Articles by JCS

Zombie Spine Care

 

 

 

 

Zombie Spine Care

 

By

 

J C Smith, MA, DC

 

Smith Spinal Care Center

 

1103 Russell Parkway

 

Warner Robins, GA 31088

 

1-800-336-2013

 

jcsmith@smithspinalcare.com


 

 

 

 

 

 

ABSTRACT    

 

Medical experts now state that many medical theories and treatments are not evidence-based, and this is most aptly seen in American spine care. Many medical critics site the huge costs, ineffective medications, ESI, low rates of surgical success, high rates of relapse and reoperations, criticism of the disc theory, overuse of MRI scans and fusions as obvious examples of the lack of evidence-based care in this epidemic of low back pain. Recent RCTs comparing the medical model with conservative care treatments have shown the long term results to be similar. With this mounting evidence supporting conservative care methods in spinal care, the question remains: when will evidence-based medicine accept the evidence-based results and give credit to conservative treatments that have proven to be cheaper, safer, and more effective in the long run? The medical bias against non-medical CAM care—coined the Fundamental Flaw—now appears to be the major stumbling block for the full integration of evidence-based conservative care, specifically, chiropractic care.

 

Key words: evidence-based spinal care; zombie science; spinal manipulation therapy; Fundamental Flaw
Chiropractors or Spine Surgeons?

 

Zombie Spine Care

Deposition in the Wilk antitrust case conducted in 1978-9 by the chiropractors-plaintiffs attorney George McAndrews of Dr. John C. Wilson, former Director of the American Academy of Orthopedic Surgery, who testified as follows[1]:

 

Q:                 Is it possible to manually move a spinal joint through a range of motion?

A:      I simply cannot answer your question in that context.

Q:                 Can you answer the question in any context including your own?

A:     No, because this is not a frame of reference in which medical doctors think, and we don’t relate to turning spinal joints around through manipulation.  That is the chiropractic concept, and we don’t understand it.  We don’t relate to it.  We don’t know what you are talking about.

Q:                 Have you ever done any research into that?

A:     No.  And I don’t have any desire to do any research into that or any other cult.

Q:     I am not really talking about cults now.  I am talking about the manual manipulation of spinal joints.

A:     No.  I have no interest in or desire to pursue the manipulation of spinal joints as a theory.

Q:                 Why?

A:     Because I don’t believe in this kind of thing.  I don’t know of any scientific basis that would cause me to pursue this as a way to help people.

 

This sordid testimony illustrates perfectly the mindset of the medical plutocracy, much of which still exists today. By his own admission, Dr. Wilson basically admits his ignorance of the concept of manual manipulation of the spine, yet he has the gall to condemn it as unworthy of his investigation. Sadly, his closed mind remains evident today despite the increasing evidence that conservative care for spinal problems is as effective if not more effective as anything the medical world has to offer.

 

Tony Rosner, PhD, testified to this opinion before The Institute of Medicine: Committee on Use of CAM by the American Public[2]:

“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.”

 

Dr. Wilson’s myopia explains a lot of extraordinary things, such as why the USA lead the world in back surgeries per capita (4 to 5 times more than the UK[3]) and spends more money, nearly $90 billion, on direct costs for back pain. Combined with neck pain and cervicogenic headaches, one must conclude that Americans have either genetically inferior spines or they are subjected to clinical iatrogenesis and have been terribly mismanaged by a medical profession suffering from intellectual dishonesty. I daresay the testimony of Dr. Wilson along with the recent research and guidelines prove the latter.

 

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.[4]

 

 “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.”[5]

 

This pattern resembles “zombie science,” according to Bruce Charlton, MD, who defines it as “a sinister consequence of evaluating scientific theories purely on the basis of enlightened self interest.”[6]

 

“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 shots and surgery.

