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EDITORIAL

Complementary Care

When Is It Appropriate? Who Will Provide It?

Marc S. Micozzi, MD, PhD

1 July 1998 | Volume 129 Issue 1 | Pages 65-66

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The Agency for Health Care Policy and Research (AHCPR) recently made history when it concluded that spinal manipulative therapy is the most effective and cost-effective treatment for acute low back pain [1]. The 1994 guidelines for acute low back pain developed by AHCPR concluded that spinal manipulation hastens recovery from acute low back pain and recommended that this therapy be used in combination with or as an alternative to nonsteroidial anti-inflammatory drugs [1]. At the same time, AHCPR concluded that various traditional methods, such as bed rest, traction, and other physical and pharmaceutical therapies were less effective than spinal manipulation and cautioned against lumbar surgery except in the most severe cases. Perhaps most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief and functional improvement. One might conclude that for acute low back pain not caused by fracture, tumor, infection, or the cauda equina syndrome, spinal manipulation is the treatment of choice.

Because acute low back pain is the most prevalent ailment and most frequent cause of disability for persons younger than 45 years of age in the United States [1], adherence to these practice guidelines could substantially increase the numbers of patients referred for spinal manipulation. Chiropractors provide 94% of spinal manipulation [2,3]; limited numbers of physical therapists and traditional osteopathic physicians provide the remainder.

In a 1994 RAND publication, Shekelle and colleagues reported on studies of the use and costs of chiropractic care [4]. These authors have followed this work by reporting, in this issue, adherence by chiropractors to expert recommendations for the use of manipulation for the treatment of low back pain [5].

It is important to note that Shekelle and colleagues focus on the decision to initiate treatment; they do not address the appropriateness of the frequency or duration of treatment. They also provide no data on actual clinical outcomes but rather simply examine the application of therapy according to standard criteria. "Appropriate" as defined in their study does not necessarily mean "beneficial."

In this study, the proportions of chiropractic spinal manipulation judged to be appropriate and inappropriate were similar to proportions previously described for certain allopathic medical procedures. However, more than one fourth of patients received spinal manipulation for indications that were judged inappropriate for this type of therapy. Therefore, effort must be placed on reducing the amount of inappropriate chiropractic spinal manipulation, as is being done for such medical procedures as carotid endarterectomy [6], coronary artery bypass surgery [7], hysterectomy [8], and tympanostomy [9].

Shekelle and colleagues' study may be an indicator of what is to come. The AHCPR is developing new guidelines for the use of chiropractic manipulation in chronic headache. The Foundation for Chiropractic Education and Research is supporting other studies by chiropractors, and a Consortial Center for Chiropractic Research has been established at the Palmer Center for Chiropractic Research in Davenport, Iowa, with support from the National Institutes of Health. There remains much controversy within the chiropractic profession about the appropriate use of various therapies, such as high-velocity adjustment. Moreover, no therapy works equally well for everyone, even when appropriately used. We need more research to identify patients and conditions that are likely to benefit from alternative therapies.

Issues relating to "appropriate" complementary care extend far beyond the scope of Shekelle and colleagues' study. When should care be initiated? What is the general quality of the care provided? How effective is that care? Who will provide this high-quality, effective care? Answering all of these questions is crucial, but the last one is of particular concern. Without enough well-trained alternative care practitioners, the potential for inappropriate care will be great.

Born in the U.S. Midwest 100 years ago, chiropractic is a uniquely American contribution to health care. It drew from "vitalist" concepts and "energetic" healing traditions that were then current in the practice of an eclectic U.S. medicine and from the desire for drugless healing in reaction to the toxicity of the materia medica of that era. Despite this rather long history, social, political and economic pressures have limited the chiropractic workforce to 56 000 practitioners in the world (52 000 of them in the United States), plus a much smaller number of "traditional" osteopathic physicians and others who practice spinal manipulation [10]. In comparison, the mainstream medical workforce in the United States consists of about 600 000 physicians.

Even with these limitations on its growth, chiropractic is clearly the largest complementary health care force in the United States. Chiropractic is also the most "professionalized" of the complementary healing traditions available in the United States, with licensure in all 50 states, educational accreditation standards, continuing education requirements, and active research and investigation. Less organized and less professionalized disciplines of complementary care may be poorly prepared to develop guidelines and conduct research. In addition, the emphasis on tailoring complementary therapy to the individual patient may be at odds with the biomedical concepts of treatment protocols, practice guidelines, and population-based research [11].

