Articles by JCS
Word count: 2781
HOW THE BACK PAIN INDUSTRY
IS COSTING US MORE AND GIVING US LESS
Richard A. Deyo, MD, MPH
Rating: 3½ Stars
Everyone in the spine research field knows the name of Richard A. Deyo, MD, MPH, a long-time researcher and whistleblower who has fought many battles with the mainstream medical spine providers.
Dr. Deyo won the 2015 International Society for the Study of the Lumbar Spine Lifetime Achievement Award among many other awards on his impressive résumé. He is currently a Kaiser Permanente Professor of Evidence-Based Family Medicine, Department of Public Health & Preventive Medicine at Oregon Health and Science University in Portland, and has been fighting the good fight for decades as the most progressive voice and prolific journalist in medicine for spine care reform.
His initial contribution in 1986 was his NEJM RCT that ended extended bed rest as a treatment for low back pain as well as debunking the value of TENS units and was among the first critics of the ‘bad disc’ premise. Indeed, he has always been a pioneer pushing the scientific envelope who has taken many cheap shots from the medical spine establishment that resents his critical reviews.
Watch Your Back!
Certainly Watch Your Back! can be taken literally as a patient seeking care and figuratively as a chiropractor or as a researcher who rocks the medical boat.
Patients are unaware medical spine care (opioids, ESIs, and fusions) will most likely make them sick to their stomach, chiropractors have seen medical spine providers take cheap shots across their bow, and researchers like Deyo and editors like Mark Schoene have constantly fought to reveal that medical spine care is terribly off-course.
Reading his recent book was enlightening as he recalled the battles he has fought, the insider-events he has witnessed as a panelist, and his review of the numerous studies undermining the basic medical spine care treatments.
As a member of the AHCPR panel on acute low back pain in adults, Dr. Deyo subsequently co-authored a 1997 article in The New England Journal of Medicine in response to a cheap shot from spine surgeons angry about the AHCPR’s recommendations, "The Messenger Under Attack—Intimidation of Researchers by Special Interest Groups."
I particularly enjoyed his story recapping JFK’s bad back that started with a sacroiliac problem and his unfortunate outcomes from multiple back surgeries and incessant epidural steroid injections while in the White House.
Dr. Deyo mentions interesting stories of other notables who also experienced failed back surgery syndrome—three star general David Fridovich, Cindy McCain, and Jerome Groopman, professor of medicine at Harvard.
Dr. Deyo writes about their common fate:
“What do these four have in common, other than being smart, ambitious, talented, and successful? Like most of us at some time, they were plagued by back pain. Unlike many of us, by virtue of position or wealth, they had access to the best health care in the world. And yet, to make matters worse, all suffered at the hands of medical professionals they consulted.”
These rich, famous, and powerful people have suffered the same bad outcomes as millions of regular Americans who are misdiagnosed (‘bad discs’), mistreated (drugs, shots, surgery), and not referred to chiropractors for conservative care initially as the guidelines suggest.
“Trust me, I’m a doctor” too often resembles Don Vito Corleone when he says, “Let me make you a deal you can’t refuse.” Indeed, even the rich and famous are victims of intimidation by political medicine.
Deyo mentions the many medical treatments disproved by research including the ‘bad disc’ diagnosis he dubbed “incidentalomas” that has led to the plethora of back fusions. He also reveals that these surgeries increased drastically from 1993 to 2011 by 660 percent, fueled by kickbacks from device manufacturers, hospitals, MRI centers, and Big Pharma.
Dr. Deyo reveals the poor results in medical spine care, a sentiment he has championed for decades:
“For back pain, here are the results: steadily increasing use of imaging tests, opioids, injections, and surgery. Costs that are rising faster than the rest of medical care. And, at a population level, worsening patient function and work disability. We’ve perfectly designed our health care system to produce these results.”
If you want to soar up the learning curve on the mess in medical spine treatments, Dr. Deyo’s book is an enjoyable lesson on the proof that medical spine care is ineffective, expensive, and out of control.
Off Tune about Chiropractic
Although much of his book was sweet music to my ears, he also hit a few sour notes about chiropractic care. Perhaps it’s just part of his inherited medical DNA, but Dr. Deyo gives short shrift to the role chiropractic plays in this pandemic of pain, he glosses over the medical war, and he misrepresents modern chiropractic beliefs with outdated concepts.
