Three years ago, Mark Crislip closed a post discussing the ABIM Foundation’s Choosing Wisely initiative with the following thought:

I wonder if a chiropractor could come up with five standards treatments in chiropractic to be avoided…

Well, now they’ve finally gone and done it, with results that, while not entirely without merit, are a bit off the mark in my opinion.

Choosing Wisely and chiropractic

For the sake of further discussion, let’s all just agree to ignore the fact, also pointed out by Dr. Crislip in his post, that chiropractic as a profession doesn’t exactly stand up to the scrutiny of the campaign’s criteria:

Choosing Wisely aims to promote conversations between clinicians and patients by helping patients choose care that is:

  • Supported by evidence
  • Not duplicative of other tests or procedures already received
  • Free from harm
  • Truly necessary

Of course to be fair, no medical intervention is completely “free from harm”, but I assume that what the ABIM Foundation actually means is that interventions should have a favorable risk to benefit assessment. This is arguably not the case when assessing chiropractic as a whole. While not all of the treatments I prescribe are based on robust randomized controlled trials, they are “supported by evidence” in the vast majority of cases, and often by very good evidence. Chiropractic doesn’t really bring anything original to the table that passes this test.

There are similar issues with the phrase “truly necessary”, whatever that means. Many medical interventions aren’t “truly necessary” in my opinion. Other Choosing Wisely lists cover a number of these, but there are also tests and treatments that may have value while perhaps not meeting this criterion absolutely depending on who is assessing the scene. But again, being charitable, I assume that the ABIM Foundation is focusing on common interventions for common human ailments that don’t tend to improve objective outcomes.

Specific treatments provided by a chiropractor might provide some objective benefit for a small sliver of musculoskeletal complaints, with those unique to chiropractic being the least helpful. But whatever improvement that can be attributed to visiting a chiropractor isn’t better than more conventional approaches, such as physical therapy or recommendations from a patient’s primary care provider for exercise, stretching, massage, etc. These approaches come with considerably less baggage and aren’t as likely to be accompanied by pseudoscience or anti-vaccine propaganda.

The Choosing Wisely lists published by participating organizations aren’t meant to serve as treatment guidelines, of course. Instead, they are intended to encourage a conversation around whether or not the listed interventions are a good idea, or if they may put patients at risk of more harm than benefit. Unfortunately, in my opinion, they have largely gone unnoticed by medical providers and the general public. I am confident that the list of questionable chiropractic interventions will be similarly ignored by practitioners.

The ACA’s list

The list in question, released in August, comes from the American Chiropractic Association (ACA). The ACA claims 15,000 members, which is less than a quarter of practicing chiropractors, and recognizes 11 specialty areas, such as chiropractic acupuncture, pediatrics, diagnosis and management of internal disorders, and forensic sciences. It describes itself with typical grandeur:

The American Chiropractic Association (ACA) is the largest professional chiropractic organization in the United States. ACA attracts the most principled and accomplished chiropractors, who understand that it takes more to be called an ACA chiropractor.

We are leading our profession in the most constructive and far-reaching ways — by working hand in hand with other health care professionals, by lobbying for pro-chiropractic legislation and policies, by supporting meaningful research and by using that research to inform our treatment practices.

We also provide professional and educational opportunities for all our members and are committed to being a positive and unifying force for the practice of modern chiropractic.

What does it take to called “an ACA chiropractor”? Membership requirements consist of being a licensed chiropractor in the United States and paying yearly dues. The ACA even goes so far as to state that they do not deny membership to anyone meeting the above qualifications as long as what they do in their practice isn’t illegal. In that way, they are similar to the American Academy of Pediatrics, which even allows pediatricians who are blatantly anti-vaccine to be members in good standing.

Here are the five things that chiropractors and their patients should question according to the ACA:

Do not obtain spinal imaging for patients with acute low-back pain during the six (6) weeks after onset in the absence of red flags.

What red flags, you ask? The ACA mentions “history of cancer, fracture or suspected fracture based on clinical history, progressive neurologic symptoms and infection, as well as conditions that potentially preclude a dynamic thrust to the spine, such as osteopenia, osteoporosis, axial spondyloarthritis and tumors”. I would argue that if you have any of these red flags, you should not be under the care of a chiropractor. There isn’t any evidence to support superiority of chiropractic care to conventional approaches for acute low-back pain anyway.

Do not perform repeat imaging to monitor patients’ progress.

They list idiopathic scoliosis as an exception, despite the fact that their own research shows no good evidence to support chiropractic management of this condition. I agree with this recommendation, and the reasoning of the ACA in this case is sound. I’m just not holding my breath while waiting to see if this will change anything, however.

Avoid protracted use of passive or palliative physical therapeutic modalities for low-back pain disorders unless they support the goal(s) of an active treatment plan.

