Chiropractic vs. Medicine for Acute LBP: No Contest (from Dynamic Chiropractic)
We here at www.lasvegaschiro.com have always known this and there has been multiple studies done that show the benefits of chiropractic especially for lower back pain! Now if we can just teach our medical colleagues what we do so they understand better how to refer and when to refer to chiropractors. Can you imagine the world as a better place with fewer missed days of work due to back pain and fewer people on heavy narcotics…..we can….
Chiropractic vs. Medicine for Acute LBP: No Contest
Acute low back pain patients demonstrate significantly greater improvement with chiropractic than “usual care.”
By Editorial Staff
With the publication of the Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study1 in The Spine Journal, one of the most frequently cited spine research journals in the world,2 the health care community at large may finally appreciate what the chiropractic profession has known for more than a century: Patients with acute mechanical low back pain enjoy significant improvement with chiropractic care, but little to no improvement with the usual care they receive from a family physician.
Published in the December 2010 edition of The Spine Journal, the study found that after 16 weeks of care, patients referred to medical doctors saw almost no improvement in their disability scores, were likely to still be taking pain drugs and saw no benefit with added physical therapy – and yet were unlikely to be referred to a doctor of chiropractic.
The study is “the first reported randomized controlled trial comparing full CPG [clinical practice guidelines]-based treatment, including spinal manipulative therapy administered by chiropractors, to family physician-directed UC [usual care] in the treatment of patients with AM-LBP (acute mechanical low back pain).” (Evidence-based clinical practice guidelines have been established for acute mechanical low back pain in many countries around the world, but sadly, most primary care medical doctors don’t follow these guidelines.) Researchers found that “treatment including CSMT [chiropractic spinal manipulative therapy] is associated with significantly greater improvement in condition-specific functioning” than usual care provided by a family physician.
Study Parameters
The Chiropractic Hospital-based Interventions Research Outcome (CHIRO) initiative was “designed to evaluate the outcomes of spinal pain patient management strategies that involve a component of chiropractic assessment and/or spinal manipulative therapy, administered in a hospital-based spine program outpatient clinic.” The study utilized the CHIRO framework “to examine the effectiveness of current evidence-based CPG-recommended treatments for patients with AM-LBP pain.”
CPG “study care” (SC) was compared with the usual care (UC) provided by family physicians. Patients were first seen by a spine physician and then randomly assigned to either the SC group or the UC group.
Patients in the SC group received acetaminophen, a “progressive walking program” and up to four weeks of lumbar chiropractic spinal manipulative therapy. The manipulative therapy was provided “using conventional side-posture, high-velocity, low-amplitude techniques” to the lumbar region only, and only by a chiropractor.
Patients assigned to the UC group were referred back to their family physician, who was “simply advised to treat at their own discretion.” Patients in this group received treatment from “a variety of professionals including family physicians, massage therapists, kinesiologists, and/or physiotherapists.”
All care was provided at a hospital-based spine program outpatient clinic. The primary outcome measure was the Roland-Morris Disability Questionnaire (RDQ), administered at the beginning of care and at 16 weeks, when acute low back pain is considered to become chronic. The RDQ was also administered at eight and 24 weeks.
Other Important Findings
After 16 weeks, “78% of patients in the UC group were still taking narcotic analgesic medications on either a daily or as needed basis.” (Only 6 percent of this group received chiropractic care.)
Condition-specific improvement after 16 weeks “clearly favored the SC group, with mean RDQ improvement scores of 2.7 in the SC group compared with only 0.1 in the UC group (p=.003).”
While the difference in improvement “was not quite significant at 8 weeks,” it was found to be “clearly significant at 24 weeks of follow-up (0.004).”
Both groups showed improvement in bodily pain and physical functioning, but “patients in the UC group uniquely showed no improvement whatsoever in back-specific functioning (RDQ scores) throughout the entire study period.”
The inclusion of NSAIDs and manipulation/mobilization performed by physical therapists were no more effective in treating patients than family doctors who offered patients advice and acetaminophen. The study found: “[T]he addition of NSAIDs and a form of spinal manipulative therapy or mobilization administered by a physiotherapist to the lumbar spine, thoracic spine, sacroiliac joint, pelvis, and hip (compared with a detuned ultrasound as placebo manipulative therapy), to family physician ‘advice’ and acetaminophen were shown to have no clinically worthwhile benefit when compared with advice and acetaminophen alone.” [Italics ours]
The study criticizes a 2007 report that had derided the efficacy of spinal manipulation by pointing out that the older report based its conclusions on the outcomes of therapies performed by non-chiropractors. The 2007 study concluded that patients “do not recover more quickly with the addition of diclofenac or spinal manipulative therapy.”3 By contrast, the CHIRO study noted: “Although spinal-manipulative therapy is currently administered by many different healthcare professionals, including: chiropractors, osteopaths, orthopedic surgeons, family physicians, kinesiologists, naturopaths, and physiotherapists, the levels of training and clinical acumen vary widely. The study design used by Hancock, et al., therefore, differs from our study because [their study] did not use chiropracticspinal manipulation, and current guideline based care does not endorse any forms of spinal manipulation administered by any other practitioners.” [Italics ours]
References
- Bishop PB, Quon JA, Fisher CG, Dvorak MFS. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: 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. Spine Journal, 2010;10:1055-1064. www.ncbi.nlm.nih.gov/pubmed/20889389
- Brunarski D. “Impact of the Chiropractic Literature.” Dynamic Chiropractic, Dec. 2, 2010;28(25).
- Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, Day RO, Spindler MF, McAuley JH. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: a randomised controlled trial. Lancet, 2007 Nov 10;370(9599):1638-43. www.ncbi.nlm.nih.gov/pubmed/17993364
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Inside Cheerleading: The Most Dangerous Sport for Women
www.LasVegasChiro.com, here at West Valley Chiropractic Ctr. Dr. Kaldy treats many athletes, especially the younger athletes. His own daughter is a competitive All-Star Cheerleader and he treats many of her teamates and individuals from the other teams. Doc truely believes and has taught his daughter to understand that the more flexible and warmed up your muscles and joints are the better you will do during competitions and the less likely you will sustain injuries during these competitions and during practice. We dare anyone to say that these men and women are not athletes, competitive cheerleading is extremely physical and very demanding!
Inside Cheerleading: The Most Dangerous Sport for Women
The Risks, the Rigors and the Role of Chiropractic Care
By Brenda Duran
On a warm evening in 2003, Krista Parks was beaming with pride on a football field as a cheerleader at the University of Memphis. This was her moment – her squad was practicing for the national cheer championship in Orlando, Fla.
Parks was to pull off an ambitious stunt – a high front flip in the air from the top of the pyramid, landing in the arms of her squad; instead, she lost her momentum and fell head first onto a 2-inch foam mat on concrete. The result: a broken neck, a blood clot in her brain and multiple fractures.
“I couldn’t feel or move anything,” Parks recalled. “I was pretty miserable.”
Following the incident Parks underwent three surgeries, had to wear a neck brace, and then had to deal with years of physical therapy. A permanent shunt was placed in her spine to help drain fluid from her brain because her body can no longer do it.
Today, she is also dealing with life-altering changes to her cognitive abilities – loss of memory, delayed comprehension and mental fogginess.
“It’s not just throwing around pom poms, it is a real, dangerous athletic activity that comes with risks,” said Parks, now executive director for the National Cheer Safety Foundation. “There is a lot that needs to be done to make it safer.”
And one of the things that can make it much safer – and healing faster – is consistent chiropractic care, she said.
“Chiropractic care has helped me with pain management, I can sleep better and not have to finish my day in agonizing pain,” said Parks, who also works as a physical therapy assistant at Spinal Healthcare Associates in Memphis, Tenn. “It’s an approach to pain management I really love.”
Since she started chiropractic care for her catastrophic injuries a few years ago, Parks said her pain level has decreased to the point where she can function much better on a daily basis.
The Most Dangerous Female Sport
In a 2009 report, the National Center for Catastrophic Sports Injury (NCCSI) Research at the University of North Carolina at Chapel Hill, N.C., declared cheerleading the “most dangerous female sport in the United States” based on injury data they obtained from 1982-2008 that showed approximately two-thirds of severe school sports injuries over the past 25 years were from cheerleading.
The reason is quite straightforward: At many high schools and colleges, and at the professional level, it is no longer enough for the cheer squad to simply coordinate chants and perform dance routines.
Today, highly demanding acrobatic moves have become the norm, experts say. National competitions have upped the ante, by fomenting a “can you top this” attitude that pushes kids to do even riskier stunts.
As a result, their jumps, splits, and acrobatic tumbles have become to cheerleaders what the blindside hits, collisions and flying tackles are to the football players out on the field. The jolts to their bodies are serious.
But while injuries have made cheerleading the most dangerous sport for young American women, experts say that the risk and severity of injury can be kept to a minimum with chiropractic care. Chiropractors identify injuries early and properly manage them before they progress to something more serious, which is the key to people like Parks who has had to ensure her body heals properly.
Natural Healing
Krista Parks (in photo) was a University of Memphis cheerleader in 2003 when an ambitious front-flip maneuver during practice turned disastrous, ending her career and necessitating years of rehabilitation. With cheerleading calling for ever-higher degrees of athleticism, chiropractors say they are able to provide a unique understanding of the rigorous training and physical toll that the sport has on the body, unlike any other type of physician.
“Doctors of chiropractic are the only healthcare professionals who specialize in the process of correcting spinal misalignments with adjustments,” said Dr. Steve Goninan, a chiropractor at Integrity Chiropractic in Georgia. “These adjustments re-energize the nervous system, reduce biomechanical stress, optimize the athlete’s agility without the athlete having to overcome the side effects of drugs or irreversible surgeries.”
Dr. Goninan, who has written about the benefits of chiropractic care for cheerleading, notes that chiropractic works with the nervous system, which controls and coordinates the functions of all other bodily systems. When injury occurs to the spine – one of the key structures that surrounds and protects the nervous system it can impede the nervous system’s ability to govern the body and maintain a balance necessary for health, he said.
Some of the most common injuries for cheerleading these days include overuse of the shoulders, wrists, and elbows, neck injuries, head traumas, fractured wrists and dislocations. These tend to happen from falls onto hard gym floors and tracks.
Other factors such as the length of the cheerleading season, which lasts from the fall to spring also sets up much more potential for nagging injuries that are never fully allowed to heal, said Dr. Goninan. “Like all athletes there has to be some down time to in order to allow the body to recover,” he said.
Dr. Goninan also said cheerleaders need to take occasional breaks of 3-4 days during the year when there are no games or practices. They should also do more weight training to strengthen their shoulders and upper body and implement nutritional supplements like all other athletes to boost performance. “This helps reduce the risk of injuries and helps manage the wear and tear that the never-ending season causes.”
Dr. Enrico Esposito, a chiropractor who has treated various cheerleaders in Alabama, said it is the younger cheerleaders who tend to suffer from repetitive motion injuries like patellar tendonitis, ankle sprains, stress fractures, hip strains, and inflammation around the hips. There are also low-back injuries that can become chronic without proper care. But chiropractic care for younger cheerleaders can help reduce the risk of even more serious injuries in the future, he said.
“Any injury at a young age that is not rehabbed properly will undoubtedly result in residual problems later on,” said Dr. Esposito. “A lot of injuries can prevent kids from excelling as good athletes down the line. Chiropractic care can decrease inflammation, re-strengthen and rehabilitate by balancing the body.”
