Science is hard; good science is more difficult.

When I entered this profession in the late 1970s my naive belief was that since chiropractors were obviously getting people better, all we needed for our ac-ceptance to skyrocket was research showing that chiropractic works.

Flash forward to today. Despite many practice challenges, chiropractic is now far better accepted socially, as well as by other healthcare professionals. It’s been quite a while since I've been called a quack. Last week I went to dinner with six DCs and six MDs- neurosurgeons, neurologists and other NMS docs. The topic of mutual referral underlies many of the conversations, but these collaborations would never have occurred 20 years ago. Plus demand is up, as there’s been a tremendous increase in the problem back pain during the 21st century – a good thing for those treating back pain.

But are chiropractors’ social popularity and success skyrocketing?

Insurance companies continue to tighten the economics of practice as we enter the grand PPACA healthcare system experiment, better known as ObamaCare. Time will tell whether it was bold or foolish, but no one is claiming it is going to fix the growing problem of back pain in an aging, slumped over society.

It seems as though just as physicians and other providers accept us more, the individual practitioner has less ability to steer patients to DCs, because now the MD has become an employee. Medical Homes and other entities with acronyms like ACOs and PCMHs are ascendant, with protocols written by committees of administrators and accountants (as well as some clinicians) who look at the ―scientific evidence.”

And research does show the value of spinal manipulation, but often in less glowing terms than myself and our researchers hoped.

The problem of quantifying back pain

The problem—science is hard. My friends who are scientists continually repeat that the plural of anecdote is not data. They require the use of dimly recalled things from Statistics 101 like chi-square and T tests to determine “statistical significance.” To scientifically and statistically prove something requires showing there is less than one chance in 20 that whatever you are studying happened by chance. Also known as P= <.05, reaching this probability means controlling for all other possible variables.

For back pain, there’s an amazing variance of flavors of patients and their com-plaints. Patient history and the specifics of the problem onset and character is one. Does the pain radiate into the SI joint in the low back only, both SI joints, or going into the buttocks? A really important but often neglected factor is bio-psycho-social, where intertwining of the person's psychological involvement with their pain creates psychological and personal benefits (think more attention or a bigger settlement) and creates a spiral of negative behavior.

The multifactorial nature of back pain is probably the one thing on which all the low back pain research agrees. Regarding spinal manipulation, unfortunately the 200 plus studies currently in the journals don’t fully agree, but new exciting studies are coming out which demonstrate the effectiveness of chiropractic, as well as pointing to a role for the DC in the health delivery system.

Meta-studies draw improved conclusions

A big trend in science is doing a study to look at a number of other studies in a meta-study, which is essentially pooling data to see what works best.

A 2013 study published in SPINE by Goertz looked at eight of these systematic reviews and reported that, indeed, chiropractic manipulative therapy can moderately reduce low back pain and disability.

The study: “Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: Results of a pragmatic randomized comparative effectiveness study.”

The results: “Chiropractic manipulative therapy in conjunction with standard medical care offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute LBP” care.¹

In other words, chiropractic makes medical care better.

A possible suggestion for these researchers’ next study: Compare chiropractic plus medical care to chiropractic care alone. Another even more exciting study was just published in the Annals of Internal Medicine. “Spinal Manipulation and Home Exercise With Advice for Subacute and Chronic Back-Related Leg Pain” looked at what happens when you add chiroprac-tic to an exercise and posture advice program already shown to improve low back pain.

Bradford’s team at Northwestern University of Health Science Advice taught ge-neric awareness such as, “Patients were also instructed in methods for developing spine posture awareness related to their activities of daily living, such as lifting, pushing and pulling, sitting, and getting out of bed.”

The study’s result: Adding chiropractic gave even better results than the exercise and advice alone.² In both of these studies, researchers controlled for a multifactorial problem by adding chiropractic to something whose effectiveness was already measured. Both studies’ results counter the arguments that back pain is psychological, or that some improvements occur when you teach people exercises and give them postural advice. In other words, posture training helps and placebo effects may be real…but so are the positive changes seen with chiropractic manipulative therapy.

