The Lancet Elephant
Part 2: Practitioners vs. Academic Elitists
The Lancet panel was foremost an ensemble of the “evidence-based medicine” (EBM) advocates who apparently placed little regard on “practice-based evidence” (PBE) gleaned from empirical clinical work. As such, the panelists came to many ‘nonspecific’ conclusions.
These EBM vs. PBE adversaries already had locked horns in the ACA Choosing Wisely ordeal when academic elitists vs. chiropractic practitioners argued which type of “evidence” is more valuable — hands-on clinical results or scientific studies. In the end, the House of Delegates rejected the Choosing Wisely effort for further consideration as well as “unelected” the ACA’s president who pushed this radical departure.
Practice Tyranny
As founder of EBM, Dr. David L. Sackett wrote in his paper, Evidence Based Medicine: What It Is and What It Isn’t, “best practices” constitutes more than just evidence-based information 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…”[1]
There are a few researchers-practitioners who also care for patients and combine EBM with PBE although they were not members of The Lancet panel.
Three studies by Donald Murphy and Eric Hurwitz found joint dysfunction was the cause of neck pain in 69 percent of cases and the cause of low back pain (lumbar and sacroiliac) in 50 percent of patients.[2],[3]
Another 2006 study by Drs. Murphy and Hurwitz on lumbar spinal stenosis also found patients treated with distraction manipulation had an astounding self-rated patient improvement of 75 percent overall; the study concluded:[4]
A treatment approach focusing on distraction manipulation and neural mobilization may be useful in bringing about clinically meaningful improvement in disability in patients with lumbar spinal stenosis.
Not only did these studies by Murphy and Hurwitz support the use of spinal manipulative therapy for spinal stenosis, neck, and LBP, it also proves another point David Sackett suggested — combining EBM with PBE.
Dr. Murphy is an EBM researcher who also blends his PBE experience into his overall practice. His study on Lumbar Spinal Stenosis was cited by the North American Spine Society, Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis (Revised 2011) > Technical Report.
Dr. Murphy also addressed the relationship between pathoanatomy and pathophysiology — the difference in diagnostics between surgeons looking for ‘bad discs’ (pathoanatomy) and classic chiropractors looking for vertebral subluxations (pathophysiology):
“Pathoanatomy only creates the potential for pain. Physiology is what determines whether pain actually occurs or not, and psychology determines how much suffering results from that pain.”[5]
This is an important observation since pathoanatomy alone is rarely the cause of LBP as the MRI research has confirmed finding ‘bad disc’ in pain-free people starting with Boden’s and Wiesel’s study[6] in 1990 and accumulating with the 2015 with the Mayo Clinic systematic review[7] headed by W. Brinjikji:
CONCLUSION:
Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.
For example, despite a 75 percent success rate for pain control in Murphy’s study on lumbar spinal stenosis, patients afterwards still had the pathoanatomy of spinal stenosis, just as patients with degenerative disc disease who improved with chiropractic care still have ‘bad discs’ afterwards.
What improved was the functioning (physiology) of spinal mechanics (restoring joint play) while the spinal pathoanatomy (‘bad discs’, stenosis) remained the same.
I asked Dr. Murphy to address this clinical dilemma:
“Bingo, JC. Clearly the pathoanatomy did not change. We have this discussion frequently in the neurosurgery department when I make the point that the spine is capable of handling pathoanatomy as long as the physiology is right (and psychology, of course).[8]
Dr. Murphy admits another problem in spine care is the prevailing medical bias against chiropractors:
“Many patients are told not to go to a chiropractor, told that their spine is degenerated and the last thing they want to do is to have someone move it. In my experience, having someone move the spine is the best thing.
“The advantage we have as nonsurgical spine specialists is when it’s not clear whether a person will respond or not, there’s no harm in giving it a try. The worst thing that can happen is that they don’t respond. With surgery, if you’re not sure whether the person is going to respond or not, it’s a lot harder to just say, ‘Let’s go for it and see what happens.’ You’re making a permanent change in the structure of the spine.”[9]
The primary importance of physiology in spine care explains why the diagnosis of a ‘bad disc’ was deemed a “red herring”[10] by Dr. Murphy, very similar to Dr. Rick Deyo’s term “incidentaloma,”[11] and why ‘bad discs’ remains a diagnostic mistake that has led to millions of unnecessary and unsuccessful spine surgeries.
