TO: EDITOR: HEALTH AGENDA
FROM: JC Smith, MA, DC
RE: BACK TO BASICS by Libby Hakim
While reading Libby Hakim’s article about the plight of back pain, Back to Basics (Health Agenda, July 2018), it quickly became obvious she had not done her homework on this important topic despite her appealing headline, “If you’re facing the possibility of spinal surgery, here are some key things to consider.”
Unfortunately, Ms Hakim omitted the main key things to consider; in effect, her article became a free advertisement for spine surgeons.
Ostensibly the reader will be drawn into Ms Hakim’s article since most informed people want to avoid opioid painkillers, epidural steroid injections, and spine surgery, but the reader will quickly be deceived by what Ms Hakim fails to mention—namely chiropractic care.
First of all, it is bewildering anyone writing an article about low back pain (LBP) fails to mention chiropractic care in this day when every evidence-based guideline places this brand of conservative spine care at the top of the list of treatments, especially in light of the opioid painkiller crisis.
For example, Anthony Rosner, PhD, testified before The Institute of Medicine confirming the ascension of chiropractic care, “Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.”
Considering chiropractors comprise the 3rd largest physician-level health profession in the world and the leaders in conservative spine care (nondrug, nonsurgical), Ms Hakim’s omission speaks volumes about either her bias and/or lack of due diligence as a science writer during this opioid painkiller crisis and epidemic of failed back surgery.
Scott Haldeman, MD, PhD, DC, a world renowned spine expert, confirms that every guideline on spine care now recommends conservative care such as chiropractic first:
“The paradigm shift has already taken place. Non-surgical, non-invasive care is already the first choice for treatment for spinal disorders in the absence of red flags for serious pathology in virtually all guidelines.”
Mr Schoene has been painfully honest about the current state of affairs in American spine care that he deemed a “national scandal” in his 2013 article, “U.S. Spine Care System in a State of Continuing Decline”:
“Medical spine care is the poster child of inefficient care…such an important area of medicine has fallen to this level of dysfunction should be a national scandal. In fact, this situation is bringing the United States disrespect internationally.”
In this light, it becomes clear Ms Hakim was less concerned about a balanced article featuring conservative care to help readers avoid the “inefficient care” of medical muck such as opioids, shots, and surgery.
The Lancet Strikes
Obviously Ms Hakim needs help on this issue, so let me present the latest research and evidence-based guidelines on LBP. I realize this paper is too long and too scientific for lay publication, but it will give you a thorough understanding of this issue as well as my criticism of Ms Hakim’s article that demands a rebuttal.
If she had done her homework on the issue of LBP, she would have known in March, 2018, the prominent British medical journal, The Lancet, published a comprehensive 3-part review on low back pain by a panel of 31 international spine experts, including four Australians:
- What low back pain is and why we need to pay attention by Jan Hartvigsen, DC, PhD
- Low back pain: a call for action by Prof Rachelle Buchbinder, PhD
- Prevention and treatment of low back pain: evidence, challenges, and promising directions by Prof Nadine E Foster, DPhil
The Lancet review acknowledges the overuse of traditional medical spine care treatments and recommends the use of nonpharmacological care such as chiropractic spinal manipulative therapy (SMT), massage, acupuncture, Tai Chi and yoga:
- Non-evidence-based practice is apparent across all income settings; common problems are presentations to emergency departments and liberal use of imaging, opioids, spinal injections, and surgery.
- The reduced emphasis on pharmacological care is shown by the US guideline, which recommends non-pharmacological care as the first treatment option and reserves pharmacological care for patients for whom non-pharmacological care has not worked. These guidelines endorse the use of exercise and a range of other non-pharmacological therapies, alone and in combination, such as massage, acupuncture, spinal manipulation, Tai Chi and yoga.
This panel also acknowledged the barriers to change by the medical spine community, healthcare payors, and, I might add, the medical press that disseminate “widespread misconceptions”:
“Other barriers to optimal evidence-based management include widespread misconceptions of the general public and health professionals about the causes and prognosis of low back pain and the effectiveness of different treatments, fragmented and outdated models of care, and the widespread use of ineffective and harmful care, particularly in countries regarded as models of high quality care.”
I am surprised Ms Hakim failed to mention the Lancet report considering Australia is a hotbed of good back pain research including four Australians on this expert panel who would have made for more interesting interviews than the two spine surgeons she selected:
- Rachelle Buchbinder, Monash University
- Chris G Maher, University of Sydney
- Mark Hancock, Macquarie University
- Damian Hoy, The University of Queensland
- Paulo H Ferreira & Manuela Ferreira from Brazil are on appointment at the University of Sydney
Ms Hakim’s article is troubling for many reasons. She suggests “Key Things to Consider” although many actually would qualify as “widespread misconceptions…about the causes and prognosis of low back pain and the effectiveness of different treatments.” This is especially true when she quotes Drs Yanni Sergides and Richard Parkinson, both neurosurgeons with vested interests in this subject.
She also failed to make any mention of research revealing the downside of the medical management of LBP. Instead, she presents minimally invasive spine surgery as the Holy Grail of surgery although many spine surgeons disagree.
Let me review a few of her “Key Things to Consider” including Wrong Keys she omitted.
Wrong Key #1: Inept MDs
It became obvious quickly Ms Hakim failed to do her homework when she relied solely upon medical doctors as the experts in the pandemic of LBP considering their controversial treatments have led to this medical mess of opioid addiction, the rise of spine surgery, and the alarming failed back surgery syndrome.
