Articles by JCS

Stabbed in the Back

Stabbed in the Back

Zombie Ethics

By

JCS

 “Zombie science,” according to medical ethicist Bruce Charlton, MD, has “a sinister consequence of evaluating scientific theories purely on the basis of enlightened self interest.”[1]

“Although the classical ideal is that scientific theories are evaluated by a careful teasing out of their internal logic and external implications, and checking whether these deductions and predictions are in-line with old and new observations; the fact that so many vague, dumb or incoherent scientific theories are apparently believed by so many scientists for so many years is suggestive that this ideal does not necessarily reflect real world practice.

“In the real world, it looks more like most scientists are quite willing to pursue wrong ideas so long as they are rewarded with a better chance of achieving more grants, publications and status.” [Or making great livelihoods doing drugs, shots, and spine surgery.]

Undoubtedly, zombie science is very much prevalent in the back pain business. Famed author Jerry Groopman, MD, admitted as much in The New Yorker magazine when his orthopedist, knowing perfectly well of the controversial nature of spine fusions, nonetheless told him: “If I don't do them, they'll go around the corner and the other surgeon will.” [2]

Say goodbye to medical ethics, and say hello to zombie medicine.

Sadly, greed, not evidence or ethics, is the guiding light of too many American spine care doctors who “willing to pursue wrong ideas so long as they are rewarded.” Examples are plentiful from skyrocketing ineffective zombie spine treatments to so-called medical ethicists who sound like medical Nazis.

Rather than referring spine-related disorders (SRDs) to those pesky chiropractors who have worked exclusively with spine problems for over a century, the medical zombie believes if the medical professionals can’t find the cause of back pain on an MRI image, than it can’t be found, or they tend to blame the patient by telling them “it’s all in your head.”

“It is impossible to identify a cause for most cases of common back pain,” according to Nortin Hadler, MD, in his book, Worried Sick: A Prescription for Health in an Overtreated America.

“We do not know what causes particular episodes of regional musculoskeletal pain...That means we have no more reason to label a regional backache an injury than we have to label a spontaneous headache an injury.”[3]

I must interject that Dr. Hadler is not just a rheumatologist, but he postures himself as a leading medical ethicist, once described as an equal opportunity critic who lashes out at every type of spine practitioner and “confronts back pain in an overtreated society.”

As a graduate of Harvard University (1968), he did his residency at the famous Massachusetts General Hospital in Boston, and now is a professor of medicine at the University of North Carolina at Chapel Hill. Dr. Hadler is best known for his grandiloquence as a writer and lecturer. In fact, he spoke at ACC-RAC last year despite his unfavorable remarks about “chiropractics” in his latest book, Stabbed in the Back.

What Dr. Hadler fails to admit is his limited medical perspective of SRDs. Like most MDs, he cannot explain why a back attack occurs since the medical model for years has analyzed these episodes from a static perspective of pathoanatomical problems like disc abnormalities and arthritis  instead from a dynamic pathophysiologic perspective—how the spine functions—that includes spinal structure (proper alignment, strength, flexibility), joint dysfunction, ligamentous instability, excessive and prolonged axial disc compression, segmental buckling effects, bad leverage, and over-loading.

The New Zealand Commission of Inquiry into Chiropractic in 1978-79 also indicated the difference in medical vs. chiropractic analysis:

The problem is a functional not a structural one...the medical profession simply fails to see the direction and subtlety of the chiropractic approach towards spinal dysfunction. Because the chiropractor uses x-ray extensively the medical practitioner thinks he is looking for a gross bony change, and when the medical practitioner cannot see this on the x-ray the chiropractor is using he immediately becomes skeptical.  He might as well expect to see a limp, or a headache or any other functional problem on x-ray.[4]

Indeed, the medical diagnosis has simplified back pain to pulled muscles or abnormal discs that, despite the dwindling scientific proof. This is a perfect example of zombie science that the vast majority of MDs still treat exclusively with zombie treatments—drugs, shots, and surgery.

Dr. Hadler is more than willing to admit that disc abnormalities as the cause of pain is misguided and admits most MRIs and spine surgeries are unnecessary.  He even suggests that “regional low back pain” is undiagnoseable by imaging and virtually untreatable except for NSAIDs (recall he is a rheumatologist). Indeed, Hadler gives little hope to people suffering from back pain that medical care might help.

“Whatever we see on the MRI is likely to have been present when the person heals. The discal hypothesis—the idea promulgated seventy years ago that the ‘ruptured disc’ is the culprit—has not withstood scientific scrutiny well. It is largely untenable for axial pain, and marginal for radicular pain. Magnetic resonance imaging cannot be used to predict back pain. Magnetic resonance imaging is not even sensitive to anatomical changes that might correlate with new symptoms. Why is it so important to define the anatomy of the lumbo-sacral spine of patients with regional low back pain?”[5]

Indeed, the anatomy (except for cancer, fractures, serious pathologies or those cases of disc prolapse unresponsive to SMT) is not as important as the physiologic, mechanical issue of spine function. This oversight is not due to ignorance, so the question remains, as Dr. Charlton suggests,  why spine surgeries continue unabated?

