Articles by JCS
Guess what? Those chiropractors were right all along!
After 100 years of being the outcasts in the medical world, modern research on low back pain has vindicated those chiropractors whose been ridiculed for years. In fact, not only has spinal manipulation proven effective and safe for most back pain cases, the same research shows that the medical approach of drugs, shots, and spine surgery are ineffective, costly, and risky.
So, to all those medical chauvinists who scoffed at friends using chiropractic care for their aches and pains, you owe them an apology. When you told them you didn’t “believe in chiropractic,” apparently believing in drugs, shots and surgery were the real false idols.
In fact, the medical solutions to low back pain have been routinely denounced by international medical researchers. Just as appendectomies, tonsillectomies, and hysterectomies were all once popular but now deemed unnecessary surgeries, the same can be said about spine fusions, implants, and artificial discs. While the surgeons and manufacturers tout these procedures, the researchers haven’t and some insurance companies now refuse to pay for these procedures unless conservative care like chiropractic is tried first.
According to Gordon Waddell, MD, orthopedist and spine researcher. “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.”
Jens Ivar Brox, MD, department of orthopaedics at National Hospital in Oslo, Norway, lead author of two RCTs comparing instrumented spinal fusion to exercise and cognitive behavioral therapy, believes that spinal fusion should be an uncommon option for patients with chronic disabling low back pain.
“As a recently retired back surgeon told me some weeks ago, we have to admit that we have been too enthusiastic about fusion in patients with back pain… Brox says that he and his colleagues no longer perform spinal fusion specifically for “degenerative disc disease” because they do not regard it as a clearly diagnosable entity.
“Although pain receptors in degenerated discs may produce severe pain, we have gradually recognized that abnormal findings and positive discography are common even in asymptomatic individuals…The concept of highly selected patients is not evidence-based.
“What we’re talking about is a paradigm shift from early and repeated imaging and activity restriction towards less imaging and more cognitive behavioral rehabilitation. Some of the orthopaedic surgeons in our department have recurrent back pain and disc degeneration. They take mediation occasionally, continue to work, and maintain an active lifestyle despite being restricted for short periods of time. These surgeons refuse to have fusion surgery or recommend fusion surgery for their family members. So the question is: why should we recommend these procedures for our patients?”
A good question rarely asked by American spine surgeons who still lead the world. One study by Drs. Cherkin Deyo, Loeser, Bush and Waddell compared international rates of back surgeries to find American surgeons are unusually excessive: “The rate of back surgery in the United States was at least 40% higher than any other country and was more than 5 times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopedic and neurosurgeons in the country.”
The correlation of disc abnormalities to back pain despite the weak evidence is a mistaken assumption that has led to unnecessary surgery, high costs, and poor outcomes that Dr. Waddell and other experts bemoan.
The Agency for Health Care Policy and Research (AHCPR), a 23-member panel headed by orthopedist Stanley Bigos, MD, unquestionably the most in-depth meta-analysis of acute LBP to date, confirmed the rare need for surgery:
“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.”6
There is now broad agreement in medical practice that disc surgery should not generally be considered until there has been a trial of conservative non-surgical care, primarily spinal manipulative therapy. 7,8,9
What makes the chiropractic story even more perplexing than to realize the research now supports spinal manipulative therapy for most cases of back pain is to realize the federal government agreed in its US Public Health Service report. In 1994, the Agency for Health Care Policy and Research (AHCPR) issued its 2-year study on acute low back pain in adults. This august panel conducted the most extensive study ever done on this epidemic of back pain, scoured over 4,000 articles in the National Library of Medicine and concluded that spinal manipulation was the preferred initial treatment. It also stated that surgery was found effective in only 1 in 100 cases. Yet this recommendation was squashed by the medical spokesmen in the media, the Agency was attacked and gutted of funding, and the researchers were sued by the orthopedic society!
Business Week, in its May 27, 2006 edition, mentioned the murder of this federal agency whose mission was to improve healthcare by endorsing evidence-based treatments.
"In 1993, the federal government's Agency for Health Care Policy and Research convened a panel to develop guidelines for back surgery. Fearing that the recommendations would cast doubt on what doctors were doing, a prominent back surgeon protested ... and lawmakers slashed funding to the agency.
John Weeks, publisher/editor of The Integrator Blog News and Reports
www.theintegratorblog.com, has written an eye-opening account how the AHCPR was murdered by medical politics. As he suggests, the real problem rests with “the economic base - not evidence-base - of U.S. medical decision making.”
