The Price of Success

In a recent editorial in the ACA Journal of Chiropractic (Sawyer, 1994) the president of the American Chiropractic Association (ACA) offers further evidence that the chiropractic profession and the ACA in particular, are not yet ready to assume responsibility for the science of chiropractic. Dr. Sawyer refers to:

... the RAND Study, the British Medical Study, the Manga Report, and over 20 other studies that prove that chiropractic care is both effective and cost-effective ...

Presumably, the "British Medical Study" to which the ACA leadership refers is the report by Meade et al. (1990) in the June 1990 issue of the British Medical Journal, which was a controlled pragmatic comparison between unspecified chiropractic care and unspecified, hospital-based, outpatient physiotherapy for patients with low back pain. Of the three reports mentioned, this is the only one which included any original data. The RAND study (Shekelle et al., 1991a&b) and the more recent report by Canadian economists headed by Pran Manga, PhD are not original research, but rather offer reviews of previously published literature. Contrary to the ACA's implication, the RAND study did not review chiropractic trials per se, but rather evaluated the current literature bearing on the effectiveness of generic spinal manipulation (including but not limited to the segment-specific thrusts chiropractors prize) for patients with low back pain. The Manga Report, intriguing though it may be, was not a controlled clinical trial, and has been criticized for the standards of evidence it employed. (Economists may have different standards than do clinical researchers.) Neither of these papers "prove" nor sought to prove anything; rather, they sought to evaluate the current state of knowledge about methods and outcomes, some of which may be used by chiropractors and other health care providers. I am unaware of any prospective, randomized, controlled comparisons of health care costs for chiropractic vs. medical care vs. anything else, and therefore can find no justification for the assertion that the cost-effectiveness of chiropractic has been "proven." I challenge the ACA president to enlighten me in this area: where are the controlled, experimental data to support the claim that chiropractic care is cost-effective?

The ACA president is in error when he claims that these papers "prove that chiropractic care is both effective and cost-effective ..." Chiropractic care, whatever that includes, cannot be said to be effective unless the target (in Meade et al.'s study, back pain) is specified. The ACA would apparently take the seeming benefit for back pain patients of unspecified chiropractic methods relative to unspecified physiotherapy (Meade et al., 1990) and extrapolate to all the possible methods and all the possible health problems with which DCs may be concerned. The ACA offers us a panacea: chiropractic works! Chiropractic care is effective and cost-effective! This is chirobabble. Next time you have a toothache, try seeking help from a chiropractor. (Remember, the ACA president says chiropractic care is effective ... period! No qualifying what adjusting may help ... it just works!)

The ACA leadership ought to know better than to make sweeping claims like this, but it is apparently unwilling or unable to adopt the critical standards of the research communities in chiropractic and other disciplines. Several years ago at the Health Fraud Conference that we both attended in Kansas City, I had the dubious honor of publicly debating Dr. Sawyer's unsubstantiated claims for the value of spinal adjusting (not chiropractic care, but adjusting) for functional nocturnal enuresis of childhood. At that time there were no controlled studies of spinal adjusting for bedwetting (there are now: Leboeuf et al., 1991; Reed et al., 1993), but this in no way deterred the good doctor from claiming that private, unsystematic, unrecorded, uncontrolled, and unpublished "results" in treating young bedwetters justified the claim that adjusting relieves nighttime incontinence. Moreover, the ACA leader was quite willing to make this bold claim in a public forum, at a health fraud conference!

I have spent several very pleasant hours in Dr. Sawyer's company, and I find him to be an amiable, honorable man and a sincere advocate of the chiropractic profession. I single him out only because of his role as spokesperson for the world's largest chiropractic membership organization. Unfortunately, the ACA and its president lack a nonsense detector, and apparently no desire to develop one. The ACA's president is a representative of chiropractors who would like to see the profession recognized as a scientific health care discipline, but will not curb their tongues. That is the real "price of success," if by success we truly mean that chiropractic should develop into a first class health science and be recognized as such by the rest of the health care community and society at large. Instead, many of the profession's leaders (in the ACA, ICA, etc.) seem to think that if we simply insist that chiropractic works often enough and loudly enough, we will "prove" our point. In my opinion, it is this sort of scientifically irresponsible rhetoric which has driven some in this profession into the ranks of the equally misguided orthopractors.

I suspect that if chiropractors never collected another piece of research data but would refrain from unsubstantiated and pancea-like claims for the value of chiropractic methods, this profession would be in a much stronger political position. But when national professional leaders make claims such as those offered in the ACA Journal, they put a little more egg on our collective faces. And no matter how hard the members of the research community work (with minimal resources and very limited support from the ACA) it only takes a few ridiculous comments such as those noted above to destroy what little scientific credibility our researchers may be able to garner.

As it stands, however, the profession seems to be content with traditional politics, wherein anecdotes, testimonials, and private empirical experiences are offered as "proof." And, when a little bit of meaningful data is collected, our political leaders blow it all out of proportion to its content. The leadership seemingly doesn't know any better, and doesn't want to know. It is not accident that we do not advance chiropractors within the ranks of political organizations like the ACA based upon their scholarly prowess. As John J. Meyer, MS, DC noted in the same issue of the ACA Journal in which Dr. Sawyer's editorial appeared, the chiropractor-scholars in this profession are officially disenfranchised within the ACA. Full-time chiropractor-faculty members are prohibited from full membership, from voting privileges and from the right to hold office in the governance structure of the ACA (Meyer, 1994). Seemingly, the ACA does not believe that the critical thinkers among the chiropractor-faculty can be trusted to exercise their influence in the organization. The ACA seemingly does not want to exercise their influence in the organization. The ACA seemingly does not want to exercise the responsibility for the science of chiropractic which it has claimed (e.g., Keating, 1992, p.45). The profession covets the trappings of science, but are unwilling to accept the rigors that go along with scholarly status.

Russ, "the price of success" in chiropractic includes self-restraint, caution in making claims, and great humility about what we may be able to offer patients. Is the profession willing to pay this price? Is the ACA willing to exercise leadership in this area?

References

Keating JC. Toward A Philosophy of the Science of Chiropractic: A Primer for Clinicians. Stockton CA: Stockton Foundation for Chiropractic Research, 1992.

Leboeuf C, Brown P, Herman A, Leembruggen K, Walton D, Crisp TC. Chiropractic care of children with nocturnal enuresis: a prospective study. Journal of Manipulative & Physiological Therapeutics 1991 (Feb); 14(2): 110-5.

Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal 1990 (Jun); 300: 1431-7.

Meyer JJ. Letter to the editor. ACA Journal of Chiropractic 1994 (Sept); 31(9): 14.

Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuretic children. Proceedings of the ICA National Conference on Chiropractic and Pediatrics, October 1993, Palm Springs, CA.

Sawyer RE. The price of success. ACA Journal of Chiropractic 1994 (Sept); 31(9): 7-8.

Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brook RH. The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review. 1991a, RAND Corporation, Santa Monica, California (Document #R-4025/1-CCR/FCER).

Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Park RE, Phillips RB, Brook RH. The Appropriateness of Spinal Manipulation for Low-Back Pain: Indications and Ratings by a Multidisciplinary Expert Panel. 1991b, RAND Corporation, Santa Monica, California (Document #R-4025/2-CCR/FCER)

Joseph Keating Jr., PhD
Whittier, California