While the ACA is fighting a civil war over its xray Prohibition, it appears the Choosing Wisely movement in Australia is far ahead of its American colleagues by addressing the bigger issues of opioid abuse and unnecessary spine fusions as I suggested we do in my last article.
Recently two articles appeared in the Australian press that essentially gave readers the basis of Informed Consent on chronic pain and spine care, shocking information the medical world has been reluctant to do.
Nonetheless, on February 14, 2018, was a headline readers in the US will probably never see, New Healthcare Advice: Benzodiazepines Will Not Help Low Back Pain, from a news release by the Faculty of Pain Medicine of the Australian and New Zealand College of Anesthetists, the professional organization for specialist pain medicine physicians that concluded:
“However, a recent review found there was no evidence to support people taking benzodiazepines as ‘muscle relaxants’ to relieve their low back pain, in addition to or instead of anti-inflammatory medicines.
It’s past time to see the crumbling of this medical house of cards in spine care—first opioids have been harshly criticized and now we see muscle relaxants publicly denounced in the media.
What’s next, spine fusions? Yes!
Another article, Health Waste: Spinal Fusion Added to List, published on the same day by The Australian.com took a swipe at spinal fusions:
“Spinal fusion for unexplained back pain will today be put on the list of unnecessary, wasteful and risky medical procedures, promising patients more clarity over their options and potentially saving the health system tens of millions of dollar a year.”
Experts are alarmed by the trend and, according to one estimate, the surgery cost $2.3 billion over a 10-year period despite more than half of those operations likely being unnecessary.
Here are their five recommendations:
1. Avoid prescribing opioids (particularly long-acting opioids) as first-line or monotherapy for chronic non-cancer pain.
- Do not continue opioid prescription for chronic non-cancer pain without ongoing demonstration of functional benefit, periodic attempts at dose reduce and screening for long-term harms.
- Avoid prescribing pregabalin (Lyrica) and gabapentin (Neurontin ) for pain which does not fulfil the criteria for neuropathic pain.
- Do not prescribe benzodiazepines (Valium and Xanax) for low back pain.
- Do not refer axial lower lumbar back pain for spinal fusion surgery.
The only issue omitted and perhaps the most important would have been to recommend seeing a chiropractor first for the pandemic of back pain but, considering the media attack on chiropractors Down Under that we witnessed the last few years, this omission was not unexpected.
Recall in 2016 the Medical Journal of Australia also called for a moratorium on spine fusions, “Spinal Fusion Surgeries Questioned”:
As I mentioned, this Choosing Wisely list would have been most impactful if it had a 6th recommendation to promote chiropractors as the primary spine providers.
Like a relay race, the baton now should be given to the chiropractic profession to announce our role as the best nondrug, nonsurgical profession to combat chronic pain in the opioid crisis as many guidelines now recommend but the public and press remain oblivious.
New Medical Guidelines on LBP Recommend SMT
- · 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
- · 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.
- · 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, announcing the new requirement for hospitals to offer nondrug alternatives to patients including chiropractic care:
“One of the new pain management elements of performance requires that organizations provide non-pharmacologic pain treatment modalities…including chiropractic therapy.”
- · 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…”
Recently online at the BMJ Open website another paper pointed out how medical radiographs often lead to misdiagnosis and unnecessary interventions. Clinician, Patient and General Public Beliefs about Diagnostic Imaging for Low Back Pain: Protocol for a Qualitative Evidence Synthesis explained “Unnecessary diagnostic imaging for low back pain drives flow-on effects such as overuse of advanced imaging, opioid prescriptions, spinal injections and surgery.”
