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Professor Pran Manga was not approached directly to undertake the review of the chiropractic manage- ment of low-back pain. The report's second authorĀ ...
LETTERS * CORRESPONDANCE

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Report on chiropractic A s two of the authors of the report on chiropractic management of low-back pain, we wish to add some balance to the article "Orthopedists have bone to pick with economist over report on chiropractic" (Can Med Assoc J 1994; 150: 1878-1881), by Fran Lowry. Professor Pran Manga was not approached directly to undertake the review of the chiropractic management of low-back pain. The report's second author, Doug Angus, was asked to do the study. Because of other commitments, Angus asked Manga to lead this research. Dr. Hamilton Hall's statement that "Manga was selected to author this report because he was 'publicly, and well before this report, a doctor hater"' is not only inaccurate but also reflects poorly on Hall. We wish that such an irresponsible remark had not -

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been included in an otherwise informative article. Furthermore, by selectively "cherry picking" the findings and recommendations from the report, the article is biased in exactly the way that Hall accused the report of being biased. Lowry would have served the readers better by including one of the report's main recommendations, that "the government should take all reasonable steps to actively encourage cooperation between providers, particularly the chiropractic, medical and physiotherapy professions. Lack of cooperation has become a major factor in the current inefficient management of LBP [low-back pain]."' Since, as Lowry states, "current, state-of-the-art medical management of low-back pain . . . is largely in agreement with chiropractic management" cooperation among the three professions (chiropractic, medicine and physiotherapy) can be achieved. The real winners in such cooperation are the patients and taxpayers for whom effective and cost-effective care is intended. Hall's criticisms are mistaken and confused. For example, we certainly did not dismiss the report of the Quebec Task Force on Spinal Disorders2 as a "useless piece of work," as Hall claims. The study with an "unusually small sample size" (a description by the study's authors, not us), published by a worker's compensation fund in the United States, examined the relative costs of chiropractic and medical management of low-back pain; it was not a randomized controlled trial (RCT) of the effectiveness of various therapies.3 This study is discussed in a chapter of our report different from the one about RCTs and other evidence on efficacy, effectiveness and safety. Hall has confused

two sets of studies, a confusion that is also evident in his other criticisms. A more careful reading of the report would make him think twice about his allegation that spinal manipulation does not work; in the specific studies discussed, the spinal manipulation was performed by physicians or physiotherapists, not chiropractors. The studies supporting chiropractic management with the use of spinal manipulation are not old; on the contrary, most were published after the report of the Quebec task force.' We do not know what Hall means when he says that the report is "self-serving." None of the authors is a professional caregiver or has financial or direct professional interests in the report's findings and recommendations. Given Hall's professional interests in this area, we would have expected him to resist intemperate and angry remarks and to avoid inaccurate and confused criticism. We cannot comment on Hall's views on the purposes or intent of the Ontario Ministry of Health. Except for a brief meeting between one of us (P.M.) and the minister of health after the report was completed, in August 1993, neither bf us had anything to do with anyone in the ministry. Pran Manga, PhD Professor and director Doug Angus Adjunct professor Master's Program in Health Administration University of Ottawa Ottawa, Ont.

References 1. Manga P, Angus D, Papadopoulos C, Swan W: The Effectiveness and CostEffectiveness of Chiropractic Management of Low-Back Pain, Kenilworth Publishing, Richmond Hill, Ont, 1993 2. Quebec Task Force on Spinal Disorders: Scientific approach to the assessment and CAN MED ASSOC J 1994; 151 (8)

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management of activity-related spinal disorders: a monograph for clinicians. [review] Spine 1987; 12 (suppl 7): S l-S59 3. Greenwood JG: Report on Work-Related Back and Neck Injury Cases in West Virginia: Issues Related to Chiropractic and Medical Costs, West Virginia Workers' Compensation Fund, WV, 1983