 

Undoubtedly, zombie science as evident by Dr. Wilson’s testimony and ineffective treatments prevail in the back pain business, reminiscent of the once routine but now considered unnecessary ritual of tonsillectomies, appendectomies, and hysterectomies. Indeed, spinal fusions and microdiskectomy ought to be considered the “sinister consequence of …enlightened self-interest.”

 

Author Jerry Groopman, MD, wrote in The New Yorker magazine[7] that his orthopedist, knowing perfectly well of the controversial nature of spine fusions nonetheless admitted: “If I don't do them, they'll go around the corner and the other surgeon will.”

 

Sadly, greed, not evidence or ethics, is the guiding light of too many American spine care doctors that perpetuates the zombie science of spine care solely for the “sinister consequence of …enlightened self-interest.”

 

Incidentalomas

Many forthright medical authors may admit the failings of the medical model of back treatments, but they resist admitting that the conservative, chiropractic model may be better for the majority of cases. Apparently zombie science may have critics, but the same critics draw the line when it comes to endorsing CAM methods.

 

For example, we saw the death of the AHCPR federal guidelines at the hands of the North American Spine Society when guideline #14 on acute LBP endorsed spinal manipulation and not spine fusions. There’s just too much money and pride as well as a bitter spoonful of professional bias at stake to swallow this medicine.

 

Fourteen years later medical researchers are still beating around the bush when it comes to the American model of back pain diagnosis and treatment despite the research similar to AHCPR and BJD. While they’re willing to admit the medical model hasn’t worked well, is very expensive, based on a suspect disc theory, “pain management” has led to many addicts, ESI are no more effective than placebo, and spine surgery has high rate of re-operations, they refuse to admit that CAM does. Indeed, it’s just bitter medicine for the medical profession to admit to the failing of its brand of spine care.

 

As 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.” [8]

 

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.” But today many medical spokesmen admit its failing.

 

Although a few medical spokesmen admit the disc theory is dead, they also admit they do not understand the nature of back pain itself. It is impossible to identify a cause for most cases of common back pain, according to Nortin Hadler, MD, in his recent book Worried Sick: A Prescription for Health in an Overtreated America.

 

“We do not know what causes particular episodes of regional musculoskeletal pain,” said Hadler. “The risk that can be attributed to particular tasks on or off the job is trivial. That means we have no more reason to label a regional backache an injury than we have to label a spontaneous headache an injury.”[9]

 

Rick Deyo, MD, MPH, also admits the disc abnormalities are “incidentalomas” that have nothing to do with the majority of back pain problems:

“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.” [10]

 

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.” [11]

 

Deyo’s 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.” [12]

 

Paradigm Shift: Static to Dynamic—Discs to Joints

What Drs. Hadler and Deyo fail to mention is their limited medical perspective of musculoskeletal pain. As most MDs, they 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 that includes spinal structure, joint dysfunction, ligamentous instability, excessive and prolonged axial disc compression, segmental buckling effects, bad leverage, and over-loading.

 

Indeed, the medical diagnosis has simplified back pain to pulled muscles or slipped discs that despite proof remains a perfect example of zombie science that the vast majority of MDs still practice.

 

Dr. Hadler acknowledges the limitation of this pathoanatomical analysis, but fails to consider the dynamic perspective.

“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.” He also has admitted in the past that “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?”[13]

 

I agree with his sentiments entirely except for his lack of insight into the physiologic, mechanical issue of spine function. The chiropractic lesson to learn by MDs is to consider another paradigm that back pain episodes are a function of a spine subject to numerous vertebral misalignments, dysfunction of the 137 synovial spinal joints, damage or weakened soft tissues from prior injuries, and then subjecting it to bad leverage, excessive compression, and over-loading causing a buckling effect. In this dynamic light, spinal manipulative therapy, flexion-distraction, and non-surgical spinal decompression along with active spinal rehab makes more sense than simply drugs, shots, spine fusion or microdiskectomy.

