Deceptive Dogmatic Reporting Despite Successful Chiropractic Outcomes
FEATURE
Revealing the deception of low back pain naturally resolving ...and the dogma of non-specific back pain
Mark Studin
DC, FASBE(C), DAAPM, DAAMLP, William J. Owens, DC, DAAMLP and Timothy Weir, DC
"Avoid exposing the patient to unhelpful or possibly risky interventions."
A report on the scientific literature
Over the past decade, a growing body of evidence has demonstrated the “how and why” of chiropractic evidenced-based results. However, there also has been a historical level of reporting dogmatic issues related to the “the natural history of back pain” and “nonspecific back pain” that deceptively enter and intersect the conversation to apparently discredit “pro-chiropractic” evidenced-based research. This review is centered on those issues, and the references for the previous comments will ensue in the following paragraphs.
The National Institute of Neurological Disorders and Stroke reports, “Most low back pain is acute or shortterm, and lasts a few days to a few weeks. It tends to resolve on its own with self-care, and there is no residual loss of function.” (https://www.ninds.nih.gov/Disorders/ Patient-Caregiver-Education/Fact-Sheets/Low-BackPain-Fact-Sheet. Kaiser Permanente, a national health system reports, “For most patients with back pain, the condition will improve within a few days or weeks.” https://wa.kaiserpermanente.org/static/pdf/public/guidelines/back-pain.pdf)
Kaiser Permanente goes on to report, “The primary goal of treatment is to maximize function and quality of life, rather than to eliminate pain. Some ongoing or recurrent pain is normal and not indicative of a serious problem. Avoid exposing the patient to unhelpful or possibly risky interventions. As a general rule, an intervention in which the patient is an active participant (e.g., physical therapy, walking, stretching, yoga) rather than a passive recipient (e.g., chiropractic, massage, acupuncture) is deemed to have greater potential to promote selfefficacy and self-management skills in the long term.”
(https://wa.kaiserpermanente.org/ static/pdf/public/guidelines/backpain.pdf)
In 2018, Gedin, Edmar, Sundberg, and Burstrom reported, “Patients with acute back pain reported statistically significant and MCID (minimal clinically important difference) improvements in back pain intensity, back disability, HRQoL (health-related quality of life instrument), and statistically significant improvements in self-rated health, over four weeks following chiropractic care. Patients with chronic back pain reported statistically significant, albeit smaller and non-MCID, changes for all PRO except self-rated health.”
Interestingly, Gedin et al. have a significant level of statistics of demonstrating percentages of subjects who showed improvement and choose not to report that in the written part of the report, thereby not rendering a statistical interpretation. However, they included a caveat to perhaps minimize the positive results by reiterating the same deceptive dogma as discussed earlier. Gedin et al. then reported, “However, it has been suggested that 90% of patients with acute low back pain recover within six weeks (van Tulder et al., 2006), which may also help explain the current findings of rapid improvements” (pg. 16). This opinion, published in 2018, was referenced and supported by a 12-year old study, which clearly ignored the contemporary literature.
Tamcan, Mannion, Eisenring, and Horisberger (2010) reported on the only population-based study these authors were able to identify and concluded: When the 12-month follow-up period was divided into four equal time periods and, subsequently, clusters, it was seen that the majority of individuals placed in the moderate persistent [pain] cluster on the basis of the first three months of data remained in this cluster at the following intervals. A reasonable consistency across time was also found for the clusters mild persistent and severe persistent. In contrast, the consistency of membership for the cluster initially identified as fluctuating was low, especially after six months, (p. 455-456)
This study, which again is the only identified population-based study, indicates that pain does not resolve “naturally” as was reported—“fluctuation was low, especially after six months.”
Knecht, Humphreys, and Wirth (2017) reported on the recurrence of low back pain and stated, “Only 1 in 3 LBP (low back pain) episodes completely resolve within a year, and the percentage of LBP that goes from acute to chronic varies among studies from 2% to 34%. ” They also went on to report:
Patients presenting with a subacute problem, lasting for more than 14 days at baseline, were at higher odds for a recurrent course, whereas the odds for a chronic course were higher only for patients presenting with a chronic problem (>3 months) at baseline. Downie et al. reported that pain duration of more than five days was a factor that negatively affects prognosis. Similarly, duration of the current episode emerged as the most consistent factor for prognosis after one year in a study by Bekkering et al. and even predicted disability after five years. These findings suggest on the one hand that it might be prudent to seek professional advice [referenced chiropractic care in the article] early on in the pain episode, (p. 431)
These papers are part of the research trend supporting what the chiropractic profession has known all along: the natural progression of low back pain resulting in resolution is based on dogma and not supported by the research evidence. Additionally, the low back pain care-path reported previously by Kaiser Permanente appears to be biased toward the denial of care and not consistent with the published literature.
