Articles by JCS

Placebo, Placebo...

                                                                                                                                               


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Placebo, Placebo, Placebo

Wild Ride on the Medical Railroad

For the past 30+ years, I’ve watched numerous people being railroaded into drugs, shots, and spine surgeries without given any information that there may be an a safer and more effective route to take for their back pain.

Unquestionably, most every DC has experienced this situation. For example, recently a new patient with acute LBP and sciatica came to my office after taking a detour from the medical express to surgery. She embarked on the medical railroad at the hospital where she was immediately given the SOP consisting of painkillers and muscle relaxors, an MRI showing she had a ‘bad disc,’ recommended to have an ESI before being scheduled for spine surgery.

This medical express is, indeed, a fast track to surgery.

Fortunately, she decided to take a detour to my office despite being told the ubiquitous chirophobia that a chiropractor might paralyze her. Nonetheless, she came because she didn’t like the narcotic painkillers, she didn’t have thousands of dollars, and she didn’t want a shot in her back or surgery.

Upon my examination, her problem was a standard sacroiliac joint sprain/strain, a common misdiagnosis among medical doctors because there is no disc to examine. A few good classic side-posture chiropractic adjustments, along with intersegmental traction, electrotherapy with ice packs, and she quickly reached her destination to be working again.

Her gratefulness outshined her beaming smile to have bypassed the otherwise eventual destinations on the medical fast track to narcotics, shots, and surgery.

Although DCs are accustomed to being the proverbial “last resort” for many, we must not forget the millions of people who are railroaded on the medical fast track despite the guidelines that recommend medical care should be the last destination rather than the first.

Unfortunately, these unsuspecting passengers on the medical train are the collateral damage in the medical war against chiropractors.

Placebo v. Placebo v. Placebo

Stunning new revelations now suggest these medical destinations actually may be mere illusions at best and dangerous, addictive, and disabling at their worse.

Recently numerous studies have appeared questioning the effectiveness of standard medical treatments for spine-related disorders (SRDs) that include both OTC and prescription meds as well as epidural steroid injections that have been shown to be no better than placebo, and even spine surgery that some studies have shown no benefit for chronic low back pain (CLBP) when compared with intensive interdisciplinary rehabilitation.[1]

These revelations support why medical spine care has been dubbed the “poster child of inefficient spine care” by Mark Schoene, editor of THEBACKLETTER, a leading international spine research journal.[2] Indeed, after decades of dominance, it appears the entire multi-billion dollar medical spine industry is built on straw and ready to crumble if and when evidence-based guidelines are followed.

Considering CLBP is the most pervasive and disabling condition in the world,[3] unfortunately, the public has also not heard that medical PCPs have been shown to be “inept” in their training on musculoskeletal disorders,[4] more likely to ignore recent guidelines[5], and more likely to suggest spine surgery than surgeons themselves.[6]

 Most medical physicians and medical media reporters suffer from professional amnesia and forget to inform patients there is a better and safer train to take than this wild ride to surgery. Consequently, at the urging of their medical conductor, many people take the medical train grasping at the medical straws of quick-fix chemical and surgical procedures.

Of course, there are caveats—the 10% of red flag cases consisting of fracture, cancer, serious infections, cauda equina, and the rare and unusual congenital cases. The last thing we DCs need to do is treat such pathoanatomical cases that do need appropriate medical spine care that may be helpful. But, for the vast majority of SRDs that are pathophysiological, not pathoanatomical, our brand of non-invasive spine care is best.

Placebo Prescription Painkillers

The latest revelation on ineffective medical spine treatments focuses on the runaway Hillbilly Heroin train fueled by “pill mills” that dispense opioid painkillers like Halloween candy.

There have been millions of passengers on this drug train. According to Clampdown on Popular Painkillers in The Wall Street Journal, opioids were dispensed to 127.86 million people with sales of $1.05 billion in 2103, up 21% from 2012.[7]

 This locomotor of narcotics painkillers recently hit another speed bump on August 21, 2014 when the DEA published its Final Rule heightening restriction of hydrocodone-combination products (HCPs).

Pure hydrocodone drugs are listed as Schedule II drugs but HCPs, those made with other non-narcotic ingredients like acetaminophen or aspirin, were listed as the less-restrictive Schedule III. The DEA is now putting HCPs on par with powerful illegal narcotics including heroin and methamphetamine, as well as commonly abused medications Adderall and Ritalin.

DEA Administrator Michele Leonhart commented, “Today’s action recognizes that these products are some of the most addictive and potentially dangerous prescription medications available.”[8]

No other class of drugs, pushed or prescribed, is responsible for as many deaths according to the CDC. [9] With that increased use have come increased deaths: 46 people per day, or almost 17,000 people per year, die from overdoses of these drugs. That’s up more than 400 percent from 1999. And for every death, more than 30 people are admitted to the emergency room because of opioid complications.[10]

Comments in The New York Times on the DEA Ruling,In Move to Curb Drug Abuse, D.E.A. Tightens Rule on Widely Prescribed Painkiller emphasize the dangers of this out of control medical train:

“Abuse of painkillers now claims the lives of more Americans than heroin and cocaine combined, according to federal data, and the number of Americans who die from prescription drug overdoses has more than tripled since the late 1990s. Prescription drugs account for the majority of all drug overdose deaths in the United States. In all, drug-induced deaths have outstripped those from traffic accidents.”[11]

The rescheduling means people will be able to receive the drugs for only up to 90 days without obtaining a new prescription in person, no longer able to phone or fax-in one, yet a small hurdle to overcome for pill mill MDs or anyone addicted to painkillers.