In fact, as many medical spine researchers have said lately, there’s more evidence for SMT for LBP than there is supporting the medical model of drugs, epidural steroid injections, and spinal fusions, yet this evidence falls on deaf ears. Perhaps medical economist Dr. Clem Blezold was right when he spoke of the “perverse motivation” in healthcare where the most expensive mousetrap is favored—indeed, it’s all about money, always!
After the AHCPR staff was sued by the orthopedists, a member of the AHCPR panel, Richard Deyo, MD, co-authored in The New England Journal of Medicine an article, The Messenger Under Attack--Intimidation of Researchers by Special Interest Groups. He wrote, “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.”
This history has been largely hidden, for a decade. It deserves a telling of more than a paragraph, and more than what I can give it here.
This was medical terrorism of the first order. Take the deified "evidence pyramid" with reviews of randomized controlled trials at the top. Frost it with a multi-stakeholder, multi-year exploration of all the evidence available. Develop a guideline. Now bomb it. Why wasn't the American Medical Association and academic medicine on hand to rebel against it?
The story of the AHCPR's demise should be a part of any practitioner's education about evidence and medicine. The story particularly should be part of the education of any CAM-IM advocate who has been told that their soft medicine is outside the tough love EBM standard of those on the inside of medicine's power circles. Yes, there is the evidence. And then there is the politics of evidence.
And those who were pushing the Rule of Evidence via the federal agency got the message: Try pushing for federal guidelines again, the same end may come to you.
The AHCPR was to be an ongoing partner, for years to come, in efforts toward betterment of US medicine. This agency was charged by Congress with being a federal arbiter of evidence and a setter of guidelines. This Congressional empowerment of the AHCPR was part of the growing national movement to begin managing care through linking practitioner choices to scientific evidence.
The AHCPR's process was to be simple, deliberate, and unfolding over time. One by one, the AHCPR was to choose conditions, focusing on high-cost, high-use conditions first. An early focus was on low back pain. Among the others empowered was a panel to examine evidence regarding treatment of headaches. To create buy-in, the AHCPR would convene multi-disciplinary panels of 18-25 experts. Highly-regarded researchers would chair the panels. The products would serve three audiences:
The guidelines would be updated, as new evidence was produced. The AHCPR would be an ongoing partner in the betterment of US medicine.
Here was the startling finding: amidst all of the pharmaceuticals and other interventions in the conventional, multi-billion dollar low-back pain industry, the AHCPR guideline was clear. The evidence was for watchful waiting or manipulation. The latter was mainly practiced by a single discipline, chiropractic.
The guideline arrived in 1994, just five years after the chiropractic profession won a 10 year anti-trust suit against the AMA, forcing an end to egregious defamation of chiropractic, and others, by medicine's powerful guild. Would the new campaign for evidence-based medicine help to further drive prejudice from medical decision-making? Would the AHCPR guidelines prove an ally in the integration process?
The AHCPR effort and the low back guideline felt like medical glasnost, the tearing down of the wall, a whole new world opening.
The Death of the AHCPR
For the Clinton healthcare reform effort, the idea of EBM was marched out to define the revolution which "managed competition" promised. EBM's founder, David Eddy, MD, PhD, and the Jackson Hole Group with which he was associated, became nearly household names. In fact, much of the ugly dearth of evidence paraded before the public by Business Week last month made its debut on the national stage in 1992-1993 to support the Clinton's effort to find a way to managing medicine.
The reform effort failed, for many reasons. Doctors chafed at being managed. They complained of violation of the doctor-patient relationship. They didn't like being told that evidence suggests that what they were doing was not okay. That maybe the evidence didn't support it. Or that what the doctor was doing was even damaging and sometimes killing people. Always, evidence meant the doctor's practice needed more reflection.
Back care, a major money maker in the orthopedic wings of hospitals, showed a particularly questionable pattern. Often worthless. Often harmful. The most variable. The evidence that most influenced the level of treatment appeared to be demographic data on the number of surgeons who were around and needed feeding. Frequently expensive. Full of adverse effects. And here was Big Brother, the AHCPR, marching into the room with a little booklet says: Watchful waiting and, worse yet, manipulation. And the devils themselves: Chiropractors!
Mission accomplished: By 1996, there was no significant evidence-based medicine guideline effort left at the federal level; the AHCPR was a shell. The entire guidelines effort had been disbanded. The effort to publish and distribute completed guidelines terminated. There was no significant EBM guideline effort left at the federal level.
In 2002, I managed a telephone conference with a group of experienced researchers who were to be on a panel at the 2002 Integrative Medicine Industry Leadership Summit. I was urging them to publicly explore the politics of evidence. I suggested that the story of the killing of AHCPR be at the center. Two of the panelists-to-be held, or had held, significant positions in the NIH. They all knew the AHCPR story. They shared with me the blunt lesson the agency's killing gave those inside the beltway and in the broader research and practice community. The whole subject of developing federally-backed guidelines as an agent to transform medicine became a non-starter. If you wanted a project funded, don't make it about guidelines.
