Who’s Got Your Back?


Who’s Got Your Back?


JC Smith, MA, DC

I have a puzzle that would dumfound most people, including NPR Puzzle Master Will Shortz.

Question: What is the third-largest physician-level health profession in the country and what does it primarily do?

Let me give you a few clues:

This mystery profession uses no drugs or surgery, has the lowest malpractice rates of all doctors, and a poll by Consumer Report rated it best for back pain.[1]

Need more clues?

In the first half of the 20th century, 12,000 practitioners were arrested allegedly for practicing medicine without a license.[2]

In 1976, four members of this profession filed and won an antitrust lawsuit against the AMA et al. for an illegal boycott. [3]

In 1994, an agency of the US Public Health Service found its treatment to be a “proven method” for acute low back pain in adults.[4]

According to “The Best and Worst Jobs,” the rank of this mystery profession improved from #56 in 2010 to #32 in 2011.[5] 

Do you know the answer to this puzzle?

If not, let me continue by saying this profession also remains a mystery to many Americans, so allow me to give you a few more hints about the main condition it treats.

This profession treats a huge silent epidemic plaguing Americans that has nothing to do with germs, genetics, or cholesterol. Nor is it related to heart disease, cancer, diabetes, or obesity.

It rarely makes the news nor are there television programs about it. This epidemic has not responded to drugs, shots, or surgery; it remains the most disabling condition nowadays in the workplace and is second only to heart disease among seniors.

Do you know what it is yet?

Epidemiologists agree that 90% of American adults will suffer from this disabling condition during their lifetime.[6] Although not lethal, it can make your life miserable and the costs to treat the pain and cope with the disability reach over $100+ billion annually.[7]

Do you need more hints?

The problem may begin insidiously with the American lifestyle itself. Our society of sedentary citizens who sit too much in front of screens and exercise too little has led to not only epidemics of obesity, heart disease, and diabetes, it has led to this silent epidemic. Combined with childhood playground accidents, sport injuries, car accidents, bad lifting habits, and even sitting too much can exacerbate this problem that is widespread, expensive, disabling, and only getting worse.

Still clueless?

The answers to this riddle are chiropractors who treat back pain and spine-related disorders (SRDs).

According to new studies, patients with back pain are routinely misdiagnosed, mistreated, and misinformed about this crippling disorder, which explains why this silent epidemic is so widespread and growing. As leading spine physicians have lamented, medical care and spine surgery have caused a “pandemic of pain” as Paul Goodley, MD,  mentioned[8] and “left a wake of disability” as Gordon Waddell, orthopedic surgeon, wrote.[9]

This puzzle is troubling since many of the traditional medical approaches have proven to be costly and ineffective. In fact, the basic medical premise of back pain—the abnormal disc theory—has now been proven to be incorrect. Medical researchers now refer to the fallacy of abnormal discs as “trivial, harmless, and irrelevant,” to the point of labeling them “incidentalomas.”[10]

Yet, only a handful of MDs will admit to the ineffectiveness of medical spine care.

Gordon Waddell warned, “Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem.”[11] This is quite an admission from a leading spine surgeon that testifies to the dilemma of back pain treatments. Compounding this problem is the medical war against chiropractors, recognized by most guidelines as the primary spine care practitioners nowadays.

Despite these new found revelations, spine surgeries remain at an all-time high.

“It’s amazing how much evidence there is that fusions don’t work, yet surgeons do them anyway,” said Sohail Mirza, a spine surgeon who chairs the Department of Orthopaedics at Dartmouth Medical School. “The only one who isn’t benefiting from the equation is the patient.”[12]

If you are among the millions who suffer daily with back pain, the challenge is to find the best treatment among the 200+ therapies, drugs, shots, or surgery now available. Scott Haldeman, DC, MD, PhD, and leading spine researcher, believes that “navigating this selection without an informed guide is analogous to shopping in a foreign supermarket without understanding the product labels.”[13]

Not only is proper treatment a confusing and daunting task, new research concerning the high costs and poor patient outcomes have led investigative reporters and health insurance executives to criticize the traditional medical treatments for back pain. Two recent articles in The Wall Street Journal about unnecessary spine surgery[14],[15] as well as similar articles on NPR[16], MSNBC[17], and the Bloomberg News[18]to name a fewhave published similar critical articles about the over-use, ineffectiveness, and expense of spine surgery.

