The ACA’s Choosing Wisely program is strangely reminiscent to Prohibition in the day of bootleggers, Al Capone, and speakeasies brought about by the 18th Amendment that banned alcohol in the US. This well-intentioned but futile effort to make America dry eventually became known as the Noble Experiment of Prohibition in the U.S.:
“President Herbert Hoover’s described Prohibition as ‘a great social and economic experiment, noble in motive and far-reaching in purpose.’ Prohibition became known as the Noble Experiment of Prohibition. Unfortunately, the Noble Experiment of Prohibition in the U.S. failed miserably. Even worse, it not only failed but was counterproductive. That is, it was worse than doing nothing.”
In a similar fashion, the ACA now attempts to police the practice of chiropractic with its five prohibitions. This futile effort will fail to convince practitioners to change their practice habits just as Prohibition did not stop Americans from inebriation.
Instead, the ACA’s Prohibition will be counterproductive by cutting into our incomes, suppressing our clinical freedom to practice as we choose, and insult their professional ethics.
Of course, the ACA Ignoble Experiment has already been hijacked by ASHN to cut the incomes of field docs as other payors will soon follow to “squeeze care to expand profits” with the blessing of the ACA.
Just as the “dry” argument did not convince the majority of “wet” Americans to stop drinking during Prohibition, let’s be clear in this chiro civil war: please don’t think the “evidence-based” medicine (EBM) “dry” argument is the epitome of proper care brought to us from on-high written in stone by the gods of science or morality.
Certainly I am not anti-science, nor am I a chiro-philosopher, but I do draw the line when spurious quasi-scientific research and reactionary remarks impugn our profession whether it’s the Science-Based Medicine trolls, the ACA anti-classic chiro contingent, or the Cochrane Reviews that are used as scripture by these antagonists.
Anyone who has read my books and commentaries realizes I back my positions with the best possible authority, but I am certainly willing to challenge medical trolls as well as EBM chiro trolls who use questionable science to denigrate our profession.
In fact, this is an on-going debate that needs to be discussed so field docs won’t be intimidated by the anti-chiropractic spokespersons who seemingly carry the shield of modern science from assault by those they cast as medical Luddites or philosophers.
War of Words
The terms “evidence-based medicine/practice” (EBM/EBP), “best practices”, “practice-based evidence” (PBE) do get confusing, so let me clarify the situation because while sounding similar they have huge differences that you need to understand.
The founder of the concept of EBM, the famous Dr. David L. Sackett, wrote in his paper, Evidence Based Medicine: What It Is and What It Isn’t, that “best practices” constitutes more than just evidence-based information gleaned from the scientific literature:
“Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence…”[1]
This is exactly how the ACA’s five Prohibitions appear to be placing DCs at risk and being tyrannized by evidence that is debatable at best and dangerous at its worst.
Mark Studin, DC, in his paper, Evidence-Based Practice vs. Best Practice, warns so-called “evidence-based” care (EBM) is actually “a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom.” This accurately summarizes the present chiro civil war over the Choosing Wisely prohibitions.
Sackett also mentioned this point: “Some fear that evidence based medicine will be hijacked by purchasers and managers to cut the costs of health care.” Yes, this is exactly what ASHN already does to “squeeze care to expand profits.” Anyone familiar with ASHN knows of its tier system where a non-practitioner DC in San Diego must approve beforehand anything the field doc wants to do. If this is not tyranny in practice, what is?
In fact, under the guise of “evidence-based care”, every chiro technique and adjunct therapy we use could be squeezed if ASHN were to follow the specious Cochrane Reviews as I will shortly divulge.
The potential “tyranny” by EBP advocates overlooks the most important factor in this equation—“individual clinical expertise”—as well as the obvious “practice-based evidence” (PBE) —the great clinical results chiro care has gotten over the years as Prof. Bruce Walker from Murdoch University described in his fascinating paper, The New Chiropractic:
The adoption of evidence-based practice (EBP) is critical to the future of chiropractic and yet there is resistance by elements within the profession…
Hard resistance against EBP occurs where it is stated that the best evidence is that based on practice experience and not research. This apparently is known as Practice-Based Evidence (PBE) and has a band of followers.
The “practice-based evidence” mantra appears to be “it works”, but it begs the more contemporary question “by how much and compared to what?” Of course, positive and negative practice-based evidence can coincide with the scientific evidence but this is simply not always the case.
