Articles by JCS

The Paradoxical Backache

 

The Paradoxical Backache

By

JCS

 

It never ceases to amaze me the huge amount of conflicting information about the epidemic of back pain in this country. One thing is true no matter who discusses this issue—back pain is a costly epidemic that is only getting worse.

Researchers tell us that up to 90% of adults will suffer from low back pain sometime in their lifetimes, over 30 million adults suffer daily with back pain, $75-100 billion is spent on this epidemic yearly in the US alone, it’s the number one Workers’ Compensation on-the-job injury, and it’s the third-leading reason for hospital admissions.[1]

Since low back pain is a worldwide epidemic, several countries have done research to solve this expensive problem and each concluded that SMT was a viable solution. These studies included:

  • 1978: New Zealand Royal Commission
  • 1994: AHCPR Acute Low Back Pain
  • 2003: Ontario Workers’ Safety and Insurance Board
  • 2004: European Back Pain Guidelines.
  • 2004: UK BEAM 
  • 2007: Guideline on Back Pain: American College of Physicians
  • 2008: Decade of Bone & Joint Disorders: CLBP

 

Yet among the 200 possible treatments available for LBP[2], the best treatments are still debated among researchers despite the recommendations of the most intensive studies every done on low back pain. The 1994 release of the US Public Health Service’s two-year study[3] (AHCPR) of 4,000 articles and Dr. Pran Manga’s review[4] of LBP treatments for the Ontario Ministry of Health in Canada shared the same conclusion that most people are still clueless about—for the vast majority of back problems, the best treatment is spinal manipulative therapy (SMT). They also agreed that the standard medical procedures were ineffective, dangerous and costly.

Lately, however, some researchers are chirping in that SMT is not as effective as some of us would like to believe. Paul Shekelle at RAND[5], Tim Carey et al at North Carolina[6], GBJ Anderson et al in the NEJM[7], Dan Cherkin and RA Deyo[8] of UW, and now Chang-Yu Hsieh[9] of LACC have concluded that SMT alone is only slightly better than simple back exercises, and they question its cost-effectiveness when compared to simply taking pain pills and doing home spinal exercises.

 Why this turn of events? Indeed, it does get confusing listening to different researchers giving us contradictory studies. Is there justification to minimize the effectiveness of SMT or is there a hidden agenda among some medical researchers? And if SMT and chiropractic care for LBP is as effective and inexpensive as some reports claim, why do the insurance companies still boycott or limit this type of care? These are questions I will address in the chapter on the paradoxical backache.

 

The Dilemma of Back Pain Treatments

Rene Cailliet, MD and author of many books on neck and back pain, wrote in 1999 in the American Journal of Clinical Chiropractic, "With all these [LBP therapies] and many more being used, it is apparent that most are not, per se, effective.”[10] Even chiropractic spinal manipulation alone has not been shown by some researchers to stabilize or cure back problems once and for all. As Paul Shekelle, MD and RAND researcher mentioned in RAND Items, “At the end of all this, our research would suggest that chiropractic is neither a quack nor a cure.”[11]

Why is it that most LBP remedies are ineffective or temporary at best? I think it depends upon how you view this problem.

First of all, spinal problems are functional, dynamic type of injuries where joint complex dysfunction (JCD) due to spinal joint misalignment has caused reflex muscle spasms, disk inflammation, nerve dysafferentiation, vaso-constriction and joint stiffness.[12] These JCDs are not static problems like a thorn in the paw or a broken bone. Most spinal problems are dynamic situations where joint motion and muscular strength issues are involved, along with neurological implications. Back pain is not just a slipped disk as a spine surgeon might say or a bone out of place as some simplistic chiropractors might tell you; nor is it simply a pulled muscle as a PT or massage therapist might explain. Indeed, it’s more complex than any of these individual explanations.

The main attribute to remember about the spine is that it’s a weight bearing column of 24 vertebrae supporting the head and sitting atop 3 pelvic bones, all interconnected by 137 joints. Consequently, the spine is very susceptible to stresses, bad posture, bad leverage in work situations, repetitive stress, trauma from sports or accidents and non-traumatic compression problems from prolonged sitting or standing. As well, the spine acts as a weight-bearing unit that constantly encounters mechanical problems. Only in sleep does the spine ever relax and remodels itself, but that can also be lost if one sleeps improperly, such as sleeping on one’s stomach. Just as a knee injury is a dynamic problem compared to a broken bone injury, the spine is in a constant state of movement and stress in an ever-changing environment. And just as most spinal problems are dynamic in nature, so should be the treatment.

 

The Disk Theory is Dead

Unfortunately, most spinal models fail to address this dynamic aspect. The static model of medicine, the disk theory, has failed to explain the cause of back pain. As the AHCPR report indicated, “Even having a lot of back pain does not by itself mean you need surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.”[13]

Recent MRI research has questioned the validity of the disk theory as espoused by most surgeons. A study found that about a quarter of people with no history of back trouble whatsoever have ruptured disks when examined with MRIs, indicating disk abnormalities may be incidental to the actual cause of back pain, which is joint dysfunction in many cases.

The research suggests that ruptured disks may not mean much for many people, and they certainly cannot be assumed to be the sole source of a patient's backache. The study suggests that disk peculiarities "may frequently be coincidental" in people with back trouble. In other words, the disk might not be the cause of the pain. And if so, fixing it with surgery is a waste of time and money.

The study[14] was conducted on 98 healthy volunteers by Dr. Maureen C. Jensen and colleagues from Hoag Memorial Hospital in Newport Beach, Calif. Their work, published in the New England Journal of Medicine, roughly duplicates a study completed four years previously by Dr. Scott Boden, an orthopedic surgeon at Emory University.

"The MRI should never be used as a screen test, which is unfortunately the way it is very commonly used today," Boden said. "In fact, use of the MRI too early in somebody's disease process can result in seeing these findings that are like gray hair--everybody gets them--and can result in over-treatment."

The AHCPR study mentioned back surgery with great reservation.

