Robert W. Ward, D.C., QME   First Response

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

TO:  chiro-list@silcom.com;  chirosci-list@silcom.com;   Chiro-news

Frank raises some very interesting points, to which I would like to respond. I had similar concerns, but unlike most of you have regular face-to-face contact with two of the authors of this study.

>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 @:
>
>http://www.acponline.org/journals/annals/01jul98/chiro.htm
>
>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 medicine...at >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".

One problem with interpreting the study is the meaning of "appropriate". The author define this term as follows:

"We defined appropriate as an indication for which the expected health benefits exceeded the expected health risks by a sufficiently wide margin that spinal manipulation was worth doing." Therefore, some scenarios that might seem appropriate to practicing chiros at a casual glance were deemed inappropriate not because manipulation was deemed totally inappropriate forever and always, but because the evidence for benefit (e.g., for chronic low back pain) was not compelling and was outweighed by the possible risk (e.g., persistent minor neurologic symptoms but no advanced imaging obtained) for the scenario presented.

To my mind, numerous questions arose as to the persons making the determination of appropriateness. The "panel of experts" is described in the following extract; I leave it to you to decide for yourself how well qualified they may be as "experts". Note that the majority of the panel neither treat patients themselves, nor do they perform manipulation themselves.

"A 9-member panel of back experts was convened, consisting of 3 chiropractors, 2 orthopedic spine surgeons, 1 osteopathic spine surgeon, 1 neurologist, 1 internist, and 1 family practitioner. Six panel members were in academic practice, 3 were in private practice, and 4 performed spinal manipulation as part of their practice. The panel members represented all major geographic regions of the United States. The panel used a scale of expected risk and benefit (ranging from 1 to 9) to rate the appropriateness of a comprehensive array of indications, or clinical scenarios, in patients who might present to a chiropractor's office."

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

In a word, no. HOWEVER; this article is not intended to set standards by which reimbursement is accepted or denied. Use of this article in such a fashion by third party payors would itself be inappropriate. The author I spoke to said that the RAND group would like to know if any third party payors are improperly denying payment based on this article, and would have no trouble issuing a statement that such use is improper.

>2. Are you secure with the documentation you generate?

I am. However, I am not a high-volume practitioner, and therefore have the "luxury" of devoting some time to documentation.

>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."

I do. I brought this very passage to the attention of the author I spoke to. He said he had not personally perused the galley proofs prior to publication, and was genuinely surprised to find this passage. He could not tell me how this particular scenario had rated during the process, but said it definitely was not on the "top five" list of inappropriate scenarios (which is given as a table in the actual article); he felt strongly that one of the "top five" should have been cited in the text as an example.

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

First of all, the authors are NOT the "expert" panel. Paul and "several DCs" did not necessarily agree with the findings of the panel that they reported. Secondly, I too would like to know why. Perhaps the panel would have felt differently if, in the scenario above, advanced imaging had been obtained to investigate the occult cause of the "minor neurologic deficit", and no contraindications to manipulation had been found.

>Please note that the 2nd Meade study:
>
>Meade, TW "Randomized comparison of chiropractic and hospital outpatient management for low back pain: Results from an extended follow-up"
>BMJ 1995; Aug 5 311: 349-51
>
>found benefit for manipulation in both sub-acute AND chronic patients...so, how is it that this article is quoted so infrequently? Or is ignored by these authors?

It's reference #47 in their bibliography.

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

The editorial which accompanies this issue is equally thought provoking. The text is not overly long, and I shall post it separately for the perusal of those interested.

Robert W. Ward, D.C., QME
Department of Diagnosis, Los Angeles College of Chiropractic
Private practice, Long Beach, CA

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