Additionally, the Agency for Health Care Policy and Research (AHCPR), a federal agency created to develop clinical practice guidelines for a number of important health problems, recently turned its attention to low back pain, among other issues (such as cataracts, prostate trouble, and depression in the elderly). AHCPR has funded a Back Pain Outcomes Assessment Team (BOAT) to study and do research on diagnostics and interventions for back pain. The team has chiropractors on its advisory panel and has even funded a randomized clinical trial comparing chiropractic care and physical therapy. In a related effort, AHCPR released a clinical practice guideline that resulted from a multiyear review of the scientific and clinical literature by a multidisciplinary team of clinicians and scholars for acute low back problems in adults. This 23 member panel, under the direction of Stanley J. Bigos, MD, included two chiropractors, John J. Triano, MA, DC, and Scott Haldeman, DC, PhD, MD. The panel made a series of principle conclusions that can be essentially summarized:
- Initial assessment should focus on detection of serious pathology; testing beyond this is usually not helpful in the first four weeks following onset of low back symptoms that limit activity.
- Relief of discomfort can be accomplished most safely with nonprescription medication and/or spinal manipulation (emphasis added).
- Bed rest beyond a few days is not helpful.
- Low stress aerobic exercise can be started early to help avoid debilitation.
- Patients should be encouraged to return to work and normal daily activities as soon as possible.
- Further evaluation may be indicated if symptoms persist.
- For those with sciatica, response is slower and further evaluation can be delayed correspondingly.
- Only patients with severe pathology or verifiable debilitating nerve root compromise or sciatica can be expected to benefit from surgery (noting that 80 percent of patients with sciatica recover with or without surgery).
- Psychosocial and socioeconomic problems may also need to be addressed in assessing recovery.
These guidelines provide some support for what proponents of nonsurgical conservative management of low back activity-limiting symptoms have reported and advocated for some time. These guidelines also made headlines by recommending something which chiropractors most often perform, a couple of weeks of spinal manipulation for adults with acute low back pain. But can we construe from this report that the "US Government recommends chiropractic care" or that AHCPR has "finally validated" or "vindicated the practice of chiropractic" as so many articles and promotional pieces in chiropractic have proclaimed lately?
As someone working in a state government agency dealing with health care policy development and research on a daily basis, I get asked a lot of questions about unsubstantiated claims and misinformation regarding chiropractic care. I also read a lot of chiropractic literature and see this material regularly. From time to time I get to hear from people that have been misquoted or taken out of context by chiropractors, and I find this a little disturbing. Given these concerns, I have asked Dr. Bigos to pen a sidebar to this column regarding his perspective on appropriate use of the AHCPR guidelines by chiropractors.
Frankly, I find it a bit puzzling that some chiropractors essentially reject the Mercy conference recommendations as being too unbalanced in favor of "researchers" (100 percent of Mercy panelists were DCs and more than 85 percent were in practice), as well as too prescriptive or restrictive in its diagnostic and treatment guidelines (explicitly up to 16 weeks of care attenuated by a positive response to treatment), while at the same time embracing and loudly promoting the AHCPR guidelines as a vindication of chiropractic.
The federal guidelines do not mention chiropractic, however the patient version does use the term "adjust." In fact, the majority of studies upon which the manipulation recommendations were made were medical and physical therapy studies. Two to four weeks of manipulation (total) along with or in place of over-the-counter analgesics and nonsteroidal anti-inflammatory drugs (in the same sentence!) for relief of discomfort of acute low back pain in adults somehow just doesn't strike me as the ultimate validation of chiropractic. Even at the press conference announcing the AHCPR results, a chiropractic spokesperson used one of the "V-words" (vindication/validation) regarding what the guidelines do for chiropractic. I wonder if the profession is really ready for AHCPR to assemble an interdisciplinary panel to judge appropriate diagnostic and therapeutic management of vertebral subluxation syndrome (killer variety?) using the same rigorous explicit methodology. Where would the chiropractic profession be after that exercise?
Overexaggerations have graced many chiropractic publications about the subject. Even some chiropractic suppliers and entrepreneurs have been jumping on the bandwagon with posters and fliers for the office plagiarizing the AHCPR artwork and offering embarrassing claims about government recommendations and validation of all things chiropractic. Dr. Joe Keating has been bashing us over the head for years about the use of exaggerated and unsubstantiated claims ("It works"). We just seem to shoot at him and others who encourage accountability and go about the business of making more unsubstantiated claims.
The chiropractic profession has spent the last 50 years trying to gain acceptance into the mainstream. Licensure, accredited schools, insurance equality, inclusion in Medicare, the military, and suing the AMA for anti-trust have topped our political agendas. As a result, we are finally beginning to see some of our people get networked into the "inner circles" of government, academia, and mainstream health care. But why must some of us alienate the very people and institutions within the mainstream that have worked so hard to be unbiased and evidence-based when it comes to chiropractic issues? This only provides ammunition to the, "I told you so's," who have been unfairly beating up on us for years. And it doesn't really matter if the mistakes and exaggerations are well-intentioned.
When chiropractors use explicit consensus processes (such as with Mercy) and come up with recommendations that there is not enough scientific information to rate something as more than equivocal, some have screamed "elitist evil scientists." But when a more stringent process is used that results in even more restrictive recommendations, headlines grace chiropractic publications proclaiming "validation and vindication." Yeah, I know the general tabloid media do that sort of thing routinely. Fine, let them do that. But when I see such exaggeration in the professional chiropractic literature and trade association newsletters, and hear spokespersons for the profession trying to turn a small but valuable positive contribution to the public domain into some kind of PR windfall, I get a sinking feeling deep inside, right around the splenic flexure.
It's kind of like suddenly getting dumped by a girlfriend/boyfriend who you've accepted into your family, trusted, and defended while your real friends and colleagues were saying, "Watch out, you're just being used." Often the scientist/practitioners in our profession have been getting warned by "colleagues" (fellow scientists) to "be careful, DCs are mostly just a self-interested, financially motivated lot." But still the researchers work for the cause, defending DCs and their methods at little personal gain, and often times are chastised by their "sweetheart" (the chiropractic profession) for not taking enough of their interests into account. After all the hard work behind the scenes on their "sweetie's" behalf, attaining some meaningful progress with society (a few mildly positive research studies, working collaborations in government, managed care organizations, and universities), they take the goodies, dump the researchers, and run amok with the limited results, neglecting the importance of process and credibility in favor of some short-term promotional gimmick. That really hurts.
All right, so the jilted-romance analogy is a bit melodramatic, but I promised all my friends that I wouldn't use a sports metaphor in this column. The point is this: As we move towards greater public acceptance and are confronted with greater public scrutiny, seemingly innocent exaggerations and claims become even greater burdens for the profession than they were before. Chiropractors must learn to avoid words like "prove," "validate," and "vindicate." We must become increasingly humble by substituting words and phrases like "tends to support," "suggests," and "provides evidence for." To increase and maintain credibility, not only do we have to avoid making unsubstantiated, anecdotal claims, we must cease to run amok with an increasing number of mildly supportive and positive reports. Remember, there are bound to be some negative ones down the pike too. I'm not exaggerating when I say that exaggeration may do more harm than good in the long term.
Click here for previous articles by Robert Mootz, DC.