Articles by JCS

Infomercial #3

Infomercial #3

 

Call for Reform in Back Treatments

 

Hello again, my name is Dr. JC Smith and I’m a chiropractor in Warner Robins.

Today I’d like to discuss the upcoming healthcare reform and how chiropractic care can reduce costs and improve outcomes in the back pain business.

 

According to the Obama White House spokesman, "The path of fiscal responsibility must run directly through health care and efforts to limit health care costs as the single most important thing we can do for long-term fiscal stability.”[1]

President Obama said, "Putting America on a sustainable fiscal course will require addressing health care," adding, "Many of you said what I believe, that the biggest source of our deficits is the rising cost of health care"

 

My previous show focused on the recent scientific research that spoke of the new guidelines that recommend spinal manipulation for acute and chronic low back pain.  Experts from the US, England, Denmark, Norway, Sweden, Canada, Australia have all compared the many treatments used for back pain and all have recommended chiropractic spinal manipulation as a proven method.

 

With the rising healthcare costs, these experts and medical economists also urge a change in treatment from drugs, shots and surgery to natural, conservative methods like chiropractic care that could save billions of dollars and improve outcomes for the millions of Americans who suffer from back pain.

 

Despite the international call for a reform in the management of back pain from drugs, shots, and surgery, little has changed, especially in middle Georgia.

And it does get more confusing for the average patient to know what works best. Today back pain care is like a supermarket with over 200 treatments and often patients seek advice from many medical doctors who frankly are not well educated in this area according to Dr. Richard Deyo, a leading spine researcher.

 

Dr. Deyo published an article in Scientific American[2] in which he mentions the fact that most primary care providers are not well trained in musculo-skeletal problems.

“Calling a physician a back-pain expert, therefore, is perhaps faint praise--medicine has at best a limited understanding of the condition. In fact, medicines’ reliance on outdated ideas may have actually contributed to the problem.”

 

According to research presented at the annual meeting of the North American Spine Society by Dr. Paul Bishop, he agrees that many problems arise with primary care physicians who manage back pain patients with old treatments.

“Typically, the family physician-based care involved excessive use of passive therapies such as massage and passive physical therapy, excessive bed rest, and excessive use of narcotic analgesics.”[3]

 

Dr. Deyo admits that medical care for the epidemic of low back pain is simply stuck in its thinking by using narcotic pain pills, steroid injections, MRIs and spine surgery when the research cannot support this model of care.

“I’m not sure we’ve made much real progress in the effectiveness of clinical care. We seem stuck in conventional models that haven’t worked very well so far.”[4]

           

According to the National Academy of Sciences, it takes an entire generation—17 years—for new technology to become mainstream.

“In the current health care system, scientific knowledge about best care is not applied systematically or expeditiously to clinical practice. An average of about 17 years is required for new knowledge generated by randomized controlled trials to be incorporated into practice, and even then application is highly uneven...”[5]

 

 

He continues to criticize what he calls “Old concepts supported only by weak evidence,” and is very critical of the reliance on MRI exams to convince patients that disc abnormalities are the cause of back pain since most adults without any back pain also have spine arthritis of some sort.

“Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”

 

And it certainly doesn’t mean every herniated or degenerated disc requires surgery. 40% of patients over 40 years of age have disc abnormalities, but no back pain. He jokingly referred to these as “incidentalomas,” and likened them to finding grey hair as the cause of your back pain.

 

Dr. Deyo also admits that:

“Some surgeons estimate that less than half the spinal fusions being performed were appropriate.”[6]

 

Not only does Deyo question many medical concepts and treatments for back pain, he also mentions chiropractic as a possible 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.”

 

Other MDs agree with Dr. Deyo, such as Aage Indahl, MD.

“Many of our ideas about low back pain have been wrong. The slow pace of change in giving up old ideas is probably a result of the lack of new ideas.”[7]

 

Indeed, “don’t confuse me with the facts or new ideas” seems to characterize the present state of affairs for some physicians and surgeons.

 

A prime example of this contempt for new ideas came after the landmark 1994 US Public Health Service’s Agency for Health Care Practice and Research extensive two-year study on acute low back pain that recommended spinal manipulation as a “proven method.”[8]

 

This was the most extensive analysis of back pain at the time—a 2-year study of over 4,000 scientific articles—and it shocked the medical profession when spinal manipulation, the mainstay method used by chiropractors, was proclaimed by the US Public Health Service agency as a “proven method” and the preferred initial professional treatment for acute low back pain.

