Articles by JCS

Pushing Over the Point

Challenge to F4CP

Pushing Over the Point

With all due respect, sir, I believe this is gonna be our finest hour,” said Gene Kranz, NASA Mission Commander, during the near disaster of the Apollo 13 ordeal with the possibility of losing three astronauts adrift in outer space or death upon re-entering the earth's atmosphere.

Our brave pioneers in chiropractic have also overcome potential disasters many times in the medical war over the past century.

Some of their astronomical efforts include:

  • Fighting the early legislative and legal battles in each state and the 85 countries around the world to establish licensure to keep chiropractors out of jail.
  • Achieving regional/federal/international accreditation of our colleges.
  • Lobbying for inclusion in WHO, TRICARE, Medicare, Workers Comp, DVA, FEP, & state health insurance programs.
  • Defeating the AMA, “the most terrifying trade association on earth,” in the Wilk antitrust trial.
  • Battling for research funding.
  • Politicking for freedom of choice in Obamacare with Section 2706.

Now we can add yet another achievement in the medical war. After twenty years of RCTs in this era of evidence-based healthcare, we can proudly say we have accomplished our own successful landing in the court of scientific opinion.

Our own Mission Commander, the renowned Scott Haldeman, MD, DC, PhD, confirms that every credible guideline on spine care now recommends conservative care first:

        The paradigm shift has already taken place. Non-surgical, non-invasive care is already the first choice for treatment for spinal disorders in the absence of red flags for serious pathology in virtually all guidelines.”[1]

With this feather in our cap as CAM providers (Chiropractic, Acupuncture, Massage therapy), it’s our turn to tout chiropractic care among the “best practices” in spine care for the majority of back pain cases, a claim now fully supported by international research and guidelines.

This revelation is enormous considering back pain is now pandemic, terribly expensive, and virtually inescapable, striking most of the 250 million American adults sometime in their lives.
          For example:

  • Nearly one-third of adults will suffer daily with low back pain, which equates to 92.5 million people;
  • Two-thirds of adults will have a back attack within the year, which equates to 190 million;
  • 85% or 212.5 million adults will have a severe back attack in their lifetime, and
  • 20% will describe their pain as severe and crippling.[2]

 Considering the fact that low back pain has become the #1 disabling condition in the nation/world with total costs nearly $300 billion annually in the USA alone,[3] DCs will be among the most valued and busiest practitioners in the new era of evidence-based fee-for-value system that will soon replace the abused fee-for-service system that has driven America to the brink of bankruptcy.

As Lou Sportelli, DC, suggests:

 “If doctors of chiropractic only cornered the market on one condition, back pain, there would not be enough [chiropractors] now to handle the volume.”[4]

Although not as dramatic as a rescued space odyssey from the earth to the moon and back, we’ve come a long way in a short 100 years from persecution to vindication.

The amassing of the numerous legislative, political, academic, research, and legal battles waged over the last century has been no less a feat to accomplish and given us the rare opportunity to crow (AHCPR, Manga).

To add more salt to the medical wound, new studies and newspaper articles now expose the overall ineffectiveness of medical spine care that has been called the “poster child of inefficient spine care” by Mark Schoene, a leading spine journal editor.[5]  

Without a doubt, the stars are now aligning for a new awakening in spine care with DCs at the forefront.

Chiropractic, We Have a Problem

Just as retrieving a crippled Apollo module was a huge challenge to NASA officials, we need to admit like the NASA folks at Houston that we have a problem, too.

We face a huge challenge to repair the decades of medical propaganda at the core of our perceived public image. Judge Susan Getzendanner of the Wilk v. AMA antitrust trial also remarked about this public defamation in her court Opinion:

“In my judgment, this injury continues to the present time and likely continues to adversely affect the plaintiffs.  The AMA has never made any attempt to publicly repair the damage the boycott did to chiropractors’ reputations.”[6]

Our public image, identity, and message have certainly been blurred after a century of medical disinformation, political demagoguery, and legal malfeasance by the “most terrifying trade association on earth,” the AMA.

