FCER MAKES A PRESENTATION TO U.S. VETERANS ADMINISTRATION CONSULTATIVE MEETING

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PRESENTATION TO U.S. VETERANS ADMINISTRATION CONSULTATIVE MEETING

Anthony L. Rosner, Ph.D.
February 24, 2000


On behalf of the Foundation for Chiropractic Education and Research, I wish to thank Thomas Holohan and the Department of Veterans Affairs for inviting me to speak briefly today. As the world's oldest and largest nonprofit foundation which has supported both research and postgraduate study on a global scale aimed at documenting the theory and practice of chiropractic healthcare, we welcome this opportunity to be able to provide input. We speak to the capabilities and potential of chiropractic management of patients within the framework of the VA.

Accomplishments:

At 105 years of existence, chiropractic has become the third largest profession of healthcare delivery in the world. It is a noninvasive healthcare discipline which emphasizes the relationship between structure and function within the body--structure usually [but not exclusively] being considered to be the spine, and function depending upon the integrity of the nervous system. To the extent possible, drugs and surgery are subordinated to the body's recuperative abilities and are not employed by chiropractors. By the same token, Doctors of Chiropractic seek to coordinate their care with referrals to and from other healthcare practitioners when it is in the best interest of the patient.

What may not be as well known as it should is that the practice of chiropractic includes a complete physical examination and establishing a diagnosis. The aim is to establish biomechanical and neurological integrity through an assortment of noninvasive measures, many [but not all] of which are manual. These would include manipulation, mobilization, soft-tissue and nonforce techniques, exercise and rehabilitation, and occasionally such educational programs as nutritional counseling or wellness care.

With regards to back pain, the efficacy and effectiveness of these procedures have been reviewed repeatedly by carefully structured guidelines, developed both within the profession1 and by multidisciplinary panels representing the governments of both the United States2 and the United Kingdom.3 Over 40 randomized clinical trials comparing spinal manipulation with other treatments in the management of back pain have been published in the scientific literature--almost all within the past 20 years.4,5 Meta-analyses addressing acute low-back pain6,7 have also appeared in the literature, supporting the appropriateness of spinal manipulation in managing acute low-back pain. According to a systematic review by van Tulder,

"There is limited evidence that manipulation is more effective than a placebo treatment."

Although contradictory results did not allow van Tulder to compare manipulation to other physiotherapeutic applications, there was no such uncertainty regarding chronic low-back pain.

Here van Tulder unequivocally states that

"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."5

The strength of these findings has actually moved many to suggest that, concerning low-back care, chiropractic has moved from alternative to mainstream status within recent years. As advances are made in all health interventions, we are not the least surprised that some of the treatment options offered by chiropractors have gained this stature. We support research and discourage preconceived biases as the cornerstone by which this information becomes available for the public benefit. We believe that our research information has delivered a treatment option with fewer side effects, less disability, and possibly at lower cost over the long run.8-22

Beyond Low-Back Pain:

In much the same way that one plays a game of Chinese checkers, clinical explorations and research addressing chiropractic effectiveness have extended beyond low-back pain. Systematic reviews of clinical trials supporting the effectiveness of manipulation now exist for the cervical spine, neck pain and headache;23-26 in fact, one trial which demonstrates the superiority of spinal manipulation over the use of a non-steroidal anti-inflammatory agents [amiltriptyline] in treating tension-type headache27 was rated in two independently conducted systematic literature reviews as the highest in quality of all clinical trials assessed.25,26

With supporting evidence in managing musculoskeletal conditions at this time, chiropractic management has extended beyond the spine into treating disorders of the extremities. It is easy to appreciate how cumulative trauma disorders are becoming the successor to back pain as the next widespread disorder in the workplace, in the performing arts, and in sports. A number of clinical trials and case studies are now appearing in the literature to support the effectiveness of both spinal manipulation and contact procedures with the extremities to manage carpal tunnel syndrome.27-31

Portal of Entry:

The well-documented rise of alternative medical procedures within the past decade, much of which is directed toward low-back pain, 32-34 as well as the establishment of a completely new national center within the National Institutes of Health within the past year, could not have resulted with chiropractors functioning as referral only, or as some have put it, mere "craft" groups. Chiropractors, as we have mentioned before, are fully licensed to diagnose and perform complete physical examinations in every state within the U.S. If they were merely craft groups, they would not have been awarded primary care, gatekeeper status in at least four managed care companies within the United States: [i] HMO Illinois,35 [ii] Family Health Plan Cooperative,36 [iii] Texas Back Institute,36 and [iv] Oxford Health Plans. Reference is made elsewhere37 of the existence as early as 1994 of a "few HMOs that have experimented with delivering limited chiropractic benefits via direct access through chiropractic independent practice associations [IPAs]." Finally, the Medical Director of the San Francisco Spine Institute [Arthur H. White, M.D.]  refers to "new" and presumably enlightened managed care organizations which are using triage organizations to funnel patients into the most appropriate level of care as rapidly as possible. Chiropractors are considered to be "very appropriate" triage individuals, who will be invited in increasing numbers to become primary care providers by the "new, more enlightened managed care organizations."38

Of major concern is the question whether medical physicians are, in fact, capable of performing complete neuromusculoskeletal examinations as first contact healthcare providers. From the results of the recent study of first-year orthopedic residents at the University of Pennsylvania, the answer would appear to be a resounding no. In this particular investigation, 82% of the 85 first-year residents failed to demonstrate basic competency on an examination in musculoskeletal medicine which had been validated by 157 chairpersons of orthopedic residency programs in the United States.39 With orthopedic residents having failed this examination, one would expect all other medical doctors to do no better and probably worse. By extrapolating this finding, we would conclude that having the patient examined by only a medical doctor necessarily deprives him or her of a major, essential portion of the physical examination.

