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Dynamic Chiropractic – November 30, 1998, Vol. 16, Issue 25

The New England Journal of Medicine Articles: Any Lessons to Be Learned?

By Louis Sportelli, DC
By now I would hope that every DC in the world has read about the findings of two research projects which appeared in the New England Journal of Medicine (NEJM). My optimism is showing. One study by Cherkin, et al. compared McKenzie treatment with chiropractic and an educational booklet; the Balon, et al. study dealt with childhood asthma. The "media" had a field day, with headlines ranging from "Chiropractic Doesn't Work" to "No Benefits for Asthma Shown in Chiropractic Study."

The Internet was deluged with opinions from the pundits who offered diametrically opposing points of view. There were those who denounced research in its entirety; others defended the research; still others defended research and chastised the researchers; while others know "it works," so why all the fuss about research findings. Many were simply asking, "What articles?"

The newspaper headlines were as clever and creative as even the best "White House spin-meister" could generate. Many denounced chiropractic as worthless; others cleverly suggested that this research project was definitive; while still others suggested major social policy involving insurance reimbursement should be crafted as a result of this one study.

By the time you will read this article, the dust will have settled, the furor will have calmed, and a new and positive discussion concerning the November Journal of the American Medical Association (JAMA) should be in full swing. We will deal with the JAMA in our next article, but for now a post-crisis evaluation of the NEJM might be in order.

There were several things which did come out of these less than complimentary articles from the prestigious NEJM. One must never forget the journal is owned by the Massachusetts Medical Society, which for years, under the influence of the now infamous Dr. Thomas Ballentine, was never a friend of chiropractic. Nonetheless, despite the opinions of the chiropractic profession, when an article appears in the NEJM, it is revered, reviewed and respected.

Many dispassionate observers, however, have begun to see the "tarnish" on this once sterling journal and are suspicious of disingenuous motives. One article suggested that this bastion of medical influence is succumbing to the critical mass of positive public and media acceptance reached by alternative and complementary providers and is using the NEJM as a "bully pulpit" to stimulate a negative opinion against chiropractic and alternative practices.

Perhaps the "knee jerk" reaction of the NEJM in its editorial denouncing any possible benefit which could arise from chiropractic services could and should be taken seriously by those who advocate its use without providing sufficient evidence, and by those who suggest there is no value to chiropractic irrespective of the evidence.

Another interesting discussion developing on the horizon is the challenge to the methodology of the research projects which attempts to "isolate" one specific item in the research project from the myriad of complex interactions that occur with each and every doctor-patient encounter.

Paradigms are changing. The once heralded "double blind" must be carefully looked to evaluate the complete patient encounter. The double blind study is designed to eliminate every possible explanation for the results except the one being tested. At best, this is not perfect; at worst it is almost impossible to match groups perfectly to eliminate all the alternative explanations.

The challenge to researchers of the future will be to design studies which will identify those more pragmatic studies that will tell more general information about the outcomes and less about what caused the outcomes.

Several researchers have viewed some of my comments about the need to "rethink" the double blind study as a naive diatribe against RCTs. Nothing could be further from the truth. Comments critical of the research studies in the NEJM were not directed specifically to these studies, but rather to rethinking the entire method and the kind of research studies which should be proposed for future investigations.

Others have stated that if the studies would have demonstrated chiropractic's superiority, the profession would have applauded the results. That may be true, but the fact still remains these particular studies fly in the face of all other studies and were flawed, which others more qualified in research methodology will challenge.

I doubt there will be many that will challenge the fact that conventional medical researchers often exhibit prejudice against complementary and alternative approaches. Alternative approaches are casualties of a double standard in studying alternative methods for treatment.

Well, several weeks have passed, the profession is still functioning, and patients are still coming to chiropractic offices to get their chiropractic care. Some patients may have greater insight than many would imagine with comments such as, "Well, Doc, I see they are at it again. You guys must be doing something right to make them afraid of you."