Dr. Gonina agrees, noting chiropractors are able to mitigate future injuries while healing prevent mishaps. “I have seen athletes fail to complete a rehabilitation regimen that led to reinjury down the road that was as bad, if not worse, than the original injury,” he said. “I have learned how valuable chiropractic is for an athlete, both as a means of treating an injury and preventing future injuries.”
The Washington Redskins cheerleaders are supporting the nonprofit Foundation for Chiropractic Progress, sharing their positive experiences with chiropractic care and how it helps keep them at the top of their game. Dr. Goninan recommends all cheerleaders have their spines checked and their muscle strength tested at least once a week during the season to detect and prevent all types of lingering injuries.
“To perform some of the athletic gymnastic moves required in cheerleading, it is absolutely essential that all muscles be firing on all cylinders,” said Goninan.
Prevention Is Key
For many cheerleaders who go on to professional teams, chiropractic care becomes even more critical to maintain healthy joints and a spine, said Dr. Jay Greenstein, chiropractor for the Washington Redskins cheerleaders.
“What’s interesting about cheerleaders is that they are true athletes; they endure a tremendous amount of physical stress,” he said. “They practice hard, there is a lot of demands on them when it comes to performance and they are doing chronic repetitive motions that put significant strain on their bodies, so they are perfect candidates for chiropractic care.”
Dr. Greenstein’s clients have been so pleased with the results of their care they recently assumed the role of being the latest ambassadors for chiropractic care by teaming up with the Foundation for Chiropractic Progress to promote chiropractic and the benefits of a healthy lifestyle.
Amanda Mitchell, who has been in the sport since high school and a professional for the last two seasons on the Redskins cheer squad, credits chiropractic care for making it possible for her to perform through a 16-game season. In fact, without it, she says, she wouldn’t have made it through her first season.
“This is a sport, we’re athletes, and cheerleading can take a very heavy toll on your body,” she said in a recent interview. “Without chiropractic it would not have been possible to stay in this.”
Mitchell said her flexibility and pain from subtle injuries have dramatically been reduced through chiropractic care. “People don’t view it as a competitive sport, but you have to try out every single year in this industry and its extremely cutthroat,” she said.
Denise Medina, a first-year member of the Redskins cheer squad, said that while the team devotes more time to dance routines than a high school or college team, “cheerleading will just tear your body up if your aren’t well-prepared.”
Diet and Stretching Matter, Too
Both Medina and Mitchell have also learned a lot of useful tips to avoid injuries. Medina said that regular exercise outside of practice and good eating habits are at least as important as warm-ups and cool-downs at practice and events. And Mitchell pointed out that while parents may not be able to control what happens at practice or a game, they can take control in the kitchen.
“It all begins with a healthy diet,” said Mitchell. “I believe staying in shape is 80 percent diet, 10 percent genetic and 10 percent workout.” She believes part of the reason why she has avoided serious injury is because she’s learned to eat the right foods at the right time of day. Training, proper warm-up and cool down, as well as practice are important too, of course, but she strongly believes that it’s her diet that has been the ultimate factor.
“It’s a cliche, but you really are what you eat,” she said. “Parents who have kids in cheerleading have to understand that poor eating habits are poor preparation and poor preparation greatly increases the risks of injury.”
On a typical day, Mitchell said she has five small meals of between 200 and 300 calories each. Breakfast often includes oatmeal and egg whites. Her morning snack is a protein shake or protein bar. Lunch is a spinach or broccoli salad, often mixed with chicken. Afternoon snack is again a shake or protein bar, usually with some almonds for “finger food.” Fish is her favorite for dinner.
“Parents have control over three of those meals, and they can help their kids get through the day by adding in healthy snacks,” she said. “If they don’t do that the kids will grab for whatever is available in the vending machine.”
Mitchell said that at practice and before a performance, stretching is also critical. “If you don’t warm up, all the jolts and tumbles are much more likely to cause an injury,” she said. “I can’t stress enough how important stretching is, because this sport can tear your body up.”
Dr. Greenstein also recommends cheerleaders also do dynamic warm-ups – a warm up activity that includes upper body and lower body movements to warm up the muscles and dynamic stretches for better flexibility two hours prior to an event. He also recommends if a cheerleader is getting their technique wrong, its best to adjust it to prevent any other injuries.
If a cheerleader does end up getting hurt, he said, with chiropractic care there are always plenty of solutions. “The goal is to decrease pain that can be done naturally through chiropractic care and also improving overall function, which also is a huge component of what chiropractors do,” he said.
10 Tips for Cheerleader Safety
- Make sure your athlete’s team has rehearsed their catastrophic emergency plan before going out on the field.
- Obtain a pre-participation physical for your athlete to ensure they are healthy and prepared.
- Look for a mature, qualified coach that knows proper technique, progressions and spotting.
- Find a safe environment to practice and learn.
- Have automatic external defibrillators available at all time in case of an emergency.
- Report injuries to www.cheerinjuryreport.com for research purposes.
- Make sure you are aware of head injuries and the signs of concussion.
- Keep your athlete hydrated and make sure they know how they prevent heat illness.
- Only allow your athlete to return to play after injury when released by a qualified health professional.
- Check that the coach has had a background check.
Source: The National Cheerleading Safety Foundation. For more information, visit www.nationalcheersafety.com.
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Back Surgery: Too Many, Too Costly, Too Ineffective, Part 2
Here is Part II of this very informative story. We here at www.lasvegaschiro.com are here to provide you with the most educational and informative information available so that you the reader can make educated decisions about your healthcare. I find it interesting that many surgeons I have spoken with state that surgery is only required about 10% of the time. However….. due to lack of education and the unwant to take care of ones self, or participate in rehabilitation programs, individuals are looking for a “magic bullet” that does not exist. Now approximately 6/10, that’s 60% with back pain try surgery first…(this information comes from local surgeons) This is alarming, because once surgery is performed, your options are significantly limited with regard to the available treatments out there. So… onto Part II.
