"Research is merely the manipulation of data to justify your prejudice."

Dr. Katherine Crafton
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Changing Views of Chiropractic …and a National Reappraisal of Nontraditional Health Care

Before one reads the article, we would like to offer our own overview of these studies.

The Rand corporation studied chiropractic and surveyed the industry.  The following is a brief publication of the discoveries regarding general chiropractic.  It would not have studied the more specific and smaller segment of Upper Cervical chiropractors that more accurately represent our office.  This study is very helpful for first time chiropractic patients to receive more accurate general information about the chiropractic practice and its true effectiveness and likely role in health care.    Being an objective and respected outside source should help the general uninformed public to understand better the value of chiropractic.

In general, the following study shows that people who use chiropractic value it greatly and that it is a legitimate and effective science.  They show that carriers must recognize this and they have accordingly lessened its role in the industry by lowering limitations (reducing the amount one is able to spend each year), increasing copayments, and generally restricting its participation.  The study shows that when people have to put forth their own personal resources, they use it less.  There exists a plan to starve chiropractic out of the nation's health care even though it's cost effective and more effective than medical care within its elected scope of practice.  It does not try to be medical; it works in areas that are not taught or practiced by the medical industry.  This article is a brief review of the studies and was published outside of the chiropractic community.  As with all summaries of studies, they are self serving by asking for more studies. 

It implies things that no one could consider to be the case, such as implying that medical studies are legitimate and should be considered the standard.  It also implies that the medical doctors are more organized and set on a protocol of care; anyone who has ever tried to find out what's wrong with them know that medical doctors do not agree and fight among themselves as to diagnosis, causes, and treatments.  Also it implies that research drives care;  this we all know is not true because research is never-ending, and independent non biased research is rare.  Clinical care has the responsibility and ethical challenge of wanting to help that person right in front of you.  Very little of what a medical doctors elect to perform is research based; most activities are clinical based.  It is a fallacy to imply that research has anything to do with what a physician elects to perform.  Seldom are medications used for purposes that they were approved for.

The article states that seeing a chiropractor is more expensive.  We really challenge this aspect of the article.  They state this and then add that the chiropractor was seen more often for the treatment.  They imply that seeing one more often costs more money.   If one went to anyone more often it would be more; what does it cost per procedure or visit is a more accurate comparison.  Otherwise it implies that a chiropractor charges more for their time than a medical doctor;  I believe that the research was done to purposely misled.    Seeing someone less times and receiving no improvement is very costly and should not justify that the doctor should be paid  more per visit for seeing you for less actually face to face time. There is nothing wrong about seeing a doctor more than a few times for a treatment session. 

The protocol for any physical therapy referral, a medical activity that was not included in this comparison study, the average number of visits is similar to the chiropractic plan of care, yet the average income per visit for the chiropractor is less money than for a physical therapist.  Physical therapists are well represented in most all health care plans, unlike chiropractors.   Per visit the chiropractor makes less money than both the therapist and the medical doctor;  the study should rather have looked as the procedure code reimbursements and at the amount of physician time.  The physical therapist is really an extended aspect of medical care and how a medical physician may elect the treat the patient by referral which best describes the medical community.  When you do not perform any treatment of someone directly, it is very difficult to justify even 5 visits.  For most visits related to the scope of practice of a chiropractor, the medical doctors just monitor the drug therapy, schedule imaging, and keep records.  It is very difficult to compare medical and chiropractic when they are still two very different delivery systems.

Even as a biased study, the Rand study is still an impressive endorsement in its representation of chiropractic as a legitimate option.  How could this study not be viewed as anything but biased when all parties contributing to the study were medical physicians and medical researchers?  When judged, you like to think you have some input into the jury.  However, we want to show this study to the public so they can see directly that our claims as to the legitimacy and public satisfaction with chiropractic care are supported by an independent respected agency.  I am sure that they pride themselves at being independent, but there is no such thing.