 

Perhaps this model is too sophisticated for spine surgeons who only look for disc abnormalities and so eager to cut since that’s where the money is, but it might be a better ergonomic explanation of why a back attack occurs. They might consider this lesson more seriously if they didn’t suffer from the Fundamental Flaw of medicine.

 

Paul Goodley, MD, orthopedic physician, author, and renowned among the early advocates of manipulative therapy, wrote of this medical bias and the ethical dilemma it poses for physicians. He coined a term to describe this blind eye toward manipulative therapy as the Fundamental Flaw of medicine.

“Eventually, the prejudice against manipulation self-perpetuated and evidence was always available to justify this attitude. There have always been [chiropractic] charlatans…So, instead of the manipulative fundamental dynamically developing as a cohesive, trustworthy guide within traditional medicine, it was discredited as the synonymous derelict symbol of its most despised competitor - chiropractic.[14]

 

Dr. Hadler alludes to the Fundamental Flaw himself in his book, The Last Well Person, when he states[15]:

“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?”

 

The answer to all his questions is an unequivocal “Yes.” Dr. Hadler admits to his own bias, but fails to take the next step. If it weren’t for the medical bias—the Fundamental Flaw—against manual medicine, the answer to his questions would be obvious.

 

His admission illustrates perfectly the medical dilemma with the present zombie science in spine care—these astute medical investigators like himself, Deyo, Cherkin, Weinstein, Boden, Brox, Carragee, Fairbank, Fritzell, Bhandari, Fouyas, Nachemson, Waddell, Rosomoff, Mennell, Shaw—are willing to admit the disc theory is mostly dead, surgeries are mostly unnecessary, and that conservative care has proven as effective and cheaper in the long run, but they can’t admit that a change in analysis and treatment paradigms should occur. In other words, they can’t admit the remote possibility that those damn chiropractors are right.

 

Medicine’s Straw Man

This medical bias is deeply rooted in most physicians and nurses, a medical catechism taught from day one in medical school that damns those chiropractic quacks. Sadly, this prejudice has not only hurt chiropractors but the millions of patients who suffer from back/neck pain and other musculo-skeletal disorders (MSDs) such as extremity joint problems, temporomandibular joint pain (TMJ) and carpal-tunnel syndrome (CTS).

 

Hadler admits in his book, The Last Well Person, to his own Fundamental Flaw about chiropractic. Rather than giving credit that manual manipulation is effective in most cases of LBP, 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 still a highly regarded principle.

“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.”[16]

 

As a 30-year chiropractic practitioner, I understand Hadler’s skepticism but I also see his myopia. Rather than speaking of vitalism—the innate healing capacity of the body—perhaps he and his medical critics should look at the neuro-skeletal-muscular aspect of organ function. Indeed, do spinal misalignments cause neurological interference leading to organic problems? I believe even the most biased MD will now admit SMT is effective for problems like sciatica and MSDs, but when it comes to organic problems, then those damn chiropractors have gone too far.

 

Certainly as a physician, Hadler understands a disc herniation in the lumbar spine may cause type M disorders like sciatica as well as type O disorders like cauda equina syndrome where bowel and bladder dysfunction occurs due to impingement/inflammation of lumbar nerves. Why is it such a leap in logic to consider similar neurologic impingements/inflammation of spinal nerves may cause other organic disorders?

 

Although many chiropractors, osteopaths and manual medicine physiatrists see type O improvements in some patients, the lack of RCTs into this area may be the result of the Fundamental Flaw as much as Hadler’s belief that “They are imaginary; no such specific skeletal changes correlate with symptoms.” Does he have any clinical proof for his assertion? Has Hadler based his opinion on fact or personal bias? Indeed, the last thing political medicine wants is proof that the subluxation theory may have legitimacy rooted in neurophysiology instead of vitalism.

 

Medical Supremacists

Whether or not this is true may never be found after the debacle at FSU a few years ago when the medical plutocracy crushed the proposed chiropractic program there. The goal of the EB chiropractic program was to determine the scope of care of manual medicine, but this noble cause was killed before it saw the light of day.