 

This guideline states:

“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.”[9]

 

Of course, chiropractors are primarily the “professionals with experience in manipulation” since we do 94% of all manipulation done in the US according to the RAND study.[10] The other 6% of spinal manipulation is done by some PTs, DOs and a few MDs called physiatrists, but without question, chiropractors are the masters of this healing art. Indeed, if it weren’t for the tenacity of chiropractors, this would be a lost art today.

 

Not only did this recommendation shock the medical profession, but another shocking conclusion in the US federal guideline warned patients about the low success rate of back surgeries.

 

“Even having a lot of back pain does not by itself mean you need surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.” [11]

 

This federal guideline also warns of the complications rate of back fusions in particular.

“Surgery increases the chance of future procedures with higher complication rates…There appears to be no good evidence from controlled trails that spinal fusion alone is effective for treatment of any type of acute low back problems in the absence of spinal fracture or dislocations…Moreover, there is no good evidence that patients who undergo fusion will return to their prior functional level.”[12]

 

This honest evaluation of spine fusions shocked and angered the medical profession despite the fact that this was the most authoritative group of investigators that included orthopedists.

 

After the release of federal guideline in December, 1994, the North American Spine Society successfully lobbied Congress to revoke the ability of the Agency on Health Care Policy and Research to do its job mandated by Congress to investigate medical procedures and to recommend treatment guidelines with the goal to lower costs and improve outcomes.

 

Its ire stemmed from the criticism levied at spinal fusions, especially those involving pedicle screws due to the findings that fusions had few scientifically validated indications and was associated with higher costs and complications rates than other types of back surgery.[13]

           

 As a member of this panel, Dr. Richard Deyo subsequently co-authored in The New England Journal of Medicine an article in response to this intimidation, "The Messenger Under Attack--Intimidation of Researchers by Special Interest Groups." He alluded that the for-profit mindset of some surgeons supersedes the value of research:

 

"The huge financial implications of many research studies invite vigorous attack... Intimidation of investigators and funding agencies by powerful constituencies may inhibit important research on health risks and rational approaches to cost-effective health care.”[14]

             

Is it any wonder why the AMA didn’t like this report since it was painfully honest about the poor results from spine surgery, especially fusions? In fact, the spine surgeon society sued to keep this report from first being released, but a federal court intervened to release it in December of 1994. After this landmark study, other countries began to study the back pain business and came to the same shocking conclusions that drugs, shots, and surgery had no long term advantage over conservative treatments like chiropractic care and active rehab exercises.

 

The most startling comment I’ve read from medical researchers regarding the epidemic of back pain and the failure of back surgery came from Dr. Gordon Waddell, orthopedic surgeon and author of The Back Pain Revolution.

“Low back pain has been a 20th century health care disaster...Back surgery has been accused of leaving more tragic human wreckage in its wake than any other operation in history.”

 

Dr. Waddell also recommends chiropractic care for this epidemic of back pain:

“There is now considerable evidence that manipulation can be an effective method of providing symptomatic relief for some patients with acute LBP.”[15]

 

Not only are back surgeries risky, the high rates of back surgery suggests either Americans have especially bad backs or Americans surgeons are out of control. According to Dr. Deyo

“The rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times those in England and Scotland.

“Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country.”[16]

 

This may explain why Macon is the back surgery capital of Georgia since it has so many spine surgeons. Not only are spine surgeries often unnecessary, patients are rarely told beforehand that there may be poor outcomes, such as:

  • 80,000 new cases of Failed Back Surgeries per year in the US.[17]
  • 19% reoperation rate[18]
  • 71% to 95% of lumbar fusion patients will never return to work[19] 
  • up to 90% of these surgeries are now deemed unnecessary.[20]

 

 

According to Dr. Lynn Johnson, director of the Center for Pain Medicine of North Carolina, while back surgery has a place, there are too many surgeries being done, and that most doctors fail to apply conservative measures such as chiropractic, physical therapy, and minimally invasive techniques before suggesting surgery.[21]

“Just about any approach is better than having surgery because all the studies have shown that, if you take a surgical population and non-surgical population, they all seem to do the same in five years.”[22]

 

Even Dr. Timothy Johnson of ABC’s World News shocked the spine surgeons when he broadcast in May of 2006:

“So why are so many back surgeries performed in this country?

“It could be a combination of too many surgeons who are too eager to operate and the impatience of many patients who want results quickly.

“The truth is that 90 percent of back pain can be resolved without surgery if both doctors and patients are willing to try other treatments that basically help the back to heal itself.”[23]

 

I might add expert now agree that chiropractic care is foremost among the “other treatments” that Dr. Johnson suggests.

