Editor's Note: Part 1 of this article appeared in the Oct. 15 issue.
Positive Findings in Military Low Back Pain Study
Where chiropractic care has been used in the military health services, it has been deemed very successful. A recent study led by Christine Goertz, DC, PhD, found that 73 percent of patients who received standard medical care and chiropractic care rated their pain "completely gone," "much better" or "moderately better." In comparison, only 17 percent of participants who received standard medical care only comparably rated their improvement as high.21
The Goertz study followed the DoD's Chiropractic Care Study, released in 2009 when chiropractic care was selectively introduced at a few TRICARE facilities with chiropractors as the primary spine providers (as researchers now suggest).22 The results were impressive23 across all branches of the military, with chiropractors scoring enormously high patient satisfaction rates:
- 94 percent satisfaction in the Army
- Twelve of 19 Air Force bases had 100 percent satisfaction rates
- Navy also reported satisfaction ratings at 90 percent or higher
- TRICARE outpatient satisfaction surveys rated chiropractors at 88 percent, which was 10 percent "higher than the overall satisfaction with all providers" (78 percent)
The Chiropractic Care Study also revealed praise from Unit Commanders, ADSM, and military treatment facilities (MTF) personnel concerning chiropractic care. Overall, the Chiropractic Care Study showed that MTFs consider chiropractic care a "valuable adjunct" to the care offered in the MTFs:
"Chiropractors returned ADSMs to duty faster, and they would select a chiropractor as much or more than a Doctor of Osteopathy or physical therapist."24
Despite these favorable results, the military health services have not fully implemented chiropractors on all bases and at all VA hospitals, as called for by federal law. Ironically, the military medical corps has no problem plying ADSM or vets with narcotics while deterring full access to more effective and drugless chiropractic care.
The Chiropractic Demonstration Project: Two Sides to the Story?
President Ronald Reagan initiated chiropractic inclusion in TRICARE in 1984, but its implementation was stymied for years by political medicine, whose stated goal was to "contain and eliminate chiropractic." A federal antitrust court described this conspiracy as "systematic, long-term wrongdoing, and the long-term intent to destroy a licensed profession."25
Finally, to push the DoD to take action, the National Defense Authorization Act for Fiscal Year 1995 mandated that Congress undertake a demonstration project to determine the cost-effectiveness of adding chiropractic care in the military health services.
The DoD began a three-year demonstration project (August 1995 to August 1998) at 13 military sites to care for their military personnel that became known as the Chiropractic Health Care Demonstration Program (CHCDP).
When the results were tallied, the House and Senate Armed Services Committees stated that chiropractic care in the military was "well-received," and "complemented and augmented traditional medical care."
Yet inexplicably, DoD senior management's analysis of the CHCDP Final Report (Feb. 20, 2000) came to an opposing conclusion when it reported inclusion of chiropractic care in the MHS was "feasible," but "not advisable" because of the costs associated with chiropractic care.
Upon closer examination, however, the DoD's version of the CHCDP Final Report only reported "raw costs" of $70.9 million for an unconstrained chiropractic benefit, and chose not to include any of the cost savings and offsets the CHCDP study identified.
However, the Minority CHCDP Final Report (March 3, 2000), written by the Oversight Advisory Committee headed by Reed Phillips, DC, PhD, adjusted the "raw cost" figure of $70.9 million given by DoD by using savings and cost offsets noted, but not factored into their cost estimate in the DoD CHCDP Final Report.
The report estimated that the inclusion of chiropractic care in the military health services would result in significant net savings of $25.8 million annually in "improved outcomes" and would also save 199,000 labor days. The areas of savings / cost offsets were noted as follows:
- $18.97 million: saved costs for PT care of back pain
- $6.7 million: saved costs with reduction of inpatient events with DC care
- $27.82 million: estimated value of 199,000 duty / labor days saved with DC care
- $11.33 million in estimated savings from eliminated health services of DME, home health, hospice, etc., with chiropractic care
- $31.92 million: estimated additional savings of PT substitution due to reduced ER and PCP visits, and other cost savings
Overcoming Military Barriers
Obviously the DoD's interpretation of the CHCDP Report was purposely skewed to misrepresent the findings of this three-year study. Similar interference continues to this day, despite federal laws calling for the total inclusion of doctors of chiropractic in TRICARE and the DVA. Neither military health service has fully included chiropractors, for reasons that remain speculative.