Gedin et al. (2018) also reported, “It has been estimated that the vast majority of back pain cases is of nonspecific origin” (p. 3). The concept of simply focusing on the treatment of nonspecific back pain would render chiropractic no different than physical therapists when focusing on the “nonspecific” nature of spine pain as the arbiter for care, while the focus must be on the biomechanical compensation and individual motor units of the spine. Previous literature has verified that the supposition that “nonspecific” is synonymous with “unobjectifiable” is erroneous since it was previously reported that chiropractic treats definite biomechanical changes in the motor units of the spine, therefore resulting in “very specific” biomechanical pathology.
In 1992, Panjabi presented a detailed work explaining how the biomechanical systems within the human spine react to the environment, and how it can become dysfunctional and cause pain. He stated:
Presented here is the conceptual basis for the assertion that the spinal stabilizing system consists of three subsystems: the vertebrae, discs, and ligaments constitute the passive subsystem; all muscles and tendons surrounding the spinal column that can apply forces to the spinal column constitute the active subsystem; and, finally, the nerves and central nervous system comprise the neural subsystem, which determines the requirements for spinal stability by monitoring the various transducer signals [of the nervous system] and directs the active subsystem to provide the needed stability.
He then stated, “A dysfunction of a component of any one of the subsystems may lead to one or more of the following three possibilities: an immediate response from other subsystems to successfully compensate; a long-term adaptation response of one or more subsystems; or an injury to one or more components of any subsystem.”
Panjabi continues, “It is conceptualized that the first response results in normal function; the second results in normal function but with an altered spinal stabilizing system; and the third leads to overall system dysfunction, producing, for example, low back pain. In situations where additional loads or complex postures are anticipated, the neural control unit may alter the muscle recruitment strategy, with the temporary goal of enhancing the spine stability beyond the normal requirements” (p. 383). This is where the idea of biomechanical compensation was identified.
Panjabi’s lifelong work is the basis for the underlying mechanics of spine pain that does not correlate well to anatomical findings. Anatomical findings are fracture, tumor, or infection, and allopathy has labeled anything else as “nonspecific low back pain,” which continues to maintain a dogmatic perspective in both clinical decision making and, all too often, the literature, despite compelling evidence to the contrary.
**It differs in the ability of chiropractors to diagnosis and manages spinal compensation. JJ
Cramer et al. (2002) further clarified the biomechanics of spinal failure at the motor until level and reported:
One component of spinal dysfunction treated by chiropractors has been described as the development of adhesions in the zygapophysial (Z) joints after hypomobility. This hypomobility may be the result of injury, inactivity, or repetitive asymmetrical movements ... one beneficial effect of spinal manipulation may be the “breaking up” of putative fibrous adhesions that develop in hypomobile or “fixed” Z joints. Spinal adjusting of the lumbar region is thought to separate or gap the articular surfaces of the Z joints. Theoretically, gapping breaks up adhesions, thus helping the motion segment reestablish a physiologic range of motion, (p. 2459)
Evans (2002) reported:
On flexion of the lumbar spine, the inferior articular process of a zygapophy seal joint moves upward, taking a meniscoid with it. On attempted extension, the inferior articular process returns toward its neutral position, but instead of re-entering the joint cavity, the meniscoid impacts against the edge of the articular cartilage and buckles, forming a space-occupying ‘lesion’ under the capsule: a meniscoid entrapment. A large number of type III and type IV nerve fibers (nociceptors) have been observed within capsules of zygapophy seal joints. Pain occurs as distension of the joint capsule provides a sufficient stimulus for these nociceptors to depolarize. Muscle spasm would then occur to prevent impaction of the meniscoid. (p. 252)
Evans (2002) continued, “A HVLA manipulation, involving gapping of the zygapophy seal joint reduces the impaction and opens the joint, so encouraging the meniscoid to return to its normal anatomical position in the joint cavity. This ceases the distension of the joint capsule, thus reducing pain” (p. 253).
The involvement of nociceptors and nociceptive impulses stimulates the cortical regions of the brain, which evokes a cortical response to that noxious stimulus. Haavik et al. (2017) reported the effects of a chiropractic spinal high-velocity, low-amplitude adjustment by stating, “These results are consistent with previous findings that have suggested increases in strength following spinal manipulation were due to descending cortical drive and could not be explained by changes at the level of the spinal cord” (p. 1).
