The recent LBP review by The Lancet, Low back pain: a call for action, mentioned much of the American spine community remains stuck in “widespread misconceptions” and “outdated models of care and the widespread use of ineffective and harmful care.”
Of course, “widespread misconceptions” includes 1) chirophobia and 2) the fallacy of degenerative disks as a reason for spine fusions. These are two topics the F4CP and the ACA should have jumped on in a massive PR campaign to confront these issues to stop the tsunami of unnecessary disk fusions.
As a chiropractor practicing for nearly 40 years now, by far the main sales pitch for spine fusions I’ve heard is the “bone on bone” diagnosis.
“My doctor says I have ‘bone on bone’ and if I don’t have surgery, I could become paralyzed. He showed me on the x-ray that I have degenerative disc disease,” as if it were an infection that needed to be excised.
Recently I saw a 75-year old patient who has had 3 back fusions. She had no trauma, fractures, cancer or any other Red Flag; as she told me, she was just “all stove up” (stiff and sore) as they say Down South. Take a look at her lumbar spine to see what a mess they made of her. Of course, she’s hurting more now than before the surgeries.
As we can see on this AP Lumbar view, she has a short left leg with a tilted sacrum. It also appears she has a subluxation between L3/4. Her Lateral Lumbar view showed little DDD above the surgical site.
This “bone on bone” misconception must be exposed for what it is as the debunked ‘bad disc’ fallacy. I have a brochure with this Mayo chart to share with new patients who have had a fusion or those who are thinking of having spine surgery. If you’re interested, see the attachment.
What the surgeon never tells his victim is that “bad discs” appear in pain-free people as this Mayo chart shows:
I showed this Mayo chart to this little old lady with 3 failed back surgeries. I pointed out at her age of 75 years old, there is a 93% chance of “bone on bone” disk degeneration, but these patients were asymptomatic!
Her pain was most likely due to lumbar subluxation / joint dysfunction due to misalignment and compression from too much sitting, but not because of her ‘bad discs.’ Plus, she has never had chiropractic adjustments, which to me is equivalent to someone who’s never seen a dentist by her age.
For spine surgeons to use “bone on bone” as a diagnosis is sheer tomfoolery and a deception, but an effective sales pitch, just as we see with the Laser Spine Institute TV ads.
When I asked why she didn’t see a chiropractor beforehand, I heard the typical chirophobic comment from her MD that a chiropractor might hurt her. She was scared to death to be “cracked,” as she said.
“But ma’am, you weren’t afraid of having 3 back surgeries?”
It’s amazing how powerful the fear of chiropractic adjustments has been implanted by the unethical medical curmudgeons, and she’s a good example of a victim of chirophobia.
This is another example of the “widespread misconceptions” we need to confront rather than avoid if we are to increase our market share.
As for those patients like her frightened to be adjusted, I also share with them this Gallup-Palmer chart showing the relative danger of different spine treatments. In fact, there is a greater chance of paralysis if they have medical treatments than chiropractic care:
Sadly, this valuable information will never reach the public as it should to stem the tide of disk fusions as we now see with the Laser Spine Institute TV ads, another marketing scam similar to the My Pillow scam.
If you’re as tired as I am seeing this widespread misconceptions and outdated models of care promoted daily on television, you might share with your patients this information on Bad Disk Scam.
Minimal Mass Media
What struck me most about the media reaction to The Lancet review was how quickly it passed without much discussion. This medically-made worldwide pandemic of disabling low back pain leading to the opioid crisis caused no outrage from Sanjay Gupta at CNN, “60 Minutes” or any investigative journalist. Instead for the most part, we saw just a few short segments on the morning news programs.
The Lancet panel review on the pandemic of chronic pain was quickly gone in the blink of an eye without any significant follow-up in the media just as we witnessed with the 1994 AHCPR guidelines on acute low back pain in adults.
Aside from stating the obvious about the current opioid crisis and LBP epidemic, perhaps the lukewarm reception of The Lancet review in the media was due to the failure to answer the Big Question: How did this travesty happen? We already knew there was an opioid crisis and a worldwide disability of LBP, but the public and press are still clueless how this pandemic of pain began.
