Evidence-based Medicine vs. Best Practices Chiro Care
Over the decades, chiropractic has been divided into many factions by clinical techniques, educational orientation, and the standard “straight vs. mixer” philosophical differences.
Now we are entering a new era with conflicts arising from evidence-based medicine (EBM) vs. “best practices” care (BPC). Outwardly one might think these two factions are similar, but they have grave differences that will impact our future.
However, if the Trump administration has its way, EBM it will become less politically-correct. On December 15, 2017, the Washington Post published an article, CDC gets list of forbidden words: Fetus, transgender, diversity:
Policy analysts at the Centers for Disease Control and Prevention in Atlanta were told of the list of forbidden terms at a meeting with senior CDC officials who oversee the budget, according to an analyst who took part in the 90-minute briefing. The forbidden terms are “vulnerable,” “entitlement,” “diversity,” “transgender,” “fetus,” “evidence-based” and “science-based.”
In some instances, the analysts were given alternative phrases. Instead of “science-based” or “evidence-based,” the suggested phrase is “CDC bases its recommendations on science in consideration with community standards and wishes,” the person said.
At the top of the list of such EBM proponents are the medical trolls in the US at Science Based Medicine (SBM) and their kissing cousins Down Under —the Friends of Science in Medicine trolls—groups of medical propagandists equivalent to the medical Nazis—biased bullys and dangerous misinformers who stand behind the shield of “evidence-based” or “scientific-based” medicine to do their dirty political work to disparage chiropractic and other CAM providers.
They camouflage their political tricks with a flowery Mission statement:
Science-Based Medicine is dedicated to evaluating medical treatments and products of interest to the public in a scientific light, and promoting the highest standards and traditions of science in health care. Online information about alternative medicine is overwhelmingly credulous and uncritical, and even mainstream media and some medical schools have bought into the hype and failed to ask the hard questions. We provide a much needed “alternative” perspective — the scientific perspective.
For your information, here is a short list of the SBM trolls:
n Dr. David Gorski
n Dr. Harriett Hall
n Dr. Steve Salzburg
n Dr. Steve Novella
n Dr. Stephen Barrett
n Jann Bellamy, Esq.
n Sam Homola, DC
n Clay Jones, MD
- Dr. Ken Harvey
- Dr. John Cunningham
- Dr. Chris Pappas
- Dr. Frank Jones
Here’s an example of the SBM’s “scientific perspective;” does this sound objective to you?
In their medical war against chiropractors they proclaim the scientific-based mantra while ignoring the elephant in the room—the massive evidence from a century of great results attain with chiropractic care. Their real goal is not scientific truth, but an ideological, political, and economic dominance over all competition.
Here is the SBM response to the new FDA ruling promoting CAM:
Don’t be confused by the SBM advocates who stand behind the shield of science when, in fact, it obscures their real goals to confuse and misguide people while ignoring other evidence including the clinical results we attain and the recommendations by medical and governmental groups.
For decades chiropractors were hounded by medical SBM advocates who said our brand of care was “quackery”, “anti-scientific”, “dangerous”, and should “wither on the vine.”
At the Wilk v. AMA trial, the judge rejected the AMA’s “patient care defense” because witnesses could not confirm their derogatory claims; instead medical witnesses themselves commented on the good results chiropractors attained.
Judge Susan Getzendanner ruled against the AMA’s patient care defense:
However, the AMA failed to establish that throughout the entire period of the boycott, from 1966 to 1980, this concern [patient care] was objectively reasonable. The court reached that conclusion on the basis of extensive testimony from both witnesses for the plaintiffs and the AMA that some forms of chiropractic treatment are effective … AMA was unable to establish that during the entire period of the conspiracy its position was objectively reasonable. Finally, the court ruled that the AMA’s concern for scientific method in patient care could have been adequately satisfied in a manner less restrictive of competition and that a nationwide conspiracy to eliminate a licensed profession was not justified by the concern for scientific method. On the basis of these findings, the court concluded that the AMA had failed to establish the patient care defense.
Of course, her ruling has not dissuaded the SBM propagandists from continuing their witch hunt in the media.
Tyranny by Evidence
The SBM advocates avoid the term “best practices” where evidence-based treatments are blended with the doctor’s clinical experience and the patient’s response, two important factors that have elevated chiro care among the top treatments in the new guidelines for the LBP epidemic and opioid crisis. Indeed, empirical evidence is worth more than the baseless opinions of bigoted medical trolls.
Mark Studin, DC, FASBE(C), DAAPM, DAAMLP, Adjunct Associate Professor of Chiropractic, University of Bridgeport, stated in his paper, Evidence-Based Practice vs. Best Practice, that so-called “evidence-based” medicine is actually “a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom.”
Apparently the tyranny depends upon which evidence the perpetrators are promoting; in our case, medical tyranny has suppressed chiropractic clinical evidence for years until recently when the new guidelines were developed that catapulted chiropractic to the forefront.
Dr. Studin suggests the SBM advocates have badly mischaracterized the founders of EBM, David L. Sackett, et al., who wrote in their BMJ paper, Evidence based medicine: what it is and what it isn’t,
“It’s about integrating individual clinical expertise and the best external evidence…Without clinical expertise, practice risks becoming tyrannized by evidence.”
In other words, “best practices” constitutes more than just evidence gleaned from the scientific literature.
“Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough.
Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.”
The potential “tyranny” of these medical EBM advocates overlooks the most obvious evidence—the great clinical results chiro care has gotten over the years. Indeed, evidence is more than peer-reviewed literature.
The Frenemy is Us!
Now we see the rise of a similar EBM movement within the chiropractic profession. Currently in chiropractic there is a strong faction of EBM advocates who would drastically change the nature of chiropractic care as we now know it. They also ridicule the very chiropractic clinical methods that now rate among the “best practices” for the epidemic of pain sweeping this country.
