“All the forces in the world are not so powerful as an idea whose time has come.” — Victor Hugo (Feb. 26, 1802 - May 22, 1885)
THE TIME HAS COME TO EXTEND THE CHIROPRACTIC PROFESSION’S REACH beyond that of being a mere option, among many, in spine-related care or just a provider of a particular form of treatment. Our opportunity to gain cultural authority has never been better. A patient’s need for impartial, scientifically valid, yet pragmatic cognitive guidance has never been greater.
Today’s patient faces a spine care system that is chaotic, ineffective and expensive. It can also be dangerous and unscrupulous. Benefits of treatments are often overstated.(1) Technology is introduced with little scientific evidence of effectiveness. (1,2) Potential harms are underreported or misrepresented.(1,3) And conflicts of interest, potentially compromising patient safety and cost, often remain undisclosed.(4,5,6,7)
Drs. Scott Haldeman and Simon Dagenais poignantly illustrated this chaos, likening our system to a “Supermarket of Spine Care.”(1) With more than 200 different treatment options, the supermarket is large. With more than 23 different clinicians offering their particular brand of care, it is filled with diverse and often conflicting opinions. Such disparity was also pointed out by Richard Deyo, MD, who stated, “There are wide variations in spine care, a fact that suggests there is professional uncertainty about the optimal approach.”(8)
Guidelines, first introduced in the United States in 1994, attempted to address such variability with an evidence-based approach.(9) Since then, at least 11 additional international guidelines have been developed, most of which are generally similar.(10) Despite the presence of these, studies have shown that they are often ignored, particularly by family physicians, leading to higher costs, increased use of narcotic medication and greater risks of adverse events.(11,12) Additional data have also illustrated the frequent inappropriate use of MRIs by general practitioners, resulting in a greater chance of surgery, larger costs per episode of care and no improvement in clinical outcomes.(13,14,15)
Interprofessional collaboration, found to enhance patient outcomes in other clinical settings, (16,17) would appear to be necessary for clinically and economically efficient spine-related care. However, such collaboration may be more illusory than real as, similar to other clinical environments, (18,19) integrated and collaborative spine care is impeded by territoriality and turf wars. (20,21) As noted earlier, there are more than 23 different clinical professionals involved in spine-related care. Most, if not all, of these focus primarily on providing care, as opposed to guiding care. This alone raises the question of how bias for one preferred form of care over another may affect any recommendations.
In 1620, Sir Frances Bacon stated, “The human understanding, when it has once adopted an opinion, draws all things else to support and agree with it.(22) Such “confirmation bias,” or the tendency of individuals to favor information supporting their own beliefs,(23) has been shown to obstruct objectivity in spine research and treatment decisions, especially when one has a vested interest in what one is doing or researching.(24,25)
Perhaps nowhere else is the evidence of spinecare chaos more alarming than at the intersection of commercial entrepreneurialism and the implementation of spine-related “technophilia.” As noted previously, many forms of technology today are introduced with little scientific evidence of effectiveness, plus using misleading advertising and kickbacks to physicians. In his book Stabbed in the Back, Dr. Norton Hadler writes how “entrepreneurial relationships that might compromise the choice of what’s best for one’s patients walk a very fine line between the sanctioned and the illegal.”(4) As an example, he relates the $40 million whistle-blower lawsuit against device manufacturer Medtronic for allegedly paying kickbacks to induce surgeons to use its spinal implants. Dr. Eugene Caragee investigated another Medtronic product, Infuse (used to enhance spinal fusion), and noted that the risk of adverse events was 10 to 15 times greater than original estimates reported in industry-sponsored peer review publications.(26)
Other studies have reinforced Caragee’s research with a more recent report stating, “There is mounting evidence in the spinal literature that utilizing BMP/INFUSE in spinal fusions contributes to major perioperative and postoperative morbidity.”(27) To its credit, Medtronic did commission a completely independent study of this product with the results carrying a mixed message. Lead investigator Dr. Harlan Krumholz stated, “There is a tremendous amount of uncertainty about the benefit it provides and how safe it is. I remain concerned that products like these are approved with too little study before they reach the market and too little afterward.”(28)
Commercialization of Spine Care
