September 29, 2008
TO: George Lundberg, MD
Editor-in-Chief of Medscape General Medicine
FROM: JC Smith, MA, DC
RE: Academic Cheap Shot
Dear Dr. Lundberg:
First of all, I am a big fan and consider you a highly respectable medical editor-journalist. Your Medscape video-editorials are often brilliant, but I must object to a recent course offered online by your Medscape.
I was shocked when I read in your Medscape email an ad promoting CME/CE for a course entitled CME/CE Spinal Manipulation May Not Be Helpful for Low Back Pain conducted by obscure Swiss researchers who came to the inexplicable conclusion that SMT is ineffective for acute LBP. Despite the obvious shortcomings of this study, the mere presence on your Medscape website suggests it’s a significant study; you even gave it CME/CE credit for an entire year.
Obviously, this flies in the face of the weight of evidence from numerous recent large studies that recommend SMT for LBP, beginning with the 1994 USPHS’s AHCPR Guideline #14 on Acute LBP in Adults that listed spinal manipulation as a “Proven Treatment,” or the recent study on chronic LBP by Haldeman et al. for the Decade of Bone and Joint Disorders that also gave clinical merit to SMT, or the more recent Guidelines for LBP by the American Pain Society that recommended SMT for both acute and chronic LBP.
I thought we were passed the point of casting suspicion at SMT by medical critics on the lowest rungs of the research ladder after the plethora of research and guidelines that now support what the chiropractic profession and other medical manual manipulators have known for a very long time. If this were a large RCT done by renowned spinal experts, it might carry some weight, but this small study by unknowns shouldn’t be a beep on anyone’s radar, certainly not on Medscape’s website and certainly not for CME/CE credit.
The danger of this misleading course knocking SMT for LBP transcends just the dubious conclusion contained in this study, but it may be used by the hostile HMOs as reason to STOP CARE for SMT as we’ve seen in the past before the era of evidence-based care emerged. Also, the political medical-media would love to see the general press disseminate this misinformation to the public in order to corner the market with their own ineffective methods. I can already see the headline in some tabloid that says, “Swiss study says chiropractic doesn’t work.”
Despite the fact that globally 85,000+ DCs (and some PTs, DOs, and Physiatrists) prove SMT works daily and evidence-based guidelines recommend SMT, this one small spurious study of 104 patients can undo all their good work in a single blow. Indeed, is this the real agenda of Medscape—to cast suspicion on SMT with a small spurious study and overlook all the supportive evidence-based data?
Even the Swiss authors admitted the limits of their small study:
“Of 104 patients with acute low back pain enrolled in this study, 52 were randomly assigned to SMT in addition to standard care, and 52 were randomly assigned to standard care alone, which consisted of general advice and use of paracetamol, diclofenac, or dihydrocodeine as needed. Other analgesics or nonpharmacologic therapies were not permitted.
Cheap “general advice” by PCPs who dispense drugs has not been shown by any credible RCT as an effective treatment for LBP; moreover, PCPs have been shown to be clinical incompetent in the diagnosis and treatment of LBP/MSDs (Freedman and Bernstein, Joy and Van Hala, Humphreys, et al.).
Even the Swiss authors admit their failings:
“Limitations of this study include restricted resources, which lowered the capacity to monitor self-administered patient diaries; missing data, particularly for reported use of analgesics; recruitment rate unexpectedly low; small sample size; and lack of blinding.”
With these many “limitations,” I’m surprised Medscape would publish this study at all.
In the face of the many flaws of this study, these Swiss authors had the gall to conclude:
“SMT is unlikely to result in relevant early pain reduction in patients with acute low back pain,” the study authors write.
As comedian Lewis Black might ask, “Where do I go to shoot myself, Dr. Lundberg?”
This Swiss study also flies in the face of clinical experiences of many medical and chiropractic professionals who use SMT very successfully. For example, in my 30-year career, I’ve treated with great success over 10,000 patients for acute and chronic LBP. Certainly you can understand why my own empirical evidence would cast doubt on the Swiss study of only 52 patients who were treated by SMT.
I daresay there are many medical professionals who also would be at odds with these Swiss researchers, including William Lauerman, chief of spine surgery and professor of orthopedic surgery at Georgetown University Hospital, who said, “I’m an orthopedic spine surgeon, so I treat all sorts of back problems, and I’m a big believer in chiropractic.” Methinks Dr. Lauerman also has treated more than 52 patients.