In the past we’ve seen other chiropractic extremists such as the Orthopractors (Who Are the “Orthopractors” and What Do they Want? Exclusive interview with Murray Katz, MD, Part II). We’ve also heard of the “spinologists” and “orthotherapists” as examples of such outcasts, including the latest inexplicable offering to change the name of our profession to “vertebratrists,” (“A Name Change Will Save Our Profession,” Dynamic Chiropractic, by Michael Reuben, DC).
Aside from these fringe groups, the chiropractic profession also has its version of EBM advocates emanating from the University of Bridgeport, such as Stephen Perle and James Lehman. What are the odds this chiro college at UB has two opposing forces engaged in an ideological battle for the minds of its students considering Mark Studin is also employed there. Undoubtedly their staff meetings must be entertaining as hell.
Perle and his ilk typify critics “without clinical expertise” whose beliefs oppose the standard chiro practice that “risks becoming tyrannized by evidence” as Studin suggests. Their mantra is “evidence-based” with their assertions based more on external evidence/opinion rather than empirical and pragmatic evidence such as the doctor’s experience and patient preferences and, of course, they ignore the great results chiropractic achieves with its current practice.
Biased Cochrane Reviews
If we were to believe every so-called evidence-based report such as the 2011 Cochrane Review by SM Rubinstein, et al., Spinal manipulative therapy for chronic low-back pain, it appears every chiropractic college should close its doors to classrooms and every chiropractic office should shutter up its windows.
“In summary, SMT appears to be no better or worse than other existing therapies for patients with chronic low-back pain.
His conclusion also admitted: “Approximately two-thirds of the studies had a high risk of bias, which means we cannot be completely confident with their results.”
Considering his reviews contradict many other comparative studies starting with the extensive AHCPR study on acute low back pain in adults published in 1994, I daresay the same “high risk of bias” can be applied to his review. It’s truly amazing how his small group can come to such different conclusions than the prestigious investigators comprising the AHCPR panel, let alone the deluge of studies and guidelines published in 2017 such as the ACP, JAMA, FDA, Joint Commission, to name a few.
Rubinstein’s other Cochran Review in 2012, Spinal manipulative therapy for acute low-back pain, was just as disheartening as his review of chronic LBP:
SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies. Our evaluation is limited by the small number of studies per comparison, outcome, and time interval. Therefore, future research is likely to have an important impact on these estimates. The decision to refer patients for SMT should be based upon costs, preferences of the patients and providers, and relative safety of SMT compared to other treatment options. Future RCTs should examine specific subgroups and include an economic evaluation.
Fortunately, the Rubinstein reviews were met with mixed reviews themselves; as one prominent researcher noted, his report was not a game-changer because the “best practices” did not support his conclusions, nor did the numerous guidelines published in 2017.
According to Robert Cooperstein, M.A., D.C., Director of Research, Director of Technique, Professor, and Palmer Center for Chiropractic Research:
“The CDC seems to be stating that EBC involves patient and doc input and not just external evidence. Sackett would agree. So would I.”
On the other hand as to be expected, medical curmudgeons used Rubinstein’s reports to bash chiropractic. Indeed, the only people who touted his reviews were medical trolls like those at Science-Based Medicine and biased bloggers such as the Blog Bitch who use his skewed review to bash our good work.
This is the biggest threat of the EBM guys who ignore clinical findings in the real world. Fortunately, the real evidence lies in results with real patients, not with the limited and biased attitudes we see in the EBM world where Stephen Perle and his ilk reside.
These EBM chiro advocates also profess:
- no-maintenance care,
Many EBM advocates are also:
- pro-prescription drugs,
As you can see, adherence to this brand of EBM care would substantially change the basic nature of classic chiro care. It’s time to expose and push back on these chiro EBM advocates before they cause more damage to students and the very nature of chiropractic practice as they’ve already done in the “new” ACA.
Just imagine the transformation of our profession if Perle and his kind prevail in this battle of ideology within chiropractic. Indeed, classic chiropractic care will lose its soul if they win the hearts and minds of students and impressionable practitioners. Sadly, the EBM has apparently already won the soul of the “new” ACA.
Chiro Civil War
EBM advocates have already infiltrated the “new” ACA. Recently on the ACA Open Forum chat room Dr. Perle and his followers have pushed their tyrannical agenda with outlandish statements and, I might add, without any push-back from the ACA Executive Committee.
I responded to their statements posted online, never expecting to become a spokesman for classic chiro care. Nor did I expect to be banned from this Open Forum by the ACA Executive Committee for expressing my viewpoint.
It started with a simple statement posted by Alan Dinehart:
“My question is, how can we practice ‘evidence based medicine’ and use the subluxation codes. Chiropractic subluxation doesn’t exist, has no standard definition and has not ever been shown to cause any malady?
Alan Dinehart DC”
JCS: So, Alan, let me ask: if VSC doesn’t exist, what have thousands of DCs over the past century being detecting and correcting?
Please give me the evidence of your statement, other than your opinion or those of other authoritarian experts on this blog.
The leading EBM advocate, Stephen Perle, responded as the voice of the anti-Vertebral Subluxation Complex (VSC) faction. He is the outspoken critic of classical chiropractic care in his capacity not only as an ACA member, but as a tenured professor at University of Bridgeport and associate editor of Chiropractic & Manual Therapies.
Stephen Perle (SP) defended the notion that VSC does not exist and cannot be detected on xrays, which stunned me. I was also shocked that none of the ACA bigwigs chirped into this discussion in defense of classic chiro care. Apparently the dark side has taken over the “new” ACA.
The following are a few excerpts from this discussion:
SP: You are making the assertion the subluxation exists. Where’s your evidence?
Ergo I will not do the impossible and provide the evidence it doesn’t exist. I’ll await your evidence of the existence of a subluxation. And of course you’ll stop talking about the VSC as that is just marketing and was never contemplated by DD, BJ, Dave, or Carver or… any of our pioneers in the profession.
