EDITOR'S NOTE:

Anthony Rosner, Ph.D., Director of Research and Education for the Foundation for Chiropractic Education and Research, presented testimony on behalf of chiropractic research and practice standards at hearings conducted at the Institute of Medicine (IOM) headquarters in Washington, D.C., on February 27, 2003. The occasion marked the first of six meetings of a study committee planned by the IOM over the next 18 months to explore the scientific and policy implications of the use of complementary and alternative medicine (CAM) therapies by the American public.

The objectives of the study committee are as follows:

1. To describe the use of CAM therapies by the American public, including the populations that use them and what is known about how they are provided;

2. To identify major scientific and policy issues related to CAM research (including gender effects), regulation, interactions with conventional medicine, and training and certification; and

3. To develop conceptual frameworks for guiding decision-making on these issues and questions.

The Institute of Medicine is a private, non-governmental organization that initiates studies in areas of medical care out of appropriations made available to federal agencies. It is a branch of the National Academy of Sciences, which was created by the federal government to be an advisor on scientific and technological matters.

Following is Dr. Rosner’s presentation to the Institute of Medicine.

For The Institute Of Medicine:   The Use of CAM by the American Public

INTRODUCTION

My dear colleagues:

I want to thank the Institute of Medicine (IOM) for two reasons; first, for inviting my testimony this afternoon, but especially for carrying what I believe is the unfulfilled work of both the National Center for Complementary and Alternative Medicine and the White House Commission on Complementary and Alternative Medicine an essential step forward by calling us to the table today.

I also want to offer my strongest assent and congratulations to the Institute for its most pertinent and insightful assessment of American healthcare — first, in its forthright reporting of medical errors in 1999; [1] second, in providing one of the most equitable definitions among the many offered for "primary care; [2]" and finally, for having published two years ago the most candid and uncompromising assessments of U.S. healthcare, Crossing the Quality Chasm: A New Health System for the 21st Century. [3]

This last publication courageously concluded that "the American healthcare system is in need of a fundamental change," especially because "what is perhaps most disturbing is the absence of real progress toward restructuring health care systems to address both quality and cost concerns. . . ." [3]

We now know that superficial makeovers will not suffice. The IOM indicated that entirely new patterns of thinking will be necessary to escape this dilemma. "Our present efforts," suggested Mark Chassin, "resemble a team of engineers trying to break the sound barrier by tinkering with a Model T Ford. We need a new vehicle, or perhaps many new vehicles. The only unacceptable alternative is not to change." [4]

With these facts in mind, I come to you as the Director of Research of a nonprofit foundation that in its 60-year history has provided over $10M for pilot projects and support for postgraduate study in areas pertaining to the theory and practice of chiropractic healthcare. I am both joyful and dismayed.

Joyful, because in terms of achieving chiropractic research goals from a scientific standpoint, I can only share with you the greatest satisfaction if not outright wonder. Until about 30 years ago, chiropractic research was considered in some quarters to be something of an oxymoron, "falsely conceived and rather clumsily executed...[with a text]...that should never have been accepted, on a subject that should never have been chosen, by [those] who never have attempted it." A depiction of chiropractic researchers? No, a description of George Gershwin's now immortal opera, Porgy and Bess, by the music critic Virgil Thompson.

Despite the fact that chiropractic has existed as a formal profession worldwide for over a century, most of what we consider to be rigorous, systematic research in support of this form of healthcare has emerged in just the past two-and-a-half decades. In 1975, Murray Goldstein of the National Institute of Neurological Diseases and Stroke concluded that there was insufficient research to either support or refute chiropractic intervention for back pain and other musculoskeletal disorders. [5] Nearly 30 years later, we now can review with great satisfaction how back pain management has been assessed by government agencies in the U.S., [6] Canada, [7] Great Britain, [8] Sweden, [9] Denmark, [10] Australia, [11] and New Zealand. [12] All of these reports are highly positive with respect to spinal manipulation. Now we could argue that chiropractic care, at least for back pain, appears to have vaulted from last place to first as a treatment option.

In just the last 20 years, at least 73 randomized clinical trials involving spinal manipulation have made their appearance in the English-language literature. Even more amazing is the fact that the majority of these have been published in general medical and orthopedic journals. These trials address not only back pain, but also headache and neck pain, the extremities, and a surprising variety of nonmusculoskeletal conditions. When spinal manipulation is employed, the majority of these trials have shown positive outcomes with the remainder yielding equivocal results.

