Articles by JCS

Response to Aussie MDs

December 2, 2011

 

TO:                 Professor Graham Pegg

            Pro Vice Chancellor and Executive Dean

           

Professor Grant Stanley

Dean Medical and Applied Sciences

Faculty of Sciences, Engineering & Health

 

Central Queensland University

Bruce Highway Rockhampton QLD 4702

            Mackay, Qld.

 

FROM:           JC Smith, MA, DC

                        Smith Spinal Care Center

                        1103 Russell Parkway        

                        Warner Robins, GA USA 31088

                       

RE: Response to Medical Objection to Chiropractic Program

Dear Sirs:

I am a doctor of chiropractic compelled to respond to the November 30, 2011 letter to you from 40 members of the medical profession complaining about the inclusion of a chiropractic program into your university.[1] I will refer to this 40 member group as the “medical mob” since no one had the courage to take authorship of this letter, instead appearing faceless among the litany of signers.

This letter is profoundly biased toward chiropractic, subtly intimidating to you, clearly misleading in details, an affront to academic freedom, and scientifically incorrect on many levels. Indeed, this letter by this medical mob smacks of professional demagoguery at its worst. I daresay as fair-minded academicians you should reject on principle the totality of their letter.

Please excuse the length of my letter as I address the many false accusations contained in the mob’s letter. For your information, I hope you are already familiar with the 1979 New Zealand Commission of Inquiry into Chiropractic, headed by Mr. BD Ingles, QC, BA, JD, and LL.D. [2]  This inquiry may be the most in-depth, balanced, and thorough investigation into all aspects of the chiropractic profession ever conducted. Numerous experts, academicians, legal counselors, patients, and leaders from the main New Zealand stakeholders participated: the Medical Association, the Society of Physiotherapists, the Chiropractors’ Association, the Department of Health, and the Consumer Council were involved in this investigation as to whether or not chiropractic services should be included in its national healthcare services.

I make this recommendation after reading the November 11th letter to you from the medical mob whose letter was absent of any objective facts and devoid of any rational argument. Instead, their letter parroted many outdated arguments that were refuted by the NZ Commission. For example, the very first paragraph sets the tone of this biased medical mindset when it includes such terms as “non-evidence based ‘pseudo’ disciplines” and “unacceptable practices undeserved imprimatur.”

Apparently instead of allowing academic inquiry and debate by different schools of thought into topical issues, this medical mob stoops to name calling as a form of intimidation and a sign of obvious prejudice. Indeed, if these medical champions are so confident, why not examine these chiropractic issues fairly in an academic environment as the NZ Commission? As the third-largest physician-level profession in the world, chiropractic deserves the same fair treatment as other health professions to exist in your university.

While chiropractic is under attack, perhaps many medical methods should also be open to scrutiny. In response to the claim of “non-evidence based ‘pseudo’ disciplines,” let’s be frank: the medical over-use of “evidence-based” treatment is very misleading. While medicine may use scientific methods, medicine itself is an applied science at best.

Furthermore, David Eddy, MD, the father of guidelines-based care, admitted in 2005 that only 15% of medicine is evidence-based.[3] It is interesting how this medical mob failed to point its accusatory finger at itself; instead suggesting everything medicine does is evidence-based, which is total hyperbole. Perhaps medicine should clean up its own house before attacking others.

For example, in regards to spine-related disorders (SRDs), the latest evidence has incriminated medical treatments of opioid drugs, epidural steroid injections, and spinal surgeries. Over the last 20 years, numerous studies have cast doubt on the medical management of low back pain, yet the medical establishment has virtually turned a blind eye in lieu of profits.

Here are some shocking words from honest medical men who admit to the inappropriate medical care for SRDs. Gordon Waddell,  DSc, MD, FRCS, author of The Back Pain Revolution, harshly criticized the affect of medical management:

 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.” [4]

Another distressing article, “Are We Making Progress?” by Glenn Pransky, MD, Jeffrey M. Borkan, MD, Amanda E Young, PhD, Daniel C. Cherkin, PhD, discussed the ineffective spine treatments, clinical iatrogenesis, and the “Low Back Pain Medical Industrial Complex” at the Tenth International Forum for Primary Care Research on Low Back Pain in June 2010 at the Harvard School of Public Health in Boston, Massachusetts.