Also note there is no mention of excessive radiation to the patients in this BMJ article, the mainstay criticism of the EBM advocates:
Unnecessary diagnostic imaging is associated with substantial harm including the risk of overdiagnosis.13 Overdiagnosis occurs when diagnostic imaging detects incidental findings that are common in the asymptomatic population (eg, intervertebral disc degeneration14) and provides the patient with a diagnostic label that brings them no benefit or causes harm. Diagnostic labeling leads to medical overuse, a problem which is growing internationally.15 Unnecessary diagnostic imaging for low back pain drives flow-on effects such as overuse of advanced imaging, opioid prescriptions, spinal injections and surgery.16 17 Evidence from clinical guidelines suggests that most of these interventions have little to no benefit, and substantial risk for harms, in patients with non-specific low back pain.18–20
A few years ago I wrote about this medical back scam myself in a series of articles in Dynamic Chiropractic showing how “incidentalomas” found on imaging lead to unnecessary interventions and surgery. Finally the medical gods agree!
Where Art Thou, ACA?
Undoubtedly the ACA’s Prohibition program will divide rather than unite the profession nor increase its membership since the ‘new’ ACA will no longer be seen as a safe haven to its thousands of members. Like a mean stepfather in a broken family, the ‘new’ ACA may find its flock seeking shelter elsewhere.
In effect, a case can be made the ‘new’ ACA inadvertently has “gaslighted” our profession. According to Wikipedia:
Gaslighting is a form of manipulation that seeks to sow seeds of doubt in a targeted individual or in members of a targeted group, hoping to make them question their own memory, perception, and sanity.
The concept of gaslighting was popularized by a 1944 mystery-thriller movie, Gaslight, with Ingrid Bergman playing the role of a woman whose husband slowly manipulates her into believing that she is going insane.
Indeed, the new ACA Prohibitions questioning the basic protocols and tenets of chiropractic care has made every classic chiropractor doubt our perceptions of practice.
Gaslighting is not a new threat to our profession. If you recall our history, the AMA’s Committee on Quackery goal did the same by sowing the seeds of doubt about chiropractic in the public’s mind, which still remains a problem in the court of public opinion since we have never publicly refuted this doubt even after the Wilk v. AMA victory.
Et Tu, Dr. Perle
The ACA Prohibition and the attack on classic chiropractic by the ACA’s leading spokesman Stephen Perle from the University of Bridgeport certainly can be seen as gaslighting chiropractic by sowing the seeds of doubt and creating contention among the rank and file.
Stephen Perle is an enigma in chiropractic. I’ve known Stephen for many years and once considered him a valued colleague with his numerous papers, energy and excellent presentations at ACC-RAC.
In the past he has defended chiro care combating medical trolls such as Edzard Ernst and he has pushed for reform and advancement of our education, science and clinical art.
Many of his early articles were intended to improve our profession:
Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF.
Chiropr Osteopat. 2008 Aug 29;16:10. doi: 10.1186/1746-1340-16-10.
Perle SM, Robert Cooperstein, Lantz C, Schneider MJ.
J Manipulative Physiol Ther. 2003 Jan;26(1):60-1; author reply 62-4. No abstract available
Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T.
Chiropr Osteopat. 2005 Jul 6;13:9.
Perle SM, French S, Haas M.
Int J Clin Pract. 2011 Jan;65(1):104-5; author reply 106
French SD, Walker BF, Perle SM.
Chiropr Osteopat. 2010 Jun 2;18:17
- The establishment of a primary spine care practitioner and its benefits to health care reform in the United States.
Murphy DR, Justice BD, Paskowski IC, Perle SM, Schneider MJ.
- Chiropr Man Therap. 2011 Jul 21;19(1):17
- Chiropractic identity, role and future: a survey of North American chiropractic students.
Gliedt JA, Hawk C, Anderson M, Ahmad K, Bunn D, Cambron J, Gleberzon B, Hart J, Kizhakkeveettil A, Perle SM, Ramcharan M, Sullivan S, Zhang L.
Chiropr Man Therap. 2015 Feb 2;23(1):4
Gleberzon BJ, Cooperstein R, Perle SM.
J Can Chiropr Assoc. 2005 Jun;49(2):69-73
Keating JC Jr, Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF. Chiropr Osteopat. 2005 Aug 10;13:17.
