Understanding Science: Six Things An Orthopaedic Surgeon of 20 Years Experience Got Wrong

I was researching back pain treatment options in Singapore and I came across two articles written by an orthopedic surgeon. The articles were positioned to be evidence-based and authoritative. However, I realised the content was not congruent with the latest research.

This is a long, heavy read. As usual, I included many, many (in-text) references for easier fact checking.

If you are unhappy with any of this article, please do feel free to write to me.

Here is our response to the orthopaedic surgeon’s articles:

Dear Doctor,

Here are six things you got wrong.

#1: Incorrect posture and lifting causes pain

Improving your posture and lifting techniques are common strategies to help with lower back pain. In fact, even Harvard Health made the same (false) claim about bad posture and a study reported over 75% of physiotherapists perceived straight or neutral back lifting to be safer.

But what does peer-reviewed, legitimate research say?

Yes, there is an association between lifting and lower back pain but no, lifting itself doesn’t CAUSE lower back pain.

The best example to understand the difference between association and causation: Roosters crow at dawn and the sun rises soon after.

While it is true the rooster’s crow precedes sunrise, it is FALSE that the sun rises because of a rooster’s crow.

A pain-specific example would be that if you cut yourself on the finger and put your finger under running water, it will hurt. If you were to bring it away from the running water, the pain would dramatically subside.

Does that mean the running water caused your pain? No.

However, it did aggravate your pain and there’s an association (relationship) between running water and increased pain.

The most common criteria used to determine if X causes Y is Bradford Hill’s criteria of causation. The study on lifting used this criteria and the findings didn’t support a causative relationship.

The nine (or ten) criteria are:

• Strength of association – if A causes B, then having A will greatly increase the odds of B (not to be confused with dose-response)
• Consistency or reproducibility – multiple studies must be able to derive at the same findings
• Specificity – if A leads to B only, the specificity is higher than if A leads to B, C, D, E, etc
• Temporality – if A causes B, then A has to happen BEFORE B
• Dose-response or biological gradient – if A causes B, an increase of As will lead to more Bs
• Biological plausibility – must be possible based on the current knowledge body
• Coherence
• Experiment
• Analogy

Four posture and lifting techniques studies for your consideration:

Study 1: Systematic review: occupational physical activity and low back pain

This systematic review of eight systematic reviews (looking at total of 99 studies) did not find evidence to support that occupational physical activities are linked to lower back pain.

Study 2: Dose-response relationship between work-related cumulative postural exposure and low back pain

This systematic review of eight studies (a total of 7023 subjects) also found no dose-response relationship between posture at work and lower back pain. The authors further reported that the evidence for range of motion and prolonged flexed posture to be considered risk factors for lower back pain to be poor.

Study 3: Effectiveness of preventive back educational interventions for low back pain

Educational interventions including those on safe lifting, handling, or transfer strategies are not effective in preventing lower back pain.

Study 4: Prevention of Low Back Pain: A Systematic Review and Meta-analysis

Exercise on its own is effective at preventing lower back pain. However, education or back belt alone are ineffective.

There is a robust body of research that doesn’t support that bad posture or poor lifting strategies causes back pain. It’s a narrative that healthcare providers from chiropractors to surgeons seem to regularly utilise but research is saying negative back pain beliefs.

#2: There is no evidence supporting spinal adjustments

I am quite vocal about what chiropractic adjustments cannot do but that doesn’t mean spinal manipulation is NOT supported by research.

Four studies to support spinal manipulation for lower back pain:

Study 1: Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain in British Medical Journal, 2019

The study found that spinal manipulative therapy produces similar effects to recommended treatments for chronic low back pain. Some of the recommended treatments include: soft tissue therapy, joint mobilisation, conventional physiotherapy (stretching, TENS, massage), acupuncture.

In essence, spinal manipulation works as well as other typical passive therapy treatments – no better, no worse.

p.s. Out of the 9211 participants in the study, only one participant experienced a serious adverse outcome – recurrent back spasticity after a spinal manipulation.

p.p.s. The serious adverse event in concern occurred after an osteopathic manipulation delivered by an osteopath. I am not saying this to throw osteopaths under the bus but pointing out two facts: adverse events are rare and not all adverse events are “caused” by chiropractors.