Opioid Phobia

Over the years I have discovered that 9 out of 10 patients taking prescription painkillers like Vicadin, OxyContin, Hydrocodone, Percocet, Demerol, Codeine, Lorcet, to name just a few, have no idea they are opiates.

When I mention these meds are equivalent to Heroin, their eyes widen in disbelief since no one else had told them. Perhaps they would be more hesitant to take them if their medical doctor used their street names such as Apache, China girl, Dance fever, Goodfella, Murder 8, Tango and Cash, China white, Friend, and Jackpot.

Indeed, this drug train has a long history according to OxyContin and the Opium Epidemic of the 21st Century:

The drug companies have been ingenious in promoting the opium plant, the same molecular entity that has a history of destroying communities and families for thousands of years.

In the drug company’s promotional campaigns, the public is presented with an individual who is in true need of relief and support. The results have become a convoluted outcome that includes an epidemic of death and addiction. In this period of history, for the opium poppy, the destruction is being fostered under the guise of ‘pain relief’.

In spite of no long term studies or weak documentation at best that conclusively support the use of opium derivatives for chronic pain relief, the distribution of the opioids continues to increase. The same doctors who distribute thousands of pills that include oxycodone and hydrocodone do not understand the causes of addiction and “cravings”…

However, we continue to give unqualified doctors a carte blanche on distribution. If someone was selling OxyContin in your front yard, you would be calling the police during the first drug deal.[12]

Although initially prescribed only for terminally ill cancer patients with intractable pain, twenty years ago Big Pharma waged a publicity campaign to convince wary primary care physicians to prescribe narcotic painkillers for CLBP and MSDs.

To persuade and intimidate ethical MDs who could see the writing on the wall of massive addiction problems, the medical shills for Big Pharma coined the term “opioid phobia” to ridicule those wary of narcotics.

Despite the serious Hillbilly Heroin addiction rampant in our society, there are still “pain management” physicians like Sanford Roth, MD, Chief Executive Officer, Arizona Research and Education, who promote the use of these narcotics, claiming it to be no less than a duty of the Hippocratic Oath.

Dr. Roth wrote of his dismay at criticism of opioid use; in fact, he decries its “under-use” in his Letter to the Editor to Pain Management News:

I am writing because it was disheartening that some presentations by thought leaders at the conference focused upon the physician fears and risks attendant to the prescription use of opioids for chronic nonmalignant pain therapy…At stake is the under-use of opioids—which are the only potent agents available for chronic pain that are not end-organ toxic…Pain medicine physicians need to speak out forthrightly about what we already know from such existing validated, randomized, controlled trials—that providing around-the-clock relief using opioids is not a sign of abuse but, rather, safely counters long-term suffering and restores quality-of-life activities… The result can be restoring quality of life to suffering pain patients and allowing them to return to the work force, thus fulfilling our Oath of Hippocrates.”[13]

I never realized keeping patients stoned on narcotics was fulfilling the Hippocratic Oath, especially when there are non-drug solutions available for chronic pain. Somewhere Dr. Roth has forgotten the creed to “Do No Harm.”

Perhaps Dr. Thomas Frieden, Director of the CDC, was thinking of Dr. Roth when he said, “physicians have supplanted street corner drug pushers as the most important suppliers of illicit narcotics.”[14]

A 2010 study from Denmark, A Population-Based Cohort Study On Chronic Pain: The Role Of Opioids, revealed more disturbing news on opioid use. Although proponents of opioid drugs like Dr. Roth speculate they provide significant pain relief, improve function, and enhance quality of life over the long term, a study by Per Sjøgren, MD, and colleagues refute this claim. To the contrary, they found the use of opioids was associated with inadequate pain relief, poor quality of life, long-term unemployment, and high levels of medical care-seeking.[15]

In 2014, An Update of the Cochrane Review in Spine, Opioids Compared With Placebo or Other Treatments for Chronic Low Back Pain, also mentioned the unproven effectiveness of opioids for long-term use:

Conclusion. There is evidence of short-term efficacy (moderate for pain and small for function) of opioids to treat CLBP compared with placebo. The effectiveness and safety of long-term opioid therapy for treatment of CLBP remains unproven.[16]

Fortunately there are a few sober physicians like Rick Deyo, MD, MPH, who urged caution about this wild ride on the medical train:

“I think we need to be more careful about using our treatments in unproven circumstances. Our data, showing increasing costs without apparent benefit, may be a consequence of ‘promiscuous prescribing’ in the broad sense…I would argue that we may be subjecting patients to side effects and costs without knowing if there’s a benefit.”[17]

Doctor, Heal Thyself

This lunacy makes one wonder if these proponents should be checked for opioid dependency themselves, which isn’t a wild idea considering Medscape suggests in its article, Why MDs Abuse Prescription Drugs, that 69% of the physicians had misused prescription drugs sometime in the past.”

Ironically, the reason given why MDs abuse prescription drugs sounds painfully similar to what most patients might say, too:

Several of the physicians who said that they misused drugs …reported that it was because they had trouble trusting the recommendations from their treating provider.”

Indeed, someone is asleep at the wheel of the Hillbilly Heroin train when both patients and physicians alike are addicted and the prevailing mantra by the shills for Big Pharma ridicule cautious MDs accusing them with “opioid phobia.”

Maybe these pain management specialists and Big Pharma reps should adopt Bob Dylan’s infamous song, Everybody Must Get Stoned.

Undoubtedly, the DEA’s heighten restriction for opioid painkillers will have little impact as long as pain management conductors like Sanford Roth ignore the restrictions and believe pushing narcotics is fulfilling the Oath of Hippocrates.

