Two factors make this article especially harmful, the credibility of Consumer Reports in the minds of the public and the fact that readers save copies of the publication for future reference. What this means to members of the chiropractic profession is that they have been condemned by a power that is above reproach and it won't go away when next month's issue comes out.
The charges levied against chiropractic in this unbalanced piece cannot go unchallenged, and doctors of chiropractic must be armed with answers to the questions that will inevitably arise. A number of major fallacies emerge in the article. The Foundation for Chiropractic Education and Research (FCER) offers this point by point response to allegations taken directly from the text of Consumer Reports.
Chiropractors have already seen their fortunes rise in recent years with some important political and scientific victories.
This would come as a surprise to the average chiropractor who earns a net annual income of $74,000, according to recent statistics compiled by the U.S. Department of Labor, Bureau of Labor Statistics. This is in comparison to MDs who netted $155,800 annually. The fact is that when compared to other health care professionals, doctors of chiropractic earn a comfortable living, however, they can hardly be accused of "being in it for the money."
Consumer Reports cites Wilk et al. vs. AMA as a political victory won by chiropractic. Indeed, this famous antitrust case forged the way for chiropractic legitimacy in the eyes of many, but it is not the only victory earned by chiropractic. In Florida and New Jersey, doctors of chiropractic are accorded primary care status, the U.S. military has cleared the way to award commissions to doctors of chiropractic, and chiropractic is reimbursed by Medicare and Medicaid. Surely, the federal court system, state legislation, the U.S. military, and the federal government were not bullied into these positions by a zealous group of chiropractors. Quite simply, they saw merit in the chiropractic profession and the kind and quality of health care that it delivers.
On the scientific front, the RAND study, which was partially funded by the American Chiropractic Association (ACA), is just the tip of the iceberg. Such prestigious and credible journals as the British Medical Journal, the Journal of Occupational Medicine, the Western Journal of Medicine, the Journal of American Health Policy, the Journal of Manipulative and Physiological Therapeutics, and the Journal of Family Practice, have published articles supporting the use of spinal manipulation and chiropractic. These journals are listed in the Index Medicus and consulted by the entire medical community.
The caliber of those who are conducting chiropractic research is beyond reproach. In addition to the research that has been carried out at chiropractic colleges, representatives of the College of William and Mary, the Medical College of Virginia, the University of Richmond, Royal Melbourne Institute of Technology in Australia, the University of Alberta, the University of Limberg in the Netherlands, and the Center for Studies in Health Policy, Inc., have entered into the arena of chiropractic research, with positive results.
[Chiropractors are] Barred in most states from prescribing drug or performing surgery.
This statement shows basic ignorance of chiropractic philosophy. Chiropractors do not prescribe drugs or perform surgery by choice, not due to state legislation. Since 1895, the chiropractic profession has been dedicated to a drugless, non-invasive alternative to traditional medical care. In the spirit of free choice and competition, chiropractic provides a vital service.
... many experts have criticized the Manga Report for drawing conclusion that go beyond the available data.It is to be expected that any report with as far-reaching ramifications as the Manga report, which recommends that chiropractic should be the treatment of choice of low back pain to the exclusion of medical care, might be the target of criticism. While the approach of the RAND Corporation was conservative in the extreme in their well-known study on low back pain, Pran Manga, PhD, author of the Manga report took a more universal approach.
In order to uncover any inherent flaws in the Manga report, Richard E. Wagner, PhD, chair of the economics department of George Mason University, reviewed this important document at the request of FCER. In his soon-to-published analysis, Dr. Wagner concluded, "I would have little hesitation in using 'overwhelming' if the case being made is the foolhardy character of failures to give chiropractic claims equal standing with physician claims with respect to the treatment of lower back pain. All knowledge is necessarily incomplete, and one can never go wrong in calling for further research."
He also stated, "... on the value of chiropractic care for lower back pain, the Manga report offers a loud voice in affirmation of the chiropractic claims, and at a decibel level that might perhaps be only slightly higher than the extant evidence truly warrants."
