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March 10, 1999

Clinical Crossroads: A 45-Year-Old Man With Low Back Pain

Author Affiliations

Margaret A.WinkerMD, Deputy EditorIndividualAuthorPhil B.FontanarosaMD, Interim CoeditorIndividualAuthor

JAMA. 1999;281(10):893-895. doi:10-1001/pubs.JAMA-ISSN-0098-7484-281-10-jac90000

To the Editor: The article by Dr Weinstein1 offered sound advice on the prudent use of radiologic diagnostic studies. For too long these expensive and potentially harmful tests have taken the place of an investigative clinical examination and history taking and may have led to unnecessary intervention.

In addition to coordinating provider networks for managed care groups, I am a chiropractic physician practicing with a large group of orthopedic surgeons, so I am in a unique position to see health care from many sides. After reading Weinstein's remarks concerning chiropractic efficacy in the treatment of low back pain, I am reminded that old bias and inherent prejudices continue—many times to the detriment of the patient. Weinstein states, "There remain many anecdotal reports of beneficial outcomes and sudden recovery from manipulative and traction therapies." I would hardly call the abundance of quality studies on the efficacy of chiropractic management anecdotal. Clinical investigation from the distinguished RAND Corporation as well as studies published in respected medical journals have clearly shown chiropractic management to be effective,2 as well as cost-efficient.2,3 Organized medicine's continued allegations of only anecdotal evidence of the validity of chiropractic therapeutic techniques is interesting when according to medical researchers such a small percentage of medical studies and everyday interventions are supported by solid scientific evidence.4,5 Nevertheless, these practices continue to benefit patients, who care less about science and more about their health and quality of life. Weinstein also mentions the Agency for Health Care Policy and Research guidelines and comments that the report offers "little evidence to support passive physical therapy (eg, heat, ice, massage, manipulation, braces, biofeedback, traction, etc)." But the report advises that manipulation is 1 of the 2 best management tools in the treatment of low back pain. Why did Weinstein classify manipulation with physical therapy rather than chiropractic therapy when chiropractors deliver more than 94% of all manipulations in the United States?6