It would have been helpful if The Lancet panel had given the backstory of this LBP epidemic the world now faces caused by medical spine cartel making billions off the backs of misled naïve patients using ineffective and dangerous treatments.
Today it is clear decades of opioid painkillers, epidural steroid injections, and spinal disc fusions have failed miserably except for making the spine cartel extremely wealthy.
Regrettably the panel failed to explain the most important socio-political factor that contributed to the present state of affairs was the boycott and defamation of chiropractic. If the AMA’s illegal smear campaign had not created the medical bias against chiropractors, aka, chirophobia, undoubtedly the chiropractic profession would have taken its rightful role as POE for MSDs to prevent this scourge of opioids and LBP disability. Undeniably, chiropractic care has proven to be the best nondrug, noninvasive treatments, but this fact went unmentioned by The Lancet panel.
Poster Opioid Addict
Lancet panelist and editor of The Back Letter, Mark Schoene once described medical spine care as “the poster child of inefficient care.” [i] Actually he was being too kind in his assessment. Not only are most MDs ill-trained in musculoskeletal disorders,[ii] Mr. Schoene admits most primary care providers are dangerous:
“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. This is simply because of the high rates of opioid prescription in these settings. [iii]
Today the “poster child” has become the poster opioid addict suffering from failed back surgery, disabled from work and suffering from depression in the new Quiet Epidemic as two Princeton professors discovered.
One simply cannot comprehend why and how this LBP disaster actually developed without understanding the backstory of the medical war against chiropractors and its devastating impact upon the public by denying the best nondrug, noninvasive treatment for neck and low back pain.
This is not a new issue, just one that remains an untold story in the medically-minded and pharmaceutically-sponsored media.[iv] For example, when was the last time you’ve read an in-depth fair and balanced article about the benefits chiropractors bring to an ailing world?
At best we have seen an occasional article, but certainly not an investigative study revealing the depths of medical sabotage and political dirty tricks to undermine the use of chiropractic care that have led to the current opioid crisis and LBP disability.
It’s time to place blame where it is past due.
Short Shrift in the News
The Lancet review was mostly ignored in the mass media with a few exceptions in television news segments and newspaper articles compared to the hundreds of articles that went viral after the Playmate Katie May accident.
We witnessed the same minimal coverage last year with the release of the ACP, JAMA, and FDA guidelines on LBP when the media gave them attention only on the day of release without any follow-up discussion.
Here is a sampling of a few TV news segments in the USA:
- ABC Good Morning America: New report warns of widespread ineffectiveness of lower back pain treatments.
The GMA’s in-house MD gave the most critical account of medical spine care, but she failed to mention chiropractic care by name although she did post on screen “other treatments” including spinal manipulation.
- NBC News: “Low back pain the top cause of disability, gets wrong treatments: Poor treatment is fueling the opioid epidemic.”
Once again, chiropractic did not appear in the text, nor was spinal manipulation mentioned. Instead it offered other alternatives of lesser renown:
“Studies show what works best to treat lower back pain: physical therapy, psychological counseling, stretching, massage and other non-invasive treatments.”
However, The Lancet panel did not recommend much of what this article proposed, such as physical therapy and stretching. SMT was also not mentioned in this article; I presume chiro care falls in the category of “non-invasive treatments.” As the 3rd largest physician-level primary care profession in the world, I think we deserved better!
The following chart gives the Lancet’s recommendations.
Below in the chart are the numerous medical treatments that are generally not recommended with the warning, “inefficient evidence.” Too bad the primary care MDs were not honest to inform their patients of these recommendations and non-recommendations.
Here a more articles from other countries:
- Canada: We’re treating lower back pain all wrong. Here’s how to do it right,an interview with Dr. Doug Gross from the Department of Physical Therapy at the University of Alberta who gave his own spin on the topic:
“The only thing that has been consistently found to have any effect is exercise. A good, thorough exercise program does help to prevent low back pain.”
While exercise does help LBP, most specifically spinal core exercises instead of general exercises, no where was it written in The Lancet review or any of the other guidelines that the “only thing that has been consistently found to have any effect is exercise.” Dr. Gross seems to be stretching the truth!