The call to repair the damage to our reputation is not new. Many chiropractic associations over the years have taken this task to hand. In 2002, I was assigned to the ACA’s PR AD HOC Committee and compiled the following report of previous campaigns that I presented at NCLC in March of 2003. You can read this lengthy (no, not me) and fascinating study of the many previous programs and commentaries.

         Table of Contents 

1.   Chiropractic Deafness            

2.   Australia: 1992                         

    Dangar Research Group

3.   Canadian Report: 1994                  

         On Attitudes Toward Chiropractic

4.   Public Relations Program: 1992          

    For The ACA by Clayton Davis & Associates  

5.   New Zealand Report: 1993      

         Understanding the Market Qualitative Report

6.   Oklahoma Poll: 1984                    

        “I wouldn’t want my daughter to marry one.”     

7.   Pennsylvania Report: 1982         

         The Role And Image Of Chiropractic Services

8.   Chiropractic Opinion Survey      

    Reader’s Digest Insert

9.   An Image Of A Doctor   

         By Jerome F. McAndrews, DC

10.  “The Voice of Reason”                    

           Summary & Recommendations by JC Smith, MA, DC


Pushing the Envelope of PR

Dynamic Chiropractic publisher, Donald Petersen, Jr, recently mentioned in his editorial, Changing Times, the need to change our message and image by promoting our value to society:

“While it is definitely important to continue our efforts in research and public relations, it is time to change the message. It's time to focus on the benefits of chiropractic care and the value of good spinal health. Research can certainly confirm this, but the public needs to appreciate the impact their doctor of chiropractic can have on their current and continued health. This message would certainly include our cost-effectiveness.

“The public must see chiropractic as every bit as valuable as podiatry, dentistry and medicine before the average DC gets paid more. We are only halfway there in communicating our value proposition. We need to work harder on this.”[7]

Even with this progress in the court of scientific opinion, our biggest battle remains in the court of public opinion. The jury is still out in the public’s mind due to a century of “unreasonable” doubt imprinted by the AMA’s indelible and illegal party line that “everybody knows that chiropractic is an unscientific cult.”[8]

No other profession has survived such atrocious defamation. Our challenge is to replace that doubt with newsworthy evidence to show the public that “chiropractors have their backs” and the time has never been better as we approach our own finest hour.

 This will require a new message, a new agenda, and a new image to replace the ill-begotten reputation contrived by our medical curmudgeons and, unfortunately, at times aided by chiropractic demagogues and scalawags who occasionally shot our professional image in the foot.

Despite the battles won by litigation in the courts and legislation on Capitol Hill, winning in the court of public opinion will be a more formidable task to:

  1. Promote the evidence-based guidelines endorsing our brand of care
  2. Emphasize to the public of the ineffectiveness of medical spine care.
  3. Push back the unacceptable medical prejudice and perceived wisdom about chiropractic.
  4. Challenge the journalistic amnesia that ignores our profession.
  5. Show the public that we can help millions and save billions.

The challenges on this list may seem daunting, but underlying issues must be addressed before the public and press clearly understand our controversial plight, the benefits we offer, and buy into our paradigm.

As you can imagine, vetting chiropractic is more difficult effort than selling new Coke or re-branding diet beer. We can’t continue to assume nothing is wrong with our image or message when only 10% of Americans utilize our services.

Aside from the new guidelines endorsing our services, another ace in our hand that we must play includes the satisfaction of practicing chiropractic. Indeed, people must wonder why anyone would want to be a chiropractor knowing the medical discrimination we face—they simply don’t realize our thick skins or the enjoyment we experience.

Few people appreciate that chiropractors now rank 11th according to “Best and Worst Jobs of 2013” in a review of 200 jobs in America while “general physician” ranked #45 and “surgeon” ranked #51.[9]

This revelation is perhaps more shocking than the evidence-based guidelines recommending our brand of care. As the Oklahoma poll found, one respondent frankly admitted, “I wouldn’t want my daughter to marry one.”

Our high ranking speaks volumes and will surprise most folks who do not realize the qualimetrics of our job—the aesthetics, low stress levels, good results, high patient satisfaction rates, and the remuneration that will only improve when our PR exposure improves.

Promoting a New Message

The main message now is to present ourselves as the evidence-based spine care providers offering the most clinically and cost-effective treatments for the majority of spine-related problems, a claim we never before could flaunt.

