Articles by JCS

Helping Millions

Chiropractic Spinal Care

Helping Millions,

Saving Billions

By

JCS

 “If we do not fix our health care system, America may go the way of General Motors; paying more, getting less, and going broke.” [1]

President Barack Obama

President Obama’s sentiment of “paying more, getting less, and going broke,” is most apparent in medical spine care. The present pandemic of back pain demands attention considering upwards of 90% of adult Americans will suffer from back pain, which is also the leading cause of work injury and disability in this country.

“No matter what happens to President Obama’s health care reforms after the November elections,” wrote the editors of The New York Times Sunday Review, “the disjointed, costly American health care system must find ways to slow the rate of spending while delivering quality care. There is widespread pessimism that anything much can be achieved quickly, but innovative solutions are emerging in unexpected places.” [2]

One of the most unexpected places to find innovative solutions to the back pain pandemic is the chiropractic profession. After nearly a century of defamation by the AMA, the chiropractic profession is now poised to help millions of Americans suffering from spinal disorders that will save the healthcare system billions of dollars by avoiding the use of opioid drugs, MRI scans, expensive hospital stays, and ineffective and over-utilized spine surgery based on a disproved disc theory according to new research.

Actually, this is not new criticism of spine surgery. On June 9, 2006, the CBS Evening News aired a segment, “Attacking Rising Health Costs,” stating 30-40% of spinal fusions surgeries were unnecessary according to Dr. Elliott Fisher of The Dartmouth Institute of Health Policy, who later said that 30 percent of hospital stays in the United States are probably unnecessary.[3] He noted the problems included patients who were not given good information to make an “informed consent” decision as to alternatives like chiropractic care or the inherent risks of medical procedures.

Another problem is that few people realize the huge amount of money involved in spine care since it is not featured with reports on the deadly chronic diseases like heart disease, cancer, and diabetes. Nor is spine care a featured topic on the heroic television programs about emergency rooms despite its pandemic nature.

Indeed, few people realize the number of back pain patients and the staggering costs. Musculoskeletal disorders (MSDs) alone currently affect 44.6 million Americans and cost our society an estimated $267.2 billion every year[4], and when combined with all persons with MSDs in addition to other medical conditions, the cost of treatment in the 2002-2004 time period was estimated to be $849 billion per year.[5]

Another recent study from the Decade of Bone and Joint Disorders reported in The Spine Journal by Scott Haldeman, DC, MD, PhD, the epidemic nature of back pain:

    • The prevalence of chronic low back pain daily in the general adult population is estimated at 37%
    • The 1-year prevalence is 76%
    • The lifetime prevalence is 85%, and
    • Approximately 20% of sufferers describe their pain as severe or disabling.[6]

This represents a huge amount of people who could be helped and money that could be drastically reduced if the “green technology” of chiropractic care was used first instead of drugs, shots, and the 500,000 spine surgeries as recommended by every guideline, including the ground-breaking 1994 US Public Health Service’s Agency for Health Care Policy and Research (AHCPR) guideline #14 on acute low back pain in adults. This study concluded only one in 100 cases of low back pain required surgery and rated spinal manipulation as a “proven treatment” to be used before medical methods.[7]

Unfortunately, this recommendation was ignored. In fact, the AHCPR funding was nearly gutted in a backlash by the spine surgeon’s advocacy group on Capitol Hill. Consequently, instead of reducing the use of drugs, shots, and spine surgery as the guideline recommended, afterwards a tsunami of medical spine care poured fuel on the fire of these rising costs.

From 1994 to 2007, the patient population increased by only 12%, but MRIs increased 307%, spinal fusion surgery increased 204%, spinal injections increased 629%, and opiate use increased 423%.[8] The most complex type of back surgery has increased dramatically between 2002 and 2007 with a 15-fold increase.[9]

Richard Deyo, MD, MPH, one of the most vocal medical critics in spine care, suggested that “It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just six years.” Deyo and his colleagues found the mean hospital costs alone for surgical decompression and complex fusions ranged from $23,724 for the former and $80,888 for the latter.

Among the various reasons for such a large increase, he mentioned the obvious motivation—“financial incentives involving both surgeons and hospitals.”[10]

These costs are unsustainable and can certainly be lowered drastically if chiropractic care were utilized as primary spine care providers as it should be rather than being marginalized. Indeed, the medical war against chiropractors is an untold story that needs to be understood if America is to improve its dire healthcare impasse.

Fortunately, this change is slowly happening as more people speak out in favor of chiropractic care.

"In the last decade of the 20th century, chiropractic has begun to shed its status as a marginal or deviant approach to care and is becoming more mainstream," said Paul Shekelle, M.D. and director of RAND's Southern California Evidence-Based Practice Center. He played a key role in RAND's landmark investigations of chiropractic that stimulated a national reappraisal of this and other nontraditional health care approaches.[11]

What led to the change in attitude toward chiropractic? RAND concluded the major events included:

  • The 1990 U.S. Supreme Court decision on a lawsuit, known as the Wilk v. AMA case that found the AMA and others guilty of illegal conspiracy against the chiropractic profession.
  • Recognition by the established medical community that most medical therapies for back pain are ineffective.
  • RAND's 1992 groundbreaking analysis of spinal manipulation that showed this intervention does benefit some people with acute low-back pain. This study directly influenced the Agency for Healthcare Research and Quality to include positive recommendations on spinal manipulation in its 1994 clinical practice guidelines on low-back pain. This federal agency issued such guidelines to help the medical community improve the quality of health care in the United States.

