The Permanent Injunction Order against the AMA, published on the adjoining page, does, we can all hope, signal the end of the legal confrontation between doctors of medicine and doctors of chiropractic in the United States. It will be sad if the two professions have not both learned from the experience. It was a confrontation neither sought nor desired by the chiropractic profession. Now it is time for dialogue -- not confrontation. Quite frankly, the chiropractic profession invites the cooperation of medical physicians and their related scientific community in determining what is best for all patients -- both yours and ours.
A recent newspaper story illustrates the tasks ahead:
"In June 1989, Robert M. Centor, a prominent doctor of internal medicine from Richmond, Virginia, sat down at a congressional witness table and made a remarkable confession.
"When a patient comes to see him with a complaint, such as a sore throat or an aching back, Centor said he lacks the tools he needs to make a sound decision because medical science cannot tell him what kind of treatment works best for many common ailments.
"'In order for me to make a good judgment, I need to have some data. And right now I don't have enough data to make that decision,' said Centor, chairman of the division of general medicine and primary care at the Medical College of Virginia.
"Centor's testimony -- delivered on behalf of the 65,000 members of the American College of Physicians -- reflects a crisis of confidence that is just now being widely acknowledged in medicine.
"With surprising candor, doctors are admitting that they aren't sure what really helps their patients and what is useless or even harmful. Near the end of a century of extraordinary medical progress and generally improving health, doctors still don't know what works." (Fort Wayne News-Sentinel, Feb. 2, 1990.)
Some readers of AMN are aware of the fact that an increasing number of fully accredited hospitals have initiated chiropractic programs and, more importantly, have expressed satisfaction with such arrangements. The RAND Corporation has just completed a Project Overview and Literature Review of the appropriateness of spinal manipulation for low-back pain in which it concluded that "support is consistent for the use of spinal manipulation as a treatment for patients with acute low back pain and an absence of other signs or symptoms of lower limb nerve-root involvement." (RAND Publication Series, 1991, R-4025/1-CCR/FCER.) The same study reported that doctors of chiropractic deliver 94 percent of all manipulative care for which reimbursement was sought, with osteopaths delivering 4 percent, and general practitioners and orthopedic surgeons accounting for the remainder.
Chiropractors ordinarily utilize "adjustive" manipulation as opposed to generalized manipulation or mobilization. Some studies have indicated that adjustive manipulation may be up to twice as effective as other types. Rather important skills are necessary in performing adjustive manipulation. The difference is neither illusory nor a question of sematics. In the early 1940s, Dr. Irvin Hendryson (who later served as an AMA trustee) conducted possibly the first controlled trial of orthopedic versus chiropractic care. In his analysis of the results, he stated:
"There was among other interesting noted items the fact that in the presence of an objective 'pop' or 'snap,' it was felt by the patient and also by the manipulator that the total end result seemed to be better and more impressive than if no objective 'pop' were noted. I have no real explanation for this except for the fact that there may be some psychosomatic factor involved; there conceivably could be unlocking of ligamentous structures in the facet region which permitted this audible sound; or, quite possibly, there may well have been some pathology present that we were not able to evaluate in view of our limited means which was of significance."
As recently as June of 1990, a prospective, pragmatic study reported in the British Medical Journal, concluded that:
"Chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain. A benefit of about 7 percent points on the Oswestry scale was seen at two years.
"For patients with low back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain." (BMJ, Vol. 300:1431-1437, 2 June 1990.)
The BMJ report suggested that significant cost savings and reduction in unnecessary sickness absences might result from the use of doctors of chiropractic. The hospital outpatient care in the BMJ study included, among other treatments, Maitland mobilization or manipulation. The chiropractors used adjustive manipulation.
The North American Spine Society, in 1991, listed chiropractic adjustments as "generally accepted, well-established, and widely used ... therapeutic procedures for patients with lumbosacral spinal disorders." (Spine Journal, 16(10):1161-1167, 1991.)
In July of 1990, Lancet criticized physiotherapists as having "a poor record of initiating and responding to research, and numerous treatment techniques are used with little, if any, scientific backing." (Lancet,-July 29, 1990, p 220.)
The Lancet article went on to state: "Physiotherapists need to shake off years of prejudice and take on board the skills that the chiropractors have developed so successfully."
What many medical physicians do not know is that there are several retrospective studies involving workmens' compensation programs performed by medical physicians (and also others) during the past two decades, that indicate, as does the BMJ study, that doctors of chiropractic may be twice as effective as medical physicians and physical therapists in returning injured workers, having non-surgical back problems, to work. One, in California, should be enough to arouse a thoughtful person's curiosity:
California Workmens' Compensation Study (1972), C Richard Wolf, M.D.:
"Average lost time per employee -- 32 days in the MD-treated group, 15.6 days in the chiropractor-treated group.
"Employees reporting no lost time -- 21% in the MD-treated group, 6.7% in the chiropractor-treated group.
"Employees reporting lost time in excess of 60 days -- 13.2% in the MD-treated group, 6.7% in the chiropractor-treated group.
"Employees reporting complete recovery -- 34.8% in the MD-treated group, 51% in the chiropractor-treated group."
