Chiropractic Research: The Kid Stays in the Picture

More than 50 years ago, a relatively unknown actor named Robert Evans ran into trouble in the movies. A number of his fellow actors apparently wanted him thrown off the set during the making of a film. But the famous studio head Darryl F. Zanuck overruled this coup attempt with a quote that has reverberated through the ages: "The kid stays in the picture." And so, Robert Evans was able to go on, first as an actor, and then (more significantly) as one of the most successful producers in Hollywood history, who also happened to save Paramount Pictures from oblivion with such blockbusters as The Godfather, Chinatown and Rosemary's Baby, to name a few.

Admittedly, he hit a few personal bumps in the road, but that's not the main point. He ultimately prevailed and made the most of the opportunity that was handed to him from a higher authority. What if Zanuck hadn't prevailed or at least interceded? Chances are Robert Evans would have been a complete unknown and the seminal motion pictures quoted above never would have been made. Basically, Evans would have made the transition from "Who's Who?" to "Who's He?" and instead of having our gangster film genre elevated by the likes of The Godfather, we might still be watching reruns of The Untouchables.

But I digress. The reason all this might appear in a family newspaper about chiropractic is that the parallels which reflect the position of chiropractic in the glitzy and sometimes Hollywoodesque world of mainstream medicine are striking and worth examining. Had such highly influential detractors of chiropractic and alternative medicine, such as the former editors of JAMA and The New England Journal of Medicine, Morris Fishbein,¹ Marcia Angell,² Arnold Relman³ and the American Medical Association¹ been given free rein, chiropractic may very well have been run off the set in the same manner some of Robert Evans' fellow actors tried to have him banished from the movie lot. To extract a couple of choice quotations from prominent personages:

• Arnold Relman: "Integrating alternative medicine with mainstream medicine, as things stand now, would not be an advance but a return to the past ... most alternative systems of treatment are based on irrational or fanciful thinking."³
• H.L. Mencken: "That [chiropractic] pathology is grounded upon the doctrine that all human ills are caused by the pressure of a misplaced vertebrae upon the nerves which come out of the spinal cord ... in other words, that every disease is the result of a pinch. This, plainly enough, is buncombe. The chiropractic therapeutics rest upon the doctrine that the way to get rid of such pinches is to climb upon a table and submit to the heroic pummeling by a retired piano-mover."⁴

That the latter choice comment was made more than 80 years ago does not diminish the fact it was made by an extremely influential columnist from the Baltimore Sun, and its substance became a driving force for much of the anti-chiropractic sentiment which unfortunately exists even today.

The point is that chiropractic, like our hero Robert Evans, had to display some sort of credential and mettle to be able to stay on the scene. Its credentialing, educational standards and accrediting, licensure and practice patterns have all been elegantly presented elsewhere⁵ and certainly played a role in bootstrapping this form of health care to a more recognized position today. However, it is the objective, documented evidence we associated with research that has been the means by which chiropractic has been able to begin to claim a basis generally recognized as scientific. And, over the past 30 years in particular, the chiropractic community has benefited from what are still extremely limited resources, to be able to gain publication in (and readership of) no fewer than 20 non-chiropractic peer-reviewed journals. This fact alone should be an effective deterrent to those who insist chiropractors are not scientific because they have never been published in anything but the following chiropractic journals. (However, I unfortunately can't say "often," at least not yet):⁶

• Annals of Internal Medicine
• Medical Journal of Australia
• Manual Medicine
• Medical Care
• European Spine Journal
• Pain
• The New England Journal of Medicine
• Journal of the American Medical Association
• British Medical Journal
• Canadian Medical Association Journal
• Australian and New Zealand Journal of Medicine
• Canadian Family Physician
• Spine
• Journal of Orthopaedic Medicine
• American Journal of Physical Medicine
• Journal of Occupational Medicine
• Journal of the American Osteopathic Association
• Cephalalgia
• Alternative Therapies in Health and Medicine
• The Spine Journal

