In December 1994 the FCER and the chiropractic profession took great pride in what it regarded as the crown jewel to what was until then a nearly self-supporting effort to document and publish good low back pain research: the emergence from the Agency for Health Care Policy and Research (AHCPR) of Clinical Practice Guideline No. 14: Acute Low Back Problems in Adults.1 It showcased the efforts of a multdisciplinary panel, including chiropractic representation, to provide a rigorous evaluation of the published literature, encompassing all the means available from various health care providers to manage low back pain. The publication of these guidelines, strenuously contested by special interest groups representing surgical and other aspects of medical care which fared poorly in the ratings, in many ways symbolized the emergence of chiropractic from the alternative to the mainstream venues in the treatment of the lower back, causing many barriers to third-party reimbursement for chiropractic services to crumble. A major portion of the key research that was able to secure this recognition was funded by the FCER and NCMIC.
It was with bated breath that the FCER, NCMIC and other chiropractic research groups participated in - and awaited - the preparation of a similar set of guidelines from the AHCPR addressing the treatment of headache. Boline and Nelson had just published a major clinical trial that demonstrated that spinal manipulative therapy provided effective treatment in the treatment of tension headaches, without the side effects of amiltriptyline therapy to which SMT was compared. In addition, the effects of SMT appeared to be longer-lasting than those achieved with medication after the cessation of treatment.2 Furthermore, of the headache trials reviewed in the literature since 1966, this particular study was rated the highest in methodological quality.3 Like much of the back pain research leading to the AHCPR panel's recognition of spinal manipulation in Clinical Practice Guideline No. 14, Boline and Nelson's study was made possible by a grant from FCER.
Indeed, an impressive array of research from such individuals as Lewit,4 Vernon,5 Droz,6 Turk,7 Jensen,8 Whittingham,9 Mootz10 and Nilsson11 lay waiting in the journals, and it was with considerable pride that I was able to write the public testimony that George McClelland presented before an AHCPR panel on October 31, 1995, in preparation for the writing and release of another set of clinical guidelines. We had every reason to believe that spinal manipulation would again achieve high marks in the AHCPR panel review, gaining much-deserved public recognition in a second clinical area for spinal manipulation.
We all know, of course, that members of the chiropractic research and clinical community, like so many anxious relatives waiting on the New York piers for the arrival of the Titanic, never saw their ship come in. Special interest groups that felt stung by the back pain guidelines not only managed to scuttle the production of the headache guidelines by the AHCPR, but also took the AHCPR out of the business of developing any further guidelines and nearly succeeded in torching the entire agency. In the middle of 1996 we were informed that no additional guidelines would be produced by the AHCPR, and that the material produced by the headache panel had been impounded at the Center for Health Policy Research at Duke University.
For nearly three more years the FCER stubbornly clung to these guidelines like barnacles to a pier. Through a number of phone calls to Duke, the FCER was able to recommend several reviewers to evaluate and edit the material as it was transmogrified into a series of "evidence reports," then reissued as monographs from Duke with the AHCPR imprimatur. There were further funding cuts and delays, until what was to be disseminated by Duke was only on the topic of migraine headache - which, at the time the AHCPR panel had originally assembled its evidence (1995), had much weaker representation in the literature in the area of spinal manipulation.12-14 Spinal manipulation received virtually no recognition in what emerged earlier this year, as one could surmise from the following titles which give this unfortunate secret away:
Technical Review 2.1: Resource Utilization and Costs for Treatment of Chronic Headache; Technical Review 2.2: Behavioral and Physical Treatments for Migraine Headache;
Technical Review 2.3: Drug Treatments for the Prevention of Migraine Headache;
Technical Review 2.4: Self-Administered Drug Treatments for Acute Migraine Headache;
and Technical Review 2.5: Parenteral Drug Treatments for Acute Migraine Headache.
You get the picture: Out of 1,175 pages of text in these reports, only
15 dealt with physical treatments, and only
two mentioned manipulation or mobilization, solely due to the Parker investigation.