Some chiropractors would like to see the profession limit itself to musculoskeletal problems unless and until there's convincing evidence that chiropractic techniques are safe and effective for other problems. But they are in the minority.
It has been said many times that the chiropractic profession is held to different standards than the medical profession. Consider the frequently quoted observation of David M. Eddy, MD, PhD, professor of health policy and management at Duke University, North Carolina, that only 15 percent of all medical interventions are supported by scientific evidence. Held to the same standards espoused in Consumer Reports, 85 percent of all medical interventions that are now being used would be halted. This is an unrealistic and unfair expectation.
This double standard is clearly illustrated by James P. Carter, MD, DrPH, in the introduction to his hard-hitting book, Racketeering in Medicine: The Suppression of Alternatives. Dr. Carter charges that while the medical profession was quick to embrace heart bypass surgery and balloon angioplasty, neither have been "proven" by double-blind, placebo-controlled studies. This, he says, does not in itself negate the benefits of either procedure or their contributions to patients' quality of life.
Dr. Carter also states, "American medicine has also isolated and quarantined new ideas and treatment which have arisen in this country, especially when they have been contrary to the prevailing point of view or when the discoverer was unpopular or did not have the right credentials."
In a recent issue of the British Medical Journal, Douglas G. Altman, head of the medical statistic laboratory of the Imperial Cancer Research Fund made this unsettling statement, "When I tell friends outside medicine that many papers published in medical journals are misleading because of methodological weaknesses they are rightly shocked. Huge sums of money are spent annually on research that is seriously flawed through the use of inappropriate designs, unrepresentative samples, small samples, incorrect methods of analysis, and faulty interpretation."
Critics point out that chiropractors simply don't have the training to function as "family doctors."
Meredith Gonyea, PhD, of the Center for Studies in Health Policy, Inc., addressed this issue in the comprehensive study, "The role of the doctor of chiropractic in the health care system in comparison with doctors of allopathic medicine and doctors of osteopathic medicine." Based on an in-depth investigation of the health care system and the education, licensure, and practice of doctors of chiropractic, Dr. Gonyea concludes, "The DC can provide all three levels of primary care interventions and therefore is a primary care provider, as are MDs and DOs. The doctor of chiropractic is a gatekeeper to the health care system and an independent practitioner who provides primary care services. The DC's office is a direct access portal of entry to the full scope of services."
Equally compelling is, "The chiropractor as a primary health care provider in rural, health professional shortage areas of the U.S.," a recently completed survey that indicates that doctors of chiropractic are responding to the primary care crisis in rural America by acting as first contact primary care providers. This survey of 260 DCs demonstrates that in rural areas where there are no medical doctors or doctors of osteopathy, 41.1 percent of the surveyed DCs are currently providing first contact care to 76 percent to 100 percent of their patients and another 23.1 percent provide first contact care to 51 percent to 75 percent of their patients.
Many chiropractors use strange methods of diagnosis and treatment that go beyond traditional chiropractic theory.
The chiropractic profession is addressing the use of unorthodox methods, such as those described in Consumer Reports, and showcased on "20/20." The Mercy Conference Guidelines were forged by members of the chiropractic profession in an effort to stop irresponsible forms of treatment and purge the chiropractic profession of unsafe procedures. The New Jersey State Board of Chiropractic Examiners has outlawed surrogate testing because the profession recognized the danger of allowing this "diagnostic procedure" to be associated with the chiropractic profession.
There are aberrations in every profession and chiropractic is no exception. Responsible representatives of the majority of the chiropractic profession are stepping forward to condemn and abolish these practices.
... many also promote the use of vitamins, minerals, and food supplements with unproven claims that they can treat or prevent disease.The chiropractic profession has long embraced nutrition as part of a non-drug, non-surgical paradigm. In contrast, it has been a stepchild of medicine for many years.
The controversial work of Nobel Prize winner Linus Pauling, PhD, on the health benefits of nutrients, especially vitamin C, is being vindicated in light of new research on the benefits of antioxidants, including vitamin C. High fiber foods are now acknowledged to be beneficial as part of dietary health.