There are 43 trials addressing acute, subacute, and chronic low back pain with 30 showing us that manipulation is more effective than control or comparison treatments and the remaining 13 reporting no significant differences between treatment groups. None of these studies appears to have produced a negative outcome and none indicate that manipulation is any less effective than any comparison intervention. [13, 14]

Other major accomplishments

1. The appearance of a variety of favorable systematic literature reviews; [15-17]
   
   

2. The establishment of the first federally funded chiropractic Center for Excellence at Palmer University by NIH's National Center for Complementary and Alternative Medicine in 1997;
   
   

3. The publication of the Headache Report by Duke University last year; [18]
   
   

4. The securing of over $10M in federal grants within the past decade when in 1991 this accomplishment was considered to be unlikely; [19]
   
   

5. The establishment of chiropractic services within the military; and
   
   

6. The historic signing of Public Law 107-135 on January 23 of this year mandating the establishment of a permanent chiropractic health benefit within the Department of Veterans Affairs health care system.

Even more remarkable is the efficiency of chiropractic research. When compared to the NIH budget of nearly $20B, the $10M investment in federal funds is substantially less than a tenth of 1 percent, which makes it less than a rounding error or, as a couple of wags have offered in the past — obviously, the federal government must believe in alternative medicine because it has given chiropractic researchers homeopathic doses of money with which to work.

If you were to sum up my feelings about how far chiropractic research seems to have come, I'd have to resort to a pithy quotation from a baseball hero that many of us grew up with: Yogi Berra. When asked as manager of the New York Yankees whether one his star players exceeded his expectations during a banner season, Yogi's remark was, "I'd say he's done better than that!"

So then why am I dismayed? Let me share with you just one example out of many which typify our problem. A recent report on workers' compensation claimants from Florida is particularly galling. It pointed out that for industrial musculoskeletal injuries, chiropractic care demonstrates lower costs and shorter durations in both reaching maximal medical improvement and return to work. Incredibly, over the same 7-year period, the frequency of specific musculoskeletal related cases treated by chiropractors in 1999 was only 25% of the level seen in 1994 (the date that managed care was introduced into the Florida workers' compensation system). [20]

In other words, just when access of workers to chiropractic care should be increased to result in significant direct and indirect cost savings (as previously shown by Manga [21]) we are witnessing precisely the opposite. Chiropractic care seems to be getting squeezed out of the system. Look at the neighboring state of Georgia, in which chiropractic workers' compensation cost recoveries were just 0.8% of the benefits disbursed to physicians in 1997 and 1998. [22,23] Again one suspects the exclusion of chiropractic services.

Is this paranoia? Not when you consider that, despite the wealth of its research information with such little funding, it has been necessary time and time again for the chiropractic profession to seek both legislative and legal recourse to achieve its earned recognition with the most meticulous of research, ironic in light of a recent report which shows that chiropractic practices in at least one locale can demonstrate that a higher percentage of its treatments are evidence-based than found in medical interventions. [24]

Yet we still endure the opinions of past editors of such trusted sources as The New England Journal of Medicine who have debunked alternative medicine as "unscientific," often basing their own theories upon the same type of anecdotal evidence that they condemn in various branches of non-orthodox medicine. [25,26] Add medical journal articles on cerebrovascular accidents of questionable scientific validity [27-32] plus an onslaught of negative press regarding the safety of manipulation [33-38] that could only be described as a petri dish of fetid disinformation of the first magnitude. This is downright embarrassing, almost vaudeville, when you consider that medical practitioners have been shown to have failed validated competency examinations in musculoskeletal medicine. [39-41] Instead of abiding by this nonsense, we need to level the playing field instead of the patient!