At the core of this problem is the conflict between medical ethics vs. physician income. Jerry Groopman, MD, author of a revealing article, “Knife in the Back,” published in The New Yorker magazine, wrote of this quandary about back surgery while seeking care for his own back pain problem when his orthopedist admitted to him, “If I don’t do them, they’ll go around the corner and the other surgeon will.”[19]

Back surgery is big business. The average annual salary of a spine surgeon is now the highest paid of all doctors at $806,000 according to Bloomberg News.[20] This salary does not include the royalties and commissions paid by surgical hardware manufacturers that often top the million dollar level as The Wall Street Journal revealed in an article, “Top Spine Surgeons Reap Royalties, Medicare Bounty.”[21] Remarkably, the pedicle screws inserted in a spine fusion cost $100 to manufacture, but retail for $2,000. Certainly these companies like Medtronic have a huge interest to persuade spine surgeons.

Despite the call for restraint in spine fusion surgeries, a 2006 study indicated the shocking cost increase of 500 percent between 1992 and 2002 from $75 million to $482 million. [22] Deyo mentioned one strong motivation included “financial incentives involving both surgeons and hospitals.”[23]

Unfortunately, there is no sign these medical treatments are slowing down. From 1994 to 2007, the patient population increased by only 12%, but MRIs increased 307%, spinal fusion surgery increased 204%, spinal injections increased 629%, and opiate use increased 423%.[24] The most complex type of back surgery has increased dramatically between 2002 and 2007 with a 15-fold increase.[25]

Deyo also noted, “It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just six years.”  Among the various reasons for such a large increase, he mentioned one strong motivation included “financial incentives involving both surgeons and hospitals.”

Deyo found the mean hospital costs for surgical decompression and complex fusions ranged from $23,724 for the former and $80,888 for the latter. [26] He and his colleagues discovered that the more-complex type of spine surgery was associated with substantially higher risk of life-threatening complications. [27] 

Dr. Deyo mentioned to The New York Times that the spine profession is ignoring this call for restraint:

People say, “I’m not going to put up with it,” and we in the medical profession have turned to ever more aggressive medication, narcotic medication, and more invasive surgery.[28]

In his 2009 article, “Overtreating Chronic Back Pain: Time to Back Off?” Dr. Deyo speaks of the increase as well as shortcomings of the medical spine treatments in the U.S.:

Jumps in imaging, opioid prescriptions, injections, and fusion surgery might be justified if there were substantial improvements in patient outcomes. Even in successful trials of these treatments, though, most patients continue to experience some pain and dysfunction.

Prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain. We must rethink chronic back pain at fundamental levels.[29]  

If the federal government officials are concerned about Medicare going broke, it might look more closing at the escalating number of back surgeries, epidural steroid injections, opioid drugs, and MRI scans being done for SRDs that are unnecessary, expensive, and ineffective. The figures involved with spine surgery are staggering and escalating. With the average total cost of spine fusion surgery reaching nearly $100,000, back surgery has become a questionable, costly, and an unsustainable burden to healthcare reform.[30]

CBS Evening News aired a segment, “Attacking Rising Health Costs,” stating 30-40% of surgeries are unnecessary, mainly spinal fusions, angioplasty, hip replacement, and knee replacement.[31] The problem, according to Dr. Elliott Fisher of The Dartmouth Institute of Health Policy, is that patients are not given good information to make an “informed consent” decision as to alternatives and inherent risks of each procedure.

The dramatic increases in usage and cost have finally gained the attention of insurance payers who have questioned the cost effectiveness of spine surgeries. Moreover, in January, 2011, a policy change by the North Carolina Blue Cross Blue Shield shocked the spine care industry when it said it would not pay for spinal fusion if the sole indication is disc degeneration or herniation.[32] 

Not the Disc

Aside from the greed factor in spine surgery, the primary clinical problem with spine surgery rests with new evidence that fails to support the medical rationale for disc fusion. What makes these cases difficult for medical doctors to diagnose and treat is the basic medical premise of back pain—the abnormal disc theory—has been refuted as the major cause of back pain. Ironically, the reliance upon the disc theory has become the leading cause of failed back surgery syndrome.

This evidence began emerging as far back as the early 1990s when MRI studies by Scott Boden, MD, at Emory University in Atlanta, found many symptomatic patients with completely healthy spines.[33] Spine researchers now agree disc abnormalities are ubiquitous and part of the normal aging process—equivalent to finding grey hair—and certainly not a surgical condition. Researchers now agree the vast majority of back pain cases have no apparent pathoanatomical disorders like disc disease, cancer, fracture, or serious infection like spinal tuberculosis.