-Dr. Kaldy
Back Surgery: Too Many, Too Costly, Too Ineffective, Part 2
By J.C. Smith, MA, DC
David Spodick, MD, professor of medicine at the University of Massachusetts, has stated: “Surgery is the sacred cow of our health-care system and surgeons are the sacred cowboys who milk it.”33 Indeed, spine surgery has become the cash cow in the medical world and will only grow larger unless sensibility prevails over profiteering.
In reality, doctors and hospitals are making huge profits off the backs of unsuspecting patients who are not told there may be better and cheaper ways to solve their back pain with chiropractic care or other non-invasive methods. The costs of back surgeries are among the most expensive, and these costs do not include hospitalization, imaging, drugs or medications:34
- Anterior cervical fusion: $44,000
- Cervical fusion: $19,850
- Decompression back surgery: $24,000
- Lumbar laminectomy: $18,000
- Lumbar spinal fusion: $34,500
Deyo found that the mean hospital costs alone for surgical decompression and complex fusions ranged from $23,724 for the former to $80,888 for the latter.35 When combined with surgical costs, medications, MRIs, rehab, and disability, every spine surgery case approaches $100,000 or more. The direct costs are astronomical and may reach as high as $169,000 for a lumbar fusion, and for a cervical fusion as high as $112,480.36
Research suggests that of the 500,000-plus disk surgeries performed annually, as many as 90 percent are unnecessary and ineffective.37 This is unsustainable, and yet growing at incredible rates. Deyo noted, “It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just six years,” and he mentioned one strong motivation included “financial incentives involving both surgeons and hospitals.”38
In the current era of evidence-based medicine, it is difficult to understand the huge increase in spine fusions considering their high costs, poor outcomes and increased disability costs. Indeed, it certainly appears we have now entered into the era of economic-based medicine instead of evidence-based. Despite the huge increase in numbers and costs for spine surgery, the evidence shows this has been a waste.
In 2010, researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in the hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.39
After two years, only 26 percent of those who had surgery returned to work compared to 67 percent of patients who did not have surgery. Of the lumbar fusion subjects, 36 percent had complications and the reoperation rate was 27 percent for surgical patients. Permanent disability rates were 11 percent for cases and 2 percent for nonoperative controls. In what might be the most troubling finding, researchers determined that there was a 41 percent increase in the use of painkillers, with 76 percent of cases continuing opioid use after surgery. Seventeen surgical patients died by the end of the study.40
The study provides clear evidence that for many patients, fusion surgeries designed to alleviate pain from degenerating discs do not work, according to the study’s lead author, Dr. Trang Nguyen, a researcher at the University of Cincinnati College of Medicine. His study concluded: “Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a Workers’ Compensation setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor return to work status.”41
Commenting on spine surgery, Nguyen said, “The outcomes of this procedure for degenerative disc disease and disc herniation make it an unfortunate treatment choice.”42 According to the editors of The Back Letter, a newsletter from the Department of Orthopedic Surgery at Georgetown Medical Center in Washington, D.C., “This form of surgery in workers’ compensation subjects appears to be a gamble at best.”
Deyo admitted to The New York Times that the spine profession is ignoring the call for restraint on drugs, shots and back surgery. “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.”43
In his 2009 article, “Overtreating Chronic Back Pain: Time to Back Off?” Dr. Deyo speaks of the shortcomings of the medical spine treatments in the U.S.:44
“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.”
Dr. Deyo is not alone in his call for reform in spine care. The editors of The Back Letter agreed with his frustration with the medical approach:45-46
The world of spinal medicine, unfortunately, is producing patients with failed back surgery syndrome at an alarming rate … There is growing frustration over the lack of progress in the surgical treatment of degenerative disc disease. 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 … Many would like to see an entirely new research effort in this area, to see whether degenerative disc disease and/or discogenic pain are actually diagnosable and treatable conditions. (Emphasis added)
Another study conducted by Deyo and Cherkin in 1994 compared international rates of back surgeries and found the startling fact that the rate of American surgery is unusually excessive and directly attributed to the supply of spine surgeons:47
“The rate of back surgery in the United States 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.” (Emphasis added)
“While many surgeons are careful about which patients they recommend for spine operations, some are not so discriminating,” says Dr. Doris K. Cope, professor and vice chair for pain medicine at the University of Pittsburgh School of Medicine. “It’s a case of, if you have a hammer, everything looks like a nail.”48
And be certain that spine surgeons have been nailing patients for decades. Not only have spine surgeries skyrocketed, so have emerging treatments that have also not proven effective, although very profitable – the increased use of opioids and epidural steroid injections.
The recent growth in “pain management” clinics featuring epidural steroid injections (ESI) has received troubling criticism from medical experts like Robert J. Barth, a neuropsychologist, who believes these ESI treatments “reliably fail, the treatments seems to lead to a progressive worsening of the claimant’s presentation, the ineffective treatment never ends, and the original treating doctors refer the claimants into pain management simple as a means of escaping from or ‘dumping’ a problematic patient.”49
Barth believes “pain management does not accomplish anything but getting the patient addicted.” He concludes that the “pain management situation in the U.S. is, indeed, horrific.”50 Nonetheless, it is among the fastest growing segments in medicine today.
A similar review of pain management via ESI was regarded as “goofy” by R. Norman Harden, MD, in the American Pain Society Bulletin:51
“We practice at a time when unproven experimental, invasive, and expensive procedures are often compensated without question. Many of the surgical and interventional techniques have never been subjected to evidence based inquiry. Oddly, the FDA approves devices and procedures relatively easily … in this context, there has been a proliferation of extremely goofy therapies, which are expensive at best, and downright dangerous at worst.”
