Alan H. Adams

Patients using chiropractors in North America: who are they, and why are they in chiropractic care?

SUMMARY OF BACKGROUND DATA AND OBJECTIVES Alternative health care was used by an estimated 42% of the U.S. population in 1997, and chiropractors accounted for 31% of the total estimated number of visits. Despite this high level of use, there is little empirical information about who uses chiropractic care or why. METHODS The authors surveyed randomly sampled chiropractors (n = 131) at six study sites and systematically sampled chiropractic patients seeking care from participating chiropractors on 1 day (n = 1275). Surveys collected data about the patients reason for seeking chiropractic care, health status, health attitude and beliefs, and satisfaction. In addition to descriptive statistics, the authors compared data between patients and chiropractors, and between patients and previously published data on health status from other populations, corrected for the clustering of patients within chiropractors. RESULTS More than 70% of patients specified back and neck problems as their health problem for which they sought chiropractic care. Chiropractic patients had significantly worse health status on all SF-36 scales than an age- and gender-matched general population sample. Compared with medical back pain patients, chiropractic back pain patients had significantly worse mental health (6-8 point decrement). Roland-Morris scores for chiropractic back pain patients were similar to values reported for medical back pain patients. The health attitudes and beliefs of chiropractors and their patients were similar. Patients were very satisfied with their care. CONCLUSION These data support the theory that patients seek chiropractic care almost exclusively for musculoskeletal symptoms and that chiropractors and their patients share a similar belief system.

Use of chiropractic services from 1985 through 1991 in the United States and Canada

OBJECTIVES The purpose of this paper is to describe the demographic and clinical characteristics of chiropractic patients and to document chiropractic visit rates in 6 sites in the United States and Canada. METHODS Random samples of chiropractors from 5 US sites and 1 Canadian site were selected. A record abstraction system was developed to obtain demographic and clinical data from office charts. RESULTS Of the 185 eligible chiropractors sampled, 131 (71%) participated. Sixty-eight percent of the selected charts showed that care was sought for low back pain, while 32% recorded care for other reasons. Spinal manipulative therapy was recorded in 83% of all charts. There was a greater than 2-fold difference in the median number of visits related to low back pain per episode of care across sites. The chiropractic visit rates in the US sites and Ontario are estimated to be 101.2 and 140.9 visits per 100 person-years, respectively. CONCLUSIONS The chiropractic use rate in these sites is twice that of estimates made 15 years ago. The great majority of patients receive care for musculoskeletal conditions of the back and neck. The number of visits per episode varies appreciably by site.

A Randomized Trial of Chiropractic Manipulation and Mobilization for Patients With Neck Pain: Clinical Outcomes From the UCLA Neck-Pain Study

OBJECTIVES This study compared the relative effectiveness of cervical spine manipulation and mobilization for neck pain. METHODS Neck-pain patients were randomized to the following conditions: manipulation with or without heat, manipulation with or without electrical muscle stimulation, mobilization with or without heat, and mobilization with or without electrical muscle stimulation. RESULTS Of 960 eligible patients, 336 enrolled in the study. Mean reductions in pain and disability were similar in the manipulation and mobilization groups through 6 months. CONCLUSIONS Cervical spine manipulation and mobilization yield comparable clinical outcomes.

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

Study Design. A randomized clinical trial. Objectives. To compare the effectiveness of medical and chiropractic care for low back pain patients in managed care; to assess the effectiveness of physical therapy among medical patients; and to assess the effectiveness of physical modalities among chiropractic patients. Summary of Background Data. Despite the burden that low back pain places on patients, providers, and society, the relative effectiveness of common treatment strategies offered in managed care is unknown. Methods. Low back pain patients presenting to a large managed care facility from October 30, 1995, through November 9, 1998, were randomly assigned in a balanced design to medical care with and without physical therapy and to chiropractic care with and without physical modalities. The primary outcome variables are average and most severe low back pain intensity in the past week, assessed with 0 to 10 numerical rating scales, and low back-related disability, assessed with the 24-item Roland-Morris Disability Questionnaire. Results. Of 1,469 eligible patients, 681 were enrolled; 95.7% were followed through 6 months. The mean changes in low back pain intensity and disability of participants in the medical and chiropractic care-only groups were similar at each follow-up assessment (adjusted mean differences at 6 months for most severe pain, 0.27, 95% confidence interval, -0.32–0.86; average pain, 0.22, -0.25–0.69; and disability, 0.75, -0.29–1.79). Physical therapy yielded somewhat better 6-month disability outcomes than did medical care alone (1.26, 0.20–2.32). Conclusions. After 6 months of follow-up, chiropractic care and medical care for low back pain were comparable in their effectiveness. Physical therapy may be marginally more effective than medical care alone for reducing disability in some patients, but the possible benefit is small.

