Every so often, a neglected item sneaks in to wreak havoc with the order of things. We usually call such a phenomenon as being "under the radar." It is tempting to go a step further and refer to the more hidden, but more immediate beehive of activity. The activities are the more vivid events in their personal lives, which people fondly recall as being "under the boardwalk." This terminology is in shameless deference to Johnny Moore's immortal hit with The Drifters, which eventually landed that doo-wop group in the Rock n' Roll Hall of Fame.
And so it is with a very recent systematic review1 that seeks to address the shortcomings of randomized controlled trials, and many rating systems of their quality, for coming to grips with the nuances of both CAM and patient clinical encounters in general.2-4 It views a series of outcome studies through multiple lenses, comprising conventional approaches and one referred to as "whole-systems research" (WSR), which attempts to bring the evaluated research methodology into closer congruence with the paradigm of the investigated system - in this case, chiropractic care as it relates to non-musculoskeletal conditions.
As is true of boardwalks everywhere, regardless of preference (e.g., Coney Island, Atlantic City or the Santa Monica Pier), there is plenty of activity topside at which to witness and marvel. In the case of this systematic review, the new "gentler, kinder" way of ranking things through WSR includes such important and previously underrated elements in clinical research as:
The study is to be commended for having brought forth all these elements, as well as extending greater recognition to the weight and meaningfulness of observational and experimental studies, a finding that has recurred recently in the medical literature.5,6 It also has presented an extended and annotated account of non-musculoskeletal conditions, reaching into the osteopathic and physical therapy literature, as well as chiropractic, in documenting intervention. Consequently, it is able to cite upwards of 30 conditions for which responses have been reported, including the well-known conditions of dysmenorrhea, colic, enuresis, otitis media, vertigo, hypertension and asthma. It also includes items such as attention deficit disorder/hyperactivity, seizures, pneumonia, infertility, chronic obstructive pulmonary disease and constipation.1
The problem arises when one peeks below the surface, just as we realize how much carrying on there is under the boardwalk. The glaring example here is quite dramatic and involves three studies that were rated as "high quality," not only by two conventional scales (Scottish Intercollegiate Guidelines Network7 and Jadad Scale8), but also by the presumably more sensitive WSR scale. The unsuspecting reader would therefore most likely come away from this paper thinking that these three articles provided some of the strongest material yet for evidence-based medicine. As it turns out, nothing could be further from the truth: The dimensions of the problems in these studies are of such a magnitude that it largely invalidates their results.
Asthma Study: As I have described elsewhere,9 the trial used an inappropriate sham procedure (low-force manipulation of the scapular, gluteal and cranial areas, which elicited a positive response) and appears to have been underpowered. Of greater significance is the fact that only the procedure with higher force used in this study failed to produce an additional benefit under their experimental conditions. It should never be interpreted as a negative mark against chiropractic, as both the Cochrane review10 and the press have done. It also is questionable how generalizable the authors' finding may be, given that there still seemed to be a trend toward improvement in the manipulated group that didn't reach statistical significance.11
Dysmenorrhea Study: A closer look at the eligibility requirements of patients in this full-scale study reveals many departures from the pilot study, most likely in order to achieve sufficient recruitment for the full-scale trial, which was admittedly an arduous process. Patients often admitted having experienced no pain within the past 48 hours and did not have to forego exercises or NSAIDs for a blackout period prior to the trial. This was in contrast to what had been required in the pilot study, which had far stricter admission requirements. In the latter trial, only one practitioner delivered not surprisingly, the experiment delivered positive results.12 This was opposed to the lack of significant differences between the treatment and sham groups in the full-scale trial.13 Again, one could easily have been misled into thinking that manipulation conferred no measurable benefit for patients in this instance - a conjecture that is only reinforced by this study's top ratings in the WSR study.1
Colic Study: This trial failed to find substantial differences between the treatment and sham groups,14 unlike the other trials and cohort studies addressing colic.15-17
No mention was made in this particular study as to which region of the spine was manipulated. This turns out to be a significant piece of information. If the lumbar region, rather than the cervical region, was manipulated (as in the other positive studies15-17), all bets are off. This would turn the entire trial on its head such that its apparently negative outcome would be egregiously misleading.
The point here is that a comprehensive means for rating a study, and thus experimental evidence, still has a long way to go. The quality scale developed in this systematic review1 clearly did not encompass major problems in three of the highest-rated trials, which in my opinion, threatens to invalidate their results, relegating them to the level of being, at best, marginally useful. So even though one might suggest that there are privacy issues pertaining to our prying into all that is going on under the boardwalk, this level of "homeland security" surveillance and questioning is necessary if we are to effectively move forward in providing the best data for what we refer to as evidence-based medicine.
References
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