The size of this drug train is bigger than passengers realize according to the 2013 article in Medscape.com, Many Docs Still Don't Understand Opioid Dependence, that revealed opioid addiction is actually now more pervasive than those patients suffering from diabetes and cancer:

“Results showed that 12% of the adults reported personally struggling with opioid dependence, which the surveyors point out is more than those who struggle with diabetes (7%) or cancer (3%).”[18]

This survey of opioid addiction found it compounded by shame, embarrassment, fear, and the delusion that patients and doctors alike think they can get off the drug train and stop their addiction on their own:

“The survey also found that 77% of the adult participants and 93% of the clinicians said that shame, embarrassment, or fear that others would find out are among the main reasons why those with the addiction might not seek treatment.

“Although 71% of the adults and 85% of the clinicians said that many of these people think they can stop their addiction on their own, 83% and 92% agreed that a long-term combination of medication and behavioral changes is needed for successful treatment.”

In a recent NPR segment on opioid abuse in the military and DVA programs, Veterans Kick The Prescription Pill Habit, Against Doctors' Orders, Dr. Richard Friedman, director of the Psychopharmacology Clinic at Weill Cornell Medical College, spoke of this prescription painkiller abuse.

“It's like giving a football player painkillers so he can finish the game. It gets him back on the field, but might hurt him worse in the long term.”[19]

However, boarding this drug train does not begin as a voluntary choice by veterans, but the mistreatment starts when VA doctors force patients with CLBP to take narcotic painkillers and epidural steroid injections before they will be referred to chiropractors for non-drug care as I have witnessed working with veterans referred from the Dublin (GA.) VA hospital.

Ironically, if these veterans using narcotics and steroids were in the NFL, Olympics, or college football, they would be banned from playing.

Whether in private practice, the VA or military healthcare, or in sports, the Hillbilly Heroin train is running wild out of control. Recently news articles have disclosed the abuse by NFL teams of opioid painkillers that were dispensed indiscriminately to enable their players to continue their playing careers.

On July 12, 2014, journalist Michael O’Keeffe of The New York Daily News revealed the same pill mill painkiller problem among NFL football players in his exposé, EXCLUSIVE: Feds quietly investigating prescription drug abuse in NFL locker rooms, sources say:  

The Drug Enforcement Administration’s probe began after attorneys representing about 1,300 NFL retirees filed a lawsuit accusing the league of illegally handing out painkillers, sleeping pills, and other drugs without informing players of the risks of health problems and addiction. 

Former Chicago Bears quarterback Jim McMahon and other plaintiffs accuse the NFL of illegally providing prescription drugs without telling players about the risks. McMahon says he became hooked on pain pills, at one point gulping down more than 100 Percocets each month.[20]

Just like their NFL fans, little do these NFL players realize the long-term risks far outweigh the short-term high of opioids that actually remain unproven for treatment of chronic pain.[21]

Placebo OTC Medications

Not only are opioids and HCPs huge problems, but a new study has now found common OTC medications initially used in treating SRDs on the drug train were deemed no better than placebo for CLBP.

Tylenol

Many guidelines recommend OTCs before HCPs for CLBP, but apparently they are not without their own consequences, such as being ineffective and the leading cause of liver damage.

Recently a multicenter, “double-dummy” [this is Oz talk for double-blind], randomized, placebo controlled trial by Prof. Christopher G Maher, PhD, et al. across 235 primary care centers in Australia was published in The Lancet and confirmed a commonly used treatment for acute LBP, paracetamol, aka, acetaminophen (Tylenol, Panadol), was no better than placebo.

“Our findings suggest that regular or as-needed dosing with paracetamol does not affect recovery time compared with placebo in low-back pain, and question the universal endorsement of paracetamol in this patient group.”[22]

Acetaminophen overdose results in more calls to poison control centers in the US than overdose of any other pharmacological substance.[23] Almost 80,000 people per year are treated in emergency rooms because they have taken too much, and the drug is now the most common cause of liver failure in this country.[24]

Aleve

Not only is Tylenol toxic and placebo, now Aleve (over-the-counter naproxen) has failed to convince the FDA of its alleged safety. According to a report in Clinical Pain Medicine in February, FDA Advisory Committees Vote Down Lower CV Risk Claim for Naproxen, a panel of two FDA advisory committees voted against asserting that naproxen has a lower risk for cardiovascular (CV) thrombotic events than other nonsteroidal anti-inflammatory drugs (NSAIDs).

Robert G. Lahita, MD, PhD, said the most important outcome of the meeting “was clearly the Aleve story. Aleve had gotten a lot of good press regarding its being the least effective of hypertension and cardiotoxicity of all the nonsteroidals…We felt that there was still a risk and it was sort of painting something over with a patina that really didn’t apply.”[25]

Dr. Lahita added, “We can’t control what the public does with over-the-counter medications. We all know that patients take these things like candy when they buy them in the drugstore.”

Sanford Roth, MD, inexplicably criticized the use of NSAIDs, especially in high-risk groups. “We are still giving a huge number of people—the elderly—not only NSAIDs on a chronic basis but…there is no justification in the high-risk group for continuing that medication.” [26]

Despite critical of NSAIDs, Dr. Roth still recommends tramadol, other opioids, and even fish oils for the elderly:

“Now here’s what tramadol and the opioids don’t do: They are not end-organ toxic and they are not anti-inflammatory. If you want anti-inflammatory, one way to do it is to double your dose of fish oil, and that’s been fairly well shown.”

Flexeril

Another commonly prescribed med for CLBP is Flexeril, aka, cyclobenzaprine, a muscle relaxant commonly prescribed for myofascial pain (MP), injuries, and sprains. As every DC knows, this is the standard entry-level med prescribed by MDs for anyone with MP.

