in Spine Care
“Opioids do not kill pain. They kill people.”
Donald Teater, MD, National Safety Council[i]
Although many may take offense to his comment, history is replete with real examples how the media has been no friend to the chiropractic profession since the days of Morris Fishbein and columnist Ann Landers to the present medical bloggers and online trolls at Forbes.com who impugn our reputation with “fake news” and spurious allegations.
While many may disagree with President Trump about the role of the media in our democratic society, a case can easily be made the press has rarely, if ever, offered a positive, in-depth, “fair and balanced” article about the benefits chiropractors bring to an ailing society where back pain is the leading disability in our nation.
Indeed, our third-largest physician-level health profession in the world remains missing in the media; if not fake news, it definitely is “media myopia.”
Without a doubt, we are the proverbial “elephant in the news room” that goes unseen unless something bad happens, then it goes viral around the world in a matter of a few days in the lame-stream media such as we witnessed with the Katie May accident or the Witch Hunt Down Under.
Compounding these instances are the truly embarrassing stories such as Sydney chiropractor Hance Limboro fined $27,500 for cancer cure advertisements or Wichita chiropractor Daniel Dopps and his “Mensez” adhesive “lipstick” he wants women to use to contain menstrual flow.
We just never get a break in the media to tell our good news.
It’s time to clear the air about the benefits chiropractors bring to the plate and there’s no better time than at the National Press Club session featuring the F4CP’s National Campaign, “Save Lives. Stop Opioid Abuse. Choose Chiropractic,” on Tuesday, March 14, 2017, 3:00 – 4:15 PM.
Hopefully the National Press Club (NPC) session is a breakthrough moment for our profession. If you are unable to attend this press conference, there will be a live webcast of the event. You can register to watch the press briefing at http://www.f4cp.com/pressclub2017/.
This NPC meeting could not have come at a better time with the recent news release by the American College of Physicians (ACP) on the management of back pain that emphasizes nondrug care. This is truly a serendipitous event for the chiropractic profession and may be the foot in the door to open up a broader discussion about the role the chiropractic profession can play in reducing opioid usage, lowering costs, and improving outcomes for the pandemic of back pain.
For those out of the media loop, on February 14, 2017, the ACP released its Clinical Guidelines in the Annals of Internal Medicine, “Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians.”[iii]
The American College of Physicians is the largest medical specialty organization in the United States. ACP members include 148,000 internal medicine physicians (internists), related sub-specialists, and medical students.
The current recommendations for treating low back pain are not much different than the 2007 recommendations orchestrated by Dr. Roger Chou published in “Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society.”
This new ACP study immediately went viral but, in most cases, failed to mention chiropractic care by name or SMT as the leading treatment. Here are a few examples:
- “No Drugs for Back Pain, New Guidelines Say: The American College of Physicians says to use natural and alternative therapies first.” The Wall Street Journal[iv]
- “Doctors Have Been Treating Lower Back Pain All Wrong: New guidelines champion alternative treatments over drugs.” The Huffington Post[v]
- American College of Physicians issues guideline for treating nonradicular low back pain: Treatment recommendations include massage, acupuncture, spinal manipulation, tai chi, and yoga.” ACP News Release[vi]
- “New low back pain guidelines recommend drug-free treatments first,” Managed Health Care Connect.[vii]
- “Doctors finally admit drugs can’t fix most cases of back pain. The American College of Physicians now recommends heat therapy and yoga ahead of pain meds for low back pain.” VOX.com[viii]
Even with these viral articles touting nondrug care, chiropractic was still slighted. For example, while “heat therapy and yoga” are highlighted in the VOX.com article, chiropractic care is given short shrift once again:
For chronic back pain, exercise, rehabilitation therapy, acupuncture, and mindfulness-based stress reduction have the best evidence for effectiveness. After that, yoga, tai chi, motor control exercises, low-level laser therapy, cognitive behavioral therapy, and spinal manipulation can help — but the data backing these treatments is also not that strong.
Again, none of these are particularly outstanding solutions — not even chiropractic treatment.
So Dr. Roger Chou summed it up this way: Exercise should generally be the first-line therapy for chronic low back pain. “[Passive] therapies like spinal manipulation and acupuncture … should be used in conjunction with more ‘active’ therapies like [exercise, psychological therapies, yoga, mindfulness based stress reduction],” he added.
This may be a frustratingly vague answer, but maybe it’s also liberating: With no magic pill, consider heat therapy and exercises first, and then maybe move on to other interventions, like massage, and find the ones you like. And do it soon.[ix]
I could speak at length about the nonsense in this VOX.com article, but the writer, Julia Belluz, is correct about a “frustratingly vague answer” with her comment to “consider heat therapy and exercises first and then maybe move on to other interventions, like massage.”
