Family Physicians Learn about Chiropractic Care

On Saturday, February 16, 2002, at the 54^th Annual Scientific Assembly of the California Academy of Family Physicians in San Francisco, I had the opportunity to offer a presentation on "Chiropractic in Family Practice." Of the 27 presenters, I was the only chiropractor to lecture at the conference of more than 400 physicians.

I felt it was imperative to clearly and concisely communicate to the family physicians in my audience a well-documented view of contemporary chiropractic. My goal was to establish that chiropractic is safe and effective, and that it is practical for medical doctors to refer patients with back pain, neck pain, and headaches to chiropractors to improve patient outcomes and satisfaction. This was quite a challenging and demanding responsibility, considering that I had only a 45-minute window in which to give my talk.

Because my address was the last in a long day of presentations, I had been concerned that only a handfull of doctors would be in attendance, but was pleased to find an audience of approximately 70 family physicians waiting expectantly in the lecture hall.

I projected my computer-generated slides onto a large screen and began the talk. There were several important goals to achieve. I wanted the physicians to understand that the demand for chiropractic is growing rapidly. A 2002 study in the Annals of Internal Medicine¹ reported that patient use of chiropractic has tripled in the last two decades. I wanted them to appreciate that patient satisfaction with chiropractic care is consistently high. In another 2002 study,² a survey of 1,257 chiropractic patients from six locations found that overall satisfaction with care was 87.⁴ percent. It was important that the medical audience appreciated that the growth and satisfaction with chiropractic care is only the tip of a large and impressive iceberg.

In the fall of 2001, two studies authored by researchers from Harvard Medical School^3,4 noted that complementary and alternative care (CAM) were perceived to be more helpful for chronic, disabling conditions (such as headache, neck and back conditions) than conventional medical care by patients who had used both medical and CAM services in the previous year. The authors concluded that people increasingly view medical doctors as only one member of the health care team. This is consistent with the trend toward increased autonomy and personal responsibility for one's own health.

The second paper,⁴ based on a large national survey, concluded: "The use of CAM therapies by a large proportion of the sample is the result of a trend that began at least a half century ago, and suggests that a continuing demand for CAM therapies will affect health care delivery for the foreseeable future. ... These results should dispel any suggestion that use has increased for only singular CAM modalities, or that the use of CAM is a passing fad associated with one particular generation. ...The trend of increased CAM use across all cohorts since 1950, coupled with the strong persistence of use, suggests a continuing increased demand for CAM that will affect all facets of health care over the next 25 yrs."

The findings from these current studies, published in some of the most highly regarded medical journals, help establish the popularity, increasing credibility and mainstreaming of complementary and alternative health care.

The next section of my presentation reviewed several important national and international multidisciplinary evidence-based guidelines that clearly acknowledge and recommend spinal manipulation for back problems, neck problems and headaches. A 2001 review of national guidelines⁵ on the management of low back problems from 11 countries, reported that eight of the 11 countries (USA, New Zealand, Finland, United Kingdom, Switzerland, Germany, Denmark, Sweden) recommended the use of spinal manipulation. I also presented the results from a 2001 publication from the prestigious Duke University Evidence-based Practice Center - Center for Clinical Health Policy Research⁶ on management of cervicogenic and tension-type headache (HA). This study found that spinal manipulation "appeared to result in immediate improvement in headache severity when used to treat episodes of cervicogenic HA compared to a placebo." It noted that "compared to soft-tissue therapies (massage), manipulation resulted in sustained improvement in HA frequency and severity." Furthermore, the study found that "although amitriptyline returned to near-baseline values for treatment outcomes four weeks after discontinuation with care, the manipulation group exhibited a sustained reduction in HA frequency and severity."

I also reviewed two recent studies on the effectiveness of spinal manipulation as prophylaxis for migraine headache.^7,8 I described some of the recently identified neurological pathways, including the convergence of afferent input from the upper cervical spine and the face at trigeminocervical nucleus,⁹ which explain how cervical manipulation may impact on the release of serotonin, and decrease the generation of the inflammatory cascade around intracranial blood vessels.

The last two topics focused on the safety of spinal manipulation based on several studies published in 2001,^10,11 and the type of patients medical doctors should consider referring who will most likely benefit from chiropractic care.¹² I also included a recent comparative study of the academic curriculum of three medical and three chiropractic colleges.¹³ This paper indicates that chiropractic college has more hours of classroom education than medical college (4,800 hours vs. 4,667 hours); that chiropractic students on average receive 200 hours more in anatomy, and 60 hours more of physiology than medical students.

