Analysis of Misleading Chiropractic Testimony
to the Institute of Medicine's "CAM" Committee

Stephen Barrett, MD


On February 27, 2003, the Institute of Medicine's committee on complementary and alternative medicine ("CAM") held a public meeting at which it received testimony from proponents of "complementary and alternative medicine." One presenter was Anthony L. Rosner, Ph.D., Director of Research and Education of the Foundation for Chiropractic Education and Research (FCER). Although some of what Rosner says is factual, he either ignores or attempts to obfuscate information about chiropractic's shortcomings. To highlight his deception, I have inserted comments in bracketed bold-faced red text. As far as I know—and despite my advance warning that chiropractic proponents would present mininformation—the IOM "CAM" committee did not invite anyone to present accurate information about chiropractic.


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. [The White House Commission report was an atrocity written by "CAM" proponents.] 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]. [FCER actually accept IOM's definition of primary care but promotes one of its own.] 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] [Rosner acts as though medicine's possible shortcomings might somehow make chiropractic look good in comparison. Nothing could be further from the truth.]

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] [Chiropractic still clings to its century-old theory that spinal problems ("subluxations") are the underlying cause of ill health and that spinal adjustments can improve health.]

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. [FCER does not function like most research foundations. It's primary activity is not research but public relations. One of its stated research strategies has been to "use research data to position chiropractic in the minds of people who will decide which services will be used and which won't." In a fundraising letter describing clinical trials it has funded, it stated that they were "all intended to demonstrate the effectiveness of chiropractic treatment." (Under the rules of science, studies are supposed to test whether methods work, not to prove that they do.) In addition to funding research, FCER also issues booklets, a newsletter, and pamphlets that promote chiropractic care based on subluxation theory. For example, its 1993 "Ask Your Doctor" brochure titled "What does chiropractic care have to do with wellness" states:

At the core of chiropractic philosophy is the fact that the brain and nervous system control and mediate the functions of the human body. The influence of the nervous system on the rest of the body is altered when the nerves that exit the spine at the vertebrae are crowded, stretched or otherwise irritated by spinal misalignments and fixations. These conditions result in pain at the primary site, but can also affect other areas where the injured nerves travel. For instance, nerves that exit the spine between the shoulder blades travel to the stomach. This is how the brain mediates and controls stomach function. If these nerves are irritated at the level of the spine where they exit, they can cause interference with stomach function. A person may enter the chiropractic office with middle back pain, but through the course of treatment, stomach symptoms—which the individual may have thought were unrelated—improve. Not all stomach problems are caused by this type of nerve interference, but it is an extremely common contributing factor, and in many cases a primary factor.

A 1988 FCER pamphlet called "How to Put and Keep Stress in Its Place" states: "Your doctor of chiropractic can adjust any possible spinal misalignment (which can cause stress), remove neuromuscular tensions, lessen nerve cell fatigue and improve circulation." Does Rosner believe that statements like these reflect science-based thinking?]

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]. [Not quite. Goldstein was talking about spinal manipulation, not chiropractic.] 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. [But not necessarily chiropractic care. The U.S. report [6] did not mention chiropractic in its text. The New Zealand report [12] stated that chiropractors were skilled manipulators but should not function as primary care practitioners. The report further said: (a) Chiropractors do not provide an alternative comprehensive system of health care, and should not hold themselves out as doing so; and (b) The issuing of any publicity material which suggests that chiropractors provide a comprehensive health care service or should be consulted ahead of medical practitioners for general health problems should be banned.] 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. [Hardly. Although I believe that spinal manipulation can relieve appropriately selected cases of acute low-back pain, the research demonstrating effectiveness is skimpy and controversial.]

In just the last 20 years, at least 73 randomized clinical trials involving spinal manipulation have made their appearance in the English-language literature. [The majority of these studies were not performed by chiropractors and do not reflect what takes place when a typical patient consults a typical chiropractor.] 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. [Yes, and the further they go from low-back pain, the more negative the results.] 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]. [Both of these reviews are chiropractic puff-pieces.]

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. [I am not aware of any chiropractic research that has led to any significant improvement in patient care. Most studies of chiropractic diagnostic and therapeutic systems have found that they don't work. Studies of spinal manipulation have had mixed results and do not necessarily reflect what most chiropractors do.]

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]. [Chiropractors point with pride to selected worker's compensation studies that show that chiropractic care got workers back on the job sooner and for less cost than did medical care. But these studies were not scientifically controlled for the severity of the injuries and not all workmen's compensation studies have been favorable to chiropractic.] 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. [There's no reason to postulate that "discrimination" is at work. Insurance companies favor what is cost-effective and try to curb what is not.]

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]. [This may be most preposterous statement I have ever seen made by a chiropractic official. The study to which he refers involved a review of the records of 180 consecutive patients seen by one Spanish chiropractor. The study's author tabulated whether the treatment for the chief complaint described in the records appeared to be supported by published reports about the alleged value of spinal manipulation for musculoskeletal problems. The author concluded that "chiropractic care" was evidence-based 68.3% of the time, which he claimed was higher than various other studies had reported for different medical specialties. The design of the study was absurd. But even if it had been valid, it would be absurd to suggest that the work of a single Spanish practitioner work reflects what most chiropractors do in the United States. Three well-designed surveys indicate that the vast majority of American chiropractors do quacky things such as homeopathy, applied kinesiology, neck manipulation for back problems, and inappropriate prescribing of dietary supplements.]

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]. [In 1987, federal court judge Susan Getzendanner concluded that during the 1960s "there was a lot of material available to the AMA Committee on Quackery that supported its belief that all chiropractic was unscientific and deleterious." The judge also noted that chiropractors still took too many x-rays. However, she ruled that the AMA had engaged in an illegal boycott. She concluded that the dominant reason for the AMA's anti-chiropractic campaign was the belief that chiropractic was not in the best interest of patients [42]. Rosner implies chiropractic progress was retarded by alleged AMA "discrimination" that took place many years ago. The simple fact is that chiropractic research was (and still is) hampered by the widespread chiropractic belief that "chiropractic works" and does not need to be proven.]

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]. [In April 2003, the Trigon suit was dismissed in a ruling in which the judge concluded that the insurance company had not "discriminated" but had taken appropriate steps to try to control chiropractic costs.]

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 iatrogensis 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. [There is no reason to believe that increasing insurance coverage for "alternative" health care will lower costs. The studies he cites are not about chiropractic. Reference 21 is about inpatient medical care. Reference 47 is about osteopathic care.]

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. [Discrimination means "treatment or consideration based on class or category rather than individual merit; partiality or prejudice." Anti-chiropractic feelings are generated by chiropractic's shortcomings.] 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. [Chiropractic, with its limited scope, has little or nothing to contribute to solving "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. [Neither data nor logic support the idea that better access to chiropractic care is needed or can lower insurance premiums.]

References

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  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):
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  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.
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  11. Thompson CJ. Second Report, Medicare Benefits Review Committee. Canberra, 1986: Commonwealth Government Printer, Chapter 10 (Chiropractic).
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  22. www.ganet.org/sbwc/about/
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  44. The Washington Post, December 3, 2002.
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This article was posted on May 19, 2003.

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