“The presence of a herniated lumbar disk on an imaging study, however, does not necessarily imply nerve root dysfunction. Studies of asymptomatic adults commonly demonstrate intervertebral disk herniations that apparently do not entrap a nerve root or cause symptoms…Moreover, surgery increases the chance of future procedures with higher complication rates.”[15]

 

Apparently disk pathologies have little to do with back pain, but this revealing research has not had much impression upon the medical establishment or managed care organizations (MCOs). Any MRI exam revealing disk abnormalities is a green flag for many surgeons despite the guideline’s reservation. For too long, patients have been misinformed that any disk abnormality warrants back surgery, and they are also misled about SMT by surgeons who scare patients about chiropractic care with untrue horror stories despite statistics which indicate SMT causes only 1-2 accidents per million while neck surgery causes 15,600 strokes or paralysis per million.[16] This obviously begs the question: Who’s hurting who?

 

The Aching Sacro-iliac

Former comedian Jack Benny often joked about his sacroiliac pain, but most people had little idea what he was actually talking about. While the word “sacroiliac” may not be a commonly used term, it certainly applies to many painful back problems for many people. Now recent research has discovered what many low back pain patients like Jack Benny have always known—that a sacroiliac sprain is a very painful condition, and is best treated by chiropractic care.

 “The sacroiliac joint appears to be the single greatest cause of back pain. The range of motion is small and difficult to describe, but when the normal joint play is lost, agonizing pain can be precipitated,” according to John Bourdillon, MD, and Edward Day, MD.[17] Anyone who has ever “thrown out” their low back by lifting incorrectly or by suffering a bad fall can attest to what science is just now beginning to understand—that is, the sacroiliac joint is very painful when misaligned.

The sacroiliac joints are located on both sides of the sacrum or tailbone. The illum are commonly known as the hip bones that butt against the triangular shaped tailbone. Consequently, the two sacroiliac (SI) joints are main joints in the pelvis. The sacrum and SI joints are the literal basis of the spine. All loads from above (spine, trunk, upper extremities) and all forces from below (the leg) are transmitted through the pelvic ring and SI joints. The pelvis is intimately coupled with the lower vertebral column and legs by muscles, ligamental and fascial structures, along with the lumbar and pelvic nerves, such as the sciatic nerve that goes down each leg

For years the medical profession denied that the SI joints could move and had no impact on low back or leg pain. Instead, they tried to convince the public that all low back pain was due to “pulled muscles” or “slipped disks.” Most ironic is the fact that the SI joint does not have any disk cartilage like the lumbar spine, so the MRI scans for LBP excluded this area. Since there is no disk to cut out, surgeons are not interested in this joint.

After years of failed back surgeries to treat this problem, some in the medical profession have finally concluded their approach was incorrect, and that the chiropractic explanation that the SI joints may be the source of this pain was plausible. Try telling that to my patient who had 3 failed back fusions with metal screws implanted when all he needed was a few SI adjustments! His workers’ comp case cost over $1.3 million and he’s now permanently disabled.

“After years of failed back surgeries to correct this problem, the medical profession has finally concluded their approach was incorrect, and that the chiropractic explanation was correct all along,” according to Joseph Shaw, MD, orthopedic surgeon.[18]

“The conventional wisdom is that herniated discs are responsible for low back pain, and that sacroiliac joints do not move significantly and do not cause low back pain or dysfunction. The ironic reality may well be that sacroiliac joint dysfunctions are the major cause of low back pain, as well as the primary factor causing disk space degeneration, and ultimate herniation of disk material."

On the basis of a study of 1000 patients with low back pain in his clinic, Dr. Shaw concluded:

  • 98% of the patients had a mechanical dysfunction of the SI joints as a major cause of their low back pain.
  • Treatment of these patients by restoration of full sacroiliac joint motion led to relief of symptoms in almost all cases.
  • Most remarkable was the absence of need for surgery in these patients. Only two patients needed surgery for protruded discs.

 

This medical research verifies what Jack Benny and doctors of chiropractic have known for decades--that misalignments of the SI joints cause painful and widespread problems for many patients. But don't think that low back pain happens only to adults. The research has found that many children also suffer from low-back pain. After all, most adult spinal problems actually begin in youth when children suffer falls from bikes, skates, and sports activities. Too often these injuries go undetected and uncorrected, only to relapse later in life. In one study it was found that 29.9% of pupils aged 6-12 had low back pain, and that 41.5% of high school students aged 12-17 had SI joint pain.[19] These patients with SI pain responded excellently to chiropractic management with spinal adjustments.

In another study done in a Canadian hospital clinic with 283 chronic low back and leg pain patients, 117 (41%) had previously undiagnosed sacroiliac syndrome. Of these 117, who were totally disabled and had an average duration of pain of 8 years, 90% returned to normal activities of daily living after 23 weeks of daily chiropractic care. This improvement was maintained after one year.[20]

With the numerous recent clinical studies cited, it is painfully obvious that the outdated medical explanation that most low back pain is either a pulled muscle or slipped disk is wrong. Scientific research has clearly shown that the misalignment of these SI joints is the major contributor of this problem, and that chiropractic adjustments along with spinal muscular exercises are the most effective methods of treatment. If you have been suffering with low back pain, and simply taking muscle relaxes and pain pills, or worse yet, contemplating a disk surgery, take heart to learn there is a safer and more effective way to get well naturally through chiropractic spinal care.

On the other hand, unrelenting leg pain, known as “sciatica,” may indicate a prolapsed or protruded disk syndrome that may require a diskectomy if spinal manipulation hasn’t helped after a 4 week treatment period. Even for those who choose microdiscectomy for leg pain, a study by WC Peul, MD, PhD, found that after 6 months, there was no advantage to surgery![21]

Peul’s study suggests discectomies for sciatica are preferable/cost effective over conservative care in the short term (6 weeks), but admitted not in the long term (6 months). “The advantage was discernible six weeks after surgery but vanished by six months. And there were no significant differences between treatment groups in pain or disability beyond that follow-up point.”[22]

But before any patient with leg pain considers disk surgery, SMT is recommended as the first line of treatment.

