I have argued many times in this space that a solid foundation of research evidence is indispensable for building the future of chiropractic health care. That is certainly true, but sometimes it has to be delivered with the subtlety of a blowtorch. A prime example has been the profession's experience with the Veterans' Administration in incorporating chiropractic services within VA facilities.
The legislation that mandated this, a ringing recognition of the clinical evidence amassed on behalf of chiropractic and expertly presented to Capitol Hill by the ACA and other parties, initially stated:
"The effectiveness of chiropractic manipulation has been most clearly demonstrated in the acceleration of short-term recovery from acute low-back pain. In addition, several studies indicate that patient satisfaction in the relief of low-back pain is as great or greater with chiropractic than with other approaches, even when volunteer patients are randomly assigned to a treatment approach."1
As the logical extension of the Department of Defense, you would think that the Veterans' Administration would readily follow suit in adapting the DoD's inclusion of chiropractic services with first contact privileges and scope of practice in accordance with that allowed by state laws, itself the result of a lengthy and successful effort on the part of many chiropractic organizations. Unfortunately, the same type of bureaucratic and turf issues that one could argue led to the government's failure to forestall or even hint of the terrorist attacks last month in New York and Washington
2 turned this proposition into fantasy. Rather than a simple call to action with collaborative planning, this exercise at the VA turned into a religious experience.
Individuals in charge of the meetings the VA held over the past year and a half for the purpose of implementing this congressional mandate displayed foot-dragging that was more reminiscent of a performance of Richard III. The plan recommended by the VA over the summer stipulated that chiropractic services could be offered "for musculoskeletal problems of the spine," but only after "referral from a Department of Veterans Affairs (VA) primary clinician or others, as deemed appropriate." When presented with evidence supporting both first contact privileges and a broader scope of practice, the VA presented the mind-numbingly obfuscatory argument that their recommendation was only a "directive" rather than a "policy," which could simply be amended in due course - if only the chiropractic representatives present (including myself) could agree. They didn't, for reasons which should seem obvious and will only become more obvious.
Among the reasons the VA offered in its resistance to the evidence and the congressional directive included an attack against one of the primary journals publishing peer-reviewed evidence supporting the effectiveness of chiropractic. An individual (who shall remain nameless) challenged the credibility of the Journal of Manipulative and Physiological Therapeutics (JMPT) on the basis that in its history, it presented case studies documenting the chiropractic management of patients with multiple sclerosis and Parkinson's disease. To begin with, this journal happens to be included in the Index Medicus, the listing of which is obviously based more upon the journal's merits rather than any presumed shortcomings. Secondly, a study addressing tension headache and spinal manipulation published in the JMPT3 has been regarded by no less than three independent systematic literature reviews as being at or among the highest in quality of any of the randomized clinical trials evaluated.4-6 Again, this would hardly be the hallmark of a "low-rent" journal as implied these gratuitous remarks at the VA implied. And third, I would maintain that the case study remains an indispensable part of the fabric of medical evidence. (It has been suggested that our entire appreciation of the AIDS virus originated with the description of a single case of Kaposi's sacroma at a public bathhouse.7) It would appear that what we have witnessed at the VA has been evidence-based prejudice rather than evidence-based medicine.
Presented at the VA meetings as a major argument on behalf of comprehensive chiropractic inclusion was the NCMIC-funded and FCER-administered comprehensive study from a leading health policy think tank just published with major implications as to how primary care may be effectively delivered by chiropractors. Abt Associates of Cambridge, MA, convened two expert panels (one interdisciplinary, consisting primarily of allopathic physicians, and the other comprised entirely of chiropractors). Through a consensus process to develop a list of primary care activities, both concluded that with respect to a list of 53 primary care functions found to occur daily in medical offices, chiropractors are capable of making diagnoses in 92 percent of these activities and making therapeutic contributions in more than 50 percent of them.
Both panels agreed upon the terms of taxonomy used for primary care, which emphasize such aspects as information gathering with assessments; screening and prevention activities; additional diagnostic procedures and techniques; counseling and education; management of acute and chronic illnesses; services to special population groups such as geriatric or pregnancy care; coordination and referrals; and counseling on complementary modalities of care. This represents the overcoming of a substantial barrier built upon the paradigms of healthcare that separate the chiropractic and allopathic physician communities. It addresses a basic suspicion by the authors of the study that "much of what is generally considered primary could be provided by professionals other than medical doctors (MDs) and osteopaths (DOs)."8 It also confirms other recent findings that between 60-90 percent of diagnoses seen in outpatient primary care settings can be handled by certain alternative providers.9 It also underscores the importance of distinguishing primary health care from primary medical care.10
A predominating aspect of this study was the overarching sense of agreement between the allopathic and chiropractic physicians with respect to the scope of primary care activities. This would bode well for the capacity of chiropractors and medical doctors to work together in the areas of patient care and organizational strategy.
Although results of the Abt study would seem to completely contradict the directive, the VA seemed about as willing to accept this evidence as the Taliban was disposed to turning over Osama bin Laden to the U.S. government. The fact remains from this study and elsewhere that the initial recommendations from the VA were incompatible with an emerging body of credible scientific evidence.
Fortunately, this tale may yet have a happy ending. On October 23, the full House voted to approve legislation that in effect, overrides the nonsense encountered in meetings with the VA thus far. The chiropractic provision in this bill includes, among other features:
- primary care provider status, allowing enrollees to select a doctor of chiropractic as their primary care provider and thus assuring the direct contact status of practicing chiropractors;
- authorization to the Department of Veterans Affairs to hire doctors of chiropractors as staff; and
- requirement of the Secretary of the Department of Veterans Affairs to provide training and chiropractic related materials to educate other healthcare providers regarding the benefits of the appropriate use of chiropractic services.
While this legislation has many hurdles to overcome to become law, it does represent at the very least a willingness on the part of some individuals to both listen to and accept the arguments advanced by the chiropractic profession. Much of this has had to do with primary care issues, at one time a subject that many regarded as taboo vis-à-vis chiropractic care. It is only with the continuing development of research evidence such as what we do at FCER and its effective delivery to its intended target can we look forward to the survival of chiropractic healthcare.
References
- Veterans Millennium Health Care Act, H.R. 2116. AOL News, www.prnewswire.com, September 27, 1999 (Ultimately became H.R. 2792).
- Hersh S. The New Yorker, October 8, 2001.
- Boline P, 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 21(15):1746-1760.
- Kjellman GV, Skagren EI, Oberg BE. A critical analysis of randomised clinical trials on neck pain and treatment efficacy: A review of the literature. Scandinavian Journal of Rehabilitative Medicine 1999;31:139-152.
- Bronfort G, Assendelft WJJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headache: A systematic review. Journal of Manipulative and Physiological Therapeutics 2001;24(7): 457-466.
- Lawrence D. Preparing the scientific paper: Tricks of the trade. Presentation at the Research Agenda Conference VI, Kansas City, MO, July 20, 2001.
- Gaumer GL, Walker A, Su S. Chiropractic and a new taxonomy of primary care activities. Journal of Manipulative and Physiological Therapeutics 2001;24(4):239-259.
- US Government Accounting Office. Health care access: innovative programs using non-physicians. Report to the Chairman, Special Committee on Aging, U.S. Senate: August 1993.
- Bowers LJ, Mootz RD. The nature of primary care: The chiropractors' role. Topics in Clinical Chiropractic 1995;2:66-84.
Anthony Rosner,PhD
Brookline, Massachusetts rosnerfcer@aol.com