Once the RAND studies broke the ice about chiropractic research by discussing the taboo history of the profession, numerous workers’ comp studies, international studies, guidelines from numerous medical organizations, and recently health insurance companies’ policies have concluded that for most back pain cases, SMT is among the most effective initial treatments, as good if not better than anything the medical world has to offer for mechanical low back pain (LBP) that constitutes 85% of LBP cases.

An editorial in the Annals of Internal Medicine published jointly by the American College of Physicians and the American Society of Internal Medicine (1998) noted that “spinal manipulation is the treatment of choice”:

Perhaps most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief and functional improvement. One might conclude that for acute low back pain not caused by fracture, tumor, infection, or the cauda equina syndrome, spinal manipulation is the treatment of choice. [12]

Unfortunately, the medical profession has chose to ignore this newfound evidence and continues with its expensive and less effective treatments such as drugs, shots, and spine surgery. “Don’t confuse us with the facts” seems to be its attitude, and then some wonder why the spine care costs are escalating at enormous rates!

Get Less for More

Certainly medical spine care can be accused of the “get less for more” story since the medical profession refuses to follow the evidence-based guidelines that call for conservative care first as evident with the shocking increase in its most expensive medical treatments.

There is a growing consensus the present healthcare system is broken as described by TIME magazine:

…what a sinkhole the country’s healthcare system has become: the U.S. spends more to get less than just about every other industrialized country.[13]

Despite the poor comparative health stats, some mistaken media pundits and politicians still tell the public that the US has the best healthcare system, but they fail to consider that the United States ranks 43rd in infant mortality, 20th in life expectancy for women and 21st in life expectancy for men, which is down from first in 1945 and 17th in 1960. While the United States has the most expensive, high-tech healthcare system in the world, the general health of the US population is lower than most industrialized countries. [14]

Dr. Ezekiel Emanuel, health adviser to President Obama, answered the question whether or not America has the best health care in the world.

“Let’s bury this one once and for all. The United States is No. 1 in only one sense: the amount we shell out for health care. We have the most expensive system in the world per capita, but we lag behind many developed countries on virtually every health statistic you can name.”[15]

Dr. Steven Strauss, Advanced Leadership Fellow at Harvard University, mentioned this “cult-like belief” in the declining American healthcare system in his article, “America: Slouching Towards Third World Status.” This is particularly ironic considering the AMA has long-labeled chiropractic an “unscientific cult”; now the shoe is on the other foot with a leading Harvard professor accusing the public of having a cult-like attitude of the medical profession. Moreover, the medical profession has a cult-like opinion of itself despite the poor statistics.

Many Americans still have an almost cult-like belief that America is the greatest nation on earth. They systematically reject evidence suggesting we have significant room for improvement.

I defy anyone to name a single important health care metric where the U.S. is considered a best-practice example as a nation. The only thing we lead the world in... is cost of health care. We have the world's most expensive health care system. For example, our health care system costs almost twice Canada's, but we produce inferior results.

For [Speaker of the House] Rep. John Boehner (R-Ohio) to say we have the best health care system in the world, and not be laughed out of office, is at best 'trained incapacity' or 'occupational psychosis.' [16]

This “occupational psychosis” is most evident in medical spine care as mentioned by Richard Deyo, MD, MPH:

I think the truth is we have perhaps oversold what we have to offer. All the imaging we do, all the drug treatments, all the injections, all the operations have benefit for some patients. But in each of these situations, we’ve begun using those tests and treatments more widely than science would really support. [17]

We’ve witnessed disturbing practices that seem designed to maximize someone’s income, regardless of whether there was benefit or harm to patients.[18]

This deception will continue by the medical spine community, primarily the upsurge in “pain management” clinics, aka, “pill mills,” offering opioid drugs and ESIs, and the spine surgeons who still cling to an outdated disc theory that leads to the overuse of complex spine surgeries spurred by million dollar commissions from device manufacturers.[19]

Dr. Donald Berwick, who headed the federal Medicare and Medicaid programs from 2010 until last December estimated Medicare and Medicaid could save $150 billion to $250 billion a year by eliminating waste, which he defined as “activities that don’t have any value.”[20]

Berwick listed five reasons for what he described as the “extremely high level of waste.” They are over-treatment of patients, the failure to coordinate care, the administrative complexity of the health care system, burdensome rules, and fraud.
“Much is done that does not help patients at all,” Berwick told the Times, “and many physicians know it.”