 

Raymond Bellamy, orthopedist and adjunct professor, led an academic revolt against this proposed chiropractic college that would have highlighted the profession's struggle to move from broad unscientific claims to evidence-based pain treatment, but Bellamy made it into a religious war instead.

Bellamy’s blatant demagoguery mocked the proposal by circulating a map of the campus, placing a “Bigfoot Institute” and a “Crop Circle Simulation Laboratory” next to the proposed school. “I've got hundreds of petitions saying that this school is not wanted. It's a stupid idea.”[17] It appears that political medicine forgot about academic freedom at FSU where mob rule superseded academic research.

 

 

 

map

[Times art]

To poke fun at Florida State University's bid for a chiropractic school, an FSU professor has created a new campus map. Opponents of the proposed school say more than 500 faculty members have signed petitions against it

 

Apparently medical supremacists like Bellamy have as much tolerance for different ideologies as radical Muslims have for Protestants; Bellamy led what can only be seen now as a mockery against academic freedom in higher education. Bellamy omits the fact that much of medicine evolved from unproven and folk lore remedies, as well as the field of psychology and psychiatry which remain unscientific. He also refuses to admit much of his own orthopedic treatments for spine problems are questionable, if not zombie science.

Obviously Bellamy and his medical mobsters missed the point of the FSU chiropractic program as espoused by John Triano, DC, PhD, a chiropractor who served on the advisory committee for the FSU school. “The chiropractic profession as a whole . . . is ready to step up to the plate and to let its belief systems be tested scientifically,'' said Dr. Triano. “Let the chips fall where they may.'' [18]

 

The FSU school could be a force in chiropractic's transition from fringe to mainstream, according to Triano. “The transition is from the stereotypical impression of chiropractic as a bunch of people running around claiming they can treat everything, to a very evidence-based but open-minded practice approach.”

 

The argument against chiropractic is confusing since the clinical results of manual manipulation for MSDs is clouded by the vitalism espoused by the founders, DD and BJ Palmer, nearly 100 years ago. Today, medical critics still hark on the old image of “chirovangelism” to criticize the entire profession although the majority of DCs today are oblivious to vitalism and practice conservative spinal care with good results.

 

In fact, many chiropractors today are employed as primary care physicians, nutritionists, pediatricians, public health officials, some work alongside MDs in the VA and military health services, and many in the growing field of sports medicine. Indeed, this isn’t your granddaddy’s chiropractic any more.

 

This image paradox hasn’t escaped the chiropractic leadership, as Dr. Triano points out: “It’s not what we do, but what we say about what we do that matters most.”[19]

 

Unfortunately, too often the chirovangelists have gotten most of the attention with their outlandish comments that the media seeks to embarrass the mainstream chiropractic profession. As Sid E. Williams, founder and past president of Life Chiropractic College said decades ago that “The only thing chiropractic can’t cure is rigor mortis.” His hyperbole, although laughable to DCs and MDs, remains the bane of chiropractic’s public image today.

 

Triano admits his angst toward the faith-based fundamentalists within the chiropractic profession. “How long will we let the 17% of radical DCs drive the agenda of this profession? Who’s in charge of chiropractic’s destiny?” [20]

 

The issue of vitalism in chiropractic has been and remains a barrier to integrating with mainstream medicine. Despite the RCTs concerning SMT and the chiropractic brand of spinal care, MDs suffering from the Fundamental Flaw use the chiropractic vitalism as Straw Man argument to dismiss chiropractic’s effectiveness with MSDs.

 

I saw this personally when I addressed the past governor of Georgia workers’ comp meeting whose goal was to lower costs and improve outcomes. This came on the heels of the AHCPR report by Bigos et al. that recommended spinal manipulation as a “proven treatment” for acute LBP. While presenting this information to a roomful of 400+ stakeholders, an orthopedist sitting in the front row suddenly stood up and shouted, “We don’t want those chiropractors who think they can cure diabetes!”