From experience I know that no single issue will "destroy" or "build" the profession. There are some who are fearful that the NEJM articles will eliminate or destroy the profession. Relax, they're just two more articles and two more research projects to learn from.

Some are calling for funds to do a media blitz, as if a one-time splash in the media will "eliminate all negative press" against the profession. A media blitz may only serve to call attention to the negatives of the studies rather than enhance the profession.

The irony in the negative press generated by the NEJM articles is that the news media and many corporations did not stop focusing on chiropractic. USA Today carried a full page advertisement for Mercedes Benz and chiropractic was mentioned. In a feature in the October 14th issue of USA Today, a story was written about the National Football League ("Body Maintenance Key to Longevity for Backfield Star") which described Emmitt Smith of the Dallas Cowboys and his "secret" of heading to his chiropractor for several hours of bone realignment. "I started doing this on a regular basis about four or five years ago," Smith said. "I believe what I am doing is what's helping me go on. I believe Warren Moon (Seattle's 41-year old quarterback) does the same thing." What could be more positive press?

The October issue of Sky Magazine included the article, "Who's Afraid of Back Spasms," in which chiropractic was mentioned. Better Homes and Gardens ran an article, "Back on Track: Battling Back Pain." Nothing new, but spinal manipulation was mentioned. The list goes on and on, but the important thing is to recognize that there is a recognition of chiropractic which is unprecedented during any other era in chiropractic. We have arrived! We have become commonplace in the consciousness of the media and public relations firms. We have now become targets for recognition, praise, jousting, and barbs from comedians to journalists. The more significant our profession becomes, the more attention it receives. To be ignored would be the most negative position possible.

What can we learn, what can we observe, and is there something we can do to become proactive in this ongoing quest for recognition and cultural authority? The answer is most assuredly, yes!

Mr. Irvin Davis, former PR consultant to the ACA, created an award for Emmitt Smith. A story which was done several years ago and the benefits of this effort continue on as evidenced in the USA Today article. The need for a long-term public enhancement and public awareness program has been suggested by Mr. Davis and many others who have viewed the chiropractic profession and our negative image. They have all concluded that a "long-term, systematic, ongoing program is the only solution." The problem is that this solution has no emotional appeal and no method of creating the same passion that negative press and legislation can create.

The irony of this solution is that it appears the only time the chiropractic profession will demonstrate anything but apathy is when a "crisis" is upon us. When reimbursement is taken away, as in the recent New Jersey debacle, or when negative articles or research projects appear in the media, suddenly there is a cry to fight back, boycott, litigate, or some other equally inappropriate call to action.

If there is a lesson to be learned from the recent NEJM article, it is that chiropractic is here to stay. No amount of press releases, no single research project, no piece of legislation, no anti-AMA propaganda, no self-proclaimed anti-chiropractic expert (Stephen Barrett) will destroy the profession. There has been critical mass reached in society for the value of chiropractic practice and the public has made its desires known. It is time to review our past performance and recognize that only one thing can destroy the profession and that is the loss of credibility in the eyes of the general public. The "court of public opinion" has been molded. Chiropractic and the entire alternative movement has gained significant ground. The public demands for chiropractic services are increasing and the benefits of our services are now under siege by those who may wish to see chiropractic destroyed.

Our challenge lies not in reacting to the NEJM or any other challenge of the moment, but how to generate and sustain the same kind of enthusiasm and commitment to act within the profession to build a systematic and ongoing program of positive promotion for chiropractic during times when there is no crisis. It is obvious we could really do it. The time is right; the information is clear; the receptiveness of the public is open; the media is listening and the profession is eager. Will it happen? Who knows, but one thing for certain: the New England Journal of Medicine is not going to do it for us. We should ask, "If not us, who? If not now, when?" And more importantly, "If no action, then what?"

Louis Sportelli, DC
Palmerton, Pennsylvania

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