One huge problem are those patients using ER for their primary care, and for many, back pain is their emergency. Getting these emergency room “super-users” into chiropractic primary spine care would be a giant first step.  “This is exactly the kind of innovation we need to see what works, both in cost and quality,” said Amy Rohling McGee, president of the Health Policy Institute of Ohio.[21]

According to the 1993 Manga Report , “The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain,”[22] this evidence-based study concluded spinal manipulation was the “therapy of choice for most low back pain.” More recent studies agree with Dr. Manga.

In 2009, Niteesh Choudhry, MD, PhD, from Harvard Medical School and Arnold Milstein, MD, from Mercer Health and Benefits consulting firm, investigated an important issue:  “Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans?”  They found in terms of clinical effectiveness and cost together, “chiropractic physician care for low back and neck pain is highly cost-effective, represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds.”[23]

Not only is chiropractic care more clinically-effective, another study shows it is less costly than medical care. A study published in 2010 revealed data over a two-year span from 85,000 Blue Cross Blue Shield beneficiaries with low back pain in Tennessee. The patients had open access to MDs and DCs through self-referral, and there were no limits applied to the number of visits allowed and no differences in co-pays. Results show that paid costs for episodes of care initiated by a chiropractor were almost 40 percent less than care initiated through an MD. They estimated that allowing DC-initiated episodes of care would have led to an annual cost savings of $2.3 million for BCBS of Tennessee.[24]

I might add another $100+ billion could be saved if hospitalists and spine surgeons in all 50 states were to follow the recommendations from all guidelines to initially use non-invasive, non-drug, conservative treatments like chiropractic care before ordering MRIs, or dispensing narcotics, ESIs, or spine surgery.

And many physicians know it, too, which begs the questions:

  • Are they unaware of these spine guidelines?
  • Are they biased against chiropractors?
  • Is it simply a matter of greed?

If the truth be known, probably all three reasons have a bearing.

If chiropractic’s role in healthcare was unimpeded by medical skullduggery to limit its usage in hospitals, military health services, the VA, and if chiropractors weren’t hamstrung by HMO coverage, millions more would be saved from medical spine care failure and billions of dollars—perhaps 50% of the present costs in the realm of $100+ billion—would be saved.

This prospect of cost savings is not a new idea, just one that has been ignored.

According to Pran Manga, PhD, Ontario (Canada) health economist who conducted two of the most thorough studies on the subject and concluded:

There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management.[25]

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 U.S., the U.K. 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. [26]

 

Regrettably, victims in the War on Chiropractic include the collateral damage of patients who were not informed by their MDs that conservative chiropractic care may be the best treatment for their back pain. Sadly, many patients have been disabled from unnecessary spine fusions who might have been helped by chiropractic care.

This sentiment was best expressed by Gordon Waddell, DSc, MD, FRCS, orthopedic surgeon, and author of The Back Pain Revolution.

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...It [back surgery] has been accused of leaving more tragic human wreckage in its wake than any other operation in history.[27]

Indeed, too many lives have been wrecked by unsuccessful spine fusions or addictions to opioid drugs after failed back surgeries that certainly could have been avoided as every chiropractor knows.

However, that scenario will hopefully be changing due to the unsustainable costs and ineffectiveness of medical spine care. According to researchers, health expenditures of individuals with spine problems swelled from $61 billion in 2000 to $108 billion in 2004—and then dropped to $80 billion in 2008.[28]

However, not all spine surgeries have dipped. Martin noted that utilization and costs have not declined uniformly across the spine field. Fusion surgery continues to demonstrate resilient growth and generate fierce costs—as well as controversy regarding its indications. “Lumbar fusion surgery continued to increase in volume, population rates, and costs from 2005 to 2009,” according to Martin.[29]

There is a growing call for healthcare reform not only from the Obama administration, but from private interests as well who foresee the end of healthcare insurance as we now know it unless radical changes occur quickly. Although private interests may change the Rube Goldberg formula now seen in healthcare insurance, until the virtual boycott of chiropractic is totally eliminated, the spine care market will continue to see astronomical costs and the “get less for more” story.[30]

Court of Scientific Research

The early 1990s were a huge turning point in spine care. Once the medical war against all-things-chiropractic, including spinal manipulation therapy (SMT), ended after the Wilk trial, researchers began to investigate the massive epidemic of back pain. Once the veil of the AMA’s threat to sanction any college or researcher who worked with chiropractors was lifted, the taboo nature of chiropractic revealed the AMA’s worst nightmare.

RAND admitted in 1992, “that most medical therapies for back pain are ineffective,” so the search began to understand which treatments are most effective and the closer they dug, the more they were lead to SMT. Not only did international studies appear recommending conservative chiropractic care over medical spine care, the seminal research in the spine care paradigm shift occurred with startling MRI research.

For the most part, researchers found spine fusions were based on an outdated disc theory. The initial breakthrough in spine care diagnosis began in 1990 by Scott Boden, MD, et al.[31] at Emory whose MRI studies revealed disc abnormalities were found in asymptomatic back pain patients.