Many of the studies are cited in the RAND report. They are mentioned, not to incite incredulity or hostility, but simply to stimulate curiosity and urge an open mind. Back problems alone are estimated to cost our economy in excess of $24 billion. The musculoskeletal systems comprise 60 percent of the body's systems. The issue is deserving of intense scrutiny. In a scientific context, it is always unsettling when a court has to find that supposed advocates of science "did not have open minds to pro-chiropractic arguments or evidence."
In 1979, the government-appointed Royal Commission of Inquiry on Chiropractic in New Zealand concluded:
"The Commission has found it established beyond any reasonable degree of doubt that chiropractors have a more thorough training in spinal mechanics and spinal manual therapy than any other health professional. It would therefore be astonishing to contemplate that a chiropractor, in those areas of expertise, should be subject to the directions of a medical practitioner who is largely ignorant of those matters simply because he has had no training in them." (NZR, p. 305.)
The special and prolonged education of chiropractors helps explain just why, out of billions of adjustive manipulations rendered over the past decades, the number of reported adverse incidents has been statistically insignificant -- far fewer than one in every million -- an extremely favorable benefit/risk ratio when compared to most other active medical procedures.
Whatever criticism one may choose to make of the methodologies or conclusions of the numerous studies, they all appear to be consistent in their results. The medical physicians conducting the studies had no reason to slant or bias the outcome.
The research arms of the chiropractic profession are implementing protocols and attempting to obtain funding and appropriate patient population for additional scientific studies to determine the parameters of value of chiropractic care for such ailments as certain headaches, certain respiratory problems, certain gastrointestinal problems, certain vascular problems, and certain other structural (e.g. painful backs of women during pregnancy, etc.) or stress-related, induced or influenced maladies. More studies, suggested by clinical experience with millions of patients, will follow.
Doctors of chiropractic have always been concerned with diet, exercise, emotional, environmental and psychological influences on health.
If some 17 million patients visit an estimated 40,000 doctors of chiropractic each year, is it too much to ask, when considering the growing body of supportive scientific literature, that the medical world should at least suspect that those patients are receiving beneficial care not generally available elsewhere?
Some 10,000 students are attending chiropractic's fully accredited professional colleges. Their faculties have impressive academic credentials. You are cordially invited to visit the colleges. You may be surprised at the quality of the diagnostic and therapeutic training the students receive in the four or five-year programs of study, which follow an average of more than three years of undergraduate preparation.
Thousands of well-intentioned medical physicians have offered a friendly and cooperative hand to doctors of chiropractic. We salute and thank them.
The profession is not opposed to vigorous analysis and criticism as long as it is directed toward a search for scientific truth and the betterment of the human condition. The profession will continue to resist mean-spirited, exaggerated, close-minded and anti-competitive actions but will welcome cooperative ventures and properly formulated and coordinated trials to prove or disprove the accuracy or validity of 96 years of accumulated clinical anecdotal evidence, case studies, and other more ambitious studies. It is through dialogue that unscientific dogma still being adhered to by any member of the health care sciences, whether medical physician or chiropractic physician, can be addressed, debated, and hopefully reduced to a minimum.
The profession of chiropractic, through its leadership, is absolutely committed to continuing its pursuit of scientific validation and requests the cooperation of well-intentioned medical physicians in every setting -- academic, hospital, clinical, cooperative care of patients, and research. To the extent that the financial and material resources of the chiropractic profession are inadequate to fund all of the necessary research, the profession requests the assistance of medical physicians and medical physician-influenced institutions in obtaining funding.
If you or your institution are interested in examining various research protocols or cooperating in the establishment of properly funded and designed experiments on the efficacy of chiropractic care, please contact either:
- Foundation for Chiropractic Education and Research, 1701 Clarendon Road, Arlington, Va. 22209, (703) 276-7445.
- Consortium for Chiropractic Research, 1095 Dunford Way, Synnyvale, California 94087, (408) 983-4000.
- Any of the colleges of chiropractic.
To the extent some of you may have treated the profession of chiropractic like a bad penny that wouldn't go away, let me respectfully request that you view its birth development and growth in the following light: It is a patient-driven health care profession -- it has provided help in improving the quality of life of millions of humans. It has survived notwithstanding what the court called a "lengthy, systematic, successful, and unlawful boycott." It is not easy to conduct appropriate scientific studies in a manner acceptable to the scientific community under the pressure of such a boycott.
Even if we grant the AMA the benefit of the doubt on the reason for the boycott (concern for scientific method), we are haunted by the court's statement that "there was evidence showing that the AMA was motivated by economic concerns as well."
With the cloud of boycott now lifted, the pace of research has accelerated.
It is axiomatic that medical physicians and chiropractic physicians, when acting individually and not collusively, cannot be forced to praise, sponsor or associate with each other. This request is not about compulsion -- it is about cooperation.
Thank you for your courtesy in reading my request for dialogue.
George P. McAndrews, Esquire
Chicago, Illinois
George McAndrews served as lead trial counsel for the successful plaintiffs in the celebrated 14-year antitrust case, Wilk et al v. AMA et al.; and as lead plaintiff's counsel in the racketeering case Chinnici v Central DuPage Hospital et al. (1990). Learn more by clicking here.