Study 2: Thoracic spine manipulation for the management of mechanical neck pain in PLOS, 2019

Thoracic spine manipulation is more beneficial than standard care in the short-term.

Standard care refers to: tai chi (under exercise I believe), infrared radiation, education, stretching and strengthening exercises, joint mobilisation.

Study 3: The Impact of Spinal Manipulation on Migraine Pain and Disability, in Headache 2019

“Spinal manipulation may be an effective therapeutic technique to reduce migraine days and pain/intensity.”

Study 4: Manipulation and mobilization for treating chronic low back pain: in Spine 2018

The paper found moderate-quality evidence that manipulation and mobilisation are both likely to improve pain and function for chronic low back pain. Manipulation had a larger effect than mobilisation!

The latest research ALL supports spinal manipulation for various conditions. They are all published within a year-ish in very prestigious medical journals.

Bottom line: It’s totally unfair to dismiss spinal manipulation in its entirety. There are plenty of research supporting its efficacy in the short-term. At worst, spinal manipulation perform as well as any standard physiotherapy intervention.

Don’t be confused though – rehabilitative exercise and active care is the first choice treatment for lower back pain across multiple guidelines. There is fair evidence supporting manual therapy for short term improvement in pain and function. Current recommendations put them as second line treatment or adjunctive therapy.

#3: Use ice packs, ointments with methyl salicylate, and medicated plasters

Clinical Guideline 1: The Lancet, published 2018

No mention of icing, ointments of ANY kind, or medicated plasters. Superficial heat (i.e. actual heat. NOT the sensation of warm from tiger balm or deep heat patches, etc) made the cut though.

Clinical Guideline 2: American College of Physicians, published 2017 and endorsed by American Academy of Family Physicians in the same year

As above – no mention of ice, ointments, or medicated plasters. Heat made the cut as well. (Interestingly enough so did spinal manipulation.)

Clinical Guideline 3: National Institute for Health and Care Excellence (UK), published 2016

No mention of ice, ointments, or medicated plasters. Also, no mention of heat.

The orthopaedic surgeon mentioned traction as a treatment option as part of physiotherapy. NICE guidelines specifically recommended AGAINST traction.

I think this is a good time to clarify what orthopedic surgeons do. They take a surgical approach to treatmenting the musculoskeletal system, i.e. bones and joints. The scope of orthopaedic conditions that is covered is fairly wide-ranging from a complete hip replacement to minimally invasive knee surgery. They also work with sports injuries – traumatic rotator cuff tears, foot and ankle surgery. You get the the drift.

In this case, it’s totally fair for surgeons to not be update-to-date with conservative care options. I mean, would you rather they know if heat or ice is the right way to go or would you rather they are proficit at performing joints replacement?

For conservative, non-invasive pain managemnet for back pain, start with heat.

#4: Rest

Okay, the orthopaedic surgeon wasn’t clear on the parameters of his rest recommendation and it’s very hard to find evidence-based advice on this. So, let’s look into it a little.

First, North American Spine Society specifically recommended AGAINST rest. The official ultra-specific recommendation is to remain as active as possible. This recommendation is coherent with what Journal of American Medical Society, The Lancet are pushing for.

In Singapore, SingHealth’s recommendation for low back pain is particularly nocebic* and directly contradicts best evidence clinical guidelines. To quote them:

Rest is very crucial for patients with episodic attacks of back pain. Rest here may involve going home and lying down for a few hours, or it may be as simple as keeping the back straight and avoiding further stress to the back in the form of bending, lifting and sitting. In severe attacks, lying down for a day or two may significantly reduce the severity of the pain. If it does not, further bed-rest is not helpful.

This article was contributed by the Department of Orthopedic Surgery at Singapore General Hospital in 2018. I am sure they have a wonderful orthopaedic clinic and that they help a lot of people from orthopaedic trauma to sports medicine on a daily basis.

But to ask patients to try resting, when it doesn’t work in the first place, isn’t going to help. And of course more rest, or more of what doesn’t work, isn’t going to help.

Here’s the thing though, studies upon studies have repeatedly emphasised that keeping as active as possible is better than to rest in bed.

Why is a public health organisation dishing out advice that is not best-research compliant?

I don’t know. But it seems to be a global norm.