In 2003 Boden et al. in their study,Emerging Techniques for Treatment of Degenerative Lumbar Disc Disease,” investigated fusion, disc replacement, and intradiscal electrothermal therapy once again stated “Symptomatic disc degeneration is believed to be a common cause of chronic low back pain…It should be emphasized that back pain is not necessarily correlated or associated with morphologic or biomechanical changes in the disc.”[32]

This paper also admitted that none of these risky and expensive surgeries are superior to natural history or nonoperative treatment”:

It should be emphasized that all of the aforementioned procedures for low back pain have unpredictable outcomes; therefore, these procedures should be only considered after failure of conservative therapy of at least 6 months and with the full understanding of patients who are well informed about the potential advantages, disadvantages, and unpredictable outcomes. It is not established in the literature that any of these procedures, including fusion techniques, are superior to natural history or nonoperative treatment.” [33]

Surprisingly, although most MDs and many in the public remain convinced that a disc problem requires surgery, most guidelines now recommend non-surgical care before surgery. The North American Spine Society (NASS), the same organization that attacked the AHCPR findings in 1994, has now published online a Public Education Series that includes “Spinal Fusion.” Remarkably, this explanation proved to be very accurate, including 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.”

The NASS stated:

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.

 

Unfortunately, current techniques to precisely identify which of the many structures in the spine could be the source of a patient’s back or neck pain are not perfect. Because it can be so hard to locate the source of pain, treatment of back or neck pain alone by spinal fusion is somewhat controversial. Fusion under these conditions is usually viewed as a last resort and should be considered only after other conservative (nonsurgical) measures have failed. [34] (emphasis added)

The admission by NASS that fusion should be a last resort is a huge warning that has been unheard by the public. More surprisingly, the NASS again admitted that spinal manipulation should be considered before surgery 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.[35]

To no one’s surprise, this new evidence has been ignored by spine surgeons who resist change and the potential loss of income.

As a profession that prides itself on being scientific, an onerous characteristic of the medical society is its inability to change or to accept different or alternative health care methods. This is most prevalent in medical spine care.

The editors at The BACKLetter, a monthly newsletter on spine issues from Georgetown University Medical Center, revealed it takes 17 years for a new treatment to become mainstream in medicine but, more shocking, it takes 44 years for an ineffective treatment to be purged.[36]

Incidentally, that was 22 years ago—exactly half of the 44 year period for an ineffective treatment to be purged. This suggests it may take another 22 years before the era of unnecessary and experimental disc fusions will end.

Obviously this medical intransigence is a function of bias, profit, and tradition rather than the emerging evidence in spine care. Indeed, if the electronics industry were as slow as medicine, it would still be in the vacuum tube era.

Until then, imagine the millions of patients who will be victimized and disabled by unnecessary spine surgery and the many more who will become addicted to narcotic opioids allthewhile the majority could have been helped with chiropractic care as the research now shows.

Richard Deyo, MD, MPH, noted this misleading disc theory has led to “false positive” misdiagnosis, suggesting that “many of these disc abnormalities are trivial, harmless, and irrelevant, so they have been dubbed incidentalomas,”  and “they are likely to lead to more tests, patient anxiety, and perhaps even unnecessary surgery.” [37]

The differential diagnosis and management of musculoskeletal disorders are trying to move away from the pathoanatomical abnormal disc perspective according to Gwen Jull, PhD:

The focus on pathoanatomical diagnoses is generally shifting towards a more pathophysiological approach in the recognition that in the majority of neck disorders a definitive pathoanatomical cause may not be able to be readily identified in up to 80% of neck pain patients.[38]

Her remarks echo Dr. Deyo when he opined that 85 percent of low back pain cannot be attributed to pathoanatomical findings either:

Up to 85% of patients cannot be given a definitive diagnosis because of weak associations among symptoms, pathological changes, and imaging results.[39]

Paul Goodley, MD, author of Release from Pain, answered Dr. Deyo’s admission with his belief that the fundamental bias against manipulative therapy is the main reason for this pandemic of pain. I accuse that a big slice of the 85 percent of undetermined diagnosis of back pain is ignorance and is accountable for the rejection of the thinking involved in manipulative approaches.”[40]

Despite its claim to be evidence-based, there is little encouragement in medical spine care for new technology unless it is another expensive and experimental surgical procedure as we saw with the artificial disc phenomenon a few years ago that turned out to be another bankrupt idea similar to other complex spinal fusions.

Another controversial issue is Medtronic’s Infuse bone graft device. Infuse is a bio-engineered bone graft device that is marketed for lumbar surgery. A recent FDA investigation discovered this product may cause cancer, infection, ectopic bone growth, cyst formation, difficulty breathing, nerve damage, and death when the product is used in the cervical spine.

Similar injuries occurred in lumbar surgery patients who alleged that Medtronic understated the risk of uncontrolled bone growth, inflammatory reactions, retrograde ejaculation, urinary retention, bone reabsorption, implant displacement, sterility, and cancer. The report, published in The Spine Journal, found that approximately 10% to 50% of patients who were part of clinical trials experienced complications. By Medtronic's estimates, Infuse has been used in more than 500,000 spinal fusion surgery patients.