Another criticism of ESI appeared in the American Pain Society Bulletin by Steven H. Sanders, PhD, who revealed nerve blocks for back pain are not supported by scientific research: “From the current review, we must conclude injections and nerve blocks produce a large amount of money with very little science to support their application.”52
Not only have epidural injections come under criticism; so has the widespread use of opioids in the long-term treatment of back pain. “There is increasing recognition that this massive treatment movement may have been a mistake,” opined the editors of The Back Letter. “The proven benefits of opioids do not extend to the long-term treatment of chronic pain … Editorials and commentaries in medical journals are starting to pose the question, ‘How could this have happened?’”53
A new study on opioid use from Denmark reveals more disturbing news. Although proponents of opioid drugs speculate they provide significant pain relief, improve function, and enhance quality of life over the long term, a new study by Per Sjogren, MD, and colleagues refutes this claim. They found the use of opioids was associated with inadequate pain relief, poor quality of life, long-term unemployment, and high levels of medical care-seeking.54
“Furthermore, the results indicated that individuals with chronic pain using strong opioids had a higher risk of death than individuals without chronic pain,” according to Sjogren.”55
Chiropractic: The Best Buy
Not only can most medical spine treatments be avoided, but they also must be reigned in if America hopes to reduce its health-care spending crisis. This problem has become more apparent after research found that the Fortune 500 companies spent over $500 million a year on avoidable back surgeries for their workers and lost as much as $1.5 billion in indirect costs associated with these procedures in the form of missed work and lost productivity, according to a two-year study by Consumer’s Medical Resource (CMR).56
This CMR study, “Back Surgery: A Costly Fortune 500 Burden,” found one out of three workers recommended for back surgery said they avoided an unnecessary procedure after being given independent, high-quality medical research on their diagnosed condition and treatment options. In addition, those patients who refused surgery and opted for alternative and less invasive procedures to treat their back pain reported healthier and more personally satisfying outcomes.
As the TRICARE study found, patients are more satisfied with chiropractic care than medical care treatments for low back pain. T.W. Meade, MD, of the Wolfson Institute of Preventive Medicine, London, England, surveyed patients three years after treatment and found that “significantly more of those patients who were treated by chiropractic expressed satisfaction with their outcome at three years than those treated in hospitals – 84.7 percent vs. 65.5 percent.”57
A recent comparative study of back pain treatments by Antonio P. Legorreta, MD, MPH, et al., “found cost savings relating to chiropractic treatment of common complaints such as neck and back pain. Focusing on low back pain diagnoses that were selected specifically for comparability between medical and chiropractic practice, our analysis found that patients with chiropractic coverage had significantly lower rates of use of resource-intensive technologies, such as x-ray examinations, MR image, and surgery, and lower use of more expensive patient care settings, such as inpatient care. This is reflected in the significantly lower cost, at both the episode level and the patient level, of providing care for back pain.”58
Another study by Niteesh Choudhry, MD, PhD, from Harvard Medical School and Arnold Milstein, MD, from Mercer Health and Benefits consulting firm, also found, in terms of clinical and cost effectiveness, that “chiropractic physician care for low back and neck pain is highly cost-effective, represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds.”59
Not only is manual therapy more clinically effective, another large study shows it is also less costly than medical care. A study published in 2010 revealed data over a two-year span from 85,000 Blue Cross Blue Shield beneficiaries with low back pain in Tennessee. The patients had open access to MDs and DCs through self-referral, and there were no limits applied to the number of visits allowed and no differences in co-pays. Results show that paid costs for episodes of care initiated by a chiropractor were almost 40 percent less than care initiated through an MD. They estimated that allowing DC-initiated episodes of care would have led to an annual cost savings of $2.3 million for BCBS of Tennessee.60
Not only are these spine surgeries very expensive and in many cases unnecessary; the latest research has shown that chiropractic care is more effective and less expensive. However, the medical profession has ignored this call for restraint and in many cases, continues its boycott of chiropractic care despite the evidence. Indeed, it appears to be a case of “don’t confuse us with the facts.”
Editor’s note: Part 1 of this article appeared in the March 26 issue; part 3 will appear in the next (April 22) issue.
References
35. “New Study Demonstrates a Three-Fold Increase in Life-Threatening Complications With Complex Surgery.” The Back Letter, June 2010;25(6):66.
36. Schlapia A, Eland J. “Multiple Back Surgeries and People Still Hurt.” April 22, 2003.
37. Finneson BF. A lumbar disk surgery predictive score card: a retrospective evaluation.” Spine, 1979:141-144.
38. Ibid.
39. Carroll L. “Back Surgery May Backfire on Patients in Pain.” MSNBC.com, Oct. 14, 2010.
40. Nguyen TH, Randolph, DC, et al. Long-term outcomes of lumbar fusion among workers’ compensation subjects: an historical cohort study. Spine, Feb. 15, 2011;36(4):320-331.
41. Ibid.
42. “Dismal Results for Spinal Fusion Among Patients With Workers’ Compensation Claims.” The Back Letter, November 2010;25(11):121.
43. Kolata J. “With Costs Rising, Treating Back Pain Often Seems Futile.” New York Times, Feb. 9, 2004.
44. Deyo RA, et al. Overtreating chronic back pain: time to back off? J Am Board Fam Med, 2009;22(1):62-68.
45. The Back Letter, July 2994;12(7):79.
46. The BACKPage Editorial. The Back Letter, March 2005;20(7):84.
47. Cherkin DC, et al. An international comparison of back surgery rates. Spine, June 2004;19(11):1201-1206.
48. Carroll L, Op Cit.
49. Barth RJ. “Saying No!–Unjustified Surgeries, Pain Management and Tests.” For the Defense, March 2006;48(3):33-39. Washington & Lee Law School Current Law Journal Content.
