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Dynamic Chiropractic – February 11, 1994, Vol. 12, Issue 04

Getting Around to RAND

By Arthur Croft, DC, MS, MPH, FACO
We should all be concerned now about the slow, silent hemorrhage that threatens our very existence. Most alarming is the fact that our wounds are largely self-inflicted -- brought about by greed, avarice, and apathy. Sure, we've all heard that song before so I'll skip the part about greed and avarice. But please read on.

Not long ago I read a disturbing diatribe, written in another chiropractic tabloid, criticizing the RAND report on spinal manipulation. The author felt somehow betrayed by the RAND report because it failed to specifically vindicate and validate chiropractic. But it really did! The authors of the RAND report studied, by meta-analysis, a number of reports concerning spinal manipulation for acute low back pain. Not surprisingly, most of the manipulation was delivered by MDs, DOs or RPTs since most of the studies came from medical institutions. The RAND report could not draw any conclusions about chiropractic manipulation, sciatica or chronic low back pain simply because the studies they analyzed, for the most part, did not use chiropractic methods. Moreover, these studies all looked only at uncomplicated, acute low back pain. But it takes no great dialectic to discern the importance of the RAND report for chiropractic. Who better than chiropractors can manipulate the human spine? These others are trivial and can be resolved with ongoing research.

Meanwhile, RAND has been one of the most respected think tanks in this country for the last 50 years. RAND is independent and therefore their findings and opinions are unfettered by suspicions of ulterior motive or hidden agenda. And, most importantly, when RAND speaks, people in high places listen. In fact, the recent report on spinal manipulation was instrumental in keeping this profession in the bidding regarding health care reform. It came at a most opportune time for us. Let me say that another way. We got a lot of mileage out of the RAND report.

Vituperative commentaries, such as the one I mentioned, reflect an unfortunate paranoia which is engendered by an ignorance of the way science proceeds and fueled by a surprising lack of insight. At a time when chiropractors, orthopaedic surgeons and neurosurgeons alike are being asked for proof (in the form of randomized, controlled trials) that their methods are safe and efficacious, we can hardly turn our back on such a gold mine of opportunity as a RAND study suggesting that spinal manipulation is effective. To do so would be to shoot ourselves in both feet.

By now I expect some of you are saying, "Gee, it's too bad some of us just don't get it. Oh well, they're only a minority." Guess again. In the latest RAND effort, they randomly selected a group of DCs and asked for their cooperation. The commitment from the DCs would require only 20 minutes of their time and space in a quiet corner of the office for a RAND researcher for one day. As we've discussed (in my last five columns in DC which were devoted to research issues) the strength of such a study depends on numbers. When most of the randomly selected doctors participate, for example, we can reasonably expect that they are representative of all chiropractors and therefore, our conclusions about our findings will be reliable and well founded. Conversely, if only a small percentage of the doctors participate, the strength of the study dwindles. In fact, at less than about 70 percent participation, most reputable journals would refuse to publish the results because of the weakness of the study.

Now take a look at how we chiropractors in Southern California participated this year. In San Diego, RAND gained the cooperation of 68 percent of the doctors selected. Good but not great. In Los Angeles, in a second study on chiropractic adherence, the chiropractic participation was a dismal 29 percent. Not exactly what we would term esprit de corps. We truly seem to be living in the Golden Age of Apathy. But the good news is that RAND is coming to your state soon. You may be one of the hundred or so doctors randomly selected to participate in the new utilization study. Your participation is crucial, so please do volunteer a few moments of your time to help in the growth and advancement of your profession. And, if you are a local society or association director or a chiropractic educator, I urge you to pass on this message to other chiropractors you know. It really is terribly important. Let's all shoot for a new high water mark in chiropractic rather than down at the shoes on our feet. We all have time to get around to RAND.

Arthur C. Croft, DC, MS, FACO
Coronado, California

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