Articles by JCS

Reframing Reformers

Time to Reframe the Reframers

A recent editorial in the British Journal of Sports Medicine, Is It Time To Reframe How We Care For People With Non-Traumatic Musculoskeletal Pain?, bLoadingby Jeremy Lewis and Peter O’Sullivan  seems to be a follow-up to The Lancet review by Jan Hartvigsen, et al., What Low Back Pain Is And Why We Need To Pay Attention. Both are great reads that every conscientious DC will enjoy.


The new article is quite clear:

The current approach to musculoskeletal pain is failing: The majority of persistent non-traumatic musculoskeletal pain disorders do not have a pathoanatomical diagnosis that adequately explains the individual’s pain experience and disability.”

While this is very true evident by the Mayo Clinic systematic review finding “bad disks” in pain-free people, the authors Lewis and O’Sullivan failed to mention pathophysiological issues at play, such as the classic chiropractic concept of vertebral subluxation, aka, “joint dysfunction” as John McMillan Mennell described this functional problem in many spine disorders.

It always astounds me when spine researchers ignore the spine anatomy itself as a clue to chronic back pain, such as the numerous  joints in the spine. It seems these medical authors fail to keep in mind the spine is a precarious weight-bearing pillar of 364 joints interlocking 24 vertebrae interconnected by 23 cartilaginous disks that act as shock absorbers. This joint total includes all synovial, symphysis and syndesmosis joints according to Gregory D. Cramer, DC, PhD, Dean of Research at National University of Health Sciences.[1]

They seem clueless to understand how the spine functions is the key to spine health. Only lately have they admitted how the spine looks, e.g., “bad disk,” on imaging is not the problem, but they seem blind to the concepts of spinal alignment, core strength, joint flexibility, and axial compression as the 4 cornerstones of good spinal health.

This is similar to the Lancet review that spoke of “widespread misconceptions” in medical spine care. Obviously since the medical spine professionals seem unaware of pathophysiology, they are clueless how to treat this disability evident by their poor outcomes:

Contemporary evidence demonstrates that many musculoskeletal pain conditions are associated with long term disability that are often resistant to current treatments

In the management of these conditions, the focus is not on providing a ‘cure’ but rather the discussion is about providing a ‘management’ plan to control the disorder and limit its impact on the person’s well-being. While the signs and symptoms of many of these chronic problems may reduce to the level that the individual no longer feels disabled or symptomatic, ongoing self-management is essential.

 

Hallelujah! I agree a “management plan” is needed, but such overtures are often chided even by some chiropractors who rail at the concept of spinal maintenance care. They ignored the studies that have shown the value of regular chiropractic care:

·        Descarreaux M, Blouin JS, Drolet M, Papadimitriou S, Teasdale N.    Efficacy of preventative spinal manipulation for chronic low back pain and related disabilities: a preliminary study. J Manipulative Physiol Ther 2004;27(8):509-14.

·       Senna MK, Machaly SA.  

Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome? Spine (Phila Pa 1976) 2011;36(10);1427-37.

 

Of course, these are the same naysayers who gaslight the concept of vertebral subluxation while never offering their own explanation for the chronicity of LBP. Some have made a career denouncing classic chiropractic adjustments in their myopic crawl to infamy. Sadly, some are in leadership roles in national associations and teaching positions in chiro colleges.

Authors Lewis and O’Sullivan, both physiotherapists, suggest “A new approach is needed,” but they too cannot offer such an approach although they certainly feel capable of casting ridicule at chiropractors:

Reframed in this manner, patients would no longer be led to expect a ‘magic’ manipulation or other passive approach to ‘cure’ their condition, and this in turn may reduce stress and burnout experienced by many clinicians who are unable to deliver on such unsubstantiated promises.

As a 40-year chiropractic practitioner myself, my “magic” manipulations have worked well on the vast majority of patients and I certainly am not stressed or suffer burnout as are many medical clinicians who persist in using drugs, shots, and surgeries or PTs who live by ineffective modalities or “other passive approaches to ‘cure’ their condition.” If Lewis and O’Sullivan disagree with my sentiments, let’s check the evidence.


Numerous recent comparative studies have also found the clinical and cost-effectiveness of chiropractic care compared to medical care and physiotherapy:

·   1995: The Outcomes and Costs of Care for Acute Low Back Pain among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons, the mean cost of a chiropractor was $783 per case.[2] Aside from the cost, chiropractors rated much higher than the primary care providers, HMO providers (physical therapists), and orthopedists in both Satisfaction of Care and Perception of Care:

·   2011: Health maintenance care in work-related low back pain and its association with disability recurrence found that chiropractic actually helps patients return to work quicker than traditional medical or physical therapy care as well as avoid future episodes of back pain.[3]

The mean average duration of disability days for the physician group was 119 versus 58 for the physical therapy group and 49 for the chiropractic group.

