Waste Disposal: An Errant Attack on the Chiropractic Profession

Editor's note: Dr. Rosner joins fellow columnists Drs. Christine Goertz and Dana Lawrence in addressing the recent Forbes opinion piece by Steven Salzberg. Dr. Rosner provides an evidence-based rebuttal to the article; Drs. Goertz / Lawrence provide tips on how DCs should (and should not) respond (click here to read).

The degree of bias and misinformation hurled at the chiropractic profession in Steven Salzberg's recent article in Forbes¹ ["New Medicare Data Reveal Startling $496 Million Wasted on Chiropractors"] has struck this writer as reaching a nadir in journalism, conjuring up images no more hospitable than orangutans throwing feces at each other at the municipal zoo. In just two pages, Salzberg's article has attempted to tattoo the chiropractic profession with no less than eight alarming darts by:

1. Stating that subluxations have no scientific basis
2. Citing the $496 million disbursed by Medicare for chiropractic services as "stunning"
3. Arguing that the funds allocated by the NIH for alternative medicine through NCCAM is "an egregious waste of money"
4. Calling the practice of chiropractic "highly dubious"
5. Insisting that "the entire field [of chiropractic] was invented out of thin air"
6. Warning that chiropractic manipulation can cause a stroke
7. Trotting out the anti-vaccine position taken by some chiropractors
8. Comparing spinal adjustments to what transpires in the wrestling ring, spiced with a nearly full-page lurid image of two women twisting each other into the shapes of pretzels

Each of these points can be easily and thoroughly refuted, with just a sampling shown as follows:

1. Subluxations: The fact that spinal fixations and/or inflammations can produce pathological results which are reproducibly identifiable can be traced to numerous published studies, not the least of which are Henderson and Cramer's descriptions of the effects of induced fixations² or Song's segment specific reduction through spinal adjustments of a variety of indicators of inflammation³ which, if prolonged, could be construed to be life-threatening.
   


2. Medicare expenditures: A recent special edition of Time magazine pointed out that the medical-industrial complex spends more than three times as much as what has been spent by the military-industrial complex in Washington, D.C. Indeed, this entire edition was titled, "Why Medical Bills Are Killing Us."⁴ This information has been artfully ignored in Salzberg's arguments, nor do I recall chiropractors ever having been mentioned even once in this publication.
   
   It is ironic that Salzberg bemoans Medicare's presumably gargantuan sum of $496 million disbursed to chiropractors (all 48,000-plus of them within the U.S.), whereas in the very same article he states that an amount more than 20 percent greater than that ($610 million) has been doled out to just 100 of the 878,194 actively licensed physicians in the same territory.⁵
   
   From 1994-2004, low back pain-related Medicare expenses increased by 629 percent for epidural steroid injections, 423 percent for opioid medications, 307 percent for MRIs and 220 percent for lumbar fusion surgeries, while chronicity and disability related to spinal-related disorders have steadily increased.⁶ Again, I don't recall chiropractors ever having been mentioned in these figures.
   


3. NCCAM allocations: The NCCAM allocation from the NIH in 2013 was $123.813 million.⁷ The entire NIH budget for the same year, on the other hand, was $30.80 billion.⁸ What "egregious" bite out of the NIH budget could NCCAM's share possibly be? You do the math (0.41 percent). And this for a health care paradigm that no less a body than the Institute of Medicine argues is mandatory over the next decade.⁹
   
   While on the subject, let's talk about those "egregious" expenditures. In 2008, medical errors cost the United States $19.5 billion, with $17 billion directly associated with additional medical costs (ancillary services, prescription drugs, inpatient and outpatient care), $1.4 billion attributed to increased mortality rates, and $1.1 billion due to 10 million days of lost productivity.¹⁰ Does anyone wish to belabor the term egregious here?
   


4. Highly dubious profession: Given the high rating for spinal manipulation (well above that for spinal surgery) back in 1994 by what was then the Agency for Healthcare Policy Research,¹¹ and given that as many as 94 percent of spinal manipulations are performed by chiropractors,¹² what actually emerges as the dubious factor here is Salzberg's desperate attempt to staple this term onto the chiropractic profession.
   


5. Field of chiropractic invented out of thin air: Chiropractic was derived from clinical observation. A careful reading of D.D. Palmer's early works attests to the attempts to ground chiropractic on the evidence available to the practitioner at that time.¹³ Early descriptions of endocrinology, for example, were no more precise, with estrogens not even being understood until the 1930s.
   


6. Chiropractic can cause a stroke: The fact that spontaneous dissections occur at frequencies far exceeding those that studies have attempted to link to chiropractic,¹⁴ plus thorough descriptions as to the actual mechanisms of arterial dissection,^15-16 should give ample pause to the suggestion chiropractic is a likely cause of stroke.
   
