Poisoned Pen


Poisoned Pen

The very ink with which history is written is merely fluid prejudice.

Mark Twain

Author Cathryn Jakobson Ramin makes a convincing argument in her new book, Crooked: Outwitting the Back Pain Industry and Getting On the Road to Recovery, about the problems in spine care in America, a topic I also have written about for decades.

However, I found her book insidiously dangerous because it contains just enough good information about the corrupt medical back pain industry (drugs, shots, surgery) to sway unwitting readers to believe her shockingly and unfounded bad advice she offers about chiropractic care.

Ms. Ramin’s comments about chiropractic were clearly fake news – mean-spirited, one-sided and terribly misleading. She cleverly positions herself as one who has been ripped off with her own back pain experiences, so readers are apt to trust her every word—“just believe me” is her allure as a consumer advocate (even though much of what she says about chiropractic contradicts numerous Consumer Reports articles).

Ms. Ramin’s chapter about chiropractic care is laden with outward bias filled with the typical yada, yada, yada of anecdotal hyperbole we’ve seen for years, petty historical points about DD Palmer, irrelevant comments by HL Mencken and, of course, the typical Chicken Little journalism about strokes aimed to alarm the public.

Her “crooked” opinion of chiropractic will be more harmful than helpful to readers; in fact, her bad advice will only add to the defamation and medical boycott already in place that led to the “national scandal” and the “poster child of inefficient medical spine care” as described by Mark Schoene, editor of The BackLetter.

Instead, Ms. Ramin dredged up every bit of mud in her smear campaign to discredit chiropractors while ignoring the recent bounty of guidelines supporting our profession. Ironically, her omission of the truth about the new guidelines and studies endorsing chiropractic will inevitably leave mud on her face as this truth becomes better known.

Caveat Emptor

Let me warn her readers “buyers beware” because she is a wolf-in-sheep’s clothing with her attack on one of the most effective nondrug and nonsurgical treatments — chiropractic care – as the research and guidelines now support.

In her attempt to “outwit the back pain industry”, her jaded information about chiropractic will bamboozle her unsuspecting readers with disinformation to “contain and eliminate” chiropractors not seen since the days of the AMA’s illegal Committee on Quackery that hired third-party goons such as writer Ralph Lee Smith and columnist Ann Landers to make it appear “everyone knows chiropractic is an unscientific cult.” [1]

Perhaps the most inane remark against chiropractors coming from Ann Landers’ poisoned pen was her infamous, “The truth is, he’d probably have been cured if he had fanned himself with goofus feathers.”[2] Although silly, it did fan the flame of prejudice.

Ms. Ramin now surpasses Ann Landers as the newest shill in the lineage of journalists taking cheap shots at chiropractors. When Landers stated her nonsense years ago when there was scant research to refute her lies, today there is totally a different situation.

KQED Radio Interview

As a socialite rubbing elbows at cocktail parties in San Francisco and New York City, Ms. Ramin has already made token media appearances unabashedly stating her dislike for chiropractors. You can hear Ramin’s story, How the Back Pain Industry is Taking Patients for a Dangerous Ride, in her May 22, 2017, interview with host Eric Westervelt on KQED Radio, public broadcasting in the Bay Area.

Radio host Eric Westervelt commented on her slam against chiropractors:

“You indict many of the big players in the back pain arena. One of them is chiropractors. Thirty-five million Americans see chiropractors. They’re going to be shocked by that indictment.”

Her response offers more spurious comments:

“I assume the chiropractic folk will be quite upset. If you just developed back pain, there’s evidence that one to two sessions with a chiropractor may help you. More than that, there’s absolutely no evidence for it, and anyone who has gone to see a chiropractor knows there are very few chiropractors who want to see you for one to two sessions. The moment you come through that door, you are told that, for maintenance purposes, you need to come very, very regularly for a very, very long time, maybe forever. And there is no evidence at all for that.”

This is just the start of many vitriolic comments by Ms. Ramin. To the contrary, I know of no “evidence that one to two sessions with a chiropractor may help” but I am “very, very” eager to learn of her sources.

To refute her claim “there is no evidence at all” for  maintenance care, let me share evidence from a 2011 study, Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?

This study concluded:

The group that was given spinal manipulations (SM) during the follow-up period showed more improvement in pain and disability scores at the 10-month evaluation. In the non-maintained SMT group, however, the mean pain and disability scores returned back near to their pretreatment level.

