Congruence between decisions to initiate chiropractic spinal manipulation for low back pain and appropriateness criteria in North America

Background: Recent U.S. practice guidelines recommend spinal manipulation for some patients with low back pain. If followed, these guidelines are likely to increase the number of persons referred for chiropractic care. Concerns have been raised about the appropriate use of chiropractic care, but systematic data are lacking. Objective: To determine the appropriateness of chiropractors' decisions to use spinal manipulation for patients with low back pain. Design: Retrospective review of chiropractic office records against preset criteria for appropriateness that were developed from a systematic review of the literature and a nine-member panel of chiropractic and medical specialists. Appropriateness criteria reflect the expected balance between risk and benefit. Setting: 131 of 185 (71%) chiropractic offices randomly sampled from sites in the United States and Canada. Patients: 10 randomly selected records of patients presenting with low back pain from each office (1310 patients total). Measurements: Sociodemographic data on patients and chiropractors; use of health care services by patients; assessment of the decision to initiate spinal manipulation as appropriate, uncertain, or inappropriate. Results: Of the 1310 patients who sought chiropractic care for low back pain, 1088 (83%) had spinal manipulation. For 859 of these patients (79%), records contained data sufficient to determine whether care was congruent with appropriateness criteria. Care was classified as appropriate in 46% of cases, uncertain in 25% of cases, and inappropriate in 29% of cases. Patients who did not undergo spinal manipulation were less likely to have a presentation judged appropriate and were more likely to have a presentation judged inappropriate than were patients who did undergo spinal manipulation (P = 0.01). Conclusions: The proportion of chiropractic spinal manipulation judged to be congruent with appropriateness criteria is similar to proportions previously described for medical procedures; thus, the findings provide some reassurance about the appropriate application of chiropractic care. However, more than one quarter of patients were treated for indications that were judged inappropriate. The number of inappropriate decisions to use chiropractic spinal manipulation should be decreased.