSurgery or #Chiropractors Cry Foul to stir public empathy.

Indeed, the ACA’s present PR program has been abysmal and a derelict of duty to its members. As a former member of the ACA Ad Hoc PR Committee, I compiled a history of the many past PR programs from around this country and the world that were filled with fascinating ideas that have been ignored. I urge every ACA bigwig to read my lengthy report.

 

2.                  Break the Glass Ceiling for DCs:

Everywhere in the healthcare system DCs are limited in treatments/frequency allowed, equitable charges, and access by the public. Only 3.6% of DCs enjoy hospital privileges (200 in 5000 hospitals) and 6.7% are employed to care for active military and retirees. And when included, we are severely handcuffed as we see in TRICARE where only 25% of 238 military treatment facilities utilize chiro care. The VA now provides chiropractic care (via hired or contracted staff) at 70 major VA treatment facilities within the United States. Unfortunately, an overwhelming majority of America’s veterans still do not have access to chiropractic care because the VA has taken no action to provide chiropractic care at nearly 100 of its major medical facilities.

Chiropractors are limited to billing three CPT codes under Medicare: 98940 (chiropractic manipulative treatment; spinal, one to two regions), 98941 (three to four regions), and 98942 (five regions). We are virtually invisible in all state and federal WC programs even though legally included. Although the Wilk v. AMA antitrust trial was a legal victory, little has been done to apply this to confront the boycott to expand our market. Without question the boycott of chiropractors remains entrenched as we see with the restrictions of chiropractors in the workplace, Medicare, VA, MHS, and TRICARE.

3.      Improve our Public Image:

How can we claim to be primary spine providers when the public still harbors the bigotry from medical trolls that chiropractic is an unscientific cult, dangerous, and quackery—issues our associations have never refuted publicly. We have no voice or face in the commercial/earned media and the F4CP’s ten-year $10 million effort was sorely ineffective. Fortunately the F4CP has finally changed its consulting firm, but the ACA cannot relinquish its role to the F4CP. More newspaper ads will not change a skeptical public soiled by medical propaganda. We need articulate spokes-persons to engage the media, but this requires knowledge of the medical war, past and present, and the sociology of why the public thinks the way they do about our profession.

Until we publicly confront this medical propaganda in the earned media to condemn chirophobia that has also led to the current opioid crisis and tsunami of back surgeries, this medical propaganda will continue to be our biggest barrier for new patients and acceptance as America’s primary spine providers.

4.      Challenge the Medical Fake News Media

This dilemma explains why I began my website Chiropractors for Fair Journalism.  The problem is obvious: despite being the 3rd largest physician-level health providers in the nation, when was the last time you’ve seen an in-depth, fair and balanced article about the benefits we bring with our nondrug, nonsurgical care for the pandemic of LBP, the leading disability in the workplace, VA, and military? Of course, the answer is never.

The main PR problem is the simple fact the ACA has never rebuked the AMA’s defamation campaign against chiropractors, aka, chirophobia, so the medical muck continues unabated as public lore to soil our image. It’s the elephant in the room we continue to ignore.

5. Stimulate the Base & Organize Our Resistance

We need a PR Boot Camp to train new speakers and writers to be placed in the local news media on TV and radio talk shows by a professional publicist. We must talk about the medical war against chiropractors rather than speaking about backpacks and LBP. We must address the history, people, events and healthcare reform issues that have led to our present status caring for only 14% of the population

If the ACA were to drop its list of five prohibitions and embrace the recommendations I’ve suggested, then the disenfranchised DCs might look to the ACA for leadership and hope.

Just as Napoleon guessed incorrectly against Wellington, so has the ACA. Indeed, whose idea was this Waterloo strategy?

Pledge of Allegiance to ACA

To pour salt on the wound inflicted by the minimalist policy of Choosing Wisely, recently I received a very attractive Membership PR package with the ‘new’ ACA putting on a new face with its ‘new’ Mission Statement:

ACA is leading the chiropractic profession in a bold new direction. After years of fighting with others for acceptance and fighting among ourselves, we’re launching a movement in our profession that’s built on the highest membership standards, on working hand in hand with other health care professionals, on being evidence based and on making sure the ACA logo is a sign to patients that our members promise the best possible care.