In terms of brand awareness, our profession must follow the advice to lay claim as “America’s primary spine care providers” (PSP) as suggested by the brain trust of chiropractic reformers Drs. Donald Murphy, Stephen Perle, Michael Schneider, Brian Justice, and Ian Paskowski.

This is not a far reach since DCs already do 94% of all SMT according to a 1992 RAND report, staking this claim is perfectly legitimate.[10] The AHCPR report also concluded that spinal manipulation was a “proven treatment” for acute low back pain in adults and “should only be done by a professional with experience in manipulation,” which was, in effect, another endorsement of chiropractors.[11]

This branding is identical to the World Federation of Chiropractic’s (WFC) in a 2005 Report by a 40-person Identity Task Force consensus that determined the most appropriate public identity for the chiropractic profession is primarily “the spinal health care experts in the health care system.”

This brand must become our cornerstone in each and every ad, PSA, and interview we do to imprint this identity onto the public before the MDs, DOs, and PTs attempt to do the same considering we are the best prepared primary care physicians to manage these cases that will help millions and save billions.

Pushing Back on Disinformation

Aside from pushing this good news, we also must push back on the bad news. We have recently seen anti-chiropractic articles go viral overnight in the media and, for the most part, these cheap shots impugn our reputation without fair and balanced reporting that I refer to as Chicken Little journalism.

Such one-sided disinformation is a problem we rarely have the opportunity to confront, defend, or explain why chiropractic is effective in a public forum during the war on chiropractic in the media.

As recently as 2012, a spurious article by an unknown physiotherapy instructor at a remote small British college took a swipe at chiropractors contending SMT caused strokes. There was no evidence of any injured patient; it was merely the instructor’s hyperbole fueling this attack that took off with ten articles appearing within days of each other on the same issue—the safety of chiropractic.

I responded to this nonsense with facts in a letter to the editor of the UK newspaper that printed the original article. This is just one of many “push-back” letters and articles I have written in defense of the chiropractic profession over the years.

Pushing Back the Doubt

Text Box: Although responding to such attacks is important, at best it may be too little, too late. This is where we might take a lesson from our medical merchants of misinformation by using the same proactive tactic to plant seeds of suspicion about medical care.

However, rather than using slander, now we can use the scientific evidence in our strategy to create cognitive dissonance, the feeling of intellectual discomfort that results from having two conflicting beliefs, which aptly describes the difference between medical and chiropractic spine care.

Today we must use the new powerful information to reach such a tipping point in the public’s mind to make them very uncomfortable about medical spine care to replace the old stigma that “everyone knows chiropractic is an unscientific cult” that makes patients leery about chiropractic care.

Fortunately, this proactive tactic has been handed to us by the media. Certainly the tsunami of news articles about the dangers of medical spine treatments have already created public discomfort about ESIs causing meningitis, opioid painkillers causing thousands of deaths and addictions and, of course, the scourge of unnecessary spine surgery.

Many articles over the last few years have criticized spine surgery, such as:

These articles confirm that “spinal medicine in the US is a poster child for inefficient spine care,” and this beat continues in the media to this day.

As recently as July 29, 2013, the JAMA Internal Medicine journal highlighted the Worsening Trends in the Management and Treatment of Back Pain, a rather shocking admission for JAMA to print, don’t you think?

The authors admitted the importance of their study:

“Back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines. Few studies have evaluated recent national trends in guideline adherence of spine-related care.”

The study concluded:

“Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care. Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care.”

Immediately the mainstream media popularized this article in the LA Times, “Back pain: Doctors increasingly ignore clinical guidelines,” and USA Today, “Patients with back pain often get the wrong treatment.”

Medscape Medical News also featured a similar article, “Worrisome Trends in Back Pain Managementthat shed more heat than light on LBP care. Although these “worsening trends are worrisome,” lead author John N. Mafi, MD, stressed his own conflicted feelings:

“Not all physician referrals, MRIs, CT scans, opiate prescriptions, or even all back surgeries are bad. Under certain circumstances they can be very helpful. My main point is just that they are increasingly being overused and unnecessarily so.”

