ROBERT D. MOOTZ, DC   Second Response

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

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Frank:

Sure you can post 'em. Don't be discouraged though, remember the context of the study limitations. 46% is the indisputable appropriate according to the lofty criteria. 20% or something was uncertain due to records, unknowns in the criteria, etc. Further, the 29% inappropriate means inappropriate according to criteria developed many years ago by a largely "skeptical" panel with a large number of non-manipulators. (It's results differed from the all chiropractic panel in appropriateness for radiculopathy, chronicity, etc and occurred before some of the later RCT studies). And the classifications are that, classifications, not medicolegal adjudications fergunnesakes.

Consider that the C-Spine panel some 5 years later (which has even less evidence than L-spine) had similar appropriateness indications to the LBP recommendations! This despite greater side-effect risks implying the experts' level of comfort on appropriateness of manipulation decisions in general must have increased just 5 years later! One criticism I had of the RAND LBP indications was that they didn't include a role for patient preference, but it did acknowledge a role for previous experience with manipulation decision making, something we incorporated to greater extent in the C-Spine study (I worte the C-spine indications with Hansen and Meeker). Much of the discomfort the original LBP panel had on chronicity reflects an absence of evidence (not evidence against), as well as the lack of understanding/consensus on episodic, recurrent, or chronic definitions. What may show up in a DC's chart as a chronic LBP case may be a recurrent "acute" episode, I don't recall the Shekelle paper or the original LBP criteria accounting for this very well. Now that Meade and others have come out, that might soften from inappropriate to uncertain if the expert panel reconvened. (I'll bet I disagree with Paul on that). How the indications are worded also impact the appropriateness ratings the panels give. And the inappropriate cases were a hodgepodge of these evidence-limited inappropriates, and as the paper said, do not construe harmful (like whacking away on bilateral motor weakness, bowel control loss folks) practice.

The playing field is completely level on this one, these limitations are the same kinds of limitations that similar studies have done on medical procedures, hence the comparison. Everyone (the anti-chiro folks) expected that applying such rigorous criteria to chiros would annihilate us. It didn't. Every time we are placed toe to toe with competition, we hold our own at least. We need to mature into the big leagues and not expect every piece of research to look like a glowing press release form a trade association.

With this kind of scrutiny increasing on everyone, more fun ahead. Stay tuned in the evidence-based practice game. The nature, quality, and relevance of evidence and how it applies to case-by-case practice will be interesting. Check out that BMJ editorial (July 18, BMJ 316: ; 1621-22) on their move to publish evidence based case reports.

OK, back to the grind, Bob

Robert D. Mootz, DC
Associate Medical Director
State of Washington Department of Labor and Industries

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