In 2012, over 26 million prescriptions made it widely available. The DEA lists it as “a drug of concern” that is used to enhance the effect of mind-altering drugs or combined with alcohol and other depressants to induce deep states of relaxation.

According to the Cochrane Review, Cyclobenzaprine For The Treatment Of Myofascial Pain In Adults,  the authors concluded “There was insufficient evidence to support the use of cyclobenzaprine in the treatment of MP.”[27]

Obviously there is no drug solution to CLPB, whether OTC or prescription medications. Now there is even question whether these popular yet ineffective drugs do anything but harm the patients while making physicians and Big Pharma a lot of money.

Dr. Sanford Roth was spot on when he admitted:

“In the practical world, it’s industry and not the government that brings us these drugs. It’s completely skewed by the fact that profit influences where the interest and studies go. It goes ultimately to marketing potential.”

Dr. Sanjay Gupta discussed on CNN another drug treatment for chronic pain from a study published in JAMA, Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010, that finds that states with medical pot have 25% less deaths from painkiller overdoses.[28]

Does it come as a surprise that Dr. Gupta is again pushing pot for pain while he refuses to recommend a legal, safe, and proven treatment for chronic LBP, namely chiropractic care? As a neurosurgeon, it may be asking too much for him to follow the accepted guidelines for non-drug treatment of a competitor before he recommends yet another drug for pain control.

Indeed, perhaps in the future (or presently in Colorado or Washington) a new destination on the medical train will be “pop and pot” to give patients the best of both worlds.

Placebo Injections

Another common yet controversial treatment used extensively ‘off-label’ on the medical drug train include epidural steroids injections (ESIs) that have never been approved by the FDA for back pain[29] and recently found to be no better than placebo.[30]

In 2011 the British Medical Journal published a very revealing comparative study for the ESI treatment of chronic low back pain that was performed in Norway, Effect Of Caudal Epidural Steroid Or Saline Injection In Chronic Lumbar Radiculopathy: Multicentre, Blinded, Randomised Controlled Trial.[31]

The investigators recruited a severely disabled group of 116 patients with chronic low back pain and randomly assigned them into 3 groups. The active treatment group received epidural injections of cortisone; the control group received epidural injections of saline; and the third group received a sham treatment of saline injected subcutaneously.

As it turned out, there was no difference between the three treatment groups for all time points. All patients improved, but the epidural injection of prednisone did not lead to a better improvement than a sham injection.

According to Hans-Christoph Diener, MD, PhD,

“This study is very important when we talk to our patients who have low back pain. I think we can tell them that this invasive procedure is not better than placebo treatment. Our advice should be to stay with conservative treatments like regular exercise, physical therapy [chiropractic care], and if necessary intake of nonsteroidal anti-inflammatory drugs and behavioral therapy.”

THEBACKLETTER recently reported another death knell study for ESIs.[32]  Janna Friedly, MD, of the University of Washington and colleagues evaluated the impact of epidural steroid injections on patients with back, buttock, and/or leg symptoms stemming from central spinal stenosis.

“Compared to injections with local anesthetic alone, injections with glucocorticosteroids provided these patients with minimal or no additional benefit.” [33]

This study drew comment from Chris Maher, PhD whose research group published in 2012 in the Annals of Internal Medicine, showing the benefits of epidural steroid injections were too small to have a clinically significant impact.[34] He also was involved in the aforementioned paracetamol study in Australia published in The Lancet17:

“This trial is not the first to question the use of steroid injections for back pain. Research conclusively shows that, regardless of the type of back pain you have, the area of the back that is injected, or the route of administration, steroid injections are ineffective for back conditions.”27

The emerging trend is clear that epidural injections are ineffective in the management of spinal stenosis but also in the treatment of sciatica related to disc herniations.

An earlier criticism of ESI appeared in the American Pain Society Bulletin in 2000 by Steven H. Sanders, PhD, who revealed nerve blocks for back pain were not supported by scientific research:  “From the current review, we must conclude injections and nerve blocks produce a large amount of money with very little science to support their application.”[35]

Placebo Surgery

In 1994 the AHCPR guideline found surgery to be helpful in only 1 in 100 cases of low back problems.[36] This guideline fell on deaf ears considering just a few years later between 2002 and 2007, passengers on the medical train destined to spine fusions actually increased 15-fold[37] despite the research debunking the ‘bad disc’ theory, now dubbed “incidentalomas”[38] because ‘bad discs’ are found in pain-free people, too.

The paradigm shift in spine diagnosis and treatment began in 1990 when MRI research by Scott Boden, MD, now director of the Spine Center at Emory University, debunked the discogenic theory when he found many people without back pain also had herniated or degenerated discs,[39] but this ‘bad disc’ diagnosis remains the basis of most back surgeries.

David Newman-Toker, MD, a neurologist at Johns Hopkins Hospital, has studied the problem of medical mistakes and admits that diagnostic errors are rampant. This is especially true for misdiagnosis of back pain that remains embedded in pathoanatomic issues, i.e., ‘bad discs’,  rather than pathophysiologic issues like movement, compression, and functional problems.

Dr. Toker also suggests the primary reason doctors mess up a diagnosis is “overconfidence”:

“Doctors may not take the time or be willing to consider alternative possibilities for a patient’s symptoms. Doctors are trained in medical school that if it sounds like hooves, then it must be a horse. But what if it’s a zebra?”[40]

Indeed, if it’s not the horse’s disc, maybe it’s the zebra of joint dysfunction. Although back pain can have various causes that are helped by various professionals, such as disc derangement, radiculopathy, and muscle trigger points, the single-largest source is due to joint pain. Two studies by Murphy and Hurwitz found joint dysfunction was the cause of neck pain in 69% of cases and the cause of low back pain (lumbar and sacroiliac) in 50% of patients.[41],[42]

Considering there are over 300 joints in the spine[43], joint dysfunction sounds keenly possible, yet ignored by inept or biased MDs or those who stand to lose a lot of money when this fact gains popular ground.