Finally, chiropractors in the field need to become avid consumers of the evidence provided by good quality research as this will assist lifelong learning and best practice.
Although Dr. Walker favors EBP, obviously an academician and not a practitioner, he acknowledges the role of PBE as well and admits almost reluctantly “practice-based evidence (PBE) can coincide with the scientific evidence.”
As a nearly 40-year practitioner myself, let me recommend to ASHN instead of limiting our spinal exams sans xrays, limiting our treatment schedule to only acute care, limiting our adjunct therapies (such as 15-minute massage), and denying post-exams, if ASHN bureaucrats knew anything about the real world of spinal care, I suggest they let us use whatever tools we need, aka, “clinical expertise”, and then recommend a post-treatment evaluation to see the results—not only the Oswestry index to see pain and ADL improvements, but to do post xrays to see structural improvements or areas of permanent impairment that require maintenance care to prevent relapse and the additional costs of disability and acute care.
As we’ve learned about ASHN, any mention of “maintenance care” makes its cost cutters go catatonic, a syndrome characterized by muscular rigidity and mental stupor. However, if they are committed to EBM, they cannot ignore these studies on MC:
- Mohammed K. Senna, Shereen A. Machaly confirmed the value of maintenance care in their paper, Does maintained Spinal manipulation therapy for chronic non-specific low back pain result in better long term outcome?
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.
- Another recent award-winning study by Andreas Eklund et al., Prevention of Low Back Pain: Effect of Chiropractic Maintenance Care as Compared to Symptomatic Treatment – A Pragmatic Randomized Clinical Trial, concluded:
Maintenance care treatment on a regular basis regardless symptoms is more effective than symptomatic treatment (after pain has recurred) in reducing the number of days with bothersome pain for patients with recurrent and persistent LBP.
So, where is the EBM peer-reviewed study that suggests MC is not helpful in the prevention of future spinal problems? If one existed, I’m sure ASHN would cite it for all to hear.
Instead of the ACA and ASHN’s cost-cutter prohibitions, I suggest “best practices” should be aimed to improve outcomes to lower the overall cost over a patient’s lifetime by incentivising maintenance care just as dentists do.
Let field docs be graded by clinical results instead of the cost per acute case. Let us be graded by the reduction in the Oswestry Index, the amount of spinal correction, and the doctor’s ability to educate patients how to take care of their spines rather than going from “back attack” to “back attack” as most patients do without any preventative measures in between.
As I teach my patients, they need to develop a Dental Attitude toward their spines with periodic professional care and daily home care as well as ADLs to avoid risky behavior that may cause a new back attack (lifting, bending, sleeping, prolong sitting, etc)
Of course, ASHN is not interested in “best practices” as I describe; its cost-cutter managed care policy wants to “squeeze care to expand profits” under the guise of the Choosing Wisely prohibitions. I do wonder what the ACA is getting from ASHN in this quid pro quo deal—some type of sponsorship, no doubt.
Cost-Cutter Cookbook
Dr. Sackett also warns, “Evidence based medicine is not ‘cookbook’ medicine,” which is exactly what the ACA and ASHN appear to do with its Prohibition:
“Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients’ choice, it cannot result in slavish, cookbook approaches to individual patient care.”
Perhaps this is the problem with the ‘new’ ACA—being led by EBM advocates/academicians promoting its five Choosing Wisely Prohibitions that appear to be “slavish, cookbook approaches” rejecting the basic elements of our pragmatic practice-based evidence and procedures that field docs use to create our brand of “best practices.”
Indeed, when Dr. Walker said, “The ‘practice-based evidence’ mantra appears to be ‘it works,’” and there’s a lot of proof to his claim.
Scientific Tyranny
If we were only to follow systematic reviews as the EBM advocates desire, such as the 2011 Cochrane Review by Sidney Rubinstein, et al., Spinal manipulative therapy for chronic low-back pain, every chiropractic college would close its classroom doors, every chiropractic office should shutter up its windows, every new guideline should re-write its recommendations, and every medical troll would whet her poisoned pen with delight to attack our profession with “scientific proof.”
