Thank you, Mr. Chairman, for this opportunity to speak once again to the committee. My name is Dr. Arlan W. Fuhr. I am a chiropractic physician and president of the National Institute of Chiropractic Research (NICR), a non-profit foundation which conducts and supports research in chiropractic. I have prepared a short oral statement, and respectfully request my full written statement be included in the record.
Mr. Chairman, as we have in each of the past two years (Fuhr, 1990, 1991), we come before you today to ask once again for a strong commitment for chiropractic research and education. We note once more the growing body of scientific literature (Meade et al., 1990a; Shekelle et al., 1991 a&b; Waagen, 1986) which suggests that chiropractic care is clinically effective and cost effective for the kinds of health problems that have helped to drive health care costs in America to the crisis stage: musculoskeletal and stress related conditions. At our last presentation to this committee we called attention to the estimate in the prestigious journal, Science, that for every dollar spent on chiropractic care, four dollars would be saved (British study, 1990). In the intervening years, a number of additional reports published by the British Medical Journal (BMJ), the Journal of Occupation Medicine, and the RAND Corporation have provided further significant support for our contention that chiropractic care is the most sensible first choice for patients with musculoskeletal disorders, particularly back pain. Among these additional findings are:
- A RAND Corporation study, which involved a comprehensive review of the scientific literature since 1955 related to spinal manipulation for back disorders. Funded solely by the chiropractic profession, RAND assembled a panel of expert clinicians and researchers in medicine and chiropractic, who concluded that despite the unevenness of the available data, "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." Lesser degrees of scientific scrutiny and support were available for other subcategories of back pain (Shekelle et al., 1991 a&b).
- Investigators in a retrospective but case-controlled comparison of chiropractic vs. medical care for workers' compensation claimants in Utah, found that "cost for care was significantly more for medical claims, and compensation costs were ten-fold less for chiropractic claims" (Jarvis et al., 1991).
- Just two months ago, the BMJ reported a randomized clinical trial of manipulation vs. physiotherapy, vs. medical care of 256 patients with back and neck pain (Koes, 1992). At the one year follow-up, manipulation was more effective in relieving pain and restoring physical function than either physiotherapy or medical care. These results essentially replicate the 748 patient controlled comparison of chiropractic care vs. physiotherapy reported by clinical epidemiologist, Thomas Meade, a year ago, which concluded that "chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain. The benefit of chiropractic treatment became more evident throughout the follow-up period. Secondary outcome measurers also showed that chiropractic was more beneficial" (Meade et al., 1990a).
We would also like to call your attention to the significant efforts by chiropractors this past year to fund and develop standards of care (consensus guidelines) for assuring the quality of chiropractic services to the public and to help reduce the costs of our services. The document, known as the Mercy Center Conference Report, a preliminary draft, (Exhibit 1), produced 304 specific clinical recommendations to guide the practitioner in choosing appropriate and cost effective chiropractic methods of healing. As was true for the RAND report, this initiative was funded entirely from within the chiropractic profession.
Mr. Chairman, we are pleased to note the small but important initial steps taken by the Agency for Health Care Policy Research (AHCPR) to include at least a few comparisons of chiropractic methods with those of medicine and surgery in several of the projects AHCPR has recently funded. Additionally, we heartily agree with the appropriateness of AHCPR's appointment of chiropractors to its new clinical guideline panel on chronic low back pain. Although these primary steps will do relatively little to meet the American public's need for better information, greater quality control and wider availability of chiropractic services, they do represent inroads at the federal level. We are appreciative of this committee's efforts to direct agencies to use funds for chiropractic patients at the National Institutes of Health.
As we noted last year, medical and chiropractic investigators have acknowledged the "knowledge gap" in health care (e.g., Cotton, 1991; Eddy, 1990; Fuhr, 1990, 1991). We do not yet have the necessary data to best meet our patients' needs for accurate diagnosis, prevention and treatment of most health care problems. As a consequence, Americans risk spending phenomenal sums of money for potentially harmful and/or unnecessary health care services. Mr. Chairman, the chiropractic profession is strategically placed to help close that information gap in areas of profound suffering and great economic hardship to the nation. The sorts of research our colleges and research organizations wish to conduct (e.g., Exhibits 2-5) closely parallel many of the priority topics that NIH has recognized (e.g., Frymoyer & Gordon, 1989), and several of our investigators have been at the forefront in defining relevant issues (e.g., Frymoyer et al., 1986; Kirkaldy-Willis & Cassidy, 1985; Triano & Schultz, 1987).