Such commercialization of spine-related care has even greater reach extending to common services such as imaging and injections. Mitchell has shown that imaging, epidural steroid injections and even complex surgeries are significantly higher when physicians have a vested financial interest in the facility performing the procedures.(29) The need for intellectual integrity becomes even more palpable when procedures such as epidural steroids, felt by many to be extremely safe, are found to be associated with the potential risk of brain edema and seizures.(30) Also, Jack Stern, MD, a writer for the North American Spine Society, states, “To date, laser discectomy may be more effective in attracting patients than in treating them.” (31,32,33,34)
Moving beyond the promotional hype that often supersedes reality, our current system of spinecare delivery has failed. Between 2000 and 2007, the prevalence of back pain has increased by 29 percent. Chronic back pain has increased by 64 percent, and per-person spine expenditures were 73 percent greater in the United States as compared with other industrialized societies.35 Between 1997 and 2005, total spending rose 65 percent, yet the percentage of patients with impaired spinal function, including total disability, has increased.(36,37) Even first-time spine pain patients face increased risks with estimates that up to 45 percent of such individuals may experience a less than optimum outcome.(38)
All spine-care professionals bear some responsibility for the inadequacy of our current system. However, if a recent study on Medicare utilization of chiropractic exemplifies what occurs with non- Medicare insurance plans, we may contribute more to this problem by our absence than our presence. This study showed that between 2005 and 2008, Medicare spending for chiropractic decreased by 17 to 18 percent, in contrast to a 10 to 16 percent growth in spending for other Medicare services and that chiropractic accounted for less than onetenth of 1 percent of overall Medicare spending.(39)
Chiropractic care, like other interventions for spinal pain, suffers from a lack of unequivocal evidence of effectiveness. A recent Cochrane review on acute and sub-acute back pain showed chiropractic care resulted in improved short- and medium-term pain and disability but no substantial benefit as compared with other interventions on long-term outcomes.(40) Another Cochrane review of chiropractic and chronic back pain concluded that, “in general, there is high-quality evidence that SMT has a small, statistically signifi- cant but not clinically relevant, short-term effect on pain relief and functional status as compared to other interventions.”(41) These citations are not meant to disparage chiropractic care, but rather to illustrate the difficulty in obtaining unequivocal proof of effectiveness with any intervention.
With so much attention being placed on researching our specific method of treatment (spinal manipulation), what seems to be less recognized is the potential benefit of our collective thought processes and how these positively affect patient outcomes. Several studies have provided such evidence, but possibly more tangentially than directly. For example, two different papers by Stanos et al. demonstrated that overall medical costs were much less for patients initiating their care with a DC as compared with an MD or DO, noting that the total cost difference was approximately $1,000 over a two-year period and attributed to lower in patient utilization.(42,43) Phelan et al. examined data from more than 100,000 work injury claims and found that less than 1 percent were treated by DCs and that their average expense for treatment was $663 as compared with a “medical care” average of $3,519.44 Brooks et al. more recently added to this literature by also demonstrating a significant reduction in overall health-related costs when “CAM” providers are utilized, once again attributing this to less utilization of inpatient services.(45)
Joan Didion has stated, “Most of our platitudes notwithstanding, self-deception remains the most difficult deception.”(46) Much of today’s medical approach toward spine care remains caught in this trap, seduced by a “belief” in technology, despite outcomes calling for a dramatically different approach.
It is here where knowledge and intellectual integrity can assist our patients in navigating a complicated field of options and in so doing gain greater levels of cultural authority. As a profession, we are far greater than our techniques.
Our minds would be a terrible thing to waste.
1. Haldeman S, Dagenais S. A supermarket approach to the evidence-informed management of chronic low back pain. The Spine Journal
8 (2008) 1–7.
2. Deyo R. Crossing the Threshold: How Experimental Medical Technology Becomes Standard Care. Robert Wood Johnson Foundation: Investigator Awards in Health Policy Research. 2000.
3. Carragee E, Hurwitz E, Weiner B. A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned. The Spine Journal.
Volume 11, Issue 6 2011.
4. Nortin Hadler. Stabbed in the back: Confronting Back Pain in an Overtreated Society. www.amazon.com/Stabbed-Back-Confronting-Overtreated-Society/dp/0807833487.
5. Abelson R. Medtronic will settle accusations on kickbacks. New York Times
, July 19, 2006:C4.
6. Abelson R. Financial ties are cited as issue in spine study. New York Times
, Jan. 30, 2008.