I’ve never seen a subluxation (except for one as Medicare describes it – which is fundamentally different than how you describe it). So please show me one. Please provide the evidence that one exists.
JCS: Stephen, I urge you to retake chiro radiography 101 to learn how to detect subluxations. If you balk at labeling these “spinal lesions” as VSC, what do you call them? Or do you teach non-specific manipulation for non-specific LBP? Indeed, how far have you watered-down the chiro analysis and treatment?
SP: Let’s see the citations to the literature not musings of a typically cherry picked marketing piece from Dr. Studin. This is a question of science not marketing.
JCS: I find your dismissal of Dr. Studin to be offensive, reflecting the authoritarian nature of your stance to shout-down anyone who disagrees with you. I find Dr. Studin’s work to be among the best in the business and certainly not a marketing ploy as you suggest.
SP: “The onus is on you to provide the evidence for your assertion that the subluxation exists. Citation please to the literature.”
JCS: Why don’t you ask the founders of chiropractic and technique gurus this question since the VSC is not my creation? Start with Solon Longworthy, BJ, Gonstead, Pettibone, Pierce-Stillwagon, to name a few.
Moreover, ask the thousands of DCs over the century who detected and corrected VSC and gotten great results.
SP: “We don’t know that any chiropractor has ever detected or corrected one. We know that chiropractors have performed spinal manipulation with positive effects on some aspect of some patients’ health.”
JCS: Again, you seem to be splitting hairs, and your lukewarm credit is shocking…”positive effects on some aspect of some patients’ health”. Call them what you want, but the fact remains DCs have been adjusting subluxations and getting great results for over a 100 years. Now you and your ilk claim no one “has ever detected or corrected one.” What gall! Maybe you haven’t, but thousands of other DCs have.
So, let me ask, what is your point? To demean traditional chiro analysis (VSC, xrays) and to put your sketchy non-specific method in place instead? Do you discredit traditional DCs like me and experts like Dr. Studin to advance your own position in our profession?
I also find your position dangerous to the profession. Undoubtedly our medical foes will quote your awkward position to undermine our credibility as experts in MSDs. Your authoritarian stance sounds eerily similar to the medical trolls online who also shout-down DCs and quote each other as experts, just as you’re doing. Instead of advancing our professional understanding of spine-related disorders and SMT, you seem to want to undermine the chiropractic approach or change it to another profession altogether, such as we’ve seen in the past with “spinologists” and “orthopractors,” or the latest offering, “vertebratrist.”
You tout no-VSC, no-xrays, no-philosophy, no-maintenance care and pro-drugs, pro-vaccines. Are you also non-SMT, non-instrument, non-acupuncture, no-dietary advice, and no-massage therapy? Just what constitutes your vision of chiropractic care?
I find your authoritarian attitude disturbing as the so-called Associate Editor of Chiropractic & Manual Therapies. Your bias is obvious and I wonder how objective you can be since you seem to be pushing your agenda rather than debating the issue in a truly academic fashion of open-mindedness.
As I quickly discovered, Perle is not open to anything a classic chiropractor might say—his EBM mind is frozen. These EBM DCs ridicule and shout down their opponents. Debate is not their goal, but derision is.
Like medical trolls at the Science-Based Medicine website, these EBM chiro trolls partake in “citation laundering” whereby writers misrepresent the issues, mischaracterize their opponents, ignore alternative facts, and embellish stories; they only quote each other, parrot incendiary comments, and pass them on as “perceived wisdom” to like-minded advocates. 
Authoritarians vs. Radicals
As luck would have it, another article appeared in Dynamic Chiropractor during the same period that shed more light on this battle of words with Dr. Perle.
Noted researcher and nutritionist, David Seaman, DC, MS, DABCN, addressed this issue in his latest article, Vaccines and Autism: A Different Perspective (Pt. 1), in which he mentions Perle by name.
Here is an excerpt where Seaman describes the two opposing groups—Authoritarians vs. Fundamentalist Radicals; as well, he offers the Objectivist point of view. Instead of the EBM vs. BPC argument, Dr. Seaman spoke of a similar conflict in the vaccine argument; he even mentioned Dr. Perle by name:
They have no patience for anyone who questions the “validity” of vaccines. They believe everyone should be vaccinated and there are absolutely no significant health concerns at all. In general, authoritarians defend “positions” of the group and have little interest in evidence. Their authority is the evidence.1
When someone questions authority, especially when it is an intolerant, elitist, establishment view, the individual is typically labeled a conspiracy theorist. Vaccine authoritarians use this type of labeling against those who are overtly, or appear to be, anti-vaxers [or pro-VSC]. Perle states that if you oppose vaccines, it is because you are one or more of the following:
The anti-vaxers strike me as fundamentalist radicals who believe vaccines are catastrophic for all and that no one should be vaccinated … ever; and that vaccines should be feared like the plague.
The outcome is that anti-vaxers appear as dogmatic as the authoritarians with the opposite position.
The Objectivist View
From my perspective, an objectivist view can lead to a position that could be reasonably favorable or unfavorable toward vaccines and vaccine policy. Tim Perenich, DC, recently wrote two articles that put forth an objectivist view, wherein he rationally presents an unfavorable view of vaccines.
As Dr. Seaman suggests, the Authoritarian viewpoint has taken the bully pulpit, which is not a position for any debate. Either you believe as Dr. Perle, or else branded a Radical Fundamentalist (or worse) and suffer the same ridicule as we’ve seen with the Science-Based Medicine trolls.
However, in this chiro EBM vs. BPC argument, there are bigger implications when Perle castigates the basic principles of classic chiropractic—the VSC and the use of xrays to detect them.
VSC: Where Art Thou?
This controversy concerning the existence of VSC is not new. As we’ve seen before, the medical curmudgeons describe VSC as imaginary because they could not detect them.