This Mission Statement also struck a dissident chord in me in that a ‘bold new direction’ may actually cause more ‘fighting among ourselves’ and ‘being evidence based’ may not improve but hinder the ‘promise for the best possible care.’

This package also included the Pledge of Professional Values from the ACA.

Pledge of Professional Values

As an ACA chiropractor, I pledge to make Accountability to my patients and the public a priority by adhering to treatment standards and best practices adopted by the association and by focusing on patient outcomes.

I strive to provide higher quality care and Consistency for my patients by using evidence to inform my practice, remaining committed to the ACA Code of Ethics and exhibiting the highest level of professional excellence.

I treat fellow members with courtesy and respect while embracing a collaborative approach and new philosophical Attitude toward other health care professionals that moves the organization, and the profession, forward.

This loyalty oath is a very slippery slope. Indeed, it reminded me of Principle 3 in the Medical Code of Ethics that demanded MDs and hospitals not to cooperate with chiropractors or else fear reprisal—loss of licensure—an illegal policy that led to the Wilk v. AMA antitrust trial.

James D. Edwards, DC, past chairman of the ACA, wrote an op-ed piece in the Dynamic Chiropractic, I Will Never Sign the ACA Pledge!

 “It is beyond my comprehension that a membership association that has lost thousands of members is essentially now trying to ‘brand’ itself as some kind of quasi national licensing board did the ACA obtain the formal approval the Federation of Chiropractic Licensing Boards (FCLB) before attempting to usurp the authority of their state boards?” 

I presume the ‘new’ ACA leadership is ready for a growing uproar when some DCs reject their Pledge of Professional Values. Again, considering over half of DCs use methods not strongly supported in research, will they willingly abandon their methods to appease the ‘new’ ACA?

Let me explain how this Mission Statement might impact every member. If the ACA demands ‘adhering to treatment standards and best practices adopted by the association,’ this may exclude many adjusting techniques and adjunct therapies not highly rated in the research many chiropractors now use.

This evidence-based only policy may potentially affect over 60% of DCs according to two evidence-based studies comparing different adjusting methods for LBP including instrument adjusting that doesn’t conform with the evidence.

  • Gatterman Study

In 2001, JMPT published an article, “Rating specific chiropractic technique procedures for common low back conditions” by Meridel Gatterman, DC, Robert Cooperstein, DC, Charles Lantz, DC, PhD, Stephen M. Perle, MA, DC, and Michael J. Schneider, DC, PhD. [4]

In the rating scale of 1-10, the effectiveness of procedure ratings for acute low back pain for 10 procedures was quite revealing. Ranking them for low back pain found the following:

1. HVLA, no drop table (side posture)                                     9.5
2. HVLA, prone, with drop table assist                                    8.7
3. Distraction technique                                                           8.7
4. Mobilization                                                                          8.0
5. HVLA, prone, without drop table assist                                6.4
6. Pelvic blocking procedures                                                   6.3
7. Lower extremity adjusting                                                     3.7
8. Instrument adjusting                                                              3.7
9. Non-thrust/reflex/low force                                                     3.5
10. Upper cervical                                                                      3.3

Conclusions:
The ratings for the effectiveness of chiropractic technique procedures for the treatment of common low back conditions are not equal. Those procedures rated highest are supported by the highest quality of literature. Much more evidence is necessary for chiropractors to understand which procedures maximally benefit patients for which conditions.

So, let me ask those ACA members who use instrument adjusting, low force or upper cervical methods: are you willing to abandon your beloved techniques because of the lack of evidence shown in this study? 

If not, you may be violating your pledge of allegiance to the ACA.

  • Schneider Study

Another comparative study was revealed at the 2014 ACC-RAC conference in a presentation, “A Comparison of Spinal Manipulation Methods and Usual Medical Care for Acute Low Back Pain, presented by noted researcher, Michael Schneider, DC, PhD; co-authors were Mitchell Haas, DC; Joel Stevans, DC; Ronald Glick, MD; and Doug Landsittel, PhD.