Mark Schoene, the 25-year editor of The BACKLetter, an international spine journal, commented on the medical management of back pain as “the worst pain management crisis in the history of modern medicine”:
Primary care physicians and pain specialists don’t have unimpeachable backgrounds in the management of chronic pain in the U.S. These are the medical professions primarily responsible for the opioid overtreatment crisis. Are the two professions that helped create the worst pain management crisis in the history of modern medicine capable of leading the way forward? That remains to be seen.
Since every current evidence-based guideline recommends the backbone of chiropractic care, namely spinal manipulation, as a front-line treatment, by failing to mention chiropractors in her article, Ms Hakim did a great disservice to the millions of people suffering with LBP who would appreciate a nondrug, nonsurgical solution to their acute and chronic LBP.
Never did Ms Hakim explore the belief that medical incompetence is a main cause of this LBP crisis despite the opinions of many medical experts such as Aussie Rachelle Buchbinder, PhD, who published in 2009 a revealing article in the journal SPINE, Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain, indicating most MDs are inept in spine care, even those who purportedly specialize in back pain management:
A special interest in back pain is associated with back pain management beliefs contrary to the best available evidence. This has serious implications for management of back pain in the community.
Mr. Schoene also makes the case primary care medical practitioners are actually dangerous to patients:
“One can make the argument that the most perilous setting for the treatment of low back pain in the United States is currently the offices of primary care medical practitioners. This is simply because of the high rates of opioid prescription in these settings.
In fact, researchers have revealed that medical primary care physicians are actually the least educated to diagnose and treat musculoskeletal chronic pain problems.
Researcher Richard Deyo, MD, MPH, author of “Watch Your Back!” also mentioned physician incompetence in the 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.”
Dr. Deyo recognized in 1998 what The Lancet review acknowledged twenty years later in 2018—the outdated medical models of care used by incompetent MDs. Nothing has changed except the trail of medical iatrogenic malpractice has increased with more opioid problems, more failed back surgeries, and greater expense and wasted resources.
Dr. Scott Boden, 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.”
Research has long shown medical primary care physicians lack training in musculoskeletal disorders (MSDs) such as low back pain (LBP), are more prone to ignore recent guidelines, more likely to suggest spine surgery than surgeons themselves, and only 2% of medical PCPs refer to DCs despite chiropractors’ superior training and results with LBP.
Certainly Ms Hakim’s article did not clarify this medical incompetence or their dangerous “worst pain management” practices as a “Key Thing to Consider.” The problem remains the public is unaware their family medical practitioners are poorly educated in back problems who too often practice “outdated models of care and the widespread use of ineffective and harmful care” contrary to the evidence-based guidelines.
Dangers of Medical Care
Ironically, medical propagandists promote the falsehood that chiropractic care is dangerous as we witnessed in the pediatric chiropractic debacle. On April 22, 2016, the bias media raised its ugly head with an unwarranted attack on a chiropractor adjusting infants for colic, “Doctors speak out against chiropractors treating children,” by Ann Arnold from the program “RN” on the Australian Broadcasting Corporation network.
In her article about colicky babies, it should be noted there was no infant victim in this case, no complaints by the parents nor was the treating chiropractor convicted of any charges by the AHPRA other than being a scapegoat of skulduggery of her design.
In fact, research substantiates chiropractic can help colicky babies. If the RN reporter had thoroughly researched this topic about pediatric chiropractic care, a simple search on PubMed.gov would have discovered articles in support of chiropractic care for colicky babies, such as:
Our findings reveal that chiropractic care is a viable alternative to the care of infantile colic and congruent with evidence-based practice, particularly when one considers that medical care options are no better than placebo or have associated adverse events.
- Efficacy of Chiropractic Manual Therapy on Infant Colic: A Pragmatic Single-Blind, Randomized Controlled Trial.
In this study, chiropractic manual therapy improved crying behavior in infants with colic.
The majority of the included trials appeared to indicate that the parents of infants receiving manipulative therapies reported fewer hours crying per day than parents whose infants did not, based on contemporaneous crying diaries, and this difference was statistically significant.
With this research in mind, Ms Arnold’s article appears to be nothing more than an unsubstantiated witch hunt to cast aspersion at the idea of pediatric chiropractic care. Ms Arnold clearly failed to do balanced journalism on this issue, instead choosing to partake in fear-mongering with the assistance of Dr John Cunningham, a spine surgeon, not a pediatrician, who ridiculed the concept that chiropractic care helps colic:
Melbourne surgeon John Cunningham, who specialises in spines, watched that YouTube video [featuring chiropractor Ian Rossborough], and says he cannot fathom why a chiropractor would adjust the spine of a newborn.
“There’s not many things that make an orthopedic surgeon emotional, but when you see a premature baby having its back cracked, it literally makes my eyes water,’ he says. [I wonder if his eyes water seeing the trail of failed back surgeries.]
“There would be risks of harm. There would be risks that the child could suffer some sort of fracture. Why would you do it? This is the thing that goes through my mind when I watch that video. Why on earth would you do that to a newborn?”