 

Who Pulled the Muscle?

Another misconception about back pain is the “pulled muscle” scenario espoused by most general practitioners and physical therapists. The AHCPR study was very critical of the over-use of pain pills and muscle relaxants commonly dispensed by MDs.

“Muscle relaxants seem no more effective than NSAIDs for treating patients with low back symptoms…Side effects including drowsiness have been reported in up to 30 percent of patients taking muscle relaxants.”[23]

As well, this study also failed to endorse the procedures used by PTs. Despite their many modalities, the AHCPR guideline questioned these procedures noting they didn’t correct the underlying problem and were quite expensive.

“Physical modalities, such as massage, diathermy, ultrasound, cutaneous laser treatment, biofeedback, and TENS also have no proven efficacy in the treatment of low back symptoms.”[24]

 

Other medical invasive methods like injections were also not recommended by the AHCPR.

“Invasive techniques such as needle acupuncture and injection procedures (injection of trigger points the back; injection of facet joints; injection of steroids, lidocaine, or opioids in the epidural space) have no proven benefit in the treatment of acute low back pain.”[25]

 

It’s not that muscle spasms don’t occur in back pain syndromes, but the problem rests with the underlying cause of the spasms. Reportedly, muscle spasms are due to a nerve reflex by mechano-receptors in dysfunctional spinal joints so, in reality, rarely does anyone actually “pull” a muscle as much as they have misaligned spinal joints causing this reflex spasm. In this regard, it’s easy to understand why the medical treatments of pain pills, muscle relaxants and hot packs just don’t work to correct the underlying cause of this malady.

The same can be said about massage therapy—it doesn’t correct the underlying reflex spasm causing the muscle spasm, so an MT can work on you till the cows come home, but until the spinal joints are adjusted, the spasm will return. And living on pain pills and muscle relaxants prescribed by general practitioners are useless and dangerous. Most pill-popping patients aren’t aware that as many people died last year from NSAIDs as those who died of HIV (16,500). Obviously drugs are not the answer.

 

The Chiropractic Explanation

Many medical experts now agree that disk abnormalities or pulled muscles have nothing to do with back pain as MRI research has shown. The fact is you don’t slip disks, but you do slip spinal joints. Again, keep in mind that the human spine has 137 spinal joints interconnecting the 24 vertebrae to the head and 3 pelvic bones. In this light, it’s easy to understand that joint misalignments are the cause of the vast majority of back pain and, hence, why spinal manipulation has always worked so well.

The AHCPR study mentioned SMT for acute low back pain:

“Manipulation, defined as manual loading of the spine using short or long leverage methods, is safe and effective for patients in the first month of acute low back symptoms without radiculopathy. For patients with symptoms lasting longer than one month, manipulation is probably safe but its efficacy is unproven.” [26]

 

While spinal adjustments of these subluxated (slight dislocations) joints restore normal joint play, that alone will not stabilize a spine, perhaps explaining why the long term efficacy of SMT for LBP is unproven.

As a 40+ year sufferer of low back pain myself and as a 30 year chiropractic practitioner, I think I know the answer to this paradox. As I teach my patients, the three principles of spinal rehabilitation are 1) alignment of the spinal vertebrae, 2) strength of the spinal muscles, and 3) flexibility of the spinal joints. Just like an injured football knee, until the alignment, strength and flexibility is restored, the knee will not stabilize.

The same can be said about the spine, and since there are many more joints and muscles involved, along with the spinal cord and nerve roots, back pain will never cease altogether until the patient improves his A-S-F. While spinal manipulative therapy (SMT) works to restore joint play/flexibility, and that alone may temporarily help a patient feel better, it doesn’t stabilize the spinal weakness altogether.

Regrettably, too few chiropractors’ offices are equipped with rehab equipment so most spinal injured patients never have the opportunity to stabilize their weakened or injured spines. Not only are Back Schools effective according to researchers like Chang-Yu Hsieh, DC, but they are inexpensive as well. As Dr. Hsieh and Dr. Cherkin both found in their comparative studies, SMT alone was slightly more effective than simple back exercises, but not enough they felt to justify the added costs. While many DCs objected to these conclusions, in part I found them to be true. Together, SMT and spinal exercises are essential to recovery. If patients are smart enough to understand the madness behind these methods, their recovery is significantly better than someone doing drugs, shots and surgery.

 

The Dilemma of Spinal Care

Aside from the MCOs prohibiting many patients access to chiropractic care with their use of medical gatekeepers, another dilemma for back pain sufferers is the fact that most patients are misled about these injuries. It seems every school of thought in the back pain business works to the exclusion of all others. Consequently, few patients ever learn of a comprehensive perspective about how to manage their spinal problems.

As one who has experienced three serious back injuries during my early adulthood years, and as a practicing chiropractor for nearly thirty years caring for almost ten thousand patients, I can attest that most patients are unaware of the nature of these injuries and the nature of their proper treatment.

Providentially or just coincidentally, my three serious spinal injuries were assets in disguise. They forced me to learn how to manage a damaged spine which led me down my path to chiropractic first, then to spinal rehab secondly. After years in practice now, I’ve seen various types of treatment for back pain problems by various practitioners—surgeons, chiropractors, physical therapists—and I’ve come to conclude that most all are ineffective at their worst or incomplete care at their best.

Abraham Maslow Photo

"What shall we think of a well-adjusted slave?"

Abraham Maslow

 Sadly, too many practitioners have tunnel vision and refuse to accept tools from outside their own box. As para-psychologist Abraham H. Maslow, PhD, reportedly said, “If your only tool is a hammer, everyone looks like a nail.”

While it pains me as a chiropractor to admit that spinal adjustments alone are incomplete care, my own personal and professional experiences have led me to that conclusion. Although chiropractors adjust spinal joints to reduce joint dysfunction and the muscle reflex spasm, unless there is extensive follow-up spinal rehab to 1) restore joint flexibility, 2) restore muscle strength, and 3) restore normal alignment, there is little hope for spinal stability. I’ve found very few rehab facilities in chiropractic offices, and I’ve also found a general antipathy by many DCs to include such a program in their offices.