The article is directly quoted below:

"For half a century, the American Medical Association waged war against chiropractic, an intervention that relies on spinal adjustments to treat health problems. Chiropractors were regarded as the modern-day equivalent of snake-oil salesmen. (They still do, but at least we do not prescribe "snake-oil" or least its chemical equivalent)

Today, chiropractors are the third largest group of health care providers, after physicians and dentists, who treat patients directly. AMA policy now states that it is ethical for physicians not only to associate professionally with chiropractors but also to refer patients to them for diagnostic or therapeutic services.

The following are direct quotes from this article.

"In the last decade of the 20th century, chiropractic has begun to shed its status as a marginal or deviant approach to care and is becoming more mainstream," said Paul Shekelle, M.D. and director of RAND's Southern California Evidence-Based Practice Center. He played a key role in RAND's landmark investigations of chiropractic that stimulated a national reappraisal of this and other nontraditional health care approaches.

What led to the change in attitude toward chiropractic? Major events included:

  • The 1990 U.S. Supreme Court decision on a lawsuit, known as the Wilks case, that found the AMA and others guilty of illegal conspiracy against the chiropractic profession.
  • Recognition by the established medical community that most medical therapies for back pain are ineffective.
  • RAND's 1992 groundbreaking analysis of spinal manipulation that showed this intervention does benefit some people with acute low-back pain. This study directly influenced the Agency for Healthcare Research and Quality to include positive recommendations on spinal manipulation in its 1994 clinical practice guidelines on low-back pain. This federal agency issues such guidelines to help the medical community improve the quality of health care in the United States.

Chiropractic: Then and Now

Chiropractic, a term used both as a noun and adjective, comes from the Greek and means "done by hand." The practice originated in the late 1890s with Daniel David Palmer, a self-taught healer in Iowa who sought a cure for illness and disease that did not rely on drugs or surgery. Palmer reported curing deafness in a man who had lost his hearing after straining doing heavy work. Palmer attributed the hearing loss to a displaced vertebra and treated it by adjusting the man's spine. Based on this and other cases he treated with spinal manipulation (also called spinal adjustment), Palmer advanced his theory that most disease is caused by misaligned vertebrae that impinge on spinal nerves. Such misalignments are called subluxations. According to Palmer, correcting these misalignments reestablishes normal nerve and brain function and allows the body to heal itself. (This was at the same time surgeons refused to wash their hands)

Today, only a small fraction of chiropractors believe that their treatments can substitute for traditional medicine to care for all illness and disease. Many practitioners focus on musculoskeletal problems of the spine, that is, conditions affecting the backbone and associated muscles. In fact, most people go to chiropractors for low-back pain.

Chiropractors most commonly adjust the spine by using their hands to apply forceful pressure, known as a high-velocity thrust, on areas that are out of alignment or that do not have normal range of motion. Sometimes this causes an audible "pop." At times, a chiropractor will do an adjustment with an instrument called an activator. Practitioners also use mobilization (manual therapy that does not involve a high-velocity thrust) as well as physical therapy.

Although spinal manipulation is the key component of chiropractic care, most practitioners take a holistic approach and include such things as nutrition counseling and exercise advice in their treatment program.

In order to be called a Doctor of Chiropractic Medicine (DC), practitioners must graduate from one of the 16 chiropractic schools currently accredited by the Council on Chiropractic Education. Table 1 compares basic science education between chiropractic and medical schools. Before chiropractors can practice, they must be licensed by their state. All states require them to pass the National Chiropractic Board examination.

Chiropractic services are covered by most health insurance plans, including Medicare (This is not true.  How could they say this?). However, conflict between the chiropractic and medical communities continues over such issues as limitations on insurance reimbursements for chiropractic services and allowing health care providers other than chiropractors to do spinal adjustments.

Shedding Light on Chiropractic

Prior to 1990, very little was known about chiropractic care in terms of use, costs, effectiveness, or quality—parameters used to evaluate mainstream medical practices. That changed when RAND researchers published a series of landmark studies that broke through this information barrier. The studies address a number of key questions:

Who goes to chiropractors and why? Patients are primarily middle-aged, married people. Biggest complaint: low-back pain (Shekelle and Brook, 1991; Hurwitz et al., 1998).

