Dan Becker, DC, DABCN   First response

This section is compiled by Frank M. Painter, D.C.
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At 07:46 AM 7/23/98 -0700, Robert W. Ward, D.C., QME wrote:

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.

The definition used for "appropriate" leaves the individual total relying on their opinion. I believe the key word (and weakness of the def.) is "expected health benefit". I don't believe a person has to perform manipulation to have a feel for what can be "expected health benefit" when applied to various scenarios, but they should have a very close working relationship such that first hand experience of results of the application of manipulation is known. The "expected health benefit" is too dependent on the authors of the study opinion in choosing the panel as the panelist expectations are what is being relied on for the results of this study.

Which leads to the next statement that follows. I question this panel's make up. Thus I looked at the RAND study with the all DC panel for comparison. (See further down.)

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."

>>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."


In the all DC panel report, I could not find this exact scenario. But there are very similar scenarios. The appropriateness scale is: 1=extremely inappropriate, 5=equivocal, 9=extremely appropriate. Appropriate = rating 7 to 9, without disagreement. Inappropriate = rating 1 to 3 without disagreement. For:

1. Spinal manipulation is indicated in patients with chronic low back pain (three months or more since onset of pain), no prior manipulative treatment, and minor neurological findings, and no sciatic nerve irritation, and continued biomechanical or psychosocial stress present and physical findings indicative of joint dysfunction; the median rating was 7.0, mean absolute deviation from the median = 1.4, and 'I' = they neither agreed or disagreed.

2. Same as 1 but: ...and sciatic nerve irritation... the rating was the same.

3. Spinal manipulation is indicated in patients with chronic low back pain (three months or more since onset of pain), no prior manipulative treatment, LS spine radiographs show no contraindications and imaging studies show no HNP and no spinal stenosis, minor neurological findings, with sciatic nerve irritation, continued biomechanical or psychosocial stress present and physical findings indicative of joint dysfunction. Rating = 7.0, mean absolute deviation from the median = 1.1, I = they neither agreed or disagreed.

4. Same as 3. with ...imaging studies show central HNP or spinal stenosis, or free fragment, Rating = 6.0, mean absolute deviation from the median = 1.6, I.

I do not have the portion of the report with the mixed panel. I do recall that the DC's were more aggressive with the use of manipulation.

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.

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.

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

My concerns with this study are: that it will be received as the definitive work on defining appropriate care (regardless of the authors disclaimers) because of the journal of publication. The second concern is, why has Dr. Shekelle redone a study, and published it when he had already performed similar work, which appears to be of greater quality (the overall RAND project used mixed and pure DC panels then compared the two)that has not been publish in a similar manor? Third, this study performed with DC's as supports (being co authors) furthers the big brother medicine concept.

Even though the health care world acknowledges that DC's are the major providers of manipulation, it does not allow the accolade of "expert" as the MD specialist is always consulted for the final opinion on such. This is a problem that all CAM providers are facing. Personally, I find that such a position has to do more with political influence than actual academic prowess. In fact, it is interesting to note that in the Minn. report on CAM that "65 to 80% of the rest of the world's health services currently would fall under the rubric of CAM", via the WHO. The title of "back experts" in this new study is used to imply that these members are experts on the application of manipulation, and I believe the researchers on this list have voiced their concerns in the past on such stretches.

Finally, I truly believe that until we move the fight for acceptance of chiropractic (our opinion of the appropriate application of the general base of knowledge on how to promote health and healing in humans) into the court of business law, we will always be one step below autonomy. We will not win autonomy, thus receive the accolade of "expert" (receive the benefits of societal recognition as a profession) in our style of use of the knowledge if we stay in the court of research. It is ludicrous to think that the government can possibly ever fully recognize any other group than allopathic medicine as experts without first recognizing the other group as a competitor to allopathic medicine as oppose to "complimentary or alternative". If this new study stands without a response from our profession (both academic and business) then we will have further perpetuated the idea that allopathic medicine is all knowledgeable. I do not believe that the fact that DC's and MD's have jointly published a "lets play telephone with the literature" piece of research is evidence that our profession is achieving the autonomy and respect, within society and it's economic system, as a profession; which we believe we deserve. I am in favor of true joint sharing of basic knowledge. But opinions are just that, no matter where, and who publishes them. I hope the ACC with the ACA/ICA is working on a response to this study.

And that goes for me too!

Dan Becker, DC, DABCN

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