The same can be said about the average PT who would prefer simply using modalities for high fees then struggle with helping back patients rehab their weaken muscles with extensive exercise. Believe me: hot/ice packs, ultrasound or electric-stim may be helpful to control inflammation, they have never rehab any injured spine, and if that’s all the PT practitioner is doing, he’s short-changing the patient greatly.

As well, a general practitioner MD acting as a gatekeeper handing out pain pills and muscle relaxants which simply masks the problem without correcting the underlying cause is the classic medical mis-management of back problems. Or the anesthesiologist who injects steroids into the hot disk is only masking the underlying mechanical problems. Yet these quick fixes are exactly what most doctors prefer to do to get rid of the patient since they have little understanding of these dynamic spinal problems.

The dilemma of back pain treatments is compounded not only by their ineffective treatments, but this situation is exacerbated by incomplete care too. Whether it’s chiropractic SMT only, physical therapy or Back Schools alone, medical care like pain pills, shots or surgery only, none of these treatments alone will stabilize a weakened spine. As hard as it may be to admit for some chiropractors, chiropractic adjustments alone will not completely correct the underlying weaknesses of a spinal problem either.

Consequently, unless the back patient is very proactive and willing to do spinal exercises extensively on his own, at best the chiropractors’ treatments will be temporary. Perhaps this is why many chiropractic patients relapse, then complain, “I tried chiropractic, but it didn’t last”?

Compounding the inherent weakness from spinal injuries that act to de-stabilize a spinal joint dysfunction, patients also face the “de-conditioning” process that leads to weaker spinal musculature and more bouts of relapse. Perhaps that’s why comedian Bob Hope once said, “You know you’re getting old when your back goes out more often than you do.” While this joke is funny, it’s also too true and a fact that most people would just as much like to ignore.

Is it little wonder why backache treatments seem paradoxical in that most treatments alone have not proven to be effective in the long run? Most seem to want a “quick-fix, be-fixed” treatment where the DC gives a “wonder” adjustment to cure them once and for all. And if that doesn’t happen, they run off to the surgeon for his quick-fix solution. When they still hurt, often they go back for another surgery until they’re finally disabled.

As well, we chiropractors have been unsuccessful in imprinting in patients’ minds the need for proactive care, similar to what the dentists have done so well. In many cases, once a spinal patient feels better, they disappear until a relapse occurs. I tell these prodigal patients that’s equivalent to a dental patient who only brushes his teeth once they have a toothache. While they laugh at that analogy, they often don’t want to see my point that these dynamic spinal weaknesses are injuries that must be managed daily with spinal exercises and periodic spinal adjustments.

I firmly believe the public and many back pain practitioners are unaware of the true nature of these maladies, and they certainly are unaware of the solution to fix them. It may be a case of “don’t confuse me with the facts.” Stabilizing an injured spine is a bigger job than most want to admit, and the dedication to fix these problems becomes a lifetime effort. Until the various health professionals sift through the ineffective methods and come to an agreement, the public will continue to be misled.

 

The Effective Solution: Take the Best and Leave the Rest

So, what’s the solution to this massive epidemic of back pain in America? While the medical cartel would have you believe their answer of more drugs and surgeries is best, the facts don’t agree. Back surgeries are ineffective, unnecessary and very expensive, and most often leave patients worse off than before with permanent disability. Indeed, the medical cures are often worse than the problem of back pain itself.

On the other hand, back exercises alone done by PTs or SMT alone done by DCs have not proven to have lasting results either.

Drugs, shots, and surgery rarely correct the underlying cause of most back pain, and they often do more harm than good to the rest of your body.

So, what’s the best solution I can offer to the millions of Americans suffering from this malady? I’m glad you asked.

Again, as a back pain sufferer myself and as a chiropractic practitioner, I suggest giving patients the best of all the various treatments in health care.

First, keep in mind that the spine consists of 24 vertebrae sitting on top of 3 pelvic bones interconnected by 137 joints and covered by six layers of ligaments, tendons and muscles. And then the spinal column is asked to balance a head on top of that pillar of bones, constantly subjected to the stresses and strains of daily activities, not to mention the blows from accidents, sports or innumerable mishaps our spines experience daily.

Can you imagine if your leg consisted of 24 little bones stacked on top of themselves instead of just a couple of long bones connected by one knee joint? It gives you an idea how unstable the spine actually is when you can picture 24 little bones instead of two sets of long bones. Indeed, the “backbone” is mislabeled because it’s actually a bunch of “backbones.”

So, what’s the answer to this dilemma of spinal problems? Start with SMT to restore joint play and to relieve pressure on joints, disks  and nerves. Chiropractors are the best at SMT, so don’t fool around with a PT, DO, or MD who “thinks” they can perform SMT. Since chiropractors do 94% of all SMT in this country according to the RAND Corporation study on acute low back pain, one must acknowledge that DCs are the leaders in this form of treatment.[27]

Secondly, begin flexibility spinal exercises and, if there’s no pain or problems, then lead into spinal strengthening exercises. Many chiropractors are now involved in functional and structural spinal rehabilitation to remodel the proper spinal weight-bearing curves to avoid future problems.[28], [29]

According to the laws of mechanical engineering, researchers concede that any joint which has continuous abnormal stresses and strains will eventually reach the point of failure unless normal alignment and strength is maintained to withstand these forces, otherwise joint dysfunction and relapse are inevitable. [30], [31]  When structural rehab isn’t possible at a spinal rehab facility, other rehab efforts like home exercises aimed at functional remodeling will allow patients to become active in their daily activities, but their spinal weaknesses will still be susceptible to relapse eventually.

