An Adjustment from Your M.D.?

179920_surgeon_3[originally published in KCN, September 2005]

Ever think you’ll see the day when you’ll visit your friendly M.D. and have him roll up his sleeves and adjust your spine instead of reaching for his prescription pad? Don’t hold your breath — they’ve already studied the possibility.

Chiropractic received an incredible boost in 1994 when the United States’ Agency for Health Care Policy and Research (AHCPR), a branch of the Department of Health and Human Services, released their Clinical Practice Guidelines for Acute Lower Back Pain in Adults.  The guidelines were written by a panel of lower back pain experts ranging from orthopedic surgeons to pharmacists — occupational therapists to psychologists.  They even had a couple of chiropractors.  This 23-member panel reviewed over 10,000 research articles pertaining to lower back pain.  Their goal was to find what treatment methods worked, while taking into consideration the risk factors involved and their relative costs.  Among other things, the panel concluded that spinal manipulation (the type of care delivered primarily 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.   Now mind you, the panel never specifically mentioned “chiropractic” in their conclusion.  But, since chiropractic is responsible for 94% of the spinal manipulations in this country, it didn’t take a brain surgeon to connect the two.  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.  This was a major endorsement for chiropractic and a blow to the allopathic profession.

It should come as no surprise that this news did not bring the same feelings of joy and elation to the medical doctors that the chiropractors were experiencing.  Lawsuits from angry surgeons were threatened, and six months later behind the scenes pressures abolished the AHCPR (despite the fact that they were midway through writing guidelines on headaches).  Interestingly, around the same time that the AHCPR was killed, our profession learned, via the Freedom of Information Act, that the branch of our government (Health and Human Services) that funded the lower back guidelines, ponied up 1.35 million of our tax dollars to fund a rather unusual study.   This study would “determine whether allopathic physicians [could] effectively integrate manual therapy, including spinal manipulation, into primary care practice.”  As one article on the subject so candidly put it, “…after years of condemning chiropractic health care, they now [planned] to bring spinal manipulation into the mainstream of allopathic medicine.”

Nearly five years later, the study finally hit the November 15, 2000 edition of the medical journal Spine.  Without launching into a ten-page article, let me just say, this was a very weird study.  Weird, in that, at first glance, one would might ascertain that the M.D.’s had conceded that spinal manipulation was obviously an effective form of treatment for acute lower back pain, and therefore, worthy of perhaps adding to their armature of patient care.  But when reading the article, and their related grant proposal, it became very clear that they just didn’t “get it.”

The first tip off was their view point that manual techniques were “simple” — their words, not mine.  Learning to adjust the spine was one of the hardest things I’ve ever learned how to do, and it took 4 years to learn it.  They ran their M.D.’s through a 2-day course.  And, to add insult to injury, they opted to train them in an older, outdated, crude style of manipulation that put the patient at undo risk because “it was easier for physicians to learn.”  This was outrageous!

I was impressed that they consulted chiropractic texts; from which they learned that successful treatment was dependent on an accurate mechanical diagnosis followed by specific therapeutic maneuvers.  This impressive feeling was quickly doused, however, when  they chose to disregard this advice and, instead, rationalized that a specific diagnosis beyond back pain really wasn’t necessary.  Because, in their “experience and observations,”  patients seem to get the same treatment anyway.  (Not true, by the way).   So, they came up with a “standard sequence of maneuvers” that was to be done on every patient — 5 maneuvers per side of the trunk and call me in the morning.  This was like shooting a gun (with very limited gun-handling experience) with a blindfold on.  Oh, did I mention that the study allowed them to prescribe medications if they wanted?  Turns out that 35% of the patients received narcotic analgesics and 68.5% received muscle relaxants.  What was the purpose of the study again??

Perhaps, they felt the need to fall back on their trusty meds because during their intensive 2-day manual therapy training, it was made very clear to them that  “the effectiveness of manual therapy for acute low back pain was not yet well validated.”  Not well validated?  Did they not read the AHCPR Guidelines?  Was it not these very guidelines that prompted this study in the first place?  Why bother?   At the end of the study we learned that only 43.4% of the patients in the manual therapy group actually received the “full dose” of care as initially planned.  The other ones were only given partial doses because of the physicians’ lack of confidence in what they were doing.  Some physicians  reportedly were concerned  about the effectiveness of the techniques, and what their patients might think.

Oh, by the way, the overall conclusion of the study was that it didn’t work.  Or put more eloquently:  “Limited training in manual therapy techniques [offered] very modest benefits compared with high quality (enhanced) care for acute low back pain.” [I love how they refer to their type of care… the type of care that was NOT recommended by the AHCPR Guidelines… as “high quality, enhanced, care”].

They should be grateful that they were able to use the word “benefit” in their conclusion, no matter how “modest” it might have been.  Instead, with their lack of adequate training and crude technique, they could have been reporting on the number of injuries.

So what did this study show us?  Was it a total waste of $1.35 million?  Well, maybe not.  Apparently, even the “modest benefits” that were seen were impressive enough to the participating MD’s that, two years after their limited training, most continued to use some of the manual techniques in their practice.  Having gone through the study they now found themselves performing more complete examinations, touching their patients more, relying less on narcotics, reducing their referrals to specialists, and increasing their referrals to chiropractors.

Interesting how a study that  reeked of disrespect,  turned out, in a weird kind of way, to show respect.  Well, I’m exhausted.  I need to get some rest  for this weekend’s crash course on spinal fusion surgery.  I have a patient scheduled for Monday.


Sources used for this article:
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.
Clum, Gerald. The latest stuff from Gerry:  personal commentary from the president of Life Chiropractic College West. Life Chiropractic College West website.  March 15, 1996.               
Curtis P, Carey TS, Evans P, Rowane MP, Garrett JM, Jackman A. Training primary care physicians to give l limited manual therapy for low back pain. Spine 2000;25:2954-2961.
Johnson, M.  Are medial adjustments in our future?  Dynamic Chiropractic.  July 3, 1995.            
Mertz, JA., president of the American Chiropractic Association.  Letter to the editor of Spine. re: training primary care physicians t give limited manual therapy for low back pain – patient outcomes.  December 2000.
Petersen, D.  Duh!  Teaching MDs not all it could be.  Dynamic Chiropractic.  December 14, 2000.
Training M.D.’s to adjust offers “little extra benefit,” study says.  Dynamic Chiropractic. December 14, 2000.
Triano to teach MD’s manipulation:  program to evaluate use of manual therapy by medical doctors.  The Chiropractic Journal.  May 1996.
Lamar, T. The Spinal Column:  Oh what a headache it has been.
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