The researchers also followed the period after the initial episode of back pain and found chiropractic patients were less prone to relapse compared to patients in the physician and physical therapy groups. 16.9% of physical therapy patients had recurring disability versus 12.5% of physician patients and just 6.2% of chiropractic patients.

The researchers suggest part of the reason with the success of chiropractic could lie in preventing patients from receiving treatments of “unproven cost utility or dubious efficacy” from medical or PT providers.

·   2011: Health maintenance care in work-related low back pain and its association with disability recurrence found that chiropractic actually helps patients return to work quicker than traditional medical or physical therapy care as well as avoid future episodes of back pain.[4]

The mean average duration of disability days for the physician group was 119 versus 58 for the physical therapy group and 49 for the chiropractic group.

 

As the research shows, chiropractors prevail well in head to head comparisons with MDs and PTs, so it is understandable why Lewis and O’Sullivan may have a bias against DCs with their “magic manipulation” slur. Indeed, it is magical to many patients, thank you very much.

As many principled DCs experience, I’m having too much fun teaching patients how to take care of their spines for a lifetime—not only with magic manipulations but plenty of daily self-care exercises,  regular SMT, massage therapy, and positive thinking!

Lewis and O’Sullivan also noted a few appropriate worries about medical acceptance, implementation and patient expectations:

There would be many obstacles to overcome and respect when considering such an approach. For clinicians, these might be pain beliefs, professional identity, time, financial pressures and lack of adequate training. Patient beliefs and expectations may also pose a significant challenge for clinicians, especially when they desire a structural diagnosis and a ‘fix’ for their pain. For patients, creating an understanding and expectation that, as with other chronic health conditions, there is no magic cure for many persistent and disabling musculoskeletal pain conditions, and that ultimately ongoing evidence informed self-management is the key.

This comment is painfully true and reminiscent of similar comments from The Lancet review made by panelists unaware of what classic chiropractors actually do since there were no classic chiropractors in its 31 member panel.

Indeed, the holistic treatment of LBP is not new territory for DCs, at least those practicing in the USA. Our ancestors have already explored the issue of spine care and have created effective treatment plans for both acute and chronic care.

The Lancet review also noted the “vested interests” in spine care has a barrier to progress:

The global challenge is to prevent the use of practices that are harmful or wasteful while ensuring equitable access to effective and affordable health care for those who need it.

Protection of the public from unproven or harmful approaches to managing low back pain requires that governments and health-care leaders tackle entrenched and counterproductive reimbursement strategies, vested interests, and financial and professional incentives that maintain the status quo.

The observations by The Lancet indeed describe perverse motivations behind the present mess in medical spine care. Until a Chiro Wave can drain the medical swamp of these predators, little will change.

Their fortitude to keep this healing art alive during the medical war to “contain and eliminate chiropractic” has led to a new wave of appreciation for this timeless remedy to the scourge of LBP:

Such accolades include:

·        1997: The U.S. Public Health Service published another study, “Chiropractic in the United States: Training, Practice and Research,” admitting “chiropractic has undergone a remarkable transformation” as well as other very positive conclusions:

Spinal manipulation and the profession most closely associated with its use, chiropractic, have gained legitimacy within the United States health care system that until very recently seemed unimaginable.

In the past several decades, chiropractic has undergone a remarkable transformation. Labeled an ‘unscientific cult’ by organized medicine as little as 20 years ago, chiropractic is now recognized as the principal source of one of the few treatments recommended by national evidence-based guidelines for the treatment of low-back pain, spinal manipulation. In the areas of training, practice, and research, chiropractic has emerged from the periphery of the health care system and is playing an increasingly important role in discussions of health care policy.

·   2007: The American College of Physicians and the American Pain Society published Joint Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain that concluded:

Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation. [5]

·   2010: the NASS released “Contemporary Concepts in Spine Care: Spinal Manipulation Therapy for Acute Low Back Pain” recommending spinal manipulation: Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, and should be considered before surgery.

·   2012: the NASS published “Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Lumbar Disk Herniation with Radiculopathy” that found:

“…patients with lumbar radiculopathy due to lumbar disk herniation, 60% will benefit  from  spinal  manipulation  to  the  same  degree  as  if  they  undergo surgical intervention. For the 40% that are unsatisfied, surgery provides an excellent outcome.”

As Anthony Rosner PhD, testified before The Institute of Medicine: Committee on Use of CAM by the American Public on February 27, 2003:

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.”[6]

I also wholeheartedly agree with Jeremy Lewis and Peter O’Sullivan when they admit medical spine care is a bust:

We contend this requires those of us working in the musculoskeletal field to acknowledge the limitations of current surgical and non-surgical interventions for persistent and disabling non-traumatic presentations

Indeed, this is the rub—how to change medical spine care when it is perpetrating the leading “widespread misconceptions” and the medical profession remains the dominant force in the market place.

