Oh What a Headache it’s Been!

[originally published in KCN, May 2001 / cartoon provided by TomLamarCartoon.com]

Did you know that chiropractic can be extremely effective at treating headaches?  Not a lot of people do, and from the looks of things, that’s just fine with some.  However, a much anticipated headache evidence report released by Duke University earlier this year might help to reverse this troubling trend.  Ironically though, with the events that led up to this point, I don’t think we as a chiropractic profession were expecting to contend with a headache of our own.

I suppose our headache began back in December of 1994 — although, from the outset, one would not have immediately realized it.  No, our thoughts were far from headaches.  We were thinking of back pain.  For  the United States Agency for Health Care Policy and Research (AHCPR), an agency within the Department of Health and Human Services, had just unveiled their Clinical Practice Guidline for Acute Low Back Problems in Adults. This was a pretty remarkable guideline in that it was composed by a 23-member panel (whittled down from more than 200 nominees) representing the fields of biomechanical and spine research, chiropractic care, emergency medicine, family medicine, internal medicine, neurology, neurosurgery, occupational health nursing, occupational medicine, occupational therapy, orthopedics, osteopathic medicine, physical and rehabilitation medicine, physical therapy, psychology, rheumatology, and radiology.  In all, this well-rounded panel, sifted through more then 10,000 research articles published since 1984 on lower back problems to formulate their conclusions —  conclusions, as you’ll soon learn, would rock the lower back pain boat as we knew it.

Among other things, the panel found that spinal manipulation (the type of care primarily delivered by chiropractors) to be a preferred form of treatment for acute lower back pain.  The panel downplayed the use of prescription medications (eg. muscle relaxers and steroids) and bed rest — and was highly critical of surgery.  Needless to say, the media took this and ran — instantly elevating chiropractic’s “approval rating” in a matter of a few sound bites and front page headlines.

As you might imagine, not everyone was celebrating like the chiropractors.  It was actually rumored that when a particular surgical company caught wind of the panel’s findings before the offical release date, they threatened a lawsuit.  And once the findings were released, the American Medical Association was quick to hire a medical writer and a panel of MD’s to write their own guidelines (American Medical Association Pocket Guide to Back Pain:  The Latest Information on All Treatment Options, Including Medication, Physical Therapy, and Surgery).  Interestingly, in this  guide to “the latest information on all treatment options” for back pain, spinal manipulation was left out.  In fact, not one reference was made to it  — effectively slapping the face of the AHCPR’s interdisciplinary panel of experts that recommended spinal manipulation as a safe and effective treatment for acute lower back pain.   In an article on the subject, Chester Wilks, D.C., called this action by the AMA  a “gross misrepresentation by exclusion”  and postulated that the only reason the AMA would put themselves in such an irresponsible and vulnerable position was in an effort to avoid lawsuits.  With the AHCPR guidelines being so critical of disc surgery and media reports of the day indicating that 80,000 unnecessary disc surgeries were performed every year, the AMA was in a tight spot.  In essence, they were literally forced into publishing their own set of back pain guidelines as tactical decission  to neutralize any poetential surgery litigation by unhappy or outraged disc surgey patients.

The story doesn’t end there, however.  The AHCPR soon faced great political pressures to justify its guidelines and other future guidelines they were planning.  Edward Seljestos, M.D., of the American Asociation of Neurological Surgeons, said the panel had “overstepped [its bounds] regarding surgical treatment.”  I guess the fact that surgeons sat on the panel and that the current scientific research was reviewed on the subject really didn’t mean much.  A surgical group calling itself the “Center for Patient Advocacy,” as one article put it, then began an “effort to chop the AHCPR off at the knees.”  Stoically, the AHCPR moved forward through all of these pressures on plans to develop headache guidelines — more exciting news for us chiropractors, as we know that we have effectively helped many patients with headaches and have some decent literature to back it up.  They had contracted with Duke University’s Center for Health Policy Research and Education and would again involve a multidisciplinary panel of experts in the field (this time 18 — one of which was a chiropractor).  But our visions of increased validation for what we do were soon doused, or as one news article vividly worded it, “Then came the axe.”