Concerns about ineffective treatments and iatrogenesis were discussed at greater length here than at any previous Forum since the Forums began in 1995. Research results may have led to reduction in the use of potentially harmful and unproven therapies such as bed rest and intradiscal therapy, but other harmful treatments may have taken their place, especially in the United States.

Despite explosive growth in the number, range, and quality of investigations of LBP in primary care since 1990, there was a sense at recent Forums that progress in reducing the medical and economic impact or burden of suffering from LBP has been disappointing. Few treatments presented at earlier Forums withstood the test of randomized controlled trials, and the “LBP epidemic” remains a burden in Western countries. Evidence-based guidelines and systematic reviews flourished, but seem to have had little impact on actual primary care practices.[5]

Richard Deyo, MD, MPH, a leading spine researcher and outspoken critic of spine surgery now at Kaiser Permanente Professor of Evidence-Based Family Medicine at Oregon Health and Science University in Portland, Oregon, mentioned to The New York Times that the spine profession is ignoring this call for restraint of ineffective medical care:

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, and more invasive surgery.[6]

Spine researcher Chien-Jen Hsu, MD, admitted in the journal Spine:

By far the number one reason back surgeries are not effective and some patients experience continued pain after surgery is because the lesion that was operated on is not, in fact, the cause of the patient’s pain. [7]

This alludes to a major change in the back pain business—the suspect disc theory as the cause of back pain. This paradigm shift dates back to 1990 when orthopedist Scott Boden found no correlation between abnormal discs and patients with and without back pain. In a follow-up study in 2003, Boden reaffirmed his previous findings:

It should be emphasized that back pain is not necessarily correlated or associated with morphologic or biomechanical changes in the disc. The vast majority of people with back pain aren’t candidates for disc surgery.[8]

Dr. Maureen Jensen’s study also confirmed early suspicions that herniated discs were “coincidental” and not the holy grail of back pain causation:

The relation between abnormalities in the lumbar spine and low back pain is controversial. We examined the prevalence of abnormal findings on magnetic resonance imaging (MRI) scans of the lumbar spine in people without back pain.

On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.[9]

Raj Rao, M.D., director of spine surgery in the Department of Orthopaedic Surgery at the Medical College of Wisconsin, also spoke of this paradox in spine imaging:

You can look at the MRIs of two people, both showing degenerative discs, but in one case there is little to no pain, while in the other, extreme pain. On the other hand, you can see a healthy spine but the patient has severe pain.[10]

Despite the new research undermining spine fusions, this erroneous non-evidenced-based disc theory remains very much alive in the medical profession that is unwilling to forego this lucrative fusion surgery nor are they willing to have chiropractors compete on a level playing field for these cases.

If the medical authors of the November letter to you are so willing to discuss why a chiropractic program should not exist, are they equally willing to debate the fact that their own non-evidenced based treatments for low back pain are now considered ineffective, expensive, and leaving a wake of disability? Indeed, methinks we see a double standard with the pot calling the kettle black in this case.

Their letter also misleads you by stating that spinal manipulations are “marginally effective.” Again, these biased authors simply do not understand the new research in order to give credit where it is due.

According to Pran Manga, PhD, Canadian health economist who conducted two comparative effectiveness studies on low back pain, “There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management.” [11]

In an article by Jo Jordan, PhD,, “Are There Any Effective Nonsurgical Treatments for Painful Disc Herniations?she wrote that spinal manipulation may be the “lone ray of light” for back pain treatment.[12] Her comment is just one among many that now vindicate chiropractic care in the form of spinal manipulation for the treatment of this worldwide epidemic of back pain.

By the end of the 1990s, evidence-based research from Europe and America recommended major changes to the management of patients with low back pain, including those diagnosed with disc herniation. Studies in the U.S.[13], U.K.[14], Canada[15], and Denmark[16] all concluded: back surgeries were excessive, and conservative care such as spinal manipulative therapy and active rehab were the best initial approaches to the vast majority of low back pain (LBP) problems.

