This is also surprising considering the fact that the Annals of Internal Medicine is read by the large conservative element of the medical profession that has until now refused to consider chiropractic care as a viable form of health care. The answer to this puzzle can be found possibly by noting the authorship of the paper:
Paul G. Shekelle, M.D., MPH -- Well known in the chiropractic community for his work in the RAND study, and well-respected in the medical community for his work at RAND, and as chief methodologist for the Agency for Health Care Policy and Research (AHCPR's) guidelines panel on back pain.
Alan Adams, DC, MSEd, DACBN -- A well-respected researcher and administrator at Los Angeles College of Chiropractic. Dr. Adams has been involved in numerous chiropractic research projects as well as the development of chiropractic guidelines as a member of the Mercy Conference Steering Committee.
Mark R. Chassin, M.D., MPH, MPP -- A world renowned health care guidelines "guru." Dr. Chassin's work in clinical guidelines and standards of care, through AHCPR, National Institute of Medicine, and RAND has been a major force in the development of current health care policy. He is currently the chief administrator for health care in the state of New York.
Eric Hurwitz, D.C., M.S. -- A Ph.D. candidate at the Department of Epidemiology, School of Public Health, University of California, Los Angeles (UCLA), and a major chiropractic resource at RAND.
Robert H. Brook, M.D., ScD -- Director of Health Science Program at the RAND Corporation. Dr. Brook's criticisms of the waste and overutilization in all areas of health care (particularly surgery) have helped to bring about major changes in the focus of health care efficiency and how health care is purchased. (Please see "How Doctors Have Ruined Health Care," in the March 14, 1990 issue of "DC.")
What is not surprising is that this article is a very conservative look at spinal manipulation. The authors begin by separating spinal manipulation from chiropractic care in an effort to desensitize the subject from their readership. The average chiropractor reading this paper would tend to be angered by its strict adherence to the most rigorous scientific standards.
One of the strengths this article offers is the fact that it is a meta-analysis. This kind of assessment is performed on data reports such as randomized clinical trials (RCTs). Fortunately, the procedure of manipulation for the management of back pain has considerable data from RCTs, far more than any other low back procedure. Additionally, the authors have subjected this data to a fairly new kind of analysis called confidence profile method, which was developed for this purpose by David Eddy, M.D., MPH, and others. Because Eddy's methodology was used, this report has attracted keen interest by health authorities world-wide.
But the reader must understand the future scrutiny and criticism this ground-breaking article will have to endure. Still, the conclusions give spinal manipulation initial credibility with an opportunity for future research to enhance this position:
Conclusion: Spinal manipulation is of short-term benefit in some patients, particularly those with uncomplicated, acute low back pain. Data are insufficient concerning the efficacy of spinal manipulation for chronic low back pain.
There may be strong direction with regard to "medical necessity" from this report, and it may have medicolegal implications to primary care allopathic physicians. What if, based on this kind of convincing evidence, it becomes a standard of care for the purpose of informed consent, that allopathic physicians will inform their patients that spinal manipulation is an option for their back problem? And, what if such physicians are compelled to refer those patients that choose to receive spinal manipulation to competent practitioners in their community?
The most important aspect of this paper is the exposure it provided to the most conservative within the medical establishment. At the end of the article, it is stated that grant support (funding) for this project was "in part by the California Chiropractic Foundation, and the Foundation for Chiropractic Education and Research (Grant 89-038)." This demonstrates to the world the chiropractic profession's willingness to fund quality research, something unknown outside our own profession.
Perhaps the most exciting part of this research project was the 65 references listed at the end of the paper. These references make the reader aware of the significant amount of quality research currently available on spinal manipulation. It also introduces physicians health researchers and health regulators all around the world to some of our chiropractic researchers, scientific publications, and research organizations/institutions.
It is very encouraging to see the men and women who have dedicated themselves to chiropractic research gain recognition outside our profession. The works of Nyiendo, Phillips, Butler, Hooper, Laderman, Rupert, Ezzeldin, Waagen, Cook, Lopez, DeBoer, Bronfort, Cassidy, Mierau, McGregor, Potter, and Cox are now gaining greater exposure within the health care community. And now the most recent contributions of Hsieh, Triano, Hondras, Meeker, Mootz, Waldorf, and others continue that trend. Add to this list the credibility gained with appointments to federally-sponsored, cross-specialty panels of Phillips, Hansen, Triano, Haldeman, and Kaibel. Yes, the chiropractic profession is making an impact.
Some of our scientific publications are referenced in this article: Journal of Manipulative and Physiological Therapeutics, Journal of the Canadian Chiropractic Association and (the now defunct) American Journal of Chiropractic Medicine. In addition, the American Chiropractic Association, International Chiropractors Association, Foundation for the Advancement of Chiropractic Tenets and Science (FACTS), and Foundation for Chiropractic Education and Research (FCER) were also listed.
For the practicing chiropractor, there may be benefits realized by the dissemination of this information to the medical profession. If some DC practitioners are starting to realize an increased number of referrals from the medical practitioners in their community, what should your reaction be? Should you take the position, "See I told you so, we're being put in that 'low back pain box' and will become a tertiary or referral specialty only?" Or, can you see the positive opportunity that is knocking at your clinic door?" Sure, I'll accept these referrals for back pain, because I am confident that those patients will likely respond favorably to my kind of care, and, while they are patients in my office, there is opportunity to educate them about the other attributes of chiropractic so as to benefit their family and friends." Thus, the individual chiropractor has to make the decision to welcome this opportunity, or shun this movement to interact with the rest of the health care community.
Considering the mainline medical audience, this scientific paper is an excellent introduction to spinal manipulation (and the chiropractic profession) under the most critical analysis by some of the more authoritative experts in health care. This paper should be a part of the chiropractor's library enabling them to interact with other physicians in their community when the opportunity arises.
Dynamic Chiropractic editorial staff members research, investigate and write articles for the publication on an ongoing basis. To contact the Editorial Department or submit an article of your own for consideration, email
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