These pathoanatomical cases, however, comprise only 3% of back pain cases according to Richard Deyo who believes 97% of back pain is “mechanical” in nature, and disc abnormalities specifically account for only 1% of back problems.[34] Not only are the vast majority of back pain cases misdiagnosed, the number of back surgeries are also unwarranted.

Another study conducted by Deyo in 1994 compared international rates of back surgeries and found the startling fact that the rate of American surgery was at least 40% higher than any other country and was more than five-times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopedic and neurosurgeons in that country.[35]

Nortin Hadler, MD, professor at UNC Chapel Hill and author of many books critical of an “overtreated society,” commented on the fallacy of the disc theory:

The discal hypothesis—the idea promulgated seventy years ago that the ‘ruptured disc’ is the culprit—has not withstood scientific scrutiny well. It is largely untenable for axial pain, and marginal for radicular pain. Magnetic resonance imaging cannot be used to predict back pain. Magnetic resonance imaging is not even sensitive to anatomical changes that might correlate with new symptoms. Why is it so important to define the anatomy of the lumbo-sacral spine of patients with regional low back pain?”[36]

Dr. Hadler’s admonition is not new; in fact, over thirty years ago in 1978-79 the New Zealand Commission of Inquiry into Chiropractic also indicated the difference in medical vs. chiropractic analysis:

The problem is a functional not a structural one…the medical profession simply fails to see the direction and subtlety of the chiropractic approach towards spinal dysfunction. Because the chiropractor uses x-ray extensively the medical practitioner thinks he is looking for a gross bony change, and when the medical practitioner cannot see this on the x-ray the chiropractor is using he immediately becomes skeptical.  He might as well expect to see a limp, or a headache or any other functional problem on x-ray.[37]

These non-specific (meaning there are no pathoanatomical issues such as cancer, fractures or serious pathologies) spine related  disorders (SRDs) are pathophysiologic cases that have in common musculoskeletal issues like vertebral misalignment, soft-tissue weakness or injury, joint motion problems, or any mechanical problem such as disc compression that makes it painful to sit, twist, or bend. According to chiropractors, the key is how the spine functions, not necessarily the amount of arthritis or anatomical disorders.[38]

One must consider the anatomy of the spine itself to understand the probable cause of back pain. The medical explanation remains “slipped discs” or “pulled muscles.” Most people accept these old concepts, so pain pills, muscle relaxants, epidural shots, and spine surgery seem appropriate. They have also been shown to be temporary at best; addictive, disabling, and unnecessary at the worst.

Before the new research impacts the public victimized by these outdated medical treatments, Americans need a paradigm shift in its understanding of what causes back pain. Simply put, you don’t slip discs as much as you do slip joints.

While there are 24 spinal vertebrae with 23 discs in the spine, most people are totally unaware there are numerous joints in and about the spine. Counting all the vertebral joints, sacroiliac joints, rib heads, and pelvic joints, new research now suggest the total is 313, a fact that is lost even to most physicians. This total includes all synovial, symphysis, and syndesmosis joints according to new research by Gregory D. Cramer, DC, PhD, Dean of Research at National University of Health Sciences.[39]

The evidence that led experts to believe disc abnormalities are incidental is sweet music to chiropractors who have long championed the key to a healthy spine is how the spine functions—in other words, the alignment of the spinal vertebrae, the core strength of spinal muscles, and the normal flexibility of spinal and pelvic joints.

Nearly 80-85% of non-specific, spine-related disorders are considered dysfunctional joint cases that chiropractors most likely can help with their spinal adjustments.[40],[41] Even if only half of this figure is true, that is still a huge reduction in costs and post-operative disability. Considering the nearly 500,000 spine surgeries done annually, the savings are obvious considering the majority of these cases could be helped with chiropractic care.

Dummy Doctors

Increasingly we hear more calls for primary spine care practitioners such as DCs to act as portal of entry for the epidemic of SRDs that calls for the advent of primary spine care providers rather than the use of untrained primary medical care providers who know painfully little about these SRDs. In terms of basic competency for musculoskeletal disorders, medical investigators concluded, “We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.” [42]

The same inadequacy extends into physician practices according to Paul B. Bishop, DC, MD, PhD, Clinical Associate Professor in the Department of Orthopaedics at University of British Columbia. “Typically, the family physician-based care involved excessive use of passive therapies such as massage and passive physical therapy, excessive bed rest, and excessive use of narcotic analgesics.” [43]

This failure by the medical profession to produce clinicians schooled in the current evidence-based treatments concerning SRDs has created calls for a new type of primary care spine specialists.

