Chiropractic News Digest, edited by Christopher J. Erickson, M.D. and cosponsored by NCAHF and Quackwatch, summarizes scientific and political developments; enforcement actions; and other news relevant to the chiropractic marketplace.
Two literature reviews raise doubt about chiropractic benefits. The Annals of Internal Medicine has published a well designed meta-analysis of spinal manipulation for low-back pain. [Assendelft WJ and others. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Annals of Internal Medicine, 138(11):871-81, June 3, 2003]. Based on randomized controlled trials published up to January 2000 , the authors concluded:
- Spinal manipulative therapy (SMT) had clinically and statistically significant benefits only when it was compared with either sham manipulation or the group of therapies judged to be ineffective or even harmful.
- SMT was no more effective than general practitioner care, analgesics, physical therapy, back school, or exercise in clinical trials.
- SMT is very unlikely to be a particularly effective therapy for any group of patients with back pain.
- Systematic reviews that provided the basis for national guidelines are partially discordant and did not include the larger high-quality trials that have been published over the previous few years.
The authors include Paul Shekelle, MD, PhD who wrote a similar review in Annals of Internal Medicine in 1992 and headed the panel that produced an influential 1991 RAND report. These publications supported manipulation and were warmly greeted by chiropractors. However, the current meta-analysis concluded that more recent trials of spinal manipulation were of higher quality, and that “advances in meta-analysis methods” allowed more useful comparisons with other therapies. Indeed, the authors detail their methods of analysis in two pages in the body of the paper and describe their raw data and scoring system in a 13-page appendix. They conclude that “Spinal manipulation is substantially less effective than previously estimated.”
After the literature search for this meta-analysis was performed, another randomized controlled trial found no relative advantage for chiropractic care [Hurwitz EL and others. A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain: 6-month follow-up outcomes from the UCLA low back pain study. Spine 27:2193-204, 2002].
The second review focused on randomized controlled trials to study the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain [Cherkin DC and others. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Annals of Internal Medicine, 138: 898-906, 2003]. The authors concluded: “Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy.” In a Wall Street Journal story, both Shekelle and Dr. George McClelland of the ACA predicted that the studies would result in a negative influence on chiropractic coverage. [Rundle R. Study questions efficacy of chiropractic care. Wall Street Journal. June 3, 2003]. Shekelle questioned whether payers would continue more expensive therapies merely for greater satisfaction rates. Given some indications that massage therapy has a higher satisfaction rate and lower cost than chiropractic (and overall costs), guidelines for back pain may change substantially for many organizations.
Even though the review studies were done carefully, chiropractic leaders criticized them and several news reports that they generated. ICA executive director Ronald M. Hendrickson said that his organization is exploring the possibility of Congressional hearings into the use of the media for anti-competitive purposes. In Chiropractic Economics, he stated, “If the hearing process reveals any hard data on what we suspect, the next step is for the Justice Department to see if there is any violation of the [AMA] injunction.” [Wall Street Journal article refutes benefits of chiropractic. Chiropractic Economics. June 2003]
ACA President Dr. Daryl D. Wills complained that the study did not take into account the Manga reports. This is a peculiar argument because Manga’s analyses did not include the most recent studies and have little credibility outside of chiropractic circles. Wills also claimed that the meta-analysis “also failed to address the federal government’s guidelines on low back problems.” [American Chiropractic Association: New study is further support for safe alternatives to drugs. ACA News release June 2, 2003]. This, too, is peculiar because the guidelines to which he referred were published in 1994 and based on almost the same body of literature as the 1991 RAND report.
Wills also stated that chiropractic can still fill a niche for back pain by providing a “safer form of care, without sacrificing any of the benefit.” In letters to various media, Mills has claimed that chiropractic treatment is safer than nonsteroidal antiinflammatory drugs (NSAIDs), which are capable of producing serious side effects. However, this has not been studied scientifically, and a true comparison would have to take many factors into account:
- No prospective randomized trial conclusively demonstrates that chiropractic management reduces the incidence of serious NSAID complications, such as fatal gastrointestinal bleeding. NSAIDs taken at recommended doses for a short time are generally very low-risk for appropriately selected patients—particularly the relatively young not on corticosteriods, anticoagulants, alcohol or tobacco and without a history of ulcers or severe comorbid illness.
- Many patients continue to take NSAIDs while undergoing spinal manipulation. Moreover, spinal manipulation can frequently cause an exacerbation of pain, which might cause some patients to increase or initiate NSAID therapy. [Ernst E. Prospective investigations into the safety of spinal manipulation. Journal of Pain and Symptom Management, 21(3): 238-242, March 2001].
- Herbal recommendations seem to be common among DCs; some remedies have actions similar to NSAIDs, while others directly affect bleeding per se. A recent set of reports by the North American Spine Society includes an 18-page reference chart listing approximately 70 herbs with their uses, potential side effects, and (known) potential interactions.
- While side effects of low-back manipulation appear to be very uncommon, some chiropractic back-pain patients also receive neck manipulation, which entails additional risks.
- Manipulation is much more expensive thatn NSAID treatment. So if both are equally effective, manipulation would be much less cost-effective.
