Dynamic Chiropractic - July 27, 1998, Volume 16, Issue 16|
New Study Looks at Appropriate Use of Chiropractic
"The message of our new study is a mixed one. First, everybody needs to stop treating chiropractors as if they are quacks." -- Paul Shekelle, MD, PhD
The July issue of the Annals of Internal Medicine features "The Congruence between Decisions to Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America." The authors of the paper are well-known to chiropractic: Paul Shekelle, MD, PhD; Ian Coulter, PhD; Eric Hurwitz, DC, PhD; Barbara Genovese, MA; Alan Adams, DC; Silvano Mior, DC; and Robert Brook, MD, ScD.
The reason for the study is presented in the abstract:
‘ manipulation for some patients with low back pain. If followed, these guidelines are likely to increase the number of persons referred for chiropractic care. Concerns have been raised about the appropriate use of chiropractic care, but systematic data are lacking."
The authors used a retrospective review of chiropractic office records to "determine the appropriateness of chiropractors' decisions to use "spinal manipulation" for patients with low back pain." They compared a "preset criteria for appropriateness" to the actual chiropractic patient records. The appropriateness criteria used was that established in the RAND study1 for low back pain using a multidisciplinary panel.
The authors selected 131 chiropractic offices randomly sampled from San Diego, California; Portland, Oregon; Vancouver, Washington; Minneapolis-St. Paul, Minnesota; Miami, Florida; and Toronto, Ontario, Canada. In addition, they chose offices in the rural areas around Portland, Minneapolis-St. Paul, and Toronto.
From each office they randomly selected 10 records of patients presenting with low back pain. Of the total number of 1,310 patients, 1,088 (83%) received some form of spinal manipulation. Of these, 859 (79%) had patient records containing sufficient information to determine whether care was congruent with the RAND appropriateness criteria.
The following table was presented as a breakdown of their findings:
InappropriateAs the table shows, chiropractic care received by the low-back pain patients was considered appropriate 46 percent of the time. The conclusion of the authors was:
On the negative side, the chiropractic care delivered was considered inappropriate in 29 percent of the cases and uncertain in 25 percent. The authors note "parallels" between these results and those for conventional medical procedures:
In their discussion, the authors directed their attention to medical referrals:
In a corresponding news release issues by the RAND Corporation, primary investigator Dr. Paul Shekelle made these comments:
1. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brook RH.
The Appropriate Use of Spinal Manipulation for Back Pain: Indicators and
Ratings by a Multidisciplinary Expert Panel. Santa Monica, CA: RAND; 1991.