Misleading Research
Let
the Chips Fall
By
JC Smith, MA,
DC
The supermarket of care for spinal disorders just got more confusing with the release of an RCT by WC Peul et al. (Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: Two-year results of a randomized controlled trial, BMJ, 2008.).
Dr.
Peul is Director of the Spine
Intervention Prognostic Study Group at
In the lead
article of the June edition of The BACK LETTER, “Balancing Costs and Benefits: Is Disc Surgery Cost-Effective?” (vol. 23, no. 6, 2008), Peul and his associates clouded the treatment of sciatica with a study
that is filled with dumbfounding comparisons, glaring omissions, and obvious bias.
Sadly, this flawed study may be used against conservative treatments despite
its obvious shortcomings that only a professional versed in conservative care
and manual medicine would notice.
Peul’s study suggests discectomies for
sciatica are preferable/cost effective over conservative care in the short term
(6 weeks), but admitted not in the long term (6 months). “The advantage
was discernible six weeks after surgery but vanished by six months. And there
were no significant differences between treatment groups in pain or disability
beyond that follow-up point.”
OBVIOUS
FLAWS
1.
Definition of Conservative Care
First of all, there are many concerns about this Peul study, most prominently,
the definition of “conservative care.” From the Peul study:
“Treatment methods were straightforward. Those allocated to disc
surgery underwent microdiscectomy and removal of loose degenerated disc
material from the disc space. General
practitioners supervised conservative care. There are no proven nonoperative
treatments for sciatica, so the treatment approach was empirical. It included information,
reassurance, pain control, and encouragement to return to normal activity.
Those who were fearful of movement were referred for physical therapy. Both
groups had access to research nurses for advice and encouragement.”
It seems
Peul’s definition of conservative care doomed a true comparison before it
started in that he failed to offer the most effective treatments such as spinal manipulative therapy,
flexion-distraction, non-surgical spinal decompression and active rehab. In
essence, they offered cheap advice and pain pills by general practitioners—the
typical medical mis-management of back pain. This is ridiculous as well as
ineffective, and it is certainly misleading to suggest this represents the best
of conservative care.
Considering the avoidance of the best
treatments of conservative care that I mention, I did find it ironic that even using
inferior conservative treatments still proved comparable in the long run with
spine surgery. Apparently the second-string of conservative care proved equal
to the best in microdiscectomy in the long run. I can only imagine the results
if the best of conservative care were used.
2. No Proven Nonoperative Treatments for
Sciatica
I find it peculiar
that this author states “There are no proven nonoperative
treatments for sciatica.” As a
practicing DC who’s personally suffered with sciatica and who’s treated a few
thousand sciatica cases over the past 30 years, I find his opinion bizarre,
perhaps indicating his professional bias as a neurosurgeon.
This begs the
question: is Peul totally unfamiliar with manual medicine or what?
Dr. Peul’s omission
is perplexing considering one quick scan of Medline for sciatica/herniated
discs/manual medicine would reveal a plethora of studies showing the effectiveness
of spinal manipulative therapy,
flexion-distraction, and non-surgical spinal decompression for leg
pain/herniated discs.
Here is a short
sampling of research supporting manual therapy (SMT, Flexion/distraction, non-surgical
spinal decompression) for LBP/leg pain:
·
Henderson RS (1952) The treatment of lumbar
intervertebral disk protrusion: an assessment of conservative measures, Br. Med J 2:597-598.
·
Mensor MD (1955) Non-operative
treatment, including manipulation, for lumbar intervertebral disc syndrome, J Bone Joint Surg 37A:926-935.
·
Kuo PP, Loh
Z (1987) Treatment of lumbar intervertebral disc protrusions by manipulation, Clin Orthop 215:47-55.
·
Cassidy JD, Thiel HW, Kirkaldy-Willis WH.Side posture manipulation for lumbar intervertebral disk
herniation. J Manipulative Physiol Ther. 1993 Feb;16(2):96-103.
·
Troyanovich SJ,
Harrison DD,
·
Quon JA, Cassidy JD, O'Connor SM, Kirkaldy-Willis
WH. Lumbar intervertebral disc herniation: treatment by rotational
manipulation. J Manipulative Physiol Ther. 1989 Jun;12(3):220-7.