In other words, commonly recommended interventions like heat, ultrasound, and electrical stimulation, shouldn’t be used in isolation because they don’t provide much benefit. The absolute worst thing you can do to prevent or treat lower back pain, which virtually all humans will experience at some point in their lifetime thanks to evolution, is nothing. General physical activity and back specific exercises are key, and in no way unique to chiropractic.

I don’t think you will find many chiropractors not recommending an exercise regimen for lower back pain disorders, so this item is a bit odd. You also won’t find many that won’t provide some kind of spinal manipulation, because that’s their thing that they do. In this section, the ACA writes that physical activity and back exercises “may lead to better outcomes when combined with spinal manipulation.” In reality, spinal manipulation is more like multiplying by one. It changes nothing for the long term outcome.

Do not provide long-term pain management without a psychosocial screening or assessment.

Chronic pain disorders often have a psychosocial component. Chronic pain can cause or be caused/exacerbated by anxiety and depression, for example. Some patients are at risk for the development of chronic pain because of a variety of psychosocial factors and chiropractors are not trained to evaluate or manage them. The ACA recommends that chiropractors use a screening tool and refer when necessary because the ACA imagines chiropractors to be primary care providers.

Do not prescribe lumbar supports or braces for the long-term treatment or prevention of low-back pain.

Another odd inclusion. Chiropractors simply aren’t out there putting people in back braces for long periods of time for treatment or prevention of back pain. I was easily able to find that this recommendation is already widely accepted. Meanwhile, the ACA is inviting speakers to their conferences to promote nonsense like the Activator Method.

The ACA press release announcing their participation in Choosing Wisely is interesting. They point out that multiple other organizations already participating have included recommendations to avoid spinal imaging for acute lower back pain. It’s a solid recommendation, but instead of actually attempting to show a commitment to change by pointing out some of the abject nonsense they have supported sans evidence, they went the safe route. And in the press release they essentially give their members enough wiggle room that they can continue obtaining frequent spinal films without losing any sleep.

My favorite quote involves the practice of “defensive medicine”:

As with many of our colleagues in the health care professions, we have learned from experience to practice “defensive medicine.” This perspective may be even more deeply ingrained within the chiropractic profession based on our prior experiences with bias and/or lack of understanding regarding chiropractic care. As an example, just look how long it took before Choosing Wisely® was even willing to consider a chiropractic list!

So do chiropractors practice defensively, which implies a concern for facing a malpractice suit, or not? It would appear that the latter is the case when you consider how often they point out how undeniably safe chiropractic is. Often this is done in the context of attacking conventional medical care. It’s also unclear to me how the medical community’s lack of “understanding regarding chiropractic care” encourages defensive practice.

Conclusion: The ABIM did not Choose Wisely

How does the ACA describe chiropractic on the Choosing Wisely website? Just as you would expect them to, of course. Remember though that this is an organization that is fighting for chiropractors to be considered primary care physicians complete with the right to prescribe medications.

Chiropractors focus on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health and function. Chiropractic services are used most often to treat conditions such as back pain, neck pain, pain in the joints of the arms or legs, and headaches. Widely known for their expertise in spinal manipulation, chiropractors practice a hands-on, drug-free approach to health care that includes patient examination, diagnosis and treatment.

The ABIM Foundation is very likely completely ignorant of both the history and the current reality of the chiropractic profession. Frankly I think it’s ridiculous that a chiropractic organization was invited to participate. We certainly have come a long way from Wilk v. AMA, haven’t we?

This is just another example, in a very long line, of the undeserved legitimization of alternative medicine that will serve as more of a marketing purpose than as a means of improving chiropractic practice. All that the ACA has done is provide a list of redundant or unnecessary recommendations. And the few chiropractors who already avoid excessive spinal imaging will continue to do so, while the vast majority will compartmentalize these “suggestions” and carry on as is.

Extras

  • Here is a response to the ACA Choosing Wisely list from the International Chiropractic Association.
  • Here is an ACA video describing the benefits of pediatric chiropractic.
    In March of 2017, the ACA reaffirmed its public policy on chiropractors as primary care providers. This policy includes the following:

Doctors of chiropractic also recommend and manage dietary changes, nutritional interventions, botanical medicines, homeopathic medicines, acupuncture and other services when indicated.

The ACA, while not overtly anti-vaccine in policy, supports conscience waivers.

Posted by Clay Jones

Clay Jones, M.D. is a pediatrician practicing at Newton-Wellesley Hospital in Newton, MA, and a regular contributor to the Science-Based Medicine blog. He primarily cares for healthy newborns and hospitalized children, and devotes his full time to educating pediatric residents and medical students. Dr. Jones first became aware of and interested in the incursion of pseudoscience into his chosen profession while completing his pediatric residency at Vanderbilt Children’s Hospital a decade ago. He has since focused his efforts on teaching the application of critical thinking and scientific skepticism to the practice of pediatric medicine. Dr. Jones has no conflicts of interest to disclose and no ties to the pharmaceutical industry. He can be found on Twitter as @skepticpedi and is the co-host of The Prism Podcast with fellow SBM contributor Grant Ritchey.