August 2003 Bulletin

Survey shows how orthopaedists perceive, relate to CAM providers

By John W. Wickenden, MD

According to a recent article in Spine,1 complementary therapists–primarily chiropractors–are sought far more often than orthopaedic surgeons by patients with back and neck pain–54 percent vs. 37 percent. Moreover, chiropractors are deemed to be "very helpful" by 61 percent of these patients. Conventional providers were rated as "very helpful" by only 27 percent of the patients who sought their care.

The AAOS Complementary and Alternative Medicine (CAM) Committee is charged to identify, define, gather and evaluate information about CAM modalities as they relate to musculoskeletal care. It is obvious that CAM, and especially chiropractic treatment, is relevant to our patients. The CAM Committee believes that the Fellowship must be adequately informed of the range of complementary and alternative care modalities that our patients embrace.

The CAM Committee believes that we can more directly meet the needs of our Fellowship if we investigate how orthopaedic surgeons perceive, and relate to, chiropractors and other providers of complementary medicine such as acupuncturists and massage therapists. With the assistance of the AAOS department of research and scientific affairs, the CAM Committee conducted a survey of the Fellowship. With an exceptionally high response rate, statistically valid results were obtained, providing an accurate reflection of current Fellowship thought on the topic.

Referrals to CAM practitioners

Academy Fellows make frequent or occasional referrals to CAM practitioners more often than we expected. Of those surveyed, 30 percent of Fellows make referrals to massage therapists, 22 percent to chiropractors and 16 percent to acupuncturists. Some orthopaedic practices, though fewer than 5 percent, actually employ one of these practitioners.

Forty percent of orthopaedic surgeons who report having a focus in adult spine reported referring patients to chiropractors frequently or occasionally. Only 19 percent of non-spine-focused orthopaedists reported making such referrals. Referrals from CAM practitioners to orthopaedic surgeons are even more common. Almost 66 percent of orthopaedic surgeons reported receiving frequent or occasional referrals from chiropractors, and only about 10 percent never receive such referrals.

Responding to patient questions

The overwhelming majority of orthopaedic surgeons have had patients inquire about the safety or efficacy of CAM treatments for musculoskeletal problems: 95 percent report being asked about chiropraxis, 89 percent about massage therapy, 86 percent about acupuncture and 74 percent report that their patients have asked about other CAM treatment modalities.

Do Fellows have adequate knowledge to answer their patients’ questions? Seventy-two percent of Fellows surveyed believed that they possessed adequate knowledge about chiropraxis. Only 47 percent surveyed thought that they had adequate knowledge about acupuncture or other alternative treatments. Older surgeons felt more knowledgeable than younger surgeons, and Fellows with a self-reported focus on the spine felt more knowledgeable than generalists or other specialists.

Favorable versus effective

Our colleagues rate their overall experience in working with CAM practitioners more favorably than anticipated. On a scale of 1 to 10, with 1 being "unfavorable" and 10 being "favorable," the orthopaedic surgeons surveyed reported mean responses of 6.02 for working with massage therapists, 5.39 for working with acupuncturists and 5.37 for working with chiropractors.

Orthopaedic surgeons, in contrast to their patients (as noted in the first paragraph of this article), did not rate the effectiveness of CAM treatments as highly as they rated their overall experience. Nevertheless, the surgeons’ perceptions of the efficacy of massage therapy, acupuncture and chiropraxis were about midway between "not at all effective" (a rating of 1) and "very effective" (a rating of 10). The mean responses were 5.24 for massage therapy, 4.33 for acupuncture and 4.67 for chiropraxis.

A role for CAM

Recognizing that we orthopedic surgeons do not have definitive answers to every clinical problem, one Fellow acknowledged that alternative medicine options may be no worse than what we can offer if there is no surgical indication. The CAM Committee will continue to provide education and information for the Fellowship about CAM modalities, trends and practitioners.

We encourage you to visit the CAM home page on the AAOS Web We also welcome your e-mail feedback at


  1. Wolsko PM, Eisenberg DM, Davis RB, Kessler R, Phillips RS: "Patterns and Perceptions of Care for Treatment of Back and Neck Pain: Results of a National Survey." Spine 2003 Feb 1;28(3):292-7.

John W. Wickenden, MD, is chair of the AAOS Complementary and Alternative Medicine Committee. He can be contacted at

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