My comments on the article- Congruence between Decisions To Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America


This section is compiled by Frank M. Painter, D.C.
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Listers and friends,

I'd like to raise an issue with this article:

"Congruence between Decisions To Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America"
Paul G. Shekelle, MD, PhD; Ian Coulter, PhD; et al.
Annals of Internal Medicine 1998; 129: 9-17

It (FULL TXT) is located @:

It states: "Of the 1310 patients who sought chiropractic care for low back pain, 1088 (83%) had spinal manipulation. For 859 of these patients (79%), records contained data sufficient to determine whether care was congruent with appropriateness criteria. Care was classified as appropriate in 46% of cases, uncertain in 25% of cases, and inappropriate in 29% of cases."

It later states that: "Our results for chiropractic care share some parallels with findings seen with conventional medical procedures. When studied a decade ago by use of identical methods, the rates of appropriate and inappropriate use for carotid endarterectomy were 35% and 32%, respectively, and the rates for coronary artery bypass graft surgery were 56% and 14%, respectively (6, 7). In addition, as with some medical procedures (26), we have shown that the appropriateness with which chiropractic spinal manipulation is initiated varies according to geographic location. The cause or causes of these variations are unknown but have been postulated to be due to local differences in uncertainty (27) or enthusiasm (28) about the use of spinal manipulation. "

I am sure the authors feel this puts us on equal footing with least in the respect that both of us "seem" to be inappropriate way too much in our selection of candidates or in when to give "care".

I ask you:

1. Do you feel your records could justify ongoing care based on the precise standard this article sets?

2. Are you secure with the documentation you generate?

3. Do you agree that this patient is NOT a candidate for care:

"A patient with chronic low back pain of greater than 6 months' duration, with no prior manipulative therapy, whose radiographs show no contraindication to manipulative therapy, with no advanced imaging study performed, with minor neurologic findings and no sciatic nerve irritation, who has spinal joint dysfunction on physical examination, and who has ongoing biomechanical or psychosocial distress."

Paul Shekelle and several DC's agree that this person IS NOT a candidate, and I for one would like to know WHY???

Please note that the 2nd Meade study:

Randomised Comparison of Chiropractic and Hospital Outpatient Management
for Low Back Pain: Results from Extended Follow up

British Medical Journal 1995 (Aug 5);   311 (7001):   349351

found benefit for manipulation in both sub-acute AND chronic, how is it that this article is quoted so infrequently? Or is ignored by these authors?

I hope this will raise some stimulating conversation, as well as some well crafted, thoughtful and immediate letters to the editors at AIM.

Frank M. Painter, D.C.

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