JAMA Goes Alternative

If you've ever speculated about the level of cooperation between the major medical journals, you can stop wondering. November was "alternative medicine" month: almost 80 abstracts, papers, editorials, letters and book reviews on alternative forms of care featured in eight of the 10 journals published by the American Medical Association (AMA).

The topical breakdown was:

Topic	# of papers published
Alternative Care (general)	30
Aroma Therapy	1
Acupuncture	6
Chinese Medicine	3
Chiropractic	2
Herbal Medicine	16
Homeopathy	2
Mind-Body Healing	2
Native/Spiritual Healing	3
Nutrition/Vitamins/Diet	8
Other Alternative Care	6

Here are reviews of the three most relevant papers. (Please see also in this issue, "Alternative No More," a review of Dr. Eisenberg's latest survey of alternative care use.)

Medical Malpractice Implications of Alternative Medicine¹

In this paper, the authors compared alternative providers and medical practitioners on two fronts: malpractice coverage and experience. The study's hypothesis was that "physicians worry that they will be sued if a patient they refer to an alternative medical practitioner suffers a poor outcome."

The results of the malpractice concerns? See below:

Claims per 100 Policyholders                 1990 1991 1992 1993 1994 1995 1996 Massage Therapy N/A N/A N/A 0.2 0.2 0.2 0.1 Chiropractic 2.7 2.7 2.8 3.0 2.7 2.6 2.2 Primary Care MDs 5.9 5.7 6.9 7.1 6.7 6.2 N/A All Medical Providers 7.7 8.2 9.1 9.8 9.5 9.0 N/A

Average Indemnity Payment per Paid Claim               MTs Chiros Primary Care All MDs 1990 N/A $33,625 $129,213 $137,900 1991 N/A $43,670 $148,533 $159,788 1992 N/A $40,621 $143,730 $183,541 1993 $12,011 $52,231 $147,084 $185,243 1994 $4,251 $65,597 $151,001 $182,003 1995 $4,864 $52,385 $149,028 $179,732 1996 $4,253 $60,985 $166,379 $202,772

Percentage of Claims Paid               MTs Chiros Primary Care All MDs 1990 N/A 49.1% 32.5% 31.9% 1991 N/A 49.0% 32.0% 33.1% 1992 N/A 47..5% 33.9% 33.2% 1993 38.5% 56.9% 30.7% 30.3% 1994 44.8% 46.0% 30.2% 31.7% 1995 63.0% 49.5% 30.3% 30.2% 1995 23.8% 46.0% 29.9% 28.6%

Based on the study, the authors made the following statement:

"We conclude that malpractice concerns alone should not inhibit physicians from referring patients to alternative medicine practitioners, particularly where those practitioners are licensed and accredited."

Spinal Manipulation in the Treatment of Episodic Tension-Type Headache²

The one-year prevalence for tension-type headache (TTH) is greater than 38 percent. This 19-week randomized controlled trial compared the effects of chiropractic manipulation (with "deep friction massage") against deep friction massage only for TTH patients.

Each group consisted of 37 patients, with each patient receiving a total of eight treatments over a four-week period. The treatments were all given by the same chiropractor.

The outcomes measures showed very similar improvement for both groups:

Average Analgesic Use per Day       Baseline 7 11 15 19 Manipulation Group .66 .38 .41 .48 .48 Control Group .82 .59 .54 .60 .56             Average Headache Hours per Day                 Manipulation Group 2.8 1.5 1.6 1.6 2.1 Control Group 3.4 1.9 1.7 2.1 2.2             Average Headache Intensity                 Manipulation Group 37 38 36 29 35 Control Group 37 34 30 33 26

The authors note that a previous study on chiropractic manipulation for cervicogenic headache was quite favorable. This study, in contrast, shows positive outcomes for both analgesic use and headache hours per day for both groups.

Chiropractic : Origins, Controversies and Contributions³

This paper appeared in the November issue of the Archives in Internal Medicine. It begins with a statement that sets the tone for the rest of the paper:

"Chiropractic is an important component of the U.S. health care system and the largest alternative medical profession. In this overview of chiropractic, we examine its history, theory, and development; its scientific evidence; and its approach to the art of medicine. Chiropractic's position in society is contradictory, and we reveal a complex dynamic of conflict and diversity. Internally, chiropractic has a dramatic legacy of strife and factionalism. Externally, it has defended itself from vigorous opposition by conventional medicine. Despite such tensions, chiropractors have maintained a unified profession with an uninterrupted commitment to clinical care. While the core chiropractic belief that the correction of spinal abnormality is a critical health care intervention is open to debate, chiropractic's most important contribution may have to do with the patient-physician relationship."

The paper also discusses:

• dissension within the movement;
• spinal manipulation, the core chiropractic act;
• chiropractic battle for acceptance;
• chiropractic health care;
• patient perceptions;
• scientific evidence for spinal manipulation;
• chiropractic's effectiveness.

The paper is an even-handed look at chiropractic from the prospective of two health care researchers and will go far to initiate other health care providers toward including chiropractic as a consideration for referral. The authors close with these remarks:

"Chiropractic has endured, grown, and thrived in the United States, despite internal contentiousness and external opposition. Its persistence suggests it will continue to endure as an important component of health care in the United States. In response to the countless requests for the treatment of pain, chiropractors have consistently offered the promise, assurance, and perception of relief. Chiropractic's ultimate lesson may be to reinforce the principle that the patient-physician relationship is fundamentally about words and deeds of connection and compassion. Chiropractic has managed to embody this message in the gift of the hands."

This sudden outburst of papers on alternative forms of care underscores the need for more, higher quality research in this area. This plethora of papers also gives one pause: Is the AMA considering a new JAMA, the Journal of the Alternative Medical Association? "If you can't beat 'em, join 'em," may become the AMA's new policy statement on alternative care.

Editor's note: If you would like to receive a review of most of the above papers, you may request a free copy of the Chiropractic Research Review by calling (800) 359-2289.

1. Studdert DM, Eisenberg DM, Miller FH, Curto DA, Kaptchuk TJ, Brennan TA. Medical malpractice implications of alternative medicine. JAMA 1998;280:1610-1615.

    

2. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache. JAMA 1998;280:1576-1579.

    

3. Kaptchuk TJ, Eisenberg DM. Chiropractic: origins, controversies and contributions. Arch Intern Med 1998;158:2215-2224.