No doubt the “overconfidence” and professional amnesia stems from being atop the medical pecking order where spine surgeons have the highest average salary of all physicians at $806,000 according to Bloomberg News, “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies.” In many instances, the kickbacks from hospitals, MRI centers, device manufacturers and, of course, Big Pharma, total over one million dollars more than the average surgeon’s salary.[44]

In spite of the proof of the many placebo treatments in medical spine care, it makes too much money for the medical train to change tracks and follow the evidence-based guidelines in this era of healthcare reform whose goal is to improve outcomes and lower costs.

This detour away from spine surgery became more confusing with the release of a 2008 RCT in the British Medical Journal by WC  Peul, MD, et al., Prolonged Conservative Care Versus Early Surgery In Patients With Sciatica Caused By Lumbar Disc Herniation: Two-Year Results Of A Randomized Controlled Trial.[45]

Peul and his associates clouded the treatment of sciatica with a study that was filled with dumbfounding opinion, omissions, bias, and most prominently, the definition and administration of “conservative care” that “comprised the prescription of effective painkillers according to prevailing guidelines and the advice to resume daily activities if feasible.”

From the Peul study summary:

“Treatment methods were straightforward. Those allocated to disc surgery underwent microdiscectomy and removal of loose degenerated disc material from the disc space. General practitioners supervised conservative care. There are no proven nonoperative treatments for sciatica, so the treatment approach was empirical. It included information, reassurance, pain control, and encouragement to return to normal activity. Those who were fearful of movement were referred for physical therapy. Both groups had access to research nurses for advice and encouragement.”

Inexplicably, this study had obvious shortcomings that only a professional versed in conservative spine care would notice. While I have no problem with microdiscectomy for the removal of loose material from the disc space, I did find five other comments rather skewed:

  1. “General practitioners supervised conservative care.” Okay, stop gasping because it is well-established that primary care physicians have little, if any, education or training in musculoskeletal disorders.[46]
  2. “There are no proven nonoperative treatments for sciatica.” There are many studies supporting the use of manual medicine in the treatment of LBP/leg pain; just take a look at the lengthy reference list in the endnotes.[47]
  3. “It included information, reassurance, pain control, and encouragement to return to normal activity.” Okay, now stop laughing. Apparently ‘happy talk’ and taking painkillers is regarded as the norm for “conservative care” for these untrained medical personnel.
  4. “Those who were fearful of movement were referred for physical therapy.” This referral policy is incredulous since DCs are the primary spine care providers, not PTs using physiotherapeutics.
  5. “Both groups had access to research nurses for advice and encouragement.” Gimme a break. What advice can a “research nurse” give to patients on the care of CLBP other than to ply them with more drugs and ‘happy talk’.

Rather than “straightforward,” I found this study to be riddled with astonishing misconceptions and promoting mistreatments.

If Peul wanted a true comparison between surgery and the best of conservative care, he should have used DCs administering SMT, axial decompression, spine exercises, and acupuncture, along with the aid of therapeutic massage therapists.

 His conclusion as a neurosurgeon was even more astonishing when Peul suggested discectomies for sciatica were preferable and cost-effective over conservative care in the short term (6 weeks), but admitted not in the long term (6 months):

The advantage was discernible six weeks after surgery but vanished by six months. And there were no significant differences between treatment groups in pain or disability beyond that follow-up point.”

Not only were there long term “significant differences” for surgery over medically-administered conservative care, another factor omitted in Peul’s study is that most patients who were considered a “surgical success” were still living on pain pills:

“The definition of success did not consider pain relief or opioid medication use. 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.”[48]

Regrettably, despite the many cost-effectiveness studies supporting the use of CAM conservative care in the treatment of LBP/leg pain32, Peul’s study will be used to dash the role of chiropractic care by medical trolls who fall for his ill-begotten comparison, such as the 2013 Cochrane review update, Spinal Manipulative Therapy For Acute Low Back Pain: An Update Of The Cochrane Review, that” downgraded the effects of chiropractic from statistically but not clinically significant to non-existent.”

This study by Rubinstein et al. concluded,

“SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies.”[49] 

Fortunately, Drs. Stephen Perle and Mike Schneider wrote a response to this Cochrane Review that explains the pros and cons of the systematic review, Challenges and Limitations of the Cochrane Systematic Review of Spinal Therapy.[50]  

Of course, the Cochrane Review flies in the face of notable studies such as the 2008 guideline for LBP issued by the American Pain Society, Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society, that principally recommends CAM methods for LBP when self-care fails:

“…clinicians should consider the addition of nonpharmacologic therapy with proven benefits for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga…”

It also mentions grave concerns about the small improvement after back surgery:

Some studies have shown no benefit of surgery compared with intensive interdisciplinary rehabilitation, with a significant proportion of patients experiencing suboptimal outcomes, including persistent pain or functional deficits after surgery.