7. Baker L. December 2010. Acquisition of MRI Equipment by Doctors Drives Up Imaging Use and Spending. Health Affairs
8. Deyo R, Weinstein D. New England Journal of Medicine
, Feb. 2001
9. Bigos SJ, Bowyer R, Braen R, et al. Clinical Practice Guideline 14. Acute Low Back Problems in Adults: AHCPR 1994.
10. Koes B, van Tulder M, Ostelo R, Kim Burton A, Waddell G. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine.
2001;26(22):2504-2513, discussion 2513-2504.
11. Williams CM1, Maher CG, Hancock MJ, McAuley JH, McLachlan AJ, Britt H, Fahridin S, Harrison C, Latimer J. Low back pain and best practice care: A survey of general practice physicians. Arch Intern Med.
2010 Feb 8;170(3).
12. Bishop PB, et al. 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. International Society for the Study of Lumbar Spine, Hong Kong, 2007.
13. Gilbert FJ, Grant AM, Gillan MG, et al. Low back pain: influence of early MR imaging or CT on treatment and outcome–multicenter randomized trial. Radiology
2004;231:343–51. 14. Emery DJ, Shojania KG, Forster AJ, Mojaverian
N, Feasby TE. Overuse of Magnetic Resonance Imaging. JAMA Intern Med.
15. Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine
16. Cullen L, Fraser D, Symonds I. Strategies for interprofessional education: the Interprofessional Team Objective Structured Clinical Examination for midwifery and medical students. Nurse Educ Today.
17. Reeves S, Freeth D. The London training ward: an innovative inter-professional learning initiative. J Interprof Care.
18. Bate P. Changing the culture of a hospital: from hierarchy to networked community. Public Adm.
19. Axelsson SB, Axelsson R. From territoriality to altruism in interprofessional collaboration and leadership.J Interprof Care.
20. Chung C, Manga J, McGregor M, Michailidis C, Stavros D and Woodhouse J. Interprofessional Collaboration and Turf Wars How Prevalent Are Hidden Attitudes? J Chiropr Educ.
2012 Spring; 26(1).
21. Eisner W. Orthopedics this Week. Nov. 16, 2013 https://ryortho.com/breaking/interventionalist-spine-surgeons-call-to-arms/.
22. Bacon F. Ovum Organism. Reprinted in Burt EA, ed. The English Philosophers from Bacon to Mill. New York, New York; Random House; 1939:36.
23. Ridley M. The perils of confirmation bias: part 1. Wall Street Journal.
July 22, 2012.
24. Chapman J. Eliminating bias/living with bias. Avid Based Spine Care J.
Aug 2012; 3(3).
25. Auerbach JD1, McGowan KB, Halevi M, Gerling MC, Sharan AD, Whang PG, Maislin G. Mitigating adverse event reporting bias in spine surgery. J Bone Joint Surg Am.
2013 Aug 21;95(16).
26. Caragee E, Hurwitz E, Weiner B. A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned. The Spine Journal.
Volume 11, Issue 6 2011.
27. Epstein NE. Complications due to the use of BMP/INFUSE in spine surgery: The evidence continues to mount. Surg Neurol Int.
2013 Jul 9;4(Suppl 5):S343-52.
28. Michelle Fay Cortez. Medtronic’s Infuse No Better Than Bone Graft With Risk. www.bloomberg.com/news/2013-06-17/medtronic-s-infuse-benefits-equal-bone-graft-with-risk.html.
29. J Mitchell. August 2007. Utilization Changes Following Market Entry by Physician-Owned Specialty Hospitals. Medical Care Research and Review 64(4): 395–415.
30. Robert Lowes. Spinal Corticosteroids Run Risk of Severe Neuro Effects. April 23, 2014.www.medscape.com
31. Choy DSJ, Case RB, Fielding W, et al. Percutaneous laser nucleolysis of lumbar disc. N Eng J Med.
32. Singh V, Manchikanti L, Calodney AK, Staats PS, Falco FJ, Caraway DL, Hirsch JA, Cohen SP. Percutaneous lumbar laser disc decompression: an update of current evidence. Pain Physician.
2013 Apr;16(2 Suppl):SE229-60.
33. Jack Stern. Lasers in Spine Surgery: A Review. North American Spine Society Newsletter. Sept-Oct 2009.
34. David Armstrong. Laser Spine Surgery More Profitable Than Google Sees Complaints. Bloomberg. www.bloomberg.com/news/2011-05-04/laser-spine-surgery-more-profitablethan-google-sees-surge-in-complaints.html.
