MEDICAL COLLUSION

The similarity is quite striking.

The impending Special Counsel Robert Mueller Report concerning President Donald Trump’s alleged collusion with Russian Czar Putin is a dramatic turn-around in American history. Undoubtedly many former presidents who dealt with the Russian Communist bear are rolling over in their graves wondering about Trump’s five private meetings with Czar Putin and the alleged Trump Tower deal in Moscow. Indeed, as one pundit said, something is “fishy,” and we won’t know the degree of collusion until the Special Counsel’s Investigation is over.

There is also something very fishy with the ‘new’ American Chiropractic Association leadership that has taken a shine to the medical profession, chiropractic’s long-time archenemy in what also appears to be collusion. Perhaps this generation of ‘new’ ACA members has forgotten our history or else they might not be so eager to adopt the AMA as its new best friend. Now the chiropractic leadership appears like sheep being lured into a trap of collusion and submission with the medical opportunists.

COMMITTEE ON QUACKERY

These chiro novices appear naïve about the medical cold war against chiropractors that has never officially ended. I would have hoped our ‘new’ ACA bureaucrats had learned an important lesson from history, but apparently not, so let me remind them of the medical dogma that has never been rescinded or renounced by the AMA leadership.

In 1963, Roger Youngerman, a Department of Investigation lawyer of the AMA, reported “that the ultimate objective of the AMA theoretically, is the complete elimination of the chiropractic profession.” This goal has never been repealed; it simply went underground.

He wrote that chiropractors “…present a clear and present danger to the health and welfare of the public, and it would seem that as guardians of our nation’s health, doctors of medicine should be dedicated to the total elimination of any such unscientific cult.”[1]

Youngerman likened chiropractors to “rabid dogs and killers” [2] and fomented medical propaganda among their members and the public despite the lack of proof.

According to court records, the AMA’s attorney Robert Throckmorton clearly spelled out his equivalence to the Final Solution in his Iowa Plan, “What Medicine Should Do about the Chiropractic Menace.”[3]

The AMA’s Principle 3 in its Code of Medical Ethics was similar to the 1934 Civil Servant Oath demanded of Germans to swear loyalty to Adolf Hitler rather than to their nation or their constitution; consequently democratic legal rights were abridged by the Nazi agenda. Members of the AMA had to swear to the obvious bigotry aimed at chiropractors and all providers who did not conform to allopathy medicine, regardless if these alternative methods were effective or not. Just as it was political suicide for Germans not to take the Civil Servant Oath in 1934, it was political and economic suicide for MDs not to abide by Principle 3 in 1963 for fear of losing licensure.

The public remains today unaware of the clandestine organization behind this medical war against chiropractors, and few people understand the backstory of this illegal restraint of trade that eventually was revealed in an antitrust federal lawsuit filed in 1976 in the United States District Court for the Northern District of Illinois.[4]

The carnage left by this Iowa Plan resulted in a “lengthy, systematic, successful, and unlawful boycott”[5] described by the judge to eliminate the profession of chiropractic that has never been properly acknowledged. Judge Getzendanner admitted in her Opinion that “The AMA has never made any attempt to publicly repair the damage the boycott did to chiropractors’ reputations.”[6]

CHIROPHOBIA

With a public suffering from widespread medical dementia—chirophobia—the prejudice against chiropractors—why isn’t the ACA or F4CP directly confronting this bias as the leading hurdle to overcome the damage to our collective reputations?

If we are to get to the cause of this social “dis-ease” that damaged our collective reputation, it requires more than a few billboards or bumper slogans on Facebook. It requires educating the public to the truth about the medical war, the failure of medical spine care, and the proven benefits of chiropractic.

It seems analogous to MLK, Jr. or the NAACP talking about racial injustice without mentioning racism. Until the chiropractic leadership addresses this defamation to our image, we cannot expect the public to see the medical stigma as unvarnished bigotry designed to corner the market.

I seriously doubt repairing the damage will come as a result of DCs prescribing drugs or the ‘new’ ACA jumping into bed with our enemies and sponsors such as the Laser Spine Institute promoting “widespread misconceptions” such as the ‘bad disk’ fallacy to lure gullible patients into futile fusions. We’ve all seen their misleading ads on TV touting band-aid solutions. Is this really evidence-based medicine or a tacky misleading marketing scam?