 

The call for reform also comes from the editors of The BackLetter, a foremost journal in the world of spine care.

"The world of spinal medicine, unfortunately, is producing patients with failed back surgery syndrome at an alarming rate…Despite a steady stream of technological innovations over the past 15 years—from pedical screws to fusion cages to artificial discs—there is little evidence that patient outcomes have improved.”[24]

 

The BackLetter also admits that neck surgery is just as inappropriate.

“However, no form of cervical surgery has been proven to be superior to nonsurgical care—or waiting out the symptoms.”[25]

 

I.P. Fouyas, MD, also questions the role of neck surgery when compared to non-surgical methods like spinal manipulation.

“There was no significant difference in results between people who received surgery compared with those who had non-surgical treatments.

“It is not clear whether the short-term risks of surgery are offset by any long-term benefits.” [26] 

 

Not only is neck surgery questionable, but epidural steroid injections were also suspect to the researchers who found no benefit for steroid injections in the treatment of patients with neck pain after motor vehicle accidents.[27]

 

According to Steven H. Sanders, PhD, nerve blocks for neck pain are not supported by scientific efficacy:  

“Thus the scientific efficacy is not present…From the current review, we must conclude injections and blocks produce a large amount of money with very little science to support their application.”[28]

 

 

According to Dr. SK Mirza, among those patients who’ve had a neck or back surgery, most admit they are still using narcotics for pain control.

Even among the patients classified as having a successful result, most were still using narcotic medications at the 2-year follow-up, including 64% of the successful-result patients in the disc replacement group and 84% in the fusion group.”[29]

 

The BACKLETTER recently reported the popularity of spinal manipulation for acute back pain.

“Numerous international guidelines have endorsed the use spinal manipulation as a treatment for acute back pain—as part of an evidence-based treatment program.”[30]

 

Needless to say, this call for reform by the federal agency and international experts has fallen on deaf ears for the most part in America due to the huge monies involved—in fact, surgeons and hospitals are making money hand over fist.

The direct and indirect costs of back pain approach

  • $100 billion annually in America.[31]
  • 1,175,000 inpatient spinal surgeries in the U.S. alone[32]
  • as many as 90% are unnecessary and ineffective.[33]
  • The direct costs are astronomical and may reach for a
    • lumbar fusion as high as $169,000,
    • lumbar laminectomy: $82,614,
    • cervical laminectomy: $60,304, and
    • cervical fusion: $112,480.[34]

 

Is there any wonder why there’s an international call for reform now?

 

Dr. Richard Deyo also calls for reform:

''People say, 'I'm not going to put up with it,’ and we in the medical profession have turned to ever more aggressive narcotic medication and more invasive surgery.'' [35]

More people are interested in getting on the gravy train than on stopping the gravy train”.

 

And there’s many doctors who want to drive the gravy train despite the overwhelming evidence that conservative care for back pain is more clinically and cost-effective than the short term methods of drugs, shots and surgery.                     

 

Once again, let me quote Anthony Rosner, PhD, when he testified before The Institute of Medicine:

“Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.” [36]

 

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

 

Despite the major advances in medical research and disease treatment, the American healthcare system is failing to improve the care of patients,” according to their experts. This report also states that most troubling is that proven methods that can lower costs and improve patient outcomes are not being used in everyday practice, such as chiropractic care for the epidemic of back pain.

 

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

             

 

If you’re suffering with low back or neck pain, and if your family doctor has not referred you to a chiropractor and you’re living on pain pills, muscle relaxers, contemplating epidural shots or surgery, then I can honestly suggest you might change doctors and find one who follows the guidelines and recommendations of these experts. After all, it’s your body and your suffering that we’re talking about here.

 

I understand that these facts, recommendations and warnings by medical experts may shock you, especially if you’ve already had a spine surgery. Rarely are people told the truth about the risky and costly nature of spine surgery, nor are they told the cold facts about the failure of pain pills and epidural shots. In middle Georgia, it just continues with “Old concepts supported only by weak evidence,” as Dr. Deyo mentioned.

 

If you want to learn more about my office, logon to www.smithspinalcare.com to see the new scientific findings and learn more about how we can help you overcome your back pain.

 



[1] Condon, CongressDaily, 2/23

[2] Deyo, RA. Low -back pain, Scientific American, pp. 49-53, August 1998.

