News / Profession

AHCPR Panel Holds Public Low Back Pain Hearing

ACA, FCER, Mercy Commission Represented: Mercy Guidelines Presented

Editorial Staff

WASHINGTON, D.C. -- The Low Back Pain Panel of the Agency for Health Care Policy and Research (AHCPR) held a public hearing September 16, 1992 on "Clinical Practice Guidelines for Low Back Problems," under the auspices of the Department of Health and Human Services. The hearing was part of the development of guidelines on the "assessment and treatment of acute low back problems (i.e., within the first three months of symptoms) in adults."

The AHCPR's Low Back Pain Panel consists of "health care experts and consumer representatives" including two chiropractors: John Triano, M.A., D.C., and Scott Haldeman, D.C., M.D., Ph.D. (please see "AHCPR Sponsors Low Back Disorder Panel" in the January 3, 1992 issue). The panel is chaired by Stanley Bigos, M.D.

While many written testimonies were submitted, only 21 organizations were invited to speak. Presentations were given by the American Chiropractic Association (ACA), the Foundation for Chiropractic Education and Research (FCER), and the Mercy Conference Guidelines Commission:

Oral Presentations

Blood, S.D., DO, FACGP, FAAO American Academy of Osteopathy

Danyliw, Thomas Dr. Danbury Health Center Affiliates

Delitto, Anthony, Dr. American P.T. Association

Doyne, Mark, M.D. Texas Back Institute

Eismont, Frank J., M.D. American Acad. of Orthopaedic Surgeons

Gracovetsky, Serge A., Ph.D Spinex Medical Technologies, Inc.

Kahanovitz, Neil, MD National Spine Ctr. at Anderson Clinic

Kraus, Hans MD NY Pain Treatment Prg., Lenox Hill Hosp.

Lee, Casey K. MD NJ Medical School, Dept. of Orthopaedics

Mandel, Robert American Academy of Osteopathy

Marcus, Norman MD NY Pain Treatment Prg., Lenox Hill Hosp.

McClelland, George B., DC Foundation for Chiropractic Education and Research

McIlwain, William A., MD, FACS Bristol Orthopaedic Assoc., P.C.

Murtland, Albert M., MD Guthrie Clinic LTD

Petersen, Donald M. Jr., B.S., HCD Chiropractic Guidelines Commission

Steele-Rosomoff, Rene Association of Rehabilitation Nurses

Webster, Barbara, RPT Liberty Mutual Insurance Co.

White, Arthur H., MD North American Spine Society (NASS)

White, Kemlee, RN Amer. Assoc. of Occup. Health Nurses

Yuan, Hansen, MD National Spine Ctr. at Anderson Clinic

The chiropractic profession enjoyed an excellent representation before the panel. Dr. Balduc from the ACA gave the profession's clinical perspective, including some impressive statistics and an excellent examination of the patient benefits of chiropractic. Dr. McClelland presented the research side of the profession with plenty of references to studies demonstrating the efficacy and efficiency of chiropractic care. But the heart of Dr. McClelland's presentation was the Mercy Conference and the chiropractic profession's quest to create its own practice guidelines.

The Mercy Guidelines were then formally presented, a moment that represented the culmination of years of work and effort by many individuals and organizations within the profession. The Mercy document stands as an example of chiropractic's commitment to development of standards. The existence of the Mercy Guidelines will help to influence the AHCPR's direction as it develops the government's guidelines on back pain care.

The physical therapists made a strong case for their own inclusion in the guidelines. They stressed the importance of PTs providing exercise programs and manipulation. The osteopaths' presentation contained an even greater emphasis on manipulation. If one didn't know their credentials, the DO's presentation could easily have been confused with chiropractic's.

There were also several written testimonies submitted. Below are some excerpts from statements of non-DCs that were very positive toward chiropractic care:

"The purpose of my testimony is to provide evidence on cost comparisons between chiropractic patients and medical patients treated for low back conditions. My ongoing research provides evidence of cost comparisons that strongly favor chiropractic users and thus support the need for clinical guidelines which are sufficiently flexible to include chiropractic treatment. Failure to do so would eliminate potentially cost-effective and clinically-effective forms of care. Failure to do so may also damage the competitive influence exerted on our health care system by the availability of alternative provider groups."

Miron Stano, Ph.D.
Rochester, Michigan
Professor of Economics and Management
School of Business Administration
Oakland University

"In the diagnosis and treatment of low back problems, chiropractic is a well established and distinct healing profession with a well satisfied constituency of its own. While the efficacy of chiropractic is not limited to back pain, its demonstrated superiority in this area should be acknowledged in your guidelines. There is little doubt that the services of a competent chiropractor offer considerable therapeutic value. Thank you for the opportunity to present this testimony."

Ronald L. Caplan, Ph.D.
New Brunswick, New Jersey
Health Economist
Faculty of Planning
Rutgers University

"Many of my patients go to chiropractors...and have had excellent comments and good relief and help for their low back and neck problems, whereby avoiding surgical intervention many times. ...I've found in my own personal case that chiropractic care provided a form of care that could not be duplicated and facilitated the healing of my damaged nerve.

"... I have had only positive experiences and would certainly recommend that in a scheme to manage acute and chronic neck and low back pain that the guidelines include chiropractic care as part of the treatment strategy. I believe that without the chiropractic care that I received, I would have had an extremely expensive operation with anterior surgical fusion with an implant from my right iliac crest, with the complications and sequellae pertaining to that including a 20 percent chance of nonfusion and a possibility within five to ten years of problems at the cervical level above and below the fused area.

"Therefore, I would urge the committee to include chiropractic evaluation and care."

David W. Brewer Jr., M.D., FACOG

"The clinical practice guidelines should include all models of spinal care, including the chiropractic model. My experiences been a positive one and I feel that chiropractic services must play a role along with other healing disciplines for spinal problems."

Walter J. Kavanaugh
New Jersey Assemblyman
Somerset-Morris Counties
Vice Chairman, Ways and Means Committee

The chiropractic physician is well trained in diagnostic and conservative therapeutics, not just manipulative treatment to play a pivotal role in guiding spine care in a cost effective manner.

Frank Catania
New Jersey Assemblyman
Passaic County
Deputy Speaker

"In my experience with chiropractic care for low back problems, I have found it to be both an efficient and effective approach to the treatment of a wide range of traumatic and degenerative low back disorders that do not require surgical intervention. I feel that any clinical guidelines that AHCPR develops would be incomplete without the inclusion of chiropractic care guidelines. The chiropractor (DC) provides a form of non-duplicated care that has demonstrated the ability to stabilize the patient, control pain, manage the patient through recovery, and educate the patient to help prevent recurrence."

Herbert M. Weinman, M.D.

If the public hearing is any indication, the big losers of the AHCPR's Clinical Practice Guidelines for Low Back Problems will probably be surgery and advocates of bed rest. It appears that manipulation will be included in AHCPR guidelines, but not necessarily chiropractic. If anything, the question of who will provide manipulative services to the public looks to be the next battleground for the chiropractic profession. In the eyes of the "Feds," the issue that must be resolved is there a difference between "Brand X" manipulation and the chiropractic adjustment?

The Low Back Pain Panel will ultimately produce national guidelines for low back pain sometime after February 1993. These guidelines will probably have a great effect upon the chiropractic profession, as well as every other health care profession that is involved in the treatment of the low back.

October 1992