Alternative Course Selections for Medscape
I certainly don’t need to lecture you about the many medical critics like Hadler, Deyo, Cherkin, Waddell, Boden, Goodley, Haldeman, Brox, Bigos, Fairbank, Fritzell, Weinstein, Nachemson, Rosomoff, Mennell, Shaw, Manga, to name but a few of the increasing number of medical men willing to admit the tsunami of spine surgery is unwarranted or that many treatments in the medical model are inconclusive, temporary at best, certainly expensive and, most troubling, many are just ineffective.
As Scott Haldeman wrote in his BJD report on chronic LBP:
“With CLBP, however, treatment options appear virtually endless and increasing every year, have strong and vocal advocates, and often limited scientific evidence…analogous to shopping in a foreign supermarket without understanding the product labels.”
This Swiss study certainly does nothing to help shoppers and only clouds the picture with questionable “limited scientific evidence” and a suspect conclusion.
If Medscape is willing to give CME/CE credit for this dubious Swiss study, may I suggest other courses that would have greater credibility?
- Indeed, when will I see a similar CME/CE course entitled, “Spine Surgery May Not Be Helpful for Low Back Pain”? At least this course can be supported by many studies by renowned researchers rather than a couple of Swiss wannabees.
- Will we see another CME/CE course entitled “Drugs, ESIs, prolotherapy, botulinum toxin injections, facet joint injection, sacroiliac joint injection, radiofrequency denervation, and intradiskal electrothermal therapy are not supported by convincing, consistent evidence of benefit from randomized trials,” as Dr. Roger Chou wrote in his recent American Pain Society guideline article?
- On your Medscape program is another article concerning LBP that contradicts this Swiss study: Low Back Pain Guidelines Expanded to Include Interventional Procedures concerning the American Pain Society study that recommends SMT for both acute and low back pain. Why isn’t this study given CME/CE credits?
- The BACK Letter recently reported that the Centers for Medicare and Medicaid Services (CMS) has proposed that the evidence is adequate to conclude that thermal intradiscal procedures do not improve health outcomes, as well as artificial discs, vertebroplasty and kyphoplasty as treatments for osteoporotic and other spinal fractures, multilevel lumbar fusion for degenerative disc disease, bone morphogenetic proteins in spinal fusion, and bisphosphonates for osteopenia and osteoporosis. Can we expect a course on these CMS findings?
I also have written commentaries on health care policy and clinical spine care issues that I would like to offer to Medscape as CME/CE courses that would be more academic, relevant, and more interesting than this Swiss study.
- My recent commentary, Zombie Spine Care, elaborates on the many critics of the standard medical procedures for LBP. This pattern resembles “zombie science,” according to Bruce Charlton, MD, who defines it as “a sinister consequence of evaluating scientific theories purely on the basis of enlightened self interest.” Can I expect a CME/CE course on this compilation of legitimate studies and opinions by medical experts who outweigh these Swiss authors who came to an apparent “sinister” conclusion based on spurious limitations?
- Perhaps you might also include a course on Misleading Research to show your readers how some researchers distort the RCTs and jump to bias conclusions as we saw with the recent WC Peul et al. study when he admitted microdiscectomy for sciatica was no more effective than conservative care after 6 months, but still suggested it was a better buy. Talk about zombie science—this is a clear example.
- Paul Goodley, MD, often writes about the Fundamental Flaw in medicine—the bias against manipulative therapy—so you might also include a course on Medical Racism.
- In regards to the epidemic of unnecessary back surgeries, may I recommend a course on the Back Surgery Scam?
- In regards to the lack of free market forces in healthcare driving up costs, another interesting course might include Distributive Injustice, a concept Dr. Pran Manga coined in regards to the obstruction of cost effective care in Canada. With the current imploding of the USA economy, Dr. Manga’s advice should find a favorable audience today.
- Another very controversial but true story, Medical Murder of AHCPR, includes an article by John Weeks, “Back Surgeons, Chiropractic, and the Murder of a Federal Agency on Evidence-Based Medicine.” Certainly Dr. Deyo, who was sued by North American Spine Society for his role in the AHCPR, will enjoy this recap how NASS destroyed the former ACHPR after it released its 14th guideline on acute low back pain in adults, an infamous account of medical thuggery.