“No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation,” according to Jeremy Fairbank, MD, lead investigator, British Spine Study (UK BEAM). “And spine care providers should offer intensive rehabilitation enthusiastically, as it finds clear support in the scientific literature, and will prevent unnecessary surgery in a substantial proportion of patients.”[17]

TheBACKLETTER editorial staff also noticed the stubbornness of physicians to implement the new guidelines for low back pain, which includes the use of spinal manipulation as a first route of treatment before surgery:

Numerous international guidelines have endorsed the use spinal manipulation as a treatment for acute back pain—as part of an evidence-based treatment algorithm. But researchers have been slow to examine the impact of guidelines-based care in rigorous clinical trials—to see if an evidence-based approach actually works in real-world clinical settings.[18]

Obviously the medical mob’s letter attempt to minimize the effectiveness of manipulative therapy is unsupported by the evidence. As well, their letter makes harsh condemnation of the impact of vertebral subluxation upon organic disorders and the overall health of patients: “But a practice limited to spinal area musculo-skeletal discomfort is not what modern chiropractic is all about.”

Inexplicably, their letter to you instead cites the claim from the founder of chiropractic over 100 years ago that chiropractic care—“corrects 95% of all man’s ailments.” This is ridiculous as if it was still professed and equivalent to suggesting modern medicine still uses leeches and bloodletting to cure “all man’s ailments.”

If the medical mob were aware of the history of this issue, it would have known by the 1960’s this alleged perception of all disease being caused by spinal subluxation was rejected by the chiropractic profession. The chiropractors’ national associations, both the American Chiropractic Association and the International Chiropractors’ Association, published a White Paper in May, 1969, explaining that chiropractic was not premised on “one cause, one cure.”[19]

Another criticism by the medical mob in its November letter focused on “the ‘innate intelligence’ which controls all normal bodily functions is contained within the spinal column.” This is another ridiculous, nonsensical statement aimed to besmirch the idea of vitalism. The innate intelligence referred to is the inborn intelligence of the body that emanates from the brain, an issue apparently lost to this medical mob, which may be, in effect, severely lacking itself.

Again, this medical mob’s insinuation is obvious that vitalism has no place in “scientific” medicine. While this criticism may sound appealing to hard-core scientists, it is hardly realistic considering the human body is not a hard-core machine. In fact, many healing professions speak of a vital force—aka, the God factor—that keeps the body alive and healthy when functioning without nerve interference, physical injury, or chemical toxins. Unfortunately, the bio-medical model fails to acknowledge this integrative aspect of health care; instead, most MDs place their faith in drugs.

Rather than the appearance of medical ethicists warning of quackery as this mob suggests, the alarm of this medical mob resembles the sentiments of medical atheists. According to an unnerving admission by Francis R. Collins, MD, director of the National Institutes of Health in the USA, he admits as many as sixty percent of doctors and scientists are atheists.[20]  Dr. Collins wrote of his own experience in medical school when the prevailing academic dogma to be strictly scientific ridiculed any supernatural belief in the God factor in the healing process.

Undoubtedly this attitude made it easy for atheistic MDs to attack chiropractors who did believe in the God factor in healing—in chiropractic parlance, the Innate Intelligence in the body. Apparently allopathic medicine has become so cynical that a simple belief in God is now a professional sin that should be shunned in academia. On the other hand, it may explain the callous attitudes they have toward supernatural or spontaneous healing and the feeling of superiority they have about themselves.

Modern Neurophysiology & Chiropractic Care

While the argument about the God factor in health is equivalent to debating religion, the medical mob also seems ignorant about how chiropractic care may affect the neurophysiology of the body. A major complaint in the letter of the medical mob focused on “Most chiropractors believe and teach that spinal area ‘adjustment’ can be used to treat the vast majority of medical problems.”

First of all, “medical problems” are not the sole domain of allopathic medicine; indeed, this malapropism should be “health problems.” Many other types of health care professions treat health problems quite successfully; perhaps often more effectively than drugs and surgery. This medical chauvinistic attitude stems from its century long war against chiropractic and other non-allopathic professions to eliminate all competitors.[21] While inappropriate, it is typical of a medical monopoly to think it alone as the answer to all problems.

In regards to how chiropractic care may help some organic disorders, clearly these medical men need a lesson in neurophysiology to understand this principle. The original and rather archaic “pinched nerve” theory has been abandoned and replaced by the “reflex-based” theory. While this was investigated by the New Zealand Commission in 1978-79, it too has been modified by recent investigators.[22]

This contention has always been a leap into controversy for many people who are unschooled in neurophysiology, and it may have taken a century for science to explain DD Palmer’s quaint claims, but modern neurophysiologists now give a clearer understanding of the impact of the spine upon the physiology and homeostasis of the body. Of course, the medical profession continues its knee-jerk rejection of this concept, but research now disagrees.