This is why weight loss and muscle toning are absolutely important to maintain a healthy spine. The more stress and strain one puts on his spine, along with the structural misalignments, the more likely it is that back pain will occur when the spinal joints finally fatigue due to the overload. This explains why some patients admit that all they did to cause their back attack was to bend over to brush their teeth. In effect, they simply exceeded this tipping point of no return with a pre-existing joint misalignments combined with too much weight and bad leverage. It certainly doesn’t take a bad fall or car wreck to have a serious back attack when all these co-factors exist.

Thirdly, if pain persists, I recommend taking natural anti-inflammatories like ginger/herbal supplements and using ice packs rather than NSAIDs or pharmaceutical drugs which will eat up your stomach, liver, kidneys or destroy the cartilage in your joints. Forget about muscle relaxants and hot packs.

And understand that spinal care, like dental care, is a lifelong effort to manage. These dynamic spinal problems require dynamic, multi-faceted solutions for a lifetime. Aside from re-occurring injuries from the stresses and strains of daily living, we all face the inevitable deconditioning process from aging. No one escapes Father Time’s effect upon our bodies, and this is especially true with our damaged backs.

Even for those lost souls who have undergone a back surgery which failed, and most of them do fail, you can still be helped in many cases by following a comprehensive program of spinal adjustments along with spinal exercises. Forget about more surgeries as the answer to your dilemma—that’s equivalent to throwin’ more money in after bad, as they say playing poker.

Until the joint alignment is restored, flexibility maintained, and spinal muscles strengthened, you will continue to have back pain, and some unethical surgeon will again try to convince you to undergo another surgery. He will show you cute little pictures on x-rays or MRI scans to convince you of some disk pathology and the need for another disk surgery. He may tell you the first surgery “didn’t take.” He may even scare you into another surgery if you ask about chiropractic, “If you’re dumb enough to go to a quack to let him crack your back, don’t come running back to me when you’re paralyzed.” He’ll huff and puff until you cave in to another useless surgery based on a false “slipped disk” premise. If you think I’m exaggerating, just ask any honest OR nurse and she’ll tell you some horror stories about back surgeries that will make your head spin.

"The world of spinal medicine, unfortunately, is producing patients with failed back surgery syndrome at an alarming rate…Despite a steady stream of technological innovations over the past 15 years—from pedical screws to fusion cages to artificial discs—there is little evidence that patient outcomes have improved.”[32] Please don’t just take my advice from 30+ years in practice; listen to the experts’ advice and don’t become another victim of drugs, shots and surgery.

         

Bias in a Sham Marketplace

The dilemma about the backache epidemic may appear, in fact, be mostly a conflict between the chiropractic profession’s preference for SMT and the medical establishment’s preference for its more expensive treatments like surgery. But it’s really more than just an argument among practitioners; this is a multi-billion dollar annual industry with lots of money at stake, so honesty is a hard commodity to come by in the medical world.

In reality, most researchers are MDs or PhDs who are all closely tied at the hip to funding issued by other MD bureaucrats in government, making for a suspicious relationship with an inherent conflict of interest and medical bias toward non-MD procedures.

Forget about research or clinical results alone as the guiding lights in healthcare. If that were the case, the guideline on acute low back pain established in 1994 by the Agency on Health Care Policy and Research (AHCPR) of the US Public Health Service would have been implemented nationwide. This is the most definitive analysis of low back pain ever done in the history of civilization, and their recommendations stunned the medical community when they place spinal manipulation under the heading of “Proven Treatments.”

This panel of 23 health care experts headed by an orthopedic surgeon also stated that only one in 100 cases of LBP required surgery. Despite this definitive report, their guideline has not only been ignored by the medical community, the orthopedic society filed an injunction to prohibit the release of this guideline since it did not endorse their surgeries.

Obviously, the most powerful influence on healthcare in the US is the almighty dollar. As we’ve seen already in many MCO horror stories, often times what is best for the patient is not what’s best for the medical profession (giving too much questionable care) or the insurance companies (denying care). In both cases, their bottom line is paramount, not what’s best for the patients or what method may be most clinically-effective. Sadly, the motto of MCOs has become “squeeze care to expand profits.”

Even government programs like Medicare and state and national legislators are heavily influenced by the AMA’s lobby and PAC money to the point where patients’ rights are secondary to physicians’ compensation. Just one look at the failure to pass the Patients’ Bill of Rights is testament to the medical special interest groups on Capitol Hill who like the system just the way it has always been—a virtual medical monopoly.

Whether it’s medical mistakes by physicians or obscene salaries for MCO executives or patient care being curtailed for dubious reasons (Congress having to pass a federal law to allow birthing mothers one extra day of recuperation in hospitals is a prime example), the ethics of most MCOs and the medical establishment are very suspect. Indeed, MCO seems to mean Managed Cost Organization or Mangled Care Organization rather than Managed Care Organizations aimed at give patients the required care they need. In fact, MCOs hire researchers whose goal is to Stop Care by citing marginal methods that may be popular, but they never in turn Continue Care by citing effective methods that they simply don’t want to pay for—like active rehab with SMT.

In many cases, the injustice of MCOs is not only disallowing some medical treatments, they also seemingly show little interest in avoiding less costly and clinically-effective non-medical treatments. Whereas most people seek the best service/product at the lowest price, this quality of an open marketplace does not prevail in healthcare, or so it seems, consequently many patients are railroaded into treatments that are ineffective and costly.

Medical economists will admit the MCOs follow a “perverse motivation”. Most people think these MCOs would choose the cheapest mousetrap to use, but that’s not true in for-profit healthcare. Unfortunately, the insurance system works where premiums are tied to expenses, so the more they pay out, the more they can charge. Obviously in this equation, they stand to make more by allowing expensive, yet ineffective, procedures like back surgery than using SMT instead. While we chiropractors brag about being cheaper, faster, safer with three-times the patient satisfaction rates, being cost-effective appears to be a negative quality in this system where profit reigns over what treatment is utilized.

Since free enterprise does not prevail within the healthcare system, competition on a level playing field does not exist to offer better services at lower prices. Without chiropractic care able to compete directly with orthopedists for back pain patients, too many are railroaded into unnecessary back surgeries who could have been help with spinal manipulation instead as the AHCPR and Manga reports indicated.

