Washington Post Puts Chiropractic "Into the Mainstream"

The "Health" section of the Aug. 23, 1993 issue of the Washington Post contained the most comprehensive, well-balanced article yet to appear on chiropractic.

The front page of the section features a full-page color picture of a man's back, his spinal vertebrae (as one would see in an x-ray) and a superimposed set of hands. The headline reads, "Chiropractors Come Into the Mainstream." The subheading cautions: "But Questions Remain About Treating Problems Other Than Back Pain."

Reporter Sarah Glazer did her homework. She began with an account of a woman who discovered relief from neck pain, and chronic ear and sinus infection through chiropractic adjustments. The article not only covers the issues surrounding spinal manipulation but is also reasonably clear about the diversity that is a part of the chiropractic profession.

The article's subtitles provide a good outline:

• Spinal Alignment Is Key
• No Drugs or Surgery
• New Respectability
• Theory Behind Chiropractic
• Targeting Children
• Will Insurers Pay?

In addition, three sidebar articles are included:

• "'We Should Have Open Minds'"
• "AMA's Attitude toward Chiropractors Has Mellowed"
• "How Chiropractors' Training Differs from that of Physicians"

The Post article got various perspectives from within and outside the profession, including quotes from:

• Stephanie Poe, the chiropractic patient with the neck pain and sinus and ear infections;
• Larry G. Brown, DC, Ms. Poe's chiropractor;
• Scott Haldeman, DC, MD, PhD -- internationally known chiropractic authority;
• Daniel Futch, DC, executive director of the National Association for Chiropractic Medicine, an organization that believes chiropractic care should be limited to "relieving musculoskeletal pain";
• Paul Shekelle, MD, MPH, chief investigator of the RAND study;
• Bruce Kaufman, MD, a neurosurgeon who operated on a tumor in a small child that a chiropractor had missed. (Dr. Kaufman admitted that the tumor might have gone undiscovered by a pediatrician);
• Rand Swenson, DC, MD, PhD, editor of Journal of the Neuromusculoskeletal System;
• James Strain, MD, executive director of the American Academy of Pediatrics;
• Jerome F. McAndrews, DC, the American Chiropractic Association's vice president for professional affairs;
• John Erb, consultant for A. Foster Higgens & Co., a New York-based consulting firm that advises companies on employee benefits.

The three sidebar articles also contained several interesting perspectives on chiropractic. "We Should Have Open Minds" features David W. Brewer, MD, an obstetrician who chose chiropractic care over back surgery.

"AMA's Attitude toward Chiropractors Has Mellowed" includes statements from Scott Haldeman, DC, MD, PhD, and Thomas J. Errico, MD, professor of orthopedic surgery at New York University Medical Center, who has been successful in referring patients to chiropractors. Peter Slabaugh, MD, an Oakland, Calif. orthopedic surgeon stated, "What the average MD tells the patient is 'Don't worry about it. It will go away.' The average medical student gets hardly any education in back pain and musculoskeletal problems. The average physician would like the patient with back pain to get out of his office." Daniel Cherkin, PhD, a researcher whose published studies have shown that chiropractors are much more comfortable dealing with patients with low back pain and that chiropractic patients were three times more satisfied with the care they received than their medical counterparts stated, "Traction is ineffective; bed rest is counterproductive. For physical therapy and exercises, we don't know what the effect is. There is probably more evidence for manipulation than any other treatment being used for low back pain."

"How Chiropractor's Training Differs from that of Physicians" featured Alan Adams, DC, MS, and vice president of professional affairs at Los Angeles College of Chiropractic. Chiropractic students' lack of exposure to hospital training was especially noted.

The March 18, 1993 Wall Street Journal article that focused on the chiropractic profession expanding its practice to children is considered in the subsection "Targeting Children."

While the article includes both positive and negative opinions of chiropractic, as you would expect, it presents a good assessment of how far the profession has come to now enter the mainstream.

Canadian Report Extols Benefits of Chiropractic

The Ministry of Health of the Ontario has just released its commissioned report. The principal authors are two independent health economists: Professor Pran Manga, MA, PhD, director of the Health Administration program at the University of Ottawa, and Douglas Angus, adjunct professor of Health Economics at the University of Ottawa.

The executive summary of the report sets the tone of the study.

The serious fiscal crisis of all governments in Canada is compelling them to contain and reduce health care costs. It has brought a new and unprecedented emphasis on evidence-based allocation of resources, with an overriding objective of improving the cost-effectiveness of health care services. Today, LBP has become one of the most costly causes of illness and disability in Canada; a phenomenon which does not appear to be generally appreciated or understood in medical and governmental circles in Canada. Much of the treatment of LBP appears to be inefficient. In this study we focused principally on the effectiveness and cost effectiveness of chiropractic and medical management of LBP.

