Daniel: Welcome to The Future Adjustment: Chiropractic Economics Podcast Series on what’s new and notable in the world of chiropractic. I’m Dan Sosnoski, the Editor-in-Chief of Chiropractic Economics. And our guests today hardly need an introduction.
They are two of the most famous names in chiropractic. First, let me welcome Dr. Arlan Fuhr, inventor of the Activator Adjusting Instrument and President of Activator International. We’re also pleased to welcome Dr. James Cox, the creator of the Cox Technic. Dr. Fuhr, welcome to our show.
I understand that you’ve known Jim Cox for more than 30 years. – [Dr. Fuhr] About 40 now, I believe.
– Okay. Is it true that he was one of your inspirations in becoming an evidence-based chiropractor?
– Yeah. He probably doesn’t remember this. But it was at a seminar several years ago. And he got up and did a presentation, doing articles from the literature. And I was sitting in the room, and I said to myself, “Oh my gosh, we’re behind. We have to get going here because Jim has got the right idea in putting out his material in an evidence-based style.”
So he was an inspiration to me.
– Yes. We’ve seen that the whole industry is heading in that direction but we still do need, you know, leaders such as yourselves to, you know, really kind of blaze the trail and show other people, you know, how vital and important it is to work with the science on your side. I know, Dr. Fuhr, you’ve referred to yourself a number of times as being an evidence-based vitalist. Can you explain that in a little more detail?
– Yes. I wrote an article here in Karwika, as a matter of fact, to the students talking about vitalism versus mechanism. And I made it clear that when I started the article that I was an evidence-based vitalist. And what I mean by that is I have a saying that the data always wins.
And that goes no matter if you’re in a court situation, or if you’re in a research setting, or if you’re in a government meeting, or if you’re before a Board of Examiners. The data will always carry you and win the day. And so, that’s what I meant by being an evidence-based vitalist.
– Absolutely. Very good. Well, Dr. Cox, welcome to our show. Looking at spine care today, could you give us your assessment of the status of spinal manipulation? – [Dr. Cox] Thank you. Yes. If you go back in chiropractic 50 years ago, we did not see the research, the clinical evidence-based outcomes that we have today. Who would have dreamt 50 years ago that you can see the Journal of the American Medical Association, the American Pain Society, the American College of Physicians, Harvard Medical School, and others say that the first line of care for back pain is spinal manipulation and chiropractic.
Now, that’s based upon research and clinical evidence out base studies. If it wasn’t for that, we wouldn’t see, for instance, VA hospitals having chiropractors on staff. We wouldn’t see all of the hospitals today having chiropractors serve as the primary care doctor seen my back pain patients who then direct and triage the treatment of that patient.
So, I see that chiropractic has a tremendous future that we didn’t appreciate 50 years ago, namely that if we are seeing and depending on who you quote, we’re seeing anywhere from 8.6% of the public to a third of the public.
Well, just imagine what will happen when the public learns of what we can do in chiropractic. In the treatment of the most expensive ailment, the second most common ailment, the people who go to a doctor for spine and radicular pain. So the future of chiropractic is great, though the big problem we have is dissemination of true literature outcomes that is that the public…remember, sometimes they say it takes 17 years for a new concept to filter down the common knowledge.
And so we have education to do, and I think that’s taking place. So I think that the future of chiropractic is very, very bright.
– It definitely is. And in addition to the studies and trends that you just referred to in terms of the college of physicians and other MD groups are now issuing guidelines about back pain management and urging the conservative approach dispersed.
The congress has passed and enacted into law something called the Care for our Heroes Act, which effectively authorizes DCs to provide upper tier testing in the VA system where they could not do that before. And as you know, a lot of MDs get their training and residency in the VA system.
And we anticipate that as they see chiropractors working as co-equal colleagues side by side, that’s going to have a very good trend towards MD to DC referrals. It’s still important.
– Well, that’s true. That’s true. But think about this. We say that chiropractic is first-line care of spine and radicular component. But think about this. It is, today, last-line care. If you think of the number of spine surgeries done, and look at some of the papers that 50%of the people will have the same or worse pain afterward, it’s only after that chiropractic becomes involved.
And there are studies done that we showed that 70% of people had well over 50% relief in postsurgical continued pain patients. So, these facts will not only take care of people with then back surgery, they will stimulate people to have a stronger chiropractic component before the surgery.
– That’s true.
– Yeah. This is what I was alluding to. Before, that data always wins. I’m a fully credentialed VA physician. I started the chiropractic service in the Phoenix VA. And, you know, the problems that the VA hospital been having, chiropractic wasn’t one of them. We have a three-month waiting list for our service in the VA and we had people there that had been through every medical procedure.