Show Me the Subluxation
On the other hand, now he has taken on the role of chief naysayer condemning the cornerstone of chiropractic care—the vertebral subluxation—and has become an opponent to xrays and chiro philosophy.
His opinion is even more shocking in light of the fact he is chairman of ACA’s Research Advisory Board and as the associate editor of Chiropractic & Manual Therapies.
It appears Dr. Perle has now gone to the dark side. Instead of uniting our profession, he has become a polarizing wedge; rather than a progressive in our profession as he once was, now he appears divisive by gaslighting our beliefs rather than shining light on the truth.
For example, recently Dr. Perle revealed himself:
“I’ve never seen a subluxation… So please show me one. Please provide the evidence that one exists…We don’t know that any chiropractor has ever detected or corrected one.”
Yes, you heard that right—a tenured professor at a chiro college is now gaslighting students by asserting subluxations are non-existent and xrays are worthless.
Dr. Perle also threw down the gauntlet:
“The onus is on you to provide the evidence for your assertion that the subluxation exists. Citation please to the literature.”
Okay, let me help our skeptics with a quick search on PubMed where I discovered there were 5291 articles cited for “vertebral subluxation.” This search also found shocking images of mild to extreme cases of subluxation. Certainly many of these were not chiropractic subluxations, but searching specifically for “vertebral subluxation chiropractic” found 109 articles; here are a few:
- Evaluation of publicly available documents to trace chiropractic technique systems that advocate radiography for subluxation analysis: a proposed genealogy.
Alcantara J, Plaugher G, Van Wyngarden DL.
- Chiropractic care of a patient with vertebral subluxations and unsuccessful surgery of the cervical spine.
- Practice-based randomized controlled-comparison clinical trial of chiropractic adjustments and brief massage treatment at sites of subluxation in subjects with essential hypertension: pilot study.
- Independent guideline appraisal summary report for vertebral subluxation in chiropractic practice (CCP) guidelines.
Alcantara J, Plaugher G,
- Chiropractic care of a patient with vertebral subluxations and unsuccessful surgery of the cervical spine.
Alcantara J, Plaugher G
- Management of a patient with lamina fracture of the sixth cervical vertebrae and concomitant subluxation.
Budgell BS, Sato A
- Conservative management of posttraumatic cervical intersegmental hypermobility and anterior subluxation.
I find it odd Dr. Perle, an editor of a peer-reviewed journal, would confess he has never found evidence that subluxations exist when numerous authors apparently feel they do exist in one form or another.
Dr. Perle further gaslights his argument when he lays down another gauntlet: “Ergo I will not do the impossible and provide the evidence it doesn’t exist.”
So, he admits he cannot prove VSC do not exist while he ignores articles on PubMed suggesting subluxations do exist. Perhaps he’s gaslighted himself in this confusion!
He also ignores the practice-based evidence (PBE) from a century of thousands of DCs adjusting millions of people with subluxations.
Dr. Phil Arnone, ACA delegate and committee chair investigating the xray issue, put this gaslighting into a historical perspective:
When did we, who have asked so many patients for so many years to trust what we could not prove, become so willing to accept what Evidence-based medicine can not prove?
We must remember that 50 years ago all of chiropractic was considered controversial, yet somehow today the results of our profession and our success in caring for patients have prevailed through the years.
What if we decided then to only practice what science could prove?
Boycotting our Best Tool
While gaslighting subluxations, Dr. Perle also scoffs at the notion xrays are valid methods to detect subluxations. He claims xrays appear “sciency” as a part of “our pre-scientific past” that offer 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.”
To prove his point, Dr. Perle often cites a paper by André E. Bussières, DC, et al., Diagnostic Imaging Practice Guidelines For Musculoskeletal Complaints In Adults—An Evidence-Based Approach—Part 3: Spinal Disorders, to support his belief that “using radiographs is a scientific way to find where to adjust is erroneous…inconsistent with the science.”