Donald E. Casey, MD, said in the same article:

 "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."[12]

It appears Drs. Mafi and Casey remain at the bottom of the learning curve unaware that these comparative studies and evidence-based guidelines have already been done and, as Dr. Haldeman stated, conservative care is the treatment of choice.

CBS This Morning also carried a related televised segment, “New solutions for long-lingering back pain - CBS News” that reported:

“Across the nation, 80 percent of people suffer from back pain at some point in their lives. Researchers from Harvard Medical School tracked the treatment of back pain between 1999 and 2010, and their results indicated that many treatments are actually inconsistent with clinical guidelines.”

The CBS medical reporter, Dr. Norman Marcus, Director of Muscle Pain Research at New York University School of Medicine, mentioned the discordant nature of the non-evidence-based treatments still prescribed by MDs and, most surprising, he reveals his own discordant medical advice:

"The study tells us that we're not getting the recommended treatments...If you have back pain, it should be treated simply with simple drugs."

Inexplicably, he also suggests that patients "stay under the care of your family doctor" and not seek medical specialists, failing to acknowledge the lack of musculoskeletal training by PCP MDs as Scott Boden, MD, currently director of the Emory Orthopaedic and Spine Center in Atlanta, has confessed,  “Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders.”[13]

Not only has this CBS reporter given PCPs more credit than is due about MSDs, his report shows that he, too, suffers from professional amnesia when he inexcusably forgot to inform patients that clinical guidelines recommend chiropractic care as an initial option to the “inefficient” medical methods.[14]

          Although the growing case against medical spine care has been made for us in the media, our task now is to interject ourselves into this equation of care, a factor most noticeably absent considering not one of these articles mentioned chiropractic care as a viable, non-drug, non-surgical alternative, illustrating how we remain missing in the media.

Indeed, how can anyone do an article on back pain and ignore chiropractors, the third-largest physician-level profession in the nation that specializes in spine-related disorders unless, of course, they suffer from a bad case of medical bias or shoddy journalism as we’ve seen with Dr. Sanjay Gupta at CNN?

These many news articles are certainly reason enough to create public skepticism about medical spine care. Now we must use this information repeatedly as evidence that medical spine care (opioids, ESIs, and disc surgery) should be the last resort, not the first.

This new information should be the nail on the medical coffin to finally end the exploitation patients by spine surgeons “gone wild. This is the 800-pound gorilla the spine surgeons hope never becomes public knowledge and, undoubtedly, is the biggest game-changer—the reliance on the outdated “bad disc” theory—the pole of spine surgery for decades.

Dr. Norman Marcus mentioned this on CBS news when he dismissed the pathoanatomical disc problems, aka, incidentalomas, found on MRIs in asymptomatic patients that spine surgeons are so keen to use as selling points to unsuspecting patients.[15]

"If you get an MRI, I guarantee you it's going to be abnormal. 40% of people on the street with no pain have herniated discs. 70% have degenerated discs, with no pain.”

Spine researcher Chien-Jen Hsu, MD, flatly admitted his disbelief in the disc theory:

"By far the number one reason back surgeries are not effective and some patients experience continued pain after surgery is because the disc lesion that was operated on is not, in fact, the cause of the patient's pain."[16]

Therein lies the rub to our public message: The traditional medical model continues to view the cause of back pain as primarily anatomical incidentalomas with surgery as the logical solution when, in reality, most spine pain—up to 85%—is now believed to be a pathophysiologic problem, primarily as vertebral joint complex dysfunction.

This is the basic paradigm shift that we need to explain to the public why medical spine care is so “inefficient” today—the focus on the secondary clinical findings of “bad discs” by MDs and surgeons who ignore the primordial problem of joint dysfunction and the value of spinal manipulative therapy to restore joint play/motion.

The primordial role of joint dysfunction was stated by John Mennell , MD, in his testimony at the Wilk trial in 1976 :

“Eight out of ten patients that come out of any doctor’s office complain of a musculoskeletal system problem, regardless of what system the pain is coming from…I will say 100 percent of those complaints…are due to joint dysfunction in the musculoskeletal [system].