It’s time for a historical review of the medical war against chiropractic in order to understand how Dr. Deyo has mischaracterized this section of his book as only a chiropractor could notice.
Indeed, the very first paragraph in his chapter on chiropractic, “Manipulating the Pain,” illustrates how he minimizes the medical war to destroy chiropractic:
“It’s no secret that medical doctors and chiropractors historically had little use for each other. Doctors often called chiropractors quacks. Chiropractors called a medical editor a medical Mussolini.”
This superficial explanation belies the actual history of this one-sided medical war of annihilation. There was no mention that the infamous Medical Mussolini who Dr. Deyo refers to was Morris Fishbein who ran the AMA from 1924 to 1949 as its tyrannical leader.
Chiropractic historian, Russell Gibbons, recognized the singular impact of Fishbein and concluded he was “the most important non-chiropractor to influence the chiropractic profession.”
In 1932 the AMA board officially adopted Fishbein’s goal to destroy chiropractic according to historian Walter Wardwell:
“Eight years ago officials of the American Medical Association met in secret conclave in Chicago and adopted the slogan ‘Chiropractic must die.’ They gave themselves ten years in which to exterminate it.”
In this light, for Dr. Deyo to say that Fishbein was just an “editor” is a discredit to the Medical Mussolini’s true power. Indeed, he was the face, voice, and heavy-hand of the AMA that Fishbein made into the “most terrifying trade association on earth.”
Back to the Future
Dr. Deyo also mischaracterizes the early concepts of chiropractic when he noted that DD Palmer proposed that “95 percent of all diseases arose from misaligned or ‘subluxated’ vertebrae.” Of course, that was written in 1910.
On face value that claim may certainly be seen as hyperbolic by today’s standards, but how different is it from allopathy’s ‘pill for every ill’ mantra that is also hyperbolic but goes without question even today?
It appears that Dr. Deyo does not understand the expanse of neurophysiology. DD Palmer espoused the early principles of neurophysiology that altered structure caused organ dysfunction due to disruption of the nerve system.
Palmer was definitely ahead of his time when he wrote of the role of neurophysiology and his ideas of “functionating” and “tone” that are affected by nerve interference from the spine. He was on the right track, but he wouldn’t live long enough to see his quaint concepts come to fruition, nor would allopaths or scientists at that time appreciate his vision.
To understand the essence of chiropractic science requires a paradigm shift to “think out of the medical box” or, as chiropractic educator, James Winterstein, so aptly put it, to avoid the “allopathic trap”.
“We must be “whole health healers,” and not fall into the trap of so many allopathic “specialists” who look at a fraction of the human being and then wonder why the pathological process continues unabated following some special procedure.”
That was the perspective DD suggested with his concept of neurophysiology,
not back pain, as the core of chiropractic.
According to historian Joseph Keating, PhD, during the early stage of chiropractic in the period from 1897 through 1902, DD Palmer believed that displaced anatomy was the cause of inflammation and disease.
Palmer believed that vertebral subluxations usually produced an increase in nerve tension, thereby accelerating mental (vibrational) impulses to end organs, which resulted in increased “molecular vibrations, friction, heat and inflammation.” In this respect, “as ever, chiropractic was predominantly a theory of inflammation,” according to Keating.
Ironically, Palmer’s concepts are now supported by medical research. For example, recently the Huffington Post published Hacking The Nervous System by Gaia Vince (5/29/2015) that began with the statement, “One nerve [specifically the vagus nerve] connects your vital organs, sensing and shaping your health. If we learn to control it, the future of medicine will be electric.”
Offhand, I would say that sounds a lot like DD Palmer talking about “functionating” of the nerve system.
Gaia Vince continues to state:
“It was an extraordinary idea – if Tracey [Dr. Kevin Tracey, a neurosurgeon from New York] was right, inflammation in body tissues was being directly regulated by the brain. Communication between the immune system’s specialist cells in our organs and bloodstream and the electrical connections of the nervous system had been considered impossible. Now Tracey was apparently discovering that the two systems were intricately linked.”
This discovery by Tracey, however, comes a century late. Many other researchers have previously mentioned the role of inflammation in back pain and chronic diseases.