On the basis of the evidence, Dr. Chou said, they were unable to give strong recommendations for surgery, "but we think there may be some patients for whom surgery, fusion specifically, might be helpful, but it's really important for doctors to discuss the fact that surgery doesn't tend to lead to huge improvements on average. You're talking about a 10- to 20-point improvement in function on a 100-point scale, so that's pretty small, and a significant proportion of patients still need to take pain medication and don't return to full function."[51]

Another study in JAMA in 2006, Surgical Vs Nonoperative Treatment For Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial (SPORT) Observational Cohort, showed surgery modestly superior to nonoperative care, principally medical conservative care, in both RCTs and observational studies. [52]  

However, after a 2013 systematic review comparing surgical to nonsurgical care for degenerative spinal stenosis, Dutch researchers Wilco Jacobs, PhD, and colleagues, offered a lukewarm endorsement:

“In conclusion, surgery appears to result in better outcomes (leg pain and disability) with regard to conservative interventions, but the evidence is heterogeneous and the underlying methodology is of low quality.”[53]

At the crux of this comparison is the “appropriate nonsurgical conservative care that is impossible to define at the moment” according to THEBACKLETTER. The quandary seems to be the medical version of conservative care versus the CAM version of Chiropractic, Acupuncture, and Massage therapy.

Indeed, a true heavyweight fight between medical conservative care versus CAM spine care would be a fight worth betting on!

Curabo Effect

A revealing study from Switzerland reported in Spine, “Prognosis or "Curabo Effect?": Physician Prediction and Patient Outcome of Surgery for Low Back Pain and Sciatica,”  also suggests a surgeon’s optimistic attitude to perform surgery may also be deceiving patients with an unrealistic prognosis compared to actual patient outcomes.[54]

According to this study done at the University of Lausanne, 197 patients had surgery for low back pain or sciatica whose surgeons forecasted “excellent or at least moderate improvement” for nearly all (99%). Rather than the optimistic 99% prediction by surgeons, in fact, 56% of the patients still showed no significant improvements in their general health a year after their back surgery.

The Swiss team concluded that “surgeons tended to give overly optimistic predictions that were not correlated with patient outcome.”

The researchers believe the “more optimistic physician expectation was associated with better improvement of psychological dimensions,” what they referred to as the “curabo effect,” that is, the power of suggestion, not unlike the “placebo effect” where patients think they improve without any real intervention.

The “curabo effect” typifies many problems with spine surgery today, beginning with the surgeons’ power of persuasion, spine surgeries based on “incidentalomas” detected from ‘false-positive’ MRIs often leading to poor outcomes at high costs then to recidivism and often disability. Indeed, back surgery has become a deceptive web woven by surgeons who prey upon unsuspecting patients.

For too many patients, this medical wild ride on placeboes often ends in a crash, which explains the “tragic human wreckage” according to 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.”[55]

Medical Myopia

Clearly the wild ride on the medical train has had many casualties due to misdiagnosis, mistreatments, and misinformation about alternative destinations, which may explain the critical comment of the editor of THEBACKLETTER:

"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.”[56]

Dr. Tim Johnson, former ABC World News medical spokesman, also questions this wild ride to surgery:

“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.”[57] 

Do I hear an “amen” from the chiropractic choir?

The obvious question remains for a profession purportedly steeped in the scientific mindset: why are they doing addictive drugs, ineffective ESIs, and expensive, risky surgery when the research now show the long term results are no better than placebo?

Okay, stop laughing because we know why: MONEY, and a lot of it, too. Back pain alone is the #1 disabling condition in the nation with total costs approaching $300 billion in the US,[58] and for all musculoskeletal disorders (MSDs), this figure jumps to $850 billion annually.[59]

Perhaps Dr. Jerry Groopman answered Johnson’s question when he admitted in his article in The New Yorker magazine, "If I don't do them, they'll go around the corner and the other surgeon will.”[60]

Rick Deyo, MD, MPH, renowned spine researcher, admits the medical train is out of control:

''People say, 'I'm not going to put up with it,’ and we in the medical profession have turned to ever more aggressive medication, narcotic medication, surgery, more invasive surgery.''[61]

Despite Dr. Deyo’s chagrin, as long as billions of dollars are at stake, we can’t expect the medical spine industry to make the ethical choice and refer these SRDs to chiropractors, which explains why the profit motive in American healthcare has created what is best termed “zombie spine care.”

This medical fast track in zombie spine care today reminds me of the iconic 1948 cartoon, "Daffy Duck Slept Here". Daffy, posing as a train conductor, announces, "Train leaving on Track 5 for Anaheim, Azusa and Cuuuuucamonga" as he pushes an unsuspecting Porky Pig out the hotel window onto the imaginary train.

Indeed, back pain passengers should not be surprised when the fast track medical train embarks and the conductor calls out the destinations, “placebo drugs, placebo shots, and plaaaacebo surgery.”



[1] Low Back Pain Guidelines Expanded to Include Interventional Procedures, American Pain Society 27th Annual Scientific Meeting: Symposium 312. Presented May 8, 2008.

[2] US Spine Care System in a State of Continuing Decline?, The BACKLetter, vol. 28, #10, 2012, pp.1

[3] Peter W. Crownfield, Back Pain Is #1 Cause of Disability Worldwide, Global Burden of Disease 2010 highlights the pressing need to prevent, treat spinal and musculoskeletal disorders. Dynamic Chiropractic – February 15, 2013, Vol. 31, Issue 04

[4] EA Joy, S Van Hala, “Musculoskeletal Curricula in Medical Education-- Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/11 (November 2004).

[5] PB Bishop 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.

[6] SS Bederman, NN Mahomed, HJ Kreder, et al. In the Eye of the Beholder: Preferences Of Patients, Family Physicians, And Surgeons For Lumbar Spinal Surgery,” Spine 135/1 (2010):108-115

[7] Louise Radnofsky and Joseph Walker, Clampdown on Popular Painkillers, WSJ, 8/22/2014.

[9] Louise Radnofsky and Joseph Walker, Clampdown on Popular Painkillers, WSJ, 8/22/2014.