As all business owners know, workers’ compensation insurance is a very expensive program and, when used, employers are penalized with higher rates. This is especially true if the workers’ compensation carrier is a “for-profit” insurer as opposed to “self-insured.” Most employers do not realize that these carriers work on a “cost-plus” basis, which explains why these insurers are not concerned about increasing expenses. They simply charge higher premiums to cover their costs.

This for-profit, cost-plus incentive is the leading economic reason why the better mousetrap concept is being ignored in health care. Medical economists and futurists, such as Clement Bezold, Ph.D of the Institute for Alternative Futures deem this incentive as a “perverse motivation.”[33]   This cost-plus, perverse motivation is one reason why workers’ compensation insurance is so expensive—there is no real incentive on the insurers’ parts to decrease costs.

Simply put: higher gross cash flow = higher percentage take.

Instead of embracing chiropractic care as a cheap, safe and effective method of treatment, MCOs, PPOs, Workers’ Compensation, PI attorneys and many group health insurance programs stand to profit more by forcing patients into the unproven medical methods that have been shown to be very ineffective and expensive. Indeed, when the US Public Health Service’s report stated that “Surgery has been found to be helpful in only one in 100 cases of low back problems,”[34] something is amiss when these insurance companies still discriminate against spinal manipulation in lieu of back surgery.

 

The Military Mess

For example, chiropractic has been fighting for inclusion into the military health system (MHS) since 1984 at President Reagan’s request. Since then the medical men inside the DoD have fought this despite positive research from their own Chiropractic Health Care Demonstration Program. The only opposition from DoD is based on DoD’s own high-dollar “cost estimate” for adding chiropractic care as a new benefit for military personnel, which they estimate to be around $70 million.

However, what the DoD’s estimate failed to consider were the cost savings. Estimates by Birch & Davis indicate that costs will be reduced by offsets for inpatient care, emergency room services, physician services, physical therapy, surgery and recovered days. As their report summarized, “These cost offsets which will result in annual net savings to the DoD of $25.8 million, explicitly demonstrate the advisability of adding chiropractic care to the MHS.[35]

According to research from John Hopkins, unintentional and musculoskeletal injuries are the greatest threat to military personnel.  “...in all three branches of the service, injuries and musculoskeletal conditions still adversely affected the health of service members and troop readiness more than any other single diagnosis.”  The study, along with five other reports on injuries in the military, appeared in a special injury supplement in the April 2000 issue of the American Journal of Preventive Medicine.  Injuries and musculoskeletal disorders (MSDs) resulted in more soldiers missing time from work than any other health condition.  In the Army, for example, “the combined categories...accounted for slightly more than 30 percent of all hospitalizations in 1992.”  MSDs, among all groups of disorders, resulted in more soldiers missing time from work than any other health condition.[36]

Obviously both clinical superiority and cost-savings of spinal manipulation cannot persuade the medical gatekeepers of the MHS to include their long-time nemesis, chiropractic. In fact, since the original authorization to implement chiropractic care in the MHS, Congress has had to pass three additional bills to force this implementation. The DoD Authorization Bill in 2006 identified 11 air force facilities that have not complied with the Pentagon plan to make chiropractic care available to active duty members of the military. This bill would increase the number of military bases with a chiropractor on duty from 42 to 53.

This bill clearly demanded the complete implementation by Sept. 30, 2006, yet this date passed without any movement and another bill was passed to extend this deadline by Sept. 30, 2009. Despite the obvious benefits to patients, the medical cartel inside the DoD would prefer using their own ineffective methods to combat this epidemic, which they estimate disables 20% of their own personnel. Since they obviously are losing this battle with LBP, is this an example of sheer stubbornness or medical politics as usual--“our way or no way”?

 

Perverse Motivations in Healthcare

Another non-clinical issue to address in the dilemma of back pain treatment is the political nature of healthcare in the United States. As researchers on the AHCPR panel found when they were sued by the orthopedic society, what good is research when only favorable research to the status quo is utilized, and unfavorable research is scorned, such as what happened with the AHCPR conclusions that recommended SMT over surgery?

Apparently, the AMA special interest groups were successful in eliminating the messengers who reported the many ineffective and costly medical procedures that have driven up health care costs to the trillion dollar range.  A member of the AHCPR panel, Richard Deyo, MD, MPH, of the University of Washington Medical School, co-authored in The New England Journal of Medicine an article, "The messenger under attack -- intimidation of researchers by special interest groups."  He wrote that "The huge financial implications of many research studies invite vigorous attack ... Intimidation of investigators and funding agencies by powerful constituencies may inhibit important research on health risks and rational approaches to cost-effective health care."[37]

Perhaps Dr. Deyo is feeling the same type of venomous response to the AHCPR's guideline that the chiropractic profession has felt from other biased reports. Apparently offering a better service at a lower price not only is disadvantageous, but it creates a backlash from the powers-to-be. Considering back procedures is the number three reason for hospital admissions, if chiropractic care was in every hospital, there would be a lot of disgruntled orthopedists and hospital administrators losing a lot of money.

This perverse motivation is the real reason why chiropractic care has not been fully embraced by the medical cartel. They stand to lose money by utilizing SMT over back surgeries, which explains why most hospitals still boycott chiropractors on staff and back surgeries are increasing despite the overwhelming research against them.

