David Chapman-Smith led off with a presentation about "The Science & Politics of Research - The Good, the Bad, and the Ugly." He related that the clinical experience of a profession is equally as important as scientific research. Unfortunately, in health care, research is often affected by politics, public relations and advertising. Hard science runs headlong into the fact that health care is soft science - predominantly an art. "Controlled trials were developed for agriculture, where all factors can be controlled, not health care, where many factors remain beyond control." Researchers and clinicians desperately need each other, and research must be more fully supported by the profession and networked into more interprofessional teams for quality research.
David Koch, DC, a former president of Sherman College of Straight Chiropractic who has lectured and written extensively on modern chiropractic philosophic themes, chaired a roundtable discussion on chiropractic philosophy. Among other things, he remarked that chiropractic philosophy is an ongoing process, and that much of the past chiropractic philosophic tenets represent "dogma," and are not representative of present-day chiropractic philosophy.
Meridel Gatterman, DC, MA, MEd, spoke about whether the "Subluxation Was Science or Science Fiction." She related the variety of subluxation definitions, depending upon the specific interests of different cultural domains. It is apparent that a single definition does not fit all. The researcher may not agree with the educator; an orthopedic surgeon would rarely agree with a chiropractor; and some definitions are affected by political /legal colorings. She concluded: "There are those who would prefer to lose the term subluxation altogether, treating mechanical back pain only, and those who wish to deal with subluxations only, ignoring any pathology that accompanies the subluxation." She felt that both groups tend to ignore the patient as a whole. Subluxation, as the primary lesion treated by chiropractors, must be recognized and kept in the context of the whole person, in the patient's interest. Subluxation, depending on the domain, can be science or fiction.
Jennifer Bolton, BSc, PhD, MA Ed, ILTM, FCC (hon), who is the director of research and postgraduate studies at the Anglo-European College of Chiropractic, spoke on "Facts and Myths" about clinical research. She discussed the role of evidence-based practice (EBP), which refers to the use of evidence, specifically from quantitative research data, to inform clinical decision-making, especially regarding the most effective treatment intervention.
While it is plausible that research and clinical practice should go "hand in hand," there is still no definitive proof that EBP improves the health of the patients, compared with "practice as usual." A major problem relying on EBP ideas in practice is that research on large groups does not necessarily apply to an individual patient, since clinical trials are often conducted in isolated and highly controlled conditions that ignore individual needs, the reality of patient acceptability of the proposed treatment, and, of course, the experience and intuition of the clinician.
It is possible that case reports may be more effective in changing clinician's minds, and there is a move on to combine case reports with the steps of EBP, creating an "evidence-based case report." There is an enormous gap between research and practice. As others at the ECU stressed, researchers need to communicate with clinicians and "Clinicians are part of the solution and not part of the problem." Dr. Bolton concluded that in the end, EBP is good for chiropractic, and has, in fact, arrived. It is the chiropractic profession's duty to educate itself about research methodology and make use of research for improving care for patients, instead of proving that it works for political expediency.
Walter Herzog, PhD, a full professor in the faculties of kinesiology, medicine and engineering at the University of Calgary, discussed "Vertebral Artery Mechanics During Spinal Manipulative Treatment: Myths, Misunderstandings, Science." He related the first study on vertebral artery mechanics during neck spinal manipulative therapy (SMT): "The stresses and strains experienced by the vertebral artery during neck manipulations are well within the normal range of motion of everyday movements, and therefore neck SMT does not put the vertebral artery at risk of mechanical injury, such as tearing and dissection, beyond the risk associated with head rotation and vertebrobasilar insufficiency testing" (Herzog W, et al. JMPT 2002;25:504-510).
Anthony Rosner, PhD, LLD, discussed his paper, "The Role of Homocysteine in the Early Detection of Spontaneous Vertebral Artery Dissection." He stated that a high homocysteine level is linked to the disruption of collagen and elastin of the arterial wall, and recommended that it would be a plausible, rapid and inexpensive procedure to determine homocysteine levels as a predictor of arterial fragility. Increasing folate and vitamin B12 might be expected to reduce elevated homocysteine levels, and therefore reduce the risk of spontaneous VAD.
I discussed the "myth" that "just adjusting" is not enough to completely alleviate the "subluxation." For years, I have stressed that since the spine is a passive structure, moved and supported by soft tissue structures, we cannot rely on just freeing up the articulation and automatically expect total spinal freedom. This subject would be a perfect study that some researcher could conduct - comparing spinal manipulation with spinal manipulation combined with a variety of soft tissue treatments. There are already some case studies proving this concept. Maybe a researcher who can combine his or her research with a clinician could create an evidence-based study.
Warren Hammer, MS, DC, DABCO
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