Inexplicably the writer also states, “Again, none of these are particularly outstanding solutions — not even chiropractic treatment.”
Just where is the proof these minor therapies are superior to SMT? I have not read of such support in the AHCPR study[x], Manga[xi], Optum[xii], NASS[xiii], DoD[xiv] or any of the reputable comparative studies over the past decades.
Foremost the writer mischaracterized the supportive research about spinal manipulation while enhancing minor therapies like yoga, heat, tai chi, motor control exercises, low-level laser therapy, and cognitive behavioral therapy. While these may be helpful secondary treatments, they certainly will not correct subluxations, restore normal joint play or stabilize a weakened spine, the main problems of mechanical LBP.
Indeed, give me a break!
Now you see why I agree with Trump that the “media is the enemy of the American people” in regards to the chiropractic profession over the years.
After a century of offering nondrug spine care, isn’t it time we DCs were given credit by the press for being knowledgeable about this pandemic of back pain since that is the bulk of our patient cases and DCs do 94% of all spinal manipulation according to RAND?[xv]
Apparently the media on its own volition will not give us any credit, so our only tactic now is to publicly stake our claim as America’s primary nondrug spine care providers and there’s no better place to do that than at the NPC-F4CP press conference.
If anything is to stick in the minds of the NPC members concerning chiropractic care, there must be something more than just the opioid epidemic that is now old news since the release of the CDC guideline last year embellished this issue. [xvi]
A more titillating claim that will stick at the NPC meeting is that the chiropractic profession should demand after the ACP guidelines it is now incumbent upon MDs to refer these chronic pain cases to chiropractors, just as they ought to refer someone with dental issues to dentists.
This is a perfectly reasonable request considering the present opioid situation and the LBP epidemic are both physician-driven problems with the aid of Big Pharma, of course.
Indeed, we are years ahead of this ACP Guideline, but without a national voice, no one knows it. Unfortunately, due to the on-going boycott of chiropractic in the press, most people are totally unaware of our achievements, what we do, and how this opioid pandemic could have been decreased greatly if DCs were known as America’s primary nondrug spine care providers.
We need to transform the press corps with solid information—our transformative “alternative facts” to the medical facts—just as we do with skeptical patients in order to achieve an “ah-ha” moment when they finally understand the madness behind our methods.
Change Providers, Change Results
With the ACP news release and CDC study in mind, the NPC meeting would be the opportune time for the chiropractic profession to lay claim as America’s best nondrug spine care providers, which we have been in effect for over a century.
The ACP news release about drugs for back pain was a shot across the bow of the medical profession, and it is past time to shoot a few more broadsides with the help of medical experts.
Foremost, little does the public realize the incompetence of MDs and the ineffectiveness of medical spine care treatments has led to this opioid crisis. It is incumbent upon us to inform the press and public of this state of affairs of medical incompetence, misdiagnosis and mistreatments.
One thing is certain: prejudice, politics, and profit drive spine care in the U.S., not evidence-based guidelines, “best practices,” or doing what is best for patients, which explains why medical spine care has been deemed a “national scandal” by Mr. Mark Schoene, the 25-year editor of The BackLetter, a leading spine journal, who admits it “is bringing the United States disrespect internationally.”[xvii]
While this may be too confrontational for many, it is imperative to challenge the medical status quo if we are to win this war of words in the media. Never before have we had this opportunity.
In fact, medical incompetence with MSDs is not a new revelation, just not known by the public and never spoken in the media.
A study often cited by attorney George McAndrews with his “admissions against interest” strategy is the 2012 investigation performed at the Department of Orthopaedic Surgery by Nathan W. Skelley, MD, et al., at The Johns Hopkins University, Medical Student Musculoskeletal Education: An Institutional Survey.[xviii]
This investigation found the “inadequate” formal education by medical students on MSDs, and I might add this includes a lack of education on alternative and complementary methods that the ACP now recommends:
In the United States, musculoskeletal disorders represent the most common health complaints, accounting for more than 130 million physician visits and 10% to 28% of all primary care visits each year and costing approximately $850 billion a year. These costs account for a substantial portion of the country’s health-care expenditures.
Despite these facts, our own institution has had no required medical student musculoskeletal clerkship rotation or elective for several decades, and a landmark study in 2003 by DiCaprio et al.[xix] found that only 20% of allopathic medical schools in the United States had a dedicated musculoskeletal clerkship, making the quality of musculoskeletal training for medical school graduates inadequate.