Recently lawsuits have been filed, alleging that Medtronic paid millions of dollars to "opinion leaders" to influence surgeons to increase off label use of Infuse in posterior spine surgical procedures.[41] Medtronic allegedly failed to report these serious complications and side effects during clinical trials.  However, those problems failed to appear in a number of studies published by researchers with financial ties to the manufacturer.[42]

Senate Finance Committee Chairman Max Baucus (D-Mont.) and Senior Member Charles Grassley (R-Iowa) have called for a Senate investigation. They are "extremely troubled by press reports" suggesting that in its own funded clinical trials, Medtronic and its paid consultant physicians may have "unreported or under-reported" potential risks associated with the use of Infuse.[43]

Whether these radical spine surgeries consisting of the implant of pedical screws/plates, artificial discs, or Infuse bone grafts, the shocking reality is most of these disc surgeries are based on a suspect disc theory. Indeed, the sad fact is many of these radical surgeries were unnecessary in the first place.

Scott Boden in 2003 also criticized these radical spine surgeries:

It should be emphasized that all of the aforementioned [surgical] procedures for low back pain have unpredictable outcomes; therefore, these procedures should be only considered after failure of conservative therapy of at least 6 months and with the full understanding of patients who are well informed about the potential advantages, disadvantages, and unpredictable outcomes. It is not established in the literature that any of these procedures, including fusion techniques, are superior to natural history or nonoperative treatment.[44]

Even the popular and less damaging microdiscectomy surgeries where the bulging disc is shaved but not fused were found to be no more effective than conservative care after six months, and 20% of these surgical patients were worse after two years. [45]  

In an interview, WC Peul , MD, the lead researcher, admitted the downside of microdiscectomy: 

However, some patients had recurrent complaints. And at one year 13% had bad outcomes. And at two years, the proportion of patients with unsuccessful outcomes rose to 20%. This is a huge issue. We are not doing something right.[46]

On the other hand, a recent 2010 study in Calgary, Alberta, Canada, by Gordon McMorland et al. compared spinal manipulation against microdiscectomy in patients with sciatica secondary to lumbar disc herniation. The authors found sixty percent of patients with sciatica benefited from spinal manipulation that corrected the underlying joint dysfunction. [47]

Despite the proof of positive results via SMT for LBP and sciatica, most people don’t understand how chiropractic care helps these so-called disc problems. In fact, most MDs and spine surgeons also don’t understand this important research. This is crucial if the paradigm shift in spine care is to become widespread and for chiropractors to be recognized as America’s primary spine care providers.

Basically, what these surgeons are “not doing…right” is treating a secondary disc issue while ignoring the mechanical dynamics of the spine as a functioning unit that caused the disc to herniate in the first place. Peul, like most spine surgeons, views back pain as primarily a static pathoanatomical disc problem with surgery as the logical solution when, in reality, most spine pain is now viewed as a dynamic pathophysiologic problem, primarily known as a joint complex dysfunction that is triggered by a buckling effect. [48]

The same paradox exists for lumbar spinal stenosis that affects many senior citizens. According to the NASS Clinical Guidelines for Degenerative Lumbar Spinal Stenosis, the classic working definition include:

Lumbar spinal stenosis describes a clinical syndrome of buttock or lower extremity pain, which may occur with or without back pain, associated with diminished space available for the neural and vascular elements in the lumbar spine. Symptomatic lumbar spinal stenosis has certain characteristic provocative and palliative features. Provocative features include exercise or positionally-induced neurogenic claudication. Palliative features commonly include symptomatic relief with forward flexion, sitting and/or recumbency.[49]

This NASS guideline included many treatment evaluations, including a 2006 study by Donald Murphy DC, DACAN, Clinical Director, Rhode Island Spine Center, et al. investigating SMT for stenosis that found patients’ “Self-rated improvement was 75.6% overall.”[50]

Not only does this outcome encourage the use of SMT for this condition, it raises the question: despite the 75% success rate, these improved patients still had the pathoanatomy of spinal stenosis. Just like patients with degenerative disc disease who visit chiropractors and improve, this is evidence that the pathoanatomical symptoms were improved by physiological interventions.

Even NASS admits that conservative care offers a valuable treatment. In 2006, NASS stated, “Of patients with mild to moderate lumbar spinal stenosis initially receiving medical/interventional treatment and followed for 2 to 10 years, approximately 20-40% will ultimately require surgical intervention.” NASS adds, “Of the patients who do not require surgical intervention, 50-70% will have improvement in their pain.”[51]

Dr. Murphy says that chiropractic does offer substantive hope to many patients. “According to our data, there are things [SMT] that can be done to make actual long-term changes.”

One of the problems is that stenosis continues to be poorly understood by allopaths, says Dr. Murphy. “Many patients are told not to go to a chiropractor, told that their spine is degenerated and the last thing they want to do is to have someone move it. In my experience, having someone move the spine is the best thing. But the only way to change minds is to come up with credible evidence and substantive argument.”[52]

So the question remains: if abnormalities like stenosis and disc degeneration are not the keys to back pain, what is—pathoanatomic or pathophysiologic factors or both?