And when we came there, we were looked upon very, very… where people were hands-off. After we were there for six months, the head of orthopedics came up to me and said, “Boy, we’re glad you guys are here because we are sending the stuff that we can’t help you.” And I said, “So where you’re dumping grounds?” And they said, “You might say that.” And I said, “Well, let me ask you a question. How are they doing?”
He said, “Well, that’s a surprising part. They’re getting better.” I just did a paper…What you just said, Arlan, is so true. Just this morning in my PubMed search, I got a paper and Bart Green’s on the paper, pointing out that they did a study of women in the military with neck pain. How pleased they were, how successful they were.
And I think it was only in two visits going to chiropractors in the VA system. So we’re making a mark and that willl continue to grow.
– Yeah. And also, while we’re on this topic, Dr. Cox, the Cox Technique seems to involve manipulation, physical hands-on adjustment and manipulation in conjunction with the table offering of flexion distraction.
You know what, flexion distraction has been kind of a cyclic item in the chiropractic field. Where do we stand today with that modality?
– I started this technique in 1964. And the reasons for its institution was I never ever intended to be in research or in the lecture circuit. I graduated from National College in ’63, I wanted to go back to Fort Wayne and live a very quiet life.
But it happened that I had a patient who I gave a lumbar roll to. And I found out that I’m not the only one this has happened to. They gave the lumbar roll and the girl went to surgery the next day. And I said, “There’s got to be a better way.” And my stepfather who was a DCDO said, “Son, you may well be in way of learn.”
And so I studied osteopathy and chiropractic. And I put together the two systems of spinal manipulation. And in the last few decades, this has grown to the point that all schools, but one, teaching in some fashion, the New Keiser University, which is the first university in the United States that I know of that now has its school of chiropractic, are using my work.
They have two of our certified doctors teaching the technique there, and it is growing. We’re having certified doctors, and national are now using it, Palmer are looking to make it core curriculum. So, to answer your question, the acceptance has been great. And then the question is why.
Why? Well, and the answer to that is that every patient cannot tolerate high-velocity, low amplitude trust. Now, when you look at the age of people and we are dealing today with spinal stenosis and people over 50 has probably, in my opinion, the greatest challenge to chiropractic today.
That is spinal stenosis with or without degenerative scoliosis. These people can’t tolerate high-velocity adjusting. So to me, it’s up to the chiropractic profession to consistently be supervising and improvement the quality of spinal manipulation because, let’s face it, the public expect us to be the conservative care of spine pain.
So we consistently learn. Now, Arlan has a technique, which is certainly not high-velocity, mine is. Certainly, there are many other techniques that don’t involve high-velocity technique. And let’s face it, there are conditions like advanced degenerative disc disease, spinal stenosis, ankylosing spondylitis. They can’t tolerate that.
So it’s up to our profession to serve the public and develop these new techniques. That’s why I develop my technique because it works, it gets cavitation when nothing else work off times. And now, today, we see that that technique is really gaining a foothold and making a very strong footprint in chiropractic manipulation based upon the fact, like it or not, that you see physical therapists using it consistently as writing papers on it today.
– Yeah. And to look at it from the other side as well, one problem that chiropractors face is the high-amplitude. Thrusts can lead to repetitive motion injuries and truncate an, otherwise, promising career and Activator Method and Cox technique both I think offer DCs a way to practice a lot longer themselves because it’s gentler around the spine.
– Yeah. I think Jim is right about this. What we’re serving right now a huge geriatric population. And in Activator, we did a study and it’s coming out of the University of Madrid in Spain on osteoporosis. Is it safe to adjust osteoporotic patients? Well, once in a while in research, you get lucky.
And the researchers, they are found not only was it safe to adjust something with osteoporosis, but also we can regenerate osteoporosis, the trabeculum in the actual bones. And so, think about that. And I’ve seen it clinically, but didn’t understand it that we’d have somebody come in that was elderly person on a walker. And three months later, they’d be walking on their own.
Now, we’re finding out that we actually have bone growth taking place. And that’s a big thing because of that geriatric population. The other thing is we just had another webinar here the other night. And NCMIC, the largest, you know, company that when chair chiropractors said the number one thing that they have for a complaint is a cervical adjustment.
They said that’s where they pay the most money. Well, in Activator, we keep them in a neutral position, we don’t turn their head, and we just don’t have that problem. So what I think we’re doing in these techniques is adapting so the patient is the beneficiary.
– Very good.
– No, that’s absolutely right. If we don’t adapt spinal manipulation, somebody else will. In the chiropractic profession, the public think of us we are branded, good branded as spinal conservative non-surgical treatment. We must build on that as a profession, and we will only increase in our patient loads, our clinical outcome studies, and the success of the chiropractic profession.