In an ideal world, scientific debate would be carried on at a high level and documented evidence would be enthusiastically accepted and incorporated into guidelines and practice. In the real world, unfortunately, there have been too many examples of resistance such that chiropractic healthcare would probably not even have existed had such lawsuits as the Wilk case against the AMA for restraint of trade not been brought to bear. [42]

Now the profession faces discrimination in reimbursement practices in the insurance industry requiring two more ongoing lawsuits headed by the American Chiropractic Association against both Trigon Blue Cross Blue Shield and the Health Care Financing Administration's Medicare Part C regulations. [43]

How has the insurance industry and the AMA responded to attempting to control the costs of healthcare? By advocating such legislation as the Help Efficient Accessible, Low-cost, Timely Healthcare Act of 2003 designed to cap pain and suffering awards to patients suing for malpractice. [44] In light of the IOM's own data on iatrogenesis and medical errors [2,3] as well as more recent reports that tells us that efforts to improve upon these errors have not been forthcoming and that their mandatory reporting has actually been resisted by doctors and hospitals, [45] this seems to be an exceptionally cynical and ill-conceived response to the needs of the American public. So is its ignoring the real culprit of runaway costs: runway prescription drug spending. [46] Realizing already documented [21,47] cost savings by allowing patients access to alternative means of healthcare, including chiropractic, seems far more efficient as well as effective.

Chiropractic interventions which manifest tangible results, a commitment to research and documentation of the highest recognized quality, [15-17] high patient satisfaction, and cost-effectiveness should not have to continually resort to legislation and costly legal action to continue to survive. In this presentation I request that the IOM display a commitment to working with us in order to halt the spread of both discriminatory policies which impede access to healthcare and the propagation of disinformation in the media that can only be described as an epidemic of alarming proportions.

By commitment I am specifically referring to adequate as well as qualified chiropractic representation in matters of healthcare policy and decision-making as we attempt to address the leading problems in America's healthcare. All too often this effective seat at the table has been denied as part of the discriminatory pattern I referred to earlier. Skyrocketing health insurance premiums and the known shortages of healthcare professionals can both be addressed with better access to chiropractic healthcare.

REFERENCES:

1. Kohn LT, Corrigan JM, Donaldson M, eds. To Err is Human: Building a Safer Health System. Washington, DC: Institute of Medicine, 1999.
   
   

2. Institute of Medicine: Defining primary care: An interim report. Washington, DC: National Academy Press, 1994.
   
   

3. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001.
   
   

4. Chassin MR, Galvin RW, National Roundtable on Healthcare Quality. The urgent need to improve health-care quality.
   Journal of the American Medical Association 1998; 280(11): 1000-1005.
   
   

5. Goldstein M (ed): Monograph No. 15. The Research Status of Spinal Manipulation. Washington, 1975, U.S. Department of Health, Education, and Welfare.
   
   

6. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Pain in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, 1994, Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.
   
   

7. Manga P, Angus D, Papadopoulos C, Swan W. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain. Richmond Hill, 1993, Kenilworth.
   
   

8. Rosen M. Back Pain: Report of a Clinical Standards Advisory Group Committee on Back Pain. London, 1994, HMSO.
   
   

9. Commission on Alternative Medicine, Social Departementete. Legitimization for Vissa Kiropraktorer. Stockholm, 12: 13-16, 1987.
   
   

10. Danish Institute for Health Technology Assessment. Low-back pain, frequency, management, and prevention from an HTA perspective.
    Danish Health Technology Assessment 1(1), 1999.
    
    

11. Thompson CJ. Second Report, Medicare Benefits Review Committee. Canberra, 1986: Commonwealth Government Printer, Chapter 10 (Chiropractic).
    
    

12. Hasselberg PD. Chiropractic in New Zealand: Report of a Commission of Inquiry. Wellington, 1979, Government Printer.
    
    

13. Meeker WC, Mootz RD, Haldeman S. Back to basics...The state of chiropractic research.
    Topics in Clinical Chiropractic 2002; 9(1): 1-13.
    
    

14. Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and alternative medicine.
    Annual Review of Internal Medicine 2002; 136: 216-227.
    
    

15. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: A systematic review of the literature.
    Spine 21(15): 1746-1760.
    
    

16. Kjellman GV, Skagren EI, Oberg BE. A critical analysis of randomised clinical trials on neck pain and treatment efficacy: A review of the literature.
    Scandinavian Journal of Rehabilitative Medicine 1999; 31: 139-152.
    
    

17. Bronfort G, Assendelft WJJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headache: A systematic review.
    Journal of Manipulative and Physiological Therapeutics 2001; 24(7): 457-466.
    
    

18. McCrory DC, Penzien DB, Hasselblad V, Gray RN. Evidence Report: Behavioral and Physical Treatments for Tension-Type and Cervicogenic Headache. Des Moines, IA: Foundation for Chiropractic Education and Research, 2001.
    