According to Richard D. Guyer, president of the North American Spine Society, “The stakes are great as there is big money in spine…in 2005 dollars, between $100 and $200 billion per year are spent on spine care…US spinal device manufacturers was estimated at $2.5 billion…[38]

“To paraphrase Jerry Maguire: ‘Show me the data.’ We are being forced to. There is tremendous practice variation among both surgeons and non-operative physicians… What is the ideal rate…We do not know the correct numbers for quality spine care.”[39]

We do know the USA does 40% more spine surgeries than any other country in the world and 4 to 5 times more back surgery than the UK and Scotland combined, so that should be a good indication of the excessive number of spine surgeries in this country.[40]

The ineffectiveness of spinal surgeries, especially spinal fusion, is no longer a secret shared only by patient-victims of these unnecessary and ineffective procedures.  In the AHCPR's clinical practice guidelines, the section on spinal fusion clearly summarizes the research:

"There appears to be no good evidence from controlled trials that spinal fusion alone is effective for treatment of any type of acute low back problems in the absence of spinal fractures or dislocation ... Moreover, there is no good evidence that patients who undergo fusion will return to their prior functional level."[41]

 

The irony of the situation is the typical medical venom that spews from their mouths whenever they are held accountable and criticized: whether it's the massive medical mistakes that some experts say kill 3,000 patients in hospitals weekly; the overuse of antibiotics in children leading to super-germ infections later in life; the belief that as much as 78-90% of all surgeries are deemed unnecessary; the gross overmedication of geriatric patients; or the fact that the Office of Technology Assessment reported that only 15-20% of medical procedures can be supported by research. It's obvious that research is ignored or condemned when it disproves the money-making methods of the medical professionals, as evidenced by the total avoidance of the AHCPR's Acute Low Back Pain in Adults guideline.

As well, with the monopolistic, anti-competitive environment in healthcare, the profit motive over-rides the research motive. Namely, hospitals, insurance companies, PI attorneys, and Workers’ Compensation companies stand to make more profit by utilizing costly surgery rather than SMT. If they pay out more, then they can charge more in premiums, so “there’s more money for everyone,” as I was once told—another example of profit reigning over research.

Until free enterprise allows for more competition to offer better services at lower costs, we will continue to see this perverse motivation, a sham marketplace and higher costs in healthcare. And we will continue to see the rise of unsuccessful back surgery victims disabled, escalating costs, buyer’s remorse and distributive injustice for the chiropractic profession.

 

A Focus on a Solution

In this light, ignoring chiropractic care for back pain is woefully outdated clinically, perpetuates inadequate standards of care, a waste of tax money, increases the cost of health insurance premiums for consumers, and it denies patients access to the best care possible. This has led to increased costs for employers and increased unsuccessful outcomes for patients. In all, this medical scenario has lead to low quality care for patients with back problems.

It also has denied doctors of chiropractic the right to compete on a level playing field, which is the keystone of a free enterprise society that fosters the better mousetrap concept to allow better products and services to prevail. As noted, only in health care is this market competition discouraged or ignored. The concept of free market forces in health care is referred to by Dr. Pran Manga, medical economist, as “distributive justice.”

“We would argue that the principle of distributive justice, and a parallel principle of equality of opportunity, require that the government implement all cost-effective substitutions; failure to do so results in unfairness to the taxpayers and unfairness to certain health care professionals…The monopolization of the health care services turf is also inequitable from yet another perspective. It denies some professions equal opportunity to earn income commensurate with their ability, effectiveness and effort…Inefficient use of health human resources is not just economically wasteful, it is also inequitable and generates higher levels of taxation…Equity is likely to become more important as the struggle over the health care turf becomes fiercer, and as taxpayers demand even greater value for the taxes they pay.”[42]

 

“Chiropractic care is a cost-effective alternative to the management of neuromusculoskeletal conditions by other professions. It is also safer and increasingly accepted by the public, as reflected in the growing use and high patient retention rates. There is much and repeated evidence that patients prefer chiropractic care over other forms of care for the more common musculoskeletal conditions… The integration of chiropractic care into the health care system should serve to reduce health care costs, improve accessibility to needed care, and improve health outcomes.”[43]

 

Cutting Chiropractic, Not Surgery

A poignant illustration of the perverse motivation in health care insurance companies, in 2001 Aetna announced it was cutting back on chiropractic treatment due to heavy losses. Aetna plans to limit the number of chiropractic treatments it covers, according to The New York Times. The cut will make up for losses associated with other soaring health care costs, such as prescription drugs and outpatient surgery. Aetna posted a first-quarter loss of $48.2 million.[44]

Despite the overwhelming proof of the clinical and cost-effectiveness of chiropractic care for the majority of LBP cases, Aetna thumbs its nose at these facts rather than following the numerous guidelines that recommend SMT over expensive and ineffective back surgery. And it’s not just Aetna that has this discriminatory policy. The Blues also have severely limited chiropractic care in terms of visits allowed and remuneration

It’s obvious the medical gatekeepers and health insurance industry have no interest in utilizing chiropractic care as Dr. Manga and the AHCPR suggest to improve patient outcomes and to save costs. As long as for-profit, cost-plus insurance exists, there will never be an interest in the better mousetrap that is safer, cheaper and better.

We need to take an innovative approach to this boycott, and our colleague, Dr. Robert Mootz, may have the answer with a new marketing approach that bypasses the insurance brokers and goes straight to the consumers.

“Demand management,” as defined by Dr. Robert Mootz in his article[45], Demand Management: The Next Big Thing? “sometimes referred to as demand moderation, is a set of behavioral change strategies directed at consumers and providers to affect how they respond to indications of injury, illness and disease. Typically, the strategies include community-wide or targeted group education to help consumers interpret signs and symptoms, learn self-care strategies, obtain ready access to diagnostic information, and in some cases, even deploy alternative "expert" access mechanisms, such as medical consultation by phone, website, or other means.

“The concept of demand management is being harnessed. Ideally, demand management is a strategy aimed at fostering informed, appropriate demands by consumers for medical and pharmaceutical interventions, with greater reliance on self-diagnosis, care, and social support. Advantages and limitations depend on the stability of the condition, the level of commitment of the consumer, and the integrity of the demand management strategies. A successful example is the public/private partnerships in diabetes education.”

 

Rather than waiting for the medical professionals to refer Musculoskeletal Disorders (MSDs) to DCs, a demand management PR campaign to educate consumers about the clinical and cost-effectiveness of SMT for this epidemic of MSDs could do wonders to circumvent the covert boycott of the medical gatekeepers. As Dr. David Eisenberg found in his two surveys about the trend to alternative health care methods, the American baby-boomers make informed decisions about their health care, and we must make our science better known to these consumers.[46]

As Dr. Mootz mentioned in his article, “The distinguishing characteristic of demand management is the promotion of patient knowledge in the choices of care and providers.” Regrettably, we as a profession have failed to do so.