And Arlan mentioned osteoporosis. Well, I’ll tell you, you don’t thrust on these osteoporotic people, and many of them have fractures, whether detected or not, and you have to have some alternative form of spinal manipulation to treat them. And that’s what Arlan is talking about, that’s what I’m talking about. We’ll even demonstrate it this week in our conference here in Hawaii.
It’s a tough detail. We’re here in Hawaii doing this. But we’ll demonstrate the treatment of fractures, and osteoporosis, and conditions that there’s no way that you can deliver high-velocity for us, too.
– Well, hey, since you bring it up, yeah, you’re both speaking with me from the island of Mali, I believe. And you’re going to hold a joint seminar tomorrow. Can you give us a quick overview of what you’re planning on talking about?
– Well, I can start. We’ve got a mixed group here. We’ve got Cox people and Activator people. And I mentioned to Jim that the last time I remember a couple of technique developers getting together was when I was invited as a kid, you go to Japan with Klay Thompson. And it was Gonstead, Thompson, and DJ Arnett.
I mean, that was the major force in chiropractic. And so, here was Activator, but I was just a beginner. But I learned from those guys many things in what they thought and what they did. And what Jim said before, how far we’ve advanced. Activator has over 150 peer-reviewed papers, 26 clinical trials. And somebody said, “Well, that’s not hard.”
They said, “No, it only took us 30 years to get 26 clinical trials.” Those things take time too.
– Yeah, they do. Go ahead.
– Yeah. We’ll have a joint seminar. And Arlan mentioned some major [inaudible] and Klay Thompson, I knew, I’m so old. I knew both of these gentlemen. I’ve learned from them so much in my life time and respected them.
And today, we’re doing a combined technique. And I suppose many people are shocked to death. I’m not shocked by it. How else are we going to advance if we don’t share ideas, you know? I think it’s great.
– Yeah. The attendees, there are definitely in for a treat. And I’m sure they’re going to be talking about this later on in their careers. But how lucky they were to hear you both talk. And Dr.Cox, you said that competition in the medical world of spine care demands expertise. What is this competition?
And how do DCs best compete with it?
– Look at this fact to begin with. Of all the people who have spine or radicular pain, arm and leg pain, 1% of them really go to surgery, about 2% to 3%.
That means that over 95% of these people are wanting non-surgical, the best conservative care. That’s the chiropractic contribution. We will build on that to continually increasing our clinical outcome studies. Now, you talked about competition.
You rest assured there’s competition in treating spine pain because depending upon who you talk about, I remember Stol Persnot [SP], Senior Analyst with Liberty Mutual Insurance, Tony said, “Can low back pain cost more than the national debt?” Well, it’s not nice to say, but you’ve got both pain and expense, and back pain.
And so the agencies, the insurance companies, the third-party payers, the Federal Government are going to be interested in how do we get the best bang for a buck. And chiropractic stands at the threshold of answering that question. And that’s why the research is important.
Arlan mentioned the research papers. In my, staff I’ve been very happy and I never dreamt that I would see today the federally funded research that we see in our profession. In 1992, the Federal Government said they would fund chiropractic research as long as it’s done in combination with a medical and osteopathic school.
And at that time, Dr. Ram Gudavalli came to national, and John Triano was the head of research at the time, and we were doing my work there. Well, Ram came from University of Cincinnati International, we applied and got one of the first three grants from the Federal Government.
And very interestingly, to carry your question just one step further, the first thing that Shannon Mulroney from…and Bill Clinton was President then, and Donna Shalala was the head of HHS. You know what? The first question….yeah. The first thing they said to us was, “We want you to show us what happens when you do this spinal manipulation.”
We were all taken aback by that, but they wanted to see what happens in the human spine when you manipulate. And so, our first study done from 1994 to 1997 was a funded health resources and services administration from the Department of HHS study to show that. And we found that five things happen when we use Cox Technique in treating spine pain.
That led to another study because the Federal Government said, interestingly, they said, “We wanted to do a study comparing this form of manipulation to medical care for chronic low back pain,” which is the most expensive ailment treated between 20 and 50 in this country today. And so, we did that and our clinical results were about 250% better than exercise and physical therapy in treating radicular patients.
That led to a third study on cervical spine. And these have all been published papers in refereed journals like European Spine Journal, Trials, all published papers. And for me, that’s what our profession needs. Arlan mentioned the papers he did.
I’ve mentioned the papers we’ve done. This is what the world of medicine reads. That’s who the Norse, the KNO are going to look to, to lead and pay for spinal manipulation.
– All right. Well, very good. Dr. Fuhr and Dr. Cox, I want to thank you so much for spending this time with us today. You’ve brought up some excellent points reflecting your long careers in the field.
And you’ve given us an evidence-based perspective on the future adjustment. I’m Dan Sosnoski, we’ll see you next time.