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Dynamic Chiropractic – January 16, 1995, Vol. 13, Issue 02

AHCPR -- It Did Not Happen By Accident

What Will We Do With It?

By Louis Sportelli, DC
I hope by now there is not a doctor of chiropractic or a member of the consuming public who has not heard about the AHCPR report on acute low back problems announced amid considerable fanfare on December 8, 1994 at a news conference in the Hubert H. Humprey Building.

The media listened intently to the findings of the panel and recognized that acute low back pain was a significant disorder affecting millions of people each day. The panel of experts concluded that fortunately many cases of low back pain will resolve within a few days and require no treatment. The media was also told that millions of dollars are spent annually on therapies that simply do not work, and expensive and often times dangerous surgeries are not required in the vast majority of instances. What does work, however, came as a surprise to many -- simple analgesics, such as aspirin and spinal manipulation were very effective in the early treatment of acute low back pain.

The media did something very unusual and equated spinal manipulation with chiropractic! They were not apprehensive about using the word chiropractic in questions asked to the panelists, in newspaper headlines, and in commentary and discussion on television.

What Happened to Bring about this Recognition?

It is time to take a few steps back and look at the overall picture and determine why what has happened. Thanks to the clear vision of a few very special people in this profession, a plan of action was conceived and coordinated to ensure implementation. I know that I will unknowingly offend some by not mentioning all the names that could be mentioned, but Alan Adams, MSEd, DC, Scott Haldeman, DC, MD, PhD, Reed Phillips, DC, PhD, and John Triano, DC, MA, deserve particular recognition.

What was suggested to the profession was the need to fund an outside independent organization to do some research on the appropriateness of spinal manipulation. It was suggested that the RAND Corporation, a California think tank, might be that research organization. Considerable questions and concern were voiced by members of the profession:

"We won't have control over the research."
"The results will be made public by RAND."
"What if the results are not good?"

"Will or can a multidisciplinary panel be objective?"

The list went on.

The Consortium for Chiropractic Research (CCR) was excited about the project and had done some preliminary groundwork. Now it was time to begin the formidable task of selling this idea to various organizations and obtaining the necessary funding for such a project.

ACA was contacted, and fortunately the house of delegates and the board of governors had the vision to see the value of the RAND project and the willingness to commit a half-million dollars to help fund it. But more was needed. The National Chiropractic Mutual Insurance Company (NCMIC) was contacted to provide the other half-million dollars. The NCMIC board also had vision and saw the potential benefit which would occur to the profession, and they provided the balance of the funding.

This was an unusual happening in chiropractic. Much to everyone's amazement, a million dollar research project was actually conceived, funded and authorized. The right people were in the right places for the right purposes and the RAND project began. The Foundation of Chiropractic Education and Research (FCER) was commissioned to shepherd the project from conception to completion. It was show time.

The RAND study preliminary findings were reported at the convention of the American Academy of Orthopedic Surgeons in Anaheim, California. The preliminary findings were reported by Paul Shekelle, MD, MPH, to the group of physicians. This was not a news event, however a reporter from the New York Times was in the audience and the first article reporting on the back pain panel's findings hit the press with the headline: "Spinal Manipulation Gains Respectability" by Elizabeth Rosenthal. The article appeared in the July 3, 1991 "Living Section" of the New York Times and carried almost a full page about back manipulation and what was presented at the orthopedic convention.

On the heels of the New York Times story, a Time magazine article, "Is There A Method to Manipulation?", subtitled, "Once Scorned As Quackery, Chiropractic Is Winning Adherents and Respect," appeared as a full-page story in the September 23, 1991 issue. The media was having a field day. Reporters were calling the ACA almost daily. Magazines, newspapers, and journals wanted to know about this news, and it soon became a full-time job just to keep up with the media. Jerry McAndrews was hired, and soon media became a large part of his workload. The credibility of the RAND Corporation and the principle investigators of the project, Robert Brook, MD, and Paul Shekelle, MD, MPH, began talking to many diverse audiences and creating a huge interest in spinal manipulation.

The RAND consensus process, which involved a unique multidisciplinary panel, was seen as the best methodology for the type of research under consideration.

Scott Haldeman, DC, MD, PhD, and a few key individuals saw the need for another major step for chiropractic. Dr. Haldeman made a suggestion to the Congress of State Chiropractic Associations (COCSA) that a consensus panel be formed; their charge would be to develop a set of practice guidelines for the chiropractic profession. About this time, everyone was getting into the guideline business. Hundreds were being developed by AMA specialty organizations and other groups who recognized the need for guidelines.

