Articles by JCS
Time to Change Course
The Epidemic of Low-Back Pain
By J.C. Smith, MA, DC
The huge costs and suffering from low-back pain (LPB) in the United States are staggering, according to international researchers. The documented facts about LPB are astronomical in terms of the number of suffering patients and the costs.
Obviously, the epidemic of low back problems is enormous, and it's only getting worse despite the new governmental guidelines and recommendations from the Agency for Health Care Policy and Research within the U.S. Public Health Service. In effect, the governmental study now suggests that back surgeries are ineffective and costly, and that spinal manipulation is cheaper, safer, quicker, longer-lasting and has higher patient satisfaction rates. The definitive studies in the U.S. and Canada have all agreed that chiropractic management is superior to medical management of this growing epidemic.8
Two questions remain unanswered about this epidemic: What caused this epidemic, and what is the solution?
As a practicing chiropractor with 20 years of experience in this field, and as the author of How to Avoid Back Surgery: Chiropractic -- the Proven Method for Back Pain, I can attest that this issue has been exhaustively studied and researchers have come to a few conclusions that might shed some painfully honest light on this enormous health problem that would help to resolve this epidemic of low-back pain.
Let me answer my first question as to the cause this epidemic. Without a doubt, the medical boycott of chiropractic care has been the single biggest cause of the lack of effective spinal health care in this country. Although a 1987 federal antitrust case (Wilk, et al. v. AMA, et al.)9 decision prohibited this institutionalized hospital discrimination and boycott against the chiropractic profession, the boycott continues on an insidious, covert level. Patients in most hospitals are still denied chiropractic care despite this court decision and the AHCPR guideline that recommends spinal manipulative therapy (SMT) as a first form of treatment for LBP.
Not only did the AHCPR recommend SMT, their guideline also warns that "It should only be done by a professional with experience in manipulation."10 Since chiropractors do 94% of all SMT in this country according to the RAND Corporation study on low back pain, one must acknowledge that DCs are the leaders in this form of treatment.11 Yet SMT is still denied to patients by most hospitals and medical gatekeepers; instead they are given the standard pain pills, muscle relaxants, physical therapy and back surgery as their main solutions.
Although surgery is heralded by medics as the best solution to this epidemic, research fails to agree. According to the AHCPR guideline on LBP, "Surgery has been found to be helpful in only 1 in 100 cases of low back problems ... Even having a lot of back pain does not by itself mean you need surgery."12 The foremost reason why back surgery has been found to be so ineffective rests with their main premise that has been proven false -- the disc theory. Whenever a patient has a bout of LBP, the diagnosis is either a "pulled muscle" or a "slipped disc." Interesting, research has disproved both ideas.
MRI studies by Scott Boden, MD, at Emory University Medical School have shown that disc abnormalities and back pain is purely coincidental. Two-thirds of patients without back pain were shown to have disc herniations, ruptures and degeneration.13 Moreover, the AHCPR guideline also mentioned this mistaken disc premise in their assessment: "Studies of asymptomatic adults commonly demonstrated intervertebral disc herniations that apparently do not entrap a nerve root or cause symptoms."14 Obviously, the "disc theory" has failed to withstand the test of research, yet it still dominates the practice of medicine in regard to the management of LBP because it is so profitable!
Not only did the AHCPR not recommend surgery and admits that only 1% of back surgery is helpful, the Canadian study on LBP by Pran Manga, PhD, medical economist from the Ontario Ministry of Health, also compares treatments and recommends chiropractic management over medical methods. "There is overwhelming body of evidence indicating that chiropractic management of LBP is more cost-effective than medical management."15
Standard forms of care by physical therapists were also not recommended. Again, to quote from the Patient Guide, Understanding Acute Low Back Problems, published by the AHCPR, they write: "A number of other treatments are sometimes used for low back symptoms. While these treatments may give relief for a short time, none have been found to speed recovery or keep acute back problems from returning. They may also be expensive. Such treatments include: Traction, TENS, massage, biofeedback, acupuncture, injections into the back, back corsets, ultrasound."16
So, if the standard medical care and physical therapy treatments have proven expensive and, for the most part, ineffective, and if chiropractic management of LBP is the recommended choice of treatment according to the researchers, why do hospitals still boycott this form of care? The answer rests with money, of course. To reiterate, according to MetLife Insurance statistics, the average "medical nonsurgical back" costs $7,210 and the average "surgical back" costs $13,990. But, according to research from the North Carolina Back Pain Institute, the average chiropractic case cost approximately $800 for the same diagnostic code.17 Obviously, the reason for excluding chiropractors from hospitals is due simply to this economic decision to make more money from surgery than from SMT, despite the facts that have shown SMT to be safer, cheaper, more effective, longer-lasting and with three times the patient satisfaction rates.18
Now let me answer my second question as to the solutions to this epidemic of LBP. Of course, the obvious answer is to make chiropractic care available to everyone -- every health insurance policy should cover SMT done by DCs, plus every public hospital should offer SMT done by DCs. The public should be made aware of the superiority of SMT for LBP by hospital administrators and physicians who are legally obligated to obtain informed consent from every patient, which means all options to solve their problem should be given in an honest manner.