One such call came from an article in the British Medical Journal by Jan Hartvigsen, Nadine Foster, and Peter Croft that was  appropriately titled, “We Need to Rethink Front Line Care for Back Pain”:

Such “primary care musculoskeletal specialists” could provide extended and consistent evidence based management, optimizing the opportunity for improvement and prevention of chronic back pain.[44]

This Hartvigsen paper coincided with another paper that called for “a group of practitioners who are trained to function as primary care practitioners for the spine” by Donald Murphy, Brian Justice, Ian Paskowski, Stephen Perle, and Michael Schneider, all doctors of chiropractic. They concluded:

It is widely recognized that the dramatic increase in health care costs in the United States has not led to a corresponding improvement in the health care experience of patients or the clinical outcomes of medical care. In no area of medicine is this more true than in the area of spine related disorders (SRDs). Costs of medical care for SRDs have skyrocketed in recent years. Despite this, there is no evidence of improvement in the quality of this care. In fact, disability related to SRDs is on the rise. We argue that one of the key solutions to this is for the health care system to have a group of practitioners who are trained to function as primary care practitioners for the spine. [45]

Medical War Against Chiropractors

Perhaps the largest reason for this escalating problem began with the illegal and on-going medical boycott of chiropractic care that has been shown to be among the most effective treatments. For nearly a century, the AMA waged a war to “contain and eliminate” the chiropractic profession as a competitor, including an illegal boycott of chiropractors from public hospitals.[46]

Although a 1987 federal court decision in Chicago {Wilk et al. v. AMA et al.} found this to be a violation of antitrust laws, the social stigma has never been removed from the image of chiropractors. Even the judge admitted, “The AMA has never made any attempt to publicly repair the damage the boycott did to chiropractors’ reputations.”[47]

Sadly, too many Americans fell victim to the medical prejudice to boycott what is now deemed as one of the most effective type of spine care for the majority of SRDs. American and international guidelines for low back pain now recommend “conservative care” such as chiropractic care with active physical therapy for an extended period before spine surgery is considered.

As far back as 1987, a study in Spine by Nortin Hadler and Peter Curtis found those who were hurting for two to four weeks experienced a 50 percent reduction in score more rapidly with spinal manipulation. They concluded “the ability to abrogate an episode of backache, even by a few days, has major ramifications.”[48]

This trend of new supportive researched a new height in 1994 when the US Public Health Service’s Agency for Health Care Policy and Research conducted the most thorough analysis on acute low back pain and recommended spinal manipulation (SMT) in its guideline as a “proven method.”[49]

More current American guidelines such as the Milliman Care Guidelines® provide treatment options for physicians that include chiropractic care prior to lumbar fusion.[50] The American College of Physicians and the American Pain Society published in 2007 a Joint Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain that also concluded spinal manipulation to be effective for both acute and chronic low back pain.[51]

Even the guideline of the North American Spine Society, the academy of spine surgeons, recommends spinal manipulation before surgery, noting that recent “studies suggest that 5 to 10 sessions of spinal manipulative therapy administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions.”[52]

A recent 2010 study over a two-year span from 85,000 Blue Cross Blue Shield beneficiaries in Tennessee with low back pain found that treating for low back pain with chiropractic alone saves 40% on the cost of care. The study estimated that allowing DC-initiated episodes of care would have led to an annual cost savings of $2.3 million for BCBS of Tennessee. [53]

The era of evidence-based health care has finally recognized the value of conservative chiropractic care for the epidemic of back pain and SRDs. Anthony Rosner, PhD, testified before The Institute of Medicine: “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.”[54]

Dr. Rosner further described the problem that now remains: how to convince the biased MDs who have developed a bad case of “professional amnesia”—those who ignore the ascendancy of chiropractic in this back pain epidemic.[55]

During this Medicare upheaval and healthcare reform, chiropractors are poised to reduce costs and improve outcomes. If the guidelines on SRDs were followed, there would be a drastic decrease in drugs, shots, and spine surgeries that have been shown to be ineffective, costly, addictive, and disabling.

Indeed, when it comes to the question, “who’s got your back,” chiropractic remains the best type of care for the vast majority of back problems.