Effectiveness of four conservative treatments for subacute low back pain: A randomized clinical trial

Study Design. A randomized, assessor-blinded clinical trial was conducted. Objective. To investigate the relative effectiveness of three manual treatments and back school for patients with subacute low back pain. Summary of Background Data. Literature comparing the relative effectiveness of specific therapies for low back pain is limited. Methods. Among the 5925 inquiries, 206 patients met the specific admission criteria, and 200 patients randomly received one of four treatments for 3 weeks: back school, joint manipulation, myofascial therapy, and combined joint manipulation and myofascial therapy. These patients received assessments at baseline, after 3 weeks of therapy, and 6 months after the completion of therapy. The primary outcomes were evaluated using visual analog pain scales and Roland–Morris activity scales. Results. All four groups showed significant improvement in pain and activity scores after 3 weeks of care, but did not show further significant improvement at the 6-month follow-up assessment. No statistically significant between-group differences were found either at the 3-week or 6-month reassessments. Conclusions. For subacute low back pain, combined joint manipulation and myofascial therapy was as effective as joint manipulation or myofascial therapy alone. Additionally, back school was as effective as three manual treatments.

Searching biomedical databases on complementary medicine: the use of controlled vocabulary among authors, indexers and investigators

BackgroundThe optimal retrieval of a literature search in biomedicine depends on the appropriate use of Medical Subject Headings (MeSH), descriptors and keywords among authors and indexers. We hypothesized that authors, investigators and indexers in four biomedical databases are not consistent in their use of terminology in Complementary and Alternative Medicine (CAM).MethodsBased on a research question addressing the validity of spinal palpation for the diagnosis of neuromuscular dysfunction, we developed four search concepts with their respective controlled vocabulary and key terms. We calculated the frequency of MeSH, descriptors, and keywords used by authors in titles and abstracts in comparison to standard practices in semantic and analytic indexing in MEDLINE, MANTIS, CINAHL, and Web of Science.ResultsMultiple searches resulted in the final selection of 38 relevant studies that were indexed at least in one of the four selected databases. Of the four search concepts, validity showed the greatest inconsistency in terminology among authors, indexers and investigators. The use of spinal terms showed the greatest consistency. Of the 22 neuromuscular dysfunction terms provided by the investigators, 11 were not contained in the controlled vocabulary and six were never used by authors or indexers. Most authors did not seem familiar with the controlled vocabulary for validity in the area of neuromuscular dysfunction. Recently, standard glossaries have been developed to assist in the research development of manual medicine.ConclusionsSearching biomedical databases for CAM is challenging due to inconsistent use of controlled vocabulary and indexing procedures in different databases. A standard terminology should be used by investigators in conducting their search strategies and authors when writing titles, abstracts and submitting keywords for publications.

Congruence between Decisions To Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America

The direct and indirect costs of low back pain, one of the most common symptoms in adults, are estimated at