This study compared three methods for LBP care: classic HVLA chiropractic care (manual) vs. Activator (mechanical) vs. usual medical care (OTC meds).

The graphs for Oswestry and Pain were revealing: 

Text Box:  Text Box:

As you can see, classic ‘hands-on’ manual chiro care out-performed both Activator and standard medical care in terms of “Changes in Pain and OSW” results.

Dr. Schneider concluded that “manual manipulation provides significantly more reduction in disability and pain at 4 weeks as compared to mechanical manipulation or medical care.”

However, medical OTC meds also outperformed Activator in regards to “substantial improvement” in the OSW at the 4-week interval. Considering medical care OTC meds are placebo, the evidence suggests Activator was only slightly better than placebo.

Based on Schneider’s study, how well do you think this will play on Main Street among DCs and patients who prefer Activator? I daresay Arlan Fuhr and Chris Collocca may have something to say along with the many NUCCA techniques that will oppose any policy that disallows such treatments rated poorly by the literature.

I doubt this research alone will dissuade DCs from using instrument adjusting just as evidence-based research studies will not dissuade pain management MDs from prescribing narcotic painkillers, performing epidural shots or recommending spine fusions that are now considered dangerous, addictive, unnecessary and placebo.





According to the NBCE, DCs also use many adjusting techniques and adjunct therapies that may not have enough support in the literature and consequently may not be paid:

Most Frequently Used Techniques

1. Diversified 95.9%

2. Extremity manipulating/adjusting 95.5%

3. Activator Methods 62.8%

4. Gonstead 58.5%

5. Cox Flexion/Distraction 58.0%

6. Thompson 55.9%

7. Sacro Occipital Technique [SOT] 41.3%

8. Applied Kinesiology 43.2%

9. NIMMO/Receptor Tonus 40.0%

10. Cranial 37.3%

11. Manipulative/Adjustive Instruments 34.5%

12. Palmer upper cervical [HIO] 28.8%

13. Logan Basic 28.7%

14. Meric 19.9%

15. Pierce-Stillwagon 17.1%

 

According to a Cochrane Review by Sidney Rubinstein, et al., A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain, many of the most popular adjunct therapies are unsupported by evidence.

…we conclude that there are insufficient data to draw firm conclusion on the clinical effect of back schools, low-level laser therapy, patient education, massage, traction, superficial heat/cold, and lumbar supports for chronic LBP.

Here is a larger list of Cochrane Reviews that do not support many adjunct therapies:

Back Schools for chronic non-specific low back pain.

AUTHORS' CONCLUSIONS:

It is uncertain if Back School is effective for chronic low back pain.

 

Back schools for acute and subacute non-specific low-back pain.

AUTHORS' CONCLUSIONS:

It is uncertain if back schools are effective for acute and subacute non-specific LBP as there is only very low quality evidence available.

 

Traction for low-back pain with or without sciatica.

AUTHORS' CONCLUSIONS:

These findings indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBPImplications for practice to date, the use of traction as treatment for non-specific LBP cannot be motivated by the best available evidence. These conclusions are applicable to both manual and mechanical traction.

 

Massage for low-back pain.

AUTHORS' CONCLUSIONS:

We have very little confidence that massage is an effective treatment for LBP. Acute, sub-acute and chronic LBP had improvements in pain outcomes with massage only in the short-term follow-up. Functional improvement was observed in participants with sub-acute and chronic LBP when compared with inactive controls, but only for the short-term follow-up.

 

Acupuncture for treating fibromyalgia.

AUTHORS' CONCLUSIONS:

There is low to moderate-level evidence that compared with no treatment and standard therapy, acupuncture improves pain and stiffness in people with fibromyalgia. There is moderate-level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well-being.

 

A Cochrane review of electrotherapy for mechanical neck disorders.

CONCLUSIONS:

In pain as well as other outcomes, the evidence for treatment of acute or chronic mechanical neck disorders by different forms of electrotherapy is either lacking, limited, or conflicting.