13 Unfortunately, Craig Nelson's excellent migraine study (which yielded positive results very similar to the tension headache study conducted by the same research team, as discussed earlier) was published
after these evidence reports were written and could not be included. With this type of "information filtering" (some might call it censorship), I'm inclined to quote that favorite Brooklyn axiom: "We was robbed!"
This is precisely where the FCER and Duke stepped in. With further calls and correspondence to the Duke Center, I was able to secure a proposal from the research team (the director, co-director, and research associates at the Center for Clinical Health Policy Research and Evidence-based Practice Center, plus various consultants) to resurrect and update the literature file on both tension-type and cervicogenic headache - precisely those portions that had been purged from the earlier evidence reports, but which appeared to hold such promise in the earlier work of the AHCPR multidisciplinary panel's findings. The result, of course, is the recently issued Evidence Report on Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache, available from FCER and soon to be submitted in abbreviated form to a peer-reviewed journal.
To cut a long story short, I believe that through this persistent effort, both the FCER and Duke have managed to circumvent what had been a bitterly disappointing roadblock to the proper dissemination of the rigorous research supporting the efficacy of chiropractic in an area beyond low-back pain. This is precisely the type of program that we have sought to mount in support of the proper conduct and dissemination of research pertaining to back pain, headache, or other conditions or mechanisms worthy of study. To conclude, this particular tale seems to have headed toward an encouraging ending, and hopefully there will be many others like it originating from this office. This type of effort would not be possible, however, without the support from the chiropractic community that FCER and NCMIC have been able to appreciate for so many years.
References
- Bigos S, Bowyer O, Braen G, et al. Acute Low-Back Pain Problems in Adults. Clinical Practice Guideline No. 14, Agency for Health Care Policy and Research Publication 95-0642. Rockville, MD: AHCPR, 1994.
- Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amiltriptyline for the treatment of chronic tension-type headaches: A randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1995;18(3):148-154.
- Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: A systematic review of the literature. Spine 1996;21(15):1746-1760.
- Lewit K. Ligament pain and anteflexion headache. European Neurology 1971;5:365-378.
- Vernon H. Manipulative therapy in the chiropractic treatment of headaches: A retrospective and prospective study. Journal of Manipulative and Physiological Therapeutics 1982;5:109-112.
- Droz JM, Crot F. Occipital headaches: Statistical results in the treatment of vertebragenous headache. Annals of the Swiss Chiropractic Association 1985; VIII:127-136.
- Turk Z, Ratkolb O. Mobilization of the cervical spine in chronic headaches. Manual Medicine 1987;3:15-17.
- Jensen OK, Nielsen FF, Vosmar L. An open study comparing manual therapy with the use of cold packs in the treatment of post-traumatic headache. Cephalalgia 1990;10:241-250.
- Whittingham W, Ellis WB, Molyneux TP. The effect of manipulation (toggle recoil technique) for headaches with upper cervical joint dysfunction: A pilot study. Journal of Manipulative and Physiological Therapeutics 1994; 17(6): 369-375.
- Mootz RD, Dhami MSI, Hess JA, Cook RD, Schorr DB. Chiropractic treatment of chronic episodic tension-type headache in male subjects: A case series analysis. Journal of the Canadian Chiropractic Association 1994;17:369-375.
- Nilsson N. A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 18(7):435-440.
- Wight S. Migraine: A statistical analysis of chiropractic treatment. Journal of the American Chiropractic Association 1987;3:15-17.
- Parker GB, Tupling H, Pryor DS. A controlled trial of cervical manipulation for migraine. Australian and New Zealand Journal of Medicine 1987;8: 589-593.
- Stodolny J, Chmielewski H. Manual therapy in the treatment of patients with cervical migraine. Journal of Manual Medicine 1989;4:49-51.
- Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. The efficacy of spinal manipulation, amiltriptyline, and the combination of both therapies for the prophylaxis of migraine headache. Journal of Manipulative and Physiological Therapeutics 1998; 21(8):511-519.
Anthony Rosner,PhD
Brookline, Massachusetts rosnerfcer@aol.com