Medicine’s Straw Man

Hadler openly admits his bias about chiropractic, offers little proof of his zombie position against chiropractic care, but gives many unsupported and blatantly biased opinions against manipulative therapy in his book, The Last Well Person, when he states:

“I am a rheumatologist, a mainstream physician with an MD, schooled in and committed to the care of patients with musculo-skeletal disorders. Do I have to learn manual medicine? Should I seek such a salve for my own next predicament of a regional musculo-skeletal disorder? Should I refer my patients to such practitioners?” [6]

The answer to all his questions is an unequivocal “Yes.” The obvious ethical question is: why does he need to ask considering every guideline on SRDs recommends to use conservative care first.

This medical bias is deeply rooted in most physicians and nurses, a medical catechism taught from day one in medical school that condemns chiropractic as quackery, dangerous, and easily substituted by PTs or osteopaths as we now see in the military and VA systems.

Sadly, this prejudice has not only hurt the assimilation of chiropractors  into the national healthcare systems, but the millions of patients who suffer from SRDs, other musculoskeletal disorders like CTS, TMJ, extremities, and those with neuromuscular disorders amendable to chiropractic care.

Rather than giving credit that manual manipulation is effective in most cases of LBP as every spine-related guideline recommends, he throws in the proverbial medical Straw Man argument—an informal fallacy based on misrepresentation of an opponent's position—by focusing on the historic vitalism in chiropractic as if it were a working principle in the treatment of spine related  disorders. He even states that subluxations are “imaginary” and a testament to “vitalistic theories.”

“What is less defined, somewhat contentious within the chiropractic, and very contentious for mainstream medicine is the purview of the chiropractic. Is it solely the regional musculoskeletal disorders? That is not the stance of many chiropractors or many schools of chiropractic. These advocates and practitioners are willing to ‘reduce subluxations’ for a range of ailments from headaches to asthma…Subluxations are the chiropractic diagnosis that implies spinal malalignment. They are imaginary; no such specific skeletal changes correlate with symptoms…how anyone can imagine that such an event can salve asthma or diabetes or the like is a testimony to the tenacity of vitalistic theories.”[7]

This is the proverbial straw man argument since vitalism has nothing to do with the chiropractic treatment of back pain. He ignores our success with SRDs and obfuscates the issue by speaking of vitalism—the innate healing capacity of the body. Back pain and vitalism are two distinct issues totally separate, and he ignores other inquiries how “such an event can salve asthma or diabetes.”

The New Zealand Commission of Inquiry into Chiropractic examined this very issue—the question of Type O disorders amendable to chiropractic care. Perhaps the most succinct and straightforward testimony came from Dr. K.E.D. Eyre, a neurologist, who said, I would agree that spinal subluxation causes disease. We would be wasting our breath to deny otherwise.”[8]

Unquestionably, the Commission found the medical opposition and ridicule of chiropractic’s claim to help organic disorders was the most contentious issue. The Commission found that chiropractors’ inability to explain the mechanism of improvement with Type O disorders allowed the medical society to, in effect as Hadler has done, throw the baby out with the bathwater.

It is the chiropractors’ claims of success in treatment of the Type O category which principally strains the credulity of medical practitioners, and in their minds invalidates the whole chiropractic system.[9]

Certainly as a physician, Hadler understands the medical consensus that a disc herniation in the lumbar spine may cause type O disorders like cauda equina syndrome where bowel and bladder dysfunction occurs. Why is it such a leap in logic to consider that similar SRDs at other spinal column levels may cause other organic disorders? Spinal-visceral reflexes are well known now, so only someone completely ignorant of neurophysiology would believe “no such specific skeletal changes correlate with symptoms,” as Hadler wrote.

Also, let me ask: does he have any clinical proof for his assertion? Has Hadler based his opinion on fact or simply personal bias?

Indeed, the last thing political medicine wants is proof that the subluxation theory may have legitimacy rooted in neurophysiology instead of vitalism. The New Zealand Commission addressed this point as well:

However it needs to be understood that the area of spinal mechanics and its implications in neurophysiology has not been explored by orthodox medical science. In the Commission’s view chiropractic theories have only just begun to evolve on a scientific basis both with the advent of new discoveries in neurophysiology and with the increasing number of trained scientists interested in the field.

Indeed it is probably true to say that chiropractic is a form of treatment still in search of an explanation for its effectiveness.[10]

Another fact not lost on the NZ Commission was the scarcity of research by the medical profession to prove its allegations against chiropractic.