[1] “Relief for Aching Backs:  Hands-on Therapies were Top Rated by 14,000 Consumers,” Consumer Report (May 2009)

[2] Russell W Gibbons, “Go to Jail for Chiro,” Journal of Chiropractic Humanities 4 (1994): 61–71.

[3] Chester A. Wilk, James W. Bryden, Patricia A. Arthur, Michael D. Pedigo v. American Medical Association, Joint Commission on Accreditation of Hospitals, American College of Physicians, American Academy of Orthopaedic Surgeons, United States District Court Northern District of Illinois, No. 76C3777, Susan Getzendanner, Judge, Judgment dated August 27, 1987

[4] 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)

[5] Joe Light, “The Best and Worst Jobs,” The Wall Street Journal, (January 4, 2011)

[6] 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): p. 90.

[7] Paul G., Shekelle, et al, RAND Corporation Report, The Appropriateness of Spinal Manipulation for Low-Back Pain, 1992.

[8]PH Goodley, Release from Pain, www.DrGoodley.com (2005):xiv.

[9] G Waddell and OB Allan, “A Historical Perspective On Low Back Pain And Disability, “Acta Orthop Scand 60 (suppl 234), (1989)

[10] Richard Deyo, MD, MPH and Donald Patrick, PhD, MSPH, Hope or Hype, The obsession with medical advances and the high costs of false promises. 2005 AMACOM books.

[11] G Waddell and OB Allan, “A Historical Perspective On Low Back Pain And Disability, “Acta Orthop Scand 60 (suppl 234), (1989)

[12] Peter Waldman and David Armstrong, ibid.

[13] S Haldeman and S Dagenais, “A Supermarket Approach To The Evidence-Informed Management Of Chronic Low Back Pain,” The Spine Journal 8/1 (January-February 2008):1-7.

[14] John Carreyrou and Tom McGinty, “Top Spine Surgeons Reap Royalties, Medicare Bounty,” The Wall St. Journal, Dec. 20, 2010

[15] John Carreyrou and Tom McGinty,  “Medicare Records Reveal Trail of Troubling Surgeries,”  The Wall St. Journal, March 29, 2011

[16] Joanne Silberner, “Surgery May Not Be the Answer to an Aching Back,” NPR, April 6, 2010.

[17] Linda Carroll,  “Back Surgery May Backfire on Patients in Pain,” MSNBC, Nov. 14, 2010

[18] Peter Waldman and David Armstrong, “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies,” Bloomberg News, Dec. 30, 2010.

[19] Jerry Groopman The New Yorker magazine, “Knife in the Back,”  (April 8, 2002)

[20] Peter Waldman and David Armstrong, “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies” Bloomberg News, Dec. 30, 2010.

[21] John Carreyrou and Tom McGinty, “Top Spine Surgeons Reap Royalties, Medicare Bounty,” Wall St. Journal, Dec. 20, 2010

[22] JN Weinstein, JD Lurie, PR Olson, KK Bronner,  ES Fisher, “United States’ Trends and Regional Variations in Lumbar Spine Surgery: 1992-2003,” Spine 31/23 (1 November 2006):2707-2714

[23] “New Study Demonstrates a Three-Fold Increase in Life-Threatening Complications with Complex Surgery,” The BACKLETTER, 25/6 (June 2010):66

[24] Martin BI, Deyo RA, Mirza SK et al. Expenditures and health status among adults with back and neck problems. JAMA 2008; 299: 656-64

[25] J Silberner, “Surgery May Not Be The Answer To An Aching Back,”  All Things Considered, NPR (April 6, 2010)

[26] J Silberner, “Surgery May Not Be The Answer To An Aching Back,”  All Things Considered, NPR (April 6, 2010)

[27] “New Study Demonstrates A Three-Fold Increase N Life-Threatening Complications With Complex Surgery,” The BACKLETTER, 25/6 (June 2010):66

[28] G Kolata, “With Costs Rising, Treating Back Pain Often Seems Futile” by NY Times (February 9, 2004)

[29] RA Deyo, SK Mirza, JA Turner, BI Martin, “Overtreating Chronic Back Pain: Time to Back Off?” J Am Board Fam Med.  22/1 (2009):62-68. (http://www.medscape.com/viewarticle/586950 )

[30] A Schlapia, J Eland, “Multiple Back Surgeries And People Still Hurt.” Available at http://pedspain.nursing.uiowa.edu/CEU/Backpain.html Accessed April 22, 2003.

[31] CBS Evening News, “Attacking Rising Health Costs,” June 9, 2006.