This EBM debate is also a hot topic on a larger scale internationally.
In a recent article by Jason Fung, MD, The Corruption of Evidence Based Medicine — Killing for Profit, noted the unscientific nature of many EBM papers by posing the question, “So, why do prominent physicians call EBM mostly useless?”
According to Dr. Fung:
The 2 most prestigious journals of medicine in the world are The Lancet and The New England Journal of Medicine. Richard Horton, editor in chief of The Lancet said this in 2015:
“The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue.”
Dr. Marcia Angell, former editor in chief of NEJM wrote in 2009:
“It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor.”
We’ve seen such evidence of questionable EBM articles spreading “widespread misconceptions” by slamming chiropractic, such as a Cochrane Review by Sidney Rubinstein from Vrije Universiteit Amsterdam in the Netherlands:
- Spinal manipulative therapy for acute low back pain: an update of the Cochrane review by Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW concluded:
“SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies.”
On March 14, 2018, a Commentary at Medscape.com compounded this EBM dilemma with non-practitioners dictating practice standards. Jack West, MD, authored, Physicians on the Sidelines: How Can Healthcare Be Reinvented Without the People Who Actually Care for Patients?:
Of course, these [EBM] individuals provide helpful insight and some understanding of the practical issues around patient care, but it’s no exaggeration to say that the issues and challenges of the community-based [PBE] physicians who care for 20 or more patients 4-5 days every week are fundamentally different from those of the narrow subset who have such titles as “Chief Innovator” at their academic center and see a handful of patients every week…
He points out the irony of healthcare being reinvented without the help of doctors who actually care for patients:[12]
“None of these self-appointed saviors of medicine actually cares for patients. And I don’t think any viable new system can be developed without meaningfully engaging the people on the front lines.”
A good example of Dr. West’s claim was The Lancet panel comprised of MDs and PhDs who are mainly researchers and professors, clearly evidence of what Dr. West suggests, “I don’t think any viable new system can be developed without meaningfully engaging the people on the front lines.”
Indeed, no one is more entrenched on the front line fighting LBP than chiropractors.
It was unfortunate The Lancet did not convene a parallel panel of PBE practitioners to offer an alternative paper on 1) the overview of the worldwide pandemic of pain (that I will discuss in Part 3) and 2) to describe the mechanical manual therapy model of spine care rather than EBM advocates giving ‘nonspecific’ recommendations.
Search for Truth
One of the panel’s Key Messages is also worth noting:
- Address widespread misconceptions in the population and among health professionals about the causes, prognosis, and effectiveness of different treatments for low back pain, including fragmented and outdated models of care
It appears the panel failed to consider the backstory of the “widespread misconceptions” that did not develop overnight but evolved from the fallout of a century-long medical war against chiropractors to oppress chiropractic with political dirty tricks and propaganda defaming chiropractors via public humiliation in order to create the present medical monopoly by containing its main competitor in the lucrative $100 billion spine market.
The “outdated models of care” about medical spine care have already been deemed “the poster child of inefficient care” [13] by Lancet panelist and editor of The Back Letter, Mark Schoene. Yet these outdated, dangerous, expensive and mostly ineffective medical models of care still predominate despite such warnings that never seem to reach the public via the mass media or via their primary care providers.
The worldwide burden of LBP would not be what it is today if chiropractors had been assimilated into the mainstream of healthcare programs instead of being marginalized and defamed. Certainly by segregating chiropractors from hospitals and discouraging inter-professional referrals (the very basis of the Wilk v. AMA antitrust trial), the public was harmed by low value medical spine care as we now see throughout the world.
This sordid history leading to the pandemic of back pain was ignored by The Lancet panel, once again proving how the history of chiropractic was the missing elephant in the room to these researchers. It’s equivalent to understanding the Civil War without mentioning slavery, Jim Crow lynchings or the Civil Rights Act.
