I found it ironic yet fitting that the June 17, 1994 issue of Dynamic Chiropractic had the Consumer Reports article directly above the article, "The Scandal of Poor Medical Research." Most of chiropractic's problems stem from poor research.
Not one of our (chiropractic's) commonly used systems for adjusting (techniques) have been researched thoroughly for effectiveness. Those of us who have been out of school for more that a year or two and are not brainwashed to believe in chiropractic no matter what, know that some chiropractic techniques for reducing subluxations and improving function are generally better than others. But we also know that those same techniques that are generally better do not work in some cases where the generally non-effective (or occasionally harmful) techniques do work, often with absolutely miraculous and undeniable results.
Here is a typical conversation on the subject:
"That's great but how do we explain it?"
"Well, I guess the other chiropractor fixed the subluxation that I didn't."
"Okay, but how come that technique doesn't work all the time?"
"I guess we (chiropractors) do not know how to find all the subluxations. No technique has all the answers."
"What can we do to improve our profession's ability to diagnose subluxations more accurately so we can pick the technique to use to treat people more effectively?"
"I guess we need to do more research."
"What kind?"
"Uh, uhm, I don't know. I am too busy in my practice. What do you think?"
Usually people get criticism at this point for not doing clinical research in their practice, but being too busy in practice is valid and acceptable. Research is mainly for the schools to be doing. What we need to do is direct the research in the colleges so they supply our needs in practice. I do not need to know chiropractic works on low back and leg pain which is what a general clinical study will show. I already know that. I need to know which technique to use on which type of low back and leg pain and I need to know if the low back and leg pain is being caused by something in the back, something in the neck (yes, the upper cervical people do fix lower back pain in many cases), or something in the feet or legs.
How do you make the determination if you just x-ray the lumbopelvic region? You cannot. What we need in chiropractic is full spine multiposition biomechanic research and a few technique specific clinical trials: not sectional spine biomechanic research and not general clinical trials. The spine is a single working unit. No one has a neck, mid-back, and lower back. We all have a spinal column-pelvis-skull that works together as a single unit.
I have seen much mention of Alf Brieg's research but not one writer seems to have gotten the gist of his research: The meninges act as an elastic stabilizer that attaches every part of the spinal column-pelvis-skull very intimately to every other part of the spinal column-pelvis-skull, making all the pieces work as a single unit. Looking at the parts separately is what has led the medical people astray and will be the death of our profession, not to mention setting mankind back over a century in understanding the human condition.
Clinical trials are what you do when you admit you have no idea how something works. They are what you do when you know something works with some people and doesn't work with or harms others. Clinical trails are what you do when you want to know if something helps more people than it hurts. Clinical trials are the lowest starting point. They need to be done but chiropractic has been a clinical trial since its inception. While it is undeniable that chiropractic helps some people, the results are decidedly mixed because the techniques used have been mixed.
The results of a clinical trial depend a consistent method and dose of treatment and a consistent objective means to measure results. Formal chiropractic clinical trials have been, and will always be, flawed unless we use a single technique applied consistently and strictly according to the rules of that technique for each trial. Also, there needs to be an objective measure of biomechanical change. Chiropractic adjustments affect the entire body so you have to measure full spine biomechanics to really understand any changes. If you do not think that is true or think it is too sweeping a statement then you need to review the research of Breig, Kabat, and many others who have objectively demonstrated this is so. These are the points of the article, "The Scandal of Poor Medical Research." To have one doctor in a study using Gonstead, another using Logan, another using Motion Palpation (editor's note: MP is not a technique, but a diagnostic tool which can be used with any technique), and another using God-only-knows-what in the same study is not a "chiropractic" clinical trial -- it is an undefined mishmash of spinal manipulation and an exercise in futility.
That type of nontechnique specific research is really undefined research. It tries to measure too many different things at once and will always give undefined results. Nontechnique specific research or undefined biomechanical research results have been the bane of chiropractic. Some methods of moving vertebrae move the vertebrae in different directions than others, therefore the results are different. We need research that tells us what direction to move what bone for what biomechanical condition.
That brings us to point two: research based on relief of symptoms. Many different things can cause the same symptom. This is a fact confirmed in medicine, psychology, chiropractic and every other study of the human body. So just doing a research project on the clinical effectiveness of spinal manipulation or adjusting to relieve headaches leaves the question of what is causing the headache unanswered and is also nonspecific research.