 The medical profession, with its massive research resources, has made no serious attempt to seek such an explanation and certainly has not found one. Nor has organized medicine been able to prove that chiropractic does not work.[11]

.

Unlike thirty years ago, now the chiropractic reference books are plentiful, and JMPT provides peer-reviewed papers, but Hadler ignored these credible sources in his criticism, such as:

  • “Principles of Practice of Chiropractic,”  by Scott Haldeman
  • “The Chiropractic Theories” by Robert A. Leach,
  • “Low Back Pain – Mechanism Diagnosis and Treatment” by Jim Cox,
  • “The Chiropractic Profession” by David Chapman-Smith,
  • “Contemporary Chiropractic” edited by Daniel Redwood,
  • “Chiropractic: A Philosophy for Alternative Health Care by Ian Coulter,
  • “Toward a Philosophy of the Science of Chiropractic,” by Joe Keating
  • “Assessment of the Spine,” by Phillip Ebrall,
  • “Low Back Syndromes” by Craig Morris,
  • “Whiplash Injuries,” by Foreman and Croft,
  • “Differential Diagnosis for the Chiropractor,” by Tom Souza,
  • “Clinical Chiropractic,” edited by Greg Plaugher, or
  • “Chiropractic Technique” by Bergman, Peterson and Lawrence.

Instead, Hadler ignores this modern body of work and, incredulously, spews many of the same epithets. He totally ignored the research and expert testimony from the New Zealand Inquiry, he misrepresented the Wilk trial evidence, and he inexplicably trivialized the enormity of the AHCPR report despite being an advisor. Indeed, his book is appropriately named since he stabbed chiropractors in the back with half-truths and fear-mongering unlike anything seen in decades from someone who postures himself as an ethicist.

Medical Chauvinism

Nor did we hear him elaborate on the role chiropractic should play in the epidemic of back pain as a viable non-drug, non-surgical solution as fifteen international studies now suggest. Increasingly we hear more calls for primary spine care practitioners such as DCs, PTs, and traditional DOs to act as portal of entry for the epidemic of musculoskeletal disorders that calls for the advent of primary spine care providers rather than the use of uneducated, biased primary medical care providers who know painfully little about these SRDs.

According to the authors, Hartvigsen, Foster, and Croft, “We need to rethink front line care for back pain” that appeared in the British Medical Journal:

“Such “primary care musculoskeletal specialists” could provide extended and consistent evidence based management, optimizing the opportunity for improvement and prevention of chronic back pain.”[12]

This Hartvigsen paper coincided with another paper, “The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States” by Donald R Murphy, Brian D Justice, Ian C Paskowski, Stephen M Perle, and Michael J Schneider, all doctors of chiropractic. They explain:

It is widely recognized that the dramatic increase in health care costs in the United States has not led to a corresponding improvement in the health care experience of patients or the clinical outcomes of medical care. In no area of medicine is this more true than in the area of spine related disorders (SRDs). Costs of medical care for SRDs have skyrocketed in recent years. Despite this, there is no evidence of improvement in the quality of this care. In fact, disability related to SRDs is on the rise. We argue that one of the key solutions to this is for the health care system to have a group of practitioners who are trained to function as primary care practitioners for the spine. [13]

Unlike these calls for sensible reform in this epidemic of back pain, Hadler made no bones about spewing his snide remarks as he casts the same old medical aspersions. To his credit, Dr. Hadler was honest about one thing—his medical bias. Like a racist admitting to racism, perhaps his confession somehow justifies his ignorance:

I admit to chauvinism; I value my profession above all others to the extent that it tests the limits of certainty regarding the validity of its therapeutic offerings. I write extensively on how the institution of contemporary medicine has lost its way, but I also write extensively on how its practitioners hear a higher calling.[14]

Medical chauvinism, according to ethicist Hadler, is “a higher calling”? And you may wonder why to me appears to be a medical Nazi declaring the superiority of the Aryan medical profession?

We all realize many MDs stand atop a vaulted pedestal with a severe affliction of self-aggrandizement, but is this not a case of unsubstantiated arrogance facing the increasing evidence of the failure of the  medical management to solve this back pain epidemic?

Let’s be frank about the failure of the medical management of SRDs. According to Rick Deyo, MD, MPH, et al. from 1994 to 2007, the patient population increased by only 12%, but MRIs increased 307%, spinal fusion surgery increased 204%, spinal injections increased 629%, and opiate use increased 423%.[15] The most complex type of back surgery has increased dramatically between 2002 and 2007 with a 15-fold increase.[16]

This is sheer madness, not a higher calling.