[10] Special report: The dangers of painkillers, Consumers Report, July 2014

[12] Larry Golbom, OxyContin and the Opium Epidemic of the 21st Century, US Recall News, January 2, 2009

[13] Sanford H. Roth, MD, Opioid Phobia, Letter to the Editor, Pain Medicine News, August 2006 | Volume: 04:04

[14] Centers for Disease Control and Prevention Press Release, CDC Vital Signs: Overdose of Prescription Opioid Pain Relievers—United States, 1999-2008; 2011: www.cdc.gov/media/releases/2011/t1101_presecription_pain_relievers.html.

[15] Per Sjøgren et al., “A Population-Based Cohort Study On Chronic Pain: The Role Of Opioids,” Clinical Journal of Pain, 26/9 (2010):332-9

[16] Luis Enrique Chaparro, MD, Andrea D. Furlan, MD, PhD, Amol Deshpande, MD, Angela Mailis-Gagnon, MD, MSc, FRCPC, Steven Atlas, MD, Dennis C. Turk, PhD, Opioids Compared With Placebo or Other Treatments for Chronic Low Back Pain, An Update of the Cochrane Review, Spine. 2014;39(7):556-563

[17] The BackLetter® 33 Volume 23, Number 3, 2008

[18] Deborah Brauser, Many Docs Still Don't Understand Opioid Dependence,

www.medscape.com Jun 14, 2013

[19] Veterans Kick The Prescription Pill Habit, Against Doctors' Orders, by Quil Lawrence, All Things Considered,  NPR, July 11, 2014

[20] Michael O’keeffe, EXCLUSIVE: Feds quietly investigating prescription drug abuse in NFL locker rooms, sources say, NEW YORK DAILY NEWS, Saturday, July 12, 2014

[21] Luis Enrique Chaparro, MD, Andrea D. Furlan, MD, PhD, Amol Deshpande, MD, Angela Mailis-Gagnon, MD, MSc, FRCPC, Steven Atlas, MD, Dennis C. Turk, PhD, Opioids Compared With Placebo or Other Treatments for Chronic Low Back Pain, An Update of the Cochrane Review, Spine. 2014;39(7):556-563

[22] Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial, Dr Christopher M Williams PhD, Prof Christopher G Maher PhD, Prof Jane Latimer, Prof Andrew J McLachlan PhD, Mark J Hancock PhD, Prof Richard O Day MD, Chung-Wei Christine Lin PhD, The Lancet, Early Online Publication, 24 July 2014 doi:10.1016/S0140-6736(14)60805-9Cite or Link Using DOI

[23] Lee WM (2004). "Acetaminophen and the U. S. Acute Liver Failure Study Group: lowering the risks of hepatic failure". Hepatology 40 (1): 6–9. doi:10.1002/hep.20293. PMID 15239078.

[24] Special report: The dangers of painkillers, Consumers Report, July 2014

[25] FDA Advisory Committees Vote Down Lower CV Risk Claim for Naproxen, Clinical Pain Medicinek, April 2014, vol 12(4)

[26] FDA Advisory Committees Vote Down Lower CV Risk Claim for Naproxen, Clinical Pain Medicinek, April 2014, vol 12(4)

[27] Leite FM, Atallah AN, El Dib R, Grossmann E, Januzzi E, Andriolo RB, da Silva EM, Cyclobenzaprine for the treatment of myofascial pain in adults. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD006830. doi: 10.1002/14651858.CD006830.pub3

[28] Marcus A. Bachhuber, MD; Brendan Saloner, PhD; Chinazo O. Cunningham, MD, MS; Colleen L. Barry, PhD, MPP, Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010, JAMA Intern Med. Published online August 25, 2014.

[29]Epidural Corticosteroid Injection: Drug Safety Communication - Risk of Rare But Serious Neurologic Problems,” FDA, April 23, 2014

[30] Bicket MC et al, Epidural injections for spinal pain:  A systematic review and meta-analysis evaluating the “control’ injections in randomized control trials, Anesthesiology, 2013; 119 J Silberner, “Surgery May Not Be The Answer To An Aching Back,”  All Things Considered, NPR (April 6, 2010:907-31.

[33] Friedly J, et al., A randomized trial of epidural glucocorticoid injections for spinal stenosis. , New England Journal of Medicine. , 2014; 371:11–21.

[34] Pinto RZ, et al., Epidural corticosteroid injections in the management of sciatica: A systematic review and meta-analysis, Annals of Internal Medicine, 2012; 157:865–77.

[35] SH Sanders and P Vicente, Medicare and Medicaid Financing For Pain Management: The Wrong Message At The Right Time, The Journal of Pain, 1/3 (September 2000):197-198. 

[36] Bigos 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)

[37] RA Deyo, “Conservative Therapy for Low Back Pain: Distinguishing Useful From Useless Therapy,” JAMA 250 (1983):1057-62

[38] Deyo, ibid.

[39] 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.

[40] Lynn Allison, “Doctor Errors Kill 500,000 Americans a Year”, NewsmaxHealth, August 26, 2014

[41] Donald R Murphy and Eric L Hurwitz, Application of a diagnosis-based clinical decision guide in patients with neck pain, Chiropractic & Manual Therapies 2011, 19:19

[42] Donald R Murphy and Eric L Hurwitz, “Application of a diagnosis-based clinical decision guide in patients with low back pain,” Chiropractic & Manual Therapies 2011, 19:26

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

[44]Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies” by Peter Waldman and David Armstrong, Bloomberg News, Dec. 30, 2010

[46] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28(2003):524-525.