For example, the New Year began with another shot across the bow of the good ship Chiropractic from the infamous medical EBM troll, Edzard Ernst, with his January blog article, “Chiropractic is not the best treatment for back pain,” in which he also quoted chiropractor Sidney Rubinstein to support his denigration of chiropractic care.
This is the real tyranny we face—the misuse of reviews—and there are plenty of examples.
For example, Rubinstein concluded in his EBM review of chronic LBP:
“In summary, SMT appears to be no better or worse than other existing therapies for patients with chronic low-back pain.”
Rubinstein’s other Cochrane Review in 2012 for acute LBP, Spinal manipulative therapy for acute low-back pain, was just as misleading and disheartening as his review of chronic LBP:
“SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies.”
Oh well, I guess the chiropractic profession should apologize to the millions of patients we’ve helped over the century because Sidney Rubinstein says adjustments are no better than sham for either chronic or acute LBP.
I must add his conclusion on acute LBP contradicts the extensive guideline #14 on acute low back pain by the Agency on Health Care Policy & Research (AHCPR). In 1994, the AHCPR issued a 170-page study to formulate the “best practices” entitled “Acute Low Back Pain in Adults” along with an accompanying 30-page “Quick Reference Guide for Clinicians” entitled “Acute Low Back Problems in Adults: Assessment and Treatment.”[2]
The AHCPR guideline stated spinal manipulation was the preferred initial treatment of choice. The Patient Guide lists three “Proven Treatments”:
- Over-the-counter NSAIDs, which “have fewer side effects than prescription medicines.”
- Heat or cold applied to the back.
- Spinal manipulation. This treatment (using the hands to apply force to the back to ‘adjust’ the spine) can be helpful for some people in the first month of low back symptoms. It should only be done by a professional with experience in manipulation.[3]
The most shocking recommendation focused on back surgery. The panel of experts found back surgeries were costly, sometimes based on misleading tests such as MRIs, and generally were deemed ineffective, suggesting only one in 100 cases required surgery.
This AHCPR information should have revolutionized spine care in America; definitely it would have been a dagger in the pocketbooks of many spine surgeons and hospitals, but this guideline was totally annihilated by the medical powers to be when Rep. Newt Gingrich worked with the NASS to kill the agency and the new guideline.
Apparently when EBM doesn’t support the practice of spine surgeons and the medical industrial complex, politics supersedes the evidence. So much for evidence-based practices, eh?
Aside from the two Rubinstein reviews, other Cochrane Reviews are just as troubling. Don’t be surprised if ASHN and other payors use these Cochrane Reviews to deny payment for treatments commonly done in many chiro offices:
A Cochrane review of combined chiropractic interventions for low-back pain.
CONCLUSION:
Combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute/subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions.
Spinal manipulative therapy for low-back pain.
AUTHORS’ CONCLUSIONS:
There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.
A Cochrane review of combined chiropractic interventions for low-back pain.
CONCLUSION:
Combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute/subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions.
Combined chiropractic interventions for low-back pain.
AUTHORS’ CONCLUSIONS:
Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions.
There are also Cochrane Reviews undermining many adjunct therapies commonly used in chiropractic offices that may be jeopardized when payors decide to cut costs and squeeze care to expand profits:
Back Schools for chronic non-specific low back pain.
AUTHORS’ CONCLUSIONS:
It is uncertain if Back School is effective for chronic low back pain.
Back schools for acute and subacute non-specific low-back pain.
AUTHORS’ CONCLUSIONS:
It is uncertain if back schools are effective for acute and subacute non-specific LBP as there is only very low quality evidence available.
Traction for low-back pain with or without sciatica.
AUTHORS’ CONCLUSIONS:
These findings indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP… Implications for practice to date, the use of traction as treatment for non-specific LBP cannot be motivated by the best available evidence. These conclusions are applicable to both manual and mechanical traction.
Acupuncture for treating fibromyalgia.
AUTHORS’ CONCLUSIONS:
There is moderate-level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well-being.
The Effectiveness Of Acupuncture In The Management Of Acute And Chronic Low Back Pain. A Systematic Review within The Framework Of The Cochrane Collaboration Back Review Group.
CONCLUSIONS:
Because this systematic review did not clearly indicate that acupuncture is effective in the management of back pain, the authors would not recommend acupuncture as a regular treatment for patients with low back pain.
Acupuncture for low back pain.
