Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery

Here are some excerpts from this 2016 book:

Although chiropractors often tell patients that long-term treatment is essential, there is no evidence that ongoing chiropractic care of back pain (or any other symptom or disorder) is effective. The Cochrane Collaboration makes it very clear that the only evidence for chiropractic in the treatment of back pain is in cases where the pain is of a very recent onset…

I never thought to ask about those subluxations, but if I had, I would have learned that they were unidentifiable on X-rays, in hands-on examination, or by any other methods. The premise that the spinal joints can freely slip into and out of position is false; such dislocations do occur, but only in the event of serious trauma, the kind that takes you to a hospital’s emergency department rather than a chiropractor’s office. One study showed that, even when they were presented with identical copies of a patient’s X-rays, a group of experienced chiropractors could not muster consensus about where in the spine the subluxations occurred or what the proper course of treatment should be…

Like most people, I assumed that chiropractic treatment was safe. But most of the troubles that send patients to a chiropractor in the first place are included on the World Health Organization’s list of contraindications to chiropractic adjustment: disc herniation, severe or painful disc pathology, leg pain, dislocation of a vertebra, the presence of spinal hardware from fusion surgery, hypermobile joints, vertebral instability, inflammatory arthritis, osteoporosis, or a history of long-term glucocorticoid treatment, which can make bones fragile, especially in older people…

Studies show that, at any age, roughly half of all chiropractic patients experience temporary adverse side effects after treatment, including pain, numbness, stiffness, dizziness, and headaches. But these are minor in comparison with a more serious threat: the possibility that a cervical (neck) adjustment may result in a chiropractic stroke. Here’s how it happens: The vertebral arteries, which run roughly parallel to the cervical spine, make a sharp turn around the uppermost cervical vertebrae, just before those arteries travel into the brain. At the top cervical vertebrae, they form a harmless kink—until a chiropractor performs a “tug and twist” adjustment that violently rotates the neck. That movement can tear the delicate walls of one or more arteries, producing a blood clot or swelling that cuts off the blood supply to the brain. The resulting stroke may lead to permanent brain damage or death…

In 1963, after many years of seeking to contain chiropractic’s expansion, the American Medical Association established the Committee on Quackery. In a meeting of the Michigan State Medical Society, chairman and physician Joseph Sabatier observed that “rabid dogs and chiropractors fit into about the same category.” The AMA asked physicians to lobby to end federal recognition of chiropractic education and to recommend that health care plans and Medicare stop their reimbursement for chiropractic care. Five years later, the U.S. Department of Health, Education, and Welfare announced that chiropractic professionals would need to adhere to the standards of modern medicine, and stop discussing subluxations, if they were to be allowed to continue to practice. The government’s antipathy should have checked chiropractic’s popularity, but in the early 1970s, under intense pressure from chiropractic lobbying organizations, Congress ordered Medicare to pay for spinal manipulation. To be reimbursed by Medicare, the chiropractor needed to show that a subluxation existed on an X-ray. That should have imposed an impossible hurdle, because as we’ve established, subluxations are not visible on X-rays or, for that matter, in any form of imaging. Undeterred by that detail, chiropractors installed X-ray machines in their clinics and adopted the now-standard practice of taking a complete series of spinal images, and doing so repeatedly over the course of treatment, thus exposing patients to unnecessary radiation. Financially, this was a boon, allowing chiropractors to collect payments for both X-rays and treatment…

In 1990, the British Medical Journal described spinal manipulative therapy as “seven percent more effective” than standard hospital physical therapy, without acknowledging that physical therapy was notoriously ineffective as a treatment for low back pain patients. Some viewed the sampling as unreliable: Bewilderingly, even before outcomes were established, three-quarters of the chiropractic participants had dropped out of the study. Saying that chiropractic was 7 percent better than an ineffective protocol was faint praise, indeed…

The British Chiropractic Association ordered members to take down their websites in self-preservation, before their businesses and reputations were damaged. Within months, one in four British chiropractors was under investigation for profiteering, misleading marketing, and advertising excesses. In the United States, in light of this news and amid increased concern that chiropractors were taking patients for a ride on the government’s dime, Medicare altered its confusing stance—“show subluxations in an X-ray, and then we’ll pay for treatment”—instead ordering chiropractors to restrict their Medicare billings to “active therapy” rather than “maintenance services.” Quickly, chiropractors altered the way they described their treatments so that they could code every session as “active therapy.” Medicare inspectors didn’t take notice, but eventually the U.S. Office of the Inspector General did, estimating that, in 2001, Medicare had paid chiropractors some $285 million for improperly billed (and mostly unnecessary) chiropractic services.