Research in 2007 has shown that joint dysfunction not only can cause back pain, now research has shown that joint dysfunction and inflammation may also cause radiculopathy like sciatica, a condition long equated mainly to disc herniation, according to a 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.”
Inflammation was mentioned in 1995 as a cause of pain according to an article in Spine by Joel Saal et al.:
“A potential unifying feature includes inflammation of neural elements caused by the chemical components of the intervertebral disc. There is a strong theoretic basis to support the concept that the clinical features of many lumbar disc patients may be explained by inflammation caused by biochemical factors alone or combined with mechanical deformation of lumbar tissues, rather than mechanical factors alone.”
Steven Garfin et al. also agree in 1995 that “mechanical alterations combined with inflammatory changes lead to pain”:
“The pathophysiology of sciatica is not completely understood, although our understanding of its causes is increasing. Mechanical alterations combined with inflammatory changes lead to pain… Mechanical forces can lead to intraneural damage and functional changes in nerve roots. Chemical and metabolic effects can create an inflammatory response. Varying causes of inflammation coupled with varying degrees of compression can occur anywhere along the cauda equina or spinal nerve root, including the dorsal root ganglia, and contribute to the pain response and neurologic deficits associated with sciatica.” 
This explains why many patients with back and leg pain improve with spinal adjustments, plus when combined with an anti-inflammatory regime of ice packs, anti-inflammatory diet/supplements, and NSAIDs, their recovery is even faster.
According to David Seaman, DC, MS, most people do not realize that a myriad of conditions may be caused or promoted by inflammation: aches and pain, osteoarthritis, rheumatoid arthritis, osteoporosis, acne, aging, syndrome X, diabetes, cancer, heart disease, peripheral vascular disease, stroke, Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, and more.
Considering the range of problems associated with inflammation, it appears DD Palmer was on the right track and Tracey is now simply reinventing the wheel.
It also appears if a chiropractor states a far-flung premise, it is quackery, but if a neurosurgeon states the same premise, it’s an “extraordinary idea”!
DD Palmer was also prophetic when he wrote, “Is it possible that the science of Chiropractic has arrived before its time?” Yes, and it still is.
But I digress…back to the book.
Return to the War
Dr. Deyo also mentions the “rancor” between chiropractors and the AMA, but he overlooks that the Wilk v. AMA antitrust trial revealed much more than merely professional animosity. Evidence showed the political skulduggery from the shocking testimony from members of the Committee on Quackery whose goal was to “contain and eliminate chiropractic.”
Dr. David Stevens, a member of the Committee on Quackery, admitted, “We weren’t out to be fair. We were advocates. Our job was to destroy chiropractic. We certainly weren’t going to use anything that was favorable to them.”
Such sentiment sounds much more than merely “rancor” to me; in fact, it was the AMA’s death knell for the chiropractic profession. I assume Dr. Deyo knows this history since I sent him my book, The Medical War Against Chiropractors, that includes these and other sordid comments from the medical misinformers who had no compunction to inflict as much harm as possible upon the lives of chiropractors.
To Manipulate or Not to Manipulate
Dr. Deyo also misleads his readers when he writes, “Chiropractors don’t have a monopoly on spinal manipulation, of course. Some osteopathic doctors perform spinal manipulation, as do some physical therapists.”
While that may be true in part, RAND reported that 94 percent of all manipulative care was delivered by chiropractors, with osteopathic physicians delivering 4 percent, and general practitioners, physical therapists, and orthopedic surgeons accounting for the remainder. To suggest DOs or PTs are equivalent to DCs in training or skill level is also very misleading.
Certainly if SMT had been left in the hands of DOs or PTs, it would be a dead art today after the AMA’s attempted assassination of anyone utilizing manipulation. In 1962, DOs essentially gave up SMT when Medicare/Medicaid was being developed and, in order to be included, DOs sold out their philosophy and manipulative approach to the AMA and became allopathic doctors virtually overnight, which explains why so few DOs today partake in SMT. 1962 was also the same year the Committee on Quackery was formed.
Strangely, Dr. Deyo gives a rather vanilla recommendation for chiropractic care in his book although years before in 1998 he mentioned chiropractic was a good solution:
“Chiropractic is the most common choice, and evidence accumulates that spinal manipulation may indeed be an effective short-term pain remedy for patients with recent back problems.”