    

19. Corporate Health Policies Group. An Evaluation of Federal Funding Policies and Programs and Their Relationship to the Chiropractic Profession. Arlington, VA: Foundation for Chiropractic Education and Research, 1991.
    
    

20. Folsom BL, Holloway RW. Chiropractic care of Florida workers' compensation claimants: Access, costs and administrative outcome trends from 1994 to 1999.
    Topics in Clinical Chiropractic 2002; 9(4): 33-53.
    
    

21. Manga P. Enhanced chiropractic coverage under OHIP as a means for reducing health care costs, attaining better health outcomes and achieving equitable access to health services. Report to the Ontario Ministry of Health, 1998.
    
    

22. www.ganet.org/sbwc/about/
    
    

23. Smith JC. e-mail notice of August 11, 2000.
    
    

24. Wenban AB. Is chiropractic evidence based? A pilot study.
    Journal of Manipulative and Physiological Therapeutics 2003; 26(1): 47
    
    

25. Angell M, Kassirer JP. Editorial: Alternative medicine--The risks of untested and unregulated remedies.
    New England Journal of Medicine 1998; 339(11): 839-841.
    
    

26. Bunk, S. "Is Integrative Medicine in the Future? Debate between Andrew Weil, M.D., and Arnold Relman, M.D."
    The Scientist 1999; 13(10): 1,10-11.
    
    

27. Dalen JE. Is integrative medicine the medicine of the future? A debate between Arnold S. Relman, M.D., and Andrew Weil, M.D.
    Archives of Internal Medicine 1999; 159: 2122-2126.
    
    

28. Lee KP, Carlini WG, McCormick GF, Walters GW. Neurologic complications following chiropractic manipulation: A survey of California neurologists.
    Neurology 1995; 45(6): 1213-1215.
    
    

29. Bin Saeed A, Shuaib A, Al-Sulaiti G, Emery D. Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients.
    The Canadian Journal of Neurological Sciences 2000; 27(4): 292-296.
    
    

30. Hufnagel A, Hammers A, Schonle P-W, Bohm K-D, Leonhardt G. Stroke following chiropractic manipulation of the cervical spine.
    Journal of Neurology 1999; 246(8): 683-688.
    
    

31. Norris JW, Beletsky V, Nadareishvilli ZG, Canadian Stroke Consortium.
    Canadian Medical Association Journal 2000; 163(1): 38-40.
    
    

32. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: A population-based case-control study.
    Stroke 2001; 32(5): 1054-1060.
    
    

33. Brody J. When simple actions ravage arteries.
    New York Times, April 30, 2001.
    
    

34. Bill Carroll Show, CFRB 1010 radio, February 6, 2002, posted on the internet.
    
    

35. Evenson B. National Post, February 7, 2002.
    
    

36. Hamburg J, Medical Minute, WOR AM 710 radio, February 22, 2002.
    
    

37. Jaroff L. Back off, chiropractors! TIME.com, February 27, 2002.
    
    

38. A different way to heal. Episode of Scientific American Frontiers Public Broadcasting System telecast, June 4, 2002.
    
    

39. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine.
    Journal of Bone and Joint Surgery 2002; 84-A(4): 604-608.
    
    

40. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine.
    Journal of Bone and Joint Surgery 1998; 80-A(10): 1421-1427.
    
    

41. Vlahos K, Broadhurst NA, Bond MJ. Knowledge of musculoskeletal medicine at undergraduate and post-graduate levels.
    Australasian Musculoskeletal Medicine May 2002; 28-32.
    
    

42. Getzendanner S, District Judge, decision in Wilk v. AMA, 27 August 1987.
    
    

43. Cuneo GV. ACA's 2002 annual report.
    Journal of the American Chiropractic Association 2002; 39(11): 20-32.
    
    

44. http://thomas.loc.gov/ described in amednews.com, February 27, 2003.
    
    

45. The Washington Post, December 3, 2002.
    
    

46. Associated Press, Washington, DC, January 8, 2003.
    
    

47. Eldridge L. Improving quality of care lowers employer and employee costs. Presentation by Alternative Medicine, Inc. at Health Care or Wealth Care (conference on healthcare costs), Vancouver, British Columbia, CANADA, September 16, 2002.