In recent decades, chiropractors have divided over philosophical issues. Those who cling to Palmer’s metaphysical and nonscientific theories are known as “straights.” Others, called “mixers,” acknowledge the existence of bacteria, viruses, and other scientific nuts and bolts, but still adhere to most of Palmer’s tenets. Although they call themselves “chiropractic physicians” and employ the honorific “Dr.,” practitioners who entered chiropractic college before 1974, when the rules changed, may have gone directly from high school to practice after only eighteen months of training…

I spent a training weekend with Craig Liebenson, DC, who is the director of the International Society of Clinical Rehab Specialists,7 which retrains chiropractors, physical therapists, physicians, and sports medicine specialists. Liebenson practices what he preaches at L.A. Sports and Spine, a West Los Angeles clinic… Instead of being made to feel good, said Liebenson, back pain patients needed “graded exposure to feared stimuli,” which translated as intensive exercise meant to build ability, strength, and confidence. “We need to focus on function, not on pain and scans and symptoms, because all these poison the minds of patients,” he told his audience…

Unsurprisingly, Livingston didn’t realize that in the presence of a herniated disc, chiropractic treatment is contraindicated. Nor was he aware that in the acute phase—within a couple of weeks after the injury—the McKenzie Method of Mechanical Diagnosis and Therapy (MDT), also known as the McKenzie Method, could have put him back on his feet. The late Robin McKenzie, a Wellington, New Zealand, physiotherapist who died in 2013, loved to tell the story of how, quite by accident, he developed his technique. Because he was occupied with another patient at that moment, he sent his next appointment, a patient who suffered from a disc herniation—and associated back and leg pain—into a room, to wait. He told him to lie on his stomach on the examination table, in preparation for the standard ultrasound and heat therapy. But McKenzie did not know that his colleague, who used that room last, had left one end of the table elevated like the backrest of a chair, at nearly a ninety-degree angle. Given the awkward configuration, the patient evidently did his best, configuring his spine in an awkward backbend. Upon entering the room, McKenzie was horrified—until, the patient explained that the pain had finally relented. McKenzie realized that he had placed the patient’s spine in “extension,” thus eliminating the disc herniation’s pressure on the spinal nerve root. But spinal extension, he would learn, did not always end acute pain. Depending on how the protruding disc made contact with the spinal nerve root, a forward bend that put the spine in “flexion” could be just the ticket. When treatment was appropriately delivered, recovery from an acute episode could take only a few days. (Note, yet again, that many people recover from an acute episode without any professional assistance.) Once a patient knew what worked, he could rescue himself if he was in a crisis…

[PTs] order the same “cookie-cutter” routine for most low-back-pain patients, ensuring that many won’t get better. Patients who “fail physical therapy,” especially several times in succession, often use that information as evidence that the obvious next step is surgery. “They don’t recognize that cookie-cutter physical therapy is a pseudo-intervention,” said John D. Childs, director of the physical therapy program at U.S. Army–Baylor University, “or that PT serves as a holding tank for patients who are not quite ready to get on the gravy train of scans and tests and injections and surgery and pain management.”

You may have wondered why it’s often necessary to get a physician’s “prescription” for PT, when that’s not required for chiropractic or for other interventions like therapeutic massage or biofeedback or exercise. The answer lies in the hierarchical relationship between physicians and PTs. The latter have traditionally served as support staff rather than independent operators. “At the end of the day, physician lobbying groups don’t want PTs to gain direct access,” said John Childs, the Baylor therapist. “If you talk to a physician over a few beers, he will tell you that if you go to an excellent PT to treat a musculoskeletal condition, you will not need drugs, or imaging. You will not need a surgeon.” Therefore, remarked Childs, physicians have a vested interest in keeping patients under their own care…

Certified personal trainers, he explained, could get their “degrees” after a weekend online course. And recently, some had begun to abbreviate the CPT to “PT,” in this case standing for “personal trainer.” This suggested expertise and education that they did not possess…

…in a 2015 review of the medical literature, the Agency for Healthcare Research and Quality had found no evidence that epidural steroid injections were effective in treating symptoms of spinal stenosis or typical low back pain. Even in the presence of a recent disc herniation and ensuing sciatica, the benefits of injections were small…

About Luke Ford

I've written five books (see Amazon.com). My work has been followed by the New York Times, the Los Angeles Times, and 60 Minutes. I teach Alexander Technique in Beverly Hills (Alexander90210.com).
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