Nor will disavowing the vertebral subluxation or the philosophy of natural healing or mistakenly criticizing the use of spinal xrays for diagnostic/analytical purposes appear to be steps in the right direction for the ‘new’ ACA.

Apparently the ‘new’ millennial generation of DCs has sold out their heritage appearing more like the blind mice following the medical Pied Piper. I’ve read about the misguided instructors at University of Bridgeport who pride themselves on a pro-medical approach by renouncing every tenet in classic chiropractic. Of course, they offer no proof of their own while soiling the minds of their impressionable students.

Indeed, anyone familiar with classic chiropractic care must be scratching their heads in complete disbelief.

Just as Trump’s agenda has been divisive among our population, so has the ACA’s ‘new’ agenda divided our profession more than ever before. Indeed, I wonder if the ‘new’ ACA has had a rush of new members and how many like me or Steve Conway have resigned in disgust.

WIDESPREAD MISCONCEPTIONS

Despite its desired image to follow evidence-based medicine, in fact, it appears the ACA is ignorant of the latest evidence-based research. For example, the British medical journal, The Lancet, impaneled 31 experts to study the worldwide pandemic of LBP and published its 3-Part Review:

• Low back pain: a call for action.
• Prevention and Treatment of Low Back Pain: Evidence, Challenges, and Promising Directions
• Clinical practice guidelines for the management of nonspecific low back pain in primary care: an updated overview

This panel acknowledged the “barriers to optimal evidence-based management”:

“Other barriers to optimal evidence-based management include widespread misconceptions of the general public and health professionals about the causes and prognosis of low back pain and the effectiveness of different treatments, fragmented and outdated models of care, and the widespread use of ineffective and harmful care, particularly in countries regarded as models of high quality care.”

Undoubtedly this summary described US spine care. Despite the obvious need for reform evident by the growing awareness and problems associated with opioid addiction and failed back surgery, medical spine care in the US is getting worse.

Even Dr. Marc Siegel on FOX News admitted primary care providers have only 9 hours of education on the “back” and he blamed the opioid epidemic on his colleagues and pharmacists. “We’re getting a growing awareness of two things: the abuse of back surgery and the abuse of opioids.”[7]

But why hasn’t the chiropractic leadership jumped on The Lancet bandwagon by tooting this horn to every corner of the country? It’s not often when a TV medical reporter like Dr. Siegel touts our profession while criticizing his own, yet the ACA and F4CP has done nothing to use this game-breaker comment to unite our profession rather than dividing the rank and file?

Instead, the ‘new’ ACA ignores this opportunity and jumps on the Choosing Wisely bandwagon blowing the anti-xray radiation tune that has been shown to be ridiculous by numerous researchers and insulting to our professional protocols as evidence-based research shows.

A paper by André E. Bussières, DC, et al., Diagnostic Imaging Practice Guidelines For Musculoskeletal Complaints In Adults—An Evidence-Based Approach—Part 3: Spinal Disorders, differentiates between radiographs for diagnostic purposes and therapeutic purposes:

What These Guidelines Do and What They Do Not Do

“It should be emphasized that these guidelines were developed with the intent of being used for diagnostic purposes and not for therapeutic purposes such as evaluating and monitoring functional or structural rehabilitation of the spine…”

Dr. Bussières is clear the Choosing Wisely xray guideline is “not for therapeutic purposes such as evaluating and monitoring functional or structural rehabilitation of the spine,” which is exactly what DCs do! Unfortunately too many quasi-academicians and pin-head non-practitioners like Stephen Perle et al. at the West Hartford Group of Naysayers think they should dictate how we field docs practice.

Let me ask these chiropractic curmudgeons: if classic chiropractic is so wrong, why does every new guideline promote SMT as a front-line treatment? Indeed, it’s hard to argue with success.

LASER SPINE BUNK

Regrettably, both the ‘new’ ACA and the F4CP have missed a golden PR opportunity by not challenging the massive ad campaign by the Laser Spine Institute that disseminates a “widespread misconception” about the ‘bad disk’ causation of LBP, a concept long debunked by reputable researchers, an urban legend that has led many gullible patients with LBP to unnecessary spine fusion.

Instead, the F4CP recently announced it too has jumped into bed with the medical enemy appearing eager to collude:

F4CP partners with American Academy of Spine Physicians to enhance spine care

Chiropractic Economics November 13, 2018
November 13, 2018 – The Foundation for Chiropractic Progress (F4CP) announces a brand-new opportunity for its membership to work with the American Academy of Spine Physicians (AASP) to enhance the role and recognition of doctors of chiropractic in spine care.