Acupuncture, which also may be an effective therapy for back pain, is a discipline that is beginning to wrestle with these issues on a wide scale. The November 1997 National Institutes of Health Consensus Development Conference on Acupuncture concluded that acupuncture is safe, is efficacious for some clinical conditions, appears promising for others, and requires additional clinical research. However, only approximately 3000 physician-acupuncturists are practicing in the United States. Acupuncture is licensed in just two thirds of U.S. states and Washington, D.C. [12]. Because acupuncture has long been relegated to an underground, marginalized status in the United States, it is not well organized or professionalized compared with mainstream medicine or even chiropractic. As physicians are becoming increasingly willing and able to justify referral for complementary care, how will acupuncture and other healing traditions, now hundreds or thousands of years old, become more "professional" to meet the demand for care and the opportunities for integration into mainstream medicine?

We must foster the development of training, research, and clinical protocols to support integration of complementary medicine in a way that promotes favorable clinical outcomes. Alternative medicine can benefit from the kind of support from which mainstream medicine has benefited over the years. When all is said and done, what works will no longer be called mainstream or complementary-it will just be called good medicine.

Marc S. Micozzi, MD, PhD
College of Physicians of Philadelphia; Philadelphia, PA 19103
Requests for Reprints: Marc S. Micozzi, MD, PhD, College of Physicians, 19 South 22nd Street, Philadelphia, PA 19103.
Ann Intern Med. 1998;129:65-66.

References

1. Bigos SJ, Bowyer O, Braea G, Brown K, Deyo R, Haldeman S, et al.
Acute Low Back Pain Problems in Adults:
Clinical Practice Guideline no. 14
Rockville, MD: U.S. Department of Health and Human Services,
Public Health Service, Agency for Health Care Policy and Research; 1994.
AHCPR publication no. 95-0642.

2. Shekelle, P.G., Adams, A.H., Chassin, M.R. et al.
The Appropriateness of Spinal Manipulation for Low-Back Pain.
Project Overview and Literature Review
Santa Monica, CA: RAND, 1991. Report No.: R-4025/2-CCR/FCER.

3. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH.
Spinal manipulation for low-back pain.
Ann Intern Med. 1992;117:590-8.

4. Shekelle PG.
The Use and Costs of Chiropractic Care in the Health Insurance Experiment
Santa Monica, CA: RAND; 1994.

5. Shekelle, PG, Coulter, I, Hurwitz, EL, Genovese, B, Adams, AH, Mior, SA et al.
Congruence Between Decisions to Initiate Chiropractic Spinal Manipulation for Low Back Pain
and Appropriateness Criteria in North America
Annals of Internal Medicine 1998 (Jul 1); 129 (1): 9–17

6. Winslow CM, Solomon DH, Chassin MR, Kosecoff J, Merrick NJ, Brook NH.
The appropriateness of carotid endarterectomy.
N Engl J Med. 1988;318:721-7.

7. Winslow CM, Kosecoff J, Chassin M, Kanouse DE, Brook RH.
The appropriateness of performing coronary artery bypass surgery.
JAMA. 1988;260:505-9.

8. Bernstein SJ, McGlynn EA, Siu AL, Roth CP, Sherwood MJ, Keesey JW.
The appropriateness of hysterectomy. A comparison of care in seven health plans.
Health Maintenance Organization Quality of Care Consortium.
JAMA. 1993;269:2398-402.

9. Kleinman LC, Kosecoff J, Dubois RW, Brook RH.
The medical appropriateness of tympanostomy tubes proposed for children younger than 16 years in the United States.
JAMA. 1994;271:1250-5.

10. Redwood D. Chiropractic.
In: Micozzi MS, ed. Fundamentals of Complementary and Alternative Medicine.
New York: Churchill Livingstone; 1996.

11. Micozzi MS.
Characteristics of complementary and alternative medicine.
In: Micozzi MS, ed. Fundamentals of Complementary and Alternative Medicine.
New York: Churchill Livingstone; 1996.

12. Ergil K.
China's traditional medicine.
In: Micozzi MS, ed. Fundamentals of Complementary and Alternative Medicine.
New York: Churchill Livingstone; 1996.

Related articles in Annals:

Articles
Congruence between Decisions To Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America

Paul G. Shekelle, Ian Coulter, Eric L. Hurwitz, Barbara Genovese, Alan H. Adams, Silvano A. Mior, and Robert H. Brook
Annals 1998 129: 9-17.

Copyright © 1998 by the American College of Physicians.

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