Ironically, one of the Lancet panelists, Julie M. Fritz, PhD, PT, did a Randomized Clinical Trial, Early Physical Therapy vs Usual Care in Patients With Recent-Onset Low Back Pain, that found with physical therapy “the improvement was modest and did not achieve the minimum clinically important difference compared with usual care.”
Once again, we see Dr. Gross giving his limited view on the topic of LBP taken as expert wisdom when, indeed, it was only his subjective bias as a ‘blind’ PT describing the elephant of LBP.
If physiotherapist Dr. Gross were truly versed in LBP, I would have expected him to mention mechanical treatments, such as the McKenzie protocol, mobilization techniques and perhaps SMT that some PTs practice.
Unfortunately, his limited viewpoint was taken as gospel by Global News in Canada, begging the question why the news reporter instead didn’t interview the foremost Canadian DC, Don Nixdorf, who knows much more about this topic considering his body of work. Perhaps the reporter also had a bit of prevailing chirophobia?
- Australia: The Sydney Morning Heraldgave a more critical analysis of The Lancet review in Thousands of back pain sufferers given ‘harmful’ treatments[v]:
“Doctors regularly prescribe addictive opioids and potentially harmful treatments including spinal fusion surgery, despite there being little evidence these treatments work. Meanwhile, cheap treatments [chiropractic care] that do work are rarely prescribed.”[vi]
- Another critical review from Down Under was published in PN: Pharmacy News, “How Did Low Back Treatment Go So Wrong?
“Many patients told to do the exact opposite of what the evidence shows”
Too many patients with low back pain are receiving the wrong care, according to a series of Lancet papers that highlight the extent to which the condition is mistreated.
Evidence suggests that low back pain should be managed in primary care, with the first line of treatment being education and advice to keep active and at work.
However, in reality, a high proportion of patients are treated in EDs, encouraged to rest and stop work and are commonly referred for scans or surgery.
Patients are also mistakenly prescribed painkillers, including opioids, which are discouraged for low back pain.
Peter Rome, a classic chiropractor from Down Under, also put this PN article into perspective:
“Imagine that headline pinned to our profession!
“To have pushed their medical model of care questions the claim that medicine is evidence based and is hardly more than a marketing con. For medicine to survive a headline like the above says something about their political power.”
- Australia: ABC News
Once again, neither article made any mention of chiropractic care or SMT. Instead, The Australian article stated “Exercise and psychological therapy are the only things that work for most cases of chronic back pain.”
Just where is that stated in The Lancet review? Once again, we see a reporter playing loose with the facts. Certainly touting “exercise and psychological therapy” over chiropractic care is nonsense. No wonder LBP is pandemic when such advice is widespread in the media.
Undoubtedly my favorite article, The Guidelines On Low Back Pain Are Clear: Drugs And Surgery Should Be The Last Resort, published by The Conversation, May 16, 2018, was perhaps the most enlightening of all the print media accounts of The Lancet review.
This article was co-authored by Sandra Grace, Associate Professor in Osteopathy, Southern Cross University, Roger Mark Engel, Senior Lecturer, Department of Chiropractic, Macquarie University, and Subramanyam R Vemulpad, Associate Professor, Macquarie University.
They gave an accurate summary of the Lancet review and cited two articles confirming SMT was superior to standard medical care:
- Spinal high-velocity low amplitude manipulation in acute nonspecific low back pain: a double-blinded randomized controlled trial in comparison with diclofenac and placebo.
- A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain.
This article also contained a critical paper about spine surgeries:
Although the Australian press has taken a few cheap shots at chiropractors, such as the witch hunt Down Under of Melbourne pediatric chiropractor Ian Rossborough, on the other hand, the media Down Under has done much more to expose the medical spine care scandal than the American or British media.
You may recall the Medical Journal of Australia also came down hard on spine surgeries. The dire results of surgery for low back pain became evident in a 2012 study Down Under illustrating workers’ compensation in New South Wales found only 3 per cent had returned to pre-injury work duties two years after surgery. About 70 per cent were still taking strong opioids such as OxyContin in an attempt to manage their pain, suggesting these surgeries failed.