In fact, the existence of VSC was discussed at length in 1979 when the New Zealand government created a Commission of Inquiry into Chiropractic to investigate the inclusion of chiropractic care into its national healthcare.
This Commission Inquiry included David Chapman-Smith, past executive secretary of the WFC, and became the most in-depth investigation concerning the dispute about subluxation:
The problem is a functional not a structural one…the abnormal function of the spine may produce a vascular involvement as well as the neurological one… the medical profession simply fails to see the direction and subtlety of the chiropractic approach towards spinal dysfunction. Because the chiropractor uses x-ray extensively the medical practitioner thinks he is looking for a gross bony change, and when the medical practitioner cannot see this on the x-ray the chiropractor is using he immediately becomes skeptical. He might as well expect to see a limp, or a headache or any other functional problem on x-ray.
The Commission concluded the medical opposition [EBM] is “an unreasonable and unscientific stance”:
Having weighed all the evidence we accept that chiropractors are not unreasonable in believing that through their specialized training and skill they are capable of identifying and treating functional defects in the vertebral column which others without that training or skill would not regard as significant. We consider that to deny that such functional defects can exist, and can impinge on the nervous and/or vascular systems, is, in the present state of knowledge, an unreasonable and unscientific stance. The exact nature of such defects has not yet been demonstrated; nor has the mechanism by which its apparent effects are produced.
Undoubtedly chiropractors believe that there is such a condition as a chiropractic subluxation. They do so because when they apply manual therapy, supposedly to correct the subluxation, the patient’s condition in many cases improves. The fact that there is not yet any conclusive explanation of exactly what happens means nothing more than that the chiropractors’ hypothesis is so far unproven. It does not mean it is invalid.
We accept, for the purposes of this inquiry, that a chiropractor is equipped by his training and skill to locate and relieve a condition which for want of a better term he calls a subluxation, and that the result of his therapy can provide relief from, at least, back pain.
This Commission’s perspective explains the VSC argument as an Objectivist group. As the NZ Inquiry found, empirical evidence and “best practices” care wins out over the rhetoric of medical naysayers, not unlike what we hear today from Perle and his EBM fellows.
I am amazed after a century of detecting and correcting VSC with great results that evidence should be of great value, but we are now criticized from pessimists within our own profession as we see with the Authoritarian EBM advocates.
Indeed, what is their real agenda—to improve or destroy chiropractic?
Instead of developing the concept of VSC with new insights as Ted Carrick of the Carrick Institute, Scott Rosa, DC, or William Owen, DC, at SUNY Buffalo have done, they seem to be throwing the baby out with the bathwater.
Ironically, DD Palmer, the founder of chiropractic, saw this coming over a century ago when he said “Is it possible that the science of Chiropractic has arrived before its time?”
Perhaps this is similar to the torment of the original germ theorist, Louis Pasteur, trying to convince naysayers who claimed because they could not see the presence of germs that they didn’t exist.
Elephant in the Evidence
I believe results speak for themselves as pragmatic evidence. If chiropractic’s tenets were invalid as Perle suggests, I would agree with the EBM faction, but the facts are clear chiropractic works for many people and certainly works better than medical spine care consisting of drugs, shots, and surgery.
As David Seaman mentioned:
In general, authoritarians defend “positions” of the group and have little interest in evidence. Their authority is the evidence.
This authoritarian attitude was quite evident when Perle wrote, “Ergo I will not do the impossible and provide the evidence it [VSC] doesn’t exist.”
I’m not quite sure what he means, but it does sound erudite. It does sound like he cannot prove VSC doesn’t exist. Just as the medical witnesses at the Wilk trial could not prove their ugly accusations against chiropractors, nor can Perle and his EBM cohorts. As Dr. Seaman suggests, their authority is enough evidence.
Since Dr. Perle admits he cannot prove VSC doesn’t exist, then let me attempt the impossible and provide evidence to the contrary that VSC does exist and its correction results in measurable success. Results speak for themselves.
Take a look at these supportive studies, guidelines, and patient satisfaction surveys as evidence:
- The North American Spine Society (NASS) published its own guidelines supportive of chiropractic care:
- 2007: the NASS published “Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis.”
- 2010: the NASS released “Contemporary Concepts in Spine Care: Spinal Manipulation Therapy for Acute Low Back Pain” recommending spinal manipulation—5 to 10 sessions over 2 to 4 weeks—should be considered before surgery.
- 2012: the NASS also published “Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy” that found:
“…patients with lumbar radiculopathy due to lumbar disc 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.”
- New Medical Guidelines on LBP Recommend SMT
o American College of Physicians, Annals of Internal Medicine, CLINICAL GUIDELINES |4 APRIL 2017 Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians
o The Journal of the American Medical Association published on April 11, 2017: Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis, also recommending SMT before medical spine care.
o Even the Joint Commission promoted chiropractors from the ranks of the medical zombies (note: the Joint led the boycott of DCs in the 1960s leading to the Wilk v. AMA antitrust trial) with its Revisions To Pain Management effective January 1, 2015.
o The Food and Drug Administration in May, 2017, issued its FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain that included “Complementary therapies – e.g., acupuncture, chiropractic…”
- Media Reports on New Guidelines Praise SMT
- Consumer Reports
- National Public Radio: Spinal Manipulation Can Alleviate Back Pain, Study Concludes.
- Harvard Health Review: Where to Turn for Low Back Pain, Harvard Health Letter, November 2017.
First-line therapy should include nondrug therapy, such as superficial heat, massage, acupuncture, or spinal manipulation.
- Military Success with Chiropractic Care
- 2009 DoD Chiropractic Care Study
- 2013 Military Health Services, Combining Chiropractic Therapy with Traditional Treatment Significantly Improves Lower Back Pain
- 2017 RAND Corp. Study: Complementary and Alternative Medicine in the Military Health System
- Patient Satisfaction
- The DoD Chiropractic Care Study also mentioned chiropractors were rated highest among all practitioners:
- TRICARE outpatient satisfaction surveys (TROSS) rated chiropractors at 88.54, which was 10 percent “higher than the overall satisfaction with all providers” that scored at 78.31 percent.