To his credit, Hadler does admit to the failed medical management of back pain and he also is quite clear that most spine surgeons are out of control:

Spine surgeons around the world are more than willing to offer laminectomy with discectomy to their patients. Nowhere is this remedy pursued with as much vigor as in the United States, which has the highest rate of spine surgery in the world by far. Nonetheless, there was not a hint of benefit from surgery for low back pain in the short or long term; both surgically treated and non-surgically treated patients improved to the same degree at the same rate.  (There was a hint of benefit for sciatica, or leg pain.) Little heed was paid to the implications of this trial.[17]

While Hadler does call out spine surgeons, he omits manual and non-surgical therapy as the preferred alternative, even when recommended by his guru, Alf Nachemson, MD, PhD Professor and Chairman, Department of Orthopaedics, Institute for Surgical Sciences. Hadler continues:

And little heed was paid to the stentorian voice of another pioneering Scandinavian spine surgeon, the late Alf Nachemson, who was the founding editor of the journal Spine and who strutted the international stage of spine surgery both as a speaker and author. In 1996 Nachemson concluded that for regional low back pain, one should “never treat with surgery.” I had published the same conclusion repeatedly over the previous decade. But the surgical community found plenty of reasons, usually stated as different and new surgical techniques and indications, to justify surgical hubris.[18] (emphasis added)

As an example of Hadler’s “chauvinism,” although he praises Dr. Nachemson, he pays little heed to all the recommendations of his guru who also suggested manual therapy for low back pain. 

Apparently Hadler is willing to criticize spine surgery, but his omission of Nachemson’s recommendation of manual therapy illustrates the half-truths when Hadler won’t endorse his professional rivals, undoubtedly due to his medical chauvinism. 

Dr. Nachemson, regarded as the godfather of the evidence-based spine care movement, suggested:

. . . many in the medical community, and spine surgeons in particular, have been slow to embrace the results of rigorous scientific research.  As a result, many patients with back pain don’t receive optimal spine care.  Many continue to undergo unproven and counter-productive treatments.

 Fusion surgery is typically not a cure and should not be presented as such… Few patients experience complete relief of back pain following surgery. Only one in five patients in these studies became pain-free.

Examine and inform your patients, recommend activity, and advise against bed rest. Don’t perform x-ray or MRI unless there is a red flag. Offer pain medicine or manual therapy if the patient prefers it. [19]

[BTW: this was exactly the recommendations by AHCPR for acute low back pain that Hadler also overlooked.]

Again, this begs the question: Where is the “higher calling” among surgeons and Hadler when they selectively ignore their own research or misquote by omission? Hadler answers this question when he says: The pen may be mightier than the sword, but it is not mightier than the dollar.”[20] Amen to that!

Hadler’s Hocus Pocus

Hadler offered his condescending opinion of chiropractic care:

I have long been fascinated by the staying power of folk remedies such as back cracking. Clearly some, and perhaps nearly all, folk remedies are simply delusional idiosyncrasies of culture. But back cracking is sufficiently distinctive to foster entire schools of sectarian medicine. Are the practitioners self-deluding and their patients seduced by placebo events? [21]

Although Hadler admits to the longevity, effectiveness, and popularity of “folk remedies such as back cracking,he then demeans it as “simply delusional idiosyncrasies” and resorts to vitriolic terms to show his contempt with terms like “back cracking”, “placebo”, and “hocus pocus.”

As a chiropractor, I find “back cracking” to be particularly offensive, suggesting fractures caused by a crude and forceful manipulation of the spine. This ploy is commonplace among these men of a “higher calling” mainly to frighten perspective patients.

Dr. Hadler spoke of his own skepticism of the effectiveness of spinal manipulation before he conducted a survey at UNC in 1987.  He attended a weekend course in orthopaedic medicine taught by a disciple of Dr. James Cyriax in London who practiced and wrote textbooks on manipulative medicine. Nonetheless, Hadler sarcastically commented, “To my eye, it was hocus-pocus.”[22]

Scott Haldeman, DC, MC PhD, might differ with Hadler in his dislike of this “hocus-pocus.” Without question, Dr. Haldeman is a renowned leading authority in the back pain world with his multidisciplinary background. He has doctorates in chiropractic and medicine, as well as a PhD in neurophysiology. He also is an Associate Professor of Neurology at The University of California at Irvine, Adjunct Professor at the Southern California University of Health Sciences, a member of the RAND study, and chairman of the task force for chronic low back pain for the Decade of Bone and Joint Disorders. He also was the lead editor of the comprehensive textbook, The Principles and Practices of Chiropractic (Appleton & Lange, Prentice Hall, 1980). 

Dr. Haldeman commented in his testimony before the NZ Commission that to teach an MD the ropes of chiropractic analysis, science, and the art of manipulation would require a “12 months’ full time training in spinal manipulative therapy following a medical degree.”[23]

Yet Hadler believes one weekend course is sufficient time to judge a healing art steeped in history. Apparently this is enough evidence for Hadler to disavow the years of work by medical manipulators like Cyriax and the thousands of chiropractors, DOs, PTs, and physiatrists who use manual medicine.