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.

Medical Trolls

To understand the source of her rancor, I discovered the “fluid prejudice” flowing from Ms. Ramin’s poisoned pen came from the inkwells of infamous medical trolls.

In her chapter, A TALE OF TWO TABLES: Why Back Patients “Fail” Chiropractic Treatment and Physical Therapy, she bases much of her dislike for chiropractors on the opinions of members of the Institute for Science in Medicine, an alt-right organization of medical bigots, the equivalent to a medical KKK:

“In Trick or Treatment, a must-read book about fallacies in alternative medicine, science reporter Simon Singh and his coauthor, scientist Edzard Ernst, describe an experiment conducted by psychiatrist Stephen Barrett, one of the most fervent naysayers regarding chiropractic.”

Her reliance on the advice of these ISM trolls is equivalent to discussing race relations by asking only white supremacists what they think of civil rights.

Anyone with an ounce of knowledge of these curmudgeons realizes they are not respected by ethical researchers and policy makers; only yellow journalists seem interested in their viewpoint. As fate would have it, the careers of both Ernst and Barrett ended in professional disgrace.

Moreover, her comment about the “fallacies in alternative medicine” is a clear indication of her bias against CAM methods. She fails to mention Americans made more visits to CAM providers than to MDs according to a Harvard study by Dr. David Eisenberg.[3] Upon seeing the huge number of Americans using CAM practitioners, Dr. Eisenberg concluded, “Maybe ‘alternative’ isn’t so alternative anymore.”[4]

Crooked Opinions

However wrong she is about chiropractic and CAM in general, Ms. Ramin is correct about one thing—chiropractors will be upset by her book because of the complete absence of the recent studies confirming chiropractors will play an increasingly valuable role in the back pain and opioid painkiller epidemics.

Her mantra seems to be “Don’t confuse me with the facts.”

The fact she attacked chiropractic care first speaks volumes of her chirophobia; one would think she would begin with the opioid crisis and spine surgery as bigger fish to fry, instead she chose first to eviscerate chiropractors as if we were the main cause of this medical mess.

Her tirade against chiropractors undoubtedly was meant to dispel upfront any notion by her readers that chiropractic care is rising as a treatment of choice as a survey by Consumer Reports found in 2011, Alternative health treatments that work: More than 45,000 readers tell us what helpedwhere DCs were rated by consumers at the top of back care practitioners.

Ms. Ramin is not the first and certainly will not be the last writer to slam chiropractors; sadly, her role as a patient advocate will convince many gullible people to follow her insular advice with such gems as:

·         “There is no reason to let a chiropractor anywhere near your neck.”

Following the lead of the Katie May accidental death, she waxed endlessly about the dangers of SMT causing strokes suggesting every day someone will stroke out from chiropractic care. If we do not push back against her drivel, we know the media would go viral on this issue just as they did with Katie May.

Fortunately the science, guidelines, public surveys and many spine experts disagree with her.

 “The stroke question is basically resolved,” neurologist Scott Haldeman, MD, DC, PhD, and Associate Professor of Neurology at the University of California, said in a TIME article by Markham Heid,” Are Chiropractors Legitimate?”, which is definitely another “gotcha” title as we witnessed with the Dr. Oz Show, Can your chiropractor kill you?

Citing research that shows the risk of suffering a stroke following a chiropractic visit is extremely low, Dr. Haldeman’s own research found only 23 such cases among more than 134 million chiropractic manipulations. This is equivalent to one in 5.85 million office visits, which is less often than having a stroke while visiting a dentist, a hair salon or being hit by lightning.

Her derogatory comments and anecdotal stories about stroke victims failed to include studies showing most of these patients had been associated with pre-existing injuries such as a car accident, sports or workplace injury.

Ms. Ramin also ignored three landmark vertebrobasilar stroke studies:

  • The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: Executive Summary by Scott Haldeman and David J Cassidy, et al. came to two conclusions:

    • There was no smoking gun between SMT and catastrophic bleeds.

    • This study also found a similar association of strokes among patients receiving general practitioner services.

