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What Role for Chiropractic in Health Care?.
Excerpted from New England Journal of Medicine, October 8, 1998 issue.

On September 18, 1895, Daniel David Palmer manipulated the spine of Harvey Lilliard, allegedly restoring Mr. Lilliard's sense of hearing and founding the practice of chiropractic. (1) From this beginning, despite decades of persecution from government and organized medicine, chiropractors have become the third largest group of health professionals in the United States (after physicians and dentists) who have primary contact with patients. Chiropractors are licensed to practice in all 50 states, Medicare covers chiropractic care for radiographically proved subluxation of the vertebral spine, 45 states have state-mandated benefits for chiropractic, and an increasing number of insurance plans and managed-care organizations are offering chiropractic benefits. (1) In the last decade of the 20th century, chiropractic has begun to shed its status as a marginal or deviant approach to care and is becoming more mainstream. At this juncture, it seems appropriate to ask what the role of chiropractic should be in health care. There is a debate, both within the chiropractic profession and outside of it, about whether chiropractic should be considered a nonsurgical musculoskeletal specialty or a broadly based alternative to medicine. (1)

Chiropractic differs from traditional medicine in that it eschews the use of pharmaceutical agents and surgery and instead is based on the body's ability to heal itself. Central to improving the body's ability to heal itself, chiropractors assert, is the removal, or correction, of malalignments of the spine (called subluxations) through the use of spinal manipulation (called spinal adjustments). Although chiropractic treatment frequently includes advice about exercise, nutritional supplements, and lifestyle counseling, spinal manipulation is the treatment that is used most often, (2,3) and it is also the therapeutic method most closely identified with the practice of chiropractic in the United States.

What does the scientific literature tell us about the efficacy of spinal manipulation? That spinal manipulation is a somewhat effective symptomatic therapy for some patients with acute low back pain is, I believe, no longer in dispute. (4) The study by Cherkin and colleagues in this issue of the Journal again confirms this finding. (5) Cherkin et al. found that patients with low back pain who were randomly assigned to chiropractic manipulation had a small, marginally significant improvement in symptoms at four weeks as compared with patients who received no therapy other than an educational booklet. (5)

What is in dispute is the efficacy of spinal manipulation in relation to other therapies. Previous studies have compared spinal manipulation with a variety of other therapies, including back exercises, bed rest, and nonsteroidal antiinflammatory drugs. Some of these therapies, such as bed rest, are actually worse than no therapy. (6) Over the past 10 years, the importance of activity in patients with back pain has been increasingly recognized; therefore, Cherkin and colleagues compared chiropractic spinal manipulation with another popular form of treatment, the McKenzie method of physical therapy. In this approach, patients are taught exercises that will centralize their symptoms and taught to avoid movements that will peripheralize them. Cherkin et al. found no appreciable difference in outcomes between the two approaches.

The cost effectiveness of chiropractic care relative to other care is also controversial. Some have tried unconvincingly to estimate cost effectiveness on the basis of nonrandomized studies and workers' compensation data. (7) Cherkin and colleagues measured both the effectiveness and the direct health care costs of chiropractic care in a randomized study. They found that patients who received chiropractic care and those who received McKenzie physical therapy incurred about $280 more in costs over the course of two years than patients who received the educational booklet. Though they did not measure indirect costs, such costs are unlikely to differ appreciably according to the type of treatment, since the numbers of days of reduced activity, days in bed, and days of work lost were similar in all three groups. In addition, the rate of recurrence and the percentages of patients who sought care for back pain were similar among the groups, casting doubt on the hypothesis that either chiropractic care or McKenzie physical therapy saves money by reducing the rate of relapse.

Because these data on direct costs are compatible with observational data, (8,9) I conclude that chiropractic care for low back pain, at least as practiced in the United States, costs more than the usual supportive medical care delivered by health maintenance organizations. Whether the small symptomatic benefit and the enhanced satisfaction of patients, as consistently reported by studies of patients treated by chiropractors, are worth this cost is debatable. Before we judge this approach too harshly, however, we must remember that many existing medical interventions currently paid for by insurance companies provide equally small benefits or even none at all (for example, ultrasonographic therapy for shoulder disorders (10) and epidural injections of corticosteroids for sciatica (11)). Consider, too, that the cost effectiveness of chiropractic care could improve substantially. Since the number of spinal manipulations needed to achieve the maximal therapeutic effect is unknown, chiropractors may be able to deliver fewer treatments and still achieve the same results.

What about the use of spinal manipulation for other musculoskeletal problems? There is evidence from randomized clinical trials that spinal manipulation may be efficacious for some patients with neck pain. (12,13) However, neither the efficacy of manipulation relative to that of other therapies nor the cost effectiveness of such therapy has been established. Moreover, the use of cervical manipulation arouses far greater concern about safety than the use of lumbar manipulation.

The appropriateness of spinal manipulation for non-musculoskeletal conditions is the most divisive issue among medical physicians and chiropractors. Physicians generally accept the role of chiropractic in treating selected musculoskeletal problems but adamantly oppose its use for treating a diverse array of disorders, such as hypertension, asthma, and otitis media, despite numerous case reports from chiropractors of improvement in these conditions with spinal manipulation. Hindering any rational discussion has been the paucity of data from randomized, controlled trials. Therefore, the study by Balon and colleagues, which also appears in this issue of the Journal, (14) is particularly welcome.

These courageous investigators tested the effect of spinal manipulation as an adjunct to medical therapy for children with stable asthma and found no significant difference between groups in terms of physiologic outcomes, symptoms, quality of life, or patients' satisfaction. Thus, they concluded that the addition of chiropractic spinal manipulation to medical therapy had no effect on the control of childhood asthma. However, the proportion of patients who seek chiropractic for conditions such as asthma or other nonmusculoskeletal conditions is very small. For example, treatment for conditions such as asthma or otitis media accounts for less than 1 percent of patient visits to chiropractors in the United States, whereas treatment for back pain accounts for 40 to 60 percent of all visits. (2,3) Therefore, the debate about the usefulness of chiropractic care for nonmusculoskeletal conditions may be largely academic.

What is the role of chiropractic in health care? In 1979 Dr. Arnold Relman wrote an editorial for the Journal entitled "Chiropractic: Recognized but Unproved." (15) Nearly 20 years later there appears to be little evidence to support the value of spinal manipulation for nonmusculoskeletal conditions. For this reason, I think it is currently inappropriate to consider chiropractic as a broad-based alternative to traditional medical care. However, for some musculoskeletal conditions, chiropractic care does provide some benefit to some patients. The challenge for chiropractors is to demonstrate that they can achieve this benefit at a cost that patients or health insurers are willing to bear.

Paul G. Shekelle, M.D., Ph.D.
West Los Angeles Veterans Affairs Medical Center
Los Angeles, CA 90073

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