Unfortunately, I have found when patients ask physicians in their offices or in hospitals about chiropractic care, they often are given the voodoo diagnosis instead -- in effect, they are scared into surgery when the attending physician replies to their question with the classic scare job: "If you don't have my surgery, you'll get worse. And if you go to a chiropractor, he'll paralyze you!"
In light of research by RAND Corporation and other researchers, this accusation is ridiculous. The rate of iatrogenic complications like stroke or paralysis resulting from SMT is 1-2 cases per million, whereas the rate of the same problems caused by spinal surgery is 15,600 per million! Even NSAIDs like Advil and Tylenol have shown to cause serious GI problems in 1,000 to 4,000 people per million, and reportedly 7,600 patients die annually from their use.19 It's quite obvious who's hurting whom, and it's certainly not the chiropractors!
As the researchers recommend, most back problem treatment should start with conservative chiropractic care. If, after four weeks of treatment, re-evaluation should determine if referral for MRI exams and a possible surgical consultation be arranged for those few cases who fail to respond. As the Patient Guide suggests: "You should go back to your health care provider if your symptoms have not responded to spinal manipulation within four weeks."20
One proactive solution is to teach spinal concepts in schools just as dental and other health issues are discussed. Presently, scoliosis checks are done by PE teachers, which is a farce. Their exam consists of having the child bend over to check for rib cage distortions. How in high heaven can this detect much of anything?! If I were to do this to my patients, I would be sued for malpractice and laughed out of my profession. Yet, when this is done to our children, it's considered adequate!? If and when a few children are detected, they are sent to the orthopedists without any mention of chiropractic care. Again, parents are not being given informed consent about all the possible solutions to their children's spinal problems.
Another solution is to liberate public hospitals from the medical grasp by demanding equal access for chiropractors to any hospital that takes federal or state money to operate. Fair competition on a level playing field may be the rule in the open marketplace, but in the sham marketplace of health care, closing out the competition has long been the rule in the medical profession. While a private hospital may have that prerogative, any publicly sponsored hospital should allow any licensed practitioner to work.
Affirmative action may be a concept that is very applicable in regard to helping the chiropractic profession overcome the decades of discrimination and the illegal boycott by the medical profession to exclude competition in public hospitals. All I ask for is a level playing field, something the medical monopoly has long fought against!
Moreover, all health insurance policies should allow patients to seek care from any licensed health professional. "Any willing provider" laws would open the door of the medical monopoly to allow fair competition. Thus, the laws of supply and demand would work to reduce the escalating costs of medical care. After all, why would a LBP patient want to pay $14,000 for ineffective back surgery when chiropractic care costing only $800 has been shown to be more effective, longer-lasting and with three times the patient satisfaction? As it stands now, patients denied their options are being railroaded into expensive back surgeries that only drive up costs and leave many more disabled than before.
My call for true informed consent and making chiropractic care available to all Americans rests with the long-held belief in freedom of choice, something that is greatly lacking in today's health care marketplace. People are routinely denied a choice in their spinal health by virtue of discriminatory hospitals seeking higher profits; they are railroaded into drugs and surgery by medical gatekeepers that refuse to refer to chiropractors; they are forced into surgery when their health insurance refuses to pay for chiropractic care; and they are misled about their children's scoliosis by superficial spinal exams done by amateurs which route them solely to orthopedists for rod implants.
Indeed, for too long, Americans have been denied a freedom of choice about their most precious possession -- their own bodies. In light of the plethora of research which proves chiropractic care is superior to the medical management for most spinal problems, this discrimination has proven dangerous, costly and ineffective. One hopes as the trend to "alternative" care continues, more people will discover the facts about this epidemic of low back pain. If and when legislation permits people to seek the care of any and all types of licensed health care providers, patients will then be given the freedom of choice about their own bodies that they have long been denied to them. Perhaps, then, this epidemic of back problems and the huge costs associated with ineffective medical care will begin to decrease and Americans will learn of the best solution to their spinal needs -- chiropractic care.