Patients' Rights to Treatment Alternatives:

This entire discussion of portal of entry should be complemented by our consideration from the point of view of the patient. From a decision last July from the Supreme Court of New Jersey, it is now not just a privilege for patients to have access or be informed of alternatives; it is a right.

Let me share with you the essence of the decision handed down by Justice Pollock:40

"...the doctor has the duty to evaluate the relevant information and disclose all courses of treatment that are medically reasonable under the circumstances. It is for the patient to make the ultimate decision...to insure informed consent, the physician must inform patients of medically reasonable alternatives and their attendant probable risks and outcomes. Physicians do not adequately discharge that duty by disclosing only the treatment alternatives that they recommend."

If you consider this statement carefully, you can see that to deny patient the proper information and access to alternative modes of care could now be construed as something dangerously close to malpractice.

Sensible Weighing of the Evidence:

We need to digress for a moment and discuss what is sound clinical judgment. Taking a broader perspective, one has to question the validity of randomized clinical trials as the singular source of information regarding meaningful patient outcomes. First, it is important to recall that only 15% of medical procedures have been found to be supported by any literature references at all,41 only 1% of which is deemed to be scientifically rigorous.42 Second, it is easy to forget that sound, clinical observations in the doctor's office remain the cornerstone upon which all experimental approaches, including randomized clinical trials, are based. In the world of clinical treatment, erroneous judgments are as much the product of improper generalizations of RCTs [which by their definition take place within a highly restricted setting] than of the quality of the RCTs themselves. Indeed, the entire structure of evidence-based medicine is put into perspective by no less an authority than David Sackett, who argues: "External clinical evidence can inform, but never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all, and, if so, how it should be integrated into a clinical decision."43

Need to Question Treatment Standards by Appropriate Research:

Finally, from the point of view of a research foundation, I have to make an impassioned plea to leave doors open to innovation. A quick look at the Gold Standard Guidelines of 100 years ago, quoted in the Merck Index, will tell you why it is folly to accept or establish guidelines as Gospel.

At that time, the following treatments which now of course appear outrageous were recommended for specific clinical conditions:

  1. Formaldehyde for the common cold,

  2. Arsenic or ammonia for baldness,

  3. Opium and morphine for typhoid fever,

  4. Blood-letting and chloroform for streptococcal infections; and

  5. Strychnine, ice and lemon juice for diphtheria.44

Treatment alternatives must therefore always be considered and researched with an open mind!

Safety:

As with any therapeutic intervention, contraindications exist for chiropractic, however rare. Two primary complications have been reported: The frequency of developing cauda equina syndrome from lumbar manipulation has been estimated to be 1 per 100 million manipulations.23 The frequency of encountering cerebrovascular accidents has been estimated to be 0.6 per 1 million manipulations, half of which are fatal.23

These rates are 400 times less than the death rates observed from GI bleeding due to the use of NSAID medications 45 and 700 times lower than the overall mortality rate for spinal surgery.46

These are but some of the reasons that we believe chiropractic must be included as an equal partner in musculoskeletal health management within the Veterans Administration. Thank you very much for listening.

REFERENCES:

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  3. Rosen M.
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  17. Stano M.
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  19. Smith M, Stano M.
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  20. Mosley CD, Cohen IG, Arnold RM.
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  21. Manga P, Angus D, Papadopoulos C, Swan W.
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  22. Manga P, Angus DE.
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  23. Hurwitz EL, Aker PO, Adams AH, Meeker WC, Shekelle PG.
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  24. Kjellman GV, Skagren EI, Oberg BE.
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    Scanidavian Journal of Rehabilitative Medicine 1999; 31: 139-152

  25. Vernon HT.
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  26. Vernon HT.
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  27. Boline P, Kassak K, Bronfort G, Nelson C, Anderson AV.
    Spinal manipulation vs. amiltriptyline for the treatment of chronic tension-type headaches: A randomized clinical trial.
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  28. Sucher BM.
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  29. Strait BW, Kuchera ML.
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  30. Davis PT, Hulbert JR, Kassak KM, Meyer JJ.
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  31. Bersten G, McCarthy K.
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  32. Eisenberg DM, Kessler RC, Foster C, Morlock FE, Calkins DR, Delbanco TL.
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  33. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC.
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  34. Astin JA.
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  35. The Week in Chiropractic, 1999; 5(14): 1,2

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  37. McElheran LJ, Sollecito PC.
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  38. White AH.
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  39. Freeman KB, Bernstein J.
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  40. Jean Matthies v. Edward D. Mastromonaco, D.O.
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  41. Smith R.
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  42. Rachlis N, Kuschner C.
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  43. Sackett DL.
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  44. Merck's 1899 Manual, or the Materia Medica.
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  45. Dabbs V, Lauretti WE.
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  46. Deyo RA, Cherkin DC, Loesser JD, Bigos SJ, Ciol MA.
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    Journal of Bone and Joint Surgery Am 1992; 74(4): 536-543

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