Articles by JCS

Lancet Elephant Part 1

The Lancet Elephant

Part 1: Blind Researchers

Established in 1823 by its founder, Thomas Wakley to improve hospital reform, the historic British medical journal, The Lancet, on March 22, 2018, published a three-part series on Low Back Pain compiled by 31 leading researchers and professors from around the world:

·         What low back pain is and why we need to pay attention - The Lancet by Jan Hartvigsen, DC, PhD

·         Low back pain: a call for action by Prof Rachelle Buchbinder, PhD

·         Prevention and treatment of low back pain: evidence, challenges, and promising directions by Prof Nadine E Foster, DPhil

Although this effort has called more attention to the worldwide pandemic of LBP and the ineffectiveness of medical spine care, I have to say as a 40-year practitioner and journalist on spine matters this review probably will not have any significant impact on spine care, at least not in the USA.

It was another nonbinding academic exercise not unlike the ACP, JAMA, FDA and Joint Commission guidelines that fell on deaf ears to the medical spine profession. Indeed, it was a futile academic exercise that will be among other well-meaning attempts to reform the clinical corruption in spine care such as the 1994 AHCPR guideline #14  on acute low back pain in adults that was ignored then destroyed.

  • Feb. 14, 2017: The updated American College of Physicians guidelines for treating nonradicular low back pain with nondrug, nonsurgical conservative care were published in the Annals of Internal Medicine.

·   April 11, 2017:  JAMA study, “Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis.” 

·   May, 2017: the Food and Drug Administration issued its FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain.

·    January 1, 2015: the Joint Commission promoted chiropractors from the ranks of the medical zombies to the head of the table in chronic spine care with its Revisions to pain management.

I’m not aware how The Lancet review told us anything new that Scott Haldeman DC, MD, PhD, (who inexplicably was not a member of The Lancet panel) hasn’t already written about extensively in his work about this worldwide epidemic of back pain:

·         A Systematic Review of Low Back Pain Cost of Illness Studies in the United States and Internationally,

·         Spine Pain Impact on World Health (GBD 2016),

·         The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies,  

·         Global Spine Care Initiative (GSCI)

Blind Researchers

Unlike the recent American guidelines endorsing manual therapies and chiropractic specifically as front-line conservative treatments for the pandemic of chronic LBP, The Lancet panel was far from being as positive considering chiropractic was never mentioned by name.

It appears The Lancet reviewers seem disinterested to understand why chiropractic is the 3rd largest physician-level health profession treating the most disabling condition in the world with nondrug and noninvasive methods — supposedly an issue right in this panel’s wheelhouse. Sadly, the panel struck out when it should have hit a home run for chiropractic. 

Not only is classic chiropractic overlooked in The Lancet research room, this situation also resembles the parable about the blind men and the elephant.

The moral of the parable suggests people have a tendency to project their partial experiences as the whole truth and ignore other people's partial experiences.[1] In the end, however, all of them are wrong — apparently ‘group think’ has its limitations.

In the case of LBP, consider the various explanations of the blind practitioners:

·         Orthopedists: it’s a bad disc, do surgery, implant spinal cord stimulators or pain pumps

·         Chiropractors: it’s the vertebral subluxation, do adjustments

·         Primary Care MDs: it’s a back strain, prescribe Benzos, Advil or Lyrica

·         Osteopaths: it’s a spinal lesion, do OMT mobilization, stretching, gentle pressure and resistance.

·         Physical Therapists: it’s a pulled muscle, do TENS and hot packs

·         Pain Management: it’s inflammation, do ESIs and opioids

·     Psychologists: it’s psychosomatic, teach coping mechanisms, Cognitive-Behavioral Therapy, prescribe Valium or Xanax.

·         Massage Therapists: it’s muscle spasm, imbalances and rigidity, do therapeutic massage.

With every professional giving a different explanation and with PhDs and professors giving their educated guesses, no wonder the panel is confused how to describe the LBP elephant. And without a classic chiropractic ringmaster to anchor this circus, the panel's explanations were bound to be unclear and a poke in the dark.

Medscape Medical News previously featured a similar sentiment describing the proverbial elephant in an article, “Worrisome trends in back pain management,”[1] that shed more light on LBP care when Donald E. Casey, MD, said:

"We should aim to collectively sort out the differences between what really works and helps patients and what doesn't work, in a more systematic framework, by working more closely together rather than publishing each group's own different guidelines with their own different perspectives."[2]

You may recall in 2008 Dr. Scott Haldeman described the ambiguity in the LBP marketplace as a “smorgasbord” of 200+ treatments:[3]

·      60+ pharmaceutical products

·         32 different manual therapies

·         20 different exercise programs

·         26 different passive physical modalities

·         9 educational and psychological therapies

·         20+ different injections therapies

·         11 more traditional and newer surgical approaches

·         Extensive lifestyle products sold for chronic low back pain, including braces, beds, chairs, and ergonomic aides

·         Complementary and alternative medical approaches to chronic low back pain

Dr. Haldeman stated “navigating this selection without an informed guide is analogous to shopping in a foreign supermarket without understanding the product labels.”[4] Unfortunately, there are few unbiased and informed guides helping patients through this dilemma which explains his frustration that “so little has changed in the evidence available to guide stakeholders and support treatments for chronic low back pain.”[5]

Unlike The Lancet panel, however, Dr. Haldeman did state his confidence in chiropractic care for this epidemic of chronic low back pain.

