The recent successes enjoyed by the chiropractic profession have been encouraging. The latest example is the release of the AHCPR practice guidelines for acute low back pain, which stated that spinal manipulation as applied by chiropractors is a recommended treatment. Back in 1975 the National Institutes of Health published a monograph that concluded there was no evidence to support the usefulness of spinal manipulation. Since then, there has been a virtual explosion of clinical research that essentially demonstrates the value of spinal adjustments, especially when compared to other procedures for back pain. The trend will likely continue because many chiropractic clinical trials underway in the last five years are just now beginning to show up in print.
Take for example, among many projects, the RAND Corporation's collaboration with the Consortium for Chiropractic Research. They're in the midst of completing an effort mirroring the one for low back pain done several years ago. This new project is examining the scientific support for manipulation of the cervical spine. There are at least 14 randomized clinical trials of cervical manipulation, and they will be summarized in several publications. A multidisciplinary panel rated over 1,000 indications for appropriateness and this too will become a published document.
Among the self-congratulations, however, there needs to be a realistic assessment of where we really stand as a profession when it comes to defining a chiropractic discipline of knowledge. To that end, this columnist hope to make some provocative points. These should be seen as things to think about, and the solutions should be pondered by all.
There are some who say that we have studied low back pain enough, but there is virtually no data to support that chiropractic manipulation is effective for low back pain and related lower extremity radiculopathy. There is only the beginning of some promising data for treatment of subacute and chronic low back pain, and there is a paucity of data on long term outcomes. Comparisons with so-called "active" treatments (like tailored exercise programs) has yet to see the light of day. This is not to say that other things don't need to be researched. Recent chiropractic findings of clinical trials on asthma, dysmenorrhea, headache, and hypertension indicate the dedication of our research community in responding to the needs of the profession as a whole.
But interesting and serious arguments still exist over the dosage, frequency and duration of an adequate trial of manipulation. What about its preventive effects? And perhaps most interesting of all is, what technique works the best and why? This last point raises the main question: the difference between studies that have an impact of health services policy and utilization (research for chiropractors), and those that have the effect of improving individual clinical practice behavior (research for chiropractic patients).
Most of the experimental outcome research on manipulation has not involved chiropractors (although this trend is changing quickly). Some think this is important because they assume chiropractors adjust in a different and more effective way than nonchiropractors. Others think the differences are relatively minor and that the results of nonchiropractic manipulation are generalizable to chiropractic adjustments. The truth is difficult to discern, because most trials of manipulation have not described it in very much detail.
Most studies have been more than adequate to compare some generalization of manipulation to some other form of therapy, but there have been virtually no studies that have attempted to differentiate different forms of manipulation. The result has been to beneficially affect opinions of nonchiropractors about manipulation, but all those outcome studies had and will have virtually no effect on the clinical behavior of chiropractors themselves. Patients will be getting the care they've always gotten.
This is why there is a distinction between research for chiropractors and research for chiropractic patients. What we are seeing so much of is research for chiropractors, because it seems to vindicate what we basically thought to be true all along: that is that spinal adjustments lead to good patient outcomes.
What these studies do not do is improve chiropractic adjustive care for individual patients. Thus, there is a whole universe of questions that still need to be addressed. While most chiropractors in practice for a while settle on a few preferred techniques, the educational problem for chiropractic colleges and students is acute. What chiropractic techniques work the best for what kinds of patients under what types of conditions? What should be taught in the classroom and in seminars? Logic would suggest that all techniques are really not equal, although this statement is often heard. This columnist thinks that statement mitigates the effects of different opinions so that we can all get along better. But the truth is we don't really know, and it is something we should find out.
Researching the value of different chiropractic technique procedures is not a new topic. In fact, there are many efforts at assessing the various procedures that can be found in our own literature. These run the gamut from leg checks, to palpation, to surface EMG, etc. For example, the Mercy consensus document attempted to rate a number of procedures based on data and expert opinion. The Consortium for Chiropractic Research has published procedure quality assessments in its CORE proceedings for several years. Almost every issue of JMPT has a paper studying the reliability or validity of some chiropractic assessment method.
But the one thing that is singularly lacking is research on the bottom line. That is, does the application of any procedure during case management make a difference to patient outcome? For example, there is now a fair amount of research on the reliability of motion palpation. Essentially, results have been disappointing. While rates of examiner agreement are beyond chance on a grouped statistical basis, it has been difficult to show strong reliability for individual patients. Most studies suffered from understandable flaws, and there well may be good reasons for why low reliability has generally been found when it should not be.
Very few chiropractors have given up palpation because of these studies, even though these kinds of findings tend to throw doubt on the value of doing the procedure. Why? There is something missing from this research picture. Is there a difference between case management outcomes with palpation compared to case management without it? Intuitively, most chiropractors doing palpation think there is. What about other chiropractic diagnostic procedures? And what about different kinds of manipulation? Is side posture as effective as drop-piece? These kinds of questions have rarely been addressed in chiropractic (or medicine either).
This research will be hard to do. It requires randomized clinical trial designs and all the expensive manpower and resources that go with that kind of effort. We could do it, but the real challenge is attitude. Is the profession willing to change our clinical behavior if data suggests we should? If we have no willingness to improve our care for our patients' benefit, there is no point in doing the research. That would be a shame because a truly altruistic chiropractic discipline must assess it own methods for its own patients. After all, the reason chiropractic exists is to serve humanity, isn't it?
William Meeker, DC, MPH, FICC
San Jose, California
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