Even the NZ Commission found testimony from medical experts who affirmed vertebral subluxation as a cause of disease. Dr. K.E.D. Eyre, a visiting neurologist to the Auckland Hospital Board, testified “I would agree that spinal subluxation causes disease. We would be wasting our breath to deny otherwise.”[23]

Although most doctors understand that chiropractic care may help Type M (musculoskeletal) disorders, there remains much confusion how Type O (organic) disorders may be helped. Today modern research has increased our knowledge of the relationship between manipulative therapy, the nervous system, organic disorders, and the circuitry and chemistry of the brain.

The treatment by spinal manipulation of Type O disorders has been supported by more recent clinical experience and case reports according to an article in the Annals of Internal Medicine by William Meeker, DC, MPH, and Scott Haldeman, DC, MD, PhD, FRCP(C).[24] These include randomized clinical trials for primary dysmenorrhea[25],[26], hypertension[27],[28], chronic asthma[29],[30], enuresis[31], infantile colic[32], and premenstrual syndrome.[33]

“The outcomes of these completed studies have provided varied but promising results,” according to the authors.

One mechanism mentioned by Dr. Haldeman involved the possible ability of manual therapy to influence reflex activity in the central nervous system. This somatovisceral reflex, in his view, holds possibly the greatest interest for those trying to establish a role for manual therapy like chiropractic care for Type O complaints.[34]  The suggestion is that sensory input to one part of the nervous system can influence physiologic function in other parts of the body.

The somatovisceral reflex or, in regards to the spine, the “spinovisceral reflex,” is at the core of this explanation. Spinovisceral reflexes refer to a specific type of somatovisceral reflex that stems from the spinal components.  Reflex effects have been demonstrated throughout the cardiovascular system, in the digestive system, urinary system, endocrine system, and immune system, which explains why many patients—seven percent in the New Zealand Inquiry—admitted they felt improvement after chiropractic care.[35]

Recent research by Brian S. Budgell, DC, supports an explanation for the neurophysiologic concept that abnormal stimulation of spinal or paraspinal (brain) structures may lead to reflex responses of the autonomic nerve system, which in turn may alter organ function.[36] In other words, a back injury can cause the nerves in that region of the spinal column to have a reflex reaction in the organs that are innervated by them.

This is where chiropractic care can help patients with misdiagnosed problems who are not responding to medical care. For many, examination of the somatic system of the spinal column (muscles, joints, nerves, and ligaments) can hold the answer to visceral conditions that are unresponsive to medical care.

Drs. Dale Nansel and Mark Szlazak from Palmer College of Chiropractic-West in San Jose, California, did an in-depth study of somatovisceral theories of over 350 articles spanning the last 75 years and found that it has been firmly established that somatic dysfunction is notorious in its ability to create obvious signs and symptoms that can mimic or simulate rather than cause internal organ disease.  In fact, they believe as much as 10 percent of supposed heart attacks may be caused by this syndrome.[37] This is a huge revelation that may affect thousands of people who think they are having a heart attack, but are having a spinovisceral reflex that spinal adjustments may help.

Other researchers speak of the misdiagnoses stemming from the referred pain caused by spinovisceral reflexes that mimic organic problems. In their research, Drs. David Seaman and James Winterstein suggest that spinovisceral reflex caused by spinal joint complex dysfunction should be included in the differential diagnosis of pain and visceral symptoms because “joint complex dysfunction can often generate symptoms which are similar to those produced by true visceral disease.”[38]

Deaths After Chiropractic

Another misleading accusation in the medical mob’s letter suggests manipulative therapy is dangerous.  This is a particularly ironic statement considering the facts, which this mob is apparently unaware. They allege: “The literature contains details of more than 700 cases of serious complications following ‘adjustment’.”

This hyperbole has to be the most disingenuous coming from the medical mob since a simple comparison of iatrogenic problems clearly shows the extreme safety of chiropractic care compared to medical care. Indeed, this is another example of the pot calling the kettle black.

If we were to take a look at the rates of iatrogenic deaths from medical care, the numbers are staggering. Barbara Starfield, MD, MPH, of the Johns Hopkins School of Hygiene and Public Health, reported that medical care is now the third-leading cause of death in the U.S., causing 225,000 preventable deaths every year. [39] Inexplicably, the medical mob failed to note this statistic in its letter concerning the dangers of medical care.