“It also shows the positive effects of preventive chiropractic treatment in maintaining functional capacities and reducing the number and intensity of pain episodes after an acute phase of treatment.”[6] 

Nonspecific Elephant

The most obvious blind spot by the panel was the failure to recognize the unique anatomy and physiology of the spine itself as a possible explanation. The paradigm shift from ‘slipped discs’ to ‘slipped joints’ is the key to this important revelation about the major cause of LBP. Indeed, the spine is more than 23 discs as our myopic medical rivals would have it and as the public still believes despite research starting in 1990 invalidating the 'bad disc' scam that lives on today like a medical monster that will not die.

For example, missing in The Lancet report was any mention of the spine as a precarious weight-bearing pillar of 24 vertebrae sitting on top of a 3-bone pelvis interconnected by 361 joints, a fact lost to most physicians, academic elitists, and certainly the public. 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.[7]

The panel also seemed unaware of the numerous functional features in the spine as described by Anthony H. Wheeler, MD, and Stephen A. Berman, MD, PhD, MBA, who spoke of the complexity of the spine and LBP in their paper, Low Back Pain and Sciatica:

OVERVIEW

Like a modern skyscraper, the human spine defies gravity, and defines us as vertical bipeds. It forms the infrastructure of a biological machine that anchors the kinetic chain and transfers biomechanical forces into coordinated functional activities. The spine acts as a conduit for precious neural structures and possesses the physiological capacity to act as a crane for lifting and a crankshaft for walking. Subjected to aging, the spine adjusts to the wear and tear of gravity and biomechanical loading through compensatory structural and neurochemical changes, some of which can be maladaptive and cause pain, functional disability, and altered neurophysiologic circuitry. Some compensatory reactions are benign; however, some are destructive and interfere with the organism’s capacity to function and cope. Spinal pain is multifaceted, involving structural, biomechanical, biochemical, medical, and psychosocial influences that result in dilemmas of such complexity that treatment is often difficult or ineffective.[8]

Without such a detailed understanding and without a classic chiropractor on this panel to keep the focus on the spine A&P, LBP became even more confusing when the consensus of The Lancet panel was boiled down to “nonspecific,” certainly not an explanation to hang your hat on.

For nearly all people presenting with low back pain, the specific nociceptive source cannot be identified and those affected are then classified as having so-called nonspecific low back pain.”

Maybe the source “cannot be identified” by primary care physicians, PhDs, or academicians, but chiropractors have identified and treated vertebral subluxations for over a century with great results.

Imagine as a patient how unnerved you might feel suffering with a fever if your MD said you had a “nonspecific virus.” How would you feel if you were told you had “nonspecific chest pain” or a “nonspecific headache” or “nonspecific abdominal” pain?

Not very reassuring your doctor knew what he/she was talking about! Yet the panel expects patients to accept this nondescript diagnosis for the pandemic of LBP? Indeed, blind faith coming fron blind researchers!

Unfortunately, patients also accept the “you got a ‘bad disc’” explanation to justify fusion when, in fact, the experts are clear the ‘bad disc’ diagnosis is a sham. The Lancet panel also mentioned the diagnostic dilemma concerning ‘bad discs’ found in asymptomatic patients, a notion ignored by spine surgeons who’ve made a financial fortune convincing LBP patients to the need for fusions:

Many  imaging  (radiography,  CT  scan, and MRI) findings identified in people with low back pain are also         common in people without such pain, and their importance  in  diagnosis  is  a  source  of  much  debate.

Disc herniation in conjunction with local inflammation is the most common cause of radicular pain and radiculopathy. Disc herniations are, however, a frequent finding on imaging in the asymptomatic population, and they often resolve or disappear over time independent of resolution of pain.

However, the panel failed to explain how discs become inflamed due to the altered mechanics of the spine as Jay Triano described in his paper, Biomechanics of Subluxation: Modern Evidence of Buckling Mechanism.  Again, if the panel has enlisted an American classic chiropractor such as Dr. Triano, it might have better understood the mechanics of LBP.

A quick lesson would have been helpful to the panel of Dr. Triano’s paper on segmental buckling causing LBP as a function of mechanical overloading of the vertebral motor unit rather than solely a problem with the disc:

Several characteristics of buckling behavior are known. An obvious causative factor is a single overload event that exceeds critical load for the conditions. For less severe tasks, the process is more complex. Normal creep deformity occurs with prolonged static posture. Creep alters the constitutive properties of the tissue and the relative critical load. 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.[9]

I am curious to know if the panel ever investigated the Vertebral Subluxation Complex (VSC) or Joint Complex Dysfunction – traditional and modern chiropractic concepts of spinal structure, function, and physiology?