A study published in 2019 found that only 43% of the content from government agencies, hospitals, and health care organisations are accurate. It’s pretty scary if you think about it.

You are witnessing a research study result for yourself in real time.

Can you imagine the implication this have on chronic pain sufferers? Not only are they at risk of consuming inaccurate information, they are also more likely to be given inaccurate information by their orthopedic specialist!

*Nocebic comes from the Latin word noceo which means “I shall harm”.

#5: Medications can relieve back pain

So opioids is 100% out in both NICE (UK) North American Spine Society’s Choose Wisely recommendation.

It is true medications can help with back pain BUT only after non-pharmacological interventions like spinal manipulation. This is as per American College of Physicians’s (endorsed by American Academy of Family Physicians) recommendations.

NICE guidelines also put medication after non-pharmacologic treatment options.

When it comes to medication NSAIDS is an option but evidence supporting their efficacy is poor. In fact, poorer than spinal manipulation.

By the way, these are guideline recommendations from medical associations. They are not from chiropractic-based research institutions. If your orthopedic doctor starts telling you that chiropractic adjustment is bad for you and that you try medications instead, I highly recommend that you 1) fact check his/her recommendations, 2) ask them to provide references, and 3) get a second from an evidence-based opinion from another orthopedic specialist.

#6: Seeking a chiropractor can potentially endanger your health

I don’t really want to get into a fight on this so I’ll let the research speak for themselves.

Study 1: Association Between the Type of First Healthcare Provider and the Duration of Financial Compensation for Occupational Back Pain.

In the study of 5511 participants who received worker’s compensation, chiropractic patients experience the shortest duration of compensation while physiotherapy patients experience the longest.

Study 2: Low back pain-related beliefs and likely practice behaviours among final-year cross-discipline health students

602 students participated in the study.

This study annoys me a little because the abstract reads, “a greater proportion of chiropractic and physiotherapy students reported guideline-consistent recommendations compared with other disciplines.”

If we were to dig into the data published in the paper (behind a paywall, no less), when it comes to:

• Physical activity recommendations: 76.1% of chiropractic students are clinical guideline-consistent compared to 62% for physiotherapy students
• Work recommendations: 78.5% for chiropractic students vs. 75.3% for physiotherapy (not too bad I guess)
• Bed rest: 84.8% for chiropractic students vs. 74.5

In ALL measurements, chiropractic students fared BETTER. Take that. Also, this is a study by Western Australia Health Department. None of the authors were from an affiliated chiropractic institution or organisation.

If we compare curricula, chiropractors spent 310 hours dedicated to the management of spinal pain conditions in their chiropractic degree while physiotherapists only spent 112.5 hours. That’s less than half.

(If you need access to the full text, please email me.)

Study 3: Adherence to clinical practice guidelines among three primary contact professions

So another study looking at how clinical guideline chiropractors are. Well, 73% of chiropractors are adherent to best clinical practices, followed by physiotherapists at 62%, and finally medical practitioners at only 52%.

Bottom line: When it comes to spinal pain and back pain, chiropractors do what they do best. If you are asking who is the best person to see for back pain, data says chiropractors.

So these are the six things you got wrong. There are other minor inaccuracies in your articles but we will leave this as is. It is a heavy topic and I think this is a long enough read.

Personal Thoughts:

#1 I assume the orthopaedic surgeon mentioned his 20 years of experience for the purpose of establishing authority

The problem? Research shows clinical outcomes negatively correlate with years of experience. This means doctors with MORE experience actually deliver WORSE quality care. I think this is a good case in point. While he may be excellent with his surgical techniques, he is out of touch with his clinical advice.

#2 The author claim to be objective yet he repeatedly committed fallacies

Examples include

• Appeal to popularity, appeal to authority: No medical doctor sees a chiropractor or refers patients to one.Even if this was true, that doesn’t mean chiropractors are not good at their jobs!
• Reduce to absurdity: No medical doctor sees a chiropractor or refers patients to one.(Truth is I did have SMC-registered medical doctors as patients. I have since discharged them. I put this in parenthesis because social proof is irrelevant!)
• More appeal to popularity: Many readers who have see chiropractors in Singapore agree …
• More appeal to authority: I am a surgeon for 20 years
• Straw man: There is no research for chiropractic adjustments. Therefore, it is not regulated by the Ministry of HealthHe didn’t provide any references to both claims. Furthermore, there is research supporting chiropractic adjustments. As to why it is not regulated by the Ministry of Health, only they can answer it.
• More straw man: You feel better after a chiropractic adjustment. The effects are temporarily and is purely due to a placebo effect.Just because it’s temporary doesn’t mean it’s from a placebo effect. No references were provided to support this claim.