[3] Bishop PB et al., The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) part I: A randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain, presented at the annual meeting of the International Society for the Study of the Lumbar Spine, Hong Kong, 2007; presented at the annual meeting of the North American Spine Society, Austin, Texas, 2007; Spine, in press.

[4] The Back Letter, vol. 23, No. 5, 2008, pp. 58.

[5] Crossing the Quality Chasm: A New Health System for the 21st Century, The National Academy of Sciences, 2001. page 13-14.

[6] Deyo RA, Patrick DL, Hope or Hype: The obsession with medical advances and the high cost of false promises, AMACOM publication, 2002, pp. 191.

[7] The BACK Letter, Vol. 23, No. 5, 2008, pp. 55.

[8] Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, December 1994.

[9]Bigos S. et al.

[10]Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Park RE, Phillips RB, Brook RH. The Appropriateness of Spinal Manipulation for Low-Back Pain: Indications and Ratings by a Multidisciplinary Expert Panel, RAND R-4025/2-CCR/FCER, 1991.

[11] Bigos et al.

[12] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[13] Deyo RA, Psaty BM, et al. The Messenger under Attack--Intimidation of Researchers by Special-Interest Groups, NEJM, vol. 336, No. 16, pp. 1176-79, April 17, 1997.

 

[14] Deyo RA, Psaty BM, et al. The Messenger under Attack--Intimidation of Researchers by Special-Interest Groups, NEJM, vol. 336, No. 16, pp. 1176-79, April 17, 1997.

[15]Waddell G. and OB Allan, “A historical perspective on low back pain and disability, “Acta Orthop Scand 60 (suppl 234), 1989.

[16] An international comparison of back surgery rates. Cherkin DC, Deyo RA, et al. Spine. 2004 Jun 1;19(11):1201-6.

[17] Ragab A and Deshazo RD, Management of back pain in patients with previous back surgery, The American Journal of Medicine, 2008; 121:272-8.

[18] Ragab A and Deshazo RD, Management of back pain in patients with previous back surgery, The American Journal of Medicine, 2008; 121:272-8.

[19] Berger E. Later postoperative results in 1000 work related lumbar spine conditions. Surg. Neurol 2000 Aug:54 (2)101-6.

[20] Widen, M. “Back specialists are discouraging the use of surgery.” American Academy of Pain Medicine, 17th annual meeting, Miami Beach, Fl. Feb. 14-18, 2001.

[21] Widen, M. ibid.

[22] Widen, M. ibid.

[23] Back Surgery Not Always the Cure for Pain U.S. Leads the World in Procedures That Some Experts Say Could Be Avoided By Dr. Timothy Johnson ABC World News, May 23, 2006.

[24] The BackLetter, vol.12, no. 7, pp.79 July, 2004. The BackPage editorial, The BackLetter, pp. 84, vol. 20, No. 7, 2005.

[25] The BackLetter® 46 Volume 23, Number 4, 2008.

[26] Spine, 2002;27(7):736-747, April.

[27] Barnsley L et al., Lack of effect of intraarticular corticosteroids for chronic pain in the cervical zygapophyseal joints. New England Journal of Medicine, 1994; 330:1047–50 .

[28]Steven H. Sanders and Peter Vicente, Medicare and Medicaid financing for pain management: The wrong message at the right time, The Journal of Pain, Volume 1, Issue 3, September 2000, Pages 197-198. 

[29] Mirza, Sohail K. MD, MPH, Point of View: Commentary on the Research Reports that Led to Food and Drug Administration Approval of an Artificial Disc, Spine: 30(14) 15 July 2005 pp 1561-1564.

[30] The BACKLETTER  editorial, vol. 23, #1, 2008.

[31] Shekelle, Paul G., et al,  RAND Corporation Report, The Appropriateness of Spinal Manipulation for Low-Back Pain, 1992.

[32]Boyle, Matthew, The battle over your aching back: New alternatives to surgery are gaining favor. Here's a look at the best treatment options. Fortune. August 25 2006. 

[33] Finneson BF. A lumbar disc surgery predictive score card: a retrospective evaluation,” Spine (1979): 141-144.

[34] Schlapia A, Eland J. Multiple back surgeries and people still hurt. Available at http://pedspain.nursing.uiowa.edu/CEU/Backpain.html Accessed April 22, 2003.

[35] “With Costs Rising, Treating Back Pain Often Seems Futile” by Gina Kolata, NY Times, February 9, 2004.

[36] Dr. Anthony Rosner, former Director of Research at FCER, testimony before The Institute of Medicine: Committee on Use of CAM by the American Public, Testimony for Meeting, Feb. 27, 2003.

 

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