Articles by JCS
Word count: 2564
“Chiropractors are Best for Back Pain”
Wouldn’t you love to see that headline go viral on the news?
Believe it or not, that was the headline on most of the morning TV talk shows on December 8, 1994, the day after the Agency for Health Care Policy and Research (AHCPR) guideline #14 on acute low back pain in adults was released to the media after a federal judge overruled an injunction that had delayed its release for months.
The AHCPR study was the most thorough research ever done in the history of spine medicine or chiropractic:
After its two-year investigation, the AHCPR panel of experts concluded that spinal manipulation was a “proven treatment” for acute low back pain in adults and was the preferred initial professional treatment.
The literature search of articles published after 1984 was performed through the National Library of Medicine. Abstracts of 10,317 articles which met the search criteria were each independently evaluated by the orthopaedic surgeon and occupational medicine physician on the research staff. If either reviewer thought an article might be useful, the entire article was retrieved. A total of 3,918 articles (38 percent of all abstracts evaluated) was obtained for further evaluation.
Summary of Findings
"The evidence for effectiveness of manipulation varies depending on the duration and nature of the patient's presenting symptoms. For patients with acute low back symptoms without radiculopathy, the scientific evidence suggests spinal manipulation is effective in reducing pain and perhaps speeding recovery within the first month of symptoms. For patients whose low back problems persist beyond 1 month, the scientific evidence on effectiveness of manipulation was found to be inconclusive. For patients with radiculopathy, the scientific evidence was also inconclusive about either the effectiveness or the potential harms of manipulation. Finally, the panel offered the opinion that, for patients with acute low back problems and findings of possible progressive or severe neurologic deficits, assessment to rule out serious neurologic conditions is indicated before initiating manipulation therapy."
The AHCPR 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.
This recommendation was, in effect, an endorsement of chiropractic care considering DCs do 94 percent of SMT. Killing the Messenger
What would have been a huge PR breakthrough for our profession—to have the US Public Health Service’s endorsement—was instantly sabotaged by medical reporters like Dr. Art Ulene on NBC and by political hacks on Capitol Hill.
Unfortunately, the NASS and its hooligans of spine surgeons hired blowhard Newt Gingrich (R-GA) to attack the AHCPR agency to mute the AHCPR recommendations. They created a bogus third-party advocacy group, the Center for Patient Advocacy, whose main goal was to kill the guideline by getting the agency defunded.
In reality, this was not an actual “patient” group, but were members of NASS formed by Neil Kahanovitz, MD, a back surgeon from Arlington, Virginia. This assassination was a classic case of ‘killing the messenger’ of researchers on the AHCPR panel as I recounted in AHCPR Gone with the Wind.
What riled the NASS the most was not only the endorsement of SMT, but another dagger in the heart and pocketbook of the NASS was the section on Spinal Fusion from the AHCPR’s Clinical Practice Guideline that was not supportive of spine surgery:
There appears to be no good evidence from controlled trials that spinal fusion alone is effective for treatment of any type of acute low back problems in the absence of spinal fractures or dislocation....Moreover, there is no good evidence that patients who undergo fusion will return to their prior functional level.
If this sabotage had not occurred and the guideline #14 had been implemented just as the other thirteen guidelines were without objection, today we would have assumed our rightful position as the primary portal of entry for back pain cases, certainly for the 85 percent of ‘non-specific, mechanical’ LBP cases that have no pathoanatomical problems like cancer, fracture, infections, cauda equina, serious neurological deficits, etc.
This missed opportunity certainly damaged our resurgence via the official support from an agency of the US Public Health Service. Apparently chiropractic cannot "research" itself out of this dilemma knowing the political power of the AMA. The pen may be mightier than the sword, but it is not mightier than the dollar.
In the meantime, many other recent guidelines have surfaced that also recommend SMT, but two factors still prevail that hinder our potential credibility in the public sector:
We also cannot advertise ourselves out from underneath this PR dilemma, nor will WOM change our national image. Plus, this will take more than a 30-second radio/TV PSA or a 140 character tweet or the WOC testimony from any sports celebrity or an infrequent ad in The Wall Street Journal.
We’ve tried all of these, yet can we honestly say any of them have ‘moved the needle’ to increase our market share or improve our national image?
4 Types of Marketing
Obviously chiropractic remains the "elephant in the news room”—a fascinating yet untold story that will only gain traction and proper attention if and when we find a new integrated approach to marketing our profession.
Let me introduce contemporary concepts in marketing that we need to implement. We need to speak in terms such as "earned, owned, paid, and social media". Most of you understand “social media,” so let the following chart explain the other channels.
Below are more examples that we have tried:
According to the Converged Media Imperative report, advertising and media are converging:
“Rather than allow campaigns to be driven by paid media, marketers must now develop scale and expertise in owned and earned media to drive effectiveness, cultivate creative ideas, assess customer needs, cultivate influencers, develop reach, achieve authenticity and cut through clutter.”
