A new research report from the Agency for Health Care Policy and Research on the status of the chiropractic profession objectively reviewed practically everything about our profession: from history and philosophy to education, supply, utilization, insurance coverage, role in the health care system, research issues and policy considerations. It reviewed both good and bad, but mostly just reported the state of affairs our profession finds itself in. This comprehensive report funded by AHCPR indicates how far the profession has come and identifies major issues the profession must still grapple with internally (e.g., educational training, professional identity -- musculoskeletal vs. primary care, research prioritization). It also emphasizes how mainstream the profession has become and how policymakers outside the profession need to address our roles and contributions in the same way they do everybody else's (official potential bias disclaimer: I helped edit the report and contributed to several sections).
One report that has been getting a lot of play on chiropractic eþmail and chat groups is a RAND study by Shekelle and others in the Annals of Internal Medicine. It was a well-done study that went to chiropractic offices in six geographic sites around North America and extracted data from patient charts.
The aim of this study was to compare diagnostic findings in DCs' clinical documentation on low-back pain patients who underwent high-velocity manipulation and compare that to the appropriateness criteria RAND's multidisciplinary evidence and consensus-based low panel came up with many years ago. They found that your ordinary everyday practicing chiropractor applied high velocity manipulation in line with the lofty experts' appropriateness criteria 46 percent of the time and not in line with them 29 percent of the time. The rest were uncertain due to record keeping details or the LBP expert panel's inability to categorize a given set of clinical indications as appropriate or inappropriate.
The paper's conclusions (I paraphrase): The mere mortal DC's documented practices on initiating SMT match up with hard-nosed, pointy-headed, skeptical experts' opinions as often as the mere mortal MD's practices do for typical medical procedures. In other words, practicing DCs are as trustworthy with a patient's health as MDs. The report essentially concluded that DCs deserve more respect from MDs than they get. The study prompted an editorial in the same issue by Marc Micozzi of the College of Physicians calling for support of training, research and clinical protocols for complementary medicine on a par with support that his existed for mainstream medicine.
Another editorial from some Dutch manual medicine practitioners and researchers appeared in the British Medical Journal. It strongly opined that we don't know if chiropractic does more good than harm based on the existing research. They point out that most of the manipulation research trials didn't even include chiropractors, and reiterated the sorry state of the design and limitations of the research on manipulation. They also point how poorly side-effects have been studied and emphasize there are risks to manipulation, especially in the cervical spine. The conclusion: "On the basis of current evidence, it seems uncertain whether chiropractic does more good than harm. More and better research is required." Unlike the Shekelle article, the authors of this editorial did not attempt to point out how this state of affairs compares with common medical practices. (It's much the same for most medical and PT services.)
The chiropractic reaction in some places seems to be, "Those biased, condescending MDs are offering backhanded compliments as they insult us by accusing us of not even providing manipulation appropriately half the time." Some fear medicolegal implications that DCs can't manipulate appropriately. Some of us hang our heads in disgust and tout the more things change, the more they stay the same; that medicine is out to eliminate and/or absorb us.
However, all of these publications have a couple of major things in common. They clearly indicate that scientists, clinicians and social opinion leaders outside the profession are taking us very seriously. They all report data and/or state facts that lead to objective conclusions about the state of affairs in chiropractic. No, they don't read like a press release from one of our trade associations, but the implications are "give DCs respect" and "let's rally resources" for more study, better training and more and more research. Yes, they all identify areas for improvement like our education, emphasis on the need to study frequency and duration of care more, and imply how important our individual patient documentation is. And all of these reports (except the BMJ editorial) had chiropractic co-authors reflecting the by-products of the hard-working chiropractic research enterprise of the past two decades.
There was an Internet posting from a DC who was discouraged after reading the Shekelle article. He was befuddled. A patient had come in after reading a press account of the study lauding that the medical profession is saying chiropractors are as good as MDs! The reaction from an interdisciplinary crowd of folks I work with was that DCs have a lot to be proud of, funding research to examine how actual practice compares with the evidence -- a sign of taking responsibility for self-policing and quality improvement.
What many DCs may not appreciate about this kind of "buzz" in the non-chiropractic literature is that it is exactly the same kind of "buzz" that goes on every day in the medical literature about medical procedures! It is objective; it is critical; and it touts, "Learn more, research more, use evidence to help improve practice."
The point to be made here is that there is no kind of antiþchiropractic bias or conspiracy going on. It is hardcore, solid evidence of a leveling of the playing field:
- The medical, government and "social" experts on things chiropractic now include chiropractors.
- Chiropractors are as responsible in selecting their patients for care as medical providers.
- Support like that available for mainstream medicine needs to be made available for chiropractic education and research.
This is big news indeed. An Internet posting from John Triano said it best: The glass ceiling hasn't fallen, but it's getting more porous. Smile, everybody.
Cherkin DC, Mootz RD. Chiropractic in the United States: Training, Practice and Research. AHCPR Publication 98-002. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December, 1997.
Ernst E, Assendelft WJ. Chiropractic for low back pain -- we don't know whether it does more good than harm. BMJ 1998;317:160.
Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG. Use of chiropractic services from 1985-1991 in the United States and Canada. Am J Public Health 1998;88(5):771-776.
Micozzi MS. Complimentary care: when is it appropriate? Who will provide it? Ann Intern Med 1998;129(1):65-66.
Shekelle PG, Coulter ID, Hurwitz EL, et al. Congruence between decisions to initiate chiropractic spinal manipulation for low back pain and appropriateness criteria in North America. Ann Intern Med 1998;129(1):9-17.
Robert D. Mootz, DC
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