This, in turn, has helped build official recognition and acknowledgment of the effectiveness of spinal manipulation in guidelines published by government agencies in the United States,⁷ Canada,⁸ the United Kingdom,⁹ Sweden,¹⁰ Denmark,¹¹ Australia¹² and New Zealand.¹³

But, like Robert Evans, chiropractic did not arrive at this better state of affairs easily or overnight. Rather, its research, only 31 years ago, was considered by the National Institutes of Health (NIH) to be insufficient to support or detract from the effectiveness of spinal manipulation in patient care.¹⁴ Fifteen years later a report from a leading consulting firm still cited the virtual lack of federal grants for research pertaining to chiropractic, and implied that such support was not forthcoming.¹⁵ In just the past decade and a half, however, nearly $20 million in federal funding - still a drop in the bucket by medical research standards - has materialized, much of it stemming from pilot studies that were originally funded by the FCER. Now such federal agencies as the NIH, the Health Resources and Services Administration, and the Agency for Health Research and Quality have all weighted in with funds, with chiropractors holding types of grants from the NIH in particular for the first time in history only within the past five years.

Presentations by the FCER before both low-back and headache panels of the AHRQ (at that time, the AHCPR) have played an important role in helping to secure the recognition of recent research supporting the effectiveness of chiropractic health care in managing these common clinical conditions. In other areas, we can point to the demonstration projects of the Department of Defense to introduce chiropractic services into the military and a similar directive from the Veterans Administration to fully include chiropractic care in the U.S. veterans health care system. It can be argued these activities were facilitated, if not made possible in the first place, by the primarily modest research proposals the FCER has supported.

In this manner, then, the young, upstart actor - in this case, chiropractic - finally has begun to make its mark upon the research landscape ... with a long way to go. With the type of evidence that continues to appear in the medical journals and is able to attract grant funding from any number of sources, chiropractic will have nailed down a requirement for claiming a secure place in world health care systems. It will be that much harder to cast it out of the marketplace. In this manner, the kid not only will have survived the screen test, but also should be able to stay in the picture.

References

1. Wardwell WI. Chiropractic: History and Evolution of a New Profession. St. Louis, MO: Mosby Year Book, 1992.
2. Angell M, Kassirer JP. Alternative medicine: the risks of untested and unregulated remedies. The New England Journal of Medicine 1998;339(12):839-841.
3. Bunk S. "Is integrative medicine in the future?" Debate between Andrew Weil, MD, and Arnold Relman, MD. The Scientist 1999;13(10):1,10-11.
4. Hencken HL. Chiropractic. The Baltimore Evening Sun. December 8, 1924.
5. Chapman-Smith D. The Chiropractic Profession. West Des Moines, IA: NCMIC Group, Inc., 2000.
6. Complete references for specific articles are available on request.
7. 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.
8. Manga P, Angus D, Papadopoulos C, Swan W. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain. Richmond Hill, 1993.
9. Rosen M. Back Pain: Report of a Clinical Standards Advisory Group Committee on Back Pain. London, 1994, HMSO.
10. Commission on Alternative Medicine, Social Departemente Legitimization for Vissa Kiropraktorer. Stockholm, 12:13-16, 1987.
11. Danish Institute for Health Technology Assessment. Low-back pain, frequency, management and prevention from an HTA perspective. Danish Health Technology Assessment 1999;1(1).
12. Thompson CJ. Second Report, Medicare Benefits Review Committee. Canberra, 1986: Commonwealth Government Printer.
13. Hasselberg PD. Chiropractic in New Zealand: Report of a Commission of Inquiry. Wellington, 1979: Government Printer.
14. Goldstein M (ed). Monograph No. 15. The Research Status of Spinal Manipulation. U.S. Department of Health, Education, and Welfare, Washington, DC, 1975.
15. Corporate Health Policies Group. An Evaluation of Federal Funding Policies and Programs and Their Relationship to the Chiropractic Profession. Arlington, VA: Foundation for Chiropractic Education and Research, 1991.