In our case the “clutter” is medical propaganda and media bias.
Below is another illustration describing how integrated channels overlap:
We need a strategy to integrate all four channels of communication. But foremost, we remain missing in the earned media—free print articles and television interviews to educate and build trust.
Unmasking Dr. Welby
Part of our problem with earned media is not only the lack of a publicist, but also the fact that we have too few spokesmen/women who can tell our story. I have suggested a PR Boot Camp to develop such talent, but I have not gotten any support from our national associations or the F4CP.
We also need a winning strategy, which I believe has already been given to us by the chiropractic-plaintiffs’ attorney Mr. George McAndrews at the Wilk v. AMA Trial #2.
Recall that Mr. McAndrews sat across the aisle from twenty-five medical-defendants’ attorneys who were all smiling like fat Cheshire cats beaming with confidence after winning Wilk Trial #1.
But they weren’t prepared for George McAndrews’ legal cunning in this landmark victory by using ‘admissions against interests’ when medical witnesses in effect testified in behalf of the chiropractic-plaintiffs.
Among medical experts were Drs. John McMillan Mennell, Per Freitag, Irwin Hendryson, John C. Wilson, Jr., David Stevens, C. Richard Wolf, and Rolland Martin, to name a few, whose testimony or research supported chiropractic care over medical spine care.
Mr. McAndrews mentioned at NCLC in 2002 his strategy of ‘admissions against interest’. “Their own documents condemn themselves and praised chiropractors…The judge read with interest and had a knee-slapping outburst to the defendant’s interrogatory response that cited the positive medical studies about chiropractic care.”
Mr. McAndrews proved that the AMA’s discrimination policy not only harmed the reputation of chiropractors, but harmed patients as well, a central issue to the AMA’s defense its boycott was predicated on “patient safety”:
“Defendants have failed to meet their burden of proof of objective reasonableness. In fact, their conduct was more than objectively unreasonable; it was, and remains, unconscionable. Patients who testified before this Court have suffered because of defendants’ boycott.”
He also poured salt in these medical wounds in his closing remarks concerning the positive but deceptive public image the medical profession had gleaned from the fictional doctor in the TV show, Marcus Welby, MD (1969-1976):
“This is the first time anywhere in any trial where the Marcus Welby mask has been stripped away from them and they have been revealed for what they are. Their attitude was ‘to heck with the patients’...” 
Despite the chiropractic-plaintiffs’ victory at Wilk, the AMA’s defamation campaign continues taking its toll on our reputation since there was no mea culpa, public apology or admission of guilt by the AMA defendants, none of whom went to jail.
Judge Susan Getzendanner also stated in her Opinion at the conclusion of the Wilk v. AMA antitrust that the damage continues:
“The activities of the AMA undoubtedly have injured the reputation of chiropractors generally…In my judgment, this injury continues to the present time and likely continues to adversely affect the plaintiffs. The AMA has never made any attempt to publicly repair the damage the boycott did to chiropractors’ reputations.”
Nor has the chiropractic profession successfully repaired the damage the boycott did to our reputation for various reasons, principally the lack of an effective PR budget and, perhaps more importantly, a blind spot we have about integrated marketing.
(FYI: I wrote of past PR efforts done by various associations in the US and around the world in my 2002 Report on PR to the ACA.)
Without a doubt, there is no better time than now, nearly forty years after Wilk, to call attention to our profession with new admissions of current evidence that continues to mount in our favor with evidence-based guidelines from Oregon Health Plan and Optum.
Previous to these newer guidelines, including the AHCPR and Manga Reports, the most impactful ‘admission against interest’ was the guideline by the North American Spine Society that recommended patients seek SMT first in its online a Public Education Series that includes a dubious account of “Spinal Fusion.”
The NASS admitted:
“A major obstacle to the successful treatment of spine pain by fusion is the difficulty in accurately identifying the source of a patient’s pain. The theory is that pain can originate from painful spinal motion and fusing the vertebrae together to eliminate the motion will get rid of the pain.”
Upon reading this explanation, every chiropractor must be thinking if back pain originates from “painful spinal motion,” why not simply adjust the vertebral subluxation to improve the joint dysfunction?
This NASS explanation unexpectedly included the opinion that “Fusion under these conditions is usually viewed as a last resort and should be considered only after other conservative (nonsurgical) measures have failed.”
Most surprising, the NASS also admitted that spinal manipulation should be considered before surgery in an article, “NASS Contemporary Concepts in Spine Care: Spinal Manipulation Therapy for Acute Low Back Pain,” in the October, 2010, edition of The Spine Journal:
“Several RCTs (random controlled trials) have been conducted to assess the efficacy of SMT (spinal manipulative therapy) for acute LBP (low back pain) using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up. Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone.”
Considering the NASS guideline, it should also be deemed nothing less than patient deception and lack of informed consent whenever a physician fails to follow this ‘best practices’ advice to use conservative care first, mainly SMT.