In recognition of the value of the services delivered by doctors of chiropractic, in 2000 Congress enacted into law (Public Law 106-398) a permanent chiropractic benefit within the DoD health care system for active-duty military personnel, TRICARE. Similarly, Public Law 107-135 was enacted in 2001 and provided for the availability of chiropractic care within the DVA health system.
Since the clinical outcomes, high patient satisfaction surveys, and favorable accounting at MTFs fully support the inclusion of chiropractic care, one can only assume the problem rests with the historical prejudice from political medicine against chiropractors.
This dilemma surfaced in my communication in 2010 with senior management at the DoD, S. Ward Casscells, MD, the assistant secretary of Defense Health Affairs; and Mr. Michael W. O'Bar, his deputy chief, TRICARE Policy and Operations.
In Mr. O'Bar's Dec. 6, 2010 letter to me, he explained the rationale for why chiropractic care is not fully available to all TRICARE recipients as the law calls for:
"Adding chiropractic care to the primary care model was estimated to increase the number of visits per episode of care. Ultimately, this increases the costs and delays a service member's return to duty. These constraints have limited our ability to field chiropractic care beyond the 60 locations currently providing the service."
His answer contradicts the data not only from the CHCDP Final Report, but also from two additional reports that he sent to me: the Chiropractic Care Study and the Report to Congress, Study Relating to Chiropractic Services and Benefits, Section 712, National Defense Authorization Act for FY07.
Dr. Casscells also mentioned in his cover letter of March 3, 2009 to Sen. John Murta that "a comprehensive implementation of chiropractic services and benefits as outlined in the provision would not be feasible given the budgetary requirements and the findings relative to medical readiness."26 To the contrary, the CHCDP already had showed the potential cost savings by implementing chiropractic care.
Dr. Casscells also speculated that chiropractic care "delays a service member's return to duty" and further suggested, "in the absence of chiropractic care, various comparative treatment options are available to Active Duty Service Members (ADSM), their families, and other beneficiaries of the Military Health System."
However, upon review of the DoD study, Dr. Casscells' conclusions also contradict the clinical results and the preference of patients for DCs:
"Overall, the surveys showed that MTFs consider chiropractic care a valuable adjunct to the care offered in the MTFs. Unit personnel generally consider chiropractors to return ADSMs to duty faster, and they would select a chiropractor as much or more than a Doctor of Osteopathy or physical therapist."27
Dr. Casscells incorrectly assumes that osteopathic, medical, or physical therapy is a "comparable treatment" to chiropractic care. In fact, evidence now shows chiropractic is the preferred initial non-drug treatment and that most MDs, DOs, and PTs do not have equivalent education, clinical training, or comparable outcomes to DCs in regards to musculoskeletal disorders (MSDs) and, specifically, back pain.
Dr. Scott Boden, director of the Emory Orthopedics & Spine Center, admits, "Many, if not most, primary medical care providers have little training in how to manage musculoskeletal disorders."28 Other research shows that medical primary care physicians lack training in MSDs,29 are more prone to ignore recent guidelines30 and are more likely to suggest spine surgery than surgeons themselves.31 Moreover, only 2 percent of medical PCPs refer to chiropractors despite chiropractors' superior training and results.32
As well, a federal court agreed that it is unreasonable to state that non-chiropractors are qualified to render chiropractic care. In its Dec. 13, 2005 decision, the three-judge Appeals Panel overturned the ruling of the District Court in the District of Columbia allowing MDs and DOs to provide the uniquely "chiropractic service" in Medicare.33
The appeals panel ruled the issue is whether or not a practitioner is qualified to furnish the service of manual manipulation of the spine, rather than whether or not a practitioner is simply licensed.