35. Smith M, et al. Aging baby boomers and the rising cost of chronic back pain: secular trend analysis of longitudinal Medical Expenditures Survey data for years 2000-2007. JMPT.
36. Friedly J, Standaert C, and Chan L. Epidemiology of Spine Care: The Back Pain Dilemma. Phys Med Rehabil Clin N Am.
Nov 2010; 21(4): 659–677.
37. Deyo R, et al. Adults With Back and Neck Problems. JAMA
. Feb. 13, 2008—Vol 299, No. 6.
38. Hill JC, Dunn KM, Lewis M, et al. A primary care back pain screening tool: Identifying patient subgroups for initial treatment. Arthritis Rheum
39. Whedon JM, Song Y, Davis MA. Trends in the use and cost of chiropractic spinal manipulation under Medicare Part B. Spine J.
40. Walker BF, French SD, Grant W, Green S. Combined chiropractic interventions for low-back pain. The Cochrane Library 2011, Issue 2. www.thecochranelibrary.com.
41. Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. The Cochrane Library 2012, Issue 9. www.thecochranelibrary.com.
42. Stano M: A comparison of health care costs for chiropractic and medical patients. J Manipulative Physiol Ther
43. Stano M, Smith M: Chiropractic and medical costs of low back care. Med Care
44. Phelan SP, Armstrong RC, Knox DG, Hubka MJ, Ainbinder DA. An evaluation of medical and chiropractic provider utilization and costs: treating injured workers in North Carolina. J Manipulative Physiol Ther
45. Martin B, Gerkovich M, Deyo R, Sherman K, Cherkin D, Lind B, Goertz C, and Lafferty W. The Association of Complementary and Alternative Medicine Use and Health Care Expenditures for Back and Neck Problems. Med Care.
2012 (Dec); 50 (12): 1029–1036.
46. Joan Didion (b. 1934, U.S. essayist). “On Self- Respect,” Slouching Towards Bethlehem (1968).
More on Chiropractic Cultural Authority
TWO INFORMATIVE ARTICLES ON CHIROPRACTIC CULTURAL AUTHORITY are worthy of examination. In a 2008 article, the authors compare chiropractic to podiatry and note:
By focusing on a specific set of clinical problems (i.e., foot disorders) for which society had a demonstrable need for professional services, using the scientific method to explore ways to better serve society, consistently upgrading their clinical training, and appropriately policing themselves, podiatrists have successfully fulfilled the social contract. As a result, it is our experience that podiatrists are widely perceived by the public to be ethical and honest professionals who generally have their patient's best interests at heart.
The chiropractic profession has an obligation to actively divorce itself from metaphysical explanations of health and disease, as well as to actively regulate itself in refusing to tolerate fraud, abuse and quackery, which are more rampant in our profession than in other healthcare professions. This must be done on an individual practitioner basis as well as by the political, educational and regulatory bodies. In this way, the profession can fulfill its responsibility to the social contract. This will dramatically increase the level of trust in and respect for the profession from society at large. [Murphy D, Schneider M, Seaman D, Perle S and Nelson C, How can chiropractic become a respected mainstream profession? The example of podiatry.Chiropractic & Osteopathy
2008, 16:10 doi:10.1186/1746-1340-16-10. Go to www.chiroandosteo.com/content/16/1/10
Also see “In the Quest for Cultural Authority,” at www.dynamicchiropractic.com/mpacms/dc/article.php?id=46556.
Ronald D. Fudala, DC, DACAN, graduated from the National University of Health Sciences in Lombard, Ill, in 1987. Dr. Fudala was neurology chairman for the Ohio State Chiropractic Association and served on its peer review and college site approval committees. In 1995, he received OSCA’s “Chiropractor of the Year” award.
In January 2001, Dr. Fudala was invited to join the neurosurgical division of a large specialty referral practice where he remained until August 2011. During this time, he developed and supervised a structural spine care program for nonsurgical and postsurgical patients. He resigned from this practice to devote a greater portion of time to independent study, postgraduate teaching and providing oneon- one personal consulting to patients, businesses and other doctors. Dr. Fudala was a board member and educational chairman for the International Board of Electrodiagnosis and currently serves on the educational committee for the International Academy of Chiropractic Neurologists. For more, go to www.spineline.net