Dr. Richard Williams, orthopaedic surgeon and spokesperson for the Royal Australasian College of Surgeons, told MJA InSight that a key regulation called for a waiting period of 12 months before a spinal fusion surgery was performed, noting “Most patients will recover after these 12 months” without any surgery.
Professor Jeffrey Rosenfeld, senior neurosurgeon at the Alfred Hospital and director of the Monash Institute of Medical Engineering, also mentioned for patients who do not have clear indicators for spinal fusion surgery (the “red flags” of cancer, fracture, infections), a non-invasive multidisciplinary approach is preferable, which includes chiropractors.
“This will often give people better long-term pain outcomes than having multiple spinal surgeries.”[vii]
- United Kingdom: INDEPENDENT
Once again the newspaper article quotes a non-practitioner/ epidemiologist:
“The majority of cases of low back pain respond to simple physical and psychological therapies that keep people active and enable them to stay at work,” said Professor Rachelle Buchbinder, a rheumatologist at Monash University, Australia.
“Often, however, it is more aggressive treatments of dubious benefit that are promoted and reimbursed.”
Last and certainly least, the news release by the American Chiropractic Association was underwhelming; at worst it seems no one actually read or analyzed The Lancet review. For example, the ACA’s response seemed more focused on appeasing the medical profession than discussing the ramifications of the medical war that has led to this LBP pandemic:
FOR IMMEDIATE RELEASE: March 22, 2018
Arlington, Va. — American Chiropractic Association (ACA) Interim President N. Ray Tuck, Jr. released the following statement today in response to The Lancet’s new series of articles on low back pain, published yesterday, which includes a call to action for greater awareness and better approaches to this growing global problem:
“The American Chiropractic Association (ACA) commends The Lancet for bringing attention to the growing global problem of low back pain. ACA supports an individual, patient-centered and multi-faceted approach to low back pain treatment. We believe patients across the world would benefit tremendously if health care professionals work more collaboratively to identify individuals who could benefit from conservative forms of pain management, such as chiropractic services, before turning to higher-risk options such as opioids and surgery. The chiropractic profession stands ready to work together with medical colleagues and health care agencies to address low back pain, which causes not only tremendous physical suffering and disability, but also massive financial costs and loss of human potential.”
As I mentioned, it appears no one at the ACA read with a fine tooth comb the Lancet review to understand how superficial it actually was. One obvious question missing in all these reports was how this pandemic of LBP and opioid crisis originally developed due to the illegal boycott and defamation of chiropractic by the sinister AMA who now the ACA wants to jump into bed with. Can’t we at least get an apology first?
The ACA should have touted the missing elephant in the history of LBP: if the medical boycott and defamation of chiropractic had never occurred and if DCs were rightfully situated as the POE for LBP and all MSDs, the opioid crisis would never have occurred nor would the rash of epidurals and spine surgeries. There would not be a worldwide disabling LBP crisis today if DCs were given equal access in every healthcare system without medical meddling.
Just when will someone in our leadership admit this sordid affair? Does anyone have a backbone or is the new tactic simply one of appeasement?
That was the scoop missed by both The Lancet panel and the ACA that would have stirred the media pot to gain more attention with disruptive journalism. Instead of lukewarm headlines, we might have seen a few positive articles, such as:
In my next commentary, Medical Titanic, I will discuss the core issues that escaped discussion. As the great ship was sinking, someone had to ask how did the Medical Titanic get so off course to create the present medical crisis of prescription opioids, failed back surgery, and LBP disability.
[i] The BACKPage editorial vol. 27, No. 11, November 2012.
[ii] EA Joy, S Van Hala, “Musculoskeletal Curricula in Medical Education– Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/11 (November 2004).
[iii] The BackLetter, volume 30, number 10, 2015
[vi] Thousands of back pain sufferers given ‘harmful’ treatments by Liam Mannix, The Sydney Morning Herald, 21 March 2018
[vii] Charlotte Mitchell, Spinal fusion surgeries questioned, MJA InSight, 26 April, 2016