I was pleased to find that the audience remained attentive for the duration of my presentation. The doctors were polite and inquisitive. They asked numerous questions, some challenging in tenor, others respectful and practical.

At the end of the lecture, the physician in charge of the presentations approached me pensively. "That was excellent. You really gave us a lot of food for thought," he said. This response, I thought, was about the best one could ask for from a brief review of chiropractic to an audience of medical doctors. Many doctors approached me to ask intelligent and pragmatic questions, and many thanked me for the presentation. A pair of family physicians excitedly told me that they were just starting a multidisciplinary practice that including a chiropractor, a physical therapist, and an exercise physiologist.

My overall impression of the experience is that the often-rigid barriers that have restricted communication and acceptance of chiropractic by the medical community are beginning to dissolve as communication improves and evidence accumulates. Having had the opportunity to lecture to medical audiences over the course of a decade, I believe that a considerable part of the resistance to acknowledging the value of chiropractic by the medical community was generational. As the number of younger physicians increases, the antagonism wanes.

It is important that chiropractors take every available opportunity to share with the medical community the current research on chiropractic. There is now such an accumulation of convincing, credible data that it has become increasing difficult for reasonable people to deny that there is substantial evidence that chiropractic is a safe and effective intervention that may not only be beneficial for neuromusculoskeletal types of problems, but may even induce a sense of well being,^14,15 relaxation,¹⁶ and, based on some recent studies, possibly improve cognitive processing.¹⁷

The future is bright. Acceptance, although belated and often begrudging, is here. There is a growing receptivity and openness in the medical community to consider the functional, neurological and mechanical approaches of chiropractic. The time has come for the medical and chiropractic communities, through mutual understanding and cooperation, to work closely together to optimize patients' health care and enhance their quality of life.

References

1. Meeker W, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002;136(3):216-27.
2. Coulter I, et al. Patients using chiropractors in North America: Who are they, and why are they in chiropractic care? Spine 2002; 27(3):291-298.
3. Eisenberg DM, et al. Perceptions about complementary therapies relative to conventional therapies among adults who use both: Results from a national survey. Ann Intern Med. 2001;135:344-351.
4. Kessler, et al. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med. 2001;135:262-268.
5. Koes B, et al. Clinical guidelines for the management of low back pain in primary care. An international comparison. Spine 2001; 26(22): 2504-2514.
6. McCrory, et al. Evidence report: Behavioral and physical treatments for tension-type and cervicogenic headache. 2001. Duke University Evidence-based Practice Center - Center for Clinical Health Policy Research. Spine 1994;19(7):858-86.
7. Nelson CF, et al. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. JMPT 1998;21(8):511-519.
8. Tuchin P, et al. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. JMPT 2000; 23(2):91-95.
9. Cramer GD. Anatomy of the cervical spine with respect to head pain. Top Clin Chiro 1998;5(1):1-10.
10. Terrett A. Current concepts in vertebrobasilar complications following spinal manipulation. NCMIC 2001.
11. Haldeman S, et al. Arterial dissections following cervical manipulation: the chiropractic experience. Can Med Assoc J 2001;165(7):95-6.
12. Shekelle P. Spine update: spinal manipulation. Spine 1994;19(7):858-86.
13. Coulter I, PhD et al. A comparative study of chiropractic and medical education. Alternative Therapies 1998;4(5):64-75.
14. Hawk C, et al. Chiropractic care for women with chronic pelvic pain: a prospective single-group intervention study. JMPT 1997;20(2):73-79.
15. Jay TC, et al. A chiropractic service arrangement for musculoskeletal complaints in industry: a pilot study. Occup. Med. 1998;48(6):389-395.
16. Goff PJ, McConnell E, Paone P. The effect of chiropractic adjustment on frontalis EMG potentials, spinal ranges of motion and anxiety level. Journal of Chiropractic Research and Clinical Inverstigation 1991; 7(1):4-9.
17. Kelly D, Murphy B, Backhouse D. Use of a mental rotation reaction-time paradigm to measure the effect of upper cervical adjustments on cortical processing: a pilot study. JMPT 2000;23(4):246-252.

Malik Slosberg,DC,MS
Pleasanton, California
Professor,
Life Chiropractic College West
www.slosberg.com