- 94.3 percent in the Army;
- Air Force tally was also high with 12 of 19 bases scoring 100 percent;
- Navy also reported ratings in the 90 percent or higher.
- Gallup-Palmer Survey found similar results among the public at large:
Even the President’s Commission on Combating Drug Addiction and the Opioid Crisis recommends chiropractic as a nondrug solution for chronic pain to reduce the onslaught of opioid abuse.
While Perle and his fellow EBM authoritarians tell us the mainstay of traditional chiropractic—detecting and correcting VSC—are imaginary and invalid, the results and guidelines beg to differ.
As I said, results speak for themselves, not hyperbolic musings from naysayers or inflammatory remarks by Perle who have an ax to grind on classic chiro care.
I continue to wonder how Perle and the EBM naysayers claim to know more than the evidence by experts at NASS, RAND, the DoD, and the authors of the new guidelines by JAMA, American College of Physicians, FDA, and the Joint Commission that recommend SMT as among the best practices for LBP. These groups aren’t questioning the chiro methods to detect and correct VSC; instead they are praising our results.
As the NZ Commission reported:
“The fact that there is not yet any conclusive explanation of exactly what happens means nothing more than that the chiropractors’ hypothesis is so far unproven. It does not mean it is invalid.”
I also wonder what the impressionable students at UB are being taught. Perle ostensibly is a very knowledgeable editor, a very argumentative speaker/author and as a representative of UB and the “new” ACA who has traveled the world speaking to authorities, he has made his mark in our profession.
My angst is his message appears to invalidate chiropractic, not uplift it with a better hypothesis. Just how confused are his students who attend a chiro college that dispels VSC, the foundation of our profession? What is his hidden agenda?
Choosing Wisely or Guessing Wisely?
We see another chiro civil war battle over the “new” ACA’s “Choosing Wisely” campaign, an initiative of the ABIM Foundation and Consumer Reports adopted by the ACA.
The American Chiropractic Association has released a list of five tests and procedures chiropractors commonly do, but may not always necessary according to the ACA:
- X-rays for acute LBP patients in the first six weeks following onset of pain and in the absence of red flags.
- Monitoring patient progress with repeat spinal imaging / X-rays.
- Ongoing or prolonged use of passive or palliative physical therapy treatments (heat, cold, e-stim, ultrasound, etc.) for LBP that does not support the goals of an active treatment plan.
- Long-term pain management without screening for potential related psychological disorders such as depression or anxiety.
- Prescription of lumbar supports or braces for long-term treatment or prevention of LBP.
Let me address each issue from a traditional chiro point of view:
- X-rays for acute LBP patients in the first six weeks following onset of pain and in the absence of red flags
This certainly appears to be a risky double standard to begin treatment without first taking a look at the patient’s spine. If the same patient had acute chest pains, I doubt the MD would wait six weeks. If a patient had an acute toothache, again I doubt the dentist would wait six weeks. Also, how can one determine the presence of red flags without xrays? So, why is the ACA agreeing to wear a blindfold and proceed with treatment without the best scientific tool we have? Being myopic is not my idea of “best practices.”
As Dr. Studin suggests, it puts the chiropractor at “risk of treating blindly in the presence of clear biomechanical markers.”
- Monitoring patient progress with repeat spinal imaging / X-rays.
This will certainly crimp the style of any DC who subscribes to a specific adjusting method (Gonstead, Sweat, Pettibone, CBP, Pierce-Stillwagon) who finds value in post-xrays to verify the amount of correction and likelihood of permanency. Compared to the radiation from CT and MRI routinely done by MDs, xray radiation is insignificant and non-accumulative.
- Ongoing or prolonged use of passive or palliative physical therapy treatments (heat, cold, e-stim, ultrasound, etc.) for LBP that does not support the goals of an active treatment plan.
I’ve already seen this attitude condemning the need for palliative spinal care from insurance payers like ASHN who “squeeze care to expand profits” despite evidence showing the value of maintenance spinal care.
- Mohammed K. Senna, Shereen A. Machaly confirmed the value of maintenance care in their paper, Does maintained Spinal manipulation therapy for chronic non-specific low back pain result in better long term outcome?
SMT is effective for the treatment of chronic nonspecific LBP. To obtain long-term benefit, this study suggests maintenance SM after the initial intensive manipulative therapy.
- Another recent award-winning study by Andreas Eklund et al., Prevention of Low Back Pain: Effect of Chiropractic Maintenance Care as Compared to Symptomatic Treatment – A Pragmatic Randomized Clinical Trial, concluded:
Maintenance care treatment on a regular basis regardless symptoms is more effective than symptomatic treatment (after pain has recurred) in reducing the number of days with bothersome pain for patients with recurrent and persistent LBP.
- Long-term pain management without screening for potential related psychological disorders such as depression or anxiety.
What patient doesn’t have depression or anxiety concerning a chronic back problem, which is why the new guidelines recommend Cognitive Behavioral Therapy (CBT). But are practitioners trained to screen or treat for CBT? Perhaps this is why many patients turn to painkillers or pot to cope with their chronic LBP and depression.
A fascinating study by AV Apkarian, Chronic Back Pain Is Associated with Decreased Prefrontal and Thalamic Gray Matter Density, found chronic back pain actually shrinks the brain by a much as 11 percent, equivalent to the amount of gray matter lost in 10 to 20 years of normal aging.
In this light, patients can feel themselves degenerating into a downward spiral and to deny them continued care to relieve cLBP may lead to more serious mental problems leading to opioid abuse, depression, hopelessness, and too often results in suicide as Dr. Angus Deaton and Anne Case, PhD from Princeton University confirmed in their study concerning the Quiet Epidemic.