Why, he asks? In order to help the patient, which is exactly what happened but went unmentioned by Ann Arnold’s yellow journalism. She also failed to mention while these medical curmudgeons speak of the alleged dangers of care, the following chart shows who’s hurting whom and it’s painfully obvious medical spine care causes more serious side effects or death at the rate of 2,500 per 1 million compared to chiropractic care at 1 in 5.85 million cases:
Wrong Key #2: Bad Disks
Perhaps the biggest “widespread misconception” promoting “outdated medical models” about LBP focuses on the diagnosis of a ‘bad disk’, an expression for degenerative disk disease often used by surgeons to frighten patients into surgery.
In her article Ms Hakim quotes spine surgeon Yanni Sergides who states the need for spine surgery is due to “degenerative conditions that tend to occur with advancing age”. In fact, his reliance upon ‘degenerative disks’ has already been debunked by many including the Mayo Clinic review.
The ‘bad disk’ misconception was addressed in Part 1 of the Lancet series, What low back pain is and why we need to pay attention:
Disk herniation in conjunction with local inflammation is the most common cause of radicular pain and radiculopathy. Disk herniations are, however, a frequent finding on imaging in the asymptomatic population, and they often resolve or disappear over time independent of resolution of pain.
The revelation about incidental ‘bad disks’ began in 1990 with the seminal MRI research by Scott Boden, MD, and Sam W. Wiesel, MD, chair of Orthopaedic Surgery at Georgetown University, who conducted the first MRI analysis finding ‘bad disks’ in pain-free people:
- 1990: Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.
We performed magnetic resonance imaging on sixty-seven individuals who had never had low-back pain, sciatica, or neurogenic claudication. The scans were interpreted independently by three neuro-radiologists who had no knowledge about the presence or absence of clinical symptoms in the subjects. About one-third of the subjects were found to have a substantial abnormality.
In 1994, the US Public Health Service’s AHCPR guideline #14 on acute low back pain also echoed Dr Boden’s finding:
“Degenerative disks, bulging disk and even herniated disks are part of the aging process for the spine and may be irrelevant findings: they are seen on imaging tests of the lumbar spine in a significant percentage of subjects with no history of low back problems. Therefore, abnormal imaging findings seen in a patient with acute low back problems may or may not be related to that individual’s symptoms.”
Indeed, this ‘bad disk’ misconception is medicine’s dirty little secret that has become a nightmare as Gordon Waddell, orthopedist and famed author of The Back Pain Revolution, remarked:
“Sadly, we must conclude that much low back disability is iatrogenic [doctor-caused]… It [back surgery] has been accused of leaving more tragic human wreckage in its wake than any other operation in history…”
Not only has back surgery left “more tragic human wreckage in its wake than any other operation in history,” it has also created the opioid crisis we now face considering LBP is the leading reason for prescription opioid painkillers.
Another major study confirmed ‘bad disks’ appear in asymptomatic, pain-free people. In November, 2014, the Mayo Clinic released its review by Waleed Brinjikji, MD, and his colleagues, “Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations.”
The following Table 2 shows by age 50 in asymptomatic people there is an 80% chance of degenerative disk disease; there is also a 60% chance of a disk bulge at age 50. However, unethical surgeons fail to mention to patients this is part of the normal aging process thereby leading patients to unnecessary disk fusion surgery.
The Mayo Clinic review found ‘bad discs’ were as common as grey hair in the natural aging process, highly prevalent in people of all ages, and did not alone constitute the need for surgery or needle jockeys doing ESIs or other spine interventions:
“Our study suggests that imaging findings of degenerative changes such as disc degeneration, disc signal loss, disc height loss, disc protrusion, and facet arthropathy are generally part of the normal aging process rather than pathologic processes requiring intervention.”
The recent Lancet review also mentions this MRI scam:
…the development of new technologies [such as laser spine surgery], will probably exacerbate this problem. For example, the use of increasingly sensitive imaging techniques, such as MRI, can reveal findings that might be incorrectly inferred to be the cause of a patient’s symptoms.
It’s past time to reveal this scam rather than sitting idly by without comment as the public continues to be ripped off! Imagine the millions of unsuspecting patients who were conned into spine surgery on this ‘bad disk’ falsehood.
I seriously doubt most spine surgeons make any mention these ‘bad disks’ are ubiquitous in many pain-free people; nor do they reveal for years these ‘bad disks’ have been dubbed ‘incidentalomas’ by many spine experts since they are ‘incidental’ to back pain.
“An MRI is unlike any other imaging tool we use,” Dr Bruce Sangeorzan said. “It is a very sensitive tool, but it is not very specific. That’s the problem… scans almost always find something abnormal, although most abnormalities are of no consequence.”
The Lancet review also mentioned this point:
Many imaging (radiography, CT scan, and MRI) findings identified in people with low back pain are also common in people without such pain, and their importance in diagnosis is a source of much debate.
The ‘bad disk’ diagnosis is undoubtedly the biggest “widespread misconception” in spine care, but it’s easy for the gullible public to be fooled into thinking these ‘bad disks’ are the sole cause of their pain since spine surgeons use colorful TV advertisements to frighten patients by keeping this hoax alive while making millions.
Wrong Key #3: MISS
Certainly the deceptive Laser Spine Institute ads demonstrate The Lancet panel’s message of “widespread misconceptions” since ‘bad discs’ are used by MDs as a sales-pitch to convince naïve patients in pain of the need for spinal surgeries that are most likely unnecessary.