Donald Murphy answered this dilemma:

Bingo, JC. Clearly the pathoanatomy did not change. We have this discussion frequently in Spine Conference in the neurosurgery department on Monday mornings when I make the point that the spine is capable of handling pathoanatomy as long as the physiology is right (and psychology of course).

Pathoanatomy only creates the potential for pain. Physiology is what determines whether pain actually occurs or not and psychology determines how much suffering results from that pain.[53]

This dilemma over the various causes of back pain demands that America’s primary spine care providers understand this complex problem without a bias against chiropractors or a chauvinist attitude about the sanctity of the disc theory or the over-use of drugs, shots, and spine surgery.

In other words, chiropractors stand prepared to assume the role to follow the guidelines that recommend initially conservative physiological treatments aimed at improving the functioning of the spine, which covers 85% of all back pain problems.

As chiropractors have long understood, the tenuous structure of the spine itself lends to the answer when one understands the 24 vertebrae and 3 pelvic bones are interconnected by 137 synovial joints. In fact, when counting all the vertebral joints, sacroiliac joints, rib heads, and the pubic symphysis, new research now suggests the total is 313, a fact that is lost to most physicians. This total includes all synovial, symphysis, and syndesmosis joints according to Gregory D. Cramer, DC, PhD, Dean of Research at National University of Health Sciences.[54]

The concept of joint motion as the key to a healthy spine is not a new belief. Testimony by John McMillan Mennell, MD, enlightened the antitrust court as to the value of spinal manipulation during his testimony at the Wilk trial:

Eight out of ten patients that come out of any doctor’s office complain of a musculoskeletal system problem, regardless of what system the pain is coming from…I will say 100 percent of those complaints are due to joint dysfunction in the musculoskeletal [system]…

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.[55]

Recent research has shown the accumulative effect from traumatic injuries during childhood may compound and be aggravated as adults. Prolonged sitting/standing, improper lifting, and accidents will develop a functional spinal problem that may cause a “segmental buckling effect,” according to research by Jay Triano, DC, PhD, et al. while at the Texas Back Institute, an interdisciplinary clinic offering comprehensive spinal care.

The buckling effect is also known as joint hypomobility is usually defined as a temporary reduction of mobility of a zygapophyseal joint and is often the focus of treatment for mobilization or manipulation. As Dr. Triano explains, the buckling effect is a function of overloading rather than a static, abnormal disc issue alone:

Under the right conditions, even a small additional load will cause the joint to buckle. Rapidly applied loads also are associated with buckling and vibration reduces the threshold necessary to achieve it. Finally tissues that are damaged, as in discopathy, may buckle sooner and reach maximum displacement (deformation) under lower peak loads than do healthy tissues.[56]

This buckling effect explains how pre-existing spinal weaknesses from youthful accidents will cause subsequent discopathy until the spine overloads and buckles. They key is to restore joint motion, decompress the axial loading on the joints and discs, and to restrengthen the muscles in order to withstand the forces generated by activities of daily living.

This physiologic-restoring active treatment can only be accomplish via hands-on therapies, and certainly not by passive therapy, drugs, shots, or surgery. Although once slandered by the AMA as an “unscientific cult,” today there are now more RCTs for SMT for LBP than any other medical method.[57] Ironically, today the shoe is on the medical foot with a dearth of research to support its massive use of drugs, shots, and surgery.

The chiropractic profession’s role in reducing these huge surgical costs, poor outcomes, and disability costs is obvious once this new perspective is understood. Indeed, if chiropractic care were implemented into the mainstream as the primary spine care providers as many spine researchers now recommend[58], the astronomical costs of over $267.2 billion annually for spine care would be cut in half, if not more.

Court of Public Opinion

After the Wilk trial ended in 1989, the international studies in the early 1990s indicated the effectiveness of SMT for LBP. This trend continued in the 2000s and has led to recent policy changes in spine care coverage. For examples, the North Carolina BC/BS and the University of Pitt have recently announced their refusal to approve spinal fusion based solely on abnormal discs.[59] Indeed, the evidence is now in chiropractic’s favor, but the public remains unaware of this turnaround.

Despite the AMA’s illegal attempt to “contain and eliminate the chiropractic profession,” the chiropractic profession has won the legal battles, they have won the research battles, and now they must win in the court of public opinion, a task that will be more difficult due to the media’s longtime collusion with the AMA.

At the Wilk trial, the conspiracy between the AMA’s Committee on Quackery and columnist Ann Landers was revealed, and today we find every television network health programming controlled by MDs, such as Sanjay Gupta at CNN, still disseminate misinformation or just ignore the benefits from the third-largest physician-level healthcare profession in the world—chiropractic.

The resistance to change in spine care involves the complicit media that ignores the evidence-based research critical of medical spine care and continues to misrepresent or omit chiropractic care in articles as a cost-effective answer to the back pain epidemic.

