Bones of Contention

Bones of Contention

The recent editorial in JAMA by Richard A. Deyo, MD, MPH, “The Role of Spinal Manipulation in the Treatment of Low Back Pain,” published on April 11, 2017, in conjunction with the original investigation by the JAMA study, “Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis,” must be addressed by someone in the chiropractic profession in order to have any semblance of a “fair and balanced” argument.

So, let me give it a whirl.

Unquestionably Dr. Deyo is one of America’s premier spine journalists who has fought many battles with the mainstream medical spine providers. For his efforts, Dr. Deyo won the prestigious 2015 International Society for the Study of the Lumbar Spine Lifetime Achievement Award among many other awards on his impressive résumé.

I have admired his battles on the leading edge against the medical establishment, which included being booed off the stage at a NASS meeting when he exposed the rash of unnecessary disc fusions. As well, he was a panel member on the 1994 AHCPR guideline for acute LBP. Dr. Deyo subsequently co-authored a 1997 article in The New England Journal of Medicine in response to an attack from spine surgeons angry about the AHCPR’s recommendations that spoke very poorly about fusions, “The Messenger Under Attack—Intimidation of Researchers by Special Interest Groups.”[1]

Indeed, he has fought the good fight for decades as a reformer in spine care, nonetheless his biases came through in his JAMA editorial about spinal manipulation and chiropractic.

So, let me pick a few bones with him concerning his editorial comments about chiropractic:

1. Spinal manipulative therapy (SMT) is a controversial treatment option for low back pain, perhaps in part because it is most frequently administered by chiropractors.
2. Chiropractic therapy is not widely accepted by some traditional health care practitioners.
3. This may be, at least in part, because some early practitioners of chiropractic care rejected the germ theory, immunizations, and other scientific advances.
4. Spinal manipulation may restore some material in the disk between the vertebrae, or it may simply relax muscles, which could be important. There may also be mind-body interaction that comes from the ‘laying of hands’ or a trusting relationship between patients and their health care provider.
5. Many patients don’t even need to see a doctor, and many episodes of back pain are like the common cold: extremely frustrating, but rarely serious, and usually destined to improve.
6. This study incorporates the most recent data and seems to confirm that spinal manipulation is at least as effective as conventional care.

Let me address Dr. Deyo’s comments:

1. Dr. Deyo omits the most important factor in the history of this “controversial treatment option for low back pain perhaps in part because it is most frequently administered by chiropractors” that stems not from the treatment per se, but from the political war against chiropractors—a Medical Inquisition if you will—by organized medicine led by the Medical Mussolini in his quest to establish a medical monopoly. Any controversy originates from the medical propaganda, not from our clinical outcomes that have always been impressive.

It was the illegal boycott to marginalize and boycott chiropractors in the AMA’s campaign to “contain and eliminate” chiropractors that eventually led to an antitrust case in 1976 brought by four brave chiropractors led by attorney George McAndrews. The defamation campaign to discredit chiropractic as a “dangerous, unscientific cult” was exposed as a sham, but the PR damage to the image of the chiropractic profession remains fait accompli.

Judge Susan Getzendanner ruled, “By labeling all chiropractors unscientific cultists, injury to reputation was assured by the AMA’s name-calling practice,”[2] which was exactly the goal of the medical curmudgeons — to defame its main competition, to invalidate chiropractic  expertise/treatments, and to capture the healthcare marketplace.

Somehow, Dr. Deyo failed to mention this medical war against chiropractors as the underlying “backstory” in this controversy. His omission is equivalent to speaking about racism without mentioning the backstory of slavery, the Civil War, Jim Crow laws, segregation, Civil Rights Act and MLK, Jr. People without the true historical context about chiropractic cannot understand the medical war against chiropractors.

2. Let me address his second comment: “Chiropractic therapy is not widely accepted by some traditional health care practitioners.”

Again, let’s not be naïve about the medical war to segregate chiropractors. It was not a war about treatments since SMT has always worked well for many patients over the past 3000 years of recorded history.

This came to light in 1969 during discovery in the Wilk trial when a member of the AMA’s Board of Trustees, Irwin Hendryson, MD, an orthopedic surgeon, wrote of his experience in World War II when he observed a chiropractor successfully treating a Marine captain with acute LBP at Guadalcanal. He spoke to the Board on the benefits of manipulative techniques but the Board refused to acknowledge his report publicly even when one of its own spoke the truth.[3]

This boycott of Dr. Hendryson’s report typifies the mindset of the AMA’s Committee on Quackery in the 1960s to not promote the truth, but to maintain its fabrication and propaganda to dissuade the public, press, and its own members about the benefits of chiropractic care.

This war was about money and in order to capture the market place, the CoQ’s plan was to threaten its own members to boycott DCs and to publicly defame chiropractic care—the essence of the Wilk v. AMA antitrust trial. This illegal boycott is solely why “Chiropractic therapy is not widely accepted by some traditional health care practitioners.”

Dr. Deyo knows very well as a leading researcher in this field and an expert I’ve quoted extensively. The back pain business is now $177 billion[4] and there is no way spine surgeons, the richest of all MDs, are willing to let chiropractors infringe upon their “prosperous island” as author/attorney Steven Brill wrote.