Traditionally, students at chiropractic colleges devote more time to the study of nutrition than their counterparts in medical schools. Nutrition is also an area that doctors of chiropractic can pursue in advanced study.
Chiropractors typically describe their treatment methods as exceptionally safe, particularly when compared with the rate of side effects associated with surgery and prescription drugs. Such a blanket comparison, of course, is meaningless; medical doctors are much more likely to treat serious or life-threatening conditions.
It is a valid comparison. The overuse of antibiotics has been criticized in publications ranging from Newsweek to the New England Journal of Medicine. Antibiotic resistant strains are emerging due to the overuse of antibiotics for minor ailments. Recently, the Canadian Family Physician published a retrospective study that stated that while 97.7 percent of children in the U.S. with otitis media are prescribed antibiotics, they are necessary in only 5-10 percent of acute cases. As for adverse reactions to prescription drugs, a chilling account of a woman who will be permanently impaired due to a reaction to an antibiotic prescribed for a urinary tract infection was reported in the Washington Post.
There is no question that the use of antibiotics is warranted in many cases and that countless lives have been saved by antibiotic intervention. To condemn the use of antibiotics because of rare cases of complications would be irresponsible, just as it would be irresponsible to curtail the therapeutic use of chiropractic in light of the millions who are helped annually.
Criticism of unnecessary surgery that puts patients at risk is also warranted. Chiropractic has an obligation to educate patients about conservative alternatives to surgery. There are many cases when there is no option to surgery, however, the overwhelming data that supports the effectiveness of chiropractic treatment of the lower back, for example, must be made available to patients when assessing the risks versus the merits of surgery.
Several risks, though they may be remote, should be considered by anyone contemplating chiropractic care:
Direct injuries ... the authors of the Neurosurgery article found only 112 published case reports of complications due to neck manipulation in a span of about 65 years. But figures derived from a prominent company providing malpractice insurance to U.S. chiropractors suggest how misleading it can be to rely on published case reports. In 1990 alone, the company paid approximately 140 claims to patients who had suffered a stroke after spinal manipulation.
In a presentation at the 1994 International Conference on Spinal Manipulation, Allan Terrett, MAppSc, one of the leading authorities on cerebrovascular accidents (CVAs) made a startling announcement that he has uncovered numerous misrepresentations of the dangers of CVAs in the published literature on the topic. While investigating published studies linking chiropractic treatment and chiropractors to CVA episodes, Dr. Terrett found that in an unsettling number of cases the treatment was, in fact, administered by non-chiropractors. This revelation would indicate the distinct possibility of fraud in published research. Dr. Terrett plans to publish his documented findings.
The National Chiropractic Mutual Insurance Company (NCMIC), the largest provider of malpractice insurance to the chiropractic profession, was never contacted by Consumer Reports. The experience of NCMIC and clients who represent 50 percent of the nation's 46,000 doctors of chiropractic reflects a far different picture.
NCMIC President, Arnold E. Cianciulli, MS, DC, responded, "In light of our insurance position within the chiropractic profession, I feel that the cerebrovascular accidents statement made by Consumer Reports is grossly erroneous. Furthermore, the low incidence of chiropractic claims when compared to the number of medical incidents, coupled with lower payment for liability damage makes the authenticity of the data in the article all the more questionable. Based on the experience of NCMIC, the figure cited of 140 claims is grossly exaggerated. The data is severely skewed to reflect two to three times the actual risk."
Delayed medical care. Critics have long claimed that one of the worst dangers of chiropractic is that it keeps some patients from seeking timely and appropriate medical care.
Consumer Reports continues, "It's extraordinarily difficult to know how often that happens, what consequences it has, and whether it occurs more or less frequently than in the past." It is impossible to respond to the speculation that follows this statement in the text of the article. Specific cases of mismanagement can be cited in any profession and should not be used to condemn the profession as a whole.
A recent survey of the attendees of an American Back Symposium showed that of those responding, 48 percent of the MDs, 67 percent of the DOs, and 93 percent of the PTs never refer to DCs. All of these practitioners are active in the treatment of back pain and should be aware of the numerous clinical trial that support spinal manipulative therapy, as provided by DCs in the treatment of back pain.