·
Cox JM, Hazen LJ,
Mungovan M. Distraction manipulation reduction of an
L5-S1 disk herniation. J Manipulative Physiol Ther. 1993 Jun;16(5):342-6.
·
Schneider MJ, Distraction
manipulation reduction of an L5-S1 disk herniation. J Manipulative Physiol Ther. 1993 Nov-Dec;16(9):618-20
·
Slosberg M. Side
posture manipulation for lumbar intervertebral disk herniation reconsidered. J
Manipulative Physiol Ther.
1994 May;17(4):258-62.
·
Bergmann TF,
·
Shealy,
·
Gose EE, Naguszewski
WK, Naguszewski RK.Vertebral
axial decompression therapy for pain associated with herniated or degenerated
discs or facet syndrome: an outcome study. Department of Bioengineering,
As I mentioned, this list is just a quick
scan, so apparently Peul failed to do his homework when he stated “there are no
proven nonoperative treatments for sciatica” and seems to have purposely designed
his comparison with rather ineffective methods. Is it any wonder conservative
care didn’t score better in his RCT when you consider he avoided using the best
of proven conservative treatments? Is this simply a case of oversight or
intellectual dishonesty?
The Decade of Bone and Joint Disorders; Evidence-Informed
Management of Chronic Low Back Pain Without Surgery (Haldeman
et al.; The Spine Journal,
January/Feb 2008,Volume 8, Number 1) gave meager endorsements of Peul’s choices
of conservative care. If he were fair in his comparison, why didn’t Peul use the
most effective forms of non-invasive conservative care rather than the old
medical version of cheap advice and pain pills? Obviously this is a sham
comparison of apples to rotten oranges.
3. General Practitioners Incompetence
The fact that Dr. Peul chose general practitioners (GPs) to manage the
conservative care group also is strange considering most GPs know very little
about musculo-skeletal disorders (MSDs). This is unconscionable considering
many studies have shown the incompetence of GPs for diagnosing and
treatment of MSDs.
- In 1998, Freedman and
Bernstein published a landmark study in the Journal of Bone and Joint
Surgery, wherein they administered a validated musculoskeletal
competency examination to 85 recent medical graduates who had begun their
hospital residency. Of these medical doctors, 82 percent failed to
demonstrate basic competency on the examination, leading the authors to
conclude, “We therefore believe that medical school preparation in
musculoskeletal medicine is inadequate.”
- In their 2004 review
published in Physician and Sportsmedicine,
Joy and Van Hala describe the musculoskeletal
training of allopathic physicians as “woefully inadequate,” and noted that
among a sample of 85 recent medical graduates, “the average time spent in
rotations or courses devoted to orthopedics during medical school was only
2.1 weeks. One third of these examinees graduated without any formal
training in orthopedics.”
- In early 2007, Humphreys, et
al., administered the previously utilized standardized competency
examination to a sample of 123 senior chiropractic students from a single
college to find that 51 percent of these students were competent in
musculoskeletal care by this standard. Remarkably, the pass rate for a
group of 10 chiropractic doctors was 100 percent on this same examination
that was consistently failed by allopathic students, doctors and,
according to a small study, osteopathic students.
These studies
beg the question: if Peul wants an honest portrayal of care using conservative
methods, why didn’t he use DCs (or even PTs or DOs) instead of GPs since most
health professionals would agree that DCs, if good for anything, are the most
prominent managers of conservative care for spinal treatments? Again, perhaps
his bias wouldn’t allow using the best conservative care doctors for fear of
not reaching his skewed conclusion that “disc surgery is cost-effective. It
earns money for society.”
Okay, stop
laughing. Certainly it’s true that disc surgery earns money for spine surgeons,
surgical device manufacturers, imaging centers, and hospitals, but I seriously
question how anyone can suggest spine surgery is a better buy than proper conservative
care considering the average total cost of spine surgery and hospitalization
(not withstanding disability, rehab, and reoperation) reaches $50,000 to over
$100,000 for disc replacements and is shown to be no better in long-term
results.
As NM Hadler,
MD, wrote in his book, The Last Well
Person, when it comes to the medical management of LBP, ''Maybe you're
better off not going to a doctor.'' But maybe you’re best off going to a
chiropractor, I might add.