  • Neck Manipulation May Be Associated with Stroke written by José Biller, MD, professor and chair of neurology at the Loyola University Chicago Stritch School of Medicine admitted “a direct cause-and-effect link has not been established between neck manipulation and the risk of stroke”:

    •  “Treatments involving neck manipulation may be associated with stroke, though it cannot be said with certainty that neck manipulation causes strokes, according to a new scientific statement published in the American Heart Association’s journal Stroke.” [5]

·         Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation, written  by a team of neurosurgeons at the University of Pennsylvania Hershey Medical Center published in February, 2016:

o        “There is no convincing evidence to support a causal link between chiropractic manipulation and cervical artery dissection (CAD).”

Of course, she makes no mention of the rate of death and serious side effects from medical spine care (drugs, surgery) are approximately 2500 in one million. Indeed, who’s hurting whom?

Another example of her skewed recommendations inexplicably tells patients to find a chiropractor who doesn’t adjust the spine:

·        “They have stopped seeking vertebral subluxations [partial dislocations] which don’t actually exist on any X-ray or any type of scan, and have moved onto the very excellent practice of rehabilitation.” 

As luck would have it, I recently received an MRI report from a certified radiologist recently who mentions the presence of subluxation. Perhaps he forgot to read her book claiming subluxations don’t exist.

It was also alarming she referred to Craig Liebenson, DC, director of the International Society of Clinical Rehab Specialists, to degrade chiropractic adjustments:

“Liebenson maintains the ‘DC’ behind his name, but says he decided while in school that chiropractic founder Palmer’s theories were hogwash.

“Hands on adjustments is what patients want, he explained, but it is not what they need. ‘Repeat after me,’ he intoned to the group: ‘We refrain from the laying on of hands…We need to focus on function, not on pain and scans and symptoms, because all these poison the minds of patients.’”

He fails to realize Ms. Ramin’s pen will also “poison the minds of patients” in the court of public opinion.

I agree with his focus on function and rehab, a program I follow myself personally and professionally, but suggesting DCs should not adjust the spine is ridiculous.

Moreover, I daresay anyone can nitpick on the accuracy of DD Palmer’s theories written over a century ago in his original 1910 book, The Chiropractor’s Adjuster, but for the times he was a brilliant self-taught essayist and entrepreneur as Joseph Donahue, DC, wrote in his article, “The Man, the Book, the Lessons: The Chiropractor’s Adjuster, 1910:”

“That DD Palmer would be wrong about some things was inevitable. That he was right about so much is incredible.”

Although rehab and self-care habits are certainly helpful as Dr. Liebenson suggests, a wobble board will never replace an adjustment. Rehab exercises are not the starting point in spine care; until the kinetic and structural aspects of the spine and musculoskeletal system are addressed, including restoring joint play by adjusting vertebral subluxations, the spine will not heal and certainly not stabilize without consequences such as degeneration and chronic pain.

Indeed, the prerequisite role of joint function was stated by John McMillan Mennell, MD, orthopedist, author and professor, in his testimony at the Wilk trial in 1976:

“Eight out of ten patients that come out of any doctor’s office complain of a musculoskeletal system problem, regardless of what system the pain is coming from…I will say 100 percent of those complaints…are due to joint dysfunction in the musculoskeletal [system]…

“In the spine there are about 137 synovial joints…If you don’t manipulate to relieve the symptoms from this condition of joint dysfunction, then you are depriving the patient of the one thing that is likely to relieve them of their suffering…

“The science of mechanics demands that joint play movement is prerequisite to normal pain-free functioning of movement.”[6] 

Ms. Ramin casts more aspersions with grossly unproven statements:

·         “Study after study after study has shown that long-term visits to chiropractors don’t help patients. They don’t prevent back pain; they don’t solve back pain.”

Just what are these Study after study after study she mentions? Her accusations DCs are over-treating and unable to solve back pain is not only untrue, it is harmful disinformation.

Without question Ms. Ramin’s lack of a fair and balanced accounting of chiropractic care was obvious since she failed to mention the abundance of recent studies recommending chiropractic care over medical spine care. Again, “don’t confuse her with the facts” is evident in her lack of research.

Nor did she quote any reputable chiropractic thought-leaders such as Scott Haldeman, Louis Sportelli, Gerry Clum, David Chapman-Smith, Christine Goertz, Heidi Haavik, Jay Triano, Tony Rosner, Bill Meeker, Vern Saboe or Mark Studin, to name just a few of many experts who could have easily refuted her claims.