REVIEWER’S CONCLUSIONS:
The evidence summarised in this systematic review does not indicate that acupuncture is effective for the treatment of back pain.
A Cochrane review of electrotherapy for mechanical neck disorders.
CONCLUSIONS:
… the evidence for treatment of acute or chronic mechanical neck disorders by different forms of electrotherapy is either lacking, limited, or conflicting.
Electrotherapy for neck disorders.
AUTHORS’ CONCLUSIONS:
We can not make any definitive statements on electrotherapy for MND. The current evidence on Galvanic current (direct or pulsed), iontophoresis, TENS, EMS, PEMF and permanent magnets is either lacking, limited, or conflicting.
We conclude that for patients with chronic low back pain, treatment with TENS is no more effective than treatment with a placebo, and TENS adds no apparent benefit to that of exercise alone.
CONCLUSIONS:
Initial studies have found massage to be effective for persistent back pain. Spinal manipulation has small clinical benefits that are equivalent to those of other commonly used therapies. The effectiveness of acupuncture remains unclear. All of these treatments seem to be relatively safe. Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy.
CONCLUSIONS:
We have very little confidence that massage is an effective treatment for LBP. Acute, sub-acute, and chronic LBP had improvements in pain outcomes with massage only in the short-term follow-up. Functional improvement was observed in participants with sub-acute and chronic LBP when compared with inactive controls, but only for the short-term follow-up. There were only minor adverse effects with massage.
Massage for mechanical neck disorders.
AUTHORS’ CONCLUSIONS:
No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.
Physical therapy for chronic low back pain in North Carolina: overuse, underuse, or misuse?
CONCLUSIONS:
Fewer than one third of individuals with chronic LBP saw a physical therapist. Health-related and non-health-related factors were associated with physical therapy use. Individuals who saw a physical therapist did not always receive evidence-based treatments. There are potential opportunities for improving access to and quality of physical therapy for chronic LBP.
CONCLUSIONS AND RELEVANCE:
Among adults with recent-onset LBP, early physical therapy resulted in statistically significant improvement in disability, but the improvement was modest and did not achieve the minimum clinically important difference compared with usual care.
CONCLUSIONS:
Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. For acute low back pain, the only therapy with good evidence of efficacy is superficial heat.
However, the 1994 AHCPR guideline refuted the value of hot packs:
“physio-therapeutics like ultrasound, TENS, hot packs, and other standard treatments by physical therapists were also ineffective.”
Distraction manipulation of the lumbar spine: a review of the literature.
Gay RE, Bronfort G, Evans RL.
CONCLUSIONS:
Despite widespread use, the efficacy of distraction manipulation is not well established. Further research is needed to establish the efficacy and safety of distraction manipulation and to explore biomechanical, neurological, and biochemical events that may be altered by this treatment.
As you can see, there is critical EBM about the services we render, including SMT. Acupuncture is not well supported, nor is Cox flexion-distraction, TENS, physio-therapeutics, massage therapy, or traction; back schools are not helpful to teach spinal hygiene to patients.
If we were only to follow EBM and Cochrane Reviews, we should close our clinics and college doors and just tell patients “it’s all in your heads, there’s nothing we do that is helpful according to the Cochrane Review experts.”
So, will chiropractic “best practices” be guided by EBM or by conflicting Cochrane Reviews or by following your gut feeling and practice-based evidence (PBE)? If these ACA five prohibitions go into effect, you may not have a choice whether you’re “wet” or “dry.”
Unfortunately, just as the “Noble Experiment of Prohibition in the U.S. failed miserably,” so will the ACA’s Prohibition on traditional “best practices” and practice-based evidence. “Even worse, it not only failed but was counterproductive. That is, it was worse than doing nothing.”
Methinks the same fate awaits the ‘new’ ACA.
When the dust settles over this ‘new’ ACA policy to dumb-down our practices to the register ASHN prefers, many ACA members will quit the association and many others will be out of business allthewhile ASHN will laugh all the way to the bank thanking the EBM ACA guys for their help in assassinating our practices.
In Part Three: The Paradox of Choosing Wisely, I will discuss the madness behind the ACA’s method and the leadership behind this travesty.
[1] Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996) Evidence based medicine: What it is and what it isn’t. British Medical Journal, 312(7023), 71-72
[2] Bigos et al. US 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)
[3] Ibid. p. 7.