Articles by JCS
Back Pain Worldwide & Costly
Not All Epidemics Kill
JC Smith, MA, DC
The huge costs and suffering from low back pain in the United States are staggering, according to international researchers. The documented facts about low back pain (LPB) are astronomical in terms of the number of suffering patients and the costs.
¶ 80-90% of all adults will suffer with low back pain sometime in their life.
· LBP is the leading cause of disability for people under 45 years of age.
¸ LBP is the second leading cause of visits to doctors’ offices. 
¹ LBP is the third leading reason for hospital admissions and surgical procedures.
º Annual costs of back pain in the U.S. range from $20 to $75 billion; $100 billion worldwide.
» According to MetLife Insurance statistics, the average “medical non-surgical back” costs $7,210 and the average “surgical back” costs $13,990. 
¼ Statistics indicate a yearly prevalence rate of 15 to 20%, approximately 32 million cases.
Obviously, the epidemic of low back problems is enormous, and it’s only getting worse. New governmental guidelines and recommendations from the U.S. Public Health Service, the Ontario (Canada) Ministry of Health, and the British government now suggest that back surgeries are ineffective and costly, and that spinal manipulation is cheaper, safer, quicker, longer-lasting and has higher patient satisfaction rates. The definitive studies in the U.S. and Canada have all agreed that chiropractic management is superior to medical management of this growing epidemic.
Two questions remain unanswered about this epidemic: 1) What caused this epidemic? and 2) What is the solution?
As a practicing chiropractor with twenty years of experience in this field, and as the author of “How to Avoid Back Surgery: Chiropractic--the Proven Method for Back Pain,” I can attest that this issue has been extensively studied and researchers have come to a few conclusions that shed some painfully honest light on this enormous health problem that would help to resolve this epidemic of low back pain.
Let me answer my first question as to the cause of this epidemic. Without a doubt, the medical boycott of chiropractic care has been the single biggest cause of the lack of effective spinal health care in this country. Although a 1987 federal antitrust case (Wilk et al. v. AMA et al.) decision prohibited this institutionalized hospital discrimination and boycott against the chiropractic profession, the boycott continues on an insidious, covert level. Patients in most hospitals are still denied chiropractic care despite this court decision and the U.S. federal guideline that recommends spinal manipulative therapy (SMT) as a first form of treatment for LBP.
Not only did the U.S. Public Health Service recommend SMT, its guideline also warns that “It should only be done by a professional with experience in manipulation.”  Since chiropractors do 94% of all SMT in this country according to the RAND Corporation study on acute low back pain, one must acknowledge that DCs are the leaders in this form of treatment. Yet SMT is still denied to patients by most hospitals and medical gatekeepers; instead they are given the standard bedrest, pain pills, muscle relaxants, physical therapy and back surgery as their main solutions.
Although the standard medical approach is heralded by medics as the best solution to this epidemic, researchers fail to agree. According to the U.S. federal guideline on LBP, “Surgery has been found to be helpful in only 1 in 100 cases of low back problems... Even having a lot of back pain does not by itself mean you need surgery.”  This extensive study included over 100 reviewers of the final draft who evaluated 3,918 articles from the National Library of Medicine. No leaf was left unturn in this definitive study, and their conclusions shocked the medical world.
The foremost reason why back surgery has been found to be so ineffective rests with their main premise that has been proven false--the disc theory. Whenever a patient has a bout of LBP, the diagnosis usually is either a “pulled muscle” or a “slipped disc.” Interestingly, research has disproved both ideas.
MRI studies first done in 1990 by Scott Boden, MD, at Emory University Medical School have shown that disc abnormalities and back pain are purely coincidental. Two-thirds of patients without back pain were shown to have disc herniations, ruptures and degeneration. Moreover, the U.S. federal guideline also mentioned this mistaken disc premise in their assessment: “Studies of asymptomatic adults commonly demonstrated intervertebral disc herniations that apparently do not entrap a nerve root or cause symptoms.”  Obviously, the “disc theory” has failed to withstand the test of research, yet it still dominates the practice of medicine in regard to the management of LBP because it is so profitable!
