Recent Studies Focusing
on Chiropractic
The Wilk vs. AMA
(American Medical Association) Lawsuit
Another inquiry that further validated chiropractic came
about through an antitrust suit filed by four members of the chiropractic profession
against the American Medical Association (AMA). and a number of other medical
organizations in the United States (Wilk et al v. AMA et al, No.90-542, October 1990).
In 1987, following 11 years of legal action, a federal
appellate court judge ruled that the AMA had engaged in a "lengthy, systematic,
successful and unlawful boycott" designed to restrict cooperation between MDs and
chiropractors in order to eliminate the profession of chiropractic as a competitor in the
United States health care system. During the preceedings it was shown that the AMA
attempted to :
- Undermine Chiropractic schools
- Undercut insurance programs for Chiropractic patients
- Conceal evidence of the effectiveness of Chiropractic care
- Subvert government inquires into the effectiveness of
Chiropractic
- Promote other activities that would control the monopoly
that the AMA had on health care
(This was upheld by the 7th United States
Circuit Court of Appeals.)
The AMA offered a patient care defense; however, data from
Workmen's Compensation Bureau studies served to validate chiropractic care. Specifically,
studies comparing chiropractic care to care by a medical physician were presented which
showed that chiropractors were "twice as effective as medical physicians, for
comparable injuries, in returning injured workers to work at every level of injury
severity."
The settlement of the suit included an injunctive order in
which the AMA was instructed to cease its efforts to restrict the professional association
of chiropractors and AMA members. The AMA was also ordered to notify its 275,000 members
of the court's injunction. In addition, the American Hospital Association (AHA) sent out
440,000 separate notices to inform hospitals across the United States that the AHA has no
objection to allowing chiropractic care in hospitals.
Since the court findings and conclusions were released, a
growing number of medical doctors, hospitals, and health care organizations in the United
States have begun including the services of chiropractors.
Numerous research studies and various government inquiries
have resulted in increasingly widespread recognition of chiropractic, and generally
support the efficacy of chiropractic treatment. Excerpts from some of these studies have
been highlighted below.
The Agency for Health Care Policy
and Research
On December 8, 1994, The Agency for Health Care Policy and
Research (AHCPR) of the U.S. Department of Health and Human Services, released an
extensive study of diagnostic and treatment methods for acute low back pain. This
condition is the most common health complaint experienced by working Americans today, and
a condition which costs the economy at least $50 billion a year in lost wages and
productivity.
The AHCPR panel -- a 23-member committee of medical
doctors, nurses,chiropractic doctors, experts in spine research, physical therapists, a
psychologist, an occupational therapist and a consumer representative -- concluded, among
other things, that:
 spinal manipulation is
a recommended treatment for acute low back problems in adults;
conservative treatment such as manipulation should be
pursued -- in most cases -- before surgical interventions are considered;
prescription drugs such as oral steroids, antidepressant
medications and colchicine are not recommended for acute low back problems.
Canadian Studies on Chiropractic - The Manga Report
A major report on the effectiveness of chiropractic
treatment was published in 1993. Tile report, entitled The Effectiveness and
Cost-Effectiveness of Chiropractic Management of Low-Back Pain, was funded by the
Ministry of Health in Ontario to assess the most appropriate use of health care resources.
The Ministry was particularly interested in reducing the
incidence of work-related injuries and in improving the rehabilitation of disabled and
injured workers. The report stated that in the past year, "twelve to thirty percent of people in modern industrialized
societies reported low back pain.'
In light of these concerns, a massive literature review on
the effectiveness and cost effectiveness of chiropractic treatment was undertaken by an
independent panel of researchers associated with the University of Ottawa. Their findings,
outlined below, overwhelmingly support the efficacy and cost-effectiveness of chiropractic
for the treatment of low-back pain:
The report concluded with various recommendations including
fully integrating chiropractic services into the health care system, shifting policy to
encourage and prefer chiropractic services for most patients with low-back pain, employing
chiropractors in tertiary hospitals, and extending hospital privileges to chiropractors.