Mr. Chairman, few people today would dispute that the 45,000 doctors of chiropractic in the United States are the most extensively-trained practitioners of manipulative methods. We offer alternative strategies for intervening in America's health needs, and we are the experts when it comes to manipulations methods. Indeed, counsel for the medical defendants in the recently resolved Wilk antitrust case (Chapman-Smith, 1989; Getzendanner, 1987) indicated that he assumed that chiropractors provided a better service in some areas of health care than did medical doctors. The trial also revealed that the AMA and co-defendants had worked to suppress information on the benefits of chiropractic care. Clearly, we have been stymied in our efforts to systematically study the effectiveness and cost effectiveness of various chiropractic methods vs. the alternatives in medicine and surgery. We need to better understand the potential value of chiropractic primary care for routine musculoskeletal problems and in special populations, such as the elderly, patients with severely debilitating disorders, expectant mothers, and the underserved and rural populations. Clinical outcome data, the kind of research that chiropractic scientists are best able to provide, are needed both to improve our methods and to guide health care policymakers. We will require assistance in accomplishing these goals.
We believe our internally-funded activities in the past several years, including efforts to generate scientific information and to set clinical and cost effectiveness standards, plus the growing scientific validation of the effectiveness of chiropractic manipulative methods, confirm the readiness of our colleges and research agencies to play a much larger role in health care reform in this country. Funds are available (or proposed) by the federal government for research development in minority institutions, for family medicine education, nursing research, and for the recently proposed womens' health institute. Surely, a similar strategy for chiropractic colleges is reasonable, desirable, and cost effective. To date, no chiropractic college has ever received any significant funding for research or education. We have been locked out of teaching hospitals, barred from most universities, and denied the educational and scientific resources that the federal government makes available to most other health care disciplines. What we have been able to contribute has come about without any outside assistance. Now we ask that you help us to contribute more fully to the health and welfare of the nation through improved science and education.
Mr. Chairman, it is unreasonable and unwise for congress to leave the study of chiropractic science solely in the hands of the NIH bureaucracy. We offer different means of understanding and intervening in the health needs of Americans, and we, rather than the medical establishment, are better prepared to develop these possibilities. Although chiropractic investigators are publishing in refereed medical journals (e.g., Boline et al., 1992; Frymoyer et al., 1986; Jarvis et al., 1991; Kirkaldy-Willis & Cassidy, 1985; Triano & Schultz, 1987; Waagen et al., 1986) and participating in scientific meetings (e.g., American Back society, American Society of Biomechanics, American Public Health Association, Internal Society for the Study of the Lumbar Spine, and North American Spine Society), we have been locked out (de facto) from the scientific resources that Congress makes available to all other health disciplines. The "inherent bias" (Hanft, 1991) encountered by chiropractors when attempting to compete for federal research dollars with "established researchers and research teams" is compounded with whatever specific biases derive from years of defamation by organized medicine, Unintentional biases against chiropractic investigations have been discussed by Dr. Meade, principal investigator in the British study noted earlier (Meade, 1990b; Fuhr, 1991). The New Zealand government study of chiropractic found deliberate discrimination against chiropractors among federal purse string holders. They discussed:
"the prejudiced attitude of organized medicine toward chiropractic and the effect of this attitude on medically dominated federal funding agencies in the health area. This is obvious and needs no further comment ..." (New Zealand report, 1979 p. 225).
Mr. Chairman, every year the federal government spends in excess of $10 billion on medical education, research, and demonstration projects in the medical schools, the armed forces, the National Institutes of Health, the Public Health Service, and the Veterans Administration. None of these funds reach the chiropractic colleges, which continue to be more than 80 percent tuition dependent, in most cases. (The typical medical school in the United States is 5-10 percent tuition dependent, and spends in excess of 50 percent of its operating budget on research.) If the American people are ever to realize the full potential of the benefits of chiropractic care, then a program to encourage scientific growth at chiropractic educational institutions will be necessary. To leave this work in the hands of the medical community is akin to assigning the fox to guard the hen house.
Accordingly, we propose that the Congress and this committee encourage agencies such as the AHCPR, the National Institute for Arthritis, Musculoskeletal, and Skin Diseases, the National Institute on Aging, and the National Institute on Disability and Rehabilitation Research to find means to foster scientific and educational development at the chiropractic colleges. A number of short and long-term benefits would result from this investment:
- To better the health needs of the public through quantum growth in outcomes research of conservative methods. Target patients with debilitating spinal and musculoskeletal disorders, stress-related conditions, elderly, veterans, military personnel, and other underserved populations. The clinical and research talent at chiropractic institutions is the obvious and most strategic place to invest dollars in outcome studies of conservative, cost effective care of a great many musculoskeletal health problems.
- Greater savings for individual research projects. Overhead (indirect) costs for research at the largest medical research centers average about 40 percent, and can run as high as 70 percent. In contrast, the indirect costs for clinical trials conducted at chiropractic colleges are often as low as 10 percent.
- Increased stability of the infrastructure of the chiropractic colleges by reduced dependence on tuition as the primary source of operating funds. This tactic alone would enable future chiropractic physicians to receive a better education and to incur less debt upon graduation.
- Development of innovative educational programs (such as the Advantage Program at the Los Angeles College of Chiropractic, a competency-based, problem-oriented approach to chiropractic education, which is modeled after the Harvard Medical School's "New Pathways" program) and greater clinical experience for the next generation of chiropractors.