 

Her motive was to invalidate my presentation with the Straw Man hyperbole, so I responded, “Diabetes is not a workers’ comp problem nor am I speaking about that. I’m solely talking about how chiropractic care can lower costs and improve outcomes for LBP, which is the leading workers’ comp injury.”

 

Chiropractic’s Own Critics

This dilemma to eliminate the zombie science in chiropractic remains a topic of many leading chiropractors. Attorney George McAndrews dealt with the medical criticism of chiropractic’s claim to help type O disorders during the Wilk v. AMA antitrust trial and later commented:

“Make no doubt about it, no one is running from the subluxation complex.  Society and the political and economic worlds in which we exist have simply put the theory under a microscope: either prove it exists and that real health problems are affected by it or surrender all right to be compensated for taking care of the phenomena. Argument will no longer suffice--data, results, costs are the order of the day.[21]

 

George’s late brother, Jerry McAndrews, DC, former Palmer Chiropractic College president and ACA spokesman, also commented on the need for a scientific future for the profession.

 “Thank heavens we have an increasingly emerging group which collectively says, ‘we’ve had enough.’ This group supports new journals, reads them, begins to reject the smoke of the past, begins to demand that the language be accurate. Eventually, the misuse of ‘chiropractic philosophy’ will disappear and we will find the ‘philosophy of the science of chiropractic’ in its place. It already sounds stimulating.”

 

Scott Haldeman, DC, MD, PhD, and leading researcher, also admonished those within the chiropractic profession who are prone to hyperbole:

 “What must be avoided at this stage of understanding of the neurologic effects of the adjustment is the unreasonable extrapolation of current knowledge into speculation and presentation of theory as fact.”

 

Despite the trend to evidence-based education and practice in chiropractic, admittedly there remain a few enclaves that still promote the chirovangelism of yesteryear to the chagrin of Charles Lantz, DC, PhD, former Director of Research, Life Chiropractic College.

“Even in the most evidence-based institutions the resistance to scientific methodology and critical assessment is rampant.  It only takes one 'The Power that Made the Body Heals the Body' sermon to undo several semesters of efforts to teach critical thinking and an appreciation of the 'rigueur de science'. 

“Who wants the rigors of critical thinking when they can zone out on the intoxicating siren song of Innatism, or the giddy ecstasy attained from chanting the mantra S-U-B-L-U-X-A-T-I-O-N?”

 

Regrettably, the presumed zombie science of chiropractic has shrouded its proven effectiveness with MSDs and kept alive the medical chauvinism that impedes the integration of chiropractic care into the mainstream healthcare delivery system. But faith-based medicine also presents a problem in evidence-based healthcare. Faith in unproven, ineffective treatments cloaked in the appearance of science remains the problem with zombie spine care as Bruce Charlton indicated.

 

Faith-based or New Paradigms?

George Lundberg, MD, Medscape Editor in Chief, former editor-in-chief of JAMA from 1982 to 1999, spoke of this faith-based phenomenon in medicine in his webcast editorial (Evidence-Based Medicine or Faith-Based Medicine? Posted 12/10/2004)

 “Recognizing that not all interventions have been properly studied but that physicians must make clinical decisions anyway, David Sackett is credited with having defined EBM as the ‘integration of best research evidence with clinical expertise and patient values.’

“I consider the near opposite of pure EBM to be pure FBM -- faith-based medicine. St. Paul defined faith as ‘the substance of things hoped for, the evidence of things unseen. This was OK for medicine in the first century AD, but in 2004, when there is evidence, I choose it as the basis for my care.”

Apparently many medical experts remain critical of “things hoped for but unseen” in CAM treatments, but the lack of evidence for the zombie medical treatments of drugs, shots, and spine surgery for disc abnormalities has not stopped.