“In this collaborative role, doctors of chiropractic, and Foundation members specifically, have another impressive opportunity to position themselves among multidisciplinary providers as spinal care experts,” says Sherry McAllister, DC, executive vice president, F4CP, who notes that spinal disorders are a leading cause of global pain and disability. “The mission of the AASP to promote excellence in spine care through education, innovation and collaboration directly aligns with the Foundation’s goal to raise heightened public awareness about the value of safe, effective and drug-free chiropractic to further ensure patient-centered care is top of mind among providers, as well as consumers.”

So the F4CP wants DCs to joint ranks with inept MDs using “outdated models of care” to enhance our image. What’s wrong with this picture? Has no one at the ACA or F4CP read The Lancet 3-part review of the worldwide pandemic of LBP?

If the F4CP’s goal is raise public awareness about “the value of safe, effective and drug-free chiropractic” (oops, that’s a no-no to the ‘new’ ACA’s agenda), instead of colluding with the enemy, why hasn’t the brain-trust at the F4CP ever taken on the elephant in the operating room—the debunked ‘bad disk’ notion?

As The Lancet mentioned, usual medical spine care consisting of narcotic painkillers, ESI, and spine fusion surgery exemplify “outdated models of care, and the widespread use of ineffective and harmful care.”

The Lancet and Dr. Siegel are not alone in their assessment of this medical spine scam. The dire situation in US spine care was noted by Mark Schoene, a member of The Lancet panel and editor of an international spine research journal, The BACKLetter, who summarized this urgency in his article, “U.S. Spine Care System in a State of Continuing Decline”:

“Medical spine care is the poster child of inefficient care…such an important area of medicine has fallen to this level of dysfunction should be a national scandal. In fact, this situation is bringing the United States disrespect internationally.”

If President Trump is willing to shut down the government over the border wall, when will the ‘new’ ACA and F4CP find a strong backbone to expose the “national scandal” about “the poster child of inefficient care?”

A PR campaign to “heighten public awareness” about the fallacy of the ‘bad disk’ diagnosis to justify fusion surgery would do more good than all the platitudes about collusion with medical men eager to have DCs send them more gullible patients for opioids, ESIs, and disk fusion surgery.

CHIROPRACTIC WHISTLE-BLOWERS

If the ACA and F4CP leaders were savvy, they could position themselves a whistleblowers warning the public about this national scandal. The evidence is clear usual medical spine care is an expensive clinical disaster, but the public is clueless because the entire medical profession is lying to them. But the facts are clear.

Not only are most spine fusions unnecessary and based on a debunked ‘bad disk’ diagnosis, Failed Back Surgery Syndrome (FBSS) remains the largest expenditure swept under the medical rug that patients often encounter but are rarely warned beforehand with Informed Consent procedures. Little does the public realize numerous studies now estimate FBSS may be as high as 50% to 90%.

         Since attending physicians rarely do Informed Consent to prospective surgical patients about the risk of FBSS or chiropractic care as an alternative, it certainly is the duty of the surgeon to notify gullible patients of the likelihood of failure from the “low quality medical care” such as spine fusion surgery.

Dr. Pran Manga commented on failed back surgery:

Unnecessary or failed surgery is not only wasteful and costly but, ipso factor, low quality medical care. The opportunity for consultations, second opinions and wider treatment options are significant advantages we foresee from this initiative which has been employed with success in a clinical research setting at the University Hospital, Saskatoon…

However, the desired change in the healthcare delivery system will not occur by itself, by accommodation between the professions, or by actions on the part of Workers’ Compensation boards or the private sector generally. The government will have to instigate the reform and monitor the progress of the desired changes called for by our overall conclusion.[8]

         No one is suggesting that all spine surgeries are unnecessary. There are, for instance, indications for lumbar fusion in the cases of:

• fracture,
• cancer,
• spondylolisthesis of 50% or more,
• scoliosis greater than 50 degrees with loss of function,
• persistent radicular pain unresponsive to conservative care,
• persistent neurogenic claudication unresponsive to conservative care, or
• serious infections such as spinal tuberculosis.[9]
  

However, according to orthopedist SK Dhillon, these cases may be as little as 5% to 7% of all LBP cases, suggesting the list for unnecessary spine surgeries is much longer than most people realize.