4. “Incidentalomas”
Dr. Peul never
questions the validity of the suspect disc theory itself as the underlying
cause of LBP/leg pain and as the primary focus of treatment, which may explain
why the long-term benefits of disc surgery are so poor. Anyone versed in spinal
mechanics realizes that the disc is secondary to the motor unit in the spinal
area—the functioning of the spinal joints, joint capsules, ligaments, tendons,
and muscles.
Basically, the medical examination of a static spine versus the manual
medicine dynamic evaluation is, again, comparing apples to oranges. Even NM
Hadler questions the point of MRI exams for LBP: “Why is it so important to
define the anatomy of the lumbo-sacral spine of patients with regional low back
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.”
(JAMA, Need
for less imaging, better understanding June 4, 2003 vol. 289 no. 21)
Considering the disc abnormalities found on MRIs are often incidental to
back pain, other than to rule out the rare red flags like cancer or fracture,
imaging tests seem to be most useful as selling points rather than as finding
the source of the pain. Until the medical profession recognizes this problem of
misdiagnosis, patients will continue to be mistreated and misinformed about the
actual cause and best treatment for their back and leg pain.
Many researchers
have questioned the disc theory as the prominent cause of spine disorders,
referring to these imaging findings a “false-positives” or “incidentalomas”:
·
Rick Deyo and JN Weinstein:
“Early or frequent
use of these tests [CT and MRI] is discouraged because disc and other
abnormalities are common among asymptomatic adults. Degenerated, bulging, and
herniated disks are frequently incidental findings…Detecting a herniated disk
on an imaging test therefore proves only one thing conclusively: the patient
has a herniated disk.”
(Deyo RA, Weinstein
JN. Low back pain.
·
NM Hadler, MD, author of “The Last Well Person” also criticizes
the disc theory for LBP:
“‘Ruptured discs and ‘bad back’ are terms
that deserve to be relegated to the historical archives…Whatever we see on the
MRI is likely to have been present when the person heals. 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.
(JAMA, Need for less imaging, better
understanding June 4, 2003 vol. 289 no. 21)
·
The authors on www.spine-health.com
also admit the fallacy of using MRIs as a selling point for spine surgery:
“You may have a bulging disc that shows
up on an MRI scan, but that may not be the cause of your leg pain. You can have
disc degeneration or other anatomical lesions that show up on the scan, but are
not causing pain. Studies have shown that many people with no pain or other
symptoms often have some sort of disc problem show up on an MRI scan.”
Regrettably, the “incidentalomas” seen on imaging are effective selling
points by unethical surgeons who know better, but profit greatly by misleading
patients with “false positives” on images. If that selling point fails to close
the sale, too often patients are given the voodoo diagnosis by unethical surgeons
when asked if chiropractic care might help: “If you’re dumb enough to go to a
chiropractor, don’t come crawling back to me when you’re paralyzed.” Don’t
laugh because if I’ve heard this once, I’ve heard it a thousand times.
5. Similar Long
Term Results
Ironically, even when using ineffective treatments like cheap advice and
pain pills, the outcomes with surgery were comparable later on.
“There were no significant differences between treatment groups
beyond six months. Results of the two groups were identical at one-year
follow-up in terms of pain, disability, and global outcome. Over the course of
the first year, 95% of both groups reported complete recovery.”
The SPORT study published in JAMA (Weinstein et al. Nov. 2006) also showed that patients with low back and
leg pain who underwent spinal surgery fared no better two years later than
those who used non-invasive therapy. Again the obvious question remains: why
are they doing expensive, risky surgery when the long term results are no
better, even when compared to weak conservative treatments as in the Peul
study? No one wants to answer that question because it’s good for business as
Dr. Peul suggests.
According to The National Academy of Science,
implementation of new treatments is slower than one might expect in this era of
evidence-based healthcare. Indeed, if the electronic industry were as slow as
medicine, we’d still be in the vacuum tube era.
“In the current
health care system, scientific knowledge about best care is not applied
systematically or expeditiously to clinical practice. An average of about 17
years is required for new knowledge generated by randomized controlled trials
to be incorporated into practice, and even then application is highly
uneven...”
(Crossing the Quality Chasm: A New Health System for
the 21st Century, The National Academy of Sciences, 2001. page 13-14.)
Dr. Thomas Errico, past president of the North American Spine Society, told the NY Times that surgery is a last resort, but he also failed to mention manual medicine in his care. “His patients have X-rays or MRI's. They try over-the-counter anti-inflammatory drugs. They are given an exercise program, or get muscle relaxants or painkilling injections. They are told to stretch and to get their weight under control. They might get a steroid injected into the spine to reduce inflammation.
