Appropriateness of Chiropractic Treatment
September 1998; Volume 1: 107-108
Source: Shekelle PG, et al. Congruence between decisions to initiate chiropractic spinal manipulation for low back pain and appropriateness criteria in North America. Ann Intern Med 1998;129:9-17. Editorial. 1998;129: 65-66.
To determine the appropriateness of chiropractors' decisions to use spinal manipulation for patients with low back pain, researchers performed a retrospective review of chiropractic office records against preset criteria of appropriateness developed from a systematic literature review and a nine-member panel of chiropractic and medical specialists. Appropriateness criteria reflect the expected balance between risk and benefit. The authors randomly sampled 131 of 185 chiropractic offices. Ten randomly selected records of each office's patients who presented with low back pain yielded 1310 patients. Of these, 1088 had spinal manipulation, and, of these, 859 had complete enough medical records to compare with appropriateness criteria. Care was classified as appropriate in 46% of cases, inappropriate in 29%, and uncertain in 25%. Patients who did not undergo manipulation were more likely to have a presentation judged inappropriate than were patients who did undergo manipulation (P = 0.01).
COMMENT
More patients seek complementary medical treatment for low back pain than for any other ailment. Chiropractors number more than 52,000 in the United States and are licensed in all 50 states. At least 45 states mandate insurance coverage of chiropractic spinal manipulative services.
Four of the seven authors participated in the development of the Agency for Health Care Policy and Research (AHCPR) guidelines for treatment of acute low back pain without radiculopathy. These guidelines endorse spinal manipulation as equally effective with therapy administered by orthopedists or primary physicians. Times to recovery and return to work when treated by these practitioners are roughly similar. The costs of care depend on the reimbursement system, as chiropractors may see patients 10-15 visits for a single "episode" of pain.
In this study, mean patient age was 38; 46% were male. One-fourth had chronic back pain (lasting 13 weeks or more). Less than 2% had MRIs or CTs. Outcomes of other prescribed therapies, concomitant use of antiinflammatory agents, and the frequency, duration, and outcomes of visits were not reported.
The indications that were most commonly found and judged inappropriate or uncertain were "generally mixtures of subacute and chronic back pain syndromes." All chronic back pain patients were judged to have received inappropriate spinal manipulation. The authors believe that their inappropriateness estimate "is probably low because the judgment about appropriateness applies only to the decision to initiate treatment."
Geographic variation of inappropriateness ranged from 20% in Miami to 40% in Portland. In contrast, a decade ago, inappropriate use of carotid endarterectomy was 32%, and of coronary artery bypass surgery, 14%, according to Rand investigators.
Recommendation
Physicians should offer spinal manipulation as an efficacious therapeutic option for patients with acute low back pain without radiculopathy and without risk factors for cauda equina syndrome. Contraindications include the presence of free disk fragment, spinal stenosis, and neurologic findings.
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