Undoubtedly the largest advertising ploy today disseminating misconceptions about LBP treatments are the incessant TV ads promoting “minimally-invasive” laser spine surgery (MISS) by the Laser Spine Institute (LSI). Similar versions of MISS ads are also now seen in Australia and the UK.
To her credit, Ms. Hakim did mention “there has been an international escalation in the use of back surgery in the past 20 years” without giving any clues why. She also admits, “Yet the effectiveness of certain spine procedures remains an area of controversy among researchers.” However, she places no blame on the ‘bad disk’ scam by unscrupulous surgeons who exploit naïve patients.
She does admit “there has been a dramatic increase in the rate of spinal fusion in Australia,” but fails to include any criticism from leading Australian surgeons and, instead, she appears to give free advertising for minimally invasive spine surgery (MISS), the newest marketing gimmick in spine surgery.
Ms Hakim interviewed spine surgeon Yanni Sergides who touts “the available technologies and technical expertise have progressed” referring to his vested interest—MISS. She fails to balance her article with controversial information by researchers and surgeons critical of minimally invasive spine surgery.
Such hyperbolic TV ads have not gone unnoticed by an investigation by National Public Radio revealindg Laser Back Surgery Clinics Reap Profits, Complaints:
“The surgery to relieve back pain hasn’t been shown superior to laser-less versions and runs about $30,000, more than twice the amount insurer Aetna will pay for the old-fashioned approaches… One neurosurgeon who has treated former Laser Spine patients said, “It strikes me as somewhat of a scam.”
Bloomberg News reported that one laser surgery clinic had an annual profit margin of 34.3 percent from 2006 through 2009, higher than that of Google at 24.8 percent. One insurer paid Laser Spine $90,176 for an operation, a follow-up procedure, and some subsequent care. Laser Spine’s surgeons, some of whom are investors in the company, perform as many as 5,000 operations a year, which equates in a 50 working week year to be 20 surgeries daily.
Spine surgeon, Peter F. Ullrich, Jr., suggests laser MISS is mainly a marketing ploy in his article, Laser Disc Decompression for Spinal Stenosis: Does it Work?: “It seems to me that the most practical use for lasers in spine surgery is for marketing.”
Mark R. McLaughlin, MD, FACS, FAANS, was adamant about the myth of MISS. “I am trained in laser surgery. It has almost zero usefulness in your spine surgery and in fact may be harmful.”
Ms Hakim also gave Richard Parkinson, neurosurgeon, an opportunity to promote MISS when he states the alleged benefits of MISS:
“…patients who have spinal surgery are now facing lower risks, faster healing times, and better pain recovery, thanks to new surgical procedures. The new minimally invasive or keyhole techniques can be used for all types of spinal surgery, including discectomies, fusions, cancer and scoliosis surgery.”
Dr Parkinson did not, of course, disclose the potential adverse events such as the extraordinarily high re-operation rate of 38% in patients who required open disc surgery after MISS decompression surgery failed to relieve their symptoms.
A study in 2009, Tubular diskectomy vs conventional microdiskectomy for sciatica: a randomized controlled trial, contradicted Dr Parkinson when it found “Tubular discectomy resulted in less favorable results for patient self-reported leg pain, back pain, and recovery.”
Subjects in the MISS discectomy group had:
- slightly more intraoperative and postoperative complications.
- slightly greater proportion of the minimally invasive surgery group had a recurrent disc herniation,
- greater proportion had repeat surgery within a year,
- patients who underwent MISS discectomy fared worse with regard to back and leg pain, and
- fewer patients reported complete recovery at one year.
According to another article, Lasers in Spine Surgery: A Review, by Jack Stern, MD, PhD, FACS, suggests: “To date, laser discectomy may be more effective in attracting patients than in treating them.”
To his credit, Dr Parkinson was correct about one thing when he said, “If you have any concerns, get a second opinion.” Might I add, get that second opinion from a chiropractor, not another spine surgeon.
Wrong Key #4: ESI
Dr Sergides did mention “conservative approaches are almost always tried before surgery,” but inexplicably fails to mention the leading conservative treatment—chiropractic spinal manipulation—while he endorses controversial epidural steroid injections (ESI) that have been proven costly, dangerous, and ineffective by research.
ESIs are not approved by FDA for injection into the epidural space of the spine for fear of blindness, stroke and death, yet an estimated 10 million to 11 million injections (2.2 million in the Medicare population) are administered annually in the United States at costs ranging up to $2,000 each.
A research study led by Australian Prof Chris Maher, PhD, found the benefits of epidural steroid injections were too small to have a clinically significant impact:
· 2012 Epidural Corticosteroid Injections in the Management of Sciatica: A Systematic Review and Meta-analysis
“This trial is not the first to question the use of steroid injections for back pain. Research conclusively shows that, regardless of the type of back pain you have, the area of the back that is injected, or the route of administration, steroid injections are ineffective for back conditions.”
- 2018: study published in Spine, Cost-effectiveness of Lumbar Epidural Steroid Injections found lumbar epidural steroid injections (LESI) may not be cost-effective in patients with lumbar degenerative disorders.
- 2017: Medicare Payment Advisory Commission Data Book has identified many standard medical spine procedures now deemed to be “low value.” As you will see below, spinal injections are rated second in terms of frequency and expense at an astronomical $1,261,000,000:
- 2013: The Risks of Epidural and Transforaminal Steroid Injections in the Spine: Commentary and a comprehensive review of the literature, by neurosurgeon Nancy Epstein was a revealing commentary that included other adverse reactions, such as hydrocephalus, air embolism, urinary retention, allergic reactions, stroke, blindness, neurological deficits/paralysis, hematomas, seizures, and death.