 

The effectiveness of acupuncture in the management of acute and chronic low back pain. A systematic review within the framework of the cochrane collaboration back review group.

CONCLUSIONS:

Because this systematic review did not clearly indicate that acupuncture is effective in the management of back pain, the authors would not recommend acupuncture as a regular treatment for patients with low back pain.

 

Acupuncture for low back pain.

REVIEWER'S CONCLUSIONS:

The evidence summarized in this systematic review does not indicate that acupuncture is effective for the treatment of back pain.

 

Electrotherapy for neck disorders.

AUTHORS' CONCLUSIONS:

We can not make any definitive statements on electrotherapy for mechanical neck disorder (MND). The current evidence on Galvanic current (direct or pulsed), iontophoresis, TENS, EMS, PEMF and permanent magnets is either lacking, limited, or conflicting.

 

What will DCs do when ASHN rejects these treatments because the literature doesn’t support Activator or adjunct therapies? These restrictions will certainly play into ASHN’s policy to “squeeze care to expand profits” with the blessings of the ‘new’ ACA.

Dr. Gerry Clum revealed in the recent Washington State Chiro Assn debate how the Choosing Wisely guidelines may be “weaponized”:[5]

         By third party payers desirous of eliminating costs

         By managed care organizations as a screening mechanism for provider participation

         By professional liability attorneys alleging malpractice for taking a lumbar film that is ultimately read as normal

Obviously this “evidence-based” policy also broaches ethical issues when the lower rated techniques are seen as a violation of the Pledge of Professional Values by the ACA to use only methods “exhibiting the highest level of professional excellence.”

By discouraging the chiropractic profession with the ‘new’ ACA policy critical of xrays, VSC, maintenance care, and by virtue of its inexplicable pro-drugs stance, I daresay we can expect the membership to decrease dramatically once the ‘new’ ACA policies become better known and field docs feel a decrease in revenue when more insurance payors take on the barebones policy of ASHN.

I can see a letter of denial from ASHN to thousands of DCs: “We’ve not paid you because your adjusting technique and adjunct therapies were poorly rated; consequently, we will also report you for violating the ACA’s Pledge of Allegiance for not exhibiting the highest level of professional excellence.”

The bottom line is clear: the general dumbing-down of clinical chiropractic as a result of the ‘new’ ACA will decrease every DC’s practice scope and income.

It appears what Trump giveth in tax cuts, the ACA taketh away in fewer services rendered.

I daresay field docs, including ACA members, have no idea this new policy may negatively impact DCs who take xrays, use modalities, recommend maintenance care, do progress exams, and recommend lumbar supports — once considered mainstream procedures but now considered taboo.

To sell its injudicious policy, the ACA has assembled a group of five DCs at the upcoming 2018 National Chiropractic Leadership Conference to speak on this policy:  Am I Choosing Wisely? How to Implement Choosing Wisely in Your Practice. They will discuss the background and the development of the ‘new’ ACA policy and attendees will hear how the panelists are implementing these recommendations into their practices.

Is this a balanced debate or a political pitch to present this policy that was never voted upon by the ACA’s membership?

In Part 2: The Ignoble Experiment, I will show research that refutes the Choosing Wisely policy. Please don’t think the term “evidence-based” practice (EBP) is written in stone. In fact, there is an on-going debate that needs to be discussed so field docs won’t be intimidated by these ACA spokespersons.

 

 



[1] Daryl Wills, Private communication with JC Smith, 12/20/2017

[2] Scott Cuthbert, private communication with JC Smith, Jan. 10, 2018.

[3] Mark Payne, private communication with JC Smith, January 22, 2018

[4] “Rating specific chiropractic technique procedures for common low back conditions,” by Meridel I. Gatterman, DC, Robert Cooperstein, Charles Lantz, DC, Stephen M. Perle, DC Michael J. Schneider, DC, (JMPT, 2001 Sep; 24(7):449-56.).

[5] Washington State Chiropractic Association Annual Meeting on January 20, 2018, a debate on the ACA’s guidelines titled “Is Choosing Wisely a Wise Choice: a conversation on the question.”

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