Government ‘blesses’ chiropractic
Chiropractic research had been virtually nonexistent for much of the profession’s first century. However, as the 1990s dawned, this began to change. And research — reviewed by a credible governmental agency, the Agency for Health Care Policy and Research (AHCPR) —suggested that spinal manipulation was effective for patients with low back pain.
Some suggest that the birth of substantive scientific research in chiropractic can be dated to the 1975 “Conference on the Research Status of Spinal Manipulative Therapy,” held at the National Institutes of Health in Bethesda, Maryland, which had brought together chiropractors, osteopaths, manual medicine specialists and PhD investigators interested in the manual healing arts.
Conference participants came to a consensus that available data did not permit strong conclusions to be drawn about the clinical value of spinal manipulative therapy (SMT), but that continued study was definitely warranted.
By 1984, although a volume of investigations and scholarly reports on SMT had emerged, much of it was published in allopathic journals:
• Journal of Physical Medicine
• Archives of Physical Medicine & Rehabilitation
• British Journal of Industrial Medicine
• British Medical Journal
• Journal of the American Medical Association
• Journal of Bone & Joint Surgery
• Manuelle Medizin
• Medical Journal of Australia
Chiropractors had done a commendable job in gathering and critiquing the available literature on SMT in preparation for the 1975 conference, but they had been slow to begin generating controlled data themselves. Ten years later the profession was at risk of being left behind, of becoming second-class citizens in their own field of specialization.
A look at several events unveils the growth of the science of chiropractic:
• First randomized studies conducted. The ice was broken in 1986, when several chiropractors and instructors from the Palmer College of Chiropractic in Davenport, Iowa, authored the first randomized, controlled clinical trial (RCT) of adjusting, in this case, for patients with low back pain.
Led by Gerald Waagen, PhD, DC, this first chiropractic RCT employed a placebo-control group, and though the sample size was small, the difference in clinical benefit between those who had received the sham procedure and those who were administered adjustments was significant. It was an important first step, and the paper appeared in Manual Medicine.
In the next few years a number of additional trials of SMT performed by chiropractors appeared in the scientific literature,
including the profession’s leading scholarly publication, the Journal of Manipulative & Physiological Therapeutics. Trade, professional and scholarly periodicals began to fill with articles detailing the importance and ramifications of chiropractors’ participation in the scientific process.
• Interdisciplinary study in 1991. In 1991 an interdisciplinary report from the RAND Corp., funded by the Foundation for Chiropractic Education & Research (FCER), provided a thorough review of “The Appropriateness of Spinal Manipulation for Low Back Pain.” Headed by Paul Shekelle, MD, PhD, the team assessed the dozens of RCTs of SMT for back pain that had accumulated to that point and found the literature to strongly support the value of manipulation (including, but not limited to the segment-specific thrusting employed by chiropractors).
A few years later several chiropractic colleges received the first large federal grants for scientific study of chiropractic methods.
• Clinical guidelines written. In the early 1990s, chiropractors met for the first time to create guidelines for clinical practice. Held at a retreat in the San Francisco Bay area and sponsored by a number of constituents of the profession, the Mercy Conference produced the first evidence-based recommendations for chiropractic services. This effort was paralleled the following year by the chiropractors of Canada at what has become known as the Glenerin Conference.
• AHCPR study completed. Soon another interdisciplinary panel was convened, this one organized by the Agency for Health Care Policy & Research (AHCPR, a division of the U.S. Public Health Service), to undertake the broad task of reviewing and considering the wide range of therapeutics then offered to low back pain sufferers. Surgery, they concluded, was rarely warranted, and extended bed rest was frowned upon. Among the methods that AHCPR endorsed were non-steroidal anti-inflammatory medications and SMT.
Chiropractors, who provide an estimated 94 percent of all manipulative services in the United States, were justifiably elated. Political medicine’s long, monopolistic influence on federal health care policymakers was nearing an end.
Although apprehensions were created within the profession that the success of the RCTs, which prompted the federal endorsement, might pigeon-hole chiropractors as exclusively musculoskeletal practitioners, the rules of the road had changed forever. Chiropractors had entered the age of accountability, and there would be no turning back. Research had definitely and finally made a difference.