- Prescription of lumbar supports or braces for long-term treatment or prevention of LBP.
I agree lumbar supports are ineffective as a stand-alone treatment, but as a chronic LBP sufferer myself subject to acute manifestations, I do recommend patients use a lumbar support when they do prolonged sitting, driving or standing because prolong compression will make them susceptible to the “buckling effect” as John J. Triano, DC, PhD, described in his paper, Biomechanics of Subluxation: Modern Evidence of Buckling Mechanism. Indeed, an inexpensive lumbar support is a small ounce of prevention to avoid a relapse.
With this experiential evidence in mind, my overall impression is these guidelines were written by EBM DCs since they reflect medical concepts devoid of a true understanding why DCs use xrays to gain a biomechanical perspective of spinal problems as the NZ Commission reported.
It is worth noting there has also been push back from the ICA on this xray issue:
These same recommendations, originally intended to improve the practice of medicine, will discourage potential patients from seeking the care of a chiropractor when these medical standards are inappropriately applied to the practice of chiropractic.
ICA President Dr. George Curry emphasized: “The ICA believes that these recommendations are out of line with the established standards of chiropractic practice, ignore the large body of clinical and outcomes data that demonstrates the utility, indeed clinical wisdom of such procedures, and clearly can and will, if followed unquestioningly, place patients at risk by delaying or denying diagnostic procedures that have been proven to best serve patients’ needs.”
Boycotting our Best Tool
The fear of excessive radiation is also a concern cited by the anti-xray advocates although this notion has been disputed by Mark Studin in his paper, Should Chiropractic Follow the American Chiropractic Association / American Board of Internal Medicine’s Recommendations on X-Ray?
Based upon the literature, radiation is not cumulative and has rendered no evidence of long term effects. Therefore, the doctor of chiropractic must weigh the risk of treating blindly in the presence of clear biomechanical markers. Treating blindly is often done at the expense of our patients and the malpractice carriers, especially in a scenario where little risk exists.
In this light, it appears Choosing Wisely becomes actually Guessing Wisely because radiation accumulation is not an issue as Dr. Studin suggests, and not using xrays puts the chiropractor at “risk of treating blindly in the presence of clear biomechanical markers.”
I understand the goal of “Choosing Wisely” campaign was to decrease the number of worthless radiographs taken by MDs, but the use by chiropractors is minimal compared to the standard medical views and involve more than only looking for “red flags” such as fractures, cancers, infections or gross abnormalities.
Classic chiropractors analyze the same images for spinal patterns, scoliosis, subluxations, aka, neurobiomechanical lesions, and other factors that give us a visual understanding of the patient’s spinal problems as a mechanical weight-bearing pillar of vertebrae.
The NZ Commission also commented on the confusion between MDs and DCs with the use of xrays:
…the medical profession simply fails to see the direction and subtlety of the chiropractic approach towards spinal dysfunction. Because the chiropractor uses x-ray extensively the medical practitioner thinks he is looking for a gross bony change, and when the medical practitioner cannot see this on the x-ray the chiropractor is using he immediately becomes skeptical.
My opposition to the no-xray stance concerns the fact this is the best scientific tool we have to detect not only VSC, but spinal patterns, pathologies, and “red flags” contraindicating SMT, in order to give us insight into the patient’s overall problem in order to arrive at an intelligent prognosis rather than blindly guessing.
As well, many chiropractic techniques use measurements to determine a treatment program, the type of adjustments to be rendered, and an adjustment protocol based on the degree of misalignment, degeneration, and other factors gleaned from xrays.
Considering these “best practices” factors, now for the “new” ACA to ask us not to take xrays is removing our most scientific tool as well as the best educational source to explain to patients the severity of their spinal health and the need for care.
As to be expected from the EBM naysayer, Dr. Perle states xrays are “pseudo-scientific” offering no value to the evaluation of the patient’s condition:
“Finally, the belief that using radiographs is a scientific way to find where to adjust is erroneous. The evidence doesn’t support this hypothesis so really it is a pseudo-scientific approach. It looks “sciency” but is inconsistent with the science and only consistent with our pre-scientific past as a profession.”
Once again Perle uses citation laundering from his own journal to support his claim rather than citing “best practices” that incorporates the doctor’s clinical expertise and the best external evidence from xrays to manage the patient.
He also appears to refute what the original EBM guru, David Sackett, said:
Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough.
Ironically, instead of decreasing our risk by utilizing the most scientific tool we have to attain the “best available external evidence”, this boycott of xrays handcuffs practitioners and puts both the patient and doctor at risk and in the dark. I don’t know how this is Choosing Wisely because it seems to be taking a step back into the dark ages of health sciences before the advent of xrays in 1895 when physicians had no idea of internal bodily issues.
Certainly anyone could give a non-specific adjustment to a non-specific condition as we see done by laymen, untrained PT/MDs, and now in chiropractic franchises that cater to patients seeking discounts and NOOPE.
On the chiro blogs where some EBM advocates troll, I have asked them a simple question: what do they say when the patient asks, “How will you know what my problem is if you don’t take an xray to look?” Even patients know this is a reasonable request.
I have heard this sentiment from new patients transferring from the no-xray offices to mine. They intuitively know the “Spines ‘R Us” approach is not “best practices” although on the other hand there are K-Mart patients looking for the cheapest chiropractor who are quite content with this “pop and pray” version of ol’ time chiropractic, ya folla?
Is this the brand of “chiropractic medicine” being taught at UB?
Is this the brand of modern chiropractic espoused by the “new” ACA?
I also ask the no-xray advocates how they detect “red flags” in the 10-15% of pathoanatomical cases without the use of imaging. Indeed, if there is an adverse reaction or death, you know the first thing the plaintiff’s attorney will ask is to see the xrays.
While Perle derides xrays as “sciency” and “pseudo-scientific,” many DCs like me think they are an invaluable insight into the patient’s condition and, if an adverse reaction occurs, they are an invaluable defense; without them you may be dead in the water.
