Robert Mootz,DC, certainly has a way with words, and his recent column article, "Something, Anything-Based Practice,"1 has stuck in my brain. At some level I've known that my orientation to practice has evolved during the 40-plus years since I graduated from Logan. Bob's article stimulated me to try and put some of those changes into words.
Like chiropractors from many schools, we were trained as theory-based (or theory-informed, in the Mootz lexicon) doctors. Subluxation was an important part of the Logan basic theory, but unlike the segmentalism of the Palmers, we were trained to think of the spine as an integrated whole, or what has been termed the "structuralist"2 approach to chiropractic. This is not to say that we ignored evidence, but at that earlier time there were few if any rigorous trials of chiropractic technique.
The evidence we collected was the personal data from patient history, physical exam, and lab and x-ray findings for each new patient. These guided us to devise a plan of care suggested by the Logan basic view of health care. Of course, we also monitored patients' progress (outcomes), although in a rather informal fashion: We asked the patient whether the pain or other symptom was better, worse or no different since the last clinic visit. These were real, although primitive data, and they guided us in determining whether the treatment plan required a "rethink" or should be continued. The meticulous recordkeeping required of clinicians today was not emphasized in my training.
Times have changed, and so has chiropractic. I originated a theory and technique, initially derived from the teachings of Logan, the Derefields, DNFT and others,3 which has since been influenced by many sources. Clinical experience, my own and that of many Activator instructors and proficiency-rated doctors, has shaped our methods of analysis. A variety of basic and clinical science investigations, bearing both on assessment (e.g., isolation and pressure testing) and treatment (e.g., development of new instruments, questioning the need for specificity), have also influenced this approach to health care. However, we've also found that research often raises more questions than it answers. I appreciate that this is progress, but frankly, sometimes it's maddening! And on top of that, there never seems to be enough research to satisfy critics. I recognize that we'll never reach a plateau of knowledge or truth in chiropractic, that scientific investigation is ongoing. I sure wish they'd cut us a little slack!
One of the most significant aspects of change in chiropractic theories and practices has been a focus on the issue of outcomes. It's not profession-wide at this point, but as Dr. Mootz noted, third-party payers have progressively escalated demands that we demonstrate the value of the services we provide to patients. Quantification is increasingly the name of the game, and if it can't be measured, maybe it doesn't happen. Surprisingly, the pressure for quantification of clinical outcomes has required us to introduce ways of measuring patient progress which, until recent years, were thought to be too "subjective" to be valid. Paper-and-pencil tools, like the visual analogue scale, the Oswestry questionnaire and various other patient self-report procedures, have become increasingly routine in the chiropractor's office. Psychometricians and clinical epidemiologists report that these "soft" variables are more reliable and valid than some of the physical findings that we've long taken for granted (e.g., static and motion palpation findings, some radiographic mensuration, and certain orthopedic tests). And quite delightfully, we've found that patients' legendary satisfaction with chiropractic care is now considered a legitimate aspect of clinical outcome. It's not the whole banana, for sure, but not to be dismissed, either.
In general, this trend toward outcomes-oriented research and practice is positive. Whether one is theory-informed (e.g., Activator, Gonstead, Meric, SOT, etc.) or evidence-informed (and these are not mutually-exclusive options), we must all keep our eye on the bottom line in clinical practice, that is, whether our services are helping, hurting or making no difference for our patients and their complaints. In four decades of practice, I've never had a patient present with a request for relief of "subluxation." That's our concern, not theirs. If we really want to "save our subluxation," our best strategy may be to stop talking about lesions and focus on patient improvements. And we must investigate.
And so I offer an addendum or modification to Bob Mootz's slogan: theory-based but outcome-oriented. (This is not original; I'm borrowing from Keating,4 who borrowed from Azrin.5) Let us have evidence-sculpted theory to inform us how to proceed, but be also prepared to modify our approach in light of the patient's response, i.e., outcomes evidence. Some luminary once opined that there is no theory so good as a practical one. "Practicality" in the chiropractic healing art must necessarily be guided by benefits to patients, or, as Dr. Mootz might say, "value."
This is good advice, I suspect, not only for practice but for the direction of clinical research in chiropractic. Our theoretical notions must be weighed upon a scale of value to patients. Yet few, if any, trials of our adjustive methods have ever bothered to simultaneously monitor patient benefits and presumed subluxation parameters. Although we've been pleased with the patient improvements (positive outcomes) seen in controlled trials of adjusting and manipulation for headaches and low back pain, we haven't yet determined whether these patient improvements derive from subluxation correction or some other mechanism. It's not as though the question had already been put to the test and rejected. Rather, the "subluxation syndrome"6 is still largely unexplored territory. We can't know ahead of time how large a task this may be, nor whether our ideas about spinal dysfunction and health will stand up to the test. But we do have some idea of the general shape that this line of investigation should take.7,8
It's not the same profession I entered in 1961. We have evolved and improved in ways my mentors and classmates could not then imagine: in legitimacy; accredited education; federally financed research; and scholarly and scientific sophistication. Yet the most important challenges facing chiropractic remain surprisingly constant; we must muster our resources to better understand and meet our patients' needs. We need to challenge our own ideas about what works and what doesn't, both in terms of spinal theory and patient benefit.
How far we've come! How far we have to go!
References
- Mootz RD. Something, anything-based practice. Dynamic Chiropractic 2002 (Feb 11); 20(4): 36-7.
- Montgomery DP, Nelson JM. Evolution of chiropractic theories of practice and spinal adjustment. Chiropractic History 1985;5:70-6.
- Fuhr AW, Colloca CJ, Green JR, Keller TS. Activator Methods Chiropractic Technique. St. Louis: Mosby, 1997.
- Keating, JC. A strategy for clinical research: Theory-based but outcome-oriented. Dynamic Chiropractic, 3 December 1993, pp. 40-1.
- Azrin, NH. A strategy for applied research: Learning-based but outcome-oriented. American Psychologist 1977; 32:140-9.
- Gatterman MI, Hansen DT. Development of chiropractic nomenclature through consensus. Journal of Manipulative & Physiological Therapeutics 1994 (June);17(5):302-9.
- Keating, JC. To hunt the subluxation: Clinical research considerations. Journal of Manipulative & Physiological Therapeutics 1996 (Nov/Dec); 19(9):613-9.
- Nelson C. The subluxation question. Journal of Chiropractic Humanities 1997;7:46-55.
Arlan Fuhr,DC
Phoenix, Arizona
awfuhr@aol.com