Her comment “chiropractors don’t solve back pain” comes as yet another surprise she did not do her homework considering in 2013 a Military Study: Low-Back Pain Relief with Chiropractic Care featured the benefit of adding chiropractic care to medical spine care.

Led by Christine Goertz, DC, PhD, from the Palmer Center for Chiropractic Research, this study found:

·         73 percent of those who received standard medical care and chiropractic care rated their improvement as pain “completely gone,” “much better” or “moderately better.” 

·         In comparison, 17 percent of participants who received only standard medical care rated their improvement this way.

Proof Positive

Let me enlighten Ms. Ramin her to the recent guidelines recommending chiropractic care/SMT:

  • The updated American College of Physicians guidelines for treating nonradicular low back pain with nondrug, nonsurgical conservative care were published on Feb. 14, 2017, in the Annals of Internal Medicine:

The American College of Physicians (ACP) recommends in an evidence-based clinical practice guideline published in Annals of Internal Medicine that physicians and patients should treat acute or subacute low back pain with non-drug therapies such as superficial heat, massage, acupuncture, or spinal manipulation.

Findings:  In this systematic review and meta-analysis of 26 randomized clinical trials, spinal manipulative therapy was associated with statistically significant benefits in both pain and function, of on average modest magnitude, at up to 6 weeks.

Consumer Reports published two positive articles soon after the ACP and JAMA guidelines were released:

For the first time, the American College of Physicians is advising treating back pain with nondrug measures like tai chi, yoga, chiropractic, and massage before resorting to over-the-counter or prescription pain relievers. 

A new analysis finds that the hands-on technique works as well as pain drugs and is safer, too.

When you wrench your back, your first impulse may be to rummage through the medicine cabinet for an over-the-counter pain drug or even ask your doctor to prescribe a strong opioid painkiller such as Percocet or Vicodin. But an analysis published April 11 in the Journal of the American Medical Association finds that spinal manipulation can ease your backache and get you moving again without the risk of medication side effects.

Both pharmacologic and nonpharmacologic strategies have a role in the management of pain. The following examples are not exhaustive, but strategies may include the following:

  • Nonpharmacologic strategies: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy.

The FDA released its blueprint on educating health care providers about treating pain suggesting they “should be knowledgeable about the range of available therapies, when they may be helpful, and when they should be used as part of a multidisciplinary approach to pain management.”

  • The North American Spine Society (NASS) has released its own guidelines over the past decade supportive of chiropractic care:

  • In 2007, the NASS published Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis that found 75% of patients graded themselves as improved under chiropractic care:

    • This study provides Level IV therapeutic data suggesting that distraction manipulation and neural mobilization may be beneficial in the treatment of lumbar spinal stenosis.

  • In 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.

  • In 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.”

Inept MDs

Not only have the guidelines promoted SMT over drugs, shots and surgery for the majority of ‘nonspecific, mechanical’ back pain cases, many experts agree another problem is the fact MDs are inept in training to handle musculoskeletal disorders, which is how America got into this Pharmagedon in the first place.

“Physicians are not adequately prepared and require greater knowledge and skills to contribute to the cultural transformation in the perception and treatment of people with pain.”[7]

  • Mr. Mark Schoene, editor of The BackLetter, an international spine journal, also noted the paradox of using MDs as portal of entry for musculoskeletal disorders:

“Primary care physicians and pain specialists are primarily responsible for the opioid overtreatment crisis. Are the two professions that helped create the worst pain management crisis in history of modern medicine capable of leading the way forward? That remains to be seen.”[8]

  • Scott Boden, MD, director of the Emory Orthopaedic and Spine Center in Atlanta, also admits, “Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders.” [9]

  • Researcher Richard Deyo, MD, MPH, author of “Watch Your Back!”, also mentioned the problems with medical treatments and physician incompetence in diagnosis and treatment of low back treatments:

“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.”[10]

  • A study often cited by attorney George McAndrews is the 2012 investigation performed at the Department of Orthopaedic Surgery by Nathan W. Skelley, MD, et al., at The Johns Hopkins University, Medical Student Musculoskeletal Education: An Institutional Survey.

    • This investigation found the “inadequate” formal education by medical students on MSDs, and I might add this includes a lack of education on alternative and complementary methods that the ACP now recommends.


Click here to begin video.