Despite his bias, Hadler et al. conducted a comparative study on treatments for low back pain. Obviously, it’s hard to believe any study on manipulative therapy by Hadler would be objective. In this study, sixty volunteers received a “thorough examination from me [Hadler] designed to be most reassuring in terms of prognosis.”[24]

How is his examination considered to be “most reassuring”? This raises the obvious question: Hadler believes vertebral subluxations are “imaginary” and disc abnormalities are incidental to back pain as he has written. So, just what is he looking for in these cases with his examination?

This also begs the question: where did he receive his training in the art of detecting spinal problems? Recall he is a rheumatologist, not an orthopedist, chiropractor, physiatrist or true osteopath. Again, perhaps his “higher calling” gives him providential powers that others require years to accomplish.

As a practicing chiropractor myself with 33 years of clinical experience, I am stunned that a medical doctor without any training or clinical experience would even attempt to examine or manipulate any patient’s spine. Not only is there the academic knowledge of the biomechanics of the spine to consider, but the art of manipulation is like an athletic skill that requires years of practice to develop the touch of joint manipulation—the “knack” as DD Palmer once described this art of spinal adjusting. Even then some have it and some don’t;  and certainly anyone with a negative attitude would have a more difficult time to achieve this skill, if ever.

The AHCPR panel also recommended that manipulation only be done by an experienced practitioner. This guideline states:

This treatment (using the hands to apply force to the back to ‘adjust’ the spine) can be helpful for some people in the first month of low back symptoms.  It should only be done by a professional with experience in manipulation.[25]

Hadler’s colleague in this study, Peter Curtis, MB (Bachelor of Medicine), performed an osteopathic manipulation on half the study participants and mobilization on the other half. Hadler admits in this study those who were hurting for two to four weeks experienced a 50 percent reduction in score more rapidly with spinal manipulation. In the original 1987 study, the conclusion praised the “major ramifications” of this improvement from manipulation:

 “Those subjects who had suffered a backache for 2-4 weeks prior to entry were afforded more rapid improvement if they were subjected to spinal manipulation. In view of the extraordinary prevalence of low-back pain and its pervasive impact in so many social spheres, the ability to abrogate an episode of backache, even by a few days, has major ramifications.”[26]

Despite the initial accolades in his summary statement for manipulation, twenty two years later in his 2009 book Hadler mentions the same study, but now trivializes the same findings by saying, “However, at best this is much ado about very little. Certainly, it is little reason to advocate a form of sectarian medicine.”[27]

Ironic, isn’t it, to have the same study with two different conclusions drawn by the same man.

Hadler also reveals his misrepresentation of chiropractic care when he writes:

There is no data that repeating the crack offers anything. Nonetheless, it is this data that led the AHCPR committee to recommend a single manipulation in the treatment of acute low back pain.[28] [This is not what AHCPR recommended; in fact, 4 weeks of care was suggested]

 

            “…repeating the crack” illustrates his bias as bad as his derisive “back cracking” comment.

Hadler could not contain his prejudice any longer when he blatantly announced his torment with spinal adjustments:

I have never felt comfortable performing manipulation, recommending manipulation, or letting anyone crack my back. [29]

            In one fell swoop, Hadler expresses his total disdain for the art of spinal manipulation.  For the thousands of DCs who do SMT daily to the twenty million patients we serve annually, his queasiness is childish at best and wimpish at its worst.

Although Dr. Hadler casts his personal aspersions about “back cracking”, he does admit the scientific proof of spinal manipulation outweighs the medical methods when he wrote: But no other modality has even this much scientific support.”[30] Finally, he throws chiropractors a bone!

Despite this admission, Hadler continues to minimize the effectiveness of chiropractic care with his demeaning opinion that it’s mainly placebo for both DCs and patients:

However, chiropractors are skilled at applying brief, high velocity force to the vertebral column sufficient to create a vacuum phenomenon in the small joints of the spinal column. The joints snap back with cracking sounds and sensations that cause chiropractors to feel accomplished and their patients to feel treated.[31]

His medical prejudice has given him a blind spot for someone who purports to be on the leading edge of spinal research. Hadler shows his ignorance and bias as if he never had read the New Zealand Report, RAND, AHCPR, UK BEAM, UK NICE, Manga I or II, BJD, SPORT, or any of the subsequent research studies.

Certainly Hadler’s sentiments are not that of an objective, open-minded scientist, but that of a medical partisan and Fishbein ideologue with an ax to grind on chiropractors.