   While on this topic, I should point out that conservative estimates reveal at least 200,000 Americans die from preventable medical errors each year.^{10, 17-18} This statistic easily swamps the presumed stroke rate by at least several orders of magnitude. Does anyone wish to dwell upon the safety issue with figures like these?
   


7. Chiropractors take an anti-vaccine position: A survey undertaken in 1994 indicated at that time that more than half of the chiropractic profession did not condemn vaccination.¹⁹ Since that time, the Canadian Chiropractic Association "accepts vaccination as a cost-effective and clinically efficient public health preventive procedure for certain viral and microbial diseases, as demonstrated by the scientific community."²⁰ While the medical journal Pediatrics indicates that the anti-vaccination position taken by a minority of the profession is a "continuing source of embarrassment to their more evidence-based colleagues,"²¹ it should be remembered – as stated by Craig Nelson – that there are health professionals other than chiropractors who are capable of unreason on this subject.²²
   


8. Wrestling represents the spinal adjustments performed by chiropractors: This is vaudeville, plain and simple. It is difficult to imagine that a publication respected in its field should have signed on to such a gruesome image while professing to offer a modicum of truth in reporting. On this side of the aisle, would my having represented the author of the Forbes article as a werewolf have accomplished any meaningful objective? It is tempting to be able to dismiss Salzberg's article as infantile as it is uninformed, had it not appeared in such a respected and widely disseminated publication as Forbes.

References

1. Salzberg S. "New Medicare Data Reveal Startling $496 Million Wasted on Chiropractors." Forbes, April 20, 2014.
2. Henderson CNR, Cramer GD, Zhang Q, DeVocht JW, Fournier JT. Introducing the external link model for studying spine fixation and misalignment: Part II: Biomechanical features. JMPT, 2007;30(4):279-294.
3. Song XJ, Gan Q, Cao Jun-Li, Wang Z-B, Rupert RL. Spinal manipulation reduces pain and hyperalgesia after lumbar intervertebral foramen inflammation in the rat. JMPT, 2006;29(1):5-13.
4. Brill S. "Why Medical Bills Are Killing Us." Time (Special Edition), Feb. 26, 2013.
5. Young A, Chaudry NJ, Thomas JV, Dugan M. A census of actively licensed physicians in the United States, 2012. J Med Reg, 2013;99(2):11-24.
6. Murphy DM, Justice BD, Piskowski IC, Perle SM, Schneider MJ. The establishment of a primary spine care practitioner and its benefits to health care reform in the United States. Chiro & Manual Ther, 2011;19:17.
7. National Institutes of Health. NCCAM funding: appropriations history.
8. Kaiser J. "A Flat Budget for NIH in 2013." Science, Feb. 13, 2012. http://news.sciencemag.org/health/2012/02/flat-budget-nih-2013
9. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press, 2001.
10. Andel C, Davidow SL, Hollander M, Morena DA. The economics of health care quality and medical errors. J Health Care Finance, 2012;39(1):39-50.
11. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Pain in Adults. Clinical practice guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December 1994.
12. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brook RH. The appropriateness of spinal manipulation for low back pain: project overview and literature review. RAND: Santa Monica, CA, 1991; Monograph No. R-4025/1-CCR/FCER.
13. Palmer DD. The Chiropractor's Adjuster: The Text-Book of the Science, Art, and Philosophy of Chiropractic. Portland, OR: Portland Printing House, 1910.
14. Shievink WT, Mokri, B, O'Fallon WM. Recurrent spontaneous cervical-artery dissection. NEJM, 1994;330(6):393-397.
15. Haneline MT, Rosner AL. The etiology of cervical artery dissection. J Chiro Med, 2007;6:110-120.
16. Rosner A. Spontaneous cervical artery dissections: another perspective. JMPT, 2004;27(2):124-132.
17. Schuster M, McGlynn E, Brook R. How good is the quality of health care in the United States? Milbank Quarterly, 1996;76:517-63.
18. Starfield B. Is US health really the best in the world? JAMA, 2000;284(4):483-5.
19. Colley F, Hass M. Attitudes on immunization: a survey of American chiropractors. JMPT, 1994;17:584-90.
20. Canadian Chiropractic Association. Policy Manual 2139/93.
21. Campbell JB, Busse JW, Injeyan HS. Chiropractors and vaccination: a historical perspective. Pediatrics, 2000;105(4):e43.
22. Nelson C. Why chiropractors should embrace immunization. J Chiro, 1993;30:85-88.