Comparative studies also confirm chiropractors are safer, faster and less costly than medical spine care:

  • Clinical Utilization and Cost Outcomes from an Integrative Medicine Independent Physician Association. [11]

Conducted by Richard l. Sarnat, MD, President of Alternative Medicine Integration (AMI), this clinical and cost utilization study was based on 70,274 member-months over a 7-year period that combined chiropractic care with conventional medicine IPA performance for the same health maintenance organization product in the same geography and time frame demonstrated decreases of:

  • 60.2% in-hospital admissions,

  • 59.0% hospital days,

  • 62.0% outpatient surgeries and procedures, and

  • 85% pharmaceutical costs.

  • Regional Supply of Chiropractic Care and Visits to Primary Care Physicians for Back and Neck Pain.[12]

       Another study supporting the changing concepts in health care delivery found utilizing chiropractic care decreased costs with Medicare patients. In July 2015, the Journal of the American Board of Family Medicine published this study that performed a cross-sectional study of 17.7 million older adults who were enrolled in Medicare from 2010 to 2011 to examine the association between regional supply of chiropractic care and number of annual visits to PCPs for back and/or neck pain.

The results estimate chiropractic care is associated with a reduction of 0.37 million visits to PCPs nationally at a cost savings of $83.5 million. The authors concluded: “Greater availability of chiropractic care in some areas may be offsetting PCP services for back and/or neck pain among older adults.”

  • DoD Study

Chiropractic care was recently introduced into the military health services selectively at a few military facilities and scored enormously high patient satisfaction rates in a 2009 poll that ranged from

  • 94.3 percent in the Army;

  • the Air Force tally was also high with twelve of 19 bases scoring 100 percent;

  • the Navy also reported ratings at 90 percent or higher; and

  • the TRICARE outpatient satisfaction surveys (TROSS) rated chiropractors at 88.54 percent, which was 10 percent “higher than the overall satisfaction with all providers” that scored at 78.31 percent.

This Chiropractic Care Study[13] also commented on the Unit Commanders and military treatment facilities (MTF) personnel concerning chiropractic care. “The responses were overwhelmingly a five (the highest rating available); MTFs that offer chiropractic care are pleased to do so.”

  • The U.S. Public Health Service

In 1997, the USPHS conducted an investigation, Chiropractic in the United States: Training, Practice and Research, [14]that admitted “chiropractic has undergone a remarkable transformation” as well as other very positive conclusions:

Spinal manipulation and the profession most closely associated with its use, chiropractic, have gained legitimacy within the United States health care system that until very recently seemed unimaginable.

In the past several decades, chiropractic has undergone a remarkable transformation. Chiropractic is now recognized as the principal source of one of the few treatments recommended by national evidence-based guidelines for the treatment of low-back pain, spinal manipulation.

This in-depth study done in 2013 of internal data of 1.4 million non-surgical back pain episodes by Optum Health determined the best track to take for cost efficiency begins with a patient consulting a chiropractor first.[15]

When manipulation is introduced within the first 10-days of the episode, the Optum researchers found “Spine care is characterized by low rates of imaging, Rx, injections, and surgery when including episodes starting with a DC.”

·         Agency for Health Care Policy & Research

Ms. Ramin also made no mention of the exhaustive 1994 AHCPR guideline #14 on acute low back pain in adults recommending SMT as a “proven treatment.”[16] The US Public Health Service impaneled the most prestigious spine researchers in the nation in a two year study of thousands of studies. For Ms. Ramin to ignore this landmark study is equivalent to anti-climate change advocates who ignore NASA’s Intergovernmental Panel on Climate Change.

Ramin’s Bottom Line

Remarkably Ms. Ramin’s “Road to Recovery” advice comprised of just two things: Exercise and Cognitive Behavior Techniques (coping mechanisms).

I wish it were that simple, but it isn’t. Although many chiropractors already incorporate these aspects of self-care after treatment, she ignores the paramount need to correct vertebral subluxations by adjusting the multitude of spinal joints.

Ms. Ramin also recommends finding a “back whisperer” – someone who understands the musculoskeletal system and is able to help people build strength, balance their gaits and move effectively. For her information, many chiropractors already give essential guidance in this area.

Her alternative facts, errors and omissions reveal Ms. Ramin how badly mischaracterized the value of chiropractic care with her complete exclusion of the supportive studies and guidelines.

This oversight also points to a larger issue—her integrity as a journalist who cannot tell the whole truth.