The following are
summaries of additional Canadian studies on Chiropractic:
A
study of spinal manipulation involving 283 patients with chronic low-back and leg pain was
conducted at a "specialized university back pain clinic reserved for patients who
have not responded to previous conservative or operative treatment" located at the
University of Saskatchewan in Saskatoon, Saskatchewan. In this study, which involved
research conducted by both a medical doctor and a chiropractor, all patients were
initially classified as totally disabled. Daily spinal manipulations were administered and
the effects of this treatment were assessed at one month and at three months. Results
revealed that 81% of the patients became symptom free or achieved a state of mild
intermittent pain with no work restrictions. (Kirkaldy-Willis, Cassidy 1985).
A study of 744 patients
with neck and back pain who had been referred from hospitals, private practice
specialists, general practitioners, and chiropractors analyzed tile effectiveness of
chiropractic manipulation. The results revealed that 36% of the patients recovered (became
symptom-free with no work restrictions), 34.5% became much improved (mildly symptomatic
and able to function normally), 7.3% slightly improved (possible activity restrictions),
21.6% showed no change, and 0.6% became worse, The study also revealed that "post-
surgical patients do very well under chiropractic care, and in fact at this center,
patients are routinely referred back to us three months after surgery for maintenance
care" (Potter 1977).
The Back Pain Clinic at
the Royal University Hospital in Saskatoon, Saskatchewan, reviewed literature pertinent to
"Side Posture Manipulation for Lumbar Intervertebral Disk Herniation." The
authors of the study concluded that "the treatment Intervertebral disk herniation by
side posture manipulation is both safe and effective" (Cassidy et al. 1993).
Other Studies on Chiropractic
In addition to the Canadian studies previously cited, many
other studies have explored chiropractic treatment. These have focused on tile
effectiveness of chiropractic treatment for back pain, for work-related Injuries, and for
other disorders. The following is a brief summary of some of these studies:
RAND, a non-profit
research organization, has completed three studies in the United States on chiropractic,
with a fourth study currently underway.
- The first study, a population-based estimate concerning the
use of chiropractic services, reported in the American Journal of Public Health, that
"chiropractors deliver a substantial amount of health care to the U.S. population,
and there are significant geographic variations in the rate and intensity of use of
chiropractic services" (Skekelle 1991).
- The second study, "Spinal Manipulation for Low-Back
Pain," published in the Annals of Internal Medicine, affirmed that spinal
manipulation is of benefit to some patients with acute low-back pain (Shekelle and Adams
1992).
- The third study created two sets of appropriateness ratings
for spinal manipulation. One set of ratings was developed by a multi-disciplinary panel
and the other set was prepared by an all-chiropractic panel (Shekelle et al. 1992).
- The fourth study, currently underway, is to determine the
types of health case problems for which people seek chiropractic care and the types of
care people receive from chiropractors. This study is expected to be completed in 1994.
In Australia, a 12-month
study conducted by the Australian Centre for Chiropractic Research included all
work-related low-back pain claimants. Individuals were identified who received care either
from a chiropractor or a medical practitioner. The results indicated that:
- When chiropractic management was chosen fewer claimants
required compensation and fewer compensation days were taken
- When medical management was chosen, the average payment
per claim was greater and a greater number of patients regressed to chronic status (Ebrall 1992).
A study reported in the
British Medical Journal included 741 patients between the ages of 18 and 65 who suffered
from chronic or severe back pain and who sought care in chiropractic and hospital
out-patient clinics. After two years of patient monitoring, researchers concluded that
"for patients with low-back pain in whom manipulation is not contraindicated,
chiropractic almost certainly confers worthwhile, long-term benefit in comparison with
hospital out-patient management" (Meade et al. 1990).
Researchers conducted a
study of workers' compensation cases in Florida and concluded that "a claimant with a
back-related injury, when initially treated by a chiropractor versus a medical doctor, is
less likely to become temporarily disabled, or if disabled, remains disabled for a shorter
period of time; and claimants treated by medical doctors were hospitalized at a much
higher rate than claimants treated by chiropractors" (Wolk 1988).