And their greed is why these spine surgeons and MDs ignored the AHCPR and will presumably ignore the new American College of Physicians guidelines for treating nonradicular low back pain published in the Annals of Internal Medicine on Feb. 14, 2017.

“Don’t confuse us with the facts” is the medical mantra.

3. Another statement in Dr. Deyo’s JAMA Editorial that needs addressing was his explanation for medical bias, aka, chirophobia, was “because some early practitioners of chiropractic care rejected the germ theory, immunizations, and other scientific advances.”

He is opening up a can of worms about immunizations, the sacred cow of medicine that has turned into a raging bull for many children and parents due to the rise of autism. Instead of casting chiropractors as targets for ridicule over immunizations, today they should be seen as prophetic that vaccines are dangerous and deadly.

Just as we’ve witnessed the public outcry over lead in drinking water in Flint, Michigan, the clamor over toxic vaccines is reaching the same level of concern. Take a look at the exponential growth of autism:

Dr. Deyo must admit there is reasonable doubt about the safety and side-effects with Thimerosal-laced vaccines, especially when administered as “cocktail” shots of multiple vaccines to infants.

As a concerned patient once told me, “I’d rather my daughter have measles than autism.”

           Indeed, today it’s playing Russian roulette with vaccines—perhaps unlikely, but sometimes deadly and often damaging such as autism that now affects one in 45 children whereas in 1975 it was one in 5,000.

Certainly a case can be made “cocktail” vaccines today are risky, but too many MDs and governments have the same “so what” attitude, “We’re willing to sacrifice a few to protect the many.” Let’s just hope the “few” doesn’t include your child.

This controversy remains alive in the public sector with new whistle-blower articles such as “New Vaccines Still Cause Autism and Our Government Knows” by Gary Null, PhD.

Although proponents of vaccines are well intentioned, admittedly there is a risk as found by a 2013 research paper, A two-phase study evaluating the relationship between Thimerosal-containing vaccine administration and the risk for an autism spectrum disorder diagnosis in the United States:

Routine childhood vaccination is an important public health tool to reduce the morbidity and mortality associated with infectious diseases, but the present study provides new epidemiological evidence supporting an association between increasing organic-Hg exposure from Thimerosal-containing childhood vaccines and the subsequent risk of an ASD diagnosis.

Certainly a case can be made it is a rational decision to question the use and safety of vaccines instead of casting opposition as quackery as Dr. Andrew Wakefield encountered in his struggle noted in the documentary, “VAXXED from cover-up to catastrophe.” Indeed, the medical war includes anyone who opposes  Big Medicine and Big Pharma.

  I often ask staunch proponents of vaccines if they will offer up their arms for an HIV shot. Of course, all of them say, “Hell no!” Unlike adults, children have no say about childhood vaccines that may cause irreparable harm while adults get off Scot free.

In regards to the germ theory, the Palmers believe the patient’s natural immunity was paramount (as do many progressive physicians today).  The virulence of the germ is secondary to the body’s own immune system, which is a hygienic concept espoused by many types of natural healers including chiropractors who understood the role of chiro care to autoimmune disorders.

Malik Slosberg, DC, MS, wrote in his article, “Immune Responses to Spinal Manipulation” that “The accumulation of data from these studies suggests that a possible benefit of spinal manipulation is related to neuroimmunological effects.” [5] 

In most infectious diseases, a patient with a healthy lifestyle and strong immunity can withstand the onslaught of most germs which is why not everyone gets sick during the “cold and flu” season (notwithstanding the most virulent or new strains).

As DD Palmer once joked about the germ theory, “most people are too slow to catch a cold.”

Public health officials agree public sanitation with good waste disposal such as indoor toilets and clean food/water are most important to reduce the spread of an infectious disease. Since Dr. Deyo has a MPH degree, he knows well of this concept that public sanitation is most important.

In regards to Dr. Deyo’s comment about “other scientific advances,” I am not sure what he means by that generalization. His comment paints chiropractors as medical Luddites, who disbelieve in all-things-medical.

 But if his generalization includes opioids, epidurals and spine surgeries for the pandemic of back pain, than he is totally correct.

There is ample proof medical spine care is a “national scandal” as journal editor Mark Schoene wrote about the dangers of opioid addiction, ESIs, and spine fusions. My book, To Kill a Chiropractor, goes into detail of the medical mess in spine care today, which is as Mr. Schoene wrote, “the poster child of inefficient spine care.” I need not elaborate on the impending paradigm shift in spine care from medical to chiropractic care in this article since I discuss it at length in my book.

1. Dr. Deyo also wrote in his editorial:

“Spinal manipulation may restore some material in the disk between the vertebrae, or it may simply relax muscles, which could be important. There may also be mind-body interaction that comes from the ‘laying of hands’ or a trusting relationship between patients and their health care provider.”

Honestly, I am shocked by his naïve concept of the basis of chiropractic care. It appears the “elephant in the room” in regards to spine care is the overlooked issue of spinal joints.