Dr. Hall asserts that Professor Manga was chosen to author a recent Ontario Ministry of Health report on chiropractic, which was complimentary to that profession, because he was known to hate physicians and to be very keen on chiropractors. As general counsel to the Ontario Chiropractic Association I am aware of how Manga was chosen. Ministry representatives wanted the best health economists available. First, Jonathan Lomas of McMaster University, Hamilton, was approached, and then John Dorland of Queen's University, Kingston, was asked. Both were interested but were unavailable in the given time frame. Angus and Manga of the University of Ottawa and Queen's University, who were also regarded as in the top echelon, were then approached. They were available largely because the proposed study complemented an overall study of the cost-effectiveness of the Canadian health care system that they were working on. Manga, Angus and associates reported that the scientific evidence suggests that chiropractors generally treat patients with back pain more skilfully and cost-effectively than do other health care providers. The literature I have read supports that conclusion. Why must physicians be so defensive when good things are said about other health care providers? I agree that some chiropractors are a little strange, but so are some physicians and, I suspect, some lawyers. Viewed impartially and as a whole, the chiropractic profession has impressive standards of education, practice and research. These have been achieved with virtually no public funds and with significant barriers for patients who choose chiropractic care. It would be 1108

CAN MED ASSOC J 1994; 151 (8)

After having studied much of much better for physicians, chiropractors and patients if the profes- the same material, Dr. Paul Shekelle, sions worked together and learned who headed a study of spinal manipfrom each other. ulation, concluded, "For some paIn regard to Hall's criticism that tients with low back pain, particuManga hates physicians, I understand larly those with uncomplicated acute that, like many people, Manga has low back pain, sufficient data exist to had good and bad experiences with conclude that spinal manipulation is medical and chiropractic care. more efficacious than a sham manipulation and more efficacious than David A. Chapman-Smith, LLB medical therapies that deactivate the Toronto. Ont. patient."3 This opinion hardly supports elevation of the chiropractor to [Dr. Hall responds:] the role of gatekeeper in the Workers' Compensation Board medical My concerns, as expressed in Ms. system, as Manga, Angus and associLowry's article, were with the con- ates propose. Shekelle stated that the tent and validity of the report on chi- latter "looked at the exact same studropractic management of low-back ies as the rest of us, and no-one else pain, not with the chiropractic pro- has been able to come to those confession or with the process by which clusions."4 Only chiropractic literature supManga was selected to conduct the analysis. My criticism is not that the ports the claim that chiropractors report says "good things" about other treat patients with low-back pain health care providers but that it deliv- more skilfully than other health care providers. Determination of costers an unbalanced and biased view. Far from "cherry picking," my effectiveness by comparing manipureview of the report was a paragraph- lation with spinal fusion is fallacious. by-paragraph assessment of its con- The "impressive standards" of chirotents and recommendations. Through- practic education noted by Chapmanout the report, articles and opinions Smith include routine spinal adjustfavourable to the authors' point of ments in infants and the treatment of view are extensively covered, and otitis media through correction of negative studies such as that of the cervical vertebral subluxations. Quebec Task Force on Spinal DisorMy objection to the report is not ders are confined to a single para- that it defends manipulation. There is graph. ample evidence that this technique, The report gives lengthy de- administered by a chiropractor, physscriptions of anecdotal articles, one ician or physiotherapist, can be helppublished in the 1930s, on the value ful in short-term pain control in simof spinal manipulation.' This "space ple, acute, mechanical low-back bias" may be appropriate for a politi- pain. However, to recommend that cal testimonial, but it is hardly fitting public support be provided for chiroin a scientific document. practic training and that chiropracAlthough the authors stress the tors be allowed to admit patients to appropriateness of RCTs, most of hospital and to replace physicians as their support comes from other primary caregivers for injured worksources. Furthermore, the informa- ers requires a leap of logic that I cantion contained in the report does not not condone. substantiate the recommendations. My "professional interests in The authors state, "We believe that, this area" span 20 years of commitdespite the weakness and shortcom- ment to improving the quality of ings, the studies do allow conclu- back-pain management by all health sions with respect to the effective- care providers. I agree that patients ness of spinal manipulation."2 How- and taxpayers would be the real winever, belief is not scientific valida- ners of cooperation among physition. cians, physiotherapists and chiroLE 15 OCTOBRE 1994