These findings are further summarized in the box below. The 1991 RAND study was the first estimate of the use of chiropractic services in the United States. The 1998 study updated and expanded on it. For both studies, the researchers examined patient records from randomly selected chiropractors in the United States and Canada.

Snapshot of Chiropractic Patients and Care in the United States and Canada
  • Patients are primarily middle-aged and married; slightly more women than men visit chiropractors.
  • About two-thirds of visits are for low-back pain, followed by head and neck pain and problems with extremities.
  • Less than 10 percent of patients seek help for nonmusculo-skeletal problems, such as migraine, middle-ear inflammation (otitis media), and asthma.
  • In the United States, people make around 280 million visits each year to chiropractors.
  • People now go to chiropractors twice as often as they did 15 to 20 years ago.
  • There are large regional variations in the number of chiropractic visits needed to treat specific problems.
Comparison of Chiropractic and Medical School Curriculum

Does chiropractic work? Yes, for some low-back pain; maybe, for some neck complaints and headache (Shekelle et al., 1992; Hurwitz et al., 1996).

RAND researchers were the first to systematically evaluate all available data on spinal manipulation for low-back pain. Their 1992 report was a watershed study that triggered a national review of chiropractic and other forms of alternative health care.

Their conclusions: lumbar (lower-back) spinal manipulation hastens recovery from uncomplicated, acute (less than 3 weeks' duration) low-back pain. Not enough data were available to evaluate its long-term effect on chronic (more than 13 weeks' duration) low-back pain.

RAND researchers used the same analytical approach to evaluate treatment of the neck for neck pain and headache. They looked at studies that evaluated mobilization and physical therapy as well as manipulation. Their findings: (1) mobilization—but not manipulation or physical therapy—probably provides at least short-term relief from acute neck pain; (2) manipulation is probably slightly better than mobilization and physical therapy for subacute (3 to 13 weeks' duration) or chronic neck pain, and all three treatments are probably better than standard medical care, such as muscle relaxants, hot packs; (3) manipulation and/or mobilization may be beneficial for muscle tension headache.

Is chiropractic care appropriate? Yes, roughly half the time for acute low-back pain, which is on a par with appropriateness ratings of conventional medical procedures used for some other conditions (Shekelle et al., 1998).

RAND researchers were the first to look at the quality of chiropractic care. They reviewed office records from chiropractors randomly selected in the United States and Canada to see if the care they gave patients for acute low-back pain was appropriate. Appropriate was defined as "expected benefits exceeding expected risks," the same rule normally used to assess other medical procedures. The RAND researchers found that treatment was appropriate for nearly half of the patients; uncertain for about a quarter of them; and inappropriate for the remaining patients. These ratings are not unlike the appropriateness ratings found for some conventional medical procedures.

Is chiropractic care expensive? Yes, overall, for outpatient treatment. People cut their use of chiropractors in half if they have to pay part of the costs of care (Shekelle, Markovich, and Louie, 1995; Shekelle, Rogers, and Newhouse, 1996).

Chiropractic Health Care for Ambulatory Back-Pain Patients is Expensive

RAND researchers found that, on average, chiropractic care for outpatient treatment per episode of back pain is substantially more expensive than seeing a general practitioner. It is as expensive as seeing an orthopedist or an osteopath. (See Figure 1.) The average cost for a single chiropractic visit is less than the cost for other health care providers; however, patients require more visits to the chiropractor, and this drives up the per-episode cost. For example, a patient being treated for back pain might have an average of 10 visits with a chiropractor, compared to 5 visits with an orthopedist and 2 visits with a general practitioner. In this study, the researchers found major cost variations at the different study sites, and they caution about generalizing the findings to all of the United States.

In a second study, RAND researchers found that people use chiropractors freely if their insurance covers all costs. However, if they have to pay a 25 percent or more co-payment, their use of this alternative health care drops by half.

"This again is troubling.  This would true of medical if its patients had to pay a coinsurance as is required by most insurers exclusive to the chiropractor rather than only a set copay amount no matter how high the medical fee.  It has much more to do with the deductible or having a medical doctor more accountable upfront as to the real out of pocket costs."     Dr. Katherine Crafton   D.C.

Complementary and Alternative Medicine: Health Care out of the Mainstream

Chiropractic care is the most commonly used form of complementary and alternative medicine, or CAM. This field encompasses health care approaches that are neither taught widely in medical schools.

CAM Interventions
• herbal medicine • folk remedies
• chiropractic • lifestyle diet
• spiritual healing • energy healing
• megavitamins • homeopathy
• self-help group • hypnosis
• imagery • biofeedback
• commercial diet • acupuncture

The use of alternative medicine is common and growing, and people go to alternative medicine practitioners more often than they see primary care physicians (Figure 2). Nearly half of alternative medicine visits are to chiropractors.

"This study is very misleading and condescending because no CAM intervention is viewed as medicine.  No medical doctor performs any CAM unless its cash and exceptional to their training.  Only a chiropractor provides "chiropractic" and they may offer these other CAM interventions as an exception to their training also.  Though distinct, they both equally have a clinical doctorate and are licensed in the state and choose to practice these interventions as defined by their Examiners, but, in most cases, all CAM interventions but chiropractic could be provided by your next door neighbor if they had the confidence.  In all cases medicine must be provided by medical doctors except where it appears distinctly on private health insurance that chiropractors provide physical medicine.  No where do these insurers refer to chiropractic as a CAM intervention or they would not pay for it.  Most all practitioners (oriental medicine, acupuncturist, massage or colon therapists, nutritionist, naturopath, health store clerk, or witch doctor) of these CAM interventions have no clinical doctoral education; they may well help someone, but please do not imply anything negative toward chiropractic.    Most medical doctors or chiropractors do not get involved in these CAM interventions for numerous reasons including lack of knowledge, lack of conviction, financial, legal issues, or they're too busy."    Dr. Katherine Crafton D.C.

Use of Alternative Medicine is Common and Growing

RAND's pioneering analysis of spinal manipulation for low-back pain stimulated a national reassessment of other forms of CAM. In 1992, Congress established the National Center for Complementary and Alternative Medicine (NCCAM, initially the Office of Alternative Medicine). Its goal is to advocate for good science, objective information, and open, rational inquiry about health practices that are outside of mainstream medicine.

RAND provides technical support to NCCAM through its Southern California Evidence-Based Practice Center, one of twelve centers established nationwide by the Agency for Healthcare Research and Quality. RAND researchers have completed two studies for NCCAM on

  • mind-body therapies — such as biofeedback, guided imagery, and relaxation — used to treat gastrointestinal disorders
  • Ayurveda — the widely practiced form of traditional Indian Medicine — focusing on Ayurvedic herbs used in the treatment of diabetes.

They are also currently evaluating SAMe (S-adenosylmethionine) — a popular dietary supplement — for the treatment of depression, osteoarthritis, and chronic liver disease.

What Role Should Chiropractic Have in Health Care?

Where chiropractic fits in today's health care system is still unclear. The lack of high-quality studies reported in the medical literature makes it difficult to arrive at comprehensive conclusions about the value of chiropractic care. For example, RAND researchers could say only that spinal manipulation benefits some people with acute low-back pain. They didn't find enough data from well-designed studies to say anything about chiropractic's value for chronic low-back pain or low-back pain that involves an irritated sciatic nerve; about the complication rate of chiropractic treatment; about the number of manipulations needed to get the maximum response; or about the cost-effectiveness of manipulation compared with other types of conservative care, such as some forms of physical therapy or even home self-care.

Future Research Needs

Rigorous, randomized, controlled trials are the key to understanding chiropractic's role in health care. These studies are the gold standard for producing unbiased data about a treatment. For these studies to be informative, patients in the trials should have the same kind of health problem, for example, clinically identical low-back pain. Researchers must use well-defined interventions and control treatments, and they should determine patient response to the treatment using the standard outcome measures used in other areas of medical research.

Furthermore, an accurate accounting of the costs of chiropractic care is needed in order to understand the cost-effectiveness of this health intervention compared to conventional medical care.

Selected Bibliography

Coulter, I., A. Adams, P. Coggan, M. Wilkes, and M. Gonyea, "A Comparative Study of Chiropractic and Medical Education," Alternative Therapies, Vol. 4, No. 5, 1998, pp. 64-74. .

Hurwitz, E. L., P. D. Aker, A. H. Adams, W. C. Meeker, and P. G. Shekelle, "Manipulation and Mobilization of the Cervical Spine: A Systematic Review of the Literature," Spine, Vol. 21, No. 15, 1996, pp. 1746-1760.

Hurwitz, E. L., I. D. Coulter, A. H. Adams, B. J. Genovese, and P. G. Shekelle, "Use of Chiropractic Services from 1985 Through 1991 in the United States and Canada," American Journal of Public Health, Vol. 88, No. 5, 1998, pp. 771-776.

Shekelle, P. G., "What Role for Chiropractic in Health Care?" New England Journal of Medicine Vol. 339, No. 15, 1998, pp. 1074-1075.

Shekelle, P. G., A. H. Adams, M. R. Chassin, E. L. Hurwitz, and R. H. Brook, "Spinal Manipulation for Low-Back Pain," Annals of Internal Medicine, Vol. 117, No. 7, 1992, pp. 590-598.

Shekelle, P. G., and R. H. Brook, "A Community-Based Study of the Use of Chiropractic Services," American Journal of Public Health, Vol. 81, No. 4., 1991, pp. 439-442.

Shekelle, P. G., I. D. Coulter, E. L. Hurwitz, et al., "Congruence Between Decisions to Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America," Annals of Internal Medicine, Vol. 129, 1998, pp. 9-17.

Shekelle, P. G., and R. H. Brook, "A Community-Based Study of the Use of Chiropractic Services," American Journal of Public Health, Vol. 81, No. 4., 1991, pp. 439-442.

Shekelle, P. G., M. Markovich, and R. Louie, "Comparing the Costs Between Provider Types of Episodes of Back Pain Care," Spine, Vol. 20, No. 2, 1995, pp. 221-227.

Shekelle, P. G., W. H. Rogers, and J. P. Newhouse, "The Effect of Cost Sharing on the Use of Chiropractic Services," Medical Care, Vol. 34, No. 9, 1996, pp. 863-872.


You can see this is a very biased study with its "nose in the air" applying observations that would never be made of the medical community even though the same criticism can be made of their practices.  Further, just the use of language such as "non-traditional, complementary or alternative" or any implied association with organizations of alternative care givers, diminishes the value and education of the chiropractor by associating him/her with therapists and non-licensed or even non-certified care givers where no formal or accredited education is required.  The chiropractor holds a clinical doctorate and is licensed and certified to practice in each state as a separate and distinct practice.  This is not true of any of other people lumped into CAM. 

Also the Rand study ignores that it is nearly impossible to get any chiropractic study into a medical journal, so the argument for more studies puts another "nail in the coffin" for any "conventional or traditional" recognition by the establishment that would give the chiropractor equality and access to the public funds that are dominated and wasted by the medical community.  If chiropractic studies were welcomed into the so-called established journals, chiropractors would be represented among those making the decision.

Seldom would one ever find in any medical, educational, or "whatsoever science" research study that does not conclude that more studies are needed or a larger sample is needed.  In the Middle Ages, they placed the greatest rigors on "how many angels can stand on the head of a needle." Eventually, you get to the "necessity of action" and what's the point; we are all humans scrambling around in the dark.  Chiropractic is the only truly humble professional because it promotes innate healing, a God given quality that transcends man's arrogance to come up with another more progressive manipulation of our bodies.   Research and the established community of sciences require the monopolization of their industries under a guise of "good science" as though they are the only way to finding the truth.  Research is merely the manipulation of data to justify your prejudice.  Chiropractors have for generations published their own research sharing information with their peers; these people act like this does not exist or that it must have been done by a bunch of hacks.  What an irony?  When all research is being done by Big Pharma for big money.

We appreciate any consideration we can get, but it is not required for us to know that we help our patients who are truly unique and willing to take the path "less traveled by." Only 40% of all people would see a chiropractor; less than 20% do.  It was never intended to be part of the medical community, so this survey seems quite effete as though there is only one pathway to truth, secular, humanistic, rational, and medical.