The COCSA gave Dr. Haldeman the green light and the guideline rocket was launched. More than two years later, Scott Haldeman, David Chapman-Smith, Don Petersen Jr., and a dedicated, enthusiastic, and volunteer chiropractic steering committee worked tirelessly to bring together a group to develop chiropractic guidelines by proper consensus. The finished product resulted in the now famous Mercy Guidelines. With all its controversy, this document proved to be the most powerful, scientifically valid, consensus document ever developed by the chiropractic profession and the envy of many other professions. It is interesting to note here that one of the opening speakers for the Mercy Conference was Paul Shekelle, MD, MPH, and the other was Herve' Guillain, MD, MPH, senior policy analyst for the Agency For Health Care Policy and Research.

Chiropractic was ahead of the curve. A practice guideline, which could withstand careful scrutiny and had undergone the most rigorous scientific review process unparalleled by anything undertaken by the chiropractic profession, was now completed.

The Mercy document was received by the vast majority of this profession with open arms. A small segment had cautious reservations, and a few reacted with outright disdain and rejection. Many failed to understand the fact that this document had to represent not what we wished the scientific evidence to show, but only what the evidence could support. Mercy could proudly be offered to anyone as chiropractic guidelines, developed by a proper consensus process.

A point which must not be overlooked is the fact that AHCPR knew the profession was undertaking the painstaking guideline process and Mercy was completed just in time to present the document to the scientific panel considering clinical practice guidelines for acute low back problems.

The federal government, now in the heat of health care reform and recognizing the runaway cost of health care, developed its own agency -- The Agency For Health Care Policy and Research, charged with developing evidence-based, consensus-backed guidelines for many conditions which were determined to be costly, from benign prostatic hyerplasia to acute low back problems in adults. AHCPR was taking the most costly of conditions and investigating if the procedures used to treat them were effective, efficient, and economical.

The acute low back pain guideline panel was formed. Scott Haldeman, DC, MD, PhD, and John Triano, MA, DC, were selected as chiropractic panel members. Paul Shekelle, MD, MPH, was selected as the research methodologist. Could the chiropractic profession have been any more fortunate than to have the most knowledgeable individuals, who had just recently participated in the RAND Corporation's project and the chiropractic Mercy Guidelines consensus panel, to be selected to the AHCPR acute low back pain panel?

Another point worth mentioning here is the fact that AHCPR and the chiropractic profession were extremely fortunate to have a person with the knowledge and the integrity of Stanley J. Bigos, MD, who served as the chairman of the panel. Dr. Bigos had a very difficult job, especially because he was an orthopedic surgeon. His principles would not be compromised. The AHCPR guidelines were going to state what the scientific evidence could support -- nothing more, nothing less. Imagine the pressure which might have been brought to bear on the panel and the far-reaching effects the panel's recommendations would carry. Dr. Bigos maintained true intellectual honesty and would not risk including anything which would compromise the integrity of the document.

After almost two very difficult years, the AHCPR document, Acute Low Back Pain Problems in Adults, was released and that is where this article began. Perhaps with the proper background, an appreciation of the events of the week of December 8, 1994 will be better understood that it did not happen by accident!

It was not coincidence that the press finally equated spinal manipulation with chiropractic. The press had been getting a steady stream of information for years -- from the RAND project, from the ACA, from the research community, and the spine-off publicity from the release of the Mercy Guidelines, contributed immeasurably to the identification and link between chiropractic and spinal manipulation, chiropractic and low back pain. Now a governmental agency, AHCPR, released its findings on acute low back pain. It was acknowledged that chiropractors administer 94 percent of all spinal manipulation. The most recent ACA national survey demonstrated that 88.6 percent of all conditions treated by DCs are musculoskeletal. The vast majority of chiropractors advertise in the yellow pages and newspapers about spinal manipulation (adjustments) and the treatment of musculoskeletal problems. The advertising of the chiropractors of conditions they treat has focused largely on back pain, neck pain, headaches and musculoskeletal conditions. The general public, on the other hand, has been conditioned to view chiropractors as back doctors or doctors who perform spinal manipulation as part of their procedure.

Chiropractic has had a major identity crisis. One of the large newspapers recently reporting on the AHCPR news conference stated: "Chiropractors, the Rodney Dangerfield's of the health care professions, finally getting some R-E-S-P-E-C-T!" Now is the time to capitalize on the identity crisis which the chiropractic profession has suffered from for almost a century. Chiropractors can now lay claim and ownership to spinal manipulation.