The public, for better and worse, eventually bought the case of the poor, put-upon physician, struggling against the faceless bureaucracy of the hated HMO. Often for good reason. Yet here we are, in 2006. The very same David Eddy is the featured personality in the Business Week expose. The cry is still for EBM. And our medicine is hardly more evidence-based than it was when the EBM "revolution" began.
Lessons and Reflections
My interest in revisiting the killing of the AHCPR is akin to something going on politically in Chile and Argentina today. Both current presidents were dissidents in the 1970s when dictatorships began to systematically "disappear" thousands of opponents. The presidents, despite calls to let the ugly past be forgotten, have both found it important to re-open the old wounds. They believe it important to seek justice.
I am not sure where the justice is here. In the Business Week telling, one "prominent back surgeon protested, and lawmakers slashed funding to the agency." Others have told me it was a neurosurgeon. Others have put the finger on one, prominent, Texas back group. I have had a medical colleague from Texas tell me that the whole story about the surgeon is bull. I don't know.
That said, it might be a good thing to find the surgeon and put him up on charges. We'd need to produce the list of all who have been killed and maimed through the system's subsequent failure to produce, promote and practice with evidence-based guidelines. To estimate a number: Just last week, Donald Berwick, MD, MPH, founder of the Institute for Health Improvement, claimed that 122,300 were saved last year alone when many of the nation's hospitals finally began following evidence on a half-dozen procedures. (1) Our powerful surgeon would be in some ugly company in global history, responsible for a parade of dead stretching on into forever if we are to sum up a decade of these dead, alone.
But to focus on the one, or the small group, is to approach this like the Warren Commission approached the Kennedy murder, determined to prove it was a single killer. The Great Bad Man Theory takes us away from the more significant fact.
Does anyone believe that a single surgeon could have killed the AHCPR if the AMA had raised a hand and begun a campaign in protest? I expect, at the very least, a massive, passive sigh of relief was breathed by untold tens of thousands of doctors and the scores of organizations that lobby for them. Just a toast of good riddance.
Those Bad Chiropractors
I can honestly say that at least a two dozen times I have been forced to raise the chiropractic question when I have interviewed my medical doctor colleagues about their efforts to integrate CAM into the offerings of their hospitals and academic health centers.
When I ask about provider mix, they tick off the massage therapist, the acupuncturist, the nurse Reiki specialist, the mind-body practitioner, the Yoga teacher. I wait for the "C" word. Chiropractors typically aren't in the mix. (See Integrative Clinics - An Analysis of 27 Clinics for some evidence.) My most recent such encounter was within the last two weeks. I remind them all of the AHCPR guideline, of evidence that, at worst, is mixed.
Question: Why aren't you including chiropractors? Heck, all you have to do is find one you trust and tell your medical staff that look, here, the chiropractor will be under my supervision ...
Answer: If I did that, the orthopedic docs would kill this before it got off the ground. I want to get it going, first, with providers who aren't as controversial. Chiropractors will come later. Phase 2.
The spirit of that supposedly lone, powerful surgeon, amidst all the talk of EBM, still reaches deep into the medical landscape. Funny how, in a classic example of mirror-imaging - seeing in the other what your refuse to acknowledge in yourself - chiropractors are portrayed by conventional medicine as adversarial, always filing lawsuits, not good collaborators. If there is clear justice in this tale of the murder of the AHCPR, it is that chiropractic has earned a right, for better or worse, to be adversarial.
A lesson for all interested in integration is that quality evidence, if necessary, is for certain not sufficient. Witness the work of John Astin, PhD. funded by NIH NCCAM, to begin to understand why mind-body medicine, given its evidence base, is not better integrated into care delivery. Our strategies should reflect this unfortunate evidence. My colleague Lou Sportelli, DC, long ago shared with me the two words which he says have been most responsible for his profession's advances: legislation and litigation.
What is the federal legislation we need to really move this field?
Meantime, we are clearly making advances, step-by-step, row-by-row, human-to-human, educator-to-educator, clinician-to-clinician, discipline-to-discipline - and even based on evidence.
Yet the murder of the AHCPR should remind us that we are still living in the wild, wild West of medicine. It's just that now the idea of the Rule of Evidence is often appropriated by one or more of medicine's powerful families to lash those less well-heeled and to keep things rolling as they always did, in the good old days.
(1) "Hospitals bid to heal selves saves thousands." Seattle Post-Intelligencer, Thursday, June 15, 2006. Page 1.