Articles by JCS

NY Times response

Finally, an honest MD willing to admit to his bias about chiropractic care!

“A physician like me might suggest any number of potential treatments and therapies. But one I never considered was a referral for spinal manipulation. It appears I may have been mistaken. For initial treatment of lower back pain, it may be time for me (and other physicians) to rethink our biases.”

Wow, now if we could get the other half million MDs to admit to their biases, too.

Enjoy my remarks in [red] to this article.


For Bad Backs, It May Be Time to Rethink Biases About Chiropractors

About two of every three people will probably experience significant low back pain at some point. A physician like me might suggest any number of potential treatments and therapies. But one I never considered was a referral for spinal manipulation. [He should explain how he developed his bias, but he probably doesn’t even know—Morris Fishbein, Committee on Quackery, Wilk v. AMA, because his bias is simply part of his medical DNA.]

It appears I may have been mistaken. For initial treatment of lower back pain, it may be time for me (and other physicians) to rethink our biases. [Yes, but he does reveal his own bias and ignorance on spine care. He writes as if his opinion is the final say on this matter. Let me ask: why didn’t he consult a DC for a more balanced article?]

Spinal manipulation — along with other less traditional therapies like heat, meditation and acupuncture — seems to be as effective as many other more medical therapies we prescribe, and as safe, if not safer.

Most back pain resolves over time, so interventions that focus on relief of symptoms and allow the body to heal are ideal. [What about getting to the cause of the problem?] Many of these can be nonpharmacological in nature, like the work done by chiropractors or physical therapists. [Again, no mention of the mechanical nature of most LBP—VSC or JCD]

Physicians are traditionally wary of spinal manipulation (applying pressure on bones and joints [how crude is his description?]), in part because the practitioners are often not doctors [DCs are doctors, just not MDs, that he knows very well] and also because a few chiropractors have claimed they can address conditions that have little to do with the spine. [Will someone please explain neurophysiology to this man?] Patients with back pain haven’t seemed as skeptical [go figure]. A large survey of them from 2002 through 2008 found that more than 30 percent sought chiropractic care, significantly more than those who sought massage, acupuncture or homeopathy.

Researchers have been looking at the evidence supporting spinal manipulation for some time. Almost 35 years ago, a systematic review evaluated [He mistakenly cites the recent Deyo editorial that I also reviewed; perhaps he means the New Zealand Inquiry] the available research, most of which was judged to be low in quality, and found that there might be some short-term benefits from the procedure. Two reviews from 2003 agreed for the most part, finding that spinal manipulation worked better than a “sham procedure”, or placebo, but no better or worse than other options. [Why no mention of the AHCPR—the most thorough review yet or the New Zealand Inquiry—more evidence of his ignorance on this topic.]

Almost a decade later, a Cochrane review assessed the literature once more, and found 12 new trials had been conducted. This review was more damning. It found that spinal manipulation was no better than sham interventions. [It was also ignored by the major researchers as a skewed review.]

But since then, data have accumulated, as more higher-quality studies have been performed. Recently, in The Journal of the American Medical Association, researchers looked for new studies since 2011, as well as those that had been performed before.

The evidence from 15 randomized controlled trials, which included more than 1,700 patients, showed that spinal manipulation caused an improvement in pain of about 10 points on a 100-point scale. The evidence from 12 randomized controlled trials — which overlapped, but not completely with the other trials — of almost 1,400 patients showed that spinal manipulation also resulted in improvements in function.

In February, in Annals of Internal Medicine, another systematic review of nonpharmacologic therapies generally agreed with the other recent trials. Based upon this review, and other evidence, the American College of Physicians released new clinical practice guidelines for the noninvasive treatment of subacute back pain. They recommended that patients should try heat, massage, acupuncture or spinal manipulation as first-line therapies.

The only things that might detract from the use of spinal manipulation in this situation would be its cost [he means insurance coverage, not cost since DCs are cheap compared to PTs and MD treatments] and potential harms [again, he fails to inform the adverse effects of SMT are 1 in 5.85 million compared to 1 in 2500 per million for medical spine care].

Because they fear those potential harms, some physicians are hesitant to refer patients to chiropractors or physical therapists for care.[Yet medical care is the third-largest cause of death among Americans, but MDs have no qualms about their own methods.] But in all the studies summarized above, there were really no serious adverse events reported. It’s possible to find anecdotes of harm to the spinal cord from improper manipulations [or pre-existing injuries as with the Katie May accident], but these are rare, and almost never involve the lower spine. [Even cervical accidents are rare at 1 in 5.85 million]

Some physicians are concerned about the cost of spinal manipulation, especially since most insurance carriers don’t cover it [Where are his stats on this? In fact, laws call for coverage, but perverse ins. companies in TRICARE and worker’s comp boycott chiro care]. Visiting a chiropractor costs more than taking many non-narcotic pain medications. [Plus, SMT doesn’t destroy your liver, stomach, intestines or heart] But more invasive interventions can cost a lot of money [no shit!]. In addition, studies have shown that, in general, users of complementary and alternative medicine spend less over all for back pain than users of only traditional medicine.

Medication and surgery can also lead to harms. We shouldn’t forget that prescription pain medications, like opioids, can lead to huge costs, especially when they’re misused. [He finally fesses up to the dangers of medical spine care]

Some physicians are uncomfortable that we don’t have a clear picture of how spinal manipulation actually works to reduce pain. [If they feel “uncomfortable”, why don’t they attend a chiro seminar; his admission also shows their inept education in MSDs] It’s also possible that some chiropractors do it “better” than others, and we can’t tell. [This is too true, especially with classic vs. instrument adjustments.] This concern should be tempered by the fact that we don’t have a great understanding of why many other therapies work either. Some of the more traditional things we recommend don’t even work consistently. [Again, he admits to medical ineptness on MSDs. Why doesn’t he fully admit that patients with LBP should go directly to DCs as the primary spine care providers, which would have been the most honest admission of all!]

Still, there is no merit to many other claims about spinal manipulation [Okay, just prove it] — that it has been proved to work for things like infantile colic, painful periods, asthma, gastrointestinal problems, and more. For most conditions, the therapy lacks a good evidence base. [Apparently his bias ends with Type O disorders.]

But given the natural course of back pain — that most of it goes away no matter what you do [only to make an acute problem into a chronic problem that degenerates through time] — the ideal approach [wrong; the medical approach] is to treat the symptoms and let the body heal. Noninvasive therapies seem to do that well enough. [Again, his ignorance about what we do shines through with another curious remark.]

Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine who blogs on health research and policy at The Incidental Economist and makes videos at Healthcare Triage. Follow him on Twitter at @aaronecarroll.

As you can read, although Dr. Carroll is well-intentioned, his own bias and ignorance about spine care comes through loudly, just as we read in Rick Deyo’s editorial in JAMA.

On one hand, it’s a step in the right direction, but both Drs. Carroll and Deyo needed assistance from a chiropractor to make their articles more accurate and ‘fair and balanced.’



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