Now in his book, Deyo writes:
“The truth is that interpreting research studies on spinal manipulation is an exercise in frustration…In part, this is because advocates or detractors spin small treatment effects differently…Trials have often reached differing conclusions: CAM treatments work or they don’t. You can find randomized trials to support any position you choose.”
Since I have communicated with Dr. Deyo for years and hold him in high regard, I questioned why his endorsement of chiropractic care was so under-whelming to which he responded:
“I may disappoint you as being not enthusiastic enough. Basically I argue that chiropractic is at least as effective as conventional care, probably safer, and deserves better insurance coverage… I’m sure you’re right about my particular cultural lens and brainwashing.”
His current sentiment is also a far cry from the conclusion of the AHCPR panel that he was a member. After a two-year investigation, the AHCPR concluded that spinal manipulation was a “proven treatment” for acute low back pain in adults and was the preferred initial professional treatment. This recommendation was, in effect, an endorsement of chiropractic care.
This Patient Guide stated:
This treatment (using the hands to apply force to the back to ‘adjust’ the spine) can be helpful for some people in the first month of low back symptoms. It should only be done by a professional with experience in manipulation.
Doubting Dr. Deyo
Dr. Deyo seems like a reasonable man torn between two worlds—the world of spine medicine (opioids, ESI, fusions) that he admits to be ineffective, dangerous, abused and expensive versus the world of CAM treatments that he gives a lukewarm endorsement as well as suggests many are only placebo.
I daresay any reader would be confused as to what to do for their own back attack after reading his book.
Nonetheless, I recommend Dr. Deyo’s book to anyone who wants to understand the travesty of medical spine care from a medical insider who debunks medical methods still in use, and cites the victims like JFK that medical spine care leaves behind in its wake of disability.
Dr. Rick Deyo is a good writer who makes for an enjoyable read of rather stale research material with his interesting anecdotal stories and broad experience in this field. If he had given chiropractic more credit and a more accurate accounting of the history of the medical war, I would have given him four stars.
 Deyo RA, Psaty BM, et al. The messenger under attack --intimidation of researchers by special interest groups. NEJM April 17, 1997;336(16):1176-79.
 RA Deyo, Watch Your Back!, Cornell University Press, 2014; pp. 171.
 RW Gibbons, “From Quacks To Colleagues?” Viewing the evolution of orthodox tolerance of deviant medical practice, Journal of Chiropractic Humanities 4/1 (1994):61-71.
 Wardwell WI. Alternative medicine in the United States. Soc Sci Med 1994;38:1061-1068. (Citing Reed L. The healing cults. Chap 3, Publ No.16 of the Committee on the Costs of Medical Care, p 5. University Press, Chicago, 1932
 MS Mayer, “The Rise and Fall of Dr. Fishbein,” Harper’s Magazine, (Nov. 1949): 76-85.
 James Winterstein via private communication with JC Smith, August 27, 2008
 Joseph C. Keating, Jr., PhD, “D.D. Palmer's Forgotten Theories of Chiropractic,” A Presentation to the Canadian Memorial Chiropractic College, February 18, 1995.
 H Tachihara, S Kikuchi, S Konno, M Sekiguchi, “Does Facet Joint Inflammation Induce Radiculopathy?: An Investigation Using A Rat Model Of Lumbar Facet Joint Inflammation,” Spine 32/4 (Feb 15,2007):406-12.
 DD Palmer, The Chiropractor’s Adjuster: The Text-Book of the Science, Art and Philosophy of Chiropractic (Portland, Oregon: Portland Printing House) (1910): 847
 G McAndrews closing argument, Wilk v. AMA, (December 9, 1980):3055
 PG Shekelle, AH Adams, MR Chassin, E Hurwitz, RE Park, RB Phillips, RH Brook, “The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review,” RAND (1991):3. Santa Monica, Calif.
 RA Deyo, “Low -Back Pain,” Scientific American, (August 1998):49-53
 RA Deyo, private communication with JC Smith, 8/05/2105
 PG Shekelle, et al, RAND Corporation Report, The Appropriateness of Spinal Manipulation for Low-Back Pain
 SJ Bigos, O Bowyer, G Braea, K Brown, R Deyo, S Haldeman, et al. “Acute Low Back Pain Problems in Adults: Clinical Practice Guideline no. 14.” Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; (1994) AHCPR publication no. 95-0642. Patient Guide, p. 7.