X-rays. Fortunately, the use of full-spine x-rays has declined in recent years. But according to a 1991-1992 ACA publication, nearly 17 percent of x-ray procedures done by chiropractors are still of the full spine variety ...
Again, Consumer Reports itself provides a valid response to this criticism. "The only accepted use of full-spine radiography is to evaluate the need for surgery in scoliosis, a curvature of the spine. Most chiropractors today use smaller, regional x-rays to rule out problems that may preclude manipulation, such as metastatic cancer. But x-rays may not be necessary in every case, and repeated x-rays to track treatment results are rarely needed."
This would indicate that most chiropractors are using x-rays responsibly and appropriately. The 17 percent figure cited for full-spine x-rays is not an extraordinarily high figure.
B.J. Palmer, a chiropractic pioneer, claimed that "chiropractic adjustment cures all diseases." Today's brochures carry a similar message.
Not all brochures carry a "similar message." FCER's Staying Well Division has long been an established and trusted source of patient education materials, including brochures, booklets, videos, and more. Doctors can rely on FCER to provide responsible information for patients.
Recommendations:
See your physician first. Have a medical doctor evaluate your complaint thoroughly.
Doctors of chiropractic are licensed in all 50 states and the District of Columbia and are positioned to act as portals of entry to the health care system. Chiropractors are trained to diagnose and care for patients and are able to freely consult with and refer to the complete spectrum of health care provider from the traditional medical hierarchy, when necessary.
Professional level courses at chiropractic colleges endorsed by the Council on Chiropractic Education (CCE) include anatomy, biochemistry, physiology, and most other other subjects offered at medial colleges, including a thorough familiarity with diagnosis. Conversely, what training do the medical schools provide their students about chiropractic? How would the MD know when or when not to refer to a DC?
Get a referral from a reliable source ... The National Association for Chiropractic Medicine [NACM] and the Orthopractic Manipulation Society International [OMSI] ...
Not only do the NACM and OMSI represent a limited scope of care, the best estimate of NACM membership is 300 doctors; the OMSI claims 200 doctors in the U.S. Assuming that there is no duplication, this creates a pool of only 500 doctors representing a profession of 46,000. The chances of finding one of these doctors nearby is remote. In contrast, the ACA represents more than 16,000 practicing chiropractors.
Targeting a Growth Industry: The Well-Adjusted Child [sidebar]
The issue of chiropractic treatment of children has been exploited by the media on a number of occasions recently, notably in the Wall Street Journal and on "20/20." FCER and all responsible health care professionals condemn any doctor, chiropractic or medical, who would put patients of any age at risk or who would callously use children to build a practice or increase revenue.
Anecdotal clinical evidence has long supported chiropractic treatment of such maladies as otitis media, infantile colic, and adolescent scoliosis. Research is now underway that will scientifically evaluate the effectiveness of this treatment for all these conditions. The preliminary results of this research are encouraging and the final results should help to quell the attacks on chiropractic treatment of children.
Summary
The treatment of chiropractic in Consumer Reports was one-sided and, as evidenced by this rebuttal, inaccurate and brings into question the objectivity of Consumer Reports. As the debate over the future of health care in the United States rages on Capitol Hill, one cannot help question the timing of this series of articles on alternative health care, which seems designed to breed mistrust of all but allopathic doctors.
It falls to the members of the chiropractic profession to respond to unjust allegations in a dispassionate and reasoned manner. Mounting scientific evidence indicates that chiropractic will ultimately be vindicated of these charges. To continue this kind and caliber of research requires the commitment of each and every doctor of chiropractic.
FCER is actively involved in defending the chiropractic profession. Members of the Foundation support this goal and receive a full spectrum of membership benefits. For more information, please contact: Diana Stevens, 1701 Claredon Blvd., Arlington, VA 22209 or call (800) 637-6244 or (703) 276-7445. For more information about Staying Well products, contact FCER/Staying Well, 66 Washington Ave., Des Moines, IA 50314 or call (800) 622-6309.
Mary E. Johnson,
FCER Director of Communications