This discrepancy appears to persist beyond the training years and into the realm of clinical practice. In a survey of family care physicians, 51% said that they had insufficient training to address musculoskeletal issues, which may be related to the fact that 56% of the respondents stated that medical school was their only source for formal musculoskeletal instruction. This issue is also prevalent outside the United States. Canadian family medicine practitioners stated that 27.4% of their practice involved musculoskeletal disorders.
The “inadequate” training of MDs has led to this epidemic of opioid abuse and the high costs of MSDs cases that “represent the most common health complaints, accounting for more than 130 million physician visits and 10% to 28% of all primary care visits each year and costing approximately $850 billion a year.”
Imagine if the majority of these 130 million visits were seen by DCs instead of MDs what an impact that would make to reduce costs, improve outcomes and increase our market share. The medical profession failed in this War on Chronic Pain, so it’s time for DCs to step up to salvage this dire situation.
Considering the issue of back pain affects nearly everyone sometime in their life and has become the #1 disabling condition in the nation, military, workplace, and the world, this huge issue remains a quandary because the public remains unaware their local family MD is a part of this problem, not the solution.
Dr. Tom Frieden, director of the CDC also admits this lack of training accounts for the poor outcomes. “The prescription overdose epidemic is doctor-driven. It can be reversed in part by doctors’ actions.”[xx]
Certainly one action to reverse this problem is to consider referring spine-related disorders patients to chiropractors who are the leading nondrug primary care providers for neck and low back disorders.
Dr. Scott Boden, director of the Spine Center at Emory University, also agrees most primary care physicians are inept on MSD. “Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders.”[xxi]
The National Pain Strategy also mentioned MDs are ill-prepared to manage chronic pain:
“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.”[xxii]
Mark Schoene also makes the case primary care medical practitioners are actually dangerous to patients:
“One can make the argument that the most perilous setting for the treatment of low back pain in the United States is currently the offices of primary care medical practitioners—primary care MDs.” [xxiii]
Mr. Schoene also mentiones the irony to use MDs as the primary care physicians for chronic pain as many guidelines still recommend:
“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 history of modern medicine capable of leading the way forward? That remains to be seen.”[xxiv]
Mr. Schoene is not alone in his skepticism.
Richard Deyo, MD, MPH, agrees: “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.”[xxv]
Those “outdated ideas” include epidural steroid injections and disc fusions among many spine interventions commonly used but unsupported by research.
End of Part One
Stay tuned for Part Two: Bad Poster Child
[i] Da Hee Han, PharmD, “Survey Finds Most Doctors Prescribe Opioids for Longer Than CDC Advises,” MPR Daily Dose, March 28, 2016
[x] S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.
[xi] Manga P, et al. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain. Ontario Ministry of Health, 1993.
[xii] Optum. Conservative Care: Ensuring the Right Provider for the Right Treatment, 2012.
[xiii] Freeman MD, Mayer JM. NASS contemporary concepts in spine care: spinal manipulation therapy for acute low back pain. The Spine Journal, October 2010:918-940
[xiv] Chiropractic Care Study, Senate Report 110-335 accompanying the National Defense Authorization Act for FY 2009; letter sent to Congressmen by Ellen P. Embrey, Deputy Assistant Secretary of Defense (September 22, 2009):2.
[xv] Paul G. Shekelle, Alan H. Adams, Mark R. Chassin, Eric Hurwitz, Rolla Edward Park, Reed B. Phillips, Robert H. Brook, The Appropriateness of Spinal Manipulation for Low-Back Pain;Indications and Ratings by an All-Chiropractic Expert Panel, RAND, 1992
[xvii] US Spine Care System in a State of Continuing Decline?, The BACKLetter, vol. 28, #10, 2012, pp.1
[xix] DiCaprio MR, Covey A, Bernstein J. Curricular requirements for musculoskeletal medicine in American medical schools. J Bone Joint Surg Am. 2003 Mar;85-A(3): 565-7.
[xxi] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28 (2003):524-525.
[xxii] http://iom.nationalacademies.org/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx, pp.5.
[xxiii] Why Should the National Pain Strategy Be MD-Centric? BackLetter: February 2016 – Volume 31 – Issue 2 – p 16
[xxiv] Why Should the National Pain Strategy Be MD-Centric? BackLetter: February 2016 – Volume 31 – Issue 2 – p 16
[xxv] Deyo, RA. Low -back pain, Scientific American, pp. 49-53, August 1998.