March 2006

Shake and bake trois ‑‑ expense without benefit?

by Dr. Christopher Kent

An article titled, "Expense Without Benefit" appeared in a recent issue of Bone and Joint. [1] The author cited a randomized trial comparing medical care with and without physical therapy and chiropractic care with and without modalities for patients with low back pain. [2] Also examined was a study comparing the costs associated with these protocols. [3] The conclusion? "Physical therapy is an expensive add‑on...but provides no demonstrable clinical benefit...all four modes of care led to the same level of improvement in pain and disability...physical therapy modalities provide transient or no benefit."

This echoes the findings of others. Frost et al [4] reported the results of a controlled trial comparing routine physiotherapy with just one session of assessment and advice from a physiotherapist. The authors concluded, "Routine physiotherapy seemed to be no more effective than one session of assessment and advice from a physiotherapist." Indeed, adding PT to the mix might be harmful to both outcomes and pocketbooks. Richardson et al [5] wrote, "There is evidence that physiotherapy leads to a prolonged time before patients return to usual activities."

These findings are of tremendous significance to the chiropractor who employs physical modalities. As I noted in previous columns, there is a growing body of evidence that passive modalities commonly used in chiropractic practice, provide no benefit greater than a placebo, and may actually cause harm by prolonging disability. [6,7] This poses several significant challenges to the DC.

The first is practical. As such information becomes disseminated among third party payers and reviewers, we can expect a growing number of denials for such services. Some managed care organizations are already adopting a policy of paying one global fee per visit, rather than paying for individual modalities.

The second issue is ethical. Put simply, "It is unethical to prescribe, provide, or seek compensation for therapies that are of no benefit to the patient." [8] The Hippocratic imperative "Primum non nocere" ‑‑ first do no harm ‑‑ would preclude the use of procedures which cost money, can prolong disability, but do not contribute to favorable outcomes. Furthermore, a doctor's duties of veracity (truth telling) and beneficence (doing only that which benefits a patient) may be compromised when modalities are employed which provide only "expense without benefit."

"But these studies dealt with back pain," you say. "I use modalities to help me make the adjustment." Bad news. A search of the Medline, MANTIS, ICL, and CINAHL databases failed to disclose any scientific evidence that common passive physical therapy modalities are effective in correcting vertebral subluxations.

Where does this leave us? Chiropractic's survival is dependent upon the ability of individual chiropractors to follow the advice of evidence‑based practice in "The conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients...(It) is not restricted to randomized trials and metaanalyses. It involves tracking down the best external evidence with which to answer our clinical questions." [9]

And for PT modalities in chiropractic practice, the evidence is lacking.

References

1. "Expense without benefit." Bone and Joint 2005;11(10):120.

2. Hurwitz EL, Morgenstern H, Kominski GF, et al: "A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain: 6‑month follow‑up outcomes from the UCLA low back pain study." Spine 2002;27(20):2193‑.

3. Kominski GF, Heslin KC, Morgenstern H, et al: "Economic evaluation of four treatments for low‑back pain: results from a randomized controlled trial." Med Care 2005;43(5):428‑.

4. Frost H, Lamb SE, Doll HA, et al: "Randomised controlled trial of physiotherapy compared to advice for low back pain." BMJ 2004;329:708.

5. Richardson B, Shepstone L, Poland F, et al: "Randomised controlled trial and cost consequences study comparing initial physiotherapy assessment and management with routine practice for selected patients in an accident and emergency department of an acute hospital." Emerg Med J 2005 ;22(2):87.

6. Kent C: "Shake and bake." The Chiropractic Journal. October 1997. http://www.worldchiropracticalliance.org/tcj/1997/oct/oct1997kent.htm

7. Kent C: "Shake and bake revisited." The Chiropractic Journal. January 1998. http://www.worldchiropracticalliance.org/tcj/1998/jan/jan1998kent.htm

8. Code of Professional Ethics. ACOG 2004.

9. Sackett DL: Editorial. "Evidence‑based medicine." Spine 1998;23(10):1085.

(Dr. Christopher Kent, president of the Council on Chiropractic Practice, is a 1973 graduate of Palmer College of Chiropractic. The WCA's "Chiropractic Researcher of the Year" in 1994, and recipient of that honor from the ICA in 1991, he was also named ICA "Chiropractor of the Year" in 1998. He is director of research and a co‑founder of Chiropractic Leadership Alliance. An attorney as well as a chiropractor, Dr. Kent is a member of the California bar. With Dr. Patrick Gentempo, Jr., Dr. Kent produces a monthly audio series, "On Purpose," covering current events in science, politics and philosophy of vital interest to the practicing chiropractor. For subscription information call 800‑892‑6463.)