Date: 10/08/1998 03:56 pm (Thursday)
From: Bill Meeker
Subject: Fw: NEJM -Reply
My comments below are intended for a chiropractic audience, but portions may be valuable to use in other settings.
Comments on the NEJM Studies:
Neither study indicated that chiropractic care or spinal manipulation was worthless. Both studies were comparisons of different forms of treatment, all of which demonstrated benefits for patients.
Both studies are intriguing and welcome additions to the scientific literature but are not definitive and final by any
means. They each leave unanswered a number of questions, which further research is likely to address. Research is not a project but a process. The chiropractic profession supports continued scientific evaluations of its procedures, just as it does for all medical and health care methods, many of which also suffer from a lack of definitive research proving benefits.
On the low back pain study, it is gratifying to see experienced health services researchers conducting studies on one
chiropractic procedure, spinal manipulation, especially supported by a Federal agency, the Agency for Health Care Policy
On the asthma study, I would point out that chiropractic researchers designed and conducted the study, and that it was
funded by the chiropractic profession. The fact that it was published in the NEJM is an indication of the high quality of
the scientific work conducted by chiropractic scientists and the integrity that they bring to their efforts. It all is an
indication that chiropractic is being taken seriously as a scientific health care topic.
The real world application of these results, the generalizability beyond these two specific studies is open to question. For example, the Cherkin study actually compares only one type of physical therapy * McKenzie * against one form of
Dr. Cherkin admits that the McKenzie treatment and chiropractic both demonstrated statistically significant advantages compared to the patient booklet at 4 weeks and probably at 12 weeks. Look at Table 3. While he calls this difference marginal, I suggest that the difference is very important if you're a patient with back pain who has been having a hard time with pain and daily activities. As well, at one year, there were statistically significant advantages to both the physical treatments.
Furthermore, the results may be limited because in most settings chiropractic care includes additional things besides just one form of spinal manipulation (there are many others), also including exercise, other physical treatments, and patient
education in self-care. All of these may add benefit.
The McKenzie therapists were an elite trained group, trained by Robin McKenzie himself just prior to this study, and employed by the HMO. On the other hand, the chiropractors, as competent and experienced as they were, did not receive any high-level pressurized training prior to the study.
Finally, patients were much more satisfied with their care from the PTs or DCs compared to those not receiving care. Despite protestations, this does have very important implications.
I find it hard to believe that patients will now be satisfied to stay home instead of seeking care from the doctor or therapist simply because of this study. About 80% of Americans will experience back pain at some point in their lives. About 40% of all back patients seek care from chiropractors, and about 50% of a chiropractors' caseload is low back pain.
The asthma study is also interesting although it will have little impact on chiropractic practice since less than 1% of
patients seek care for asthma.
Even though all of these children were under standard medical care, they still had problems; that is why they were allowed in the study. So, even though one might characterize these patients as treatment falilures, they still had:
--Decrease in symptoms
--Improvement in quality of life
--Decreased reliance on medication
Even though objectively measured lung function did not improve, the satisfaction with the chiropractic care was very high. There were no adverse effects of chiropractic care.
This study supports anecdotal reports of chiropractors over the years.
What if this was your child? Would you avoid chiropractic care because of this study?
Clearly, more research needs to be done on how and why people respond to care, an issue that is summarily dismissed by the
authors invoking the pejorative placebo or hawthorne effect explanation.
The fact that patients did improve begs the question of why. Simply to dismiss these effects as "placebo" and worthless is to disrespect these patients experiences. If nothing else, this study highlights the importance of so-called non-specific
effects of care and how little we know about it.
On the other hand, we need to applaud the guts and integrity of these chiropractic researchers. The research was well-conceived and conducted under difficult circumstances. Their discussion and conclusions are technically correct; in other words chiropractic spinal adjustments do not have a specific treatment effect for these patients with asthma that is better than "caring" for these patients without actual adjustments. Let us be honest. This study should certainly cause some serious thinking about the specific effects of specific spinal adjustments compared to non-specific effects of "care."
As always, more research is needed now, perhaps more than ever before.
>>> PCU_DOM.API."Frankfirstname.lastname@example.org" 10/08/98 02:11pm >>>
Dr.'s Mootz, Liebenson, Meeker
Could you please share your insights with the chiro-lists regarding the impact of the NEJM article "A Comparison of
Physical Therapy, Chiropractic Manipulation, and Provision of an Educational Booklet for the Treatment of
Patients with Low Back Pain"
New England Journal of Medicine 1998 (Oct 8); 339 (15): 1021-1029
I use both McKenzie AND adjusting in my practice...and frankly, this abstract makes me a bit queezy.
Any constructive input would reduce my symptoms at this point. Also, would you mind if I post your responses to my LOW BACK
PAIN page, where I have just posted this article for our site users? If you don't want to, that's fine, just say so.
Frank M. Painter, D.C.
Check out the LINKS section @
and the Chiropractic Resource Organization @
Whatever you can do, or dream you can, begin it.
Boldness has genius, power, and magic in it.
From: Dr. Michael D. Beattie
Date: Thursday, October 08, 1998 7:19 AM
This week's NEJM has a few interesting articles :
A Comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma
A Comparison of Physical Therapy, Chiropractic Manipulation, and Provision of an Educational Booklet for the Treatment of
Patients with Low Back Pain
Michael D. Beattie, D.C.
Waterloo Chiropractic Health Centre
Chiro Org's Abstracts
Health is more than the absence of disease.