Chiropractic really does help back pain, as does exercise, as does postural advice. And, when it’s all combined, patients do even better!

But practice is not a research environment. In Bronfort’s study, home exercise and advice were delivered in four 1-hour, one-on-one visits during a 12-week intervention. The main program goals were to provide patients with the tools to “manage existing pain, prevent pain recurrences, and facilitate engagement in daily activities.” And while research is fantastic, in the real world chiropractic practice economics defines what can be done. Especially in these days of third party reimbursements, it’s smart to effectively fit programs into sequenced 8-15 minute encounters, program care to be systematically individualized and progressive, and be able to have different staff reliably and reproducibly teach the exercises and posture awareness.

This is why the StrongPosture® exercise protocols and PostureZone® framework is a great way to systematically teach exercise and also communicate with patients, the public and other professionals.

The PosturePractice Model

By first engaging people with a picture from an app (see above image), and then communicating concepts of PostureZone© biomechanics, the message can apply to spine care, as well as people with other neuromuscular skeletal issues including extremity concerns, hip to foot and shoulder to hand. Plus, Baby Boomers concerned about hunching over and athletes seeking performance also value posture. And while not clinical, for many a significant appeal of the PostureZone© framework is vanity’s appeal— people who stand tall with strong posture simply look better.

Once people are interested and engaged with posture awareness, the StrongPosture® exercises use the PostureZone© cueing in an actionable framework to systematically strengthen functional postural balance, alignment and motion in a daily posture exercise habit, individualized to for the patient and applicable to multiple demographics.

These posture concepts are receiving increasing coverage in national and local media. Dynamic Chiropractic’s October 1st front page article covered how posture is the DC-MD bridge, and on the general public side the November 2014 issues of SHAPE as well as RealSimple magazines talked about the benefits of improving posture.

Through the trends of both clinical research and media, it has become clear that people are interested in chiropractic care and how our services can help them to live longer, healthier lives. As we venture into a new era of healthcare practices, it makes sense to position the chiropractic profession into a place of value, both in the eyes of other wellness profes-sionals as well as those of the consumer.

About the Author

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1—Goertz, C. M., Long, C. R., Hondras, M. A., Petri, R., Delgado, R., Lawrence, D. J., . . . Meeker, W. C. (2013). Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: Results of a pragmatic randomized comparative effectiveness study. Spine, 38(8), 627-34. doi:10.1097/BRS.0b013e31827733e

2—Bronfort, G., Hondras, M. A., Schulz, C. A., Evans, R. L., Long, C. R., & Grimm, R. (2014). Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: A trial with adaptive allocation. Annals of Internal Medicine, 161(6), 381-91. doi:10.7326/M14-000

Dr. Terence Murphy, a chiropractor in Westchester, is running for the NY State Senate. His election would be very significant for the chiropractic profession as a voice in the NYS Senate. Please consider giving him your support.

You can get more information at www.VoteforMurphy.com

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About Dr. Murphy

Dr. Terrence Murphy’s family originally moved to Yorktown 52 years ago when Yorktown’s mascot, the Cornhusker, was still a common and public sight. Growing up next to Wilken’s Fruit Farm, Terrence enjoyed an incredible childhood which included apple picking and skating on Mill Pond. As the youngest of six children, Dr. Murphy learned at a young age how to stick up for himself. His father Jack, a blue-collar, union man and labor advocate who worked for Con Edison for over fifty years taught him the importance of hard work, dedication, and commitment to community.

Remembering his father’s teachings of the importance of community Dr. Murphy was always willing to help others in need. It was of little surprise to his family when he decided to study chiropractic following his graduation from Yorktown High School in 1984. Terrence’s time away from Yorktown was a blessing in disguise. It allowed him to become an independent individual, traveling the world as a member of a world class rugby team, while reinforcing his love and passion for his home town.

In 1999, Dr. Murphy made his first official mark on Yorktown by opening the Yorktown Health and Wellness Center on Commerce Street. Standing in the same storefront today as then Dr. Murphy has exhibited his father’s lessons of hard work, dedication, and commitment to his community.