50. Ibid.
51. Harden RN. “Chronic Opioid Therapy: Another Reappraisal.” APS Bulletin, January/February 2002;12(1). Pain and Public Policy, Corey D. Fox, PhD, Department Editor
52. Sanders SH, Vicente P. Medicare and Medicaid financing for pain management: the wrong message at the right time. The Journal of Pain, September 2000;1(3):197-198.
53. “How Could This Have Happened?” The Back Letter, 2011;26(1):7.
54. Per Sjogren, et al. A population-based cohort study on chronic pain: the role of opioids. Clinical Journal of Pain, 2010;26(9):332-9.
55. “Long-Term Opioid Therapy for Chronic Pain: Dismal Results in Real-World Settings?” The Back Letter, 2011;26(1):1.
56. “FORTUNE 500s Waste Over $500 Million a Year on Unnecessary Back Surgeries for Workers.” Consumer’s Medical Resource, July 21, 2008.
57. Mead TW. Letter to the Editor, British Medical Journal, July 3, 1999.
58. Legorreta AP, et al. Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs. Arch Intern Med, 2004;164:1985-1992.
59. Milstein A, Choudhry N. “Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans? An Evidence Based Assessment of Incremental Impact on Population Health and Total Healthcare Spending.” Funded by the Foundation for Chiropractic Progress.
60. Liliedahl, RL, Axene DV, Goertz CM. 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. JMPT, December 2010.
Back Surgery: Too Many, Too Costly, Too Ineffective
Back Surgery: Too Many, Too Costly, Too Ineffective
By J.C. Smith, MA, DC
If the present course for health care does not radically change, America will be financially crippled as President Obama warned: “paying more, getting less, and going broke.”1 As example, recently Blue Shield of California announced its plans to raise rates by as much as 59 percent, and as the bellwether Golden State goes, so does the nation.2
Most Americans fail to realize the huge economic impact of the medical industrial complex until they feel the crunch from unpaid medical bills that caused 62 percent of all personal bankruptcies filed in the U.S. in 2007, according to a study by Harvard researchers.3 To the surprise of even the researchers, 78 percent of those filers had medical insurance at the start of their illness, including 60.3 percent who had private coverage, not Medicare or Medicaid.4
Dr. David Himmelstein, the lead author of the study and an associate professor of medicine at Harvard, commented: “Unless you’re Bill Gates you’re just one serious illness away from bankruptcy. Most of the medically bankrupt were average Americans who happened to get sick.”
“This study provides further evidence that the U.S. healthcare system is broken,” according to James E. Dalen, MD, MPH.5The Harvard study underscored President Obama’s argument for health care reform legislation. In a letter to Democratic Senate leaders, the president said:
“Healthcare reform is not a luxury. It’s a necessity we cannot defer. Soaring healthcare costs make our current course unsustainable. It is unsustainable for our families, whose spiraling premiums and out-of-pocket expenses are pushing them into bankruptcy and forcing them to go without the checkups and prescriptions they need.”6
Not only are costs and bankruptcy skyrocketing, so is accountability. During the Obama health care reform debate of the Patient Protection and Affordable Care Act, it was notable that the medical industrial complex – the American Medical Association (AMA), the HMOs, Big Pharma, and the American Hospital Association – was not called before Congress to explain why there is a health care crisis wrought with high costs and poor outcomes.
Unlike the Detroit auto executives and Wall Street bankers, whose feet were held to the fire at congressional hearings, the medical cartel avoided such public humiliation and offered no explanations. Instead, the medical alliance continued to mislead Congress and the public by claiming to be the “best health care system in the world,” a notion also told all too often by conservative news media. However, the facts belie that claim.
Some pundits claim America has arguably the best doctors, the best medical schools, and the best hospitals. Undoubtedly those many countries whose health statistics are superior to America’s might disagree and argue that high-tech medical diagnostic tools and highly trained surgeons are not the real issues to the health care dilemma. The actual question is, how well does the American health care delivery system really work outside of the operating room?
As the statistics show, inside the operating room is nothing less than a boondoggle. In 2006, doctors performed at least 60 million surgical procedures of all types, one for every five Americans. No other country does nearly as many operations on its citizens.7
Not only are surgeries rampant, but many are also ineffective and dangerous. Barbara Starfield, MD, MPH, of the Johns Hopkins School of Hygiene and Public Health, reported that medical care is now the third-leading cause of death in the U.S., causing 225,000 preventable deaths every year as tools to make them safer go unused.8-9
Over 100,000 people die each year from complications of surgery – far more than die in car crashes; deaths from prescription drugs now rank fourth only to cancer, heart disease, and diabetes, and when added to deaths from botched surgery, over 3,000 Americans die weekly.10 Such deaths accounted for 23 percent of overall deaths in men and 32 percent of deaths in women.11
Not Much Bang for Bucks
It would seem logical that if Americans spend the most on health care and have the best educated doctors, we would have the healthiest citizens and best health care system in the world, but we do not. According to the World Health Organization (WHO), in 2000 the U.S. ranked #1 in cost, #72 in population health, #37 in health care delivery, with 48 million Americans lacking sick-care coverage.12 In contrast, France ranked #4, #4 and #1, with only 1 percent uninsured.13 Obviously the French are getting more bang for their francs than we are getting for our bucks, despite the fear-mongering in the media about socialized medicine.
The present system was described by TIMEmagazine: “[W]hat a sinkhole the country’s healthcare system has become: the U.S. spends more to get less than just about every other industrialized country.”14 Dr. Ezekiel Emanuel, health adviser to President Obama, also addressed the question whether or not America has the best health care in the world, a mistaken belief held by many people:
“Let’s bury this one once and for all. The United States is No. 1 in only one sense: the amount we shell out for health care. We have the most expensive system in the world per capita, but we lag behind many developed countries on virtually every health statistic you can name.”15
To put this cost into perspective, the U.S. spent twice as much on sick-care as it did on food in 2006 and more than China’s 1.3 billion citizens consumed altogether. In addition, the increase in U.S. health care spending in the three-year period is more than the amount U.S. consumers spent on oil and gasoline during all of 2006 when energy prices began to reach new heights.16
These facts did not escape the attention of President Obama: “Today, we are spending over $2 trillion a year on health care – almost 50 percent more per person than the next most costly nation. And yet, for all this spending, more of our citizens are uninsured; the quality of our care is often lower; and we aren’t any healthier. In fact, citizens in some countries that spend less than we do are actually living longer than we do.”17 (Emphasis added)
Back Pain Dilemma
Undoubtedly the annual cost of health care, nearly $2.4 trillion, could be reduced substantially if unnecessary treatments were decreased. Of the Top 10 list of diseases in America, “back pain” stands at number eight, which according to Forbes.com costs over $40 billion annually for treatment costs alone;18 other estimates that include disability, work loss, and total indirect costs range between $100 and $200 billion per year.19 Back pain sent over 3 million people to emergency rooms in 2008 at a cost of $9.5 billion, making it the ninth most expensive condition treated in U.S. hospitals.20
“Work-related musculoskeletal disorders remain the leading cause of workplace injury and illness in this country,” according to OSHA head David Michaels.21 Although not the killer that heart disease or cancer is, crippling back pain is expensive, disabling, and often leads later in life to osteoarthritis, which ranks ahead of back pain on the Top 10 listat $48 billion; when combined, these two musculoskeletal conditions rank fourth on the list at $88 billion.22
Recently a new wave of data by researchers has revealed the high cost and ineffectiveness of most medical back treatments. Yet these revelations have fallen on deaf ears in the medical profession as the use of opioids, epidural steroid injections, and spine surgeries has radically increased despite these warnings.
Ironically, now the chiropractic profession, long ostracized by the medical profession, has emerged as a fiscal conservative to champion this call for reducing costs in health care. Despite the historic medical prejudice, spinal manipulation has now been shown to be the most clinically and cost-effective method for the epidemic of low back pain, which happens to be the single largest cause of disability today.23
According to Pran Manga, PhD, MPhil, health economist, “There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management.”24He is not alone in his assessment. Numerous international and American studies have shown that for nonspecific back pain, manipulation was heads above all other treatments. In fact, 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.”25
Chiropractic care not only has catapulted to the top of the list for back pain care, chiropractic patients are also extremely positive about their treatments. TRICARE, the health program for military personnel and retirees, has evaluated patients’ response to chiropractic care. The enormously high patient satisfaction rates astounded the TRICARE administrators with scores of 94.3 percent in the Army; the Air Force tally was also high with 12 of 19 bases scoring 100 percent; the Navy also reported ratings of 90 percent or higher; and even the TRICARE outpatient satisfaction surveys (TROSS) rated chiropractors at 88.54, which was 10 percent “higher than the overall satisfaction with all providers” (78.31 percent). But despite these glowing satisfaction rates for chiropractic care, TRICARE continues to limit access to chiropractors at only 42 of 131 military treatment facilities due to an intransigent medical bureaucracy within the Department of Defense.26
Not only are patients well satisfied with chiropractic care, in fact, the more investigators look into this back pain epidemic, the more the medical management has come under attack and, remarkably, that chiropractic treatment has been found best for the vast majority of nonspecific low back and neck pain.
After nearly a century of warfare against the chiropractic profession, defaming it as an “unscientific cult” that deserved to be “eliminated,”27 research now has shown chiropractic care to be very effective and, ironically, now seriously questions the efficacy of the medical management of back pain – opioid drugs, epidural steroid injections, and spine surgery. Indeed, the claim to be unscientific and dangerous now seems to be on the other (medical) foot.
The Call for Restraint in Spine Surgery
It must be bitter medicine to swallow for the medical profession to realize that back surgery “has been accused of leaving more tragic human wreckage in its wake than any other operation in history,” according to Gordon Waddell, DSc, MD, FRCS. As director of an orthopedic surgical clinic for over 20 years in Glasgow, Scotland, he determined: “Low back pain has been a 20th century health care disaster. Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem.”28
Richard Deyo, MD, MPH, also mentioned the problems with medical treatments and physician incompetence in diagnosis and treatment of low back treatments: “Calling a [medical] physician a back-pain expert, therefore, is perhaps faint praise – medicine has at best a limited understanding of the condition. In fact, medicine’s reliance on outdated ideas may have actually contributed to the problem.”29
Undoubtedly, another knife in spine surgeons’ backs occurred in 1994 when the U.S. Public Health Service’s Agency for Health Care Policy & Research (AHCPR) conducted the most thorough investigation into acute low back pain in adults and concluded the following finding in its Patient Guide:
“Even having a lot of back pain does not by itself mean you need surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.30 (Emphasis added)
The AHCPR study also concluded that spinal manipulation was the preferred initial professional treatment for acute low back pain. The Patient Guide stated: “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.”31
This recommendation was, in effect, an endorsement of chiropractic care, since chiropractors do 94 percent of all spinal manipulation in the U.S.32After a century of defamation, it was a sweet vindication for the chiropractic profession finally to be endorsed by the U.S. Public Health Service. Of course, the North American Spine Society, consisting primarily of spine surgeons, took a dim view of this precedent and politicked to have the AHCPR’s mission to establish guidelines eliminated with help from Newt Gingrich’s Republican Congress. It should be noted that of the 14 guidelines done by AHCPR, the acute low back pain guideline was the only one attacked by the medical profession.