A tweet by President Trump might be amendable to our own professional situation with the media when he said, “the media is the enemy of the American people.” In fact, Ms. Ramin has clearly misled the public about chiropractic care. Unbeknownst to Ms. Ramin, her bad advice will only add to the misery of readers who may follow her simplistic solutions and her boycott of chiropractors.

The Good Fight is Never Over

History is replete with other examples of the media war against the chiropractic profession since the days of Morris Fishbein and columnist Ann Landers to the present medical bloggers and online trolls who impugn our reputation with “fake news” and spurious allegations.

As a 35-year practitioner myself, I’ve witnessed the medical failures of failed back surgery who come to my office as the proverbial “last resort.” I hear their despair of addiction and disability that began with bad advice from their inept MDs who railroaded them to opioids, shots and surgery—this is the “national scandal” the guidelines hope to correct despite the merchants of misinformation who continue to attack chiropractic care.

Ms. Ramin should read my book, To Kill a Chiropractor, to learn the paradigm shift in spine care and, if she has one ounce of journalistic pride, she should withdraw her book from the market and issue a public apology to the chiropractic profession.

If KQED and PBS subscribe to the Fairness Doctrine, they owe our profession equal time to refute her misinformation – how I would love to debate this woman and hold her feet to the fire of scientific studies.

What a disgusting disservice she has committed. Instead of enlightening the public to the new guidelines touting the benefits of our brand of nondrug, nonsurgical spine care, she discourages them from the most helpful of all treatments for the majority of back pain cases—chiropractic care.

Sadly, from her poisoned pen flows the very ink with “fluid prejudice with which history is written” unless we stop her disinformation with the truth.

If you would like to share your opinion with Ms. Ramin, I urge every DC to post your thoughts on her FB page. Now is the time for social media to create a campaign, #Chiropractors Matter, to expose the fake news from Ms. Ramin.


[1] W Trever, “in the Public Interest,” Scriptures Unlimited, Los Angeles, Calif., (1972):11

[2] Ask Ann Landers, “Chiropractors Eyed,” The Times-Picayune, New Orleans, LA. (January 28, 1971)

[3] DM Eisenberg, RC Kessler, C Foster, FE Norlock, DR Calkins, TL Delbanco, “Unconventional  Medicine In The United States — Prevalence, Costs, And Patterns Of Use,” N Engl J Med 328 (1993):246-252.

[4] DM Eisenberg, RC Kessler, C Foster, FE Norlock, DR Calkins, TL Delbanco, “Unconventional  Medicine In The United States–Prevalence, Costs, And Patterns Of Use,” N Engl J Med 328 (1993):246-252

[5] http://newsroom.heart.org/news/neck-manipulation-may-be-associated-with-stroke

[6] Transcript of testimony of John McMillan Mennell, MD, Wilk v AMA transcript, pp. 2090-2093.

[7] http://iom.nationalacademies.org/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx, pp.5.

[8] Why Should the National Pain Strategy Be MD-Centric? BackLetter: February 2016 – Volume 31 – Issue 2 – p 16

[9] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28 (2003):524-525.

[10] Deyo, RA. Low -back pain, Scientific American, pp. 49-53, August 1998.

[11] Richard L. Sarnat, MD, James Winterstein, DC, Jerrilyn A. Cambron, DC, PhD, Clinical Utilization and Cost Outcomes From an Integrative Medicine Independent Physician Association: An Additional 3-Year Update, JMPT, Volume 30, Issue 4, Pages 263-269 (May 2007)

[12] Davis MAYakusheva OGottlieb DJBynum JPRegional Supply of Chiropractic Care and Visits to Primary Care Physicians for Back and Neck Pain.”J Am Board Fam Med. 2015 Jul-Aug;28(4):481-90. doi: 10.3122/jabfm.2015.04.150005.

[13] Chiropractic Care Study, Senate Report 110-335 accompanying the National Defense Authorization Act for FY 2009; letter sent to Congressmen by Ellen P. Embrey, Deputy Assistant Secretary of Defense (September 22, 2009):2.

[14] DC Cherkin, RD Mootz, eds. “Chiropractic in the United States: Training, Practice And Research.” Rockville, Maryland: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, 1997; AHCPR Publication No. 98-N002.

[15] 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.

[16] Bigos et al. U.S. Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guideline, Number 14: Acute Low Back Problems in Adults AHCPR Publication No. 95-0642, (December 1994)