Spinal Manipulation for Low Back Pain

60 billion annually in the United States [1, 2]. Practice guidelines recently developed in the United States recommend spinal manipulation for patients with uncomplicated acute low back pain [3]. If followed, these guidelines can be expected to significantly increase the number of patients referred by medical physicians to chiropractors, who provide most manipulative therapy delivered in the United States [4]. Concerns have been raised about the quality of chiropractic care [5], but systematic data are lacking. How are patients and medical physicians to have confidence in chiropractors in the absence of data on the quality of chiropractic care? To assess the appropriateness of the use of spinal manipulation for patients with low back pain, we used a method for assessing appropriateness that has been used to study various medical procedures in North America and Europe [6-16]. In these studies, predetermined criteria for the appropriateness (as defined by expected risk versus benefit) of the study procedure (for example, hysterectomy or coronary angioplasty) are used to retrospectively assess the care delivered. We report the results of our evaluation of the use of chiropractic spinal manipulation at five geographic sites in the United States and one site in Canada. Methods Development of Appropriateness Criteria and Record Abstraction System For our study, spinal manipulation was defined as a manual procedure that involves specific short-lever dynamic thrusts (or spinal adjustments) or nonspecific long-lever manipulation. Nonthrust procedures, such as flexion-distraction and mobilization, were not considered part of manipulative therapy. The development of appropriateness criteria for spinal manipulation for low back pain has been described in detail elsewhere [17]. In brief, we first performed a systematic review of the literature. A 9-member panel of back experts was convened, consisting of 3 chiropractors, 2 orthopedic spine surgeons, 1 osteopathic spine surgeon, 1 neurologist, 1 internist, and 1 family practitioner. Six panel members were in academic practice, 3 were in private practice, and 4 performed spinal manipulation as part of their practice. The panel members represented all major geographic regions of the United States. The panel used a scale of expected risk and benefit (ranging from 1 to 9) to rate the appropriateness of a comprehensive array of indications, or clinical scenarios, in patients who might present to a chiropractors office. We defined appropriate as an indication for which the expected health benefits exceeded the expected health risks by a sufficiently wide margin that spinal manipulation was worth doing. We used a formal group-judgment process, which incorporated two rounds of ratings, a group discussion, and feedback of group ratings between rounds. Experts were to use their best clinical judgment in addition to the evidence from the systematic review we presented them. Panel disagreement on an indication occurred when two or more panelists rated the indication as appropriate and two or more panelists rated it as inappropriate. This definition of disagreement is arbitrary but is based on a face-value assessment of what constitutes disagreement among experts. The final result of the process is a rating of appropriate, inappropriate, or uncertain (depending on net expected health benefits) for each indication. Indications with a median panel rating of 7 to 9, without disagreement, were classified as appropriate. Indications with a median panel rating of 1 to 3, without disagreement, were classified as inappropriate. Indications with a median panel rating of 4 to 6 and all indications with disagreement were classified as uncertain. The panel of experts met in April 1990, before the beginning of the Agency for Health Care Policy and Research (AHCPR) Low Back Problems Clinical Practice Guideline effort in 1992. Four members of our panel later participated in the AHCPR process. The AHCPR guidelines cover patients with acute and subacute low back pain only and are similar to the appropriateness criteria created for our project. We developed a chiropractic record abstraction system that allows collection of data from a chiropractic office record about the patient, history of the back problem, findings on physical examination and diagnostic studies, and treatment rendered. The system is designed to collect sufficient information to allow the classification of delivered care as appropriate, inappropriate, or uncertain, according to the panels ratings. The abstraction instrument collects data on more than 70 clinical variables that may be present in the record. The instrument uses skip-pattern logic so that only relevant clinical variables are sought. For example, if the patients onset of back pain was associated with trauma, additional information about the type of trauma was sought. We pilot-tested our system on numerous chiropractic records obtained from colleagues around the United States and pilot-tested our methods for data collection and analysis on a small sample of chiropractors in southern California [18]. Identification of Sample We chose San Diego, California; Portland, Oregon; Vancouver, Washington; Minneapolis-St. Paul, Minnesota; Miami, Florida; and Toronto, Ontario, Canada, as sites for our study because of their geographic diversity and because they reflect a varying concentration of practicing chiropractors and differ in the chiropractic scope of practice allowed. We also included the rural areas surrounding the Portland, Minneapolis-St. Paul, and Toronto areas. We have previously shown that the base populations at the U.S. sites are similar to the general U.S. population in terms of the variables known to affect chiropractic use [19]. The geographic sampling area around Toronto encompasses 75% of the population of Ontario. At each site, we constructed our sampling frame from a combination of the telephone book yellow pages, the state or provincial board licensing list, and the mailing list of the local chiropractic college, if any. The final list was the summation (excluding duplicates) of the individual lists. We drew a random sample from this list and sent the sampled chiropractors a letter that explained the study and invited them to participate. Each letter was accompanied by cover letters from the national chiropractic association and the local chiropractic association or chiropractic college, indicating support for the study. We followed this mailing with a telephone call to determine eligibility and request participation. To be eligible, a chiropractor must have been practicing in the geographic area since 1990. Eligible chiropractors who declined our initial invitation were contacted by one or more influential state, provincial, or local chiropractors and were again urged to participate. Participating chiropractors and their staff were given, in total, a

Manipulation and Mobilization of the Cervical Spine: A Systematic Review of the Literature

130 (in both U.S. and Canadian dollars) honorarium for participation. Data Collection Trained chiropractic data collectors (senior chiropractic students or recent graduates) visited participating chiropractors during regular working hours. These data collectors underwent 2 days of training conducted by two of the authors. The data collectors were unaware of the details of the appropriateness criteria. The reliability and accuracy of the data collection were assessed in several ways. First, after classroom training, the data collectors abstracted a common set of test records obtained from various different practices and geographic areas. These were returned to one of the authors for correction, and any errors in abstraction were reviewed with the data collectors. Second, the same author accompanied the data collectors on a practice session with a local volunteer chiropractor, who agreed to let the collectors practice sampling and data abstraction in his or her office during working hours. Again, errors in either process were reviewed with the data collectors. Finally, the same author accompanied the data collectors on one of the early office visits to a chiropractor included in the sample at each geographic site. Here, the author reviewed all abstracted records; if more than one data collector was working, both data collectors abstracted a few records. Any discrepancies were reviewed with this author. In all, about 4% of records included in the sample were assessed for reliability and validity. We did not calculate formal reliability statistics. To select records, all office records were measured in inches as if they were books on a shelf. A random-number table was used to select a random number of inches measured from the start. To avoid fat-chart bias, we selected the record immediately to the right of the record located at the specified number of inches. This chart was then pulled and examined to see whether it described a first visit for low back pain that occurred between 1 January 1985 and 31 December 1991. If so, data were abstracted by using the research instrument. This process was repeated until 10 records for low back pain were abstracted from each participating practitioners office. If more than one chiropractor practiced in the same office, we abstracted data from the records of only one practitioner. Consultation with back pain experts suggested that 10 records per office is a sufficient number that is likely to fairly represent the diversity of that offices practice. Data Analysis We compiled descriptive data on the patients and the care that they received. The care of patients was classified into appropriateness categories by using the criteria determined by the expert panel. This was done with a computer program that uses unique combinations of variables that define individual indications. The reliability of this program was verified by drawing a random sample of records and comparing