Another barrier in TRICARE is the subordination of chiropractors to PTs who are presently in charge of DCs, despite PTs being ranked as technicians by both the DoD and the VA. This is equivalent to sergeants being in control of officers, since PTs are therapists, whereas DCs are considered physicians.
"Just Say No"
Undoubtedly, the benefits from chiropractic care have been stymied by medical opposition in the DVA and TRICARE, which irrefutably has led to the present "pill mill" pain management crisis. This problem rests with the combination of the historical medical war against chiropractors, medical ignorance of or defiance to the new guidelines in spine care, and the prevailing prejudice against chiropractors, a bias dubbed "chirophobia."
However, the voices of change in health care are louder today – unlike before, when chiropractors initially stood alone demanding access to patients in the military health services. Since then, this voice has been joined by members of Congress, active-duty service members, as well as our veterans who need chiropractic care.
We also hear progressive voices in the medical world joining this choir, calling for a change in the management of chronic pain and MSD injuries. Dr. Jonas speaks of the need for a "cultural transformation;" Sec. Gibson believes "we must, all of us, seize this opportunity;" Mr. Schoene speaks of the "national scandal" in medical spine care;" Dr. Aldington believes "the importance of the medically 'mundane' condition of low back pain cannot be overstated;" and Dr. Cohen admits, "We must and can do better."
When the military health services want to do better, it's time for both the DVA and DoD to "Say No to Drugs" and "Say Yes to Chiropractors" who offer a nondrug and proven treatment for back pain.34
If our military personnel are to receive the best of spinal care to avoid work disability, loss of quality of life, permanent impairment, and possible addiction to painkillers (or worse – suicides and accidental deaths from opioids), it is imperative the DVA and DoD fully institute the "best practices" for our ADSMs and vets and stop with its outdated policy to limit, substitute, boycott, or subordinate chiropractors.
21. Goertz CM, et al. Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: results of a pragmatic randomized comparative effectiveness study. Spine, 15 April 2013;38(8):627–634.
22. Murphy DR. Clinical Reasoning in Spine Pain, Volume 1: Primary Management of Low Back Disorders Using the CRISP Protocols. Donald Murphy, 2013.
23. 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): p. 2.
24. 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): p. 3.
25. Associated Press: "U.S. Judge Finds Medical Group Conspired Against Chiropractors." New York Times, 1987.
26. S. Ward Casscells, MD, cover letter to John Murtha, March 3, 2009.
27. Chiropractic Care Study, Senate Report, p. 3; Op cit.
28. Boden S, et al. Emerging techniques for treatment of degenerative lumbar disc disease. Spine, 2003;28:524-525.
29. Joy EA, Van Hala S. Musculoskeletal curricula in medical education - filling in the missing pieces. Physician & Sports Med, 2004 November;32(11).
30. Bishop PB, et al. The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes), part I: 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. Presented at the annual meeting of the International Society for the Study of the Lumbar Spine, Hong Kong, 2007; presented at the annual meeting of the North American Spine Society, Austin, Texas, 2007; published in Spine, 2010 Dec;10(12):1055-64.
31. Bederman SS, Mahomed NN, Kreder HJ, et al. In the eye of the beholder: preferences of patients, family physicians, and surgeons for lumbar spinal surgery. Spine, 2010;135(1):108-115.
32. Matzkin E, Smith MD, Freccero DC, Richardson AB,.Adequacy of education in musculoskeletal medicine. J Bone Joint Surg (U.S.), 2005;87-A:310-314.
33. Devitt M. "Landmark Decision in ACA Lawsuit Against HHS." Dynamic Chiropractic, Jan. 15, 2006.
34. Bigos, et al. US Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guideline Number 14: Acute Low Back Problems in Adults, AHCPR Publication No. 95-0642, December 1994. [Op cit ref. #14 in part 1 of this article]
Dr. J.C. Smith, 1978 graduate of Life Chiropractic College, is the author of The Medical War Against Chiropractors: The Untold Story From Persecution to Vindication. Contact Dr. Smith via his website, www.chiropractorsforfairjournalism.com.