Here is a short list of studies showing the poor outcomes and high risk of spine surgery resulting in Failed Back Surgery Syndrome (FBSS):

 Late postoperative results in 1000 work related lumbar spine conditions by Emile Berger, M.D. (FRCS(C), FACS found 71% of the single operation group had not returned to work more than 4 years after the operation, and 95% of the multiple operations group were unable to work.

The Aetiologies of Failed Back Surgery Syndrome: A systematic review:

Up to fifty percent of patients will develop FBSS following lumbar spine surgery.The Economic Impact of Failed Back Surgery Syndrome:

Estimates from randomized controlled trials indicate that up to 50% of patients may have an unsuccessful outcome following lumbar spinal surgery.

Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State: Reduced odds of surgery were observed for those under age 35, women, Hispanics, and those whose first provider was a chiropractor. 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor.

2018: Failed Back Surgery Syndrome: A Review Article, by James Daniell and Orso Osti found fusion surgery has a substantial failure rate, which they estimated as high as 46%. Moreover, many patients opt for repeat surgery, but that often leads to “diminishing returns.”

“Although slightly more than 50% of primary spinal surgeries are successful, no more than 30%, 15%, and 5% of the patients experience a successful outcome after the second, third, and fourth surgeries, respectively.”[10]

 2017: Multidisciplinary Evaluation Leads to the Decreased Utilization of Lumbar Spine Fusion: An Observational Cohort Pilot Study, at the American Association of Neurological Surgeons 2017 Annual Meeting: “When non-surgeons are empowered to make decisions, nearly 60% of patients who were recommended surgery were found to have nonsurgical options.”

2013: Nancy Epstein, neurosurgeon and editor at Surgical Neurology International (SNI), asked, Are recommended spine operations either unnecessary or too complex? Evidence from second opinions found of 183 second opinions seen over 20 months, the second opinion surgeon documented that previous spine surgeons recommended “unnecessary” (60.7%), the “wrong” (33.3%) or the “right” (6%) operations. This study suggests 94.0% of cases were given unnecessary or wrong recommendations.

2012: A study in the British Journal of Pain, The Economic Impact of Failed Back Surgery Syndrome, found up to 50% of patients may have an unsuccessful outcome following lumbar spinal surgery.

2018: Health Waste: Spinal Fusion Added to List, published by The Australian.com took a swipe at spinal fusions:

Spinal fusion for unexplained back pain will today be put on the list of unnecessary, wasteful and risky medical procedures, promising patients more clarity over their options and potentially saving the health system tens of millions of dollar a year.

Experts are alarmed by the trend and, ­according to one estimate, the surgery cost $2.3 billion over a ­10-year period despite more than half of those operations likely being unnecessary.

I’ve written extensively about this surgical ruse by the Laser Spine Institute, Marketing Plan Part 2, with its incessant TV propaganda, but the ‘new’ leadership at these two chiro organizations seems to be unaware of evidence-based medicine debunking usual medical care and they seem unconcerned about the tsunami of unnecessary spine surgery.

Instead of exposing these damaging surgeries, the ACA’s conflict of interest with Laser Spine Institute and the F4CP’s love fest with American Academy of Spine Physicians, both continue to avoid the big issues that would position itself as a whistleblower in the earned media to save patients from “outdated models of care” and the “widespread use of ineffective and harmful care” as The Lancet panel stated.

Apparently neither group is aware of this “national scandal” and the latest evidence-based research damning usual medical spine care.

ASLEEP AT THE WHEEL

Instead of TV spots in the earned media with articulate speakers talking about the “widespread misconceptions” of spine fusion surgery, the F4CP touts its street billboards as the key to public awareness. Do they really think a billboard will overcome chirophobia and re-position skeptics to our perspective?

With an operating budget of $1 million annually over the past 11 years, I daresay the return on investment for the F4CP is just not there because they’re talking about the wrong issues using the wrong venue. Obviously the F4CP needs a new PR firm that understands the unique history, research, and social dynamic of our profession.

Has our market share increased from this decade-old F4CP effort? I don’t see that the “billions of positive impressions” the F4CP brags about has turned into millions of new patients. Nor has it exposed the medical war as a diabolical, illegal defamation plot that has led to the boycott of our profession and to the addiction, impairment, and deaths of millions of people who have been using opioids for their LBP prescribed by “Dr. Chapo.”

Indeed, our silence has only added to this calamity.