The answer to that question is important because it could be an aneurism, an atlas subluxation, a sacral subluxation, or any one of more than a thousand things. For chiropractic, we need a system that will tell us if the headache is biomechanically based or is coming from some other factor and the patient needs to be referred. If the headache is biomechanically based, where is the primary biomechanical problem: the neck, thorax, lumbar, or pelvic region of the spine? Maybe the problem is from an injury to the neck; maybe from an injury to the foot, and the patient needs a proper orthotic to get a headache recovery. Maybe they need a sacral adjustment. You will never know if you are only taking cervical films or even full spines in just the standing position.
For these reasons clinical research based only on the relief of symptoms without taking into account full spine biomechanics is doomed to the same failure nontechnique specific research is for the same reason but at the other end of the project. You never really know what you are treating. You know you want to relieve the headache but what do you treat to get the relief. Even technique specific research into a symptom is undefined. It only tells you how many people with headaches in that sample had the problem addressed by that technique. The relief could have come from curing the problem or shifting the biomechanical stress to another area. Maybe you improved the person's biomechanics or maybe you made the person worse overall. You cannot know which you did without objective full spine biomechanical measurements. Which measurements are needed will be determined by measuring everything and computing the results of pre/post-treatment x-ray analyses -- doing the research.
Nontechnique specific research based on relief of symptoms has and will continue to lead to the weekend courses the medical people are taking on spinal manipulation. Those courses just teach "move the bones" with no understanding of structure and function or what moving any given vertebrae will do to the rest of the spinal column-pelvis-skull. Those courses will lead to more harmful effects of spinal manipulation being publicized than anything. Those undertrained medical people will be banging people around willy-nilly with the hope that what they do gets people better. Many of them will quit after they hurt a few people because they can see they do not know what they are doing and do not want to accidentally hurt anyone, but many won't.
Breig's research shows how great chiropractic can be. His second book, Adverse Mechanical Tension in the Central Nervous System, introduces the concept that multiple sclerosis and ALS are primarily biomechanical problems and can be helped biomechanically if you help the person into extension. That is what some of us do. His third book soundly criticizes his own medical profession for using treatments he has soundly and undeniably identified as harmful; such as traction in spinal cord injuries. The traction separates the ends of the cord preventing healing and actually causing more damage in many cases.
We in chiropractic need to identify what is effective and what is not on an objective full spine biomechanical basis. The results will apply to our profession and the other professions. It must be done or our profession is going to die. Remember when that medical doctor in Los Angles caused a patient to stroke by doing an inappropriate adjustment (it had to be inappropriate if it caused the stroke)? The newspaper printed, "Chiropractic Adjustment Causes Stroke." We know the headline should have been, "Undertrained Medical Doctor Causes Stroke" but the public does not know the difference. Until we can define what we do with full spine biomechanical research we are going to be lumped in with these untrained people and be blamed for their malpractice.
Techniques that measure and compare biomechanical measurements on x-ray are on the right track. Techniques that compare the measurements in more than one position are even closer. But until the full spine is analyzed biomechanically in more than one position, so we can make objective biomechanical diagnoses, we are whistling in the dark.
I urge you to cut out this article and send it to your college president with a donation to be used only for full spine biomechanical research. Tell them to call me I have about specific projects ready and waiting to be done. (Jesse Jutkowitz, D.C., 433 New Haven Ave., Milford, CT 06460 203 878-4609.)
Do not harken too well to he who would tell you this system will not work. He would not feel safe if people around him grew strong. The wise man tests before he talks. The critic but follows the fad of a cynical and apathetic age. You have a right to your own opinion. This system works or it doesn't according to your own experience. Not all the authorities in medicine or chiropractic can alter the natural laws of the body.
This article does not promote any chiropractic philosophy or technique, but promotes the idea that proper research will lead to better understanding and better utilization of chiropractic by both doctors (medical, naturopathic, homeopathic, chiropractic, and all other doctors) and the patients who go to doctors for help with their health.
This article gives valid reasons for researching biomechanics and the effects of any treatment on biomechanics using full spine standing and sitting x-rays and objective biomechanical measurements as the tool of the research.
It is well established that the measuring of spinal biomechanics is repeatably objective. (See, along with other published studies, the award winner research of C. Hagino, M. McGregor, S. O'Connor, and L. Papernic, "Intra/interexaminer reliability of lumbar endplate and disc angle measurements for a broad spectrum of examiner skill levels and radiographic qualities.")
The questions are what to measure and what the measurements mean in the evaluation of responses to various treatments. While chiropractic most certainly cannot cure everything, if the adjustments are in the correct direction, chiropractic can do a whole lot more than most people, even most chiropractors, believe.
Jesse Jutkowitz, DC
Milford, Connecticut
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