For several years now, many have pointed out that our major clinical intervention, that family of procedures we call adjustments/manipulation, is no longer a "quack" remedy. That designation changed dramatically over a decade ago with the publication of the RAND appropriateness studies, the AHCPR guidelines on back conditions, and a fair number of randomized clinical trials.Historically, those studies were very powerful in pulling manipulation out of the closet to where it now is - experiencing a great deal more exposure. As a result, we are seeing a renaissance of interest by osteopathic physicians and physical therapists. This in turn has led to a significant increase in the amount of research on manipulation by these professions. They are challenging chiropractic for pre-eminence in this field.
Professions, by definition, "own" their tools and their knowledge. This means that there is a cultural consensus in society that expertise in the use of professional knowledge is invested in a particular profession because that profession knows the most, is the most expert in, and can do the most good for the public with its unique tools. Lawyers know the most about laws because they make laws, study laws and apply laws. You wouldn't go to a plumber if you had a legal case. Obviously, the situation is analogous for health care. A citizen should not have any trouble deciding whom to consult for specific kinds of clinical expertise. But the situation for manipulation is becoming increasingly muddy, if the scientific publication record is any indication. We chiropractors do not enjoy an unassailable cultural consensus anymore when it comes to manipulation and adjustments. Chiropractors certainly have some authority by virtue of our history and training, but others are encroaching. We need to recognize that our authority in this area is under concerted and constant attack, and I fear that we may be losing ground.
First, a disclaimer: This is absolutely not an indictment of the extremely dedicated, highly skilled and largely underappreciated individuals who toil daily attempting to produce chiropractic science. I know these people, and they are special. And there are several chiropractic organizations that continue to fund research as best they can. There's no doubt that significant sophisticated strides have been made in the past decade, including the advent of federal funding for research in some chiropractic institutions. The most recent ACC-RAC meeting has documented that development. But let's face it, there are not many more people doing chiropractic research now than there were 10 years ago.
So ... this is an indictment of this profession's inability to grow its research enterprise. This is despite the fact that the need for research seems to be on everyone's lips; how could you possibly be against it? But when it comes down to understanding just what it takes to make quantum leaps forward, there's precious little to work with. We can't even find jobs for promising young scientists in our institutions. Only a small number of grant applications are submitted to the National Institutes of Health, even though manipulation research is explicitly on their scientific agenda.1 Our peer-reviewed scientific journals are in chronic financial trouble.
Here are some examples to illustrate why I think we are in a race for the professional ownership of manipulation. Look at what is coming out of the profession of physical therapy. Fritz, et al.,2 found that different classifications of patients with back pain benefited from manipulation or other approaches compared to treating all back pain patients alike. Fritz, et al.,3 found six patient factors that, when present, predicted a lack of success with manipulation. The same group of researchers also found six factors that predicted the clinical success of manipulation.4,5 Patients without at least some of these factors did not progress as well. These studies and others are starting to refine knowledge about what kinds of patients are most likely to benefit from manipulation, knowledge that could greatly affect clinical decision-making and our ability to provide accurate prognoses for patients and payers. Another interesting study concluded that the audible "pop" is not necessary for a successful outcome of a high-velocity manipulation.6 Physical therapy researchers are also looking at the side-effects of manipulation and whether they can be predicted,7 at the reproducibility of spinal palpation,8 and at the effects of manipulation on weight-bearing and iliac crest symmetry.9 This is just a sampling. Physical therapists were also involved, as were osteopathic physicians, in the recently published UK BEAM Trial that found a mild but significant benefit to manipulation over that of "best care" in general practice.10
Osteopathic physicians are in this race, too. They have come together politically and financially to support a major research center, which has successfully been awarded several grants from the NIH's National Center for Complementary and Alternative Medicine to focus on osteopathic manipulation. A dedicated, skilled and highly motivated group of young osteopathic physicians is very serious about researching their approach to manipulation, and their contributions cannot be ignored.
One might say in alarm, what can we do to protect our scientific "turf?" The first thing to understand is that there is really no such thing as scientific "turf" that can be protected. It cannot effectively be defended by legal means or references to history and tradition. New knowledge is owned by those who produce it; thus, our only solution is to produce the most and the best knowledge about manipulation and related topics. This means that our profession's research capacity must take a significant leap forward, and all chiropractors must understand and apply the fruits of scientific evidence.
This is easy to say, and I have said it for years. But it is a truly difficult challenge. It takes people with curiosity, knowledge, skills, motivation, time, and lots and lots of money. All of these things have always been in short supply. My opinion is that we must start and change our own professional culture. When the profession truly values research, and when our institutions and organizations understand the potential impact and deep responsibility they have, then the material resources are more likely to be found. I hope this happens soon.
- Fritz JM, Delitto A, Erhard RE. Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain. Spine 2003;28(13):1363-72.
- Fritz, JM, Whitman JM, Flynn T, Wainner RS, Childs JD. Factors related to the inability of individuals with low back pain to improve with spinal manipulation. Physical Therapy 2004;84(2):123-90.
- Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002;27:2835-43.
- Childs JD, Frita JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004;141:920-928.
- Flynn T, Fritz JM, Wainner RS, Whitman JM. The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain. Arch Phys Med Rehabil 2003;84:1057-60.
- Cagnie B, Vinck E, Beernaert A, Cambier D. How common are side effects of spinal manipulation and can these side effects be predicted? Man Ther 2004;9(3):151-6.
- Childs JD, Piva SR, Erhard RE. Immediate improvements in side-to-side weight bearing and iliac crest symmetry after manipulation in patients with low back pain. J Manipulative Physiol Ther 2004;27