The persistent utilization of “nonspecific” in reference to specific biomechanical alterations and failure in the human spine is dogmatic and deceptive since it “lumps together” all types of manual treatment. Chiropractic, based upon its unique application, differs from other forms of manual therapy performed by physical therapy, acupuncture, and massage therapy because of the ability of chiropractors to diagnose and manage spinal compensation. In comparison to each other, each discipline is disparate in goals, application, and science and when not considered as such, lends itself to continue deceptive dogmatic arguments ignoring the evidence-based truths of chiropractic.
Dr. Mark Studin is an adjunct associate professor of ▼ chiropractic at the University of Bridgeport College of Chiropractic; an adjunct professor at Cleveland j"j University-Kansas City, College of Chiropractic; ⅞⅜ - ^ an adjunct professor of clinical sciences at Texas Chiropractic College; and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for postdoctoral education. He teaches MRI spine interpretation, spinal biomechanical engineering, and triaging trauma cases. He is the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities (www.DoctorsPIProgram.com); teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally; and studies trends in health care on a national scale (www.TeachDoctors.com). He can be reached at DrMarhxf AcademyofChiropractic.com or at 631-786-4253.
References:
1. The National Institute of Neurological Disorders and Stroke (2018) Retrieved from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/ Fact-Sheets/Low-Back-Pain-FactSheet
2. Kaiser Permanente, Non-specific Back Pain Guidelines (2017) retrieved from” https://wa.kaiserpermanente.org/static/ pdf/public/guidelines/back-pain.pdf
3. Gedin, F., Dansk, V., Egmar, A. C., Sundberg, T., & Burstrom, K. (2018). Patient-reported improvements of pain, disability and health-related quality of life following chiropractic care for back pain-A national observational study in Sweden. Journal of Bodywork and Movement Therapies. 10.1016/j. jbmt.2018.02.012
4. Tamcan, O., Mannion, A. F., Eisenring, C., Horisberger, B., Elfering, A., & Muller, U. (2010). The course of chronic and recurrent low back pain in the general population. Pain, 150(3), 451-457.
5. Knecht, C., Humphreys, B. K., & Wirth, B. (2017). An Observational Study of Recurrences of Low Back Pain During the First 12 Months After Chiropractic Treatment. Journal of manipulative and physiological therapeutics, 40(6), 427-433.
6. Downie AS, Hancock MJ, Rzewuska M, Williams CM, Lin CW, Maher CG. Trajectories of acute low back pain: a latent class growth analysis. Pain. 2016;157(l):225-234
7. Bekkering GE, Hendriks HJ, van Tulder MW, et al. Prognostic factors for low back pain in patients referred for physiotherapy: comparing outcomes and varying modeling techniques. Spine (Phila Pa 1976). 2005;30(16): 1881-1886.
8. Panjabi, M. M. (1992). The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. Journal of spinal disorders, 5, 383-383.
9. Cramer, G. D., Gregerson, D. M., Knudsen, J. T., Hubbard, B. B., Ustas, L. M., & Cantu, J. A. (2002). The effects of side-posture positioning and spinal adjusting on the lumbar Z joints: A randomized controlled trial with sixty-four subjects.⅝/ne,27(22), 2459-2466.Evans, D. W. (2002). Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: Previous theories. Journal of Manipulative and Physiological Therapeutics, 25(4), 251-262.
10. Haavik, H., Niazi, I. K., Jochumsen, M., Sherwin, D., Flavel, S., & Tiirker, K. S. (2016). Impact of spinal manipulation on the cortical drive to upper and lower limb muscles. Brain Sciences, 7(1), 2.
William J. Owens, DC, DAAMLP, is presently in private practice in Buffalo and Roche ster, New York and generates the majority of his new-patient referrals directly from the primary care medical community. He is an associate adjunct professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences as well as the University of Bridgeport, College of Chiropractic, and an adjunct professor of clinical sciences at Texas Chiropractic College. He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community. He can be reached at dr owens a academyofchiropractic. com, via www.mdreferralprogram.com, or at 716-228-3847.
Timothy Weir, DC, is a 1981 graduate of Palmer College of Chi ropractic in Davenport, Iowa. He has been in practice for 37 years. He is currently the owner and clinical director of Raleigh Injury Chiropractic in Raleigh, N.C. Dr. Weir is Trauma Qualified through Cleveland University, Kansas City, Chiropractic and Health Sciences and an Active Member of the Trauma Team with the Academy of Chiropractic. He is credentialed at the Graduate Level in MRI Spine Interpretation and Spinal Biomechanical Engineering through the State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences
