Government Studies on Chiropractic

There have been a number of large investigations conducted on chiropractic by the American, Canadian, New Zealand, Swedish and Australian governments over the last few decades. In all cases, their findings have supported the effectiveness and efficacy of Chiropractic.

Canada's 1993 Manga Report strongly recommended chiropractic care over medical care for the treatment and management of most low-back conditions. The 1994 AHCPR Study from the U.S. Department of Health and Human Services suggested that chiropractic spinal manipulation was a conservative and safe treatment for many low-back conditions and should be utilized prior to any surgical interventions in most cases.

Doctors of Chiropractic have now become integral to the development of governmental guidelines for the treatment of back conditions in Canada and the U.S. In addition, many hospitals are extending privileges to chiropractors and referrals between medical doctors and chiropractors are becoming increasingly common.

• US - "The Agency on Health Care Policy and Research Study"
• CANADA - "The Manga Report"
• NEW ZEALAND - "The New Zealand Commission Report"
• SWEDEN - "The Sweden Report"
• AUSTRALIA - "The Australian Report"

US - The Agency on Health Care Policy and Research Study

On December 8, 1994, the Agency for Health Care Policy and Research (AHCPR) of the US Department of Health and Human Services released Clinical Practice Guidelines for the management of acute low back pain. Their guidelines were developed after extensive study of diagnostic and treatment methods for acute low back pain.

The guidelines were created by the AHCPR panel to provide primary care clinicians with information and recommended strategies for the assessment and treatment of acute low back problems. The AHCPR panel was made up of 23 members consisting of medical doctors, chiropractic doctors, nurses, experts in spinal research, physical therapists, an occupational therapist, a psychologist, and a consumer representative.

The following conclusions were made in this landmark study:

• Conservative treatment such as spinal manipulation should be pursued in most before cases considering surgical intervention;
• Prescription drugs such as oral steroids, antidepressant medications and colchicine are not recommended for acute low back problems.

Other interesting finds included:

• The risk of serious complications from lumbar spinal manipulation is rare;
• There is currently no evidence supporting the use of trigger point, ligamentous and facet injections, needle acupuncture or dry needling as treatment for acute back problems;
• The panel found no evidence of benefit from the application of physical agents and modalities such as ice, heat, massage, traction, ultrasound, cutaneous laser treatment, transcutaneous electrical nerve stimulation (T.E.N.S.) and biofeedback techniques.

1. Acute Low Back Problems in Adults. Clinical Practice Guidelines. Bigos S, et al. Agency for Health Care Policy and Research Publication No. 950642 (1994) - U.S. Department of Health and Human Services.

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CANADA - The Manga Report

As the largest existing analysis of scientific literature on low back pain, the 1993 Ontario Ministry of Health commissioned study drew international attention when it recommended the management of low back pain be moved from medical doctors to chiropractic doctors.

Due to serious financial problems with the Canadian governments, the different types of treatments for low back conditions were evaluated in an effort to reduce and contain health care costs. Their findings showed chiropractic manipulation was the most cost effective and efficacious care for low back pain.

The researchers also stated that studies on the prevalence and incidence of low back pain suggest that it is the leading cause of disability and morbidity in middle-aged persons, and is by far the most expensive source of workers' compensation costs North America.

The Canadian Government report concluded with the following findings:

• On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for low back pain. Many medical therapies are of questionable validity or are clearly inadequate;
• There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low back pain. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic (doctor-induced) complications for low back pain patients. Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low back pain;
• Indeed, several existing medical therapies of low back pain are generally contraindicated on the basis of the existing clinical trials. There is also some evidence in the literature to suggest that spinal manipulations are less safe and less effective when performed by nonchiropractic professionals;
• There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost-effective than medical management;
• There would be highly significant cost savings if more management of low back pain was transferred from physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions annually;
• Workers' compensation studies report that injured workers with the same specific diagnosis of low back pain returned to work much sooner when treated by chiropractors than by medical physicians;
• There is good empirical evidence that patients are very satisfied with chiropractic management of low back pain and considerably less satisfied with medical physician management;
• The use of chiropractic has grown steadily over the years and chiropractors are now accepted as a legitimate healing profession by the public and an increasing number of medical physicians;
• In our view, the following offers an overwhelming case in favor of much greater use of chiropractic services in the management of low back pain:
  • the effectiveness and cost effectiveness of chiropractic management of low back pain
  • the untested, questionable or harmful nature of many current medical therapies
  • the economic efficiency of chiropractic care for low back pain compared with medical care
  • the safety of chiropractic care
  • the higher satisfaction levels expressed by patients of chiropractors.

The following recommendations were also included in the report:

• There should be a shift in policy to encourage and prefer chiropractic services for most patients with low back pain;
• Chiropractic services should be fully insured under the Ontario Health Insurance Plan;
• Chiropractic services should be fully integrated into the health care system;
• Chiropractors should be employed by tertiary hospitals in Ontario;
• Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients' needs;
• Chiropractic should have access to all pertinent patient records and tests from hospitals, physicians, and other health care professionals upon the consent of their patients;
• Since low back pain is of such significant concern to workers' compensation, chiropractors should be engaged at a senior level by Workers' Compensation Board to assess policy, procedures and treatment of workers with low back injuries;
• A very good case can be made for making chiropractors the gatekeepers for management of low back pain in the workers' compensation system in Ontario;
• The government should make the requisite research funds and resources available for further clinical evaluations of chiropractic management of low back pain, and for further socioeconomic and policy research concerning the management of low back pain generally;
• Chiropractic education in Ontario should be in the multidisciplinary atmosphere of a university with appropriate public finding;
• Finally, the government should take all reasonable steps to actively encourage cooperation between providers, particularly the chiropractic, medical and physiotherapy professions.

1. The Effectiveness and Cost Effectiveness of Chiropractic Management of Low-Back Pain (The Manga Report). Pran Manga and Associates (1993) - University of Ottawa, Canada.

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NEW ZEALAND - The New Zealand Commission Report

This 377 page report, Chiropractic In New Zealand, was the most comprehensive and detailed independent examination of chiropractic ever undertaken at that time. The report withstood judicial hearings and extensive investigations by the Commission in New Zealand, the United States, Canada, England and Australia.

According to the researchers,

"We entered into our inquiry in early 1978. We had no clear idea what might emerge. We knew little about chiropractors. None of us had undergone any personal experience of chiropractic treatment. If we had any general impression of chiropractic it was probably that shared by many in the community: that chiropractic was an unscientific cult, not to be compared with orthodox medical or paramedical services. We might well have thought that chiropractors were people with perhaps a strong urge for healing, who had for some reason not been able to get into a field recognized by orthodox medicine and who had found an outlet outside the fringes of orthodoxy."

"But as we prepared ourselves for this inquiry it became apparent that much lay beneath the surface of these apparently simple terms of reference. In the first place it transpired that for many years chiropractors had been making strenuous efforts to gain recognition and acceptance as members of the established health care team. Secondly, it was clear that organized medicine in New Zealand was adamantly opposed to this on a variety of grounds which appeared logical and responsible. Thirdly, however, it became only too plain that the argument had been going on ever since chiropractic was developed as an individual discipline in the late 1800's, and that in the years between then and now the debate had generated considerable more heat than light."

"By the end of the inquiry we found ourselves irresistibly and with complete unanimity drawn to the conclusion that modern chiropractic is a soundly based and valuable branch of the health care in a specialized area..."

Their report includes the following findings:

• Chiropractic is a branch of the healing arts specializing in the correction by spinal manual therapy of what chiropractors identify as biomechanical disorders of the spinal column - they carry out spinal diagnosis and therapy at a sophisticated and refined level;
• Chiropractors are the only health practitioners who are necessarily equipped by their education and training to carry out spinal manual therapy;
• General medical practitioners and physiotherapists have no adequate training in spinal manual therapy;
• Spinal manual therapy in the hands of a registered chiropractor is safe;
• The education and training of a registered chiropractor are sufficient to enable him/her to determine whether there are contraindications to spinal manual therapy in a particular case, and whether the patient should have medical care instead of or as well as chiropractic care;
• Spinal manual therapy can be effective in relieving musculoskeletal symptoms, such as back pain and other symptoms known to respond to such therapy, such as migraine;
• In a limited number of cases where there are organic and/or visceral symptoms, chiropractic treatment may provide relief, but this is unpredictable, and in such cases the patient should be under concurrent medical care if that is practicable;
• In the public interest and in the interests of patients, there must be no impediment to full professional cooperation between chiropractors and medical practitioners;
• It is wrong that the present law, or any medical ethical rules, should have the effect that a patient can receive spinal manual therapy which is subsidized by a health benefit only from those health professionals least qualified to deliver it;
• The responsibility for spinal manual therapy training, because of its specialized nature, should lie with the chiropractic profession and part-time or vacation courses in spinal manual therapy for other health professionals should not be encouraged.

1. New Zealand Report. Hasselberg PD. Government Printer, Wellington - 1979.

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SWEDEN - The Sweden Report

Up until the late 1980's, Sweden had no legislation regulating the practice of chiropractic, although there were approximately 100 chiropractors in Sweden educated in accredited chiropractic colleges. In 1987, a commission on Alternative Medicine in Sweden conducted a detailed investigation of chiropractic education. They had the scientific literature assessed by university medical faculty and additionally commissioned a demographic survey by Statistics Sweden. Subsequent to the report, the Swedish government passed legislation recognizing and regulating the chiropractic profession in Sweden. Then, together with the governments from Denmark, Finland and Norway, it established a school of chiropractic at the University of Odense in Denmark to provide a regional chiropractic college for students from those countries.

The reports findings included:

• Doctors of chiropractic should become registered practitioners and be brought within the national insurance system in Sweden;
• Training for Doctors of Chiropractic follows a 4-5 year course of university level training and was found to be the equivalent to Swedish medical training - chiropractors have "competence in differential diagnosis" and should be regulated on a primary care basis";
• "Measures to improve cooperation between chiropractors, registered medical practitioners and physiotherapists are vital" in the public interest.

1. Ref 11 Supra.

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AUSTRALIA - "The Australian Report"

In July of 1984 the Australian Federal Minister for Health asked their Medicare Benefits Review Committee to "consider requests for extending the scope of Medicare (government-funded health care) arrangements to provide benefits for certain paramedical services" - which included chiropractic services.

The Committee recommended funding for chiropractic in hospitals and other public institutions, and stated:

"We are aware of the very considerable organizational and professional obstacles... orthodox practitioners and, indeed, some chiropractors may initially find the experience an uneasy one, but we consider the differences that currently exist to be unreasonable and efforts should be made to bridge the gap."

"... the continuing schism between the two professions does little to help improve the health of the many Australians who might benefit from a joint chiropractic/medical approach to their problems."

1. Second Report Medicare Benefits Review Committee. Thompson CJ. Commonwealth Government Printer, Canberra, Australia, Chapter 10 (Chiropractic) - June 1986.

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