Dr. Deyo is aware medical icons in spine care such as John McMillan Mennell and Alf Nachemson[6] have mentioned the role of joint play and compression as essentials to mechanical spine health.

The famed Dr. Alf Nachemson accused his spine colleagues of inventing “disc degeneration” (aka, “incidentalomas” as Deyo coined) as a disease that requires surgery:

“You are violating all the rules of epidemiological science when you name this a disease. You are making people sick…If this is a disease, then this room is full of very sick people.”[7]

In 1992, John McMillan Mennell published his book, The Musculoskeletal System: Differential Diagnosis from Symptoms and Physical Signs, in which he described joint dysfunction as a cause of pain and joint manipulation as the primordial correction.

In 2001, Jay Triano wrote a fascinating paper about the “segmental buckling effect”[8] while at the Texas Back Institute that elaborates on the “creep effect” on joints from prolonged compression.

Donald Murphy and Eric Hurwitz believe 50 percent of low back pain and 69 percent of neck pain is joint pain,[9],[10] which explains why spinal manipulation and other manual therapies that restore proper joint play work so well.

Greg Cramer at National University in Chicago also found there were 361 joints (syndesmosis, synovial and symphysis) in and around the spine, which explains why constant compression and accidents will easily lead to joint problems and pain. In turn, this joint model explains why SMT is so effective.

As you can see, Dr. Deyo omitted from his editorial important research findings that explain why SMT works so well. This information is crucial for the public and press to know in order to reposition chiropractic care as a valuable and essential treatment in this LBP epidemic just as the new guidelines recommend.

Since Dr. Deyo has written extensively on the topic of back pain in his book, Watch Your Back!,  I am very confused why he downplayed the role of joint dysfunction in the back pain scenario; instead he suggests DCs partake in the “laying of hands” and some sort of faith healing. I wish it were that simple.

1. Deyo takes another leap of faith when he believes back pain often clears up on its own within six weeks, the time frame researchers examined in the study.

“Many patients don’t even need to see a doctor, and many episodes of back pain are like the common cold: extremely frustrating, but rarely serious, and usually destined to improve.”

If that is true, why is LBP the leading cause of disability in the nation, military and workplace?

Certainly a patient can “wait out” chest pains, but is that prudent? Indeed, waiting is not correcting the underlying problem, only evidence of the body’s ability to cope with pain.

This may also explain why an acute problem mismanaged by masking pain with painkillers or “waiting it out” often becomes a recurrent life-long chronic problem as we witness with many adults whose initial spinal injury began in youth but was never corrected only to lead to degeneration and adult problems.

But Dr. Deyo is correct that patients don’t need to see a medical doctor for back pain problems as he wrote in Scientific American in 1998:

“Calling a physician a back-pain expert, therefore, is perhaps faint praise—medicine has at best a limited understanding of the condition. In fact, medicines’ reliance on outdated ideas may have actually contributed to the problem.”[11]

This is an important point he omitted in his JAMA editorial, a most important omission if he wants to steer people in the right direction to chiropractors. Nowhere in his article did he cast aspersions at the very doctors who created this opioid epidemic or at the surgeons who use “incidentalomas” as a false premise to do unnecessary spine fusions.

6.    Deyo added, “This study incorporates the most recent data and seems to confirm that spinal manipulation is at least as effective as conventional care.”

That is a rather lukewarm recommendation, don’t you think?

Plus, I am not sure what he means by “conventional care” other than OTC drugs, opioid painkillers, epidural shots and surgery, which have proven to be either placebo, addictive, unproven, dangerous or, in the case of disc fusions, based on the debunked ‘bad disc’ premise that Deyo chides in his many writings as “incidentalomas” because they are incidental to the actual problem.

Dr. Deyo admitted the JAMA investigation “is also one of the few systematic reviews to rigorously address safety, and concludes that serious complications are extremely rare.”

The bottom line message, says Deyo, is to avoid medication. “Even over-the-counter medications have some important side effects and complications,” Deyo says. “Spinal manipulation seems to be quite safe when it’s done in the lower back.”

Finally, a statement I can totally agree with, but, as many MDs might say, “So what!”

Elephants in Editorial

As a leading “thought leader” in spine care, Dr. Deyo’s opinions are highly respected despite his sometime skewed comments as I have indicated. Indeed, if JAMA wanted a “fair and balanced” debate, why did he not include any comments from chiropractic professionals such as Scott Haldeman, Bill Meeker, Dana Lawrence, Jay Triano, Mike Schneider, to mention only a few?

Ironically, his omission is equivalent to a medical investigation into dentistry without any feedback from dentists, but the medical profession is known to be one-sided, not fair and balanced.

Indeed, why didn’t the editors of JAMA ask any of our notable chiropractic spokesmen to chirp in on this JAMA investigation? Certainly the editors at JAMA knew the chiropractic profession has been on the vanguard in SMT and to omit any comments from our own “thought-leaders” once again smacks of chirophobia in journalism.

In summation, although Dr. Deyo was well-intentioned, his medical bias was the backstory in his editorial. Since he is not versed in chiropractic or alternative therapies, perhaps in the future he might team up with a chiropractor knowledgeable in these issues to present a truly “fair and balanced” article.