''That's what the vast majority of the 3,700 members of
the North American Spine Society do,'' Dr. Errico
said. ''The vast majority discourage surgery or don't
offer surgery as the first recourse.'' (“With Costs Rising, Treating Back Pain Often Seems Futile” by
Gina Kolata, NY
Times, February 9, 2004)
While he contends surgeons don’t encourage surgery as the first recourse, Dr. Errico failed to mention the role of manual medicine in the care of these cases. Similar to Dr. Peul’s skewed version of conservative care consisting of advice and pain pills, most of these spine surgeons consistently fail to refer to DCs for hands-on spinal therapy that has proven successful in these cases. This oversight certainly isn’t “informed decision making” nor is it ethical to exclude the entire world of manual medicine.
I can only
imagine the improved outcomes if manual medicine treatments were used instead
of the medical model of advice, pain pills, ESIs, MRIs leading to spine
surgery. Presently, many international guidelines on back pain recommend manual
medicine as a front line treatment, but the status quo medical approach has yet
to change.
Here is a list
of the most recent guidelines that endorse manual medicine for spinal problems.
•
1994: AHCPR Acute Low Back Pain in Adults
•
2003:
•
2004: European Back Pain Guidelines.
•
2004:
•
2007: Guideline on Back Pain:
•
2008: Decade of Bone & Joint Disorders: Chronic LBP
No longer can
our medical adversaries say there is no research or recommendations by
significant groups on the value of manual medicine. Now the biggest obstacle is
the medical profession that stands to lose business if their profession
actually follows these international guidelines, but I’m not holding my breath.
Recall the backlash by the North American Spine Society after the AHCPR
guideline was released.
After the
release of AHCPR in December, 1994, the North American Spine Society
successfully lobbied Congress to revoke the ability of the Agency on Health
Care Policy and Research to do its job mandated by Congress to investigate
medical procedures and to recommend treatment guidelines with the goal to lower
costs and improve outcomes.
Its ire
stemmed from the criticism levied at spinal fusions, especially those involving
pedicle screws due to the findings that fusions had few scientifically
validated indications and was associated with higher costs and complications
rates than other types of back surgery. Not only were they successful in
gutting the AHCPR, these angry orthopedists even sued the researchers involved
to discourage any other attempts to change the medical status quo.
(Turner
JA, Ersek M, Herron L, Haselkorn
J, Kent D, Ciol MA, Deyo R. Patient outcomes after
lumbar spinal fusions. JAMA 1992; 268: 907-911.
)
As a member of
the AHCPR panel, Dr. Richard Deyo subsequently co-authored in The New
England Journal of Medicine an article in response to this intimidation,
"The Messenger Under Attack--Intimidation of Researchers by Special
Interest Groups." He alluded that the for-profit mindset of some surgeons
supersedes the value of research:
"The huge financial implications of many research studies invite
vigorous attack... Intimidation of investigators and funding agencies by
powerful constituencies may inhibit important research on health risks and
rational approaches to cost-effective health care.”
(Deyo RA, Psaty BM,
et al. The Messenger under Attack--Intimidation of Researchers by
Special-Interest Groups, NEJM, vol. 336, No. 16, pp. 1176-79, April
17, 1997.)
According to RD Guyer, MD, TBI founder and current NASS president, in his
recent presidential address, he admits the huge money involved in the spine
business. “The stakes are great as there
is big money in spine…in 2005 dollars, between $100 and $200 billion per year
are spent on spine care…
Indeed, most spine
studies (BEAM, SPORT,
Even Rick
Deyo, MD, MPH, renowned spine researcher, admits:
''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, surgery, more invasive surgery.''
(“With Costs
Rising, Treating Back Pain Often Seems Futile” by
Gina Kolata, NY
Times, February 9, 2004)
Dr. Deyo also admitted, “More people are
interested in getting on the gravy train than on stopping the gravy train.”
(Reed
Abelson, Financial Ties Are Cited as Issue in Spine Study, NY Times, January 30, 2008 )
As Upton
Sinclair once said, “It is difficult to get a man to understand something when
his salary depends on his not understanding it.” The NASS v. AHCPR debacle
perfectly illustrated this conflict of interest in medicine. Sadly, in this era
of evidence-informed management of back pain with or without sciatica, the
bottom line rests not with the evidence as much as it rests with profitability.