Unfortunately, the chiropractic profession has lacked the skill to teach the public about its services with supportive research and clinical guidelines that have accrued in the last decade. Despite RAND, Manga I & II, AHCPR, Meade, and the many other notable research studies noted, the public is unaware of these supportive studies. Nor are they aware of the plethora of research that condemns the onslaught of failed back surgery. Until this information becomes common knowledge, they may never know.

With new technology emerging and new communication channels such as the Internet, more and more information is being distributed to the public.  Additionally the ages of reporters are younger and younger and this new generation of reporter is not locked into the old model of believing everything that is fed to them by the medical pundits.  They are for the most part skeptical of drugs, understand iatrogenic complications and are not deluded by the word of organized medicine.  The public is being informed on an almost daily basis about new treatment options, new alternatives and new concepts.  Nothing will stop the quest for information and nothing will hold back the advancements that will ensure a procedure that is conservative, cost-effective, and has a high degree of patient satisfaction from emerging.

 



[1] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[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] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[4] P. Manga, et al., “The Effectiveness and Cost Effectiveness of Chiropractic Management of Low Back Pain,” University of Ottawa, 1993.

[5] Shekelle, P, RAND Items newsletter, Feb. 10, 2000, #1459

[6] Carey TS, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. NEJM 1995; 333:913-7.

[7] Anderson GBJ et al. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. NEMJ 1999; 341: 1426-31.

[8] Cherkin D et al. Effects of practice style in managing back pain. Ann Intern Med 1994; 121: 187-95.

[9] Hsieh DY et al. Cost-effectiveness of four conservative managements for low back pain, presented at the annual meeting, North American Spine Society, Chicago, 1999. (as yet unpublished)

[10] Cailliet R. Therapeutic Approaches to Low Back Pain. Am J Clin Chiro 1999;
9(4): 1&5.

[11] Shekelle, P, RAND Items newsletter, Feb. 10, 2000, #1459

[12] Seaman DR, Winterstein JF. Dysafferentiation, a novel term to describe the neuropathophysiological effects of joint complex dysfunction: a look at likely mechanisms of symptom generation. J. Manipulative Physiol Ther 1998:21-:267-80.

[13] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[14] Jensen MC et al. Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain. NEJM 331 (2): 60-73; 1994.

[15] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[16] P. Shekelle, et al, “The Appropriateness of Spinal Manipulation for Low Back Pain.” RAND Corporation Report, Santa Monica, Calif., 1992.

[17] Bourdillon JF and Day EA (1987) “Spinal Manipulation”, Heinemann Medical Books, London

[18] Shaw, JL (1992) “The Role of the Sacroiliac Joints as a Cause of Low Back Pain and Dysfunction”, proceedings of the First Interdisciplinary World Congress on Low Back Pain and its Relation to the Sacroiliac joint, University of California, San Diego, Nov. 5-6, 1992

[19] Mierau DR, Cassidy JD (1984) “Sacroiliac Joint Dysfunction and Low Back Pain in School Aged Children” JMPT.

[20] Cassidy JD, Kirkaldy-Willis WH, and McCregor M (1985) “Spinal Manipulation for the Treatment of Chronic Low Back and Leg Pain: An Observational Study”

 

[22] Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: Two-year results of a randomized controlled trial, BMJ, 2008.

[23] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[24] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[25] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[26] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[27] P. Shekelle, et al, “The Appropriateness of Spinal Manipulation for Low Back Pain.” RAND Corporation Report, Santa Monica, Calif., 1992.

[28] Liebenson C. Editor. Rehabilitation of the spine: a practitioners’ manual. Baltimore: Williams & Wilkins, 1996.

[29] Harrison DD, Jackson BL, Troyanovich SJ, et al. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis. J Manipulative Physiolo Ther 1994: 17(7): 454-464.

[30] Troyanovich JS, Harrison DD, Harrison DE. A Review of the Validity, Reliability, and Clinical Effetiveness of Chiropratic Methods Employed to Restore or Rehabilitate Cervical Lordosis. Chirop. Tech 1998; 10(1): 1-7.

[31] Harrison DE, Harrison DD, Cailliet R, Janik TJ, Holland B. Pre-Post Radiographic Changes in the Sagittal Lumbar Curvature after CBP 3-Point Bending Extension Lumbar Traction. International Society for the Study of the Lumbar Spine, 27th Annual Conference, April 9-13, 2000, Adelaide, Australia.

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

 

[33] Bezold, C. “The future of chiropractic: Optimizing Health Gains” Institute for Alternative Futures. July 1998.

[34] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[35] Birch & Davis Report, Muse & Associates, page IV-2, 34; March, 2000.

[36] Inteli-Health (Johns Hopkins); March 15, 2000.

[37] Deyo RA, Psaty BM, et al. The messenger under attack -- intimidation of researchers by special interest groups. NEJM April 17, 1997;336(16):1176-79.

[38] Richard D. Guyer, Presidential address, “The paradox in medicine today—exciting technology and economic challenges, The Spine Journal, Vol. 8, No. 2, March/April 2008, pp. 279-285.

[39] Richard D. Guyer, Presidential address, “The paradox in medicine today—exciting technology and economic challenges, The Spine Journal, Vol. 8, No. 2, March/April 2008, pp. 279-285.

[40]An international comparison of back surgery rates. Cherkin DC, Deyo RA, et al. Spine. 2004 Jun 1;19(11):1201-6.

[41] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[42] Manga, P and Angus, D. “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.

[43] Manga P. Economic case for the integration of chiropractic services into the health care system. J Manipulative Physiol Ther 2000 Feb;23(2):118-22.

[44] ChiroWire, Eli Research, June 4, 01.

[45] Mootz R., Demand management: the next big thing?” Dynamic Chiropractic, June 4, 2001

[46] Eisenberg, DM et al., ibid.

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