Hadler does admit that “no other modality has even this much scientific support,” yet he expresses clearly his disdain for “back cracking,” which is certainly a pejorative meant to frighten patients by suggesting manipulation is dangerous when, in fact, it is the safest of all spinal treatments including drugs, shots, and surgery.  Indeed, one quick method to determine whose treatment is most dangerous is to compare malpractice insurance rates to learn that chiropractors pay the lowest rates of all spinal practitioners.

The NZ Commission also commented on the alleged harm done by chiropractors:

The conspicuous lack of evidence that chiropractors cause harm or allow harm to occur through neglect of medical referral can be taken to mean only one thing: that chiropractors have on the whole an impressive safety record.[32]

Hadler continues to minimize the effectiveness of manipulative therapy for low back pain, suggesting it is “modest and transient” and due mainly to chiropractors’ wonderful “bedside manner.” He appears unaware of the role of joint dysfunction in spinal care nor is he aware of the role of neurotransmitters, interference to trophic nerve function, or spino-visceral reflexes as the NZ Commission reported.

He also suggests that chiropractic patients are stupider than medical patients. Again notice his snide reference to “the chiropractic” instead of simply using the term “chiropractors”.

There have been a number of trials in which the outcomes for patients with low back pain who are offered ancillary physical treatments are compared with those for patients who are not offered such ancillary treatment. If there are benefits, they are modest and transient. So we are left with the “bedside manner” as the explanation for why patients of chiropractors return repeatedly. Fortunately, we have important insights about this interaction. The patients of the chiropractic are predominately middle-aged, white, married people whose personal philosophic orientations and preconceptions are particularly compatible with those espoused by the chiropractic. They have significantly poorer mental health than medical back pain patients. Furthermore, these psychosocial attributes bode poorly in terms of persistence of pain and incidence of recurrent episodes. The chiropractic may be providing a port in their storm, but one that the chiropractic seems little cognizant of nor much of a match for.[33] (emphasis added)

It comes with no surprise that Hadler believes chiropractic patients are stupid since he admits that he would never be “cracked”; apparently in his mind smart patients prefer drugs, shots, and surgery.

Hadler is misleading when he suggests that chiropractic patients are dumber than medical back pain patients. In 2008 the SPORT study investigated patient preferences, characteristics, and expectations for care for those with lumbar disc herniation.[34] Medical bias and the lack of informed consent where patients are often not honestly told of treatment options are big factors, but the SPORT study also found unrelated characteristics, such as “lower levels of education” and more opiate drug use.

Patients preferring surgery were younger, had lower levels of education, and higher levels of unemployment/disability. This group also reported higher pain, worse physical and mental functioning, more back pain related disability, a longer duration of symptoms, and more opiate use. [35]

A quote by Robert S. Mendelsohn, MD, author of Confessions of a Medical Heretic (Contemporary Books, Chicago, 1979), is appropriate here when he said, “Anyone who has a back surgery without seeing a chiropractor first should also have his head examined.” Certainly a back pain patient who can be frightened into risky and expensive back surgery before seeing a chiropractor for a simple spinal adjustment is either stupid or a victim of the medical profession’s demagoguery toward chiropractors.

Tony Rosner, PhD, testified to this opinion before The Institute of Medicine: Committee on Use of CAM by the American Public[36]:

“Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.”

In this era of evidence-based health care, it never ceases to amaze me how the medical spine care practitioners turn a blind eye to the emerging evidence. One not need look far to see the Hillbilly Heroin (Oxycotin) epidemic is rampant, and new evidence recently reiterated the fallacy of epidural steroid shots for low back pain were no better than sham or saline injections.[37],[38]

In regards to the epidemic of back surgeries, over the last few months, the mainstream media has jumped on the unnecessary, risky, expensive, and corrupt spine surgery scam. For example, here are a few recent media exposés on spine surgery:

• “Surgery May Not Be the Answer to an Aching Back,” by Joanne Silberner, NPR, April 6, 2010.

• “Back Surgery May Backfire on Patients in Pain,” by Linda Carroll, MSNBC, Nov. 14, 2010

• “Top Spine Surgeons Reap Royalties, Medicare Bounty,” by John Carreyrou and Tom McGinty, Wall St. Journal, Dec. 20, 2010

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

• “Spinal Fusions May Cause More Harm Than Good,” by Terrance Pagel, Daily Health Report, Jan. 20, 2011

• “Medicare Records Reveal Trail of Troubling Surgeries” by John Carreyrou and Tom McGinty, Wall St. Journal, March 29, 2011

 

Despite the new revelations, there is no sign these medical treatments are slowing down. In fact, they are increasing. Richard Deyo et al. reiterated the large increase in the rate of spine surgery in their recent study of the subsequent five years. “The most complex type of back surgery has increased dramatically between 2002 and 2007 with a 15-fold increase.”[39]

Deyo discovered that the more-complex type of spine surgery was associated with substantially higher risk of life-threatening complications.  He and his colleagues found the mean hospital costs for surgical decompression and complex fusions ranged from $23,724 for the former and $80,888 for the latter.