 

According to leading spine researcher, Daniel Cherkin, PhD, he admits to the:

 “…possibility that our thinking about back pain is fundamentally wrong. We may be missing something important. And that could be why we have not come up with any dramatic advances. And it that is the case, then the implication is that we need new paradigms. And that once we find the best paradigm, we will make more progress.” (The BACK Letter, vol. 23, No. 5, 2008, pp. 55.)

 

Dr. Rick Deyo agrees.

“I’m not sure we’ve made much real progress in the effectiveness of clinical care. We seem stuck in conventional models—involving biomechanics, ergonomics, and drug receptors—that haven’t worked very well so are. I think we’re going to have to create more holistic models that are truly biopsychosocial before we make substantial progress clinically.” (The BACK Letter, vol. 23, No. 5, 2008, pp. 58.)

 

Dr. Deyo, in his book, “Hope or Hype: The obsessions with medical advances and the high cost of false promises,” mentions the sentiments of ethical spine surgeons:

“Some surgeons, like Dr. Edward Benzel at the Cleveland Clinic Spine Institute, believe that too much spine fusion surgery is being performed. Benzel estimated to the New York Times that less than half the spinal fusions being performed were appropriate. ‘The reality of it is, we all cave in to market and economic forces,’ he was quoted as saying, adding that the current system of paying doctors is ‘totally perverted.’ Dr. Zoher Ghogawala, a Yale neurosurgeon, agreed that too much fusion surgery is done, saying, ‘I see too many patients who are recommended for fusion that absolutely do not need it.’”

 

“Many of our ideas about low back pain have been wrong,” said Aage Indahl, MD.

“The slow pace of change in giving up old ideas is probably a result of the lack of new ideas.” (The BACK Letter, Vol. 23, No. 5, 2008, pp. 55.)

 

Just in the past few years, more evidence has emerged that critiques the medical model of back pain diagnosis, treatment, and management. Dr. James Weinstein, orthopedist and lead author of the SPORT study, said the rapid growth in surgical procedures, coupled with the lack of hard evidence, points to the need to spell out all the risks and benefits for patients and let them choose—in other words, to end the medical stranglehold on the back pain business.

 

“As in most of medicine, there isn't as much evidence as we would like,” said Weinstein, director of the Dartmouth Institute for Health Policy and Clinical Practice. “We need to be clear that there is a choice of treatments,” he said, and “that one isn't necessarily better than the other.” Quite an admission from an orthopedist undoubtedly tormented that the profitable standard medical methods can’t be substantiated in this era of EBM.

 

Regrettably, his advice has fallen on deaf ears inasmuch as the rate of increase in spine surgeries has escalated leaving a wake of impairment and disability as well as huge costs, while the growth of conservative treatments like chiropractic care have not seen the same increase in usage.

 

Indeed, in most cases patients have been mislead about the cause of their back pain, treated with unproven or ineffective treatments, uninformed about the likelihood of success from surgery and reoperations, not informed about alternative treatments, and the most glaring omission concerns one alternative treatment in particular—chiropractic spinal manipulation and other manual methods like flexion-distraction and non-surgical spinal decompression.

 

The Ethical Challenge

Fortunately, there is a ray of hope to end zombie spine care and to integrate the best of both worlds as offered by Dr. Lundberg.

“If some influential individual or group in chiropractic would …loudly and openly embrace EBM, let the chips fall where they may, and, if I may push further, openly repudiate the “vertebral subluxation and resulting nerve pressure is the root of all diseases” (presumably the Palmer belief structure), then I and many other physicians could openly and without fear and derision look at what 2005 EBM chiropractors actually do and go forward together.” 

 

Although Dr. Lundberg offered an olive branch to evidence-based chiropractors, many in the medical field still display their bigotry against anything non-medical. The flap over the proposed inclusion of a chiropractic program at FSU illustrated the depths of medical plutocracy when, in reality, it would have been an excellent opportunity to separate the wheat from the chaff within zombie spine care—both medical and chiropractic.