[32] http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/lumbar_spine_fusion_surgery.pdf

[33] SD Boden, DO Davis, TS Dina, NJ Patronas, SW Wiesel, “Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects: A Prospective Investigation,” J Bone Joint Surg Am. 72 (1990):403–408.

[34] Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001 Feb 1;344(5):363-70.

[35] DC Cherkin, RA Deyo, et al. “An International Comparison Of Back Surgery Rates,” Spine, 19/11 (June 2004):1201-1206.

[36] Hadler, N, Need for less imaging, better understanding, JAMA, June 4, 2003 vol. 289 no. 21.

[37] Ibid. p. 55.

[38] DR Seaman, “Joint Complex Dysfunction, A Novel Term To Replace Subluxation/Subluxation Complex. Etiological And Treatment Considerations,” J. Manip Physiol Ther 20 (1997):634-44.

[39] G Cramer,  Dean of Research, National University of Health Sciences, via personal communication with JC Smith (April 29, 2009)

[40] G Jull, et al. Whiplash, Headache, and Neck Pain, (Churchill Livingstone, 2008).

[41] RA Deyo, “Conservative Therapy for Low Back Pain: Distinguishing Useful From Useless Therapy,” Journal of American Medical Association 250 (1983):1057-62.  

[42] KB Freedman, J Bernstein, “The Adequacy Of Medical School Education In Musculoskeletal Medicine,” J Bone Joint Surg Am. 80/10 (1998):1421-7

[43] PB Bishop et al., “The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) part I: A Randomized Controlled Trial On The Effectiveness Of Clinical Practice Guidelines In The Medical And Chiropractic Management Of Patients With Acute Mechanical Low Back Pain,” presented at the annual meeting of the International Society for the Study of the Lumbar Spine Hong Kong, 2007; presented at the annual meeting of the North American Spine Society, Austin, Texas, 2007; Spine, in press.

[44]Jan Hartvigsen Nadine E Foster, Peter R Croft, “We need to rethink front line care for back pain,”  BMJ 2011;342:d3260 doi: 10.1136/bmj.d3260

[45] Donald R Murphy, Brian D Justice, Ian C Paskowski, Stephen M Perle, Michael J Schneider, The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States, Chiropractic & Manual Therapies 2011, 19:17

[46] RB Throckmorton, legal counsel, Iowa Medical Society, “The Menace of Chiropractic,” an outline of remarks given to the North central Medical Conference, Minneapolis, , plaintiff’s exhibit 172, Wilk, 6: (November 11, 1962):126.

[47]  Chester A. Wilk, James W. Bryden, Patricia A. Arthur, Michael D. Pedigo v. American Medical Association, Joint Commission on Accreditation of Hospitals, American College of Physicians, American Academy of Orthopaedic Surgeons, United States District Court Northern District of Illinois, No. 76C3777, Susan Getzendanner, Judge, Judgment dated August 27, 1987.Opinion p. 10

[48] NM Hadler, P Curtis, DB Gillings, S Stinnet, “A Benefit of Spinal Manipulation as Adjunctive Therapy for Acute Low-Back Pain: A Stratified Controlled Trial,” Spine  12/ 7 (1987): 705.

[49] SJ Bigos, O Bowyer, G Braea, K Brown, R Deyo, S Haldeman, et al. “Acute Low Back Pain Problems in Adults: Clinical Practice Guideline no. 14.” Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; (1994) AHCPR publication no. 95-0642.

[50] Milliman Care Guidelines for Lumbar Fusion, “Low Back Pain and Lumbar Spine Conditions—Referral Management, Clinical Indications for Referral,” www.allmedmd.com

[51] R Chou, et al., “Diagnosis and Treatment of Low Back Pain:  A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society,” Low Back Pain Guidelines Panel, Annals of Internal Medicine 2 147/7 (October 2007):478-491

[52] MD Freeman and JM Mayer “NASS Contemporary Concepts in Spine Care: Spinal Manipulation Therapy For Acute Low Back Pain,” The Spine Journal  10/10 (October 2010):918-940

[53] Richard L. Liliedahl, Michael D. Finch, David V. Axene, Christine M. Goertz, “Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs. Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer,” Journal of Manipulative and Physiological Therapeutics (October, 2010)

[54] Testimony before The Institute of Medicine: Committee on Use of CAM by the American Public on Feb. 27, 2003.

[55] A Rosner, “Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient,” Dynamic Chiropractic, 20/25 (November 30, 2002)