According to research by Alan Terret et al., the rate of iatrogenic problems associated with spinal manipulative therapy as rendered by doctors of chiropractic is only 1 in 5.85 million cases, which is less than the chance of stroke in a hair salon or being hit by lightning (one in 600,000). It equated to one occurrence in 48 chiropractic careers.[40]

A Canadian study by The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders indicated there was no increased risk related to chiropractic treatment in the debate about whether neck adjustments can trigger a rare type of stroke. Researchers found patients are no more likely to suffer a stroke following a visit to a chiropractor than they would after stepping into their family doctor's office. [41]

The findings, which were published in the journal Spine, helped to shed light on earlier studies that had cast a cloud on the chiropractic profession and suggested that their actions resulted in some patients suffering a stroke after treatment. [42] In fact, the findings support the chiropractic position of its extreme safety when compared with drugs and surgery.

A study by Anthony Rosner, PhD, comparing medical procedures to chiropractic care concerning strokes, flipped this coin to mention patients need to be warned of the dangers of medical procedures rather than chiropractic care. As he suggests, “The statistics really begin to spin one's head.”[43] 

Using a baseline figure of one per one million as an estimate of stroke incidence attributed to cervical manipulations, one finds a:

  • two times greater risk of dying from transfusing one unit of blood;[44]
  • 100 times greater risk of dying from general anesthesia;[45]
  • 160-400 times greater risk of dying from use of NSAIDs;[46]
  • 700 times greater risk of dying from lumbar spinal surgery;[47]
  • 1000-10,000 times greater risk of dying from traditional gall bladder surgery;[48]
  • 10,000 times greater risk of serious harm from medical mistakes in hospitals.[49]

Despite the overwhelming support for chiropractic manipulation for neck problems, the medical mob has again raised unwarranted concern for strokes caused by manipulation. A 2010 study from England, “Deaths After Chiropractic: A Review Of Published Cases,” by Edzard Ernst of the Medical School at the University of Exeter, once again raised the level of fear over chiropractic care when he noted that “Twenty-six fatalities were published since 1934 in 23 articles.”[50]

Considering this covers 76 years and equates to 0.34 deaths per year, instead of sounding an alarm to scare people as Ernst attempted, he should have praised chiropractic care for its obvious safety since this is an extremely low rate in comparison with equivalent medical methods for the same diagnostic condition.

Ernst’s paper drew quick criticism from leading medical and chiropractic scholars. According to SM Perle, S French, and M Haas:

Ernst ignored the evidence against a causal relation between spinal manipulation and death. Instead, he went boldly along a path of fear mongering and propaganda that we expect was predetermined to establish the dangers of CSM (cervical spinal manipulation).[51]

Another review from The Dartmouth Institute for Health Policy and Clinical Practice was equally critical:

Three deaths were reported during the last 10 years of the study, so for that most recent time period, the absolute risk could be estimated to be 3/10 per 100 million, or three deaths for every billion chiropractic encounters…This rate is so low that it cannot possibly be considered significant…An interesting flip side to the research question might be: by undergoing a course of chiropractic spinal manipulation, how many patients were able to avoid death by avoiding complications of surgical intervention?[52] (emphasis added)

Another fact to consider reveals the relative safety of chiropractic care.  Malpractice insurance companies know which doctors are hurting patients, and the actuaries show that chiropractors have the lowest malpractice rates among all spine practitioners. Chiropractors pay approximately $1,600 annually[53] compared to spine surgeons, who typically derive as much as 62 percent of all of their professional income from performing surgical procedures on the lumbar spine, will pay approximately $71,000 to over $200,000,[54] which clearly suggests the safety of care provided by chiropractors.

Certainly the facts show for the medical profession to levy unsupported criticism at chiropractic care is simply crying wolf and is now seen as a shameless attack by one trade association on another competition. This bullying effort by the medical mob is also clearly an affront to the sanctity of your university as an institution of higher learning.

Academic Freedom

Whether or not the early concepts espoused by the founder of chiropractic have been proven true today is not the issue since many old medical theories have been disproven, too. The real issue is academic freedom. This medical mob stated in its November letter, “It would be most regrettable to find that financial pressures may be tempting universities to betray their academic heritage.” It would also be regrettable if political pressures also tempt universities to betray their academic heritage.