Not only did the U.S. guideline not recommend surgery and admits that only 1% of back surgery is helpful, the Canadian study on LBP by Pran Manga, Ph.D., medical economist from the Ontario Ministry of Health, also compares treatments and recommends chiropractic management over medical methods. “There is an overwhelming body of evidence indicating that chiropractic management of LBP is more cost-effective than medical management.”
Why is simple manipulative therapy more effective than expensive back surgery? The key to understanding why spinal manipulation is so effective is to understand that the spine consists of 137 joints interconnecting the 24 vertebrae and 3 pelvic bones. In essence, back pain is joint dysfunction first and foremost. Once you understand this simple fact, then you can understand why any force, trauma, poor posture or bad leverage can adversely affect any of these 137 joints. Just remember: You don’t slip discs as much as you slip spinal joints! Until the misaligned spinal joints are adjusted, no one will be free of back pain, no matter how many disc surgeries are done!
As well as surgery, standard forms of care by physical therapists were also not recommended for LBP. Again, to quote from the Patient Guide, Understanding Acute Low Back Problems, published by the U.S. Public Health Service: “A number of other treatments are sometimes used for low back symptoms. While these treatments may give relief for a short time, none have been found to speed recovery or keep acute back problems from returning. They may also be expensive. Such treatments include: Traction, TENS, massage, biofeedback, acupuncture, injections into the back, back corsets, ultrasound.” 
Inasmuch as the standard medical care and physical therapy treatments have proven expensive and, for the most part, ineffective, and since chiropractic management of LBP is the recommended choice of treatment according to the researchers, why do hospitals still boycott this form of care? The answer rests with money, of course. To reiterate, according to MetLife Insurance statistics, the average “medical non-surgical back” costs $7,210 and the average “surgical back” costs $13,990. But, according to research from the North Carolina Back Pain Institute, the average chiropractic case costs approximately $800 for the same diagnostic code. Obviously, the reason for excluding chiropractors from hospitals is due simply to this economic decision to make more money from surgery than from SMT, despite the facts that have shown SMT to be safer, cheaper, more effective, longer-lasting and with three times the patient satisfaction rates.
Now let me answer my second question as to the solutions to this epidemic of LBP. Of course, the obvious answer is to make chiropractic care available to everyone--every health insurance policy should cover SMT done by DCs, plus every public hospital should offer SMT done by DCs. The public should be made aware of the superiority of SMT for LBP by hospital administrators and physicians who are legally obligated to obtain informed consent from every patient, which means all options to solve their problem should be given in an honest manner, including the rates of side-effects from different types of treatments.
Research by RAND Corporation and other researchers estimate the rate of iatrogenic complications like stroke or paralysis resulting from SMT is 1-2 cases per million, whereas the rate of the same problems caused by spinal surgery is 15,600 per million! Even NSAIDs like Advil and Tylenol have shown to cause serious GI problems in 1,000 to 4,000 people per million, and reportedly 7,600 patients die annually from their use. It’s quite obvious who’s hurting whom, and it’s certainly not the chiropractors!
As the researchers recommend, most back problem treatment should start with conservative chiropractic care. After 4 weeks of treatment, re-evaluation should determine if referral for MRI exams and a possible surgical consultation be arranged for those few cases who fail to respond to SMT. As the Patient Guide suggests: “But you most likely will find out that your symptoms are not being caused by a dangerous medical condition [that requires surgery]. Very few people (about 1 in 200) have low back symptoms caused by such conditions.” 
In light of the new research and governmental recommendations of SMT for LBP, it’s obvious the present medical system has failed to solve this insidious epidemic which continues to worsen in terms of cost and numbers of patients. The solution to this growing epidemic has many levels to address; this multi-faceted problem requires a new understanding of the real cause of LBP, new policies toward the best treatment and innovative solutions at all levels of our society.
One proactive solution is to teach spinal concepts in schools just as dental and other health issues are discussed. Presently, scoliosis checks are done by PE teachers, which are superficial, to say the least. Their exam consists of having the child bend over to check for rib cage distortions. How in high heaven can this detect much of anything?! If I were to do this to my patients, I would be sued for malpractice and laughed out of my profession. Yet, when this is done to our children by amateurs, it’s considered adequate!? If and when a few children are detected, they are sent to the orthopedists without any mention of chiropractic care. Again, parents are not being given informed consent about all possible solutions to their children’s spinal problems; not even the best one!