But upon closer examination, Bussières’ paper actually differentiates between radiographs for diagnostic purposes and therapeutic purposes:
What These Guidelines Do and What They Do Not Do
“It should be emphasized that these guidelines were developed with the intent of being used for diagnostic purposes and not for therapeutic purposes such as evaluating and monitoring functional or structural rehabilitation of the spine…”
Dr. Bussières is clear the xray guideline is “not for therapeutic purposes such as evaluating and monitoring functional or structural rehabilitation of the spine…” that is exactly what DCs do!
If the ACA had done its homework on the xray prohibition espoused by Dr. Perle, they would have known there is a huge difference between medical diagnostic and chiropractic therapeutic radiographs.
For those DCs who analyze the spine for structural problems and not merely for points of pain in order to ‘pop and pray,’ xrays not only help in a structural analysis and treatment plan, but Dr. Bussières also noted radiographs are important legally to justify treatment in case of adverse events and to explain medical necessity to payors.
This should have been the Ace in the ACA’s poker hand to explain to nefarious insurers like ASHN why chiropractic imaging for structural problems is different and more important than medical imaging for “incidentalomas” and red flags because chiropractic radiographs have therapeutic value, too.
Once again let me quote Dr. Phil Arnone on the importance of xray in chiropractic and the irony he sees now:
I am so saddened by the current direction and commentary.
However, the ability to measure the biomechanics of the spine has a drastic effect on outcome which applies to all techniques.
Since Atlas Orthogonal, Orthospinology and NUCCA use similar standards, and CBP and Pettibone also use similar standards of measurement, it is my goal with my ACA committee to research and combine these standards. Once these are in place we can reach out to other non-orthogonal approaches and invite them to compare their process and further standardize the profession’s use and interpretation of x-rays.
In a recent conversation with Mark Studin, DC, he explained how the Orthopedic and Neurosurgery groups are now interested in spinal digitization as they are recognizing that surgical outcome can be either adversely or positively affected based on the juxta-alignment of the upper Lumbar and Thoracic region.
As a result they are looking for ways to better understand and measure spinal misalignment patterns through radiographic procedure and utilize those measurements to aid in their success. They recognize that they cannot see those patterns by visual observation.
Interesting they see the value but not our trade organization.
Apparently Dr. Perle is not a proponent of any chiropractic specific adjusting system requiring xray analysis to determine a treatment/adjustment plan. Conversely, when Dr. Perle claims xrays are “pseudoscientific,” it makes me wonder if he thinks taking no xrays makes us more scientific? Now I’m becoming gaslighted in this confusion.
Dr. Don Nixdorf, formerly the Executive Director of the British Columbia Chiropractic Association and author of Squandering Billions, commented to me that the ACA Prohibition on xray is “at best not relevant and at worst promoting sub-standard care.”
An adjustment (manual therapy) includes the awareness of osteophytes (posterior and anterior), narrowing IVD, narrowing IVF, sacralisation, lumbarization, spondylolisthesis, congenital anomaly, post-sport and -trauma alterations of position, facet injury and asymmetry, among other findings when we are able to see the vertebra.
It also makes a difference to determine the adjustment level and line of correction, neither of which is recognized by MDs and related interests. This is not relevant to MDs as they do not treat or accept the causation of 2-3 adjoining vertebra affecting nerve, blood vessel, disc, and related anatomy.
Dr. Nixdorf concludes:
For a chiropractic narrative to adopt such information from a medical source uneducated, convicted, and with continued bias is worse than the medical bias itself.
Wolf in Sheep’s Clothing
Perhaps the biggest gaslight by the ACA was the selection of Dr. Perle as keynote speaker with his presentation, “Grilled Cheese, Candles and Beer,” at the McAndrews Leadership Lecture at the upcoming ACA National Legislative Conference.
Although Perle’s speech actually sounds very entertaining, his selection may be very inappropriate considering the different history of these two scholars.
If you were to dig deeper, you would realize the selection of Stephen Perle to deliver the McAndrews lecture is troubling since his opinions are antithetical to the namesake of this award, Dr. Jerry McAndrews, a past president of Palmer Chiropractic College and the EVP of the ICA who along with his brother, George, initiated the Wilk v. AMA lawsuit.