Is not scholarly debate and scientific research to find the truth the real goal of academia rather than the exclusion of study into controversial or leading edge issues?

This medical mob is unconcerned about the quest for academic inquiry as we might expect at an institution of higher learning as much as it is interested in deterring the scholarly advancement of its rivals. In effect, this argument sounds eerily familiar to “race defilement” to avoid contamination by chiropractors in the sacrosanct halls of medicine. In reality, it smacks of demagoguery.

Humorist H. L. Mencken once defined a demagogue as “one who will preach doctrines he knows to be untrue to men he knows to be idiots.” Throughout history many demagogues have followed this doctrine which also aptly describes this medical mob. They offer no substantial proof, simply giving questionable studies and unfounded opinions. In effect, this is actually an attempt by one trade association to thwart the advancement of its rival.

This alludes to a larger question: where were the stalwart defenders for academic freedom? What is so shocking is the fact that this demagoguery would never have happened in any other academic discipline. For example, imagine the uproar if Democrats were able to block the study of conservative Republican politics from the poli-sci program. What if faith-based Creationists were allowed to ban Darwinism and the study of evolution from the biology program? Imagine the outcry if peaceniks were able to bar the ROTC program from campus as war-mongerers.

Obviously when the medical mob’s letter to you states, “However the inclusion of subluxation theory as evidence-based reality is unacceptable and will damage your reputation for academic leadership,” this is pure bunk as the research now shows and is certainly a veiled threat. The real goal of your university should be a thorough examination of the subluxation theory and “let the chips fall where they may” rather than a blanket condemnation.

An extensive inquiry into chiropractic may produce many pros and cons, and perhaps the New Zealand Commission of Inquiry into Chiropractic answered the underlying confusion about how chiropractic works when it said: “Indeed, it is probably true to say that chiropractic is a form of treatment still in search of an explanation for its effectiveness.”[55]  

This inquiry began in 1978 and took eighteen months to complete. The Commission’s findings stood in direct opposition to the position of the medical society regarding chiropractic and condemned MDs as “largely ignorant of those matters simply because he has had no training in them.” [56]

Perhaps your university should examine the entire text from the New Zealand Inquiry into Chiropractic or conduct your own inquiry to allow all parties to submit research to prove their position. It is apparent from the tone of the medical mob, however clouded by academic pretense and misleading statements, that it cannot be considered an objective voice in this matter.

Regards,

JC Smith, MA, DC

Warner Robins, GA, USA 31088

jcsmith@smithspinalcare.com

www.medicalwar.info

 



[1] Sophie Cousins, “Experts sign petition to stop Chiro degree,” The Australian Doctor, 1 December, 2011

[2] BD Inglis, B Fraser, BR Penfold,  Chiropractic in New Zealand, Report of the Commission of Inquiry into Chiropractic,  PD Hasselberg, Government Printer, Wellington, New Zealand. (1979)

[3] John Byrne, “Medical Guesswork, From heart surgery to prostate care, the health industry knows little about which common treatments really work,” Business Week, May 29, 2006.

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

[5] D Cherkin, FM Kovacs, P Croft, J Borkan, NE Foster, B Oberg, G Urrutia, J Zaore. “The Ninth International Forum For Primary Care Research On Low Back Pain. International Organizing Committee Of The Ninth International Forum For Primary Care  Research On Low Back Pain And All The Participants,” Spine 34 (2009):304-307

[6] G Kolata, “With Costs Rising, Treating Back Pain Often Seems Futile” by NY Times (February 9, 2004)

[7] CJ Hsu, et al. “Clinical Follow Up After Instrumentation-Augmented Lumbar Spinal Surgery in Patients with Unsatisfactory Outcomes. In Journal of Neurosurgery,” Spine 5/4 (October 2006):281-286.