While addressing the “outdated models of care,” it appears The Lancet panel’s suggestion to put primary care MDs in charge of LBP was, in effect, another inexplicable mistake of enabling clinical incompetence. In light of the opioid crisis stemming from the offices of primary care providers, for the panel not to address the obvious mistake of MDs as POE is equivalent to putting arsonists in charge of the fire station.
In fact, if the panel had a backbone, it should have called for the complete renunciation of MDs as POE for MSK.
Studies confirm most primary care physicians are inept in their training on musculoskeletal disorders,[14] more likely to ignore recent guidelines,[15] only 2% are likely to refer to DCs,[16] and more likely to suggest spine surgery than surgeons themselves.[17]
Researcher Rick Deyo, MD, MPH, author of “Watch Your Back!”, also mentioned physician incompetence in diagnosis and treatment of low back pain:
“Calling a [medical] physician a back pain expert, therefore, is perhaps faint praise — medicine has at best a limited understanding of the condition. In fact, medicine’s reliance on outdated ideas may have actually contributed to the problem.”[18]
Many medical experts agree physicians are a bad choice to be POE for back pain cases. Scott Boden, MD, director of the Emory Orthopedics & Spine Center, agreed with Dr. Deyo:
“Many, if not most, primary medical care providers have little training in how to manage musculoskeletal disorders.”[19]
Yet, where were these honest and harsh sentiments in The Lancet review? Were the panelists afraid to upset the domineering medical elephant in the room?
Not only are most MDs ill-trained in musculoskeletal disorders,[20] Mr. Mark Schoene, undoubtedly the most astute editor in spine literature, believes most primary care providers are downright 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. [21]
I am confused how the “outdated models of care” and “widespread misconceptions” will change if the same inept MDs remain the portal of entry for musculoskeletal disorders. This was a huge oversight by the panel when DCs were not recommended to replace MDs as the POE for spine-related disorders as some studies already recommend. [22],[23]
Just as patients do not seek MDs for dental issues, nor should they seek MDs for spinal issues; this alone could have been the most impactful message from this esteemed panel. Moreover, it dropped the ball badly when the panel also grouped chiropractors with lesser qualified spine practitioners in need of “improved training”:
Improved training and support of primary care doctors and other professionals engaged in activity and lifestyle facilitation, such as physiotherapists, chiropractors, nurses, and community workers, could minimise the use of unnecessary medical care.
A case can easily be made PCP MDs, PTs, nurses and community workers are incompetent in their training on LBP, but to include DCs in this group illustrates the panel’s lack of understanding of chiropractic education and practice. Apparently it forgot why DCs are the 3rd largest physician-level health professionals in the world already counseling patients on “activity and lifestyle facilitation”; plus we specialize in the spine with nondrug, non-invasive care unlike any other profession.
No wonder LBP is a worldwide burden when MDs are clueless acting as the portal of entry for musculoskeletal disorders. Certainly some non-US Osteopaths, McKenzie PTs, and some physiatrists may be well trained in manual therapy, but as a whole, DCs are the foremost professionals.
However, I will admit not all DCs practice the same, some chiropractic treatments are not best suited for LBP[24], and some choose not to treat LBP cases such as pediatric practitioners, but overall chiropractors are still better trained and clinically equipped to deal with this pandemic of pain than any other group of providers; after all, the spine is our specialty.
Certainly chiropractors don’t have all the answers for every patient, but we do offer 140+ methods to help in this crisis[25] as well as the common sense to refer the “red flags” to other practitioners. Perhaps our safety and effectiveness explains why chiropractors also have the lowest malpractice rates among all primary providers and spine surgeons as the Gallup-Palmer survey found:
Lest the panelists forget for over a century chiropractors have fought to “minimize the use of unnecessary medical care.” If DCs had not been segregated in the mainstream healthcare industry and if patients had unfettered access, millions more would have avoided low value medical care. The issue isn’t training for DCs, but opportunity to compete on a level playing field and patient access to our services.