In many instances, the media has been used by medical critics to stage unfounded allegations without equal time to chiropractors to defend themselves. To say the media has a bias against chiropractic is well established in the history books and in the courtroom testimonies.

Despite the medical war and media bias, the chiropractic profession has already saved Americans billions of dollars in treatments and disability costs by treating millions of patients with low-cost and highly effective care for spinal and neuromusculoskeletal disorders.

The breakthrough in spine care will only happen when chiropractors gain equal time in the electronic media to present its benefits to the public, to challenge and to refute the medical misinformation, to present the paradigm shift in spine care, and to show the public that they, too, have been collateral damage in this medical war against chiropractors.

Certainly the facts now show chiropractic is an important part of the solution to improve the healthcare crisis in this country and worldwide. After a century of persecution by a relentless medical society, the research now shows that chiropractic care for the costly and disabling pandemic of pain is equivalent to or better than anything the medical world has to offer. It’s past time for the public to understand this paradigm shift in spine care and for chiropractors to be seen as the primary spine care providers for this pandemic of pain.

This policy paradigm shift in spine care would save millions of patients from ineffective medical spine care as well as save billions of dollars in a strapped healthcare economy.

 


 



[1] Text of President Obama’s health-care speech, Jun 15, 2009, by MarketWatch

[2] Editorial, New York Times Sunday Review, “A Formula for Cutting Health Costs,” July 21, 2012

[3] The High Cost of Dying, The Independent Report, November 30, 2009

[4] The Burden of Musculoskeletal Diseases in the United States Bone and Joint Decade, Copyright © 2008 by the American Academy of Orthopaedic Surgeons. ISBN 978-0-89203-533-5, pp. 21.

[5] The Burden of Musculoskeletal Diseases in the United States Bone and Joint Decade, Copyright © 2008 by the American Academy of Orthopaedic Surgeons. ISBN 978-0-89203-533-5, pp. 195.

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

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

[8] Martin BI, Deyo RA, Mirza SK et al. Expenditures and health status among adults with back and neck problems. JAMA 2008; 299: 656-64

[9] J Silberner, “Surgery May Not Be The Answer To An Aching Back,”  All Things Considered, NPR (April 6, 2010)

[10] “New Study Demonstrates A Three-Fold Increase N Life-Threatening Complications With Complex Surgery,” The BACKLETTER, 25/6 (June 2010):66

[11] Changing Views of Chiropractic … and a National Reappraisal of ...
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[12] MS Micozz,  “Complementary Care: When Is It Appropriate? Who Will Provide It?” Annals of Internal Medicine 129/1  ( July 1998):65-66

[13] Karen Tumulty, “Can Obama Find a Cure?” TIME  174/5 (August 10, 2009)

[14] Sara R. Collins, Rachel Nuzum, Sheila D. Rustgi, Stephanie Mika, Cathy Schoen, and Karen Davis, How Health Care Reform Can Lower the Costs of Insurance Administration, The Commonwealth Fund, July, 2009.

[15] Emanuel, Ezekiel, Shannon Brownlee, Myths About Our Ailing Health-Care System, Washington Post, November 23, 2008; Page B03.

[16] “America: Slouching Towards Third World Status” by Steven Strauss, The Huffington Post,  05/20/2012

[17] T Parker-Pope, “Americans Spend More to Treat Spine Woes,” New York Times (February 13, 2008).

[18] Richard A. Deyo, MD, MPH and Donald L. Patrick, PhD, MSPH, Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises, AMACOM books, (2005): ix-x.

[19] BARRY MEIER and DUFF WILSON, Spine Experts Repudiate Medtronic Studies, June 28, 2011, New York Times

[20] Julie Mack, “So why DOES U.S. health care cost so much? A look at the myths and realities,” July 22, 2012, @mlive.com

[21] Cliff Peale, “High cost for the wrong health care,” Cinncinati.com 7/23/2012

[22] P Manga, Ph.D., D Angus, M.A., C Papadopoulos, M.H.A., W Swan, “The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain,” (funded by the Ontario Ministry of Health) p. 104, August, 1993.  

[23] Arnold Milstein and Niteesh Choudhry, "Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans? An Evidence Based Assessment of Incremental Impact on Population Health and Total Healthcare Spending." Funded by the Foundation for Chiropractic Progress, http://www.f4cp.com/pr/2009/1.pdf

[24] R L Liliedahl,  David V. Axene, Christine M. Goertz, “Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs. Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer,” Journal of Manipulative and Physiological Therapeutics (October, 2010)

[25] P Manga,  et al. “The Effectiveness and Cost-Effectiveness of chiropractic Management of Lob-Back Pain, “ Ontario Ministry of Health (1993)P Manga, ibid.

[26] P Manga, ibid.

[27] Gordon Waddell and OB Allan, “A Historical Perspective On Low Back Pain And Disability, “Acta Orthop Scand 60 (suppl 234), 1989.

[28] Is the Growth in Spine Procedures in the United States Finally Beginning to Tail Off? The BACKLetter, Vol. 27, No. 8, August 2012

[29] Martin BI et al., Trends in utilization and expenditures for spine related problems in the United States, presented at the annual meeting of International Society for the Study of the Lumbar  Spine, Spine Week 2012, Amsterdam; as yet unpublished.