Spine practitioners know their methods are ineffective, dangerous and deadly. After all, these are the same culprits who brought the world the opioid (medicinal heroin) crisis and who have left a wake of disability behind their many unnecessary spine surgeries.

They will never acknowledge their own limitations of surgical or pharmaceutical interventions—there is simple too much money and too much pride at stake.

The present strategy by the American Chiropractic Association and other medical-friendly groups is nothing less than capitulation to the enemy of the people in pain who fall for their widespread misconceptions. The false “bone-on-bone” diagnosis for fusion is the biggest scam in medicine, but not once has the ACA spoken out to warn the public. In fact, the ACA is now sponsored by the Laser Spine Institute—talk about sleeping with the enemy!

Instead of cozying up to these medical marauders, it’s past time to create a Chiro Wave similar to the Blue Wave we recently saw in the mid-term elections in the US. It’s time to drain the swamp of medical alligators.

It’s past time to expose this medical corruption in the media with the medical trolls. It’s past time to go on the offensive with articulate disruptive journalism and courageous speakers rather than leadership preferring to kiss medical butt as we now see.

It’s time to throw out the chiropractic leadership who criticize our legendary philosophy and methods that have worked so well over the past century. It’s past time to rebuke the medical wannabees who wish to prescribe meds, who have nothing to do with natural healing, and who want to collude with the enemy who has created the present medical mess.

It’s time for a Chiro Wave to undo the mess of the medical vested interests who have exploited mankind long enough over this worldwide disability of LBP that we treat so well without drugs, shots, or surgery.

The call for a paradigm shift in spine care is louder now than ever before due to the scourge of opioid painkillers, the cost of medical spine care, and the “disastrous effects of damaging medical intervention” as The Lance review stated.

Millions of people across the world are getting the wrong care for low back pain,” according to lead author of The Lancet review, Professor Jan Hartvigsen from the University of Southern Denmark.

His sentiments coincide with Lewis and O’Sullivan when he said the world is still afflicted with the “outdated models of care” principally due to the lack of governmental oversight over the omnipotent medical profession in order to “protect the public from unproven or harmful approaches to managing low back pain” with the implementation of research evidence-based guidelines.

The leading political issue with bipartisan support in our nation surrounds the high expense and poor outcomes plaguing American healthcare. Healthcare costs are astronomical today and, if the trend continues, many believe it will certainly bankrupt this country.

In 2009, President Barack Obama said, “If we do not fix our health care system, America may go the way of General Motors; paying more, getting less, and going broke.”[7]

At the top of the list of low-value medical care is medical spine care consisting of opioid painkillers, epidural steroid injections, and spine fusion surgery now considered “outdated medical models” by leading researchers.

Standard medical spine treatments have been deemed the “poster child of inefficient care” [8] by Mark Schoene, the editor of The BACKLetter, a leading international spine journal. [9] He also mentioned:

"The world of spinal medicine, unfortunately, is producing patients with failed back surgery syndrome at an alarming rate…Despite a steady stream of technological innovations over the past 15 years—from pedical screws to fusion cages to artificial discs—there is little evidence that patient outcomes have improved.”

He also suggests medical spine care has become a “national scandal” and “is bringing the United States disrespect internationally.”[10]

If a journal editor is willing to speak out, where our the chiropractic warriors to back him up?

If we DCs don’t carry the banner of reform, who will?

The global challenge is to prevent the use of practices that are harmful or wasteful while ensuring equitable access to effective and affordable health care for those who need it.

Indeed, what would BJ do? What would you do if you had the power? There has never been a better time to go on the offensive.

Are you as brave as our forefathers to keep up the good fight?

Just as millions of Americans voted to resist the nonsense of Trump, it’s time for brave DCs to do the same to save an entire world.

 



[1] Cramer, G.; Darby, S. 2014 Clinical anatomy of the spine, spinal cord, and ANS. 3rd Edition, Elsevier/Mosby, St. Louis, 559 illustrations, 672pp. Appendix I, pp. 638-642.

[2] Carey TS, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors and orthopedic surgeons. New England Journal of Medicine 1995:333;913-17.

[3] Cifuentes M, Willetts J, Wasiak R. Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine 2011; 53(4): 396-404. 

[4] Cifuentes M, Willetts J, Wasiak R. Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine 2011; 53(4): 396-404. 

[5]  R Chou, et al., “Diagnosis and Treatment of Low Back Pain:  A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society,” Low Back Pain Guidelines Panel, Annals of Internal Medicine 2 147/7 (October 2007):478-491

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

 

[7] Text of President Obama’s health-care speech, Jun 15, 2009, by MarketWatch

[8] The BACKPage editorial vol. 27, No. 11, November 2012.

[9] The BackLetter, vol.12, no. 7, pp.79 July, 2004. The BackPage editorial, The BackLetter, pp. 84, vol. 20, No. 7, 2005

[10] U.S. Spine Care System in a State of Continuing Decline?, The BACKLetter, vol. 28, No. 10, 2012, pp.1

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