Chiropractors will have a short time to demonstrate to the medical community, managed care gatekeepers, opinion makers, insurance companies, legislators, and of course the 85 percent of the public who currently do not use chiropractic services, that we are competent, capable, effective, efficient, caring and economical providers of a nondrug, nonsurgical, health care procedure.

Chiropractic has an opportunity to establish an automatic link in the minds of the public, that when they think of low back pain, they think chiropractor. When they think manipulation, they think chiropractor. If you don't believe in mental links, finish these sentences: "I'd walk a mile --- - -----!"; "Winston tastes good ---- - -------- -----!"; "Pop Pop Fizz Fizz -- ---- - ------ -- --"; "How do you spell relief? -------." Could you finish the slogans? Most of you could, because they were made indelible by a massive, ongoing grass roots public relations program, but unlike the tobacco, drug, or cereal industry, our campaign must be funded by the chiropractic profession. I personally know it can be done, because I saw it work in the support demonstrated in 1988 with the Reader's Digest project, and I am confident we can and will do it again if presented properly and packaged correctly. Incidentally, I was told the Reader's Digest project would never be supported.

The AHCPR back pain guidelines have afforded our profession the opportunity to capture the majority of market share in the area of back pain. Imagine, 80 percent of the population will have back pain some time during the year. Many will seek help and up to now, they did not have options to consider. They sought traditional medical care and consulted chiropractic only as a last resort. With this new announcement by AHCPR, the power and influence of the federal government is literally saying spinal manipulation is good, previous treatments for back pain are no longer effective and surgery is, or could be, harmful or inappropriate.

Imagine the power of a year-long campaign with ads directly to the consumer in magazines like Parade, Reader's Digest, AARP, and a host of other consumer-oriented magazines and newspapers. If the doctors of chiropractic only cornered the market on one condition, i.e., back pain, there are not enough DCs now to handle the volume.

If consumers finally recognized chiropractic care as a necessary service and one which they did not want to be without (any more than they want to be without basic medical care), every health plan would include chiropractic services by general mandate of the consumer.

There will be those who will concentrate on the fact that this concept is restrictive and limited to the low back. They reply to that charge is a simple one. After the patient comes to the office, it is the responsibility and duty of the doctor of chiropractic to educate, educate, educate. The problem currently is the fact that the doctor of chiropractic does not have the opportunity to interact with millions of patients because they do not treat them. The confidence and education of patients will naturally follow when patient education is expanded. The marketplace will be opened to 85 percent of the population we currently do not see for the very ailment (low back pain) in which the evidence is overwhelming for spinal manipulation. Think about the possibility and the ownership of spinal manipulation by doctors of chiropractic. Think about the possibility of cornering the vast marketshare for the treatment of low back pain by doctors of chiropractic. Think about the possibility with the media recognition of chiropractic as a valid, effective, health care profession.

Having gained credibility for the treatment of one specific ailment will naturally carry that credibility to other areas. As research continues to validate chiropractic's effectiveness, the marketplace will continue to expand to other areas.

All of this is possible, and what has happened today has not been an accident, but rather orchestrated by very careful planning by a segment of this profession which was sensitive to the needs of the profession, the requirements of the research community, the demands of government, and the recognition by the media. This group had the vision to see what had to be done, and the fruits of their labor are now being realized. Nothing happens by chance and luck was not much of a factor, but the harder we work, the luckier we get.

The ACA has launched a program by which every doctor of chiropractic can and should purchase the AHCPR documents and expand the area of influence by distributing them to hundreds of thousands of individuals. The program will be launched in January. Please consider being part of the most expensive professional relations and public relations program in the history of chiropractic.

1995 will be the beginning of the centennial celebration for the chiropractic profession. What a celebration it will be if we can have a copy of the AHCPR document in the hands of every legislator, insurance company, managed care organization, medical physician, dentist, podiatrist, optometrist, psychologist, bureaucrat, and potential patient in the nation. We can do it, if we all do our share. The cost to each individual DC will be minimal, the benefits to the entire profession will be enormous. Ownership of spinal manipulation by the chiropractic profession must be clearly established, and the credibility of the profession ingrained in the minds of the public if we are to benefit from this rare opportunity.

Watch for the information on availability of the AHCPR report and how to use them, coming soon from the American Chiropractic Association in one of the mailings. This is one of the finest hours of chiropractic.

If you are interested in participating in the programs, please let the ACA know by sending your name to American Chiropractic Association, 1701 Clarendon Boulevard, Arlington, VA 22209. Your enthusiastic response will certainly prompt the ACA to recognize that there is profession-wide support for such a project.

Carpe diem!

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