Unfortunately, the boycott of chiropractic remains persistent with most MDs according to an article, Managing low back pain in the primary care setting: the know-do gap:
Manipulation, which is supported by most guidelines, is recommended by PCPs in only 2% of the acute nonspecific LBP cases.[26]
The Lancet panel also described the continuing dilemma in spine care including the “gap between evidence and practice;” in other words, the medical covert boycott of the guidelines:
Low back pain is now the number one cause of disability globally.
Although there are several global initiatives to address the global burden of low back pain as a public health problem, there is a need to identify cost-effective and context-specific strategies for managing low back pain to mitigate the consequences of the current and projected future burden.
Despite many clinical guidelines with similar recommendations for the management of low back pain, the gap between evidence and practice is pervasive.
Enjoy Part 3: Follow the Money
[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
[2] Donald R Murphy and Eric L Hurwitz, Application of a diagnosis-based clinical decision guide in patients with neck pain, Chiropractic & Manual Therapies 2011, 19:19
[3] Donald R Murphy and Eric L Hurwitz, “Application of a diagnosis-based clinical decision guide in patients with low back pain,” Chiropractic & Manual Therapies 2011, 19:26
[4] Murphy DR, Hurwitz EL, Gregory AA, Clary R. A non-surgical approach to the management of lumbar
spinal stenosis: a prospective observational cohort study. BMC Musculoskelet Disord. 2006;7:16.
[5] Donald Murphy in private communication with JC Smith, July 20, 2012
[6] Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.
[7] Systematic literature review of imaging features of spinal degeneration in asymptomatic populations.
[8] Donald Murphy in private communication with JC Smith, July 20, 2012
[9] Chiropractic Approach to Lumbar Spinal Stenosis Part II: Surgery and Treatments By Carol Marleigh Kline, JACA Online editor, MAY‐JUNE 2008
[10] DR Murphy, Clinical Reasoning in Spine Pain volume 1, Primary Management of Low Back Disorders Using the CRISP Protocols © Donald Murphy 2013, p. viii
[11] Deyo RA, Patrick DL, Hope or Hype: The obsession with medical advances and the high cost of false promises, AMACOM publication, 2002, pp. 191.
[12] Physicians on the Sidelines: How Can Healthcare Be Reinvented Without the People Who Actually Care for Patients? – Medscape – Mar 14, 2018.
[13] The BACKPage editorial vol. 27, No. 11, November 2012.
[14] EA Joy, S Van Hala, “Musculoskeletal Curricula in Medical Education– Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/11 (November 2004).
[15] 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.
[16] Scott NA, Moga C, Harstall C. Managing low back pain in the primary care setting: The know-do gap. Pain Res Manag. 2010;15:392–400 [PMC free article] [PubMed]
[17] 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.
[18] Deyo, RA. Low -back pain, Scientific American, pp. 49-53, August 1998.
[19] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28(2003):524-525.
[20] EA Joy, S Van Hala, “Musculoskeletal Curricula in Medical Education– Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/11 (November 2004).
[21] The BackLetter, volume 30, number 10, 2015
[22] Thomas M. Kosloff, DC, David Elton, DC, Stephanie A. Shulman, DVM, MPH, Janice L. Clarke, RN, Alexis Skoufalos, EdD, and Amanda Solis, MS, Conservative Spine Care: Opportunities to Improve the Quality and Value of Care, Popul Health Manag. Dec 1, 2013; 16(6): 390–396.
[23] Liliedahl RL, Finch MD, Axene DV, Goertz CM. Cost of care for common back pain conditions initiated with chiropractic doctor vs. medical doctor/doctor of osteopathy as first physician experience of one Tennessee-based general health insurer. J Manipulative Physiol Ther. 2010;33:640–643 [PubMed]
[24] “Rating specific chiropractic technique procedures for common low back conditions,” JMPT, 2001 Sep; 24(7):449-56. by Meridel I. Gatterman, DC, Robert Cooperstein, Charles Lantz, DC, Stephen M. Perle, DC Michael J. Schneider, DC
[25] Christine Goertz, DC, PhD, at the DC2017 conference mentioned there are 140+ techniques today used by chiropractors.
[26] Scott NA, Moga C, Harstall C. Managing low back pain in the primary care setting: The know-do gap. Pain Res Manag. 2010;15:392–400 [PMC free article] [PubMed]