“The science of mechanics demands that joint play movement is prerequisite to normal pain-free functioning of movement.”[17] 

Until people understand “bad discs” are found in most pain-free people, they will remain prey to surgeons. Evidence of this argument was revealed in a recent workers comp study from Washington State that compared patients with low back pain whose first provider was either a chiropractor or a surgeon. This produced drastically different rates for surgery—42.7% of workers who first saw a surgeon had surgery in contrast to only 1.5% of those who saw a chiropractor.[18]

By avoiding expensive and risky spine surgery the cost savings for the payers will be enormous. Extrapolating these savings around the world would save billions of dollars in total spine costs and help millions avoid unnecessary drugs, shots, surgery, and disability.

Promoting Patient Dissonance

With this litany of events in mind, a cultural tipping point in our favor will occur when patients realize:

  • They were lied to about chiropractors by the AMA that was convicted of antitrust in a federal court.
  • Chiropractic care is now rated among the best treatments for mechanical back pain that affects 90% of adults in their lifetime.
  • There are over 300+ joints in the spinal column which is the primordial problem (joint complex dysfunction) in most back pain cases, which explains why SMT is so effective.
  • The common medical explanations for back pain are false notions; incidental “bad discs” are outdated, disproved, and commonplace in pain-free folks.
  • The medical solutions—opioid narcotics, ESIs, and disc fusions—are ineffective, addictive, dangerous, disabling, often deadly, and unnecessary in most cases.
  • And, most shocking, is the growing awareness that the majority of medical PCPs are inept in musculoskeletal training, diagnosis, and treatments.

As a result of this new information, people will realize they have been misdiagnosed, mistreated, misinformed about chiropractic, misled by inept medical PCPs, victimized by spurious pain management “pill mills,” and ripped-off by unethical spine surgeons who readily tell patients, “You have a ‘bad disc’ and whatever you do, don’t see a chiropractor,” an attitude of fear-mongering that I refer to as medical voodoo.

It’s past time to put the medical doctors on their heels by explaining why medical spine care has been a “20th century disaster” as Dr. Gordon Waddell DSc, MD, FRCS, author of The Back Pain Revolution, wrote over 24 years ago in 1989:

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. [19]

Dr. Waddell also suggests chiropractic care as a solution:

“There is now considerable evidence that manipulation can be an effective method of providing symptomatic relief for some patients with acute low back pain.”[20]

The proof is mounting and our message to patients must be to “Just Say No” to “inefficient” medical spine care, just as they were taught to “Say No to Drugs,” except for Dr. Ganja.

Pushing the Envelope at F4CP

With a membership over 4,000 DCs and corporate sponsors, the Foundation for Chiropractic Progress  (F4CP) is gaining clout, but the time is near to change strategy.

I support the Foundation’s efforts as a contributor myself, but re-inventing our image as PSPs and shedding the image of an “unscientific cult” is unlike any other PR effort in the history of marketing.

A PR campaign based on evidence-based facts from the emerging studies (both pro-chiro and anti-medical spine care) is much different than the present F4CP advertising campaign primarily featuring WOC (Wonders of Chiropractic) testimonials from celebrities and pro athletes in national newspapers like USA Today and The Wall Street Journal.

Sport celebrities pushing chiropractic is as inconsequential to mainstream Americans as movie stars like Tom Cruise and John Travolta pushing Scientology. While they may convince a few impressionable fans, most view them with a jaundiced eye. Indeed, it’s a “WOW” factor with very little sizzle to stem the tide of doubt.

I urge the Foundation to progress to the next phase of PR—the Information Age—instead of relying principally on testimonial ads that may stir emotions rather than evidence-based ads that spark reason.

Such a turnaround may seem bold, but so was bringing a damaged Apollo 13 module back from the moon. With the plethora of research and news articles now, we can do this unlike ever before. While it may take another generation to wean Americans of the medical propaganda, it may also happen overnight if just one effort on our part goes viral, too.

Instead of celebrity pitchmen, I suggest the Foundation hire a publicist who, first of all, fully understands our predicament and, secondly, has a big Rolodex with contacts in the media to schedule talk radio, TV news, and newspaper interviews to promote our profession where these issues can be vetted.

Just as we have lobbyists on Capitol Hill to organize our legislative battles in Congress, think of a publicist as our media lobbyist to create and maintain a favorable public image by developing a positive brand via interviews in the media and shocking exposés.