Was the panel even aware of historical medical manual therapists such as Andrew Taylor Still, James Cyriax and John Mennell or informed of the 3000+ year history of manipulative therapy long before the term “bonesetters” was coined in 1510 in medieval Europe?[10]

Perhaps another lesson the panel might have found helpful was the importance of spinal manipulation (SMT) as explained years ago by the late John McMillan Mennell who spoke of the value of SMT during his testimony at the Wilk v. AMA antitrust trial:

“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.”[11]

In 1992, Dr. Mennell published his book, The Musculoskeletal System: Differential Diagnosis from Symptoms and Physical Signs, in which he described the loss of joint play as a major cause of pain and joint manipulation as the best correction:

Loss of play in synovial joints is mechanical diagnostic entity designated ‘joint dysfunction,’ and this is a mechanical diagnosis of a cause of symptoms. It is common in any synovial joint anywhere in the system. To correct a mechanical fault it is logical to seek a mechanical form of treatment. This is joint manipulation.[12]

These “mechanical” explanations obviously are more comprehensive than the panel’s ‘nonspecific’ explanation. Perhaps the panel was looking for a simple explanation to a complex problem as the surgeons do with their ‘bad disc’ explanation to naïve patients, but as Mennell, Triano, Wheeler and Berman suggest, LBP is a complex multifaceted mechanical problem, not a “pulled muscle” or “slipped disc” as the medical profession has promulgated for decades.

Australian classic chiropractor, Peter L. Rome, DC, author of A Basis For The Theory Of A Central Chiropractic Principle – The Vertebral Subluxation, gave his critique of The Lancet review:

The Lancet papers seemed to focus on assessing medical evidence of LBP from a medical perspective using medical criteria, tunneled through academics eyes. They are not particularly positive for chiropractic as much as they are negative for current medical procedures.

At least they acknowledge that medical spinal care is not evidence-basedIndeed, it is a straight-forward review of the lack of medical efficacy in this field. [13] 

 

Fortunately the panelists did state much of medical spinal care is not evidence-based, but its reluctance to recommend chiropractic and other CAM therapies was odd considering every American LBP guideline now recommends conservative care as front-line treatments.

Dr. Rome also spoke of the “nonspecific” explanation by the panelists:

If their basic concepts missed the 'elephant', then their whole study is rather pointless.  The 'rhinoceros' in their room is spinal pathomechanics.

If the medical understanding of LBP virtually overlooks chiropractic adjustments and is muted on manipulation (I still feel they are 2 different things), then their model, and therefore their contribution, is limited. [14]

Howard Vernon, DC, PhD, professor at Canadian Memorial Chiropractic College, mentions a “nonspecific spinal manipulation” by a non-chiropractor (PT, MD, DO) does not rise to the level of a specific chiropractic “adjustment” in his article, Historical overview and update on subluxation theories:[15]

In several studies, the manual therapy intervention might be regarded as nonspecific and, therefore, would not qualify as an “adjustment.”

Another chiropractic educator, Christopher Good, DC and professor at University of Bridgeport, was also disappointed by the panel:

Having just read the 3 papers from Lancet, I'm dismayed that spinal manipulation received such poor support, especially given the overwhelming evidence that exists.

And to continue to claim that the tissues causing nonspecific low back pain cannot be identified in clinical practice flies in the face of the best available evidence, specifically the work of Don Murphy. On the upside, at least a chiro was involved (Jan Hartvigsen).

And no mention of joint dysfunction/subluxation, of course. I find that particularly insulting to the manual therapists (DCs, PTs, and non-US DOs and MDs) around the world who actually treat these patients with great success with SMT for joint dysfunction

Sometimes I think I'm living in Wonderland with Alice[16]


Indeed, Alice chasing the white rabbit down its hole in Wonderland  does resemble many patients going from one ineffective medical treatment to another (opioids, ESI, SCS, PT, MRI, spine surgery) until they end up as a spinal wreck or in a chiropractor’s office as the proverbial last resort who must try to help Alice find her way back to better health.





[1] http://www.medscape.com/viewarticle/808634

[2] Pauline Anderson, Worrisome Trends in Back Pain Management, Medscape Medical News, Jul 30, 2013

[3] S Haldeman and S Dagenais, “What Have We Learned About The Evidence-Informed Management Of Chronic Low Back Pain? The Spine Journal 8/1 ( January-February 2008):266-277.

[4] S Haldeman and S Dagenais, “A Supermarket Approach To The Evidence-Informed Management Of Chronic Low Back Pain,” The Spine Journal 8/1 (January-February 2008):1-7.

[5] Ibid. pp. 266-277.

[6] Ibid. pp. 266-277.

[7] Cramer, G.; Darby, S. 2014 Clinical anatomy of the spine, spinal cord, and ANS. 3rd Edition, Elsevier/Mosby, St. Louis, 559 illustrations, 672pp. Appendix I, pp. 638-642.

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

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

[12] John McMillan Mennell, The Musculoskeletal System: Differential Diagnosis from Symptoms and Physical Signs. Aspen Publications, 1992, p. 22.

[13] Private communication with JC Smith, 3/28/2018

[14] Private communication with JC Smith, 3/28/2018

[16] Private communication with JC Smith, 3/28/2018

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