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Shaw Chiropractic
A Medical-Legal Newsletter for Personal Injury Attorneys
by Dr. Steven W. Shaw

New England Journal of Medicine Blasts Chiropractic

During a pretrial conference the plaintiff’s lawyer is called to the judges chambers to discuss the merits of his case. The judge pulls out a copy of a recent Associated Press article from the Hartford Courant which says that a $1 educational booklet is more effective than chiropractic or physical therapy for back pain. The judge asks the plaintiff attorney "Are you prepared to try this case considering that your expert witness is a chiropractor?"

This really happened. Fortunately, the plaintiff attorney was prepared and defended his client and the chiropractor by demonstrating the bias in the article and his experience with the chiropractor. The tools he needed to make this defense may be useful to you as well so I have summarized the important points for you to use should you find yourself in a similar situation with a judge, jury or adjuster.

The New England Journal of Medicine in it’s October 8th 1998 issue had two primary research papers and one editorial about chiropractic. The editorial was by Paul Shekelle MD of the West Los Angeles Veteran Affairs Medical Center. Dr. Shekelle, despite his medical bias points out the following:

1. The scientific literature tells us "That spinal manipulation is a somewhat effective therapy" and "that this question is no longer in dispute".

2. "Before we judge this approach (chiropractic) too harshly, however, we must remember that many existing medical interventions currently paid for by insurance companies provide small benefits or none at all (ex ultrasound therapy, epidural corticosteroids for sciatica".

3. "There is evidence from randomized clinical trial that spinal manipulation may be efficacious for some patients with neck pain"

The original article which was publicized in the media was titled "A Comparison of Physical Therapy, Chiropractic Manipulation and Provision of an Educational Booklet for the Treatment of Patients with Low Back Pain". Allow me point out some flaws in the paper from a practicing clinicians point of view:

1. The study allowed for a maximum of 9 treatments with the average patient receiving less than 7 manipulations.

2. Only one type of spinal manipulation was performed despite the many different manipulation approaches used by chiropractic physicians.

3. No other physical treatments (complementary and preparatory) that would typically be incorporated into the chiropractic management were included in the study.

4. The study used a limited patient pool The study did not include patients with sciatica, prior back surgery, workers’ compensation claims, motor vehicle accident claims.

5. All three of the methods: manipulation, stretching and patient education are important aspects of the chiropractic treatment. In other words, chiropractors may use spinal manipulation as one form of therapy but spinal manipulation is not all inclusive of the practice of chiropractic.

There were some interesting facts in the paper which the media and the authors conveniently did not emphasize. These include:

1. The chiropractic manipulation group had less severe symptoms at 4 weeks.

2. 75 % of the patients rated their care as very good or excellent compared to only 30% of the booklet group.

3. The chiropractic and physical therapy groups had "marginally" better outcomes than the booklet groups. They do not define marginally.

4. The baseline booklet group had fewer days of restricted activity prior to the study suggesting that their conditions may have been less debilitating.

5. The percentage of patients who used back pain medication of any type decreased from 32% to 18% in the chiropractic group. This is approximately 30% less than the PT or booklet groups.

6. In the 11 months after treatment the chiropractic patients missed less than ½ the number of work days than did the PT or booklet groups.

7. The chiropractic patients also faired slightly better over time with regard to reduced activity and the need for bed rest.

For your information:

1. In 1994 the U.S. Agency for Health Care Policy and Research (AHCPR) concluded that spinal manipulation is a recommended and effective form of initial treatment for adult low back pain.

2. The prestigious RAND Corporation determined that spinal manipulation is an appropriate treatment for acute low back pain.

3. The Ontario Ministry of Health found that chiropractic manipulation was the most cost effective and efficacious care for low back pain

4. The British Medical Journal supported chiropractic’s long term effectiveness in treating low back pain (1995)

5. The American Journal of Managed Care (March 96) "Chiropractic care is an extremely promising method of treating acute back and neck discomfort" They recommended "its wider application by the managed care industry and physician community"

Despite the media’s spin I find that the facts to be supportive of chiropractic manipulation. With this information you can educate the judges, juries, adjustors and support your client’s claims.