The article continued:  “The Republican-controlled Congress, responding to pressure from medical groups, cut the agency’s budget in half.  The headache guidlines never got off the ground.  In April of 1996, six months after the release of the acute back pain guidelines, the AHCPR announced it was no longer in the business of developing health care guidelines.  AHCPR administrator Clifton Gaus, Sc.D., said the agency’s staff had ‘consulted extensively with public- and private-sector guideline users’ (eg. surgeons) and said the ‘their message is clear:  they are seeking the scientific foundation from which they can develop their own high-quality, evidence -based guidelines.’  So much for multidisicplinary panels.”

I think its fair to say that our “headache” was in full swing by now.  But just when it looked like there was no relief in sight, we found out that before the financial plug was pulled, the team of experts for the headache guideline had actually completed the first draft of the diagnosis and treatment  section of their report.  The work unfortunately sat on a shelf and was never released as guidelines.  Later on however, the work was dusted off and revisited, this time with a tighter budget — forcing them to narrow the scope of the report to strictly migraine headaches.  Instead of being published as guidelines, they were transformed into  a set of seven, stand-alone “evidence reports.”

Frustrated that much of the work by the headache panelists had been supressed due to lack of funding, the Foundation for Chiropractic Education and Research (FCER), along with the National Chiropractic Mutual Insurance Company, ponnied up the dough to have the researchers at Duke University complete the foundational work they had started regarding treatment alternatives for two other types of common headaches:  tension and cervicogenic (arising from the neck).  Their report entitled Evidence Report:  Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache, was just recently released.

The evidence in the report was clear:  1) Spinal manipulation appeared to result in immediate improvement in severity in patients with cervicogenic headaches.  2) When compared to massage, manipulation resulted in sustained improvement in headache frequency and severity in patients with cervicogenic headaches.  3) During the four-week period after treatment ceased, patients who had received manipulation for tension-type headaches were significantly better than those who had taken amitriptyline for both headache frequency and severity.

The FCER stated that “even though further research is desirable — and manditiory — this report clearly positions chiropractic as a viable treatment alternative that lacks the detrimental and sometimes fatal side effects of conventional treatment options for managing tension and cervicogenic headache patients.  Compared to other physical treatment methods (including physiotherapy, acupuncture, and electrical stimuation), the evidence supporting chiropractic appears to be more robust.”

Wondering if chiropractic can help your particular headache?  Arrange for a consultation with your local chiropractor.  Want to read the entire 188-page report or the shorter “executive report”?  Log on to http://www.fcer.org.  As for our headache, we are feeling much better now, thank you.

____________
Sources used for this article:
AHCPR & Duke to produce headache evidence reports.  Dynamic Chiropractic 15 (12). 1997.
The AHCPR undergoes reconstructive surgery.  Dynamic Chiropractic 17(18).  1999.
Bigos, et. al.  Acute low back problems in adults.  Clinical practice guidelines no. 14.  AHCPR Publication No. 95-0642. Rockville, MD:  Agency for Health Care Policy and Research, Public Health Services, U.S. Department of  Health and Human Services.  December 1994.
Duke university releases headache evidence report. Dynamic Chiropractic.  19(06). 2001.
Federal headache guideline panel formed. Dynamic Chiropractic.  13(14). 1995.
Kelly.  Chiropractic for headache relief.  Dynamic Chiropractic.  19(06).  2001.
McAndrews.  New study on headaches lauds spinal manipulation.  Advance.  22(1). 2001.
McCrory, et. al.  Evidence Report:  Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache.  Duke University Evidence-based Practice Center for Clinical Health Policy Research.  Durham, North Carolina, 2001.
Wilk.  Speaking my mind:  why the AMA rejected the AHCPR low back guidelines. Dynamic Chiropractic. 15(26).  1997.
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