Arnold Schwarzenegger advocates chiropractic, considers politics. Arnold Schwarzenegger will star in Warner Brothers’ “Terminator 3: Rise of the Machine,” opening July 2. He is also considering running for governor of California, perhaps in a special election this fall if a recall campaign facing current governor Gray Davis is successful. [AP staff. Terminator for governor? Dayton Daily News, June 6, 2003].
Schwarzenegger has regularly supported chiropractic, particularly the ICA, even after the crisis at Life University. Schwarzenegger signed a chiropractic adjusting table as part of an auction for the World Federation of Chiropractic, and was photographed with Sid Williams, D.C. and Carl Cleveland III, D.C. Schwarzenegger broadly endorses chiropractic, while disparaging other healthcare professionals:
It is truly one of the few professions that really helps people in a straightforward way with no monkey business, like some of the other professions promise to help, but this chiropractic is the real thing. . . . Chiropractic is about natural, preventive health care. . . . Whenever I have a problem—or even if I don’t have a problem—and I go to a chiropractor, my problems are gone for a long time. [Arnold Schwarzenegger headlines fitness conference. ICA Web site, accessed June 12, 2003]
Willams’s anti-medical rhetoric is well known, while Cleveland stars in “Simple Justice,”a current film hosted by the American Chiropractic Association. The film is a high-volume, blistering attack on “Political Medicine”—with accusations of “NO MERCY. NO COMPASSION”—and calls chiropractic lawsuits threatening osteopaths’ and physical therapists’ right to perform spinal manipulation “heroic” and “noble.” Despite recent setbacks in two major cases, the film describes George P. McAndrews, the attorney in chiropractric’s celebrated antitust suit, as someone who knows the issues, and knows how to win. [Simple Justice: A film about the chiropractic profession’s past and present struggles. American Chiropractic Association.]
Student’s patient-recruitment efforts highlighted. A student at Cleveland Chiropractic College in Los Angeles has described her “success” in recruiting six patients through four “spinal screenings” she attended. [The InternView. In Touch. Cleveland Chiropractic Los Angeles, April 2003, p.2]. Accreditation guidelines require that students see at least 25 new patients at the clinic. Students with no previous ties to the community in which their school is located often have difficulty reaching this number. The student’s story reflects how chiropractic students are encouraged to promote their services to people who do not need them. Cleveland Chiropractic College in Kansas City has faced two lawsuits by students who had difficulty meeting their patiuent quota. The school settled the first lawsuit for an undisclosed sum but prevailed in the second one.
Allegations of chiropractic fraud. A multi-agency, two-year sting operation has resulted in arrests for participants in a so-called “med-legal” mill in the Sacramento area. So far, two chiropractors—Dennis Nguyen, DC and Phillip Wesley Cazel, DC—were charged for “allegedly billed the undercover officers’ insurance companies for treatments they did not receive.” Legal representatives were allegedly in collusion with the DCs involved. [Undercover Ops Attack Calif. Med-Legal Mills. Insurance Journal. June 10, 2003].
A Pittsburgh chiropractor—Brian K. Watkins, DC—has pleaded innocent to fraud charges. Watkins allegedly: (a) placed advertisements in the Pitt News at the University of Pittsburgh seeking participants for a clinical study; (b) bought Highmark health insurance policies in the names of the study participants; and (c) submitted claims to Highmark which falsely indicated that the treatment was part of ordinary patient care. [Baird R. Ex-Downtown chiropractor pleads innocent to fraud. Pittsburgh Tribune-Review, June 12, 2003]
State Farm filed a civil racketeering lawsuit against a Florida company, alleging hundreds of cases of fraudulent billing across 40 states. [McKinney K. State Farm suing. Pantagraph, June 12, 2003]. The defendants in the case reportedly recruited chiropractors through seminars across the country. [O’Connor M. Suit alleges medical-test fraud plot. Chicago Tribune, June 11, 2003]. The lawsuit also alleges that the defendants gave dangerously misleading information to patients, based on unreliable noninvasive electrical tests for nerve injuries and calls the equipment-leasing arrangement by the defendants and chiropractors “nothing more than thinly disguised kickback arrangements.” A neurologist involved in the alleged scheme, Gary Weiss, MD, was also charged.
Georgia governor appoints chiropractors to board. The governor of Georgia made three new appointments to the state Chiropractic Board of Examiners, including two graduates of Life University, enabling the board to function [Governor Perdue Appoints New Members to State Boards and Commissions. The Weekly, May 29, 2003] Despite accreditation issues at Life University, the Georgia board still issues licenses to Life graduates. The current board is composed solely of chiropractors, with no consumer representative.
Patrick Gentempo to focus on “wellness centers.” Patrick Gentempo, D.C., is leaving the World Chiropractic Alliance board of directors to focus on his “Creating Wellness Alliance” (CWA), which he said is not a franchise program. The program launched with a speech from actor William Shatner. For many years, Gentempo has been marketing the “Insight Subluxation Station,” a $10,000 device whose functions include the dubious procedures of surface electromyography (SEMG) and thermography. [Dr. Gentempo moves forward with ‘Wellness Centers’. The Chiropractic Journal, June 2003].