Chiropractors say they have been vindicated by federal health officials who this week endorsed chiropractic care, along with low-stress exercise and pain relievers, as an effective treatment for acute lower back pain.
But that has not changed the minds of some medical doctors, who continue to doubt that chiropractors' manipulation of the human spine has more than a minor impact, if any, on acute back pain.
"Chiropractic does a little good," said Dr. Donlin M. Long, a medical doctor and director of neurosurgery at Johns Hopkins Medical Institutions. "You may gain a week or two in recovery, but it won't change the outcome." The cause of the pain is unclear, but it usually goes away in a few weeks by itself.
"The potential expenditures [for chiropractic] are enormous and the gain is minuscule," he said.
That attitude reminded Dr. Louis Sportelli, spokesman for the American Chiropractic Association, of "when General Motors executives looked out the windows and didn't realize foreign cars were taking over the country."
Chiropractic is effective and in expensive, he said, and ought to be a full partner in patient care.
Chiropractors, who do not attend medical school or have medical degrees, instead earn doctor of chiropractic degrees. They contend that misalignment of the skeleton -- particularly the spine -- can affect the nervous system and cause inflammation, pain and other ailments. They treat those symptoms by manipulating the spine or other joints.
The long-running fight between medical doctors and chiropractors was revived by a federal review of thousands of studies that concluded expensive tests, surgeries and some treatments for acute lower back pain are largely useless.
Lower back pain is big business. It strikes 7 out of 10 people and in 1990 cost $50 billion in medical care and lost work.
The most effective treatments, the Agency for Health Care Policy said, are taking aspirin or acetaminophen to relieve pain, and walking, swimming or biking to rebuild a tolerance for activity.
Chiropractic manipulation was also found to be effective in easing pain during the first four weeks. Other tests and treatments, including anti-inflammatory injections, surgery, bed rest and muscle-relaxing drugs were found to be useless and, in some cases harmful.
Back pain that persists beyond a month is chronic, and may signal more serious problems. The effectiveness of treatments for chronic back pain is still being studied. A loss of feeling or movement in the legs may call for more aggressive treatments, including surgery.
Chiropractic has survived more than a century in the United States. Lately it has grown in popularity, despite what Dr. Sportelli described as "a malicious political smear campaign" by traditional medicine "to discredit . . . a fierce competitor."
About 400 chiropractors practice in Maryland, according to the State Board of Chiropractic Examiners, which regulates them. Fifty more were licensed this year. Maryland has nearly 16,000 medical doctors.
Chiropractors train in federally accredited chiropractic colleges for four years, then intern at the schools' clinics for one year before entering private practice. They can receive payment from Maryland health insurers, but most health maintenance organizations do not employ chiropractors or refer patients to them.
HMOs rely on "gatekeepers" to decide what treatment is appropriate, said Dr. Audie Klingler, a Cumberland chiropractor and president of the state board. "Ninety-five to 100 percent of the gatekeepers are medical doctors, and medical doctors aren't making that referral."
That is changing, he said. "They are getting educated on the types of care we can provide, and seeing that our care is more cost effective . . . and patients are much happier."
Dr. Donlin said the idea the government presented -- that pain control and patience is the best approach to treating acute lower back pain -- isn't new. "We all recognize that patients rarely need surgery in the early stages. It's standard teaching that you wait," he said.
But he regards the evidence behind the added endorsement of chiropractic care as weak. He cited one study that suggests patients are happier with chiropractors because they offer an explanation for acute back pain that baffles medical doctors. But under both types of care, Dr. Donlin said, the outcome is the same -- the pain goes away.
And "insofar as chiropractic claims to treat any other systemic diseases," he said, "there's no scientific basis for that that I know of."
"Today," said Dr. Sportelli, "instead of claiming we can cure everything . . . what we're saying is this: If the patient doesn't respond in three months, it is probably an inappropriate mode of care."