6. Joint Play
Dr. Peul’s focus as a neurosurgeon on disc abnormalities completely ignores
the fact that many back pain problems may stem from the loss of joint play and the
subsequent inflammatory response that are resolved by manual medicine and
anti-inflammatory treatments like aspirin and simple cold packs as the AHCPR
guideline recommended. In fact, the disc is a secondary player in the back/leg
pain syndrome according to many researchers.
The paradigm shift in spinal care required by the medical profession is
to acknowledge there are 137 spinal joints that can be misaligned, buckled,
twisted, wrench apart or fixated to cause a variety of movement problems and
pain. Indeed, you don’t slip discs as much as you slip joints.
Overloading,
compression, bad leverage combined with spinal injuries from childhood, sports,
and accidents lead to loss of joint play causing axial pain and may lead to
neurological deficits due to inflammation/compression. Trying to explain this
complex cascade of events with the disc abnormality as the sole cause is
simplistic and misleading, perhaps explaining the poor results from fusion and
the short-lived results from microdiscectomy. In effect, the disc does nothing
until forced to by the dynamics of spinal mechanics.
Not only can joint dysfunction cause axial pain and disc abnormalities,
new research has shown that joint dysfunction may also cause radiculopathy like
sciatica, a condition long equated to disc herniation, according to a recent
study by H. Tachihara et al. in Spine.
“When inflammation was induced in a facet
joint, inflammatory reactions spread to nerve roots, and leg symptoms were
induced by chemical factors. These results support the possibility that facet
joint inflammation induces radiculopathy.”
(Tachihara
H, Kikuchi S, Konno S, Sekiguchi M. Does facet joint
inflammation induce radiculopathy?: an investigation
using a rat model of lumbar facet joint inflammation. Spine.
2007 Feb 15;32(4):406-12.)
JL Shaw, MD, mentioned years ago that joint dysfunction, particularly the
sacroiliac joint, may cause herniation:
“Joint dysfunctions are the major cause
of LBP as well as the primary factor causing disc space degeneration and
ultimate herniation of disc material.”
(Shaw JL, “The role
of the sacroiliac joints as a cause of low back pain and dysfunction,” speech
before the World Congress on Low Back Pain, University of California, San
Diego, Nov. 5-6, 1992 )
Other orthopedists agree with Shaw.
“The sacroiliac joint appears to be the
single greatest cause of back pain...when the normal joint play is lost,
agonizing pain can be precipitated.”
(Bourdillon
JF, Day EA (1987) Spinal manipulation, 4th edition, William Heineman
medical books, London, 216-217.)
John McMillan Mennell, MD, testified at the Wilk et al. v. AMA et al.
antitrust trial of the role of joint function in LBP:
“The science of mechanics demands that joint
play movement is prerequisite to normal pain-free functioning of movement …in
the spine there are about 137 synovial joints between the lamina facets, the
occipital condyles, the bottom of the skull as it rests on the atlas, the
sacroiliac joints, the sacrococcygeal joints, the z-joints, even the joints of
the fundusca in the neck.
“When you are dealing with manipulative
therapy in the spine…your objective is to try to restore the proper motion
joint play, which is prerequisite to the normal function in the spine…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.”
More recently, research conducted at the Texas Back Institute investigated
the joint dysfunction in LBP. According
to research by John Triano, DC, PhD, et al., the accumulative effect from
traumatic injuries during childhood compounded in adulthood by the effects from
gravity and obesity increasing spinal compression aggravated by prolonged
sitting/standing, improper lifting, accidents, will develop a functional spinal
lesion that causes a “segmental buckling effect.”
(Triano J Biomechanics of
spinal manipulation. Spine 2001;1:121-30)
Regrettably, despite the many studies supporting the use of manual
medicine in the treatment of LBP/leg pain, Peul’s study will be used to dash
the role of manual medicine in these cases. Peul’s omission of the best
conservative care is reminiscent 
of the flawed study
by Tim Carey, MD, MPH, director of the
(Carey TS, et al. The outcomes and costs of care for acute low back
pain among patients seen by primary care practitioners, chiropractors, and
orthopedic surgeons. NEJM
1995; 333:913-7.)