- Along the same line, your readers might enjoy my article, Confronting Iatrogenesis, in which I elaborate on Ivan Illich’s three levels of iatrogenesis and how it applies to the back pain business.
- Perhaps your readers might enjoy the article, Squeeze Care to Expand Profits, in which I show the obscene salaries of unscrupulous executives in the medical insurance business. This is particularly poignant today inasmuch as the same “deregulation” policy has led to the demise of all healthcare professionals’ incomes along with the huge increase in HMO executives’ salaries. Indeed, we’re all feeling the “squeeze” today in healthcare.
- Another possible course and common issue facing your readers is the sad state of American healthcare itself, as evident in the 2001 WHO study that ranked the US as #1 in cost, 37th in healthcare delivery, and a puny 72nd in overall population health. I elaborated on this concept in my article, American Healthcare: Truth or Dare?
- On a lighter note, I make fun of my own profession’s oddities in the article, Chiropractors Against White Bread.htm. I’m sure Dr. Hadler will enjoy this spoof on chiropractic’s odd ball characters and their version of vitalism since he has such disdain for the mind-body connection.
- For your readers who want to see an end to the medical bigotry against chiropractors, I’m sure they’ll enjoy my recent article, Tear Down this Wall, in which I seek an apology from the AMA for its genocide against DCs. After the recent act of contrition by the AMA toward its own black members, I believe an apology to chiropractors is also long overdue. Indeed, if the black MDs were forced to sit in the back of the medical bus, we DCs were thrown under the same bus.
As you can see, there are many interesting topics on healthcare policies, the back pain epidemic, and the effectiveness of SMT that are more accurate and important than this minor and ill-conceived Swiss study.
Fair Play in RCTs
While I’m bemoaning the issue of this spurious Swiss study as a CME/CE course, there is another general problem I’ve seen in many of the comparative RCTs on treatments for LBP. As I noted in Misleading Research, the WC Peul et al. study on microdiscectomy vs. conservative care for LBP and sciatica, the term “conservative care” is a very vague area in which SMT is included with many other methods, just as we also saw in the Weinstein et al. SPORT study. It does get confusing what is meant by conservative care.
Mixing the art of spinal manipulation in with other CAM methods, cheap advice with drugs by PCPs, or passive PT methods obscures its true value as a stand alone treatment for LBP; as well, SMT often takes the blame for poor results by these other non-manipulative methods. Often “chiropractic” is often blamed when non-DCs perform SMT with adverse effects.
So, may I recommend to these Swiss researchers, Peul, or Weinstein, for their next comparative study that skilled adjustors are involved as participants inasmuch as there is a “knack” of adjusting the spine that not every practitioner possesses?
To be sure, the art of SMT is like athletics—not every player plays the game at the same skill level. Admittedly, many DCs are not adept in this art of manipulation, which explains the rise of many non-SMT methods in this profession. As I’ve often written, chiropractors are like a box of chocolates—you just never know what you’ll get (with thanks to Forrest Gump).
In fact, I challenge these medical researchers to have a direct comparison between the main medical methods—drugs, shots, surgery—versus skilled manual manipulators who use SMT as well as flexion-distraction and non-surgical spinal decompression—the most popular and effective treatments for LBP in the chiropractic profession. Then we can let the chips fall where they may after a good, honest comparison using skilled practitioners on both sides.
As you can see, Dr. Lundberg, there are many issues about spine care and research that remain controversial, but I daresay the positive role of SMT should not be besmirched by this Swiss study that is admittedly a very poor study compared to the numerous comprehensive studies done in the USA, UK, Norway, Sweden, Canada, to name just a few.
It might be one indiscretion to include this small irrelevant Swiss study in Medscape, but to give it CME/CE is unconscionable and smacks of a hidden agenda to spread misinformation among your readership. Sadly, that damage may have already been done.
I would love to hear a video-editorial reply by you on this matter of posting a spurious RCT with CME/CE credit aimed at discrediting SMT that has been substantiated by numerous, credible RCTs and international guidelines.
Indeed, if this isn’t an academic cheap shot and Medscape smear at the heart of the chiropractic profession, what is?
JC Smith, MA, DC