Daniel Becker, DC, DABCN Response

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

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From:     Daniel Becker dan56@tiac.net>
To:       chiro-list@silcom.com; chirosci-list@silcom.com 
Subject:  Past comments on NEJM articles from V10 #11 
          1995 BackLetter
Date:     Monday, October 12, 1998 10:00 PM

I went back and reviewed commentary on the recently reported study by Cherkin et al. as noted in "The BackLetter" issue V10/11 1995.

The following are quotes:

Five hundred and six patients were identified as potential candidates for the study after an initial visit with a primary care provider for back pain. A week later they were contacted to see if they still had back pain. (321 were choosen)

The educational booklet provided basic information about back pain and exercise. In a previous study, Cherkin and colleagues had proven this booklet to have no impact on back pain outcome.

The McKenzie therapists saw their patients for an average of 4.6 visits over one month, while the chiropractors had on average, two visits more per patient. In terms of total contact time, however, the McKenzie spent more time with their patients than the chiropractors. (The chiropractors and therapists were allowed to set the exact number of visits up to 9).

The McKenzie patients received: "In addition to the therapy sessions...'Treat Your Own Back' by Bob Mckenzie and a lumbar roll." Cherkin:...it is possible tht the positive results in the McKenzie and chiropractic groups could be a result of an attention placebo effect.
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In the next issue of the BackLetter V10/12 1995 is the following concerning a new study on McKenzie protocol: A carefully designed new study in Holland will compare the efficacy and costs of McKenzie therapy, physical therapy, and treatment by a general practitioner. The study was to get under way in 1996 and assess at 3, 8,12, 26, and 52 weeks. 12 patient sessions up to an 8 week period. It was performed by Bart W. Koes, PhD. 60 subjects. I guess McKenzie does not consider his therapy to be PT. This study if it has been published should help answer the question of dosage vs MMI of the Cherkin study. Anyone have it?
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BackLetter V11/12 1996 Qutes on Cherkin study, one year follow-up; "We are going to report on costs and lon-term utilization of services and health care," says Cherkin. We will provide the data that will allow policy makers to determine whether the treatment benefits are worth the costs."

The key question is: "What price do managed care organizations put on symptom relief and patient satisfaction?"
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I guess this last above qoute sums up the purpose of this research. This Cherkin study was not a study to determine clinical application/purpose/efficacy as much as it was to determine if 9 visits was enough treatment to cure/heal the patient. In other words, could the HMO get away with 9 or less; or should they pay for any treatment for the defined population.

It was an economic/business study. I say this because we still don't know definitively what the proper dosage requirement is for McKenzie, or for chiropractic for the defined research population to achieve improved function, less reoccurances and less utilization of health care resources.

This question should have been answered before the study was performed, just as the booklet was tested. So we now know that for an average of 6 visits in chiropractic care a defined population can expect better satisfaction etc. than that which they would receive from the book for a period of one month.

We don't know though, how much treatment it would take to achieve the results which Cherkin was looking for: Improved function, less reoccurances, thus less utilization of health care resourses. Daniel Becker, DC, DABCN

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