 

Why has zombie science remained entrenched?

  • Foremost, institutionalized medical bias toward anything to do with chiropractors is the biggest reason why spinal manipulative therapy (SMT) has been ignored despite the abundance of evidence showing the clinical and cost-effectiveness of SMT.
  • Secondly, money is a huge factor considering the cost for spinal treatment is astronomical—$36 billion for treatments and up to $90 billion annually for total costs—the lion’s share of the cost of back pain comes from expenses related to work loss, disability claims, early retirement, and lost productivity. Spine surgery is the second largest money maker behind heart surgeries, so there is little interest by hospitals to change tracks despite what the evidence and ethics might indicate.
  • Thirdly, the outdated medical diagnosis of back pain, based primarily on disc abnormalities as the main focus, has been contraindicated by recent EB research, yet many medical professionals have turned a blind eye to this latest research.
  • Fourthly, numerous analyses of medical training for musculo-skeletal conditions have shown consistently low scores in Basic Competency Exams by medical students, recent medical graduates, non-orthopedic staff physicians, osteopathic students, and physical therapy students. Chiropractic clinicians with postgraduate training have showed considerably better results than chiropractic interns. Despite these failings, primary care physicians still hold themselves out to be competent diagnosticians to patients for spinal disorders when, in fact, a dentist would be just as competent, albeit just as uninformed.

 

These are the Fundamental Flaws in this war on back pain and the medical profession is unwilling to admit, for the most part that their paradigm has been wrong and those damn chiropractors may have been right all along. There’s just too much money and pride at stake to let the evidence cloud their actions. Zombie science lives on despite the evidence and trend to alternatives in spine care.

 

Kevin Patterson, MD wrote of the new ethics in medicine as a function of evidence rather than tradition: (New York Times Magazine, “What Doctors Don’t Know (Almost Everything).”  New York Times, May 5, 2002.)

“Until recently, medicine was governed by the educated guess. But a new emphasis on data is challenging that tradition – with profound implications for both doctors and patients.

“A chain of command has existed since the profession (of medicine) found its modern face – doctor’s orders – with the most senior and academic physician experts directing the decisions of specialists, family physicians and ultimately the patients. 

“This order is now in the throes of a revolution known as evidence-based medicine, which asserts the supremacy of data over authority and tradition…

“The instant the  practitioner stops saying, ‘I think you should take this therapy,’ and starts  saying, ‘The evidence is that this therapy will work this percent of the time, with these complications, this frequently; what do you want to do?’ then the power hierarchy of doctor over patient is collapsed, and  autonomy is assigned to the patient.

“Just as the idea of authority within medicine is rejected, so too, the idea of the profession of medicine itself having authority over the patient is rejected.  Giving authority to the data, instead of other people, empowers everyone, the movement (of evidence-based medicine) holds.”

 

Indeed, isn’t it time for a notable medical statesman like Hadler or Deyo to step forward and give credit where credit is due—to the evidence and those damn chiropractors—and end this charade of zombie spine care in America?



Wilk et al v AMA et al. US District Court Northern District of Illinois, No. 76C3777, Getzendanner J, Judgment dated August 27, 1987.[1]

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

[3] DC Cherkin, RA Deyo, et al. An International Comparison Of Back Surgery Rates,” Spine, 19/11 (June 2004):1201-1206.

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

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

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

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

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

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

Overtreated America.

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

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

[12] 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.

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

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

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

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

[17] Matus, Ron, Chiropractic school angers FSU professors, St. Petersburg Times, December 29, 2004

 

[18]Palm Beach Post – January 15, 2005 

[19] ACC-RAC Plenary Session, Las Vegas 2005

[20] ACC-RAC Plenary Session, Las Vegas 2005

 

[21] McAndrews, George. Private communication. March 24, 1992

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