“Although the benefits for epidural steroid injections may include transient pain relief for those with/without surgical disease, the multitude of risks attributed to these injections outweighs the benefits… For many patients with spinal pain alone and no surgical lesions, the ‘success’ of epidural injections may simply reflect the self-limited course of the disease.”
- 2011: the British Medical Journal published a very revealing comparative study for the ESI treatment of chronic low back pain that was performed in Norway, Effect Of Caudal Epidural Steroid Or Saline Injection In Chronic Lumbar Radiculopathy: Multicentre, Blinded, Randomised Controlled Trial.
According to Hans-Christoph Diener, MD, PhD:
“This study is very important when we talk to our patients who have low back pain. I think we can tell them that this invasive procedure is not better than placebo treatment. Our advice should be to stay with conservative treatments like regular exercise, physical therapy, chiropractic care, and if necessary intake of nonsteroidal anti-inflammatory drugs and behavioral therapy.”
Many ethical physicians are now speaking out. Forest Tennant, MD, a prominent pain management specialist in an interview with Pain News Network said “Have they been overused? Yes. And I’ve seen the complications. They happen when people have done far too many. I’ve seen people who’ve had two to three dozen epidurals in a given year.”
Despite such warnings and transient benefits at best, ESI are a lucrative procedure costing from a few hundred dollars to over $2,000 per injection.
“Let’s face it. The money motive is there. And this money motive is not just the anesthesiologists. It’s the surgery centers, it’s the hospitals, and it has caused problems.”
As well, the profit motive would have shed light on other reasons for the increasing rates of surgery and ESI:
- the ‘perverse incentive’ of huge profits in spine surgery and ESI motivates surgeons and hospitals to turn a blind eye to research and evidence-based guidelines;
- the boycott of chiropractic care in hospitals to protect the medical market share for the spine surgeons and needle jockeys by not giving patients access to nondrug, nonsurgical “hands-on” care.
Ms Hakim should have been familiar with the Lancet review that mentioned the need to police these perverse motivations within the medical system:
Increased use of ineffective potentially unsafe treatments has wasted limited health-care resources and harmed patients…
Protection of the public from unproven or harmful approaches to managing low back pain requires that governments and health-care leaders tackle entrenched and counterproductive reimbursement strategies, vested interests, and financial and professional incentives that maintain the status quo…
Wrong Key #5: Pain Drugs
Another noticeable omission by Ms Hakim in her Key Things to Consider was the lack of any warning about the role of both OTC and prescription drugs.
Certainly the opioid crisis has focused the Pharmageddon of abuse, addiction, and deaths from these narcotic painkillers, but few people realize they are no more effective than non-opioid drugs.
Dr Don Teater, from the National Safety Council suggests, opioid painkillers “do not kill pain, they kill people;” they also have proven no more effective than OTC drugs:
“Opioids are not powerful pain medications. In fact, taking one OTC ibuprofen (200 mg) along with one OTC acetaminophen (500 mg) relieves pain 60% more effectively than taking 2 Percocets.
“Also, taking opioids after injury or surgery delays recovery, increases medical costs, and increases disability.”
Other “outdated models of care” include common prescription and OTC drugs that have also failed to pass the muster of investigators. Prof Maher published another study about the ineffectiveness of pregabalin (Lyrica), another common prescription drug used by MDs for LBP and leg pain:
Treatment with pregabalin did not significantly reduce the intensity of leg pain associated with sciatica and did not significantly improve other outcomes, as compared with placebo, over the course of 8 weeks. The incidence of adverse events was significantly higher in the pregabalin group than in the placebo group
Profs Maher, Paulo H Ferreira, and Manuela L Ferreira were also involved in another study on back pain and paracetamol, aka, acetaminophen:
- 2015: Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials
Paracetamol is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis. These results support the reconsideration of recommendations to use paracetamol for patients with low back pain and osteoarthritis of the hip or knee in clinical practice guidelines.
Wrong Key #6: Spine Critics
The Lancet warned of the “liberal use of imaging, opioids, spinal injections, and surgery.” At the worst, Ms Hakim spoke to the wrong spine surgeons with vested interests and, at the least, she failed to talk with imminent Australian spine surgeon, Ian Harris.
In his book, Surgery, The Ultimate Placebo, Dr Harris wrote of the perverse incentives within spine surgery:
“The onus is on doctors to prove that spine fusion surgery for back pain is better than placebo before subjecting so many people to the risks of such major surgery.
“Also, with a back-of-the-envelope calculation multiplying 500,000 spine fusions a year in the US (including neck fusions) at an average cost of $100,000 each, I am certainly not convinced that it is worth $50 billion a year. Somebody is winning here and it isn’t the patients.”
An online article published in the MJA InSight newsletter on April 26, 2016, Spinal Fusion Surgeries Questioned, was painfully clear the need to stop the tsunami of back surgeries is paramount:
“Spinal fusion surgeries for chronic low back pain are on the rise, despite the lack of research to back their efficacy, and experts are now calling for tighter guidelines, including a waiting period.”
