Ruth Armstrong: Turf tussle

WAS the response to MJA InSight’s recent chiropractic story “a turf battle in a sandbox” or are other principles at stake?

A fortnight ago our regular email newsletter arrived in your inbox with the subject line “Time to team up with chiropractors”. Admittedly, the phrase was composed for maximum “clickability” in the ongoing skirmish for your online attention on a Monday morning, but within minutes of sending we realised it had garnered considerably more interest than anticipated.

If you did click through you would have read our news story about the Chiropractic Observation and Analysis Study (COAST) study. COAST used similar methods to the BEACH (Bettering the Evaluation of Care and Health) study to document what chiropractors do in clinical practice.

Among 4464 chiropractor–patient encounters, some of the findings were that 60% of appointments were for musculoskeletal conditions, “maintenance and wellness” visits were frequent, the most common treatments were spinal manipulation and soft tissue therapy, treating infants aged under 1 year was uncommon, and there was very little cross-referral between chiropractors and GPs.

In response to questioning from MJA InSight, several experts agreed that GPs and chiropractors should communicate about patients under their care, and that chiropractors could be part of a patient’s primary care team if the treatment provided was evidence-based.

Not all of our readers supported these sentiments. In the hours after the newsletter went out we were told that “the MJA should be ashamed of itself lending credence to this pseudoscience”, that we were “submitting to political correctness” by publishing any information about chiropractors and that “GPs should continue to advise their patients that chiropractic treatment, unlike medical treatment, is unscientific and can be dangerous”.

The comments kept coming throughout the week. Chiropractors joined the fray, pointing to the shortcomings of the medical profession, the body of research supporting chiropractic practices and the general arrogance of doctors. Others took the opportunity to disassociate from some of their colleagues’ questionable activities — “please don’t lump all chiros into the same nut job basket! Support the professional evidence based, journal reading, thinking chiropractors!”

Our poll — “Should GPs refer patients with musculoskeletal conditions to chiropractors?” — kept pace. A week after the poll opened 503 votes had been cast, arguably InSight’s highest ever level of reader engagement.

Reflecting the polarised views of the comments, 37% of respondents agreed, 43% said no, and only 20% took the more moderate option of “Maybe — if evidence-based”.

Like one bemused commentator, we wondered about the “vitriol” in response to the story. Was it a case of (in the words of one chiropractor) “a turf battle in a sandbox” or were there other, more objective reasons for the longstanding tension between chiropractors and doctors?

There are some very important ways in which some high-profile, but not universal, chiropractic practices such as the ill defined concept of “subluxation” are at odds with evidence-based medical thinking. Media reports of some chiropractors’ active opposition to immunisation, use of spinal manipulation for infants and covert treatment of patients (including premature and critically ill babies) while they were in hospital under medical care have also done much to erode Australian doctors’ trust in chiropractors.

Concerns about these and other practices were reflected in readers’ comments. While individual chiropractors were able to provide examples of fruitful partnerships with GPs, it is not hard to understand why some doctors are reluctant to collaborate with a profession that tolerates such variations in practice within its ranks, especially when better evidenced and regulated resources, such as physiotherapy and musculoskeletal medicine, are available.

There are similar tensions in the US, where Dr Harriet Hall, associate editor of the Science-Based Medicine blog, recently lamented the failure of chiropractic to address the unscientific behaviour of some practitioners: “What if chiropractic had policed its own ranks, limited itself to providing only short-term treatment for certain types of musculoskeletal pain, worked hard to determine which manipulation techniques were most effective, abandoned techniques that it found ineffective, and denounced vaccine rejection, applied kinesiology, and other forms of quackery? … Chiropractors could have become ‘physical therapists for the back’, experts in manipulation that MDs could refer patients to with confidence. Chiropractic might have been integrated into the medical mainstream just like osteopathy and optometry, but it didn’t even try.”

The Chiropractic Board of Australia has this year made some moves to regulate its registrants’ approach to immunisation and paediatric care by producing two position statements. The board also announced a crackdown on chiropractors “who step outside their primary role as healthcare practitioners and provide treatment that puts the public at risk.”

These moves are encouraging, as is the advice of an academic chiropractor to his colleagues, in a 2011 paper on the future of chiropractic: “… it is time for the moderates and conservatives within our profession to become more involved with shaping its future … It is about time government, other health care providers and the public were made aware that not all chiropractors are pseudo religious zealots who have abandoned science for ideology”.

On one thing doctors and chiropractors agree — millions of Australians are “voting with their feet” to seek chiropractic care each year. Whether it’s teaming up or simply talking, it seems likely that patients will benefit from a bit more cooperation in the sandbox.

Dr Ruth Armstrong is the medical editor of MJA InSight.