The recent 2007 guidelines for LBP issued by the American Pain Society
also mentions grave concerns about back surgery:
“Some studies have shown no
benefit of surgery compared with intensive interdisciplinary rehabilitation,
with a significant proportion of patients experiencing suboptimal outcomes,
including persistent pain or functional deficits after surgery. On the basis of the
evidence, Dr. Roger Chou said, they were unable to give strong recommendations
for surgery, "but we think there may be some patients for whom surgery,
fusion specifically, might be helpful, but it's really important for doctors to
discuss the fact that surgery doesn't tend to lead to huge improvements on average,"
he said. “You're talking about a 10- to 20-point improvement in function on a
100-point scale, so that's pretty small, and a significant proportion of
patients still need to take pain medication and don't return to full
function."
(Low Back Pain Guidelines
Expanded to Include Interventional Procedures, American Pain Society 27th
Annual Scientific Meeting: Symposium 312. Presented May 8,
2008.)
Dr. Tim Johnson, ABC World News medical spokesman, asks the appropriate
question: “So why are so many back surgeries performed in this country? It
could be a combination of too many surgeons who are too eager to operate and
the impatience of many patients who want results quickly. The truth is that 90
percent of back pain can be resolved without surgery if both doctors and
patients are willing to try other treatments that basically help the back to
heal itself.”
(Back Surgery Not
Always the Cure for Pain;
Perhaps Dr. Jerry Groopman answered Johnson’s question when he admitted: "If
I don't do them, they'll go around the corner and the other surgeon will.”
(The
New Yorker magazine by Dr. Jerry Groopman, "Knife in the Back,” (April 8, 2002)
Sadly, Dr. Peul’s skewed comparison and unconvincing conclusion that disc
surgery is cost-effective over so-called conservative methods is a disservice
to the millions of 
back/leg pain patients seeking relief. Dr. Scott Haldeman of the BJD research
study admits there are over 200 treatments now used for chronic LBP, which
makes a formidable choice for consumers, but skewed studies like Peul’s only
throws more confusion into this mess.
And the
question of relapse has obvious implications in the clinical management of disc
herniations, to which even Peul notes. “Physicians guiding patients with
sciatica should remember that the long-term prognosis may be less favorable
than is suggested by the first impression after successful treatment,” Peul suggests.
Finally, he gives some credible advice, but fails to mention the severity of
failed back surgery.
Of the 80,000 new cases of failed back surgery syndrome per year
in the
(Ragab
A and
I recall a
private communication a few years ago with
Finally, an
honest surgeon!
Not only is
the long term outcome for surgery no better than for conservative care, another
factor is omitted to patients—the fact that most will still be living on pain
pills, another point conveniently omitted by Peul.
“The definition of success did not consider
pain relief or opioid medication use. Even among the patients classified as
having a successful result, most were still using narcotic medications at the
2-year follow-up, including 64% of the successful-result patients in the disc
replacement group and 84% in the fusion group.”
(Mirza, Sohail K. MD,
MPH, Point of View: Commentary on the Research Reports that Led to Food and
Drug Administration Approval of an Artificial Disc, Spine: 30(14) 15
July 2005 pp 1561-1564.)
Peul’s
misleading RCT did nothing to improve patient outcomes as much as it perpetuates
mistaken beliefs and disparaged the benefits of “real” conservative care. The
fact is the drugs/shots/surgery approach to spinal pain has not proven effective
as noted by the editors of The BACK LETTER.
"The world of
spinal medicine, unfortunately, is producing patients with failed back surgery
syndrome at an alarming rate…Despite a steady stream of technological
innovations over the past 15 years—from pedical screws to fusion cages to
artificial discs—there is little evidence that patient outcomes have improved.”
(The BackLetter, vol.12, no. 7,
pp.79 July, 2004. The BackPage
editorial, The BackLetter, pp. 84, vol. 20, No. 7, 2005.)
Conclusion:
The problems with Peul’s
study is obvious to astute practitioners in this field. For too long practitioners
of manual medicine have been ignored, marginalized, and their methods have been
deemed “experimental and unproven” despite the good clinical results. Even when
recent RCTs and international guidelines recommend manual medicine for spinal
disorders, it is given short shrift by those who suffer from a professional
prejudice.
