Not only was traveling from the deep South to the far North a change in climate and culture for me, but attending the Foundation for Chiropractic Education and Research's (FCER) International Conference on Spinal Manipulation (ICSM), co-sponsored by the Canadian Memorial Chiropractic College (CMCC) and the Consortium of Canadian Chiropractic Research Centers (CCCRC), in Toronto was a huge change in the nature of most chiropractic conventions - no practice management, no motivational speakers, and no chirovangelism - just good ol' hardcore science to excite everyone there.
None of that hype was necessary to make one feel great pride in the strides this profession has taken of late in research and scientific methods. The meeting didn't showcase the faith-based chirovangelists as much as it did shine the light on many of the smartest DCs and brightest researchers and educators in our field. Rather than those who are content merely to "believe in" chiropractic, this conference was aimed at those DCs who want to "understand" the science and advances in chiropractic research. Indeed, it was a select crowd of speakers and attendees who enjoyed FCER's ICSM in Toronto.
Also impressive was the cooperation among the various chiropractic colleges and researchers in attendance. In a city of more than 100 different cultures living peacefully amongst themselves, it was refreshing to hear and speak with DCs from around the world and the entire academic community whose collective aim was to enrich the science of our profession. Indeed, the Canadian hospitality toward many chiropractic cultures was profound and enjoyable.
The numerous international researchers were given 15 minutes each to discuss their work, making for a fast-moving conference filled with many great presentations. It was refreshing to learn the mechanisms behind the results of spinal manipulative therapy (SMT). Also refreshing were the speakers' insights into effective clinical methods that would enhance practice growth on a pragmatic, rather than emotional, basis. (Abstracts of all the research presentations are in the 2002 ICSM Proceedings (www.fcer.org.)
The conference was not without irony. The keynote speaker, Dr. Neils Nilsson, undoubtedly one of the many who's who of chiropractic research in attendance, questioned why good clinical results were difficult to recapture in randomized clinical trials (RCTs), and called for a "hold" on RCTs, although "evidence-based health care will never stop doing them." He mentioned that the "optimum treatment and protocols are not known for many disorders" and that we "should use only pragmatic treatments" instead. Indeed, the translation of research to clinical treatment remains paradoxical at best.
Perhaps an even larger irony presented itself serendipitously that weekend. As you may know, Dr. Nilsson has published a highly regarded paper on headaches. He mentioned during his talk that among headache sufferers, 75 percent never seek care; the 25 percent who do seek primary care from family practitioners, DCs or PTs; only two percent seek secondary care from a neurologist; and only 0.1 percent seek specialists at a headache center.
Unbeknownst to Dr. Nilsson, the cover story of the October 7 issue of Time magazine was "Preventing Headaches: The Latest Research Offers New Hope for All of Us." As I read this article on the airplane to Toronto, I was stunned to learn that chiropractic was never mentioned, despite the research done by Nilsson and Craig Nelson, and the Duke University study. In regards to nonmedical treatments, chiropractic was strangely omitted. Instead, Time reported: "Many migraineurs swear by various nonpharmacological methods of keeping their headaches at bay, such as yoga, meditation and biofeedback."
When I asked Dr. Nilsson of this oversight, he admitted he had not seen the Time article but did say if chiropractic was not mentioned, "the writers were not being honest." He also mentioned that in the next 10 years chiropractic will be mentioned because of JMPT and Medline.
This fact was not missed by Dr. Tony Rosner, FCER's director of research, who called a meeting of interested parties to discuss the lack of media exposure of chiropractic research and positive clinical results. While many good suggestions came forth, it was obvious that chiropractic as a whole has a few glaring problems: damage control PR from Life University's loss of accreditation; media bias against chiropractic; and our own lack of positive publicity touting our research and clinical benefits.
Coincidentally, as most know, the Canadian Chiropractic Association is under attack in a malpractice suit concerning Lana Lewis, the victim of stroke allegedly caused by SMT by a DC. Though this matter is not yet resolved, the amount of bad press has had its ripple effect on all DCs despite the expert testimony.
Dr. Scott Banks elaborated on this issue in his timely course on vertebral artery injury and stroke, sponsored by NCMIC. The incidence of VAD/stroke is a minimal one case per 5.85 million treatments, an accident happens in approximately one in 43 chiropractic careers. DCs are, in effect, guilty by inference and the press has done a "tremendous over-simplification of this issue." Obviously the incidence of spontaneous VAD is "unknown." The diagnostics are unreliable; the mechanism is not the treatment, but more likely the pre-existing health of the artery. The most important clue is the patient profile and case history by the DC on a patient who has already had a stroke but doesn't know it.
Dr. Banks gave the early warning signs of a possible stroke victim: insidious, sudden onset of neck pain along with an unusual headache ("The worst headache in my life") that hasn't responded to typical treatments, a recent upper respiratory infection, and prior nonspecific neurological symptoms like vertigo; diploplia; dysarthria; dysphagia; drop attacks; nausea; numbness; nystagmus and ataxia. He summarized what to look for in the case history of a CVA brain stem ischemia: a posterior headache with autonomic dysfunction, as opposed to a frontal, migraine-type headache with neurological problems.
Dr. Banks also gave out a Vertebrobasilar/cerebrovascular questionnaire and vertebrobasilar examination forms to help doctors to screen for these rare cases that may come to your office. Along with an informed consent form to educate patients as to the remote likelihood of CVA from cervical SMT, these forms may not prevent the rare occurrence, but as long as you follow the standards of care, proper patient profiling/screening, and are aware of what to look for, at least you can minimize any potential legal problems for yourself.
While the press and medical detractors are pointing a finger at chiropractic's iatrogenic problems of one in 5.85 million treatments, the irony of this situation is that the media ignore the medical iatrogenic problems in similar neck cases, such as the rate of paralysis/death of 15,600 incidents per one million neck surgeries. Indeed, who's hurting who? Yet with the negative chiropractic publicity, DCs are fair game for the press, making Dr. Rosner's goal to publicize our research even more important.
The next research conference will be held in conjunction with the World Federation of Chiropractic's 7th Biennial Congress, co-sponsored by FCER, ACA, CCA, ICA and FICS. This dynamic symposium will feature dozens of the same prominent speakers in the clinical and research fields, and will be held in Orlando May 1-3, 2003 at the Hilton in the Walt Disney World Resort. If you're tired of rah-rah seminars or boring license renewal seminars, this is your chance to hear the best and meet with the rest of our profession's leadership.
J.C. Smith,MA,DC
Warner Robins, Georgia
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