Whenever the ACA needed a national spokesman, it turned to Jerry because of his Lincolnesque stature, diplomatic personality, and encyclopedic knowledge of everything and everyone in this profession. Not only our most articulate spokesman, he was also an advocate for more research. We lost a giant when he passed away nearly a dozen years ago and I lost my mentor and pen-pal.
I seriously doubt the NCLC attendees—students, ACA delegates, and field docs—fully understand that Perle’s anti-VSC, anti-xrays, anti-chiro philosophy, pro-vaccines and pro-prescription drugs stance seriously contradicts the classic Palmer tenets espoused by Dr. McAndrews, a protégé of David Palmer himself.
Dr. Perle certainly is entitled to his opinion as an academician, but for the ‘new’ ACA to honor him with the McAndrews Leadership Lecture apparently to associate his EBM ideas to the legacy of Dr. McAndrews would be very misleading to those unaware of his conflicts of interests with traditional chiropractic.
I fear Stephen Perle is a wolf in sheep’s clothing who by his mere presence misrepresents the namesake of Dr. McAndrews by disavowing the Palmer core values of chiropractic upon which this profession has been based for over a century.
It is one thing to be progressive to improve our clinical arts and scientific understanding of spinal neurobiomechanics as many DCs strive to do, but it’s another thing to throw the baby out with the bathwater by claiming subluxations are non-existent, xrays are obsolete and Innate is hooey.
Stephen Perle’s lecture at the upcoming NCLC is equivalent to giving a speech in church in the name of the Pope while doubting the existence of God.
Methinks Dr. McAndrews both as a classical Palmer chiropractor and as a devout Catholic might have strongly disagreed with the selection of Stephen Perle as the McAndrews Leadership Lecturer.
Moreover, to allow Dr. Perle to be a keynote speaker at the upcoming NCLC would only lead to more gaslighting by confusing members and 400 students, especially those who attend colleges that subscribe to classic chiropractic tenets
O Ye of Little Faith
Anyone who knew Dr. McAndrews understood his love of research. The McAndrews Leadership Lecture was founded on his greatest hope for our profession that rested in future research as he once told me:
Until belief-like ‘faith’ is removed from our midst, then the person with the loud voice, the nice clothes, the four-color brochures, and the methods to compound incomes will carry the day.
I’m praying for the day when our real scientists can say, ‘Chiropractic works, and here’s why.’ Perhaps that’s a challenge for the next wave of chiropractors—those better-educated, evidence-based, bio-mechanists who will improve our technology and explain the ‘how’ and the ‘why’ of the force behind the matter.
Thank heavens we have an increasingly emerging group which collectively says, ‘we’ve had enough.’ This group supports new journals, reads them, begins to reject the smoke of the past, and begins to demand that the language be accurate. Eventually, the misuse of ‘chiropractic philosophy’ will disappear and we will find the ‘philosophy of the science of chiropractic’ in its place. It already sounds stimulating.
Although both Jerry McAndrews and Stephen Perle promote research, it seems they are diametrically opposed in terms of what that means.
Perle’s goal seemingly undermines traditional chiro tenets as we witnessed with his anti-VSC stance. He fails to offer research that will “improve our technology and explain the ‘how’ and the ‘why’ of the force behind the matter,” as Dr. McAndrews extolled.
It’s one thing to “reject the smoke of the past,” but it’s another thing to replace it with gaslighting by those who would have us believe the tenets of classic chiropractic are invalid.
Apparently to Dr. Perle, who once described himself online as a “non-theist,” there is no “force behind the matter.” To the anti-philosophy faction, any talk about the role of metaphysics, vitalism, prayer, Innate, or psycho-cybernetics in healthcare is taboo.
To the EBM faction, there is no “bio” in biology; they’ve taken the “life” out of the life sciences.