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

[9] MC Jensen, MN Brant-Zawadzki, N Obuchowski, MT Modic, D Malkasian, and JS Ross, “Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain,” NEJM, 331/2 (July 14, 1994):69-73

[10] P Garfinkel, “The Back Story,” AARP: the magazine, (July & August 2009)

[11] P Manga, D Angus, C Papadopoulos, W Swan, “The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain,” (funded by the Ontario Ministry of Health) (August, 1993):104

[12] J Jordan, et al., “Herniated Lumbar Disc,” BMJ Clinical Evidence, quote in The BACKLETTER® 25/7 (July 2010):76-77

[13] 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)

[14] Her Majesty’s Stationery Office in London in its Report of a Clinical Standards Advisory Group Committee on Back Pain (1994)

[15] P Manga and D Angus, “Enhanced Chiropractic Coverage Under OHIP As A Means Of Reducing Health Care Costs, Attaining Better Health Outcomes And Achieving Equitable Access To Select Health Services.” Working paper, University of Ottawa, 98-02.

[16] C Manniche  et al. “Low-Back Pain: Frequency, Management And Prevention From An HDA Perspective,” Danish Health Technology Assessment 1/1 (1999)

[17] J Fairbank, et al., “Randomized Controlled Trial To Compare Surgical Stabilisation Of The Lumbar Spine With An Intensive Rehabilitation Programme For Patients With Chronic Low Back Pain: The MRC Spine Stabilisation Trial,” Spine Stabilisation Trial Group, BMJ  (2005):330:1233 (28 May),doi:10.1136/bmj.38441.620417.8F (May 23, 2005)

[18] “Evidence-Based Care That Includes Chiropractic Manipulation More Effective Than Usual Medical Care,” The BACKLETTER  editorial, 23/1 (2008):3.

[19] Testimony of J Winterstein and plaintiffs. PX-344

[20] Interviewed by David Hirschman, Recorded September 13, 2010, BigThink.com

 

[21] JC Smith, The Medical War Against Chiropractors. Createspace. 2011

[22] D Nansel and M Szlazak, “Somatic Dysfunction And The Phenomenon Of Visceral Disease Simulation: A Probably Explanation For The Apparent Effectiveness Of Somatic Therapy In Patients Presumed To Be Suffering From True Visceral Disease,” JMPT  18/6 (July 1995):379-397.

[23] BD Inglis, Betty Fraser, BR Penfold, Commissioners, Chiropractic in New Zealand Report 1979, PD Hasselberg, Government Printer, Wellington, New Zealand, (1979): 136

[24] WC Meeker and S Haldeman, “Chiropractic: A Profession At The Crossroads Of Mainstream And Alternative Medicine,” American College of Physicians-American Society of Internal Medicine, Ann Intern Med. 136 (2002):216-227

[25] MA Hondras, CR Long, PC Brennan,  “Spinal Manipulative Therapy Versus A Low Force Mimic Maneuver For Women With Primary Dysmenorrhea: A Randomized, Observer-Blinded, Clinical Trial,” Pain 81 (1999):105-14. [PMID: 10353498]

[26] K Kokjohn, DM Schmid, JJ Triano, PC Brennan, “The Effect Of Spinal Manipulation On Pain And Prostaglandin Levels In Women With Primary Dysmenorrhea,” J Manipulative Physiol Ther. 15 (1992):279-85. [PMID: 1535359]

[27] JP Morgan, JL Dickey, HH Hunt, PM Hudgins., “A Controlled Trial Of Spinal Manipulation In The Management Of Hypertension,” J Am Osteopath Assoc. 85 (1985):308-13. [PMID: 3900016]

[28] RG Yates, DL Lamping, NL Abram, C Wright, “Effects of Chiropractic Treatment On Blood Pressure And Anxiety: A Randomized, Controlled Trial,” J Manipulative Physiol Ther. 11 (1988):484-8. [PMID: 3075649]

[29] J Balon, PD Aker, ER Crowther, C Danielson, PG Cox, D O’Shaughnessy, et al. “A Comparison Of Active And Simulated Chiropractic Manipulation As Adjunctive Treatment For Childhood Asthma,” N Engl J Med. 339 (1998):1013-20. [PMID: 9761802]

[30] NH Nielsen, G Bronfort, T Bendix, F Madsen, B Weekes, “Chronic Asthma And Chiropractic Spinal Manipulation: A Randomized Clinical Trial,” Clin Exp Allergy. 25 (1995):80-8. [PMID: 7728627]

[31] WR Reed, S Beavers, SK Reddy, G Kern, “Chiropractic Management Of Primary Nocturnal enuresis,” J Manipulative Physiol Ther. 17 (1994):596-600. [PMID: 7884329]

[32] JM Wiberg, J Nordsteen, N Nilsson, “The Short-Term Effect of Spinal Manipulation in the Treatment of Infantile Colic: A Randomized Controlled Clinical Trial with a Blinded Observer,” J Manipulative Physiol Ther. 22 (1999):517-22. [PMID:10543581]

[33] MJ Walsh, BI Polus, “A Randomized, Placebo-Controlled Clinical Trial On The Efficacy Of Chiropractic Therapy On Premenstrual Syndrome,” J Manipulative Physiol Ther. 22 (1999):582-5. [PMID: 10626701]

[34]  BD Inglis, B Fraser, BR Penfold, Commissioners, Chiropractic in New Zealand Report 1979, PD Hasselberg, Government Printer, Wellington, New Zealand, (1979):101-2

[35] A Sato, Y Sato, RF Schmidt, “The Impact of Somatosensory Input on Autonomic Functions,” Reviews of Physiology Biochemistry and Pharmacology 130 (Berlin, 1997):1–328.

[36] BS Budgell, “Reflex Effects Of Subluxation: The Autonomic Nerve System,”  J Manipulative Physiol Ther 23/2 (Feb. 2000):104–6.

[37] D Nansel and M Szlazak, “Somatic Dysfunction And The Phenomenon Of Visceral Disease Simulation: A Probably Explanation For The Apparent Effectiveness Of Somatic Therapy In Patients Presumed To Be Suffering From True Visceral Disease,” JMPT  18/6 (July, 1995):379-397.

[38] DR Seaman and JF Winterstein, “Dysafferentiation: A Novel Term To Describe The Neuropathophysiological Effects Of Joint Complex Dysfunction. A Look At Likely Mechanisms Of Symptom Generation,” JMPT 21/4 (May 1998):267-80.

[39] B Starfield, “Is US Health Really the Best in the World?” JAMA 284/4 (July 26, 2000):483-485.

[40] AGJ Terret, “Current Concepts in Vertebrobasilar Complications Following Spinal Manipulation,” NCMIC Group Inc, West Des Moines, Iowa, (2001)

[41] G Bronfort, M Haas, R Evans, G Kawchuk, and S Dagenais, “Evidence-informed Management of Chronic Low Back Pain with Spinal Manipulation and Mobilization,” Spine 8/1 (January-February 2008):213-25.

[42] JD Cassidy, E Boyle,  P Cote, Y He, S Hogg-Johnson, FL Silver, and SJ Bondy, “Risk of Vertebrobasilar Stroke and Chiropractic Care Results of a Population-Based Case-Control and Case-Crossover Study,” Spine 33/4S, (Feb. 2009):S176–S183.

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

[44] J Paling www.healthcare speaker.com, 2000.

[45] Paling, ibid.

[46] V Dabbs, W Lauretti. “A Risk Assessment Of Cervical Manipulation Vs NSAIDs For The Treatment Of Neck Pain,” Journal of Manipulative and Physiological Therapeutics 18/8 (1995):530-536.

[47] RA Deyo, DC Cherkin, JD Loesser, SJ Bigos, MA Ciol, “Morbidity and Mortality In Association With Operations On The Lumbar Spine: The Influence Of Age, Diagnosis, And Procedure,” Journal of Bone and Joint Surgery Am 74/4 (1992):536-543.

[48] Paling, ibid.

[49] Paling, ibid.

[50] E Ernst “Deaths After Chiropractic: A Review Of Published Cases,” Int J Clin Pract, 64/8 (July 2010):1162–1165

[51] SM Perle, S French, and M Haas, “Critique of Review of  Deaths after Chiropractic, 4” Letters to editor, The International Journal of Clinical Practice, 65/1 (January 2011):102-106.

[52] JM Whedon, GM Bove, MA Davis, “Critique of review of deaths after chiropractic, 5” Letter to editor, The International Journal of Clinical Practice, 65/1 (January 2011):102-106.

[53] National Chiropractic Mutual Insurance Company rate (2009)

[54] The Burton Report, “Why Spine Care is at High Risk for Medical-Legal Suits,” www.burtonreport.com/infforensic/MedMalSpCommonCause.htm

[55] BD Inglis, B Fraser, BR Penfold,  Chiropractic in New Zealand, Report of the Commission of Inquiry into Chiropractic,  PD Hasselberg, Government Printer, Wellington, New Zealand. (1979): 43-44

[56] Ibid. PX-19-829, p. 5.

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