Dynamic Chiropractic – July 30, 1993, Vol. 11, Issue 16

Ivory Tower Review

By Joseph Keating Jr., PhD
Description is the first task of any clinical science. If we wish to make the sorts of predictions and experimental tests which might enable scientific explanation, we must begin by describing the phenomena we are curious about.
Observation and replication-enabling descriptions of chiropractic phenomena are essential if others are to look and find the same stuff we do (or fail to find such). Who will observe and describe the chiropractic phenomena?

The early history of some sciences is marked by laborious efforts to carefully observe and describe nature. In biology, for example, entire careers were spent observing and classifying the many varieties of life forms found on this planet. The first biologists did not conduct experimental studies of life processes, yet their observations and descriptions were very worthy scientific tasks. Much of what we consider fundamental, background information in biology, the baseline from which modern experimental biology eventually evolved, must be credited to these early observers. Who will provide a similar template from which a science of chiropractic may evolve?

Who will provide the first detailed report of a patient with an uncomplicated case of low-back pain to undergo adjustive care? Perhaps we think that such would be superfluous, since "we already know chiropractic works," or because there are now several controlled trials of adjustive intervention in low-back disorders. Perhaps we feel that the oral tradition by which chiropractic students have learned to intervene in the health of low-back patients is adequate for our purposes? Would the acquisition of clinical chiropractic skills be easier if interns could read a detailed description of a low-back pain patient's progress during chiropractic care? Should the intern expect quick pain relief in all cases, some cases, no cases? Are there any consistent patterns between pain relief and changes in presumed mediators, such as articular dysfunctions, gross ranges of motion, and return of functional abilities? How will we share the nuances and intricacies of the chiropractor/patient interaction in such cases with those who do not train as chiropractors?

Do we think that chiropractic care may have value for patients with other sorts of health difficulties than low-back disorder and related neuromusculoskeletal (NMS) aches and pains? Why should anyone who has not gone to a chiropractor for help with a non-NMS problem believe that a back-cracker can help? Do chiropractors' manipulative interventions have any potential value for patients with asthmatic conditions? Why should I, a patient, think so? Are we satisfied with word-of-mouth to disseminate the potential benefits of chiropractic care? Why should a clinical scientist in another discipline put any stock in notions that adjusting the spine or moving the cranial bones or pressing on the sacral ligaments could influence hypertension? Are there any descriptive reports of such goings-on? Never mind controlled clinical trials, can the curious individual turn to a health science index (e.g., Index Medicus) and find a description of what happens when patients turn to spinal care to regulate cardiovascular functions? Surely, the nonchiropractor need not look far to find all sorts of extraordinary claims for chiropractic care, but is there anything more substantial to read (like a few good case reports)? Do we really think it's sufficient to dismiss such inquiries with repetitive assertions that it works, it works, IT WORKS!?

Where should the investigator who wishes to study the potential value of chiropractic interventions for patients with psychiatric disorders turn for a detailed picture of patients' progress under adjustive care? Does anyone seriously believe that the records of the Clear View Sanitarium can provide that baseline information? How will the curious scientist, who may wish to test the possible cause-effect relationship between the Gonstead technique and phobic responses, learn about the intricacies of such care? Does upper-cervical-specific adjusting seem to reduce confusion in some psychotic patients, but not in others? How may treatments are likely necessary to produce an initial arrest (14 consecutive dry nights) in a child who wets the bed chronically? Does adjusting sometimes seem to exacerbate grand mal seizure frequency in patients with epilepsy? Do we want to know about any possible untoward effects of chiropractic care, or would that be too risky politically? Is it true, as B.J. Palmer suggested, that the science of chiropractic was developed with printer's ink? Is there any real clinical and/or scientific value in reporting careful descriptions of what goes on in the chiropractor's office? Enuf said?

Who will observe and describe chiropractic phenomena? Who will write the case reports, the uncontrolled clinical descriptions that constitute the basic unit of communication in all health care disciplines? Who will carefully describe the patient's presenting complaint, health history, physical findings, diagnoses, treatment plans, and the patient's course under that rational plan? Who will take the time to conduct a review of the literature and place the progress of a patient within the context of whatever has previously been learned about similar patients under similar or different forms of care? Will we write such reports for the sake of prior authorization by some third-party payer? Will we write such reports for the sake of sharing clinical information with other doctors (of chiropractic, of medicine, etc.)? Will we write such reports so that other patients may benefit from the insights we accumulate in our individual practices? Or, is it enough that we've always heard that patients have been getting well for all 98 years of the chiropractic story? Does the front-line, down-in-the-trenches chiropractic clinician have anything of value to offer to the worldwide health science knowledge base (i.e., the periodic literature)?

Perhaps we believe that all the anecdotes and testimonials with which we have flooded the public are a sufficient descriptive base for the science of chiropractic. Perhaps we think that we already have more than adequate clinical material. Does the reader realize that the total number of case reports published in the first nine years (1978-86) of our strongest science journal (JMPT) was 39? If we could find just one percent of the estimated 50,000 DCs worldwide who would publish merely one quality case report per year, then we would annually realize more than 12 times the total number of descriptive case studies that JMPT produced in its first decade! Is it too much to hope that one percent of the chiropractic profession would engage in the scholarly activity of submitting case reports to our few quality journals? Does anyone think that publishing one quality case study per year would drastically interfere with one's practice, or that the conduct of case studies is impossible without major funding form the National Institutes of Health? Do we think that a PhD is required to prepare a case report? Is it possible that the gray matter needed to survive the chiropractic curriculum is inadequate to the task of describing what goes on in the chiropractic office?

Do we think that case reports are too trivial to bother with? Perhaps we've come to believe that the only sorts of clinical research that have any value are controlled trials that "prove that chiropractic works," and that case reports, which are usually nonexperimental, are therefore not worthy of our attention? Consider that in 1985, when the editors of the Journal of the American Medical Association elected to reprint 51 Landmark Articles in Medicine from its first century of publication, five of the 51 papers selected were case reports! High praise indeed for the lowly step-child of clinical research designs. Is the primary purpose of research in the science of chiropractic to "prove chiropractic works" or to improve the quality of care that chiropractors provide to patients? Do case reports have the potential of enabling us to improve chiropractic care?

What about all those "unusual cases" we hear about so often in the profession? How about the "remarkable responses" and "dramatic cures" that are passed around as folklore among chiropractors? Should such phenomena remain in the status of gossip and testimonial, or should someone (especially the DC witness) write them up carefully and send them to a credible journal? Do we anticipate that someone will one day conduct a randomized, placebo controlled trial of that rare case or dramatic response? If the treating doctor doesn't take the time to report the incident, how will the rest of us know what to believe? Why, without our seminal descriptive report, would anyone be tempted to mount a major investigation? Do we want to know, or are we content with the folklore?

Who will write the case reports in chiropractic? Shall we wait for the medical community to write up our observations? Perhaps the statisticians will take care of this area of chiropractors' responsibility, and prove what we always knew was true: it works, it works, IT WORKS? If only we had more university-based chiropractic college, then the case reports would write themselves? Perhaps the full-time researchers at the National Institutes of Health will start reporting on clinical cases under chiropractic management? Perhaps Congress will authorize millions of dollars for case reports in chiropractic? Should the basic science instructors at our chiropractic colleges be required to publish descriptive papers about interesting chiropractic cases?

Who will write the case reports in chiropractic? Who is better suited to this work than the chiropractor?

Joseph C. Keating Jr., PhD
Portland, Oregon

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