Following the passing of his father, Dr. Murphy, opened Murphy’s Restaurant in Yorktown in 2006, with his Mom Deneyse, and older siblings, Colleen, Erin, Sean, Denis, and Pat. As a tribute to their father, Murphy’s stands as one of Yorktown’s largest and most successful businesses and has been recognized twice for providing employment opportunities for the mentally challenged.

Dr. Murphy’s commitment to the Yorktown community does not stop there. For fifteen years he volunteered for the Yorktown High School Athletic Department caring for our young athletes as an on-field medical professional. Terrence served for nearly ten years as a New York State certified EMT and started the watchdog organization Keeping Westchester Safe.

Today, Dr. Murphy continues his chiropractic practice while assist in managing his family’s restaurant. Always keeping family first, Dr. Murphy’s favorite time spent is with this wife Caroline, and children McKayla, Jack, and Kian.

It is with great pleasure that I announce the publication of my book Ending Back Pain.

Many of you know me as a Spinal Neurosurgeon but this book is not about surgery. I wrote Ending Back Pain to inform the public about the need to advocate for themselves in a medical system that is ill equipped to deal with this major health issue. My goal is to help the reader establish a correct diagnosis and thereby the appropriate treatment options. I review those options and wherever possible quote the pertinent medical literature that supports the treatment.

I am a former member of the Board of Trustees of the New York Chiropractic College and longtime member of the Office of Professions of the NY State Board of Regents in Chiropractic and I have seen firsthand the benefits of Chiropractic.

I hope you will consider buying the book and recommending it to your patients.

I enclose a link to a podcast from the book’s website: https://soundcloud.com/dr-jack-stern/dr-jack-stern-md-on-chiropractic-care-for-back-pain

Best Wishes,

Jack Stern, MD, PhD

Arlington, Va.—The American Chiropractic Association (ACA), in a letter to U.S. House and Senate conferees regarding legislation addressing recent health care issues uncovered at the U.S. Department of Veterans Affairs (VA), urges lawmakers to further integrate the essential services provided by doctors of chiropractic (DCs) in the VA health care system.

The letter, addressed to Chairman Jeff Miller (R-Fla.) and Ranking Member Mike Michaud (D-Maine) of the House Committee on Veterans Affairs and Chairman Bernie Sanders (I-Vt.) and Ranking Member Richard Burr (R-N.C.) of the Senate Committee on Veterans Affairs, reminds legislators that chiropractic physicians deliver conservative care for neuromusculoskeletal conditions necessary for America’s veterans.

ACA believes improved access to chiropractic services for the veteran population will result in decreasing its overuse and abuse of prescription pain medications. This can be accomplished by transitioning to a conservative-care-first model, which focuses on using conservative treatments, providing care in out-patient settings and incorporating health promotion and wellness counseling. Veterans should be afforded the opportunity to choose and have access to services provided by chiropractic physicians prior to prescription medication and surgical procedures. The need for change in the VA is urgent. Recent statistics from a Center for Investigative Reporting special report found that prescriptions in the VA for four highly addictive painkillers have surged by 270 percent since the war in Afghanistan began, far outpacing the increase in patients. Additional VA research shows that the fatal overdose rate among veteran patients is nearly double the national average.

“VA currently provides access to a DC at more than 45 major treatment facilities within the U.S. However, the overwhelming majority of eligible veterans continue to be denied access to chiropractic services because VA has failed to take any significant action to provide access at around 100 other VA facilities,” said ACA President Anthony Hamm, DC. “Action is needed to ensure that all the brave men and women who have put their lives on the line for our country have access to as much health care as they need when they get back home, regardless of the provider they wish to see.”

ACA’s letter urges conferees to integrate language from pending legislation in the U.S. House and Senate into the coming House-Senate conference report, as further integration of chiropractic physicians within VA can significantly reduce costs without compromising excellent clinical outcomes or high patient satisfaction.

The full text of the letter can be found on ACA’s website.