From a survey of those
receiving care from health maintenance organizations (HMOs) in Washington state it was
concluded that "...patients of chiropractors were three times as likely as patients
of family physicians to report that they were satisfied with the care they received for
low-back pain... Chiropractic patients were also more likely to have been satisfied with
the amount of information they were given and to believe their doctor was concerned about
them" (Cherkin and MacComack 1989)
"Family Physicians,
Chiropractors, and Back Pain," is the title of an article published in the Journal of
Family Practice (November 1992), addressing a comparative United States study of patients
of family physicians and chiropractors. The article stated that "the number of days
of disability for patients seen by family physicians was significantly higher (mean 39,7)
than for patients managed by chiropractors (mean 10.8)" (Curtis and Bove 1992). A
related editorial published in We same issue of the Journal of Family Practice stated that
family physicians should accept the fact that "...spinal manipulation is one of the
few conservative treatments for low-back pain that have [sic] been found to be effective
in randomized trials. The risks of complications from lumbar manipulation are also very
low" (Cherkin 1992). The latter conclusion is supported by a study published by the
Chiropractic Journal of Australia which reported that "a descriptive analysis of
obtainable literature on complications from low-back SMT (spinal manipulation treatment)
from 1911 to 1991 indicates that, on the average, less than one case per year occurs"
(Terrett and Kleynhans 1992).
The Journal of
Manipulative and Physiological Therapeutics, published in the United States, reported
results of a study of women between the ages of 20 and 49 with a history of dysmenorrhea
(painful menstruation); "
- SMT may be an effective and safe non-pharmacolocical
alternative for relieving the pain and distress of primary dysmenorrhea, at least for a
short period of time after treatment" (Kokjohn et al. 1992).
A number of United States
clinical studies cite success rates ranging from 72% to 90% for the treatment of
headaches utilizing spinal manipulation therapy. For example, a study reported in the
American Chiropractic Association's Journal of Chiropractic reported that 74.6% of
patients with recurring headaches, including those experiencing migraines, were either
cured or experienced reduced symptomatology associated with their headaches after
receiving chiropractic manipulation. Most importantly, the success rate was maintained two
years after treatment ended (Wight 1978).
A number of studies have
documented the effectiveness of chiropractic treatment for a variety of other conditions
including soft tissue injuries and viscera' disorders (Plaugher 1993; Lewit 1985; and Korr
1978).
Studies Focusing on the
Cost-Effectiveness of Chiropractic
Historically, chiropractors have promoted chiropractic
management of back pain as a cost effective approach to alleviating this condition. The
following studies support this assertion:
A study conducted in the
United States involving 395,641 patients with one or more of 493 neuromusculoskeletal
conditions was undertaken to compare the health care costs of patients who have received
chiropractic treatment to those treated solely by medical or osteopathic physicians. The
results showed that "patients receiving chiropractic care experienced significantly
lower health care costs ... (with) total cost differences on the order of $1000 over the
2-year period ..." The report concluded that"... these preliminary results
suggest a significant cost-saving potential for users of chiropractic care." The
report of the study also suggests the need to re-examine insurance practices and programs
relative to chiropractic coverage (Stano 1993).
The Florida study on
workers' compensation claims, previously cited in reference to back pain, found that
"the estimated average total cost of care, computed across all the major categories
of treatment cost, was substantially higher for medical patients compared with
chiropractic patients..." The authors of the study included that chiropractic care is
more cost-effective in the treatment of work-related back injuries than standard medical
care (Wow 1988).
A 1988 workers'
compensation study conducted in Utah assessed the total cost per case of chiropractic care
versus medical care for conditions with identical diagnostic codes. The results indicated
that costs were significantly higher for medical claims than for chiropractic claims, In
addition, the number of work days lost for those receiving medical care was nearly 10
times higher than for those who received chiropractic care (Jarvis, Phillips, and Morris
1991).