Deyo also noted, “It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just six years.” Among the various reasons for such a large increase, he mentioned one strong motivation included “financial incentives involving both surgeons and hospitals.”[40]

While the back pain business is huge in both numbers and dollars, medical experts now admit that it is rife with outmoded theories and 200+ treatments, most of which are unproven and ineffective, according to the recent study by Haldeman et al. on chronic LBP in the Decade of Bone and Joint Disorders, who likened consumers as shopping in a supermarket.[41]

“In this supermarket of over 200 available treatment options for CLBP, we are still in the era of caveat emptor (buyer beware)…it is somewhat disappointing to note that 14 years after [AHCPR] dozens of highly promoted new interventions, thousand of studies, millions of lost work days, and billions of dollars spent on its care, so little has changed in the evidence available to guide stakeholders and support treatments for CLBP…

 “It is hoped that this special focus issue will provide a starting point for stakeholders desiring quality information to make decisions about the evidence-informed management of CLBP…

“With CLBP, however, treatment options appear virtually endless and increasing every year, have strong and vocal advocates, and often limited scientific evidence…Conversely, approaches that have demonstrated only minimal benefit in clinical trials continue to be recommended by proponents who allege that such studies were flawed and do not accurately represent current clinical practice…

 

Despite the admonition for acute and chronic LBP treatment from both AHCPR and BJD, the most popular medical treatments like opioid drugs, epidural shots, and spine surgery fail to be supported in RCTs, but this hasn’t slowed down their usage. According to Rick Deyo, MD, MPH, “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.”[42]

Gordon Waddell, DSc, MD, FRCS, orthopedic surgeon, and author of The Back Pain Revolution, openly admits:

"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…None of us have a good answer for low back pain--orthodox medicine, professors, and methodologists least of all.

“Chiropractic is not the magic answer for back pain, and it should and can stand up to fair criticism, but orthodox medicine could potentially also learn a lot from chiropractic.

“The needs of patients with back pain should override our professional dignities, and the real need is for us all to work together.”[43]

What lesson can medicine learn from chiropractors? Perhaps the foremost lesson is to “think out of the abnormal disc box” that has entrapped everyone’s perspective. While discs may become an issue, its role is secondary to the function of spinal mechanics, a concept long ignored by surgeons who focus on the disc. As one orthopedist told me, “That’s where the money is.”

Rick Deyo, MD, MPH, admits that the cause of low back pain remains a mystery to the medical profession:

“Experts have concluded that perhaps 85% of patients with back pain can’t be given a definitive diagnosis, despite the best medical evaluation. In part, this is because so many structures in the spine can give rise to pain, including muscles, ligaments, bones, nerve roots, and parts of the discs between vertebrae [where’s the joints?]. X-rays and MRI scans often can’t distinguish which of these is the true source of an individual’s pain.” [44]

Paul Goodley, MD, author of Release from Pain, offers an explanation to Deyo’s assertion:

“I accuse that a big slice of the 85% ignorance is accountable to the rejection of the thinking involved in manipulative approaches. The conflict remains so near unimaginable that future historians may well describe the past century as a time of unnecessarily perpetuated pain.” [45]

 Deyo also admits the disc abnormalities are “incidentalomas” that have nothing to do with the majority of back pain problems. His omission of joint dysfunction as a probable cause of back pain and his omission of manipulative methods speaks volumes, although he admits the disc theory is, in effect, a big part of the zombie science of spine care.

“And we know that bulging, degenerated, and even herniated discs in the spine are common among healthy people with no symptoms. When doctors find such discs in people with back pain, the discs may be irrelevant, but they are likely to lead to more tests, patient anxiety, and perhaps even unnecessary surgery. In fact, back surgery rates are highest where MRI are the highest. In a randomized trial, we found that doing an MRI instead of a plain x-ray led to more back surgery, but didn’t improve the overall results of treatment.

“Because we see more things on these scans, certain medical problems seem to be becoming more common year after year. This is not because abnormalities are getting more common; it’s only that we’re more likely to discover them. But finding things makes doctors and patients more enthusiastic about doing the tests and seems to justify them many of these abnormalities are trivial, harmless, and irrelevant, so they’ve been dubbed ‘incidentalomas.’

“Nonetheless, these incidentalomas get treated. It’s easy to be fooled into thinking that if the patient does fine, it’s because we found an abnormality and treated it. But with an incidentalomas, the patient was destined to get better anyway because the condition was a non-disease to begin with.” [46]

 



[1] Bruce G Charlton, ”Replacing Education With Psychometrics,”  Medical Hypotheses, 71 (2008) :327–9.