Paul Goodley, orthopedic physician, author of
Release from Pain, and long-time
promoter of manual medicine, coined a term, Fundamental Flaw, concerning the
antipathy of mainstream medicine to manual medicine that he contends as led to
a pandemic of pain. I might add it has also led to a pandemic of unnecessary
drugs, shots, MRIs, spine surgery and skewed research.
“Eventually, the
prejudice against manipulation self-perpetuated and evidence was always
available to justify this attitude. There have always been [chiropractic]
charlatans. So, instead of the manipulative fundamental dynamically developing
as a cohesive, trustworthy guide within traditional medicine, it was discredited
as the synonymous derelict symbol of its most despised competitor - chiropractic.”
Even medical critics like NM Hadler, MD,
author of The Last Well Person, who
willingly debunks the disc theory, MRIs, and spinal surgery, still has trouble
admitting the need for manual medicine in his own practice.
“I am a
rheumatologist, a mainstream physician with an MD, schooled in and committed to
the care of patients with musculo-skeletal disorders. Do I have to learn manual
medicine? Should I seek such a salve for my own next predicament of a regional
musculo-skeletal disorder? Should I refer my patients to such practitioners?”
Of course he should, but even Dr. Hadler has
difficulty overcoming his own Fundamental Flaw by admitting those nefarious
chiropractors and proponents of manual medicine might have been right all
along. Indeed, it’s a bitter pill to swallow after a century of bias against
those damn chiropractors.
Apparently international medicine has moved
past its fascination with spine surgery (although not here in the USA that
leads the world in spine surgery per capita) and these costly, ineffective, and
crippling surgeries will rank top on the list of once routine but now
considered unnecessary surgery like tonsillectomy, hysterectomy, and
appendectomy. Sadly, spine surgery has left a wake of disability costs and
impairment unlike these outdated surgeries, but flawed studies like Peul’s will
only add to the suffering of patients who are not given adequate evidence-based
information to make an informed decision.
There are some people within the
“…possibility that
our thinking about back pain is fundamentally wrong. We may be missing
something important. And that could be why we have not come up with any
dramatic advances. And if that is the case, then the implication is that we
need new paradigms. And that once we find the best paradigm, we will make more
progress.”
(The Back Letter, vol. 23,
No. 5, 2008, pp. 55.)
George Lundberg, MD, Medscape Editor in Chief
and former editor-in-chief of JAMA, once told me in private
communication:
“If some
influential individual or group in chiropractic would follow your thesis, and
would loudly and openly embrace EBM, let the chips fall where they may, …then I
and many other physicians could openly and without fear and derision look at
what 2005 EBM chiropractors actually do and go forward together.”
I accept
Considering back surgery ranks with heart
surgery among the most profitable for surgeons and hospitals, the resistance to
manual medicine is obvious. Indeed, in American healthcare, the cheaper
mousetrap is not usually a welcome to those who profit dearly from the status
quo.
“The extreme
failure of the
(Kuttner,
R., Market-Based Failure — A Second Opinion on
Sadly, skewed RCTs like
Peul’s will only add to the gravy train by discouraging the implementation of
effective conservative care into the mainstream. Little will patients know when they’re told
about the ineffectiveness of “conservative care” that, in fact, it was the
least effective methods used instead of the most effective treatments.
Again, I challenge the spine researchers like
Peul, Deyo, Weinstein, Boden and all others to make a direct comparison of the
best of manual medicine versus the medical model of drugs, shots, and surgery.
Stop using sham treatments like cheap advice and pain pills and calling them
“conservative care” that only clouds the issue. Remove the inherent Fundamental
Flaw and let’s judge our various treatments for once on a level playing field
using the best players possible.
Recently the AMA House of Delegates
apologized for racism toward black physicians. I say it’s about time it did the
same about its bias toward DCs and manipulative medicine with its professional
racism/Fundamental Flaw toward DCs and manual medicine. It may stick in the
craw of many mainstream medical researchers and practitioners to admit that
manual medicine and chiropractors won’t go away despite their efforts to thwart
its growth, soil its reputation, and skew the research findings as we’ve seen
over the past century.
It’s time for mainstream medicine to heal
itself of this Fundamental Flaw toward manual medicine and give credit where
credit has long been due. The patients deserve it and the DCs and manual
medical providers also deserve a break to be unshackled from medical prejudice.
Let’s give these patients the best of all worlds, including chiropractic care.