 I can see the possible headlines now: “Chiropractors Poised to Reduce Costs and Improve Outcomes, Chiropractors Have Your Back, and “Chiropractors Demand Apology.” That ought to get the nation’s attention.

Sooner than later we must explain the underlying issues facing our profession. A good example of chiro journalism that aims at the intellect of readers rather than at their emotions was a recent article written by Dr. Don Nixdorf that appeared in the Vancouver Sun.

Dr. Nixdorf, a leading Canadian activist and co-author of Squandering Billions, interviewed Dr. Allan Gotlib, the Executive-Vice President of the Canadian Chiropractic Research Foundation (CCRF).  Under the leadership of Dr. Gotlib, Canada has witnessed the “unprecedented expansion of chiropractic research that continues to thrust the chiropractic profession into the forefront of health care.”

This type of investigative journalism requires spokesmen who understand the relevant “Talking Points” in healthcare today, the new research studies and, of course, the political issues.

Such media encounters on talk radio and television news shows do not cost anything, plus the message compared to advertising is much more impactful than WOC testimonials in terms of establishing DCs as cultural authorities as PSPs.

As examples, I have written articles for public consumption about the issues we face, such as:

I have also appeared on local TV news shows, talk radio programs, and produced a few infomercials to discuss these newsworthy issues. If DCs in every locality were to do the same, our image as professional spine specialists would improve and greatly expand our market share.

Our message is simple: this pandemic of back pain is not by accident, or the result of bad discs, bad germs, or bad genes, but by design as the result of two main causes:

  1. The “inefficient” medical mismanagement of LBP (opioids, ESIs, and spine surgery)                     
  2. The suppression of chiropractic by political medicine to corner the market in spine care by marginalizing our inclusion, defaming our image, and denying to patients our brand of spine care.

Splashdown Success

Certainly if NASA can bring a crippled space capsule back from the moon and successfully re-enter the atmosphere, we can do no less since the groundwork has been laid in the media and by researchers.

As Scott Haldeman confirmed, “The paradigm shift has already taken place.” Now is the time to tell the public about this splashdown of good news by pushing this paradigm shift over our proverbial rainbow, the tipping point in the court of public opinion.

 



[1] Private communication with JC Smith, 7/10/2013

[2] Scott Haldeman DC, MD, PhD, FRCP(C) and Simon Dagenais DC, PhD. A supermarket approach to the evidence-informed management of chronic low back pain. The Spine Journal, vol. 8, Issue 1, January-February 2008, Pages 1-7.

[3] The Burden of Musculoskeletal Diseases in the United States Bone and Joint Decade, Copyright © 2008 by the American Academy of Orthopaedic Surgeons. ISBN 978-0-89203-533-5, pp. 21.

[4] L Sportelli, “AHCPR: It Did Not Happen By Accident,” Dynamic Chiropractic 13/2 (January 16, 1995).

[5] The BACKPage editorial vol. 27, No. 11, November 2012.

[6]  Opinion p. 10

[7] Donald M. Petersen Jr, Changing Times, Dynamic Chiropractic – July 1, 2013, Vol. 31, Issue 13

[8] W Trever, “in the Public Interest,” Scriptures Unlimited, Los Angeles, Calif., (1972):11

[9] Joe Light, “The Best and Worst Jobs,” The Wall Street Journal, (January 4, 2011)

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

[11] S 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), Patient Guide:7.

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

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

[14] A Rosner, “Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient,” Dynamic Chiropractic, 20/25 (November 30, 2002)

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

[16] Hsu CJ, et al. Clinical follow up after instrumentation-augmented lumbar spinal surgery in patients with unsatisfactory outcomes. J Neurosurg: Spine, October 2006;5(4):281-286.

[17] Transcript of testimony of John McMillan Mennell, MD, Wilk v AMA transcript, pp. 2090-2093.

[18] Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KC, Franklin GM., Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State, Spine (Phila Pa 1976). 2012 Dec 12

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

[20] G Waddell and OB Allan, “A Historical Perspective On Low Back Pain And disability, “Acta Orthop Scand 60 (suppl 234), (1989)

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