INEPT MDS

Not only are thousands of “Dr. Chapos” known to be promiscuous prescribers of narcotics, the public does not realize most MDs are inept in musculoskeletal disorders.

Medical primary care physicians lack training in musculoskeletal disorders such as LBP,[11] are more prone to ignore recent guidelines,[12] more likely to suggest spine surgery than surgeons themselves,[13] and only 2% of medical PCPs refer to Doctors of Chiropractic despite their superior training and results in musculoskeletal disorders (MSDs).[14]

I tease patients by asking if they would go to an MD with a toothache. Of course not, they reply, knowing MDs are not trained in dental problems. So I ask why do you go to an MD for a back attack? Because people simply do not know MDs are inept as experts agree.

And the ACA and F4CP are not telling them either, clearly a lack of due diligence or the lack of a political backbone to tell the truth.

Not only are MDs poorly educated in MSDs and responsible for the “disastrous effects” of the opioid crisis, the National Pain Strategy admitted MDs were a poor choice to manage chronic pain cases:

“Physicians are not adequately prepared and require greater knowledge and skills to contribute to the cultural transformation in the perception and treatment of people with pain.”[15]

Editor Mark Schoene also commented on the buffoonery to use MDs as the POE for chronic pain patients considering they created this terrible opioid epidemic in the first place. He commented on this quandary in his article, “Why Should the National Pain Strategy Be MD-Centric?”[16]

“Primary care physicians and pain specialists don’t have unimpeachable backgrounds in the management of chronic pain in the U.S. These are the medical professions primarily responsible for the opioid overtreatment crisis. Are the two professions that helped create the worst pain management crisis in the history of modern medicine capable of leading the way forward? That remains to be seen.”

The problem remains the public, WC programs and general insurance payors are unaware family practitioners are poorly schooled in back problems and practice “outdated models of care” contrary to the evidence-based guidelines.

Researcher Richard Deyo, MD, MPH, author of “Watch Your Back!”, also mentioned physician incompetence in diagnosis and treatment of low back pain:

“Calling a [medical] physician a back pain expert, therefore, is perhaps faint praise — medicine has at best a limited understanding of the condition. In fact, medicine’s reliance on outdated ideas may have actually contributed to the problem.”[17]

Dr. Deyo recognized in 1998 what The Lancet review acknowledged twenty years later in 2018 — the outdated medical models of care used by incompetent MDs. Nothing has changed except the wake of disability and addictions have increased.

As Gordon Waddell mentioned:

  “Low back pain has been a 20th century health care disaster…back surgery has been accused of leaving more tragic human wreckage in its wake than any other operation in history.”[18]

Pran Manga, PhD, medical economist, stated in his study, “The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain”:

“There should be a shift in policy now to encourage the utilization of chiropractic services for the management of LBP, given the impressive body of evidence on the effectiveness and comparative cost-effectiveness of these services, and on the high levels of patient satisfaction.

“The shift in utilization from physician to chiropractic care should lead to significant savings in healthcare expenditures judging from evidence in the Canada, the US, the UK and Australia, and even larger savings if a more comprehensive view of the economic costs of low back pain is taken.”

An in-depth study of internal data from Optum Health research by David Elton, DC, and Thomas M. Kosloff, DC, et al., who co-authored Conservative Spine Care: The State of the Marketplace and Opportunities for Improvement.[19]

This study of more than 16 million episodes between 2010-2013 allowed for fairly detailed analysis down to the level of each individual provider in each state in the country. Their study found chiropractors were the best portal of entry with lower costs and improved outcomes, but they also found most often patients were not offered chiropractic care when they initially board the medical train at an MD’s office.

The researchers found “Spine care is characterized by low rates of imaging, Rx, injections, and surgery when including episodes starting with a DC.” Obviously having a chiropractor in the loop means less money for everyone else.

The authors concluded,

“Research and guidelines are consistent and clear. We don’t need another guideline, we do need to help patients receive treatment from providers aligned with research/guidelines.”

This is the message we need to send to the public rather than playing second fiddle to the medical spine guys using “outdated models of care” based on “widespread misconceptions”.

Perhaps the leadership at both the ACA and F4CP need a few lessons on spine research, the politics of spine care, and disruptive journalism before they can adequately lead our troops in the medical war against chiropractic in the court of public opinion.

To conclude, just as the State of our Nation is unsettling to say the least, the State of our Profession is just as bad. Classic chiropractic is under attack from within as well as from the medical goons. Our leadership has missed numerous PR opportunities and continues to throw good money in after bad with silly outdated methods. Our rank and file remains divided and indifferent.

