Even this seasoned scribe has blanched lately at some of the sweeping generalizations (not supported by fact) about chiropractic from supposed health care authorities. It reminds me of the basic political axiom recently articulated by Mike Murphy, John McCain's campaign manager. "Make the charge and let the other guy spend $1 million to explain it." 1
I think it's time that comments from various poobahs be exposed. Let's begin with the new guidelines drafted by Nikolai Bogduk in Australia, directed toward the management of acute lowback pain.2 He opens with:
Transparently and unashamedly, the present guidelines have been developed with the medical practitioner in mind, particularly primary care practitioners, on the grounds that it is medical practitioners who have comprehensive responsibility in the management of their patients.Bogduk sets up the medical practitioner as infallible; he then decrees their entitlement to all gatekeeping responsibilities. His reasoning is deeply suspect, given the recent study published in the Journal of Bone and Joint Surgery that revealed that of 85 first-year orthopedic residents, 82 percent failed to demonstrate basic competency in a musculoskeletal exam.3
Bogduk tells us that the guidelines from the Agency for Health Care Policy and Research (AHCPR)4 and the UK5 are inferior, because they "accepted consensus views in their recommendations, whereas the present guidelines are explicitly evidence-based." The mind boggles later on when he argues for the advisability of behavioral therapy for low back pain "despite the lack of compelling, positive evidence." Rather, he opts for the recommendations (i.e., opinions) of authorities. Back in high school English class, we were taught that this sort of liberty was a form of poetic license.
How does manual therapy stack up in his treatise? Not very well. Bogduk refers to chiropractic as a "craft group." It's all downhill from there. If chiropractic is a "craft group," how could we have been awarded primary care or gatekeeper status in the multidisciplinary frameworks of HMO Illinois,6 Family Health Plan Cooperative,7 and the Texas Back Institute?7
There is a more serious concern. Bogduk faults the strength of the evidence supporting manipulation in the management of back pain. He completely ignores chronicity and the findings of a systematic review by van Tulder on chronic lowback pain. Van Tulder stated: "There is strong evidence that manipulation is more effective than a placebo treatment....There is moderate evidence that manipulation is more effective for chronic LBP than usual care by the general practitioner, bed-rest, analgesics, and massage.8
Bogduk's conclusions fly in the face of the findings of the AHCPR4 and British5 guidelines, which were developed from multidisciplinary panels rather than his "univariate" medical approach. Space does not permit me to do complete justice to my responses to Bogduk's arbitrary and capricious comments, however, a complete document is forthcoming.9
Veterans' Administration
The second example of a breach of evidence comes from a recent directive from the Veterans' Administration (VA) which suggests that VHA medical centers and clinics may offer "chiropractic spinal manipulative therapy for musculoskeletal problems of the spine ... following a referral from a Department of Veterans' Affairs clinician"10 (who is most certainly not a DC). Clinical responses to headache or pain in the extremities appear to have been excluded by this decision, despite the efforts of chiropractic groups to provide the VA with a complete background of peer-reviewed literature and meeting with their officials in February 2000. Arguments about the primary care capabilities of chiropractors and the apparent failure of medical physicians to perform complete musculoskeletal examinations3 (as argued above3) seem to have fallen on deaf ears. Efforts by the ACA, ICA, FCER and other participating parties to overturn the VA's recent recommendation are now in progress, beginning with contacting the appropriate members of Congress to assure that the VA abides by its original directive.
Cherkin
The third example of a sweeping and damaging generalization which has dubious grounds for support appears in the Cherkin study published in the New England Journal of Medicine in October 1998.11 I've discussed this study before,12,13 and it's been extensively critiqued elsewhere.14 It will be taken up once again in the Journal of Manipulative and Physiological Therapeutics (JMPT9). The most outrageous statement made in the Cherkin study is: "given the limited benefits and high costs, it seems unwise to refer patients with low back pain for chiropractic or McKenzie therapy." Despite the fact that Bogduk et al. cite this article extensively,2 a panel in Great Britain designed to update the guidelines recently issued in that country5 concluded that "the Cherkin study neither adds nor detracts from the evidence base regarding appropriate interventions for low back-pain."15
Whether it's Bogduk, the VA, or Cherkin, the problem lies with what happens to the public perception of chiropractic after these reckless assessments find their way into the mainstream press. How is one to correct the damage done after an irresponsible proclamation is made from a presumed "authority"?
Final Thoughts
My last port of call is a letter I received in reply to my protest of the complete lack of reference to spinal manipulation in a set of back pain guidelines issued to practicing physicians of the Harvard Pilgrim Health network in Eastern Massachusetts.16 I had argued that the guidelines replicated the inexcusable crime of the AMA's publication17 in suppressing the vast body of evidence reviewed by both the U.S.4 and Great Britain.5 I received a letter from the former director of clinician education. He said I was "appropriately reflecting a passion for your field and the people you represent." He referred the profession as "chiropracty." Indeed, I would submit that the issues involved in the suppression and distortion we are seeing from certain authorities in health care hearken back to the Jim Crow laws of the first half of the 20th century. "Separate but equal" seems to have gained just as much cachet for the manner in which political medical groups often treat chiropractic. We all know how equal "equal" has turned out to be.
I previously discussed a New Jersey Supreme Court decision.18 My hope is that its description of the suppression of treatment alternatives as a form of medical negligence has the effect of the historic desegregation ruling of Brown v Board of Education decision handed down by the U.S. Supreme Court in 1954. The court found that unequal treatment of children (a black child, in this case) violated the equal protection clause of the 14th amendment to the U.S. Constitution. Chiropractors, unfortunately, are still not being treated as equals.
References
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
