Evidence-Based Prejudice: A Confederacy of Brickbats

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

1. Boston Globe, May 21, 2000, p. A3.
2. Bogduk N. Evidence-based clinical guidelines for the management of acute lowback pain. Submitted to the Medical Health and Research Council of Australia, November 1999.
3. Freeman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. Journal of Bone and Joint Surgery Am 1998;80-A:1421-1427.
4. Bigos S, Bowyer O, Braen G, et al. Acute low back pain in adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December 1994.
5. Rosen M. Back pain. Report of a clinical standards advisory group committee on back pain. May 1994, London: HMSO.
6. The Week in Chiropractic 1999; 5(14):1,2.
7. Horwitz AD, Hosek R, Boyle J, Cianciulli A, Glass J, Codario R. A new gatekeeper for back pain. The American Journal of Managed Care 1998; 4(4): 576-579.
8. Van Tulder M, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: A systematic review of randomized controlled trials of the most common interventions. Spine 1997;22(18):2128-2156.
9. Rosner A. Evidence-based clinical guidelines for the management of acute low back pain: response to the guidelines prepared for the Australian Medical Health and Research Council. Journal of Manipulative and Physiological Therapeutics 2000; accepted for publication.
10. Veterans of Health Administration Directive 2000-014, letter from Thomas Garthwaite, MD, Deputy Under Secretary of Health, May 5, 2000.
11. Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. Comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine 1998; 339(14): 1021-1029.
12. Rosner AL. Response to the Cherkin article in The New England Journal of Medicine. Dynamic Chiropractic November 2, 1998;16(23).
13. Rosner AL. Rebuttal to Cherkin comments in Dynamic Chiropractic. Dynamic Chiropractic January 1, 1999;1(1).
14. Chapman-Smith D. Back pain, science, politics and money. The Chiropractic Report. November 1998;12(6).
15. Royal College of General Practitioners, unpublished update of CSAG Guidelines [reference 2], 1999.
16. Best practice in brief. Harvard Pilgrim Health Care Continuing Education Program Newsletter July 1999;1(1).
17. AMA editorial board. AMA's Pocket Guide to Back Pain. New York, NY: Random House, 1995.
18. Rosner AL. FCER Forum: Matthies v. Mastromonaco,DO: the right to be informed, or research findings come home to roost. Dynamic Chiropractic March 25, 2000, 18(13).

Anthony Rosner,PhD FCER
Director of Research
Brookline, Massachusetts
rosnerfcer@aol.com