Although the research falls on our side more than ever before, the public fails to appreciate our victories in the courts and in the scientific trenches.

Anthony Rosner, PhD, was prophetic about the ascension of chiropractic care when the testified before The Institute of Medicine: Committee on Use of CAM by the American Public on February 27, 2003:

“Despite the fact that chiropractic has existed as a formal profession worldwide for over a century, most of what we consider to be rigorous, systematic research in support of this form of health care has emerged only in the past two-and-a-half decades…

Nearly 30 years later, we now can review with great satisfaction how back pain management has been assessed by government agencies in the U.S.; Canada; Great Britain; Sweden; Denmark; Australia; and New Zealand. All of these reports are highly positive with respect to spinal manipulation. 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.”[20]

So, when will the ‘new’ ACA and F4CP tell the world?

_{[1] Memo from Robert Youngerman to Robert Throckmorton, 24 September 1963, plaintiff’s exhibit 173, Wilk.}

_{[2] Joseph A. Sabatier, MD, Minutes from the “Chiropractic Workshop,” Michigan State Medical Society, held in Lansing on 10 May 1973, exhibit 1283, Wilk.}

_{[3] PX-172 November 11, 1962.}

_{[4] This is the subject of my book, The Medical War Against Chiropractors.}

_{[5] Chester A. Wilk, James W. Bryden, Patricia A. Arthur, Michael D. Pedigo v. American Medical Association, Joint Commission on Accreditation of Hospitals, American College of Physicians, American Academy of Orthopaedic Surgeons, United States District Court Northern District of Illinois, No. 76C3777, Susan Getzendanner, Judge, Judgment dated August 27, 1987.}

_{[6] Opinion pp. 10}

_{[7] Dynamic Chiro, May, 2017:}

 _{http://www.dynamicchiropractic.com/digital/index.php?i=1228&a_id=57942&pn=1&r=t#1}

[8] Manga Pran, PhD et al. “The Effectiveness and Cost-Effectiveness of chiropractic Management of Lob-Back Pain, “ Ontario Ministry of Health, 1993

_{[9] Milliman Care Guidelines for Lumbar Fusions, Low Back Pain and Lumbar Spine Conditions—Referral Management, www.allmedmd.com}

_{[10] Failed Back Surgery, The BACKLetter, Vol. 33, No. 7, July 2018}

_{[11] Elizabeth A. Joy, MD; Sonja Van Hala, MD, MPH, “Musculoskeletal Curricula in Medical Education– Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/ 11 (November 2004).}

_{[12] PB Bishop et al., “The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) part I: A Randomized Controlled Trial On The Effectiveness Of Clinical Practice Guidelines In The Medical And Chiropractic Management Of Patients With Acute Mechanical Low Back Pain,” presented at the annual meeting of the International Society for the Study of the Lumbar Spine Hong Kong, 2007; presented at the annual meeting of the North American Spine Society, Austin, Texas, 2007; Spine, in press.}

_{[13] SS Bederman, NN Mahomed, HJ Kreder, et al. In the Eye of the Beholder: Preferences Of Patients, Family Physicians, and Surgeons for Lumbar Spinal Surgery,” Spine 135/1 (2010):108-115.}

_{[14] Matzkin E, Smith MD, Freccero DC, Richardson AB, Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am 2005, 87-A:310-314}

_{[15] http://iom.nationalacademies.org/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx, pp.5.}

_{[16] Why Should the National Pain Strategy Be MD-Centric? BackLetter: February 2016 – Volume 31 – Issue 2 – p 16}

_{[17] Deyo, RA. Low -back pain, Scientific American, pp. 49-53, August 1998.}

_{[18] G Waddell and OB Allan, “A Historical Perspective On Low Back Pain And Disability, “Acta Orthop Scand 60 (suppl 234), (1989)}

_{[19] Thomas M. Kosloff, DC, David Elton, DC, Stephanie A. Shulman, DVM, MPH, Janice L. Clarke, RN, Alexis Skoufalos, EdD, and Amanda Solis, MS, Conservative Spine Care: Opportunities to Improve the Quality and Value of Care, Popul Health Manag. Dec 1, 2013; 16(6): 390–396.} 

_{[20] The Institute of Medicine: Committee on Use of CAM by the American Public, Testimony for Meeting, Feb. 27, 2003}