Creating a World According to Hoyle Instead of Garp

If the mission of FCER could be summed up in three words, they would be "sanctity of information." In an ideal world, this would mean that information on the theory and practice of chiropractic, or anything else, is gleaned from answering discrete, testable hypotheses, and freely transmitted thereafter. In the actual world, society rarely seems to function according to Hoyle; often, it seems to operate according to Garp.

The "sanctity of information" is an obsession of mine which, thankfully, has been upheld from a legal point of view in support of full disclosure of treatment options to the patient, as discussed in this space previously.¹ Less thankful are the numerous logical or ethical lapses threatening to turn our understanding of the world, and of health care in particular, on their respective heads. Many of the more subtle examples I have also reviewed in this space.² Some of the more blatant cases will be discussed now. The lessons learned will encourage our readers to increase their chances of publishing research in the indexed literature and developing more viable and robust research plans (i.e., increasing the chances of funding from granting organizations such as ours).

What has happened to our medical information? I am told, for example, that up to 50 percent of our health news is generated by a single journal: The New England Journal of Medicine. In Teddy Roosevelt's trust-busting days, this was known as a monopoly. NEJM's current editor, Marcia Angell, has this to say about alternative medicine: "(It) distinguishes itself by an ideology that largely ignores biologic mechanisms, often disparages modern science, and relies on what are purported to be ancient practices... with the increased interest in alternative medicine, we see a reversion to irrational approaches to medical practice... it is time for the scientific community to stop giving alternative medicine a free ride."³ The journal's previous editor, Arnold Relman, is closely in agreement: "Integrating alternative medicine with mainstream medicine, as things stand now, would not be an advance but a return to the past... it (alternative medicine) could not be woven into the fabric of the medical curriculum without confusion, contradiction, and an undermining of the scientific foundation upon which modern medicine rests."⁴

This is not rocket science. There is obviously a continuity of editorial opinion here that does not bode well for our brethren in chiropractic or other alternative health care researchers who wish to publish in NEJM and, most likely, in certain other journals. There may be more than a baton of stewardship that has been passed here from one editor to a successor. There's more than meets the eye. This is simply because both Angell and Relman have combined their households since 1993. They've become what a columnist for the Boston Globe has called "a quintessential Cambridge power couple."⁵

Thus, it is not surprising that such important and positive research as the Boline tension headache study,⁶ rated as the highest in scientific quality by two independent systematic literature reviews^7,8 and which FCER takes great pride in having funded, has been summarily rejected by the NEJM. (It took two years for the Boline study to be published, having finally and thankfully secured a berth in the Journal of Manipulative and Physiological Therapeutics.) The larger question remains: Who controls what information we receive, and by what rights are those privileges given? This seems to be a twisted inversion of the conventional notion that publication bias tends to discourage the printing of negative studies in favor of positive ones.⁹ Oddly enough, it was none other than Marcia Angell who said that journal editors should develop a formal editorial policy and base decisions to publish on the quality and logical reasoning by the authors - not the direction and strength of study results.¹⁰ My mind has been stretched here to the breaking point. Garp rules!

Complete and systematic literature reviews and meta-analyses would seem to be a brake against this kind of bias. Guidelines often emanate from such efforts, but cannot always be accepted at face value. Despite chiropractic's general adulation over the recently-issued U.S. and British government guidelines on low-back pain,^11,12 there are unfortunately too many jokers on the block. These include: [i] the AMA's not-so-subtle effort to reinterpret these guidelines in a version available in every commercial bookstore;¹³ [ii] a recent newsletter from Harvard Pilgrim Health Care, the largest HMO in Eastern Massachusetts;¹⁴ and [iii] a set of guidelines on "acute low back" very recently prepared for the Medical Health and Research Council of Australia by Nikolai Bogduk.¹⁵

What do these three publications have in common? They either delete or fallaciously discredit spinal manipulation as an option for managing low-back pain, despite the vast preponderance of literature, plus U.S.¹¹ and British¹² guidelines, which suggest otherwise. I suggest that by distorting or deleting the procedure of spinal manipulation, these three publications are a hair's breadth away from committing malpractice - based upon the principles of informed consent which were upheld in the New Jersey Supreme Court^16, and discussed in my column here previously.¹ Without our vigilance, Garp rules once more.

Or does he? How can this trend be reversed? What measures might be taken to put this house in order? A beginning is to try to come up with an assessment of journal editors' views and policies toward chiropractic research, intended to reduce the time lost to reviews with little or no chance of acceptance for publication. A second measure would be to identify means to access media other than the NEJM. A third might be to seek means by which the stronger case studies and case series gain adequate stature alongside the more traditionally-accepted randomized clinical trials. Sackett argues that clinical observations and the more constricted experimental data form the bases of truly informed and erudite clinical decisions.¹⁷

While this question cannot be easily answered, it will form the basis of an important forum ("Insuring the Integrity of Chiropractic Research through the Collaborative and Disseminative Stages") to be conducted at FCER's next International Conference on Spinal Manipulation, Minneapolis, September 21-24. We expect to have representatives from fields outside of chiropractic offer their insights into overcoming the obstacles to the dissemination of important research information. We also plan to extend this discussion into an open meeting. Please make every effort to attend. Do not hesitate to contact me with any comments or suggestions by email at rosnerfcer@aol.com .

References

1. Rosner AL. "FCER Forum: Matthies v. Mastromonaco, DO: The right to be informed, or research findings come home to roost. Dynamic Chiropractic March 25, 2000, 18(13).
2. Rosner AL. "FCER Forum: Tales from the crypt: fables of foibles, or RCTs that go bump in the night. Dynamic Chiropractic January 25, 2000, 18(3).
3. Angell M, Kassirer,JP. Editorial: Alternative medicine - The risks of untested and unregulated remedies. New England Journal of Medicine 1998;339(11):839-841.
4. Bunk S. "Is integrative medicine in the future?" Debate between Andrew Weil, M.D., and Arnold Relman, MD The Scientist 1999;113(10):10-11.
5. Shell, ER. Strong medicine. The Boston Globe Magazine, May 2, 1999.
6. Boline P, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amiltriptyline for the treatment of chronic tension-type headaches: A randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1995;18(3):148-154.
7. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: A systematic review of the literature. Spine 1996;21(15):1746-1760.
8. Kjellman GV, Skargren EI, Oberg BE. A critical analysis of randomised clinical trials on neck pain and treatment efficacy: A review of the literature. Scandinavian Journal of Rehabilitation 1999;31:139-152.
9. Dickersin K. The existence of publication bias and risk factors for its occurrence. Journal of the American Medical Association 1990; 263(10):1385-1389.
10. Angell M. Negative studies. New England Journal of Medicine 1989;321:464-466.
11. Bigos S, Bowyer O, Braen G, et al. Acute low back pain 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. December 1994.
12. Rosen M. Back Pain. Report of a Clinical Standards Advisory Group Committee on back pain. May 1994, London: HMSO.
13. AMA Editorial Board. AMA's Pocket Guide to Back Pain. New York, NY: Random House, 1995.
14. Acute low back pain. Best Practice in Brief [Harvard Pilgrim Health Care Clinician Education Program] 1999; 1(1).
15. Bogduk N. Evidence-based clinical guidelines for the management of acute low-back pain. Submitted to the Medical Health and Research Council of Australia, November 1999.
16. Jean Matthies v. Edward D. Mastromonaco, DO: Supreme Court of New Jersey [A-9-98], Pollock J, Judgment dated July 8, 1999.
17. Sackett DL. Editorial: Evidence-based medicine. Spine 1998; 23(10): 1085-1086.