The executive summary lists nine findings:

• On evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for LBP.
• There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low back pain.
• While it is prudent to call for even further clinical evidence of the effectiveness and efficacy of chiropractic management of LBP, what the literature revealed to us is the much greater need for clinical evidence of the validity of medical management of LBP. Indeed, several existing medical therapies of LBP are generally contraindicated on the basis of the existing clinical trials.
• There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management.
• There would be highly significant cost savings if more management of LBP was transferred from physicians to chiropractors.
• There is good empirical evidence that patients are very satisfied with chiropractic management of LBP and considerably less satisfied with physician management.
• Despite official medical disapproval and economic disincentive to patients (higher private, out-of-pocket cost), the use of chiropractic has grown steadily over the years.
• In our view, the constellation of the evidence of:

(a) the effectiveness and cost-effectiveness of chiropractic management of low back pain;

(b) the untested, questionable or harmful nature of many current medical therapies;

(c) thee economic efficiency of chiropractic care for low back pain compared with medical care;

(d) the safety of chiropractic care;

(e) the higher satisfaction levels expressed by patients of chiropractors, together offers and overwhelming case in favor of much greater use of chiropractic services in the management of low back pain; The government will have to instigate and monitor the reform called for by our overall conclusions, and take appropriate steps to see that the savings are captured. The greater use of chiropractic services in the health care delivery system will not occur by itself, by accommodation between the professions, or by actions on the part of the workers' compensation board or the private sector generally.

The summary concludes with 10 recommendations:

• Current policy discourages the utilization of chiropractic services for the management of LBP.
• Chiropractic services should be fully insured under the Ontario Health Insurance Plan, removing the economic disincentive for patients and referring health providers.
• Chiropractic services should be fully integrated into the health care system.
• Chiropractors should be employed by tertiary hospitals in Ontario.
• Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients' needs.
• Chiropractors should have access to all pertinent patient records and tests from hospitals, physicians, and other health care professionals upon the consent of their patients.
• Since low back pain is of such significant concern to workers' compensation, chiropractors should be engaged at a senior level by Workers' Compensation Board to assess policy, procedures and treatment of workers with back injuries.
• The government should make the requisite research funds and resources available for further clinical evaluation of chiropractic management of LBP, and for further socio-economic and policy research concerning the management of LBP generally.
• Chiropractic education in Ontario should be in the multidisciplinary atmosphere of a university with appropriate public funding.
• Finally, the government should take all reasonable steps to actively encourage cooperation between providers, particularly the chiropractic, medical and physiotherapy professions.

The significance of the findings and recommendations are clear. This was not a study by chiropractors, but an independent, government-funded study conducted by respected health economists. The conclusions of these investigators were inescapable, given the current literature on LBP.

Congress Approves $1.75 Million for Chiropractic Demo/Training Projects

On Oct. 21, President Clinton signed into law the 1994 appropriations bill for the Department of Health and Human Services (Pub. Law 103-112). The bill allocates: $750,000 for multidisciplinary research studies at chiropractic colleges and $1 million to increase chiropractic's ability to assist in medically underserved rural areas.

The funding is certainly one of the most important chiropractic victories on Capitol Hill. "This landmark decision by Congress represents the culmination of several years of lobbying and hard work by the ACA and representatives of chiropractic colleges across the nation, notably Palmer College of Chiropractic in Davenport, Iowa," said ACA President Dr. John Pammer.

Demonstration Projects. In October 1992, just prior to the adjournment of the 102nd Congress, the first federal program dedicated solely to chiropractic research demonstration projects was authorized as part of Title VII of the Public Health Service Act. This ACA-drafted initiative established the chiropractic research program that would provide funding to chiropractic colleges for:

Demonstration projects in which chiropractors and physicians collaborate to identify and provide effective treatment for spinal and lower back conditions ... These funds [will] be utilized to carry out a collaborative training and demonstration project between the Consortium for Chiropractic Research [including Palmer Chiropractic University in Davenport, Iowa] and a school of medicine or osteopathic medicine. This project shall address how so-called traditional schools of medicine and chiropractors can cooperate to identify how chiropractic can be utilized to provide effective treatment.

Training Projects. In September of this year, the Senate authorized $1 million to be used for:

Interdisciplinary training projects...of how the delivery of chiropractic health care can be improved in rural areas, and how the retention and recruitment of chiropractic health care practitioners can be increased in rural areas ... The Committee expects the Consortium for Chiropractic Research to play an integral role in the development of this rural health care initiative in fiscal year 1994, in consultation with the Secretary of Health and Human Services.

Legislative Support. Dr. Pammer identified Senators Kennedy (D-Mass) and Harkin (D-Iowa) as playing key roles in the authorization of the chiropractic research and training funding: "The chiropractic profession really owes them a great deal of gratitude for their support." Dr. Pammer also noted other legislators who played an integral part in the bill's passage: Senator Orrin Hatch (R-Utah), ranking Republican member of the Senate Labor Committee; and Congressmen Neal Smith (D-Iowa) and Jim Lightfoot (R-Iowa), senior members of the House Appropriation's Committee.

J. Ray Morgan, ACA executive vice president, said representatives of the Public Health Service have already met with ACA and FCER officials to discuss procedures for implementation of the federal research project. "The research is intended to be an ongoing project, and the ACA will be seeking new monies each year," said Mr. Morgan.

According to ACA officials, the passage of the chiropractic language in the HHS Appropriation's Bill will figure heavily in the current debate over national health care reform. "This landmark victory has come at a critically urgent time for the profession," stated ACA Board Chairman Kerwin Winkler, DC. He added, "The passage of this bill will go a long way toward producing the evidence we already know to be true; that chiropractic is a legitimate and effective form of health care that could save this country million upon million of dollars."