Indeed, I’d rather be “sciency” than negligent in the eyes of the court. I’d rather be “pseudo-scientific” than injure the 10-15% of patients with pathoanatomical problems.
Apparently thousands of successful chiropractors are “sciency” and “pseudo-scientific” who use xrays to detect VSC and other spinal health problems.
I also wonder how not using xrays is “yielding the best possible patient care”? Perhaps these non-xray practitioners use the Braille method to detect spinal pathologies and structural problems with only their fingertips. (Okay, stop laughing; I’m being sarcastic)
Imagine if a dentist followed the Choosing Wisely program. Instead of saying to a new patient, “Okay now, open wide!” he would have to say, “Keep your mouth shut for 6 weeks before I can take xrays to see what’s happening.”
This situation makes me think of what Forrest Gump might say, “Chiropractors are like a box of chocolates, you just never know what you’ll get.” At least with spinal xrays, both the chiro and patient know what they’ll get from a good picture of the spine.
Putting aside the xray debate for a moment, without question the topic of chiro philosophy evokes the most heated reactions from the Authoritarians, such as we see with EBM advocates at “UK & Europe Chiropractors – no philosophers” or in the US at the “chiropractic medicine” advocates in the West Hartford Group, which Perle belongs to both groups.
Actually I completely understand their chagrin about chiro philosophy since my initial chiro education at Sherman featured the notorious Reggie Gold and my subsequent education at Life University featured the infamous Big $id Williams; indeed, both would drive any sensible DC to drinking. This branch of our profession is commonly known as the chirovangelists, begun by BJ Palmer himself.
As a student at UC Berkeley and Rutgers University, I had never encountered such religious zealots in education who resembled the character played by Burt Lancaster in the 1960 movie, Elmer Gantry, from the book written by Sinclair Lewis about fundamentalist and evangelistic circles in the 1920s. Elmer Gantry was a hard-drinking, fast-talking traveling salesman with a charismatic personality who infuses biblical passages and fervor into his pitches as a way to ease followers and collect money.
These two photos aptly depict the similarity: on the left is from the movie and on the right is Big $id at a DE chirovangelism rally:
Other notable and legitimate Straight Fundamentalists might include Joe Strauss, Thom Gelardi, Lyle Sherman, and Fred Barge.
There are also “neo-classic” chiro philosophers such as Virgil Strang whose text, Essential Principles of Chiropractic, described chiropractic philosophy in a lexicon using the language of science rather than religion. Jim Winterstein, Louis Sportelli, Carl Cleveland the III, Joseph Janse, Hugh Logan also explained the classic tenets of our profession without theatrical chirovangelism.
Presently there are “neo-vitalists” such as Guy Riekeman, Rob Scott and Gerry Clum who blend with traditional chiropractic tenets with cutting edge science and disruptive social activities to make for a very interesting brand of chiropractic at Life University.
Indeed, there’s never a dull moment in chiropracTIC.
Bigger Idea Strategy
However, there are bigger fish to fry than squabbling over the role of philosophy in chiropractic or argue about xrays or even VSC because the fact remains the “new” ACA is focusing on the minutiae compared to bigger issues to fight.
The ACA alluded to the bigger picture:
…the Choosing Wisely campaign “is part of a multi-year effort led by the ABIM Foundation to support and engage physicians in being better stewards of finite health care resources.
If the ACA wants to help the medical profession to be “better stewards of finite health care resources,” a better position instead of omitting xrays would be to build a case in the earned media DCs are best qualified to be the primary spine care providers (PSPs) that would save billions of dollars and untold suffering by patients mismanaged by medical spine care—drugs, shots and surgery.
Instead of caving in to misguided recommendations under the guise of Choosing Wisely to save a few dollars over xrays at the expense of our analysis and patients’ well-being, perhaps the ACA might suggest the wisest choice would be to engage the public and press to understand that MDs should immediately refer acute and chronic LBP patients to DCs for the 90% of non-red flag patients, just as they would refer a patient with a toothache to a dentist.
We need to go public by staking this claim since the research and guidelines now fall on our side while medical spine care has been dubbed the “poster child” of inefficient care, dangerous, addictive and costly. There is a plethora of evidence how poorly medical spine care has managed the leading disabling condition in the workplace, military, VA—the epidemic of LBP.
Mark Schoene, the 25-year editor of The BackLetter, an international spine research journal, 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. This is simply because of the high rates of opioid prescription in these settings. 
According to ACA President David Herd, DC, “We are proud to partner with Choosing Wisely in this effort to encourage important conversations between patients and chiropractors that may reduce unneeded or overused services, yielding the best possible patient care.”
Indeed, if we are to encourage important conversations with our patients (and press) to “reduce unneeded or overused services”, let us begin by mentioning the utter failure of the medical spine care professionals who have led to the opioid crisis and tsunami of failed back surgeries.
Of course, until we confront the decades of chirophobia perpetrated upon our profession by medical bigotry, our plea will fall on deaf ears among those who still hold an unwarranted prejudice against the chiropractic profession.
Just as racism, sexism, anti-Semitism and homophobia cannot be overcome overnight, so too the medical prejudice against chiropractors has no quick fix. But we must begin this healing process by going public as I have done in my books.
We must explain how chirophobia was the design of the Medical Mussolini, Morris Fishbein, and his successors, the Committee on Quackery. Until this medical evil becomes known by the public and press, our claim to be the best qualified spine providers will continue to fall on deaf ears.
Judge Getzendanner mentioned the damage to our reputations that has never been repaired:
“The activities of the AMA undoubtedly have injured the reputation of chiropractors generally…In my judgment, this injury continues to the present time and likely continues to adversely affect the plaintiffs. The AMA has never made any attempt to publicly repair the damage the boycott did to chiropractors’ reputations.