A comparison of the cost
of chiropractic care versus the cost of medical care for various health conditions
(predominantly low-back pain, spinal-related sprains, strains, dislocations, arthritis,
and disc disorders), revealed that "chiropractic is a lower cost option for several
prominent back-related ailments ... If chiropractic care is insured to the extent other
specialists are stipulated, it may emerge as a first option for patients with certain
medical conditions. This could very well result in a decrease in overall treatment costs
for these conditions" (Dean and Schrnidt 1992),
A review of data from
over two million users of chiropractic care in the United States was reported in the
Journal of American Health Policy. Initial analysis indicated that "chiropractic
users tend to have substantially lower total health care costs" and
"chiropractic care reduces the use of both physician and hospital care" (Stano
et al. 1992).
A workers' compensation
study conducted in Oregon (1990) evaluated the loss of working time incurred by
chiropractic (DC) and medical (MD) claimants with disabling low-back work-related
injuries. Authors of the study concluded that "the median time loss days for cases
with comparable clinical presentation (severity) was 9.0 for DC cases and 11.5 for MD
cases. Chiropractic claimants had a higher frequency of return to work with one week or
less of time loss." (Nyiendo 1991).
A study, published in
1992, compared the cost-effectiveness of chiropractic care to medical care in the
commonwealth of Virginia. The report of the study indicated that chiropractic:
- has minimal cost-increasing effects on insurance and may in
fact reduce insurance costs.
- provides important therapeutic benefits at economical costs.
This study also recommended that chiropractic care be a
widely available form of health care, and noted that it is a growing and widely used
component of the health care sector (Schifrin 1992).
Utilization and Public Opinion
Surveys
Additional studies have assessed the utilization and
acceptance of chiropractic services throughout Canada and the United States. A few of
these studies are described in subsequent paragraphs:
A survey in the province
of Ontario revealed that a majority of MDs in family practice (62%) were referring
patients to chiropractors. Nearly half of these MDs (42.3%) had been referring
patients for the past 1-5 years, with the referral rate being slightly higher among MDs
who had graduated before 1960 (60%) and between 1960 and 1980 (63%) than for those who had
graduated in the past 10 years (53.8%). In addition, the study revealed that 9.5% of these
MDs had received chiropractic care themselves (Patel-Christopher 1990).
A Gallup poll conducted
in the United States and reported in March of 1991 examined the attitudes and behaviors of
both users and nonusers of chiropractic services. Of the users of chiropractic services:
- 90% felt chiropractic treatment was effective;
- more than 80% were satisfied with their treatment;
- nearly 73% felt most of their expectations had been met
during their visits;
- 68% would see a chiropractor again for treatment of a
similar condition;
- 30% would likely see a chiropractor again for other
conditions.
Of the non-users of chiropractic services:
- 62% indicated they would see a doctor of chiropractic for a
problem applicable to chiropractic treatment;
- 23% reported that someone in their household had been
treated by a chiropractor, and nearly 80% of those were satisfied with that treatment.
A 1983 survey of North
Dakota residents, also conducted by the Gallup Organization, indicated that awareness and
use of chiropractic services in the state were very high. Nearly 100% of the residents had
heard of chiropractors, and almost half of the residents (49%) reported that they had been
examined or treated by a chiropractor at some time. One in six residents (17%) had seen a
chiropractor in the past year.
Government and Legal Inquiries
Chiropractic is legally recognized or allowed to be
practiced without official sanction in approximately 39 countries. Varying degrees of
investigation into the appropriateness of chiropractic treatment preceded the official
stance of these countries.
In recent years, the Canadian and United States governments
have begun requiring that health professionals provide guidelines for use in assessing the
appropriateness of care. In an attempt to address this requirement, 33 chiropractors in
North America were invited to participate in a conference held in early 1992 at the Mercy
Center in Burlingame, California. A publication released in early 1993 entitled,
Guidelines for Chiropractic Quality Assurance and Practice Parameters, related the
proceedings of that conference.
During April 1993, the Canadian Chiropractic Association
sponsored a conference in Toronto to establish clinical guidelines for chiropractic
standards of care in Canada. The participating members included chiropractors from various
chiropractic organizations throughout Canada. Results of this conference will be published
in a report scheduled for release at the end of 1993.