Dr Richard Williams, orthopaedic surgeon and spokesperson for the Royal Australasian College of Surgeons, told MJA InSight that a key regulation should be that patients must wait a period of 12 months before a spinal fusion surgery was performed, noting “Most patients will recover after these 12 months” without any surgery.
Professor Jeffrey Rosenfeld, senior neurosurgeon at the Alfred Hospital and director of the Monash Institute of Medical Engineering, told MJA InSight that there were two main reasons for the increasing rates of spinal fusion surgeries in Australia:
“The first was that patient expectations of surgery can often be high, meaning they ‘lap up’ the positive side of the story, and don’t hear the negative side.”
The “negative side” includes the high cost, poor outcomes, and high possibility of failed back surgery.
Professor Rosenfeld also mentioned for patients who do not have clear indicators for spinal fusion surgery (cancer, fracture, infections), a multidisciplinary approach is preferable, which includes chiropractors. “This will often give people better long-term pain outcomes than having multiple spinal surgeries.”
Ms Hakim did mention the escalating rise of spine surgeries, but she failed to warn the public because many spine surgeries based on ‘bad disks’ are misdiagnosed, many are therefore unnecessary and unsuccessful.
Chien-Jen Hsu, MD, commented on this dilemma in his article published in the Journal of Neurosurgery, Clinical Follow Up After Instrumentation-Augmented Lumbar Spinal Surgery in Patients with Unsatisfactory Outcomes:
“By far the number one reason back surgeries are not effective and some patients experience continued pain after surgery is because the [disk] lesion that was operated on is not, in fact, the cause of the patient’s pain.”
The prevalence of unsuccessful spine surgery—Failed Back Surgery Syndrome (FBSS)—remains another rarely discussed problem between patients and their surgeon despite research revealing the high rate of failure:
- 2017: The Aetiologies of Failed Back Surgery Syndrome: A systematic review, found up to fifty percent of patients will develop Failed Back Surgery Syndrome (FBSS) following lumbar spine surgery.
- 2017: Prevalence, characteristics, and burden of failed back surgery syndrome: the influence of various residual symptoms on patient satisfaction and quality of life as assessed by a nationwide Internet survey in Japan, revealed the prevalence of FBSS to be 20.6%. The prevalence of low back pain, dull ache, numbness, cold sensations, and paresthesia after surgery was 94.0%, 71.1%, 69.8%, 43.3%, and 35.3%, respectively.
- 2012: study in the British Journal of Pain, The Economic Impact of Failed Back Surgery Syndrome, found up to 50% of patients may have an unsuccessful outcome following lumbar spinal surgery.
Key Things to Consider #7: the Chiropractic Solution
Chiropractic spokesperson and Adjunct Professor, Phillip Ebrall, mentioned the epidemic of low back pain has long been a concern to chiropractors:
“Over the past few weeks Australia’s consumers of government-funded health care have seen damning reports of the dangers of opioid painkillers which are frequently used in an attempt to treat low back pain and what was once seen as the ultimate surgical alternative is now claimed by Ian Harris to be largely a placebo.
“One of the major concerns in addition to the dangers associated with surgery for typical, uncomplicated low back pain is the absolute waste of Australian’s precious health care resources.”
Prof Ebrall said the scientific evidence points to a beneficial role for chiropractors in the initial management of musculoskeletal back pain. He said “chiropractic is safe, effective, affordable, mainstream and should be the first therapy to be utilised in patients presenting with low back pain.”
The Lancet also concluded “Doing more of the same will not reduce back-related disability or its long-term consequences.”
If Ms Hakim did not have a blind eye toward chiropractic care, a simple scan of PubMed.gov would have given ample evidence chiropractic care is a valuable treatment for nonspecific cases that constitute the vast majority of LBP cases including patients with herniated and degenerated disks:
- 2011: Chiropractic Management of Post-surgical Lumbar Spine Pain: A Retrospective Study of 32 Cases, showed an 81% improvement for patients with low back pain subsequent to lumbar spine surgery who were managed with chiropractic care including Cox flexion distraction technique. No adverse events were reported for any of these post-surgical patients.
§ 2018: Spinal manipulation in the treatment of patients with MRI-confirmed lumbar disc herniation and sacroiliac joint hypomobility: a quasi-experimental study
Spinal manipulative therapy can potentially improve pain, functional disability and sacroiliac joint (SIJ) mobility in patients with lumbar disc herniation (LDH) concomitant with SIJ hypomobility; therefore, it can be implemented in physical therapy programs for these patients.
§ 2010: Restoration of disk height through non-surgical spinal decompression is associated with decreased discogenic low back pain: a retrospective cohort study.
Non-surgical spinal decompression was associated with a reduction in pain and an increase in disc height. The correlation of these variables suggests that pain reduction may be mediated, at least in part, through a restoration of disc height.
§ 2011: Chiropractic management of postsurgical lumbar spine pain: a retrospective study of 32 cases.
The results of this study showed improvement for patients with low back pain subsequent to lumbar spine surgery who were managed with chiropractic care.
§ 2016: Chiropractic Distraction Spinal Manipulation on Postsurgical Continued Low Back and Radicular Pain Patients: A Retrospective Case Series.
Greater than 50% pain relief following CTFD chiropractic distraction spinal manipulation was seen in 81% of postsurgical patients receiving a mean of 11 visits over a 49-day period of active care.
Evidence suggests that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches.
Interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain. Increased benefit has been shown in several instances where a multimodal approach to neck pain has been used.
SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache. This conclusion rests upon a few trials of adequate methodological quality.
The availability of CAM services in the MHS is widespread and is being used to address a range of challenging pain and mental health conditions.
- 2013:Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State that found for patients whose first provider was a chiropractor, only 1.5 percent had surgery in contrast to 42.7 percent of workers who went through the typical medical system inevitably had surgery.
If Ms Hakim wants readers to consider a few Key Things, she might have mentioned the issue of Failed Back Surgery. When the first disk fusion fails, too often the surgeon misleads the patient with the standard excuse, “it didn’t take,” and gullible patients are seduced to have another fusion despite the diminishing returns of repeated surgery.
Another excellent paper, Failed Back Surgery Syndrome: A Review Article, written by Australians James Daniell and Orso Osti of the University of Adelaide, found fusion surgery has a substantial failure rate, which they estimated as high as 46%. Moreover, many patients opt for repeat surgery, but that often leads to diminishing returns.
According to the authors:
“Although slightly more than 50% of primary spinal surgeries are successful, no more than 30%, 15%, and 5% of the patients experience a successful outcome after the second, third, and fourth surgeries, respectively.”
Spine surgery is deemed appropriate with approximately 10% of LBP problems that stem from pathoanatomical issues – the “Red Flags” that require medical intervention, such as:
- spinal fracture,
- cancer of the spine,
- spondylolisthesis of 50% or more,
- scoliosis greater than 50 degrees with loss of function,
- persistent radicular pain or persistent neurogenic claudication unresponsive to conservative care, or
- serious infections such as spinal tuberculosis.
These are most likely to respond to surgical intervention.
The Chiropractic Paradigm
Ms Hakim and the public are well aware of the medical model of back pain—namely pulled muscles and ‘bad disks’, evident in their proliferation of muscle relaxants, opioid painkillers, and disk surgery. Unfortunately this “outdated model of care” has been deemed the “poster child of inefficient spine care.”
If Ms Hakim were keen on scanning the research, she might have informed her readers there is another spinal model of care that has been more successful over a longer period of time than the medical model.
Researchers now refer to the vast majority (80-90%) of spinal pain as “nonspecific” pathophysiological problems—how the spine functions—because there are no pathoanatomical problems as cited above, but there are mechanical problems that require thinking out of the medical box with a quick review of the spine itself.
The spine is a precarious weight-bearing pillar of 24 vertebrae interconnected by 23 cartilaginous disks that act as shock absorbers and 361 joints, a fact lost to most people. This total includes all synovial, symphysis and syndesmosis joints according to Prof Gregory D. Cramer, DC, PhD, Dean of Research at National University of Health Sciences.
Dr John McMillan Mennell, orthopedist, author, professor and a proponent of manipulation, testified at the chiropractors vs. AMA antitrust trial (Wilk case) about the nature of joint play, joint dysfunction, and the manipulative therapy as the best solution to this problem:
“To understand it, you would have to accept that the science of mechanics demands that anything that moves has joint play built between the moving parts…This joint play movement is prerequisite to normal pain-free functioning of movement…
“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.”
If Ms Hakim wanted to share the most important Key Things to Consider, the joint paradigm is the key to understanding ‘nonspecific’ back pain—in other words, ‘you don’t slip disks, but you can slip joints’ that starts the cascade of events leading to a “back attack.”
The spinal facet joints are a set of synovial joints between two adjacent vertebrae. These gliding zygapophyseal joints, aka, Z-joints, are susceptible to the ‘buckling effect’ as described by Dr John “Jay” Triano in his paper, “Biomechanics of Subluxation: Modern Evidence of Buckling Mechanism,” published in The Spine Journal”.
In other words, a “bad disk” is a secondary effect caused by compressed vertebral joints that have finally buckled, thereby overloading the disc causing spinal reflex spasms. This also may explain why a patient doing perfectly well one moment may suddenly experience excruciating back pain while virtually doing a minor act of simply twisting, prolong sitting, sneezing, coughing, or certainly a slip and fall.
In a nutshell, buckled spinal joints begin a ‘cascade of events’ to back pain initially caused by joint compression/fixation (aka in chiropractic parlance as the “vertebral subluxation”), then causing reflex muscle spasms, joint/nerve inflammation and, if uncorrected, leading to disk overloading/herniation and subsequently to disk degeneration. The key component of this cascade begins with joint dysfunction/ compression, not “bad disks,” which is a secondary problem to the functional overloading of the vertebral motor unit.
Instead of the medical model of painkillers, muscle relaxants, epidural shots, and spine surgeries, the key is to unload the compressed disk by restoring joint motion to improve the function of the spine itself as a weight-bearing unit. This physiological model explains why mechanical/structural problems constitute the majority (50-69%) of low back and neck pain cases.
A skilled chiropractor may use the following methods:
- spinal manipulation to unbuckle the joints by restoring joint play,
- intersegmental traction tables (eg, Cox, DRX) to decompress the vertebral motor unit and disks,
- massage therapy to relax the muscle spasms and increase range of motion in the spinal joints,
- recommend NSAIDs and ice/heat packs at home as necessary,
- prescribe home spine flexibility exercises, and
- suggest coping mechanisms to deal with the anxiety of pain.