Let’s also talk about Informed Consent laws and how MDs refuse to mention SMT as a viable nondrug alternative as the numerous guidelines now recommend. This is a legal requirement that MDs constantly ignore, but are legally liable nonetheless.
The Supreme Court of New Jersey ruled in the case of MATTHIES V. MASTROMONACO [Supreme Court of New Jersey. 160 N.J. 26, 1999]:
“For consent to be informed, the patient must know not only of alternatives that the physician recommends, but of medically reasonable alternatives that the physician does not recommend.”
Of course, this implies chiropractic care—a medically reasonable alternative that many physicians do not recommend due to chirophobia, but an alternative the patient is legally entitled to know.
Let’s also talk about the studies confirming most primary care physicians are inept in their training on musculoskeletal disorders, more likely to ignore recent guidelines, and more likely to suggest spine surgery than surgeons themselves.
Dr. Marc Siegel at FOX News admitted primary care providers have only 9 hours of education on “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.”
The idea DCs should be PCPs for spine-related disorders (SRD) is not new. Dr. Thomas M. Kosloff’s research at Optum concluded:
In 2013, the Optum Health internal analysis of LBP treatments determined the best track to take for cost efficiency begins with a patient consulting a chiropractor first. When a chiropractor was the first provider, treatments were “well-aligned with clinical evidence; the least fragmentation of care; low rates of imaging, injections, and prescription medications; and low total episode cost when manipulation is introduced within the first 10-days of the episode.”
The Optum researchers also found when manipulation was not provided at any time during the patient’s treatment that it to lead to higher total episode costs when using only medical spine care methods.
Let’s also talk about the medical mismanagement of spine-related disorders such as one Optum member who commented on his ride on the medical merry-go-around that most LBP patients endure:
“I started out with my primary care physician. He had back pain and turned me on to his back specialist. I went to an orthopedic surgeon. He sent me to a neurologist. Then they sent me to a pain center. I went to an acupuncturist. I went to a physical therapist. As a matter of fact, I went to three different physical therapists. During that time I always went to a chiropractor.”
This railroaded patient was one of the lucky ones who didn’t end in a train wreck with a disc fusion based on the debunked “bad disc” diagnosis.
Drs. Mark Studin and William J. Owens also addressed DCs as POE in their article, The Mechanism of the Chiropractic Spinal Adjustment/Manipulation: Chiropractic vs. Physical Therapy for Spine”:
Chiropractic offers an evidence-based approach in developing an outcome based care path for mechanical spine pain… with chiropractic as the “first option” or “Primary Spine Care” focusing on the biomechanical pathological instability, the underlying cause of the pain can be addressed, leaving no further need to manage an issue that has been simply fixed.
One impactful PR tactic would be for the F4CP and every chiro association around the country to inform the public of the debunked “bad disc” diagnosis that has made billions of dollars for the medical spine complex (surgeons, MRI centers, hospitals, device manufacturers, Big Pharma) with unnecessary spine fusions.
Undoubtedly a great PR opportunity is the systematic review in 2014 when the Mayo Clinic found “bad discs” in pain-free people, likening them to a natural part of the aging process like grey hair. This bogus diagnosis has led millions of patients into unnecessary disc fusions.
Who hasn’t heard a confused LBP patient say, “But my doctor says I have a bad disc that needs surgery. He even showed it to me.” Of course, the greedy surgeons never tell them this “bad disc” is deemed an “incidentaloma” by medical experts such as Rick Deyo, MD, MPH.
The following graph illustrates various types of abnormal discs are routinely found in asymptomatic (no pain) patients correlating to age, but the public remains unaware of this revolutionary finding:
We’ve been handed this valuable study but we have done nothing with it. Also, the recent ACP and JAMA guidelines were more feathers in our cap, but little was done on a consistent basis to inform the public of this paradigm shift in spine care.
The Bottom Line
The biggest elephant in spine care is to ask why MDs are not following the new guidelines as we’ve seen from the ACP, JAMA, FDA and the Joint Commission to use conservative care before medical spine care. Certainly their lack of education in spine care, their lack of interest in CAM, and their bias against chiropractors explain this dire situation.
If the ACA and F4CP want to elevate our position in the public arena, they should sponsor a program of infomercials placing DCs as the primary care providers for spine problems and MSDs.
This would be similar to the old ACA program developed by Irv Davis and Lou Sportelli.
The proof is here, the experts agree, and it is past time the public was told for the majority of mechanical acute and chronic LBP, DCs are the POE for SRD, LBP, and other MSDs. This type of disruptive journalism will get more attention in the earned media than a million ads on backpacks and whiplash as we now see.
 CDC gets list of forbidden words: Fetus, transgender, diversity, by Lena H. Sun and Juliet Eilperin, December 15, 2017,
 Published by order of Susan Getzendanner, US District Judge, Sept 25, 1987, JAMA, Jan 1, 1986-Vol 259, No. 1.
 Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996) Evidence based medicine: What it is and what it isn’t. British Medical Journal, 312(7023), 71-72.
 “On the Media”, NPR, March 18, 2012, http://www.onthemedia.org/2012/mar/16/calculating-body-counts
 Inglis, BD, Fraser, B, Penfold, BR, Chiropractic in New Zealand, Report of the Commission of Inquiry into Chiropractic, PD Hasselberg, Government Printer, Wellington, New Zealand. 1979, 49-55
 Inglis, ibid.
 DD Palmer, The Chiropractor’s Adjuster: The Text-Book of the Science, Art and Philosophy of Chiropractic (Portland, Oregon: Portland Printing House) (1910): 847
 The BackLetter, volume 30, number 10, 2015
 Opinion p. 10
 EA Joy, S Van Hala, “Musculoskeletal Curricula in Medical Education– Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/11 (November 2004).
 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.
 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.
 Dynamic Chiro, May, 2017:
 Richard A. Deyo, MD, MPH and Donald L. Patrick, PhD, MSPH, Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises, AMACOM books, (2005): 36-37