Back pain is one of the most common reasons for visiting a family physician. But the number of visits to chiropractors for back pain are twice as great as to physicians.¹ Or, to look at it from a different perspective, family physicians and chiropractors are providing the vast majority of ambulatory care for these musculoskeletal problems. Not only is back pain about as endemic as the common cold, it is very expensive. An estimate of the cost of each industrial back injury was $40,000 for both medical treatment and disability.² And like the common cold, there is no known cure. In recent years commonly employed therapies for back pain have come under scrutiny. Very few have been demonstrated as effective,^{3, 4} and one authority has claimed that conventional medical treatment for low back pain has failed.⁵ In terms of patient satisfaction, surveys have consistently demonstrated the least satisfaction with medical treatment.^6-8

Skepticism
For these as well as other reasons, more physicians are referring patients to chiropractors. But many remain skeptical. Curtis and Bove, in the Journal of Family Practice,⁹ cite three misperceptions which interfere with improved relationships between the two professions:

1. Chiropractors are poorly trained and could misdiagnose a serious condition;
2. Spinal manipulative therapy (SMT) lacks a scientific basis;
3. SMT is dangerous.

The authors note that these perceptions are largely unfounded or irrelevant. They estimate that the risk of vascular accidents following cervical manipulation is between 1 in 400,000 and 1 in 1 million procedures. The risk of cauda equina syndrome after lumbar manipulation is less than 1 in 100 million treatments.¹⁰

Another longstanding concern is that patients referred to chiropractors will receive manipulation for conditions having little if anything to do with the spine. Some physicians fear that patients will be persuaded to abandon medications for hypertension or diabetes in favor of a more "natural" approach.¹¹ While some chiropractors still profess to treat malignancies, metabolic diseases and other life-threatening illnesses, most do not.

Finding Competent Chiropractors
Curtis and Bove offer the following guidelines for identifying a competent chiropractor:  

One additional criterion should be mentioned. Chiropractors with whom referral relationships are established should be those who limit their treatments to those musculoskeletal conditions for which patients most often seek the services of DCs and for which some degree of efficacy by SMT has been documented. A competent chiropractor will treat within his/her appropriate scope of biomechanical expertise and leave medical management to the biomedical experts.

Guidelines and Clinical Trials
There is strong evidence for the efficacy of SMT in both acute and chronic back pain cases.^{3, 4, 12, 13} As of January 1997 there were 36 randomized controlled trials of SMT for LBP. There are also several notable evidence based reports recommending the appropriateness of SMT for patients with back pain.^14-17

Managed Care
Most HMOs and PPOs now offer a chiropractic benefit. Many HMOs have endorsed chiropractic care since it is in such high demand by members and offers a cost-effective way of achieving desirable outcomes. One Portland-based health plan created referral protocols so that physicians know when it is appropriate to make a referral to a panel chiropractor. In some parts of the U.S. capitated medical groups are signing specialty services contracts in order to facilitate chiropractic referrals at predictable costs.

Patients without a chiropractic rider are increasingly asking — even demanding — that their gatekeepers refer them for spinal manipulation. And it is quite common for chiropractors to refer patients to PCPs when they present with illnesses that are outside the chiropractic scope.

What's best for the patient?
The greatest barrier to referrals is an absence of established professional relationships between PCPs and chiropractors. Given the abundant evidence that SMT can help many of the commonly presenting spine-related complaints, PCPs and chiropractors should meet to determine referral guidelines. Chiropractic education, treatment philosophy, and scope of practice are issues which need to be addressed. The chiropractor's credentialing by and participation in managed care plans should be discussed. Referral protocols and treatment guidelines must be agreed upon. Improved outcomes, increased patient satisfaction, and cost efficiency can be obtained by the appropriate referral of patients to selected chiropractic providers.

References
1. Shekelle PG, Brook RH. A community-based study of the use of chiropractic services.  Am J Public Health 1991; 81:439-442.

2. Rihimaki H. Back and limb disorders, in Epidemiology of World Related Diseases, London: BMJ Publishing Group 1995; 207-238.

3. Deyo RA. Conservative therapy for low back pain: Distinguishing useful from useless therapy. JAMA 1983; 250:1057-62.

4. Spitzer WO, LeBlanc FE, Dupuis M et al. Scientific approach to the assessment and management of activity-related spinal disorders: A monograph for clinicians, Report of the Quebec Task Force on Spinal Disorders, Spine 1987; 12:(7 Suppl):S16-S21.

5. Waddell G. A new clinical model for the treatment of low back pain. Spine 1987; 12:632-44.

6. Cherkin DC, MacCornack FA. Patient evaluations of low back pain care from family physicians and chiropractors. West J Med 1989; 150:351-355.

7. Deyo RA, Diehl AK. Patient satisfaction with medical care for low back pain. Spine 1986; 11:28-30.

8. Carey TS, Garrett J et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. New England J Med 1995, 333(14):913-917.

9. Curtis P, Bove G. Family physicians, chiropractors and back pain. J Fam Pract 1992; 35:551-555.

10. Shekelle PG, Adams AH et al. Spinal manipulation for low back pain. Ann Intern Med 1992; 117:590-598.

11. Davis EH, Beasley JW. Letters to the Editor. J Fam Pract 1993; 36:378.

12. Meade TW, Dyer S et al. Low back pain of mechanical origin: Randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990; 300:1431-37.

13.Meade TW, Dyer S et al. Randomised comparison of chiropractic and hospital outpatient management for low back pain: Results from extended follow up. Br Med J 1995; 311:349-351.

14. Shekelle PG, Adams AH et al. The appropriateness of spinal manipulation for low back pain: Indications and ratings by a multidisciplinary expert panel, (extracts). RAND, Santa Monica California. Monograph No. R-4025/2-CCR/FCER, 1991.

15. Bigos S, Bowyer O, Braen G et al. Acute low back problems in adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD; Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.

16.Waddell G, Feder G et al. Low back pain evidence review. London, Royal College of General Practitioners, 1996.

17. Haldeman S, Chapman-Smith D and Peterson DM, eds. Guidelines for Chiropractic Quality Assurance and Practice Parameters. Aspen Publishers, Gaithersburg, Maryland, 1992.