Despite the medical resistance, these warnings are escalating as the call for restraint is growing from a whisper into a roar. Certainly when leading medical professionals from prestigious universities, journals, and the U.S. Public Health Service openly criticize the onslaught and ineffectiveness of spine surgery, this has become an epidemic of legitimate concern for payers and patients alike.
References
- Text of President Obama’s health care speech, June 15, 2009, reprinted by MarketWatch.
- Calvan CC.”Blue Shield Stands By California Health Care Premium Hikes.” The Sacramento Bee, Feb. 11, 2011.
- Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical Bankruptcy in the United States, 2007: results of a national study. The American Journal of Health, August 2009;122(8):741-746.
- Arnst C. “Study Links Medical Costs and Personal Bankruptcy, Harvard Researchers Say 62% of All Personal Bankruptcies in the U.S. in 2007 Were Caused by Health Problems — and 78% of Those Filers Had Insurance.” Business Week, June 4, 2009.
- “Harvard Study: 60% of Bankruptcies Caused by Health Problems.” Consumer Affairs, June 4, 2009.
- Arnst C, Op Cit.
- Gawande A. “The Cost Conundrum.” The New Yorker Magazine, June 1, 2009.
- Starfield B. “Is US Health Really the Best in the World?” JAMA, July 26, 2000;284(4):483-485.
- Nalder E, Crowley CF. “Patients Beware: Hospital Safety’s a Wilderness of Data. Hearst Newspapers, March 21, 2010.
- Gawande A, Op Cit.
- Dunham W. “France Best, U.S. Worst in Preventable Death Ranking,” Reuters, Jan. 8, 2008.
- World Health Organization. The World Health Report 2000: Health Systems–Improving Performance, 2000.
- Rodwin VG. “The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States.” Am J Public Health, January 2003;93(1): 31-37.
- Tumulty K. “Can Obama Find a Cure?” TIME, Aug. 10, 2009.
- Emanuel E, Brownlee S. “Myths About Our Ailing Health-Care System,” Washington Post, Nov. 23, 2008.
- Farrell DM, Jensen ES, Kocher B. “Accounting for the Cost of U.S. Health Care: A New Look at Why Americans Spend More.” McKinsey Global Institute, Nov. 8, 2008.
- Text, Op Cit.
- Van Dusen A. “America’s Most Expensive Medical Conditions,” Forbes.com, Feb. 6, 2008.
- Guyer RD. “The Paradox In Medicine Today–Exciting Technology and Economic Challenges.” The Spine Journal, March/April 2008;8(2):279-285.
- AHRQ News and Numbers: “Aching Back Sends More Than 3 Million to Emergency Departments.” Feb. 3, 2011.
- “Anti-Regulatory Forces Launch Full Assault on Public Protections.” OMB Watch, Feb. 8, 2011.
- “Top 10 Most Expensive Treatment-Disease Costs.” www.mostexpensiveworld.com/diseases/top-10-most-expensive-treatment-disease-costs.html
- Woolf AD, Pfleger B. “Burden of Major Musculoskeletal Conditions.” Bull World Health Organ, 2003;81(9):646-656.
- Manga P, Angus D, Papadopoulos C, Swan W. “The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain.” Funded by the Ontario Ministry of Health, August 1993.
- Testimony before the Institute of Medicine: Committee on Use of CAM by the American Public, Feb. 27, 2003.
- Chiropractic Care Study, Senate Report 110-335 accompanying the National Defense Authorization Act for FY 2009; letter sent to Congressmen by Ellen P. Embrey, Deputy Assistant Secretary of Defense, Sept. 22, 2009.
- Memo from Robert Youngerman to Robert Throckmorton, Sept. 24, 1963; plaintiff’s exhibit 173, Wilk.
- Waddell G, Allan OB. “A Historical Perspective on Low Back Pain and Disability.” Acta Orthop Scand, 1989;60 (suppl 234).
- Deyo RA. “Low-Back Pain.” Scientific American, August 1998:49-53
- Bigos S, et al. Acute Low Back 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, AHCPR Pub. No. 95-0642; December 1994. Patient Guide, (1992):12.
- Ibid, p. 7.
- Shekelle PG, et al. RAND Corporation Report: The Appropriateness of Spinal Manipulation for Low-Back Pain.
Ask Dr. Kaldy
Kevin L Kaldy D.C.
Chiropractic Physician NV B-929
Board Certified Independent Chiropractic Examiner
Dr. Kaldy is a 2001 graduate of Palmer College of Chiropractic-west. He is a past member of the American Association of Spine Physicians (AASP), the american chiropractic association and works side by side many Neurologists, Orthopedists and Pain Specialists in the Las Vegas area. Dr. Kaldy believes in the use of traditional and non-traditional treatment together to fight today’s most common ailments. These being, Whiplash Injuries, low back pain, neck pain, headaches, Shoulder Pain, TMJ, Carpal Tunnel, TMJ problems..
By combining all possible treatment types, being the use of chiropractic with medicine the healing time and recovery is much faster than either alone. Dr. Kaldy is one of the few chiropractors nationwide that is working towards Emergency room and hospital privileges. People ask why, and the answer again is, when used together, the patients Receives the most benefit. Dr. Kaldy graduated from Palmer College of Chiropractic-west in california, he also attended Palmer College of Chiropractic in Davenport Iowa for further training. Dr. Kaldy spent 12 years working in the emergency room of a bay area hospital, where the emergency room learned the true benefits of multi-disipline providers working together.
Dr. Kaldy’s patients get proven, evidence/research based treatment, co-management with their primary physician and other specialists. We look forward to seeing you and answering your questions. Health and wellness with a medical approach, without the medical feel (NO WHITE COATS).
National Board of Chiropractic Examiners Certified
Licensed by the Chiropractic Physicians Board of Nevada
Associations:
American Board of Independent Medical Examiners (ABIME)
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