for decades the gold standard usual medical care intervention in virtually all medical clinical guidelines for the treatment of low back pain was par-acetamol/acetaminophen/Tylenol. A study by Davies et al. in 2008 found that there had never been a sin-gle placebo-controlled trial showing effectiveness of this “gold standard” medical treatment.(2) Finally, after decades of being considered the gold standard, in 2017 the Chou et al. sys-tematic review for the American Col-lege of Physicians Clinical Practice guideline declared acetaminophen in-effective.(3) There had never been a shred of valid evidence for the clinical guidelines “gold standard” first line usual medical care intervention for low back pain! NSAIDS have also been ubiquitously recommended as first-line usual med-ical care treatment for uncomplicated spinal health issues for decades. The latest Cochrane Review published in 2020 concluded that, though there was evidence of small effects for (short term only) pain relief (7.29 points on the 100 point VAS scale) and small effects for functional improvement (2 points on the 24 point Roland Morris Disability Scale), that, “The magnitude of these effects is small and probably not clini-cally relevant.”(4) Muscle relaxants are also commonly prescribed. No valid evidence of clini-cally relevant benefit. Antidepressants are now commonly prescribed. No valid evidence of clinically relevant benefit. Usual medical care has also added glucocorticoid joint injections. No valid evidence of clinically relevant benefit, considered “off label,” yet, despite this, increasing in prevalence.(5) New cage fusion surgeries have also 26 Chiropractic and Naturopathic Doctor June 2020 been added– no valid evidence of ben-efit, ample evidence of harm, yet these too are increasing in prevalence and back surgeries now outnumber hip replacement surgeries.(6-10) I would be remiss not to mention Vioxx and opioids, which have also been added to usual medical care since the Manga Report. I think we are all aware of the devastating effects of these interventions. Physical therapy has added no new evidence-based interventions since 1993 (other than SMT) that I am aware of and the passive modalities consid-ered standard of care for decades are now considered guideline discordant.11 So, where does all this leave us? It leaves us exactly where Manga left us in 1993. It leaves us, I hope, with the knowledge that, with respect to uncom-plicated spinal health issues, there are no other professions, or healthcare professionals (HCPs), with a more evidence-based intervention than chi-ropractic SMT/adjustment and that the decades of claims to the contrary have been based on deliberate lies intended to monopolize cultural authority and re-imbursement, or ignorance of the literature, or both. The idea that chiropractors should seek approval from, or defer to, any other practitioner or profession for ex-pertise, evidence-based interventions, ethics regarding false claims, or safety with respect to uncomplicated spinal health issues, is scientifically absurd, illogical, and unethical. Certainly, there are many health issues for which we should refer to other HCPs. Uncompli-cated spinal health issues for patients of any age, just isn’t one of them. From pediatric to geriatric patients with un-complicated spinal health issues, chiro-practors represent the most highly For a list of references in this article, visit cndoctor.ca/unitingaroundtheevidence3 www.Cndoctor.ca sebra / Adobe Stock trained, most skilled, and most compe-tent healthcare professionals with the most evidence-based intervention. We need to hold our heads high and demand the cultural authority, the fair-ness of re-imbursement, the interpro-fessional respect, and the public recog-nition we have earned with our documented record of effectiveness, safety, cost-effectiveness, and patient satisfaction. We must unite around the irrefutable principle that all false claims are unacceptable regardless of whether they pertain to SMT/adjustment, soft-tissue techniques, taping tech-niques, modalities, “special” back exer-cise protocols, drugs, injections, or surgeries, or whether they pertain to athletes, children, the elderly, or adults, or whether they pertain to pain, func-tion, performance, chronic illness, or wellness. I hope this leaves us unified around some evidence-based pride tempered with some humility regarding the fact that, though we may be the best avail-able choice for most patients, we are by no means the perfect choice or the only choice. We just should, reasonably, as Manga concluded, and as the literature since has confirmed, be considered the best first choice for patients with un-complicated spinal health issues. Let’s once and for all unite around evidence-based interventions, respect each other’s clinical experience and judgment regarding the application of evidence-informed interventions, re-frain from all false claims, cut off both gangrenous, vitriolic arms of our pro-fession, and unite aound the ethical, patient-centric, evidence-based, chiro-practic SMT/adjustment-centric spine. In part 4 I will provide an evi-dence-based argument that in the peer-reviewed literature, including systematic reviews and clinical guide-lines, the effectiveness of chiropractic SMT/adjustment is often rated lower than it should be due to clinical trials that include very low doses of care, large gaps between active care delivery and outcome assessment, and a lack of distinction between thrust manipula-tion and mobilization.
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