The New Zealand Commission of
Inquiry
Another particularly significant study of chiropractic was
conducted by the New Zealand Commission of Inquiry. In its 377-page report to the House of
Representatives, the Commission states that their report followed an extended (two-year)
inquiry which at that time was "probably the most comprehensive and detailed
independent examination of chiropractic ever undertaken in any country." Excerpts
from the Commission's report follow:
"We entered into our
inquiry in early 1978. We had no clear idea what might emerge. We knew little about
chiropractors. None of us had undergone any personal experience of chiropractic treatment.
If we had any general impression of chiropractic it was probably that shared by many in
the community: that chiropractic was an unscientific cult, not to be compared with
orthodox medical or paramedical services. We might well have thought that chiropractors
were people with perhaps a strong urge for healing, who had for some reason not been able
to get into a field recognized by orthodox medicine and who had found an outlet outside
the fringes of orthodoxy.
"But as we prepared
ourselves for this inquiry it became apparent that much lay beneath the surface of these
apparently simple terms of reference. In the first place it transpired that for many years
chiropractors had been making strenuous efforts to gain recognition and acceptance as
members of the established health care team. Secondly, it was clear that organized
medicine the New Zealand was adamantly opposed to this on a variety of grounds which
appeared logical and responsible. Thirdly, however, it became only too plain that the
argument had been going on ever since chiropractic was developed as an individual
discipline in the late 1800's, and that in the years between then and now the debate had
generated considerable more heat than light.
"By the end of the inquiry we
found ourselves irresistibly and with complete unanimity drawn to the conclusion that
modern chiropractic is a soundly-based and valuable branch of the health care in a
specialized area..."
Specific conclusions of the Commission's report, based on
investigations in New Zealand, the United States, Canada, the United Kingdom, and
Australia, were as follows:
Modern chiropractic is
far from being an "unscientific cult"
Chiropractic is a branch
of the healing arts specializing in the correction by spinal manual therapy of what
chiropractors identify as biomechanical disorders of the spinal column. They carry out
spinal diagnosis and therapy at a sophisticated and refined level.
Chiropractors are the
only health practitioners who are necessarily equipped by their education and training to
carry out spinal manual therapy.
General medical
practitioners and physiotherapists have no adequate training in spinal manual therapy,
though a few have acquired skill in it subsequent to graduation.
Spinal manual therapy in
the hands of a registered chiropractor is safe.
The education and
training of a registered chiropractor are sufficient to enable him to determine whether...
the patient should have medical care instead of or as well as chiropractic care.
Spinal manual therapy can
be effective in relieving musculoskeletal symptoms such as back pain, and other symptoms
known to respond to such therapy, such as migraine.
In a limited number of
cases where there are organic and/or visceral symptoms, chiropractic treatment may provide
relief, but this is unpredictable, and in such cases the patient should be under
concurrent medical care if that is practicable.
Although the precise
nature of the biomechanical dysfunction and... the precise reasons why spinal manual
therapy provides relief have not yet been scientifically explained, chiropractors have
reasonable grounds based on clinical evidence for their belief that symptoms of the kind
described above can respond beneficially to spinal manual therapy.
In the public interest
and in the interest of patients there must be no impediment to full professional
cooperation between chiropractors and medical practitioners.
Subsequent to the New Zealand Inquiry, the Australian
Federal Minister of Health requested that a Committee be formed to consider extending the
scope of (government-funded) Medicare benefits for certain services, including
chiropractic.
The Committee accepted all of the findings of the New
Zealand commission, and also noted the "significant shift in the last decade in
attitude ... towards the issue of scientific research" in chiropractic. It also
recommended funding for chiropractic in hospitals and other public institutions, and
endorsed greater philosophical unity in chiropractic.
Swedish government's Commission on
Alternative Medicine
Another noteworthy study was conducted in 1987 by the
Swedish government's Commission on Alternative Medicine. It reached conclusions consistent
with the New Zealand and Australian studies and also stated that:
Chiropractors with the
Doctor of Chiropractic degree should become registered practitioners and be brought within
the national insurance system.
The university-level
training of DCs is equivalent to Swedish medical training.
DCs have competency in
differential diagnosis and should be regulated on a primary care basis.
Measures to improve
cooperation between chiropractors, registered medical practitioners and physiotherapists
are vital to the public interest
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