#3 His word count of his original article is 1979 words and he only cited two papers

I didn’t actually count how many words. He provided those numbers so I assumed they are true. But regardless, that’s a lot of words from just two papers.

The worst part? Out of the papers is an actual study (systematic review), which is great. The other paper is a the clinical guideline developed from that study. In short, only one data set/source.

#4 Final thought: The healthcare industry is wretched

While orthopaedic surgeon, chiropractors, physiotherapists – you name it – are claiming to be BOTH evidence-based and promoting best clinical care, few actually support their claims with data.

It is true the chiropractic industry in Singapore is unregulated and it does, in turn, allow poor clinical practices. Not regulated = no consequence = chiropractors can almost do whatever they want.

The ones who suffer the most are the patients.

Whose fault is it to not regulate the chiropractic profession?

Whose responsible is it to safeguard the health of Singaporeans?

The problem is not always in the profession. It is the people.

Patients have a tenancy to ask who they should see – the specialist, physiotherapist, chiropractor, or osteopath? For all intents and purposes, when it comes to non-specific low back pain, that is the WRONG question.The comparison shouldn’t be across professions but instead you should critique each individual healthcare professional.

A good orthopaedic surgeon will refer you on to appropriate conservative care and, likewise, a good chiropractor will refer you on to specialist care if indicated. This is as per clinical guideline recommendations!

The truth is this particular surgeon is one out of the hundreds, if not thousands, orthopaedic surgeons in Singapore. His bias, logical fallacies, and vendetta against chiropractors are of his own. They are not representative of the quality, attitudes and beliefs of all medical practitioners in Singapore.

While the intent of his article is not clear, it is at best mediocre. The article failed to educate or advise to the best interest of the readers. Despite claiming to be objective and evidence based, his bias against chiropractors is clear and, on most occasions, fallacious. His recommendations were also not all evidence-based.

In my personal opinion, this best exemplify the healthcare provider you should avoid.

Five take away lessons:

1. Years of experience doesn’t translate to better clinical outcomes OR better knowledge of best evidence practice.
2. It is possible for orthopaedic surgeons to give advice that are NOT evidence based.
3. Orthopaedic surgeons are not necessarily better evidence-informed than chiropractors. Research supports chiropractors being the most evidence-informed when it comes to low back pain.
4. You cannot take anyone’s words for it as it is. Always ask for the research. The onus is on them to provide the references.
5. We can do so, so much better in Singapore. For both healthcare providers, in our responsibility to creating high value, evidence based content, and also patients to be discerning to the content we consume and share.

“In God we trust, all others must bring data.”

I imagine some of you might be offended by the materials presented here. If I am wrong or if you know of any studies that that would contradict what I wrote, please do reach out to me at jesse@chiropractor-singapore.com.sg. Kindly provide adequate supporting references. I will review the evidence and make the necessary correction(s) within 72 hours.

If you are offended but cannot support your position with any research, I do not apologise. I implore you to reflect on your emotional response and to evaluate if your preconceived notions, attitudes, and/or beliefs are fallacious in nature.If you like to discuss any of the materials in good faith, I will be happy to. Please do reach out to me at jesse@chiropractor-singapore.com.sg.

Epilogue: There were some concerns that my public rebuttal would backfire. I do not know if this will happen. Nonetheless, I believe this to be the difficult conversations we should be having in order to develop a forward thinking healthcare community.

Gone are the days of “I am the doctor therefore I am right.” There is plenty of discussion about patient-centred care and shared decision making. It is my opinion that this can only happen if we, every stakeholder – chiropractor, physiotherapist, orthopaedic surgeons, and even patients – in the healthcare industry, are willing to engage in evidence-based education and advice.

Inter-professional rivalry, personal biases, and logical fallacies have no place, absolutely no place in best clinical practice.