1. Elizabeth A. Joy, MD; Sonja Van Hala, MD, MPH, “Musculoskeletal Curricula in Medical Education-- Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/ 11 ( November 2004).

2. PB Bishop 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.

3. SS Bederman, NN Mahomed, HJ Kreder, et al. In the Eye of the Beholder: Preferences Of Patients, Family Physicians, and Surgeons for Lumbar Spinal Surgery,” Spine 135/1 (2010):108-115.

4. Matzkin E, Smith MD, Freccero DC, Richardson AB, Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am 2005, 87-A:310-314

5 Stockard AR, Allen TW. Competence levels in musculoskeletal medicine: comparison of osteopathic and allopathic medical graduates. J Am Osteopath Assoc. 2006 Jun;106(6):350-5

6. Medical Student Musculoskeletal Education, An Institutional Survey, Nathan W. Skelley, MD, Miho J. Tanaka, MD, Logan M. Skelley, BS, and Dawn M. LaPorte, MD, Investigation performed at the Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland

[47] David Chapman-Smith, Cost-Effectiveness Revisited, The Chiropractic Report, November 2009 Vol. 23 No. 6

 1 Choudhry N, Milstein A (2009) 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 Health Care Spending. Harvard Medical School, Boston, Mercer Health and Benefits, San Francisco.

3 (2004) United Kingdom Back Pain Exercise and Manipulation (UK BEAM) Randomised Trial: Cost Effectiveness of Physical Treatments for Back Pain in Primary Care, BMJ;329:1381.

4 Manga P, Angus D (1998) Enhanced Chiropractic Coverage Under OHIP as a Means of Reducing Health Outcomes and Achieving Equitable Access to Select Health Services, Ontario Chiropractic Association, Toronto.

5 Stano M, Smith M (1996) Chiropractic and Medical Costs for Low-Back Care, Med Care 34:191-204.

6 Smith M, Stano M (1997) Cost and Recurrences of Chiropractic and Medical Episodes of Low-Back Care, J Manipulative Physiol Ther, 20:5-12.

7 Jarvis KB, Phillips RB et al. (1991) Cost per Case Comparison of Back Injury of Chiropractic versus Medical Management for Conditions with Identical Diagnosis Codes, J Occup Med, 33:847-52.

8 Ebrall PS (1992) Mechanical Low-Back Pain: A Comparison of Medical and Chiropractic Management within the Victorian Workcare Scheme, Chiro J. Aust 22:47-53.

9 Johnson W, Baldwin M (1996) Why is the Treatment of Work-Related Injuries so Costly? New Evidence from California, Inquiry 33:56-65.

10 Jay TC , Jones SL et al. (1998) A Chiropractic Service Arrangement for Musculoskeletal Complaints in Industry: A Pilot Study, Occup Med 48:389-95.

11 Mosley CD, Cohen IG et al (1996) Cost-Effectiveness of Chiropractic Care in a Managed Care Setting, Am J Managed Care 11:280-2.

12 Legorreta AP, Metz RD, Nelson CF et al. (2004) Comparative Analysis of Individuals with and without Chiropractic Coverage, Patient Characteristics, Utilization and Costs, Arch Intern Med 164:1985-1992.

13 Meade TW, Dyer S et al. (1990) Low-Back Pain of Mechanical Origin: Randomised Comparison of Chiropractic and Hospital Outpatient Treatment, Br Med J 300:1431-37.

14 Haldeman S, Carroll L et al. (2008) The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders; Executive Summary, Spine 33 (4S):S5-S7

15 Wolsko PM, Eisenberg DM et al. (2003) Patterns and Perceptions of Care for Treatment of Back and Neck Pain. Results of a National Survey, Spine 28(3):292-298.

16. Whedon JM, Song Y, Davis MA. Spine J., Trends in the use and cost of chiropractic spinal manipulation under Medicare Part B., 2013 Jun 14. pii: S1529-9430(13)00521-4. doi: 10.1016/j.spine.2013.05.012.

[48] 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.

[49] Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW (February 2013). "Spinal manipulative therapy for acute low back pain: an update of the cochrane review". Spine (Systematic Review) 38 (3): E158–77. doi:10.1097/BRS.0b013e31827dd89d. PMID 23169072

[50] J Amer Chiropr Assoc 2012 Nov-Dec;49(6):28-32

[51] Low Back Pain Guidelines Expanded to Include Interventional Procedures, American Pain Society 27th Annual Scientific Meeting: Symposium 312. Presented May 8, 2008.

[52] Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. Weinstein JN1, Lurie JDTosteson TDSkinner JSHanscom BTosteson ANHerkowitz HFischgrund JCammisa FPAlbert TDeyo RA, JAMA. 2006 Nov 22;296(20):2451-9.

[53] Jacobs WC, et al., Evidence for surgery in degenerative lumbar spine disorders. , Best Practice & Research Clinical Rheumatology. , 2013; 27:673–84.

[54] B Graz, V Wietlisbach, F Porchet, JP Vader, Prognosis or "Curabo Effect?": Physician Prediction and Patient Outcome of Surgery for Low Back Pain and Sciatica,” Spine 30/12 (June 15, 2005):1448-1452

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

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

[57] 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.

[58] The Burden of Musculoskeletal Diseases in the United States Bone and Joint Decade, Copyright © 2008 by the American Academy of Orthopaedic Surgeons, pp. 21.

[59] Medical Student Musculoskeletal Education, An Institutional Survey, Nathan W. Skelley, MD, Miho J. Tanaka, MD, Logan M. Skelley, BS, and Dawn M. LaPorte, MD, Investigation performed at the Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland

[60] The New Yorker magazine by Dr. Jerry Groopman, "Knife in the Back,“ (April 8, 2002)

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


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