Is spinal manipulation efficacious even if we can't prove how it works?
These two issues and many others were addressed in the recent paper1 by RAND Corporation researcher Paul Shekelle, MD, PhD.
While the review of manipulation was very much from a research point of view, a few points deserve to be quoted. These are particularly relevant in light of the recent criticisms chiropractic has received in the media.
"Regardless of the mechanism of action, the clinical response to spinal manipulation can be measured and quantified, and the presence or absence of clinical benefit should be the ultimate test of manipulation, rather than an understanding of the exact pathophysiologic mechanism. Clinicians used digitalis and aspirin for decades without knowing how either worked, based on the documented clinical improvements either drug caused. We can continue to use manipulation for patients in whom efficacy can be demonstrated, while research into the biomechanics of manipulation continues."While the paper didn't contain a finite statement on the risk of cervical manipulation, Dr. Shekelle did draw the following conclusion regarding lumbar manipulation:
"Regardless, we used the available data from case reports on the number of complications and from our epidemiologic study on the use of chiropractic services to estimate the number of lumbar spinal manipulations received during a time period covered by the case reports. Then, we estimated that the rate of occurrence of the cauda equina syndrome as a complication of lumbar spinal manipulation is about one case per 100 million manipulations.2 It probably is higher in patients with a herniated nucleus pulposus, and lower in patients without this anatomic abnormality.This paper is an excellent opportunity to look at manipulation, particularly chiropractic manipulation, through the eyes of a medical researcher. You will appreciate their objectivity.
References
- Shekelle PG. Spine update -- spinal manipulation. Spine 1994;7:858-61.
- Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low-back pain. Ann Intern Med 1992;117:590-8.
AMA Finances in Serious Condition
The June 6-12, 1994 edition of Crain's Chicago Business published, "Sick finances for AMA." The article had this to say:
"Officials of the American Medical Assn. are sounding alarms over high operating expenses, investment losses and a prediction of another revenue drop for 1994 just as the group approaches its annual meeting next week.
"For the 146-year-old American Medical Assn. (AMA), financial woes couldn't come at a more inopportune time. As debate over federal health care reform heats up, the AMA needs secure revenues to fuel lobbying efforts in Washington, D.C., while it supports nationwide programs to market its positions among patients and doctors.
"But the AMA's finances are in trouble. In a May 6 memo to AMA's executive staff, obtained by Crain's Chicago Business, Chief Operating Officer Kenneth E. Monroe wrote: 'Our early warning indications of downturns in many of our major revenue sources have been confirmed.
"'Significant cutbacks by the pharmaceutical companies in their advertising and operating budgets, a mortgage default by the purchaser of one of our major Chicago properties, a very substantial downward adjustment in the investment markets in the past few months and a number of other smaller revenue shortfalls have caused a significant shortfall in budgeted revenues.'
Fortunately for the AMA, their membership dues, the largest source of revenues, "remained relatively stable last year, dipping about 1%." This should be an important reminder. No matter how big an organization gets, its strength is in its membership, not in outside revenue sources.
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