- Inducement for universities and teaching hospitals to seek greater collaboration with the chiropractic colleges in the interest of patients. Federal funding for educational innovation and outcomes research would aid in breaking down a century of anti-chiropractic bias in the wider health science and health education communities.
Mr. Chairman, the Flexner report of 1910 prompted private philanthropy and the federal government to invest ever greater funding into biomedical research and training in America. These investments were not prompted by the success of the health care enterprise at the turn of the century, but because of the great need to improve the quality and quantity of medical scholarship. No similar commitment has ever been made to chiropractic health care. We recognize that earmarked funding is the exception to the rule in health care investment by the federal government. However, given the unique circumstances of the chiropractic experience in this country, the potential benefits by patients, and the skyrocketing cost of health care, we ask you to give our request serious consideration. Help us to contribute more fully to the welfare of the nation through improved science and education.
References
Boline PD, Keating JC, Haas M, Anderson AV: Interexaminer reliability and discriminant validity of inclinometric measurement of lumbar rotation in chronic low back pain patients and subjects without low back pain. Spine, 17(3):335-8, March 1992.
British study endorses chiropractic. Science, 248:1610, July 1990.
Chapman-Smith D: The Wilk case. Journal of Manipulative & Physiological Therapeutics, 12(2):142-6, April 1989.
Cotton P: Orthopedics research now asks, "Does it work?" rather than just, "How is procedure performed?" Journal of the American Medical Association, 285(17):2164-5, May 1991.
Eddy DM: Clinical decision making: from theory to practice. Journal of the American Medical Association, 263(2)287-90, Jan 12, 1990.
Flexner A: Medical Education in the United States and Canada 1910, Carnegie Foundation (reprinted 1967, Times/Arno Press, New York).
Frymoyer JW, Phillips RE, Newberg AH, MacPherson BV: A comparative analysis of the interpretation of lumbar spinal radiographs by chiropractors and medical doctors. Spine, 11:1020-23, 1986.
Frymoyer JW, Gordon SL: Research perspectives in low back pain: report of a 1988 workshop. Spine, 14(12):1384-90, 1989.
Hearings before a Subcommittee of the Committee on Appropriations. House of Representatives. 101st Congress, 2nd Session. Subcommittee on the Departments of Labor, Health and Human Services, Education and Related Agencies, Part 8A. Testimony of Members of Congress and other interested individuals and organizations, 1990, pp.H237-289.
Hearings before a Subcommittee of the Committee on Appropriations. House of Representatives. 101st Congress, 2nd Session. Subcommittee on the Departments of Labor, Health, and Human Services, Education and Related Agencies, Part 8B. Testimony of Members of Congress and other interested individuals and organizations, 1991, pp H2358-2368.
Getzendanner S (U.S. District Judge, Northern District of Illinois, Eastern Division): Memorandum opinion and order: Wilk et al., vs. American Medical Association et al., August 27, 1987.
Hanft R: Presentation at the Foundation for Chiropractic Education & Research. International Conference on Spinal Manipulation, April 12, 1991, Arlington, Virginia.
Jarvis KB, Phillips RB, Morris EK: Cost per case comparison of back injury claims of chiropractic vs. medical management for conditions with identical diagnostic codes. Journal of Occupation Medicine, 33(8):847-52, August 1991.
Kirkaldy-Willis WH, Cassidy JD: Spinal manipulation in the treatment of low back pain. Canadian Family Physician, 31:536-40, March 1985.
Koes BW, Bouter LM, van Mameren H, et al: Randomized clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of a one-year follow up. British Medical Journal, 304:601-5, March 7, 1992.
Meade TW, Dyer S, Browne W, Towsend J, Frank AO: Low back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment. 300:14310-7, June 2, 1990a.
Meade TW: Interview. Canadian Broadcasting Corporation. October 2, 1990b.
Mercy Center Conference. Proceedings from the conference for the establishment of guidelines for chiropractic quality assurance and standards of practice. Burlingame, California, January 25-30, 1992.
Report of the Commission of Inquiry, Chiropractic in New Zealand, 1979, The Government Printer, Wellington, New Zealand.
Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brook RH: The appropriateness of spinal manipulation for low back pain: project overview and literature review. 1991a. RAND Corporation, Santa Monica, California (Document #R-4025/1-CCR/FCER).
Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brook RH: The appropriateness of spinal manipulation for low back pain: indications and ratings by a multidisciplinary expert panel. 1991b, RAND Corporation, Santa Monica, California (Document #R-4025/2-CCR/FCER).
Triano JJ, Schultz AB: Correlation of objective measure of trunk motion and muscle function with low back disability ratings. Spine, 12(60):561-5, 1987.
Waagen GN, Haldeman S, Cook G, Lopez D, DeBoer KF: Short-term trial of chiropractic adjustments for the relief of chronic low back pain. Manual Medicine, 2(3):63-7, 1986.
Arlan Fuhr, D.C.
Phoenix, Arizona
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