Another solution is to liberate public hospitals from the medical grasp by demanding equal access for chiropractors to any hospital that accepts federal or state money to operate. Fair competition on a level playing field may be the rule in the open marketplace, but in the sham marketplace of healthcare, closing out the competition has long been the rule in the medical profession. While a private hospital may have that prerogative, any publicly sponsored hospital should allow any licensed practitioner to work. Affirmative action may be a concept that is very applicable in regard to helping the chiropractic profession overcome the decades of discrimination and the illegal boycott by the medical profession to exclude competition in public hospitals. All we chiropractors ask for is a level playing field, something the medical monopoly has long fought against!
Moreover, all health insurance policies should allow patients to seek care from any licensed health professional. “Any willing provider” laws would open the door of the medical monopoly to allow fair competition. Thus, the laws of supply and demand would work to reduce the escalating costs of medical care. After all, why would a LBP patient want to pay $14,000 for ineffective back surgery when chiropractic care costing only $800 has been shown to be more effective, longer-lasting and with three times the patient satisfaction? As it stands now, patients denied their options are being railroaded into expensive back surgeries that only drive up costs and leave many more disabled than before.
My call for true informed consent and making chiropractic care available to all Americans rests with the long-held belief in freedom of choice, something that is greatly lacking in today’s healthcare marketplace. People are routinely denied a choice in their spinal health by virtue of discriminatory hospitals seeking higher profits; they are railroaded into drugs and surgery by medical gatekeepers that refuse to refer to chiropractors; they are forced into surgery when some health insurance refuses to pay for chiropractic care; and they are misled about their children’s scoliosis by superficial spinal exams done by amateurs which route them solely to orthopedists for rod implants.
Indeed, for too long, Americans have been denied a freedom of choice about their most precious possession--their own bodies. In light of the plethora of research which proves chiropractic care is superior to the medical management for most spinal problems, this discrimination has proven dangerous, costly and ineffective. Hopefully, as the trend to “alternative” care continues, more people will discover the facts about this epidemic of low back pain. If and when legislation permits people to seek the care of any and all types of licensed health care providers, patients will then be given the freedom of choice about their own bodies that has long been denied to them. Perhaps, then, this epidemic of back problems and the huge costs associated with ineffective medical care will begin to decrease and Americans will learn of the best solution to their spinal needs--chiropractic care.
 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.
 S. Bigos, ibid.
 S. Bigos, ibid.
 S. Bigos, ibid.
 S. Bigos, ibid.
 M. Mushinski, “Average Hospital Charges for Medical and Surgical Treatment of Back Problems: United States, 1993,” Statistical Bulletin, Metropolitan Life Insurance Co., Health and Safety Education Division, Medical Dept., April-June 1995.
 S. Bigos, ibid.
 P. Manga, et al., “The Effectiveness and Cost Effectiveness of Chiropractic Management of Low Back Pain,” University of Ottawa, 1993.
 Wilk v. AMA U.S. District Court, Northern District of Illinois, Sept. 25, 1987.
 S. Bigos, ibid.
 P. Shekelle, et al, “The Appropriateness of Spinal Manipulation for Low Back Pain.” RAND Corporation Report, Santa Monica, Calif., 1992.
 S. Bigos, ibid.
 S.D. Boden et al., “Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects,” J. Bone Joint Surgery (AM) 72(3):403-8 (1990).
 S. Bigos, ibid.
 P. Manga, ibid.
 S. Bigos, ibid.
 Carey, TS et al. The Outcomes and Costs of Care for Acute Low Back Pain Among Patients Seen by Primary Care Practitioners, Chiropractors and Orthopedic Surgeons. New England Journal of Medicine. 333 (1995): 913-17.
 D. C. Cherkin and F.A MacCornack, “Patient Evaluation of Low Back Pain Care from Family Physicians and Chiropractors,” West. J. Med., 150(March, 1989):351-355.
 “What about serious complications of cervical manipulation?” The Backletter, 1996; 11:115.
 S. Bigos, ibid.