[30] Dave Chase, “Aetna's Remarkable Reinvention Underway,” Forbes, 3/17/2012

[31] 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.

[32] Howard An, Scott D. Boden, James Kang, Harvinder S. Sandhu, William Abdu, and James Weinstein, “Emerging Techniques for Treatment of Degenerative Lumbar Disc Disease, SPINE Volume 28, Number 15S, pp S24–S25, 2003

[33] Howard An, Scott D. Boden, James Kang, Harvinder S. Sandhu, William Abdu, and James Weinstein, “Emerging Techniques for Treatment of Degenerative Lumbar Disc Disease, SPINE Volume 28, Number 15S, pp S24–S25, 2003

[34] “Spinal Fusion,” North American Spine Society Public Education Series,  www.spine.org/documents/fusion

[35] MD Freeman and JM Mayer “NASS Contemporary Concepts in Spine Care: Spinal Manipulation Therapy For Acute Low Back Pain,” The Spine Journal 10/10 (October 2010):918-940

[36] Refuting Ineffective Treatments Takes Years, The BackLetter® 101 Volume 23, Number 9, 2008.

[37] RA Deyo and DL Patrick, Hope or Hype:  The Obsession with Medical Advances and the High Cost of False Promises (2002):191.

[38] G Jull, et al. Whiplash, Headache, and Neck Pain, (Churchill Livingstone, 2008).

[39] RA Deyo, “Conservative Therapy for Low Back Pain: Distinguishing Useful From Useless Therapy,” Journal of American Medical Association 250 (1983):1057-62.

[40]PH Goodley, Release from Pain, www.DrGoodley.com (2005): 517.

[41] Joe Saunders, Medtronic Infuse Bone Graft Lawsuits Increase, The Legal Examiner, June 23, 2012.

[43] Senators Investigate Medtronic Spine Implant, Payments to Doctors, Outpatient Surgery. Net,  June 23, 2011.

[44] Howard An, Scott D. Boden, James Kang, Harvinder S. Sandhu, William Abdu, and James Weinstein, “Emerging Techniques for Treatment of Degenerative Lumbar Disc Disease, SPINE Volume 28, Number 15S, pp S24–S25, 2003

[45] WC Peul, HC van Houwelingen, WB van den Hout, R Brand,  JAH Eekhof,  JT Tans, RTWM Thomeer, BW Koes, for the Leiden–The Hague Spine Intervention Prognostic Study Group, “Prolonged Conservative Care Versus Early Surgery In Patients With Sciatica Caused By Lumbar Disc Herniation: Two-Year Results Of A Randomized Controlled Trial,” BMJ, 23/6 (2008) 

[46] “Balancing Costs and Benefits: Is Disc Surgery Cost-Effective?” The BACK LETTER 23/6 (June 2008):61

[47] G McMorland, E Suter, S Casha, SJ du Plessis, and RJ Hurlbert, “Manipulation or Microdiskectomy for Sciatica? A Prospective Randomized Clinical Study,” JMPT 33/8 (Oct 2010):576-584.

[48] JJ Triano, et al. “Biomechanics of Spinal Manipulation,” Spine 1 (2001):121-30

[49] NASS Clinical Guidelines – Degenerative Lumbar Spinal Stenosis, Copyright © January 2007 North American Spine Society

[50] Murphy DR, Hurwitz EL, Gregory AA, Clary R. A non-surgical approach to the management of lumbar spinal stenosis: a prospective observational cohort study. BMC Musculoskelet Disord. 2006;7:16.

[51] Watters WC III, et al. Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. North American Spine Society. La Grange, IL; 2006.

[52] Chiropractic Approach to Lumbar Spinal Stenosis Part II: Surgery and Treatments By Carol Marleigh Kline, JACA Online editor, MAYJUNE 2008

[53] Donald Murphy in private communication with JC Smith, July 20, 2012 

[54] G Cramer,  Dean of Research, National University of Health Sciences, via personal communication with JC Smith (April 29, 2009)

[55] Transcript of testimony of John McMillan Mennell, M.D., Wilk v AMA transcript pp. 2090-2093.

[56] JJ Triano, et al. “Biomechanics of Spinal Manipulation,” Spine 1 (2001):121-30

[57] Rubinstein SM, Terwee CB, de Boer MR, van Tulder MW. Is the methodological quality of trials on spinal manipulative therapy for low-back pain improving? International Journal of Osteopathic Medicine. 2012;15(2):37-52.

[58] Donald R Murphy, Brian D Justice, Ian C Paskowski, Stephen M Perle, Michael J Schneider,  TThe Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States,” Chiropractic & Manual Therapies 2011, 19:17 doi:10.1186/2045-709X-19-17

[59] Crownfield, Peter W., “Chiropractic Before Spine Surgery for Chronic LBP,” Dynamic Chiropractic, vol. 30, no. 11, May 20, 2012.

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