The American Chiropractic Association (ACA), based in Arlington, Va., is the largest professional association in the United States advocating for more than 130,000 doctors of chiropractic (DCs), chiropractic assistants (CAs) and chiropractic doctoral students. ACA promotes the highest standards of ethics and patient care, contributing to the health and well-being of millions of chiropractic patients. Visit us at www.acatoday.org.

The NYSCA would like to express our deepest gratitude to the American Chiropractic Association and New York Chiropractic College for their support and advocacy regarding a proposal from the New York State Workers' Compensation Board to limit DCs' workers' compensation reimbursement.

In their recent letter, the ACA urged the Board to reconsider their proposal. Citing numerous cost effectiveness studies related to the services provided by DCs, ACA stated that such a proposal "detracts from the aims of New York's workers' compensation reforms, which include patient-centered, evidence informed and cost-effective care." ACA opposes the establishment of any system which unfairly limits one profession compared to other authorized providers and vows to voice this view strongly whenever and wherever necessary.

As always, the NYSCA and Council, through the Joint Legislative Task Force, continue to work for protecting practice rights and the services provided under New York State Workers’ Compensation. We will also keep you, our membership, informed as updates occur.

Abstract (provisional)

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Background

Low back pain is among the most common and costly chronic health care conditions. Recent research has highlighted the common occurrence of non-specific low back pain in adolescents, with prevalence estimates similar to adults. While multiple clinical trials have examined the effectiveness of commonly used therapies for the management of low back pain in adults, few trials have addressed the condition in adolescents. The purpose of this paper is to describe the methodology of a randomized clinical trial examining the effectiveness of exercise with and without spinal manipulative therapy for chronic or recurrent low back pain in adolescents.

Methods

This study is a randomized controlled trial comparing twelve weeks of exercise therapy combined with spinal manipulation to exercise therapy alone. Beginning in March 2010, a total of 184 participants, ages 12 to 18, with chronic or recurrent low back pain are enrolled across two sites. The primary outcome is self-reported low back pain intensity. Other outcomes include disability, quality of life, improvement, satisfaction, activity level, low back strength, endurance, and motion. Qualitative interviews are conducted to evaluate participants' perceptions of treatment.

Discussion

This is the first randomized clinical trial assessing the effectiveness of combining spinal manipulative therapy with exercise for adolescents with low back pain. The results of this study will provide important evidence on the role of these conservative treatments for the management of low back pain in adolescents.

Abstract (provisional)

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Background

Upright examination procedures like radiology, thermography, manual muscle testing, and spinal motion palpation may lead to spinal interventions with the patient prone. The reliability and accuracy of mapping upright examination findings to the prone position is unknown. This study had 2 primary goals: (1) investigate how erroneous spine-scapular landmark associations may lead to errors in treating and charting spine levels; and (2) study the interexaminer reliability of a novel method for mapping upright spinal sites to the prone position.

Methods

Experiment 1 was a thought experiment exploring the consequences of depending on the erroneous landmark association of the inferior scapular tip with the T7 spinous process upright and T6 spinous process prone (relatively recent studies suggest these levels are T8 and T9, respectively). This allowed deduction of targeting and charting errors. In experiment 2, 10 examiners (2 experienced, 8 novice) used an index finger to maintain contact with a mid-thoracic spinous process as each of 2 participants slowly moved from the upright to the prone position. Interexaminer reliability was assessed by computing Intraclass Correlation Coefficient, standard error of the mean, root mean squared error, and the absolute value of the mean difference for each examiner from the 10 examiner mean for each of the 2 participants.

Results

The thought experiment suggesting that using the (inaccurate) scapular tip landmark rule would result in a 3 level targeting and charting error when radiological findings are mapped to the prone position. Physical upright exam procedures like motion palpation would result in a 2 level targeting error for intervention, and a 3 level error for charting. The reliability experiment showed examiners accurately maintained contact with the same thoracic spinous process as the participant went from upright to prone, ICC (2,1) = 0.83.

Conclusions

As manual therapists, the authors have emphasized how targeting errors may impact upon manual care of the spine. Practitioners in other fields that need to accurately locate spinal levels, such as acupuncture and anesthesiology, would also be expected to draw important conclusions from these findings.