[2]Groopman, Jerry, MD,  "Knife in the Back,” April 8, 2002, The New Yorker magazine

[3] The BACK Letter,  Volume 23, Number 8, Sept. 2008. Worried Sick: A Prescription for Health in an

Overtreated America.

[4] Ibid. p. 55.

[5] Hadler, N, Need for less imaging, better understanding, JAMA, June 4, 2003 vol. 289 no. 21.

[6]Hadler, NH. The Last Well Person, McGill-Queen's University Press, 2004. ISBN 0-7735-2795-8.

[7] Hadler, NH. The Last Well Person, McGill-Queen's University Press, 2004. ISBN 0-7735-2795-8.

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

[9] Ibid. p. 43

[10] Ibid. pp. 43-44

[11] Ibid. pp. 43-44

[12]Jan Hartvigsen Nadine E Foster, Peter R Croft, “We need to rethink front line care for back pain,”  BMJ 2011;342:d3260 doi: 10.1136/bmj.d3260

[13] Donald R Murphy, Brian D Justice, Ian C Paskowski, Stephen M Perle, Michael J Schneider, The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States, Chiropractic & Manual Therapies 2011, 19:17

[14] Ibid. p.64

[15] Martin BI, Deyo RA, Mirza SK et al. Expenditures and health status among adults with back and neck problems. JAMA 2008; 299: 656-64

[16] J Silberner, “Surgery May Not Be The Answer To An Aching Back,”  All Things Considered, NPR (April 6, 2010)

[17] Ibid. p.84

[18]  Ibid. p. 85

[19] Richard A. Deyo, MD, MPH Alf Nachemson, MD, PhD, and Sophail K. Mirza, MD, “Spinal-Fusion Surgery:  The Case for Restraint,” New England Journal of Medicine 350/7 (February 12, 2004):  722-26.

[20] Hadler. p. 88

[21] Ibid. p. 68

[22] Hadler, p. 68.

[23] NZ Commission, p. 244

[24] Hadler, p. 70.

[25] Bigos, ibid, Patient Guide, p. 7.

[26] NM Hadler, P Curtis, DB Gillings, S Stinnet, “A Benefit of Spinal Manipulation as Adjunctive Therapy for Acute Low-Back Pain: A Stratified Controlled Trial,” Spine  12/ 7 (1987): 705.

[27] Hadler, Stabbed in the Back, p. 70.

[28] Ibid. p. 70.

[29] Ibid. p. 70

[30] Hadler, p. 70

[31] Ibid. p. 68

[32] Ibid. p. 78

[33] Ibid. p. 71

[34] JD Lurie, SH Berven , J Gibson-Chambers , T Tosteson , A Tosteson, SS Hu, JN Weinstein, “Patient Preferences And Expectations For Care: Determinants In Patients With Lumbar Intervertebral Disc Herniation,” Spine. 33/24 (Nov 15 2008):2663-8.

[35] James N. Weinstein, DO, MSc; Tor D. Tosteson, ScD; Jon D. Lurie, MD, MS; Anna N. A. Tosteson, ScD; Brett Hanscom, MS; Jonathan S. Skinner, PhD; William A. Abdu, MD, MS; Alan S. Hilibrand, MD; Scott D. Boden, MD; Richard A. Deyo, MD, MPH, “Surgical vs Nonoperative Treatment for Lumbar Disk Herniation The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial,” JAMA 296 (2006) :2441-2450.

[36] Rosner, A, PhD, testimony before The Institute of Medicine: Committee on Use of CAM by the American Public on Feb. 27, 2003.

[37] Ann Rheum Dis. 2003;62:639-643

[38] Iversen T, Solberg TK, Romner B, et al. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomized controlled trial. BMJ. 2011;343:2-15.

[39] J Silberner, “Surgery May Not Be The Answer To An Aching Back,”  All Things Considered, NPR (April 6, 2010)

[40] “New Study Demonstrates A Three-Fold Increase N Life-Threatening Complications With Complex Surgery,” The BACKLETTER, 25/6 (June 2010):66

[41]Haldeman, S., Dagenais, S., Evidence-Informed Management of Chronic Low Back Pain Without Surgery, The Spine Journal, January/Feb 2008,Volume 8, Number 1.

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

[43] Waddell G. Low back pain: A twentieth century health care enigma. Spine 1996 Dec 15; 21 (24):2820-5

[44] Deyo, R, Conservative Therapy for Low Back Pain: Distinguishing useful from useless therapy.
JAMA 1983: 250;1057 - 62.

[45]Goodley, Paul, MD Goodley Intentions: Resurrecting Traction; Posted 02/06/2008 MD Medscape Orthopaedics, WebMD.

[46] Deyo, R. MD, MPH, and Donald Patrick, PhD, MSPH, Hope or Hype, The obsession with medical advances and the high costs of false promises. 2005 AMACOM books.

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