Obviously the chiropractic paradigm is diametrically opposite to the medical model. Drugs and shots may deal temporarily with symptoms of pain and spasms, and spine fusion surgery deals with a secondary effect of an overloaded disk, but none of these deal with restoring the proper functioning of the spine.
Chiropractors to the Rescue
A search on PubMed.gov found many studies confirming the clinical and cost-effectiveness of chiropractic care:
· A systematic review comparing the costs of chiropractic care to other interventions for spine pain in the United States.
Although cost comparison studies suggest that health care costs were generally lower among patients whose spine pain was managed with chiropractic care, the studies reviewed had many methodological limitations.
- Recommendations for management of uncomplicated back pain in the workers’ compensation system: a focus on functional restoration.
A percentage of costs in the workers’ compensation system go towards treating uncomplicated back pain; recurrences and chronicity of back pain are key contributors to these costs, which are currently increasing. Ergonomic advice plays a key role in helping the patient with musculoskeletal injuries heal faster and prevent costly flare-ups. Conservative care, which includes chiropractic manipulation, ergonomic recommendations, and exercise rehabilitation with an emphasis on coordination and endurance training, is supported by the literature as a possible method of cost containment.
- Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes.
This study assessed the total cost per case of chiropractic claims and medical claims for conditions with identical diagnostic codes. The sample consisted of 3062 claims or 40.6% of the 7551 estimated back injury claims from the 1986 Workers’ Compensation Fund of Utah. For the total data set, cost for care was significantly more for medical claims, and compensation costs were 10-fold less for chiropractic claims.
Canadian DCs who reported a higher volume of workers’ compensation patients had practices oriented towards the treatment of injured workers, collaborated with other health care providers, and facilitated workers‘ access to care.
- Workers’ characteristics associated with the type of healthcare provider first seen for occupational back pain.
According to the 5520 analyzed claims, 85.3 % of the patients saw a physician, 11.4 % saw a chiropractor, and 3.2 % saw a physiotherapist. Longer job tenure, higher gross personal income, mixed-manual job and previous similar injury increased the odds of seeing a chiropractor rather than a physician, while the size of the community and the availability of an early return to work program in the workplace decreased it.
- Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain.
The type of healthcare provider first visited for back pain is a determinant of the duration of financial compensation during the first 5 months. Chiropractic patients experience the shortest duration of compensation, and physiotherapy patients experience the longest. These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.
- Economic case for the integration of chiropractic services into the health care system.
- Integration and reimbursement of complementary and alternative medicine by managed care and insurance providers: 2000 update and cohort analysis.
- A chiropractic service arrangement for musculoskeletal complaints in industry: a pilot study.
- Effectiveness and Economic Evaluation of Chiropractic Care for the Treatment of Low Back Pain: A Systematic Review of Pragmatic Studies.
- Cost-effectiveness of chiropractic care versus self-management in patients with musculoskeletal chest pain.
- Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: a systematic review and narrative synthesis of evidence from randomized controlled trials.
- Cost minimization analysis of low back pain claims data for chiropractic vs medicine in a managed care organization.
- Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain.
- Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs.
- Health care workforce for the twenty-first century: the impact of nonphysician clinicians.
- Current trends in the integration and reimbursement of complementary and alternative medicine by managed care, insurance carriers, and hospital providers.
- Costs and recurrences of chiropractic and medical episodes of low-back care.
- Preliminary findings of analysis of chiropractic utilization and cost in the workers’ compensation system of New South Wales, Australia.
- Does the goose really lay golden eggs? A methodological review of Workmen’s Compensation studies.
- Development of basic workers‘ comp guidelines for chiropractic care in response to needs of third party payers in Alabama.
- Improving the quality of workers’ compensation health care delivery: the Washington State Occupational Health Services Project.
- Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans?
In summation, the research shows chiropractors are faster, cheaper, safer and more effective than medical spine care. As the research proves and as payors seek the “triple aim” of cost, effectiveness, and patient satisfaction, chiropractors remain the best buy. Now the problem is getting this message to the payors and public to access chiropractors first.
Key Things to Consider
In conclusion, Ms Hakim’s Back to Basics article badly missed the mark to help readers. Just as the Australian press mischaracterized the pediatric chiropractor case, she also misrepresented the glaring issues in spine care as The Lancet review showcased as well as the numerous scientific articles by Aussie investigators.
I urge the editor of Health Agenda to consider publishing a follow-up to her article featuring the chiropractic profession that has fought for nearly a century to keep this invaluable healing art alive despite the continuing repression they still face today from the medical profession and its allies in the media.
As Dr Rosner mentioned, chiropractic has vaulted from last to first and it’s past time for the Australian public were offered a fair and balanced review instead of the outdated models of care and biased media journalism we still see today.
Imagine the improvement in spine care to lower costs and improve outcomes if chiropractors using evidence-based guidelines were the primary spine care providers instead of the inept MDs who created the opioid crisis and failed back surgery—the modern scourge reeking addiction, death and disability.
If chiropractors were the portal of entry for spine-related injuries just as dentists are the portal of entry for dental problems, the public would not be experiencing the present opioid crisis, the high costs and failure rates of spine surgery, and overall the “worst pain management in the history of medicine.”
It’s time to take the advice of The Lancet and other evidence-based guidelines to put chiropractors in charge and put an end to the “outdated models of medical care.”
As The Lancet concluded, “Doing more of the same will not reduce back-related disability or its long-term consequences.”
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