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