If every MD were to follow this NASS recommendation, we would be in the cat-bird’s seat having no problem with building our practices legitimately since LBP is the leading disabling condition in the nation.
As Louis Sportelli, DC, noted: “If the doctors of chiropractic only cornered the market on one condition, back pain, there would not be enough [chiropractors] now to handle the volume.”
Power of the Press, if You Own the Press
The admission by NASS that fusion should be a last resort is a huge ‘admission against interest’ that has been unheard by the public and unmentioned by the media, including Sanjay Gupta, MD, @ CNN who knows better as a neurosurgeon, but who remains mute on this topic in order not to offend his spine surgeon colleagues.
If there were such as thing as ‘fair and balanced’ journalism, medical reporters like Gupta could reverse this situation in one fell swoop if he were to do an exposé on chiropractic as he did on opioids in Deadly Dose or in his programs on medical marijuana.
But I’m not holding my breath that ‘Dr. Ganja’ has the backbone to reveal the controversial paradigm shift in spine care considering Gupta has never mentioned to his viewers that his colleague at Emory University, Dr. Scott Boden, revealed the fallacy of the ‘bad disc’ theory in 1990, a study done over twenty-five years ago. Nor did he mention the Mayo Clinic systematic review released in November of 2014 reaffirming the same issue that 'bad discs' appear in pain-free people.
In fact, the only time I recall Gupta speaking about chiropractic was in 2008 when he scorched on our reputation to viewers about “chiropractic causing hundreds of strokes.” After I wrote a letter complaining about his unfounded accusation, CNN removed his video, but you can still find it on YouTube.
Not to single-out only CNN, but have you ever seen or heard anyone on national news—FOX, ABC, NBC, CBS, or NPR—promoting the paradigm shift in spine care treatments that included a positive endorsement of chiropractic care?
Of course not! There has never been an in-depth, ‘fair and balanced’ program about the chiropractic profession in the earned media despite being the third-largest physician-level health profession in the world in midst of a back pain.
Is this not a newsworthy topic for our profession to discuss in a public forum—the censorship of chiropractic in an era when back pain is the #1 disabling condition in the nation, military, and world?
We can easily build a case about our superior results—the Triple Aim that the payors are looking at to improve outcomes, lower costs, and high patient satisfaction rates.
“This approach is called coverage with evidence development (CED),” according to Dr. Deyo. “At least in theory, insurers have an interest in paying for things that work and avoiding things that don’t work.”
In the for-profit medical venue, the notion of using a cheaper mousetrap is nonsense to them with their 'cost-plus' incentive, aka, 'perverse motivation,' to charge each patient as much as possible, but in the changing environment of Accountable Care Organizations (ACO), chiropractic care stands head-and-shoulders above drugs, shots, and surgery to help lower costs and improve outcomes.
Why not hold payors to CED by publicly showcasing our superior results? This is a story just waiting to explode in the media, but to gain the attention of the earned media will require the help of a professional publicist who understands the importance of our story.
Actually, one would think by now some journalist might have had a chiropractic epiphany and eager to share his/her WOC testimony with the audience about this ‘elephant in the news room’. Undoubtedly there are some, but they may be afraid to come out of the closet to reveal their appreciation of an “unscientific cult.”
I believe the time is right, the information is available and credible, and the opportunity is there for the taking, if the PR approach is implemented with an integrated strategy. Since we now have the science in our favor and the media and the public are growing more skeptical about medical spine methods, now is the time to push to our tipping point harder than ever before.
I urge everyone to contact the F4CP or its founder, Kent Greenawalt, to consider a change in tactics from paid media to earned media. As well as retaining the ad placement agency that they now have, a publicist will be necessary to get the attention of the commercial media with our people talking about these issues, which is more than an advertisement could ever do.
There has never been a better time to make our case in the court of public opinion and there is no quicker way to change attitudes than via the earned media with the new ‘admissions against interest’.
 S Bigos, ibid, Patient Guide, (1992):7.
 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; 1992. AHCPR publication no. 95-0642.
 Earned & Social Media Strategy – What’s the Difference? By Heather Timmerman, Digital Media Trends
 Speech before the National Chiropractic Legislative Conference, March 2002, Washington D.C.
 G McAndrews closing argument p. 6788.
 G McAndrews closing arguments, Wilk v. AMA, (June 26, 1987):3363-64
 Getzendanner, Memorandum Opinion and Order, p. 10
 “Spinal Fusion,” North American Spine Society Public Education Series, www.spine.org/documents/fusion
 L Sportelli, “AHCPR: It Did Not Happen By Accident,” Dynamic Chiropractic 13/2 (January 16, 1995).
 SD Boden, DO Davis, TS Dina, NJ Patronas, SW Wiesel, “Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects: A Prospective Investigation,” J Bone Joint Surg Am. 72 (1990):403–408.
 RA Deyo, Watch Your Back!, Cornell University Press, 2014; pp. 169