This is a conflict among other health practitioners, not just chiropractors, considering 60% of elite scientists and MDs are atheists according to the leading MD in this country.
Francis R. Collins, MD, author of The Language of God, The Language of Life, the past director of the Human Genome Project, presently the Director of the National Institutes of Health and undoubtedly the most powerful MD in the nation today commented on this dilemma:
…some of my scientific colleagues who are of an atheist persuasion are sometimes using science as a club over the head of believers basically suggesting that anything that can’t be reduced to a scientific question isn’t important and just represents superstition that should be gotten rid of.
Part of the problem is, I think, the extremists have occupied the stage. Those voices are the ones we hear. I think most people are actually kind of comfortable with the idea that science is a reliable way to learn about nature, but it’s not the whole story and there’s a place also for religion, for faith, for theology, for philosophy. But that harmony perspective does not get as much attention, nobody’s as interested in harmony as they are in conflict, I’m afraid.
This atheist vs. vitalist conflict continues to this day between the EBM group and those who acknowledge the God factor in healthcare.
Perle suggests the lingering problem within chiropractic is “There are many in all professions who hold to their prior thinking… doctors who might be holding on to past ways of doing things.”
Dr. Collins did not endorse but noted the same criticism when he said the atheists believe it “…just represents superstition that should be gotten rid of.”
Unfortunately as Dr. Collins warned, it is to be expected “…the extremists have occupied the stage. Those voices are the ones we hear,” and so it continues in chiropractic with Stephen Perle.
Perhaps the ACA’s Executive Committee and Dr. Perle should keep Dr. Collins’ opinion in mind:
I think most people are actually kind of comfortable with the idea that science is a reliable way to learn about nature, but it’s not the whole story and there’s a place also for religion, for faith, for theology, for philosophy.
Maybe the ACA might enjoy reconciliatory suggestions from a few notables across the spectrum of our profession.
Christopher Good, MA, DC, another faculty member from the University of Bridgeport College of Chiropractic, wrote a fascinating article, Chiropractic Identity in the United States: Wisdom, Courage, and Strength:
“The various clinical specialties and independent groups in the chiropractic profession are so different in their beliefs, practice styles, and political agendas that a common identity is unlikely to be created. Areas of disagreement, including advanced practice, vertebral subluxation, and the philosophy of chiropractic, continue to separate those in the profession. Doctors of chiropractic should accept that differences within the profession will remain for the foreseeable future and that the profession should allow each group to live peacefully and supportively alongside each other.”
From the diametrically opposite end of the chiropractic education spectrum from Sherman College of Chiropractic, John Hart, DC, MHS, offers a similar perspective on chiropractic identity in his article, Analysis and Adjustment of Vertebral Subluxation as a Separate and Distinct Identity for the Chiropractic Profession: A Commentary.
“However, settling on any particular identity for the chiropractic profession will likely be met with resistance by some, given the plethora of opinions among chiropractic professionals as to what the identity of the chiropractic profession should be. Common ground between the different factions within the chiropractic profession might be found in a unifying expression such as “functional neurology.”
“When a profession’s identity is not clear with respect to its area of interest and mission, then the public may be less inclined to seek its services. Identifying the chiropractic profession with a focus on vertebral subluxation would give the profession uniqueness not duplicated by other health care professions and, therefore, might legitimatize the existence of chiropractic as a health care profession. An identity having a focus on vertebral subluxation would also be consistent with the original intent of the founding of the chiropractic profession.”
As Dr. Good concluded, “If the profession embraces the ideals of truth, respect, and tolerance, it can continue to grow and provide diverse health care services well into the future.”
Perhaps if the ‘new’ ACA embraces this egalitarian attitude instead of the divisive authoritarian posture of Dr. Perle and the EBM advocates, the profession will come together rather than experience its Waterloo.
 Phil Arnone, private communication with JC Smith, Jan. 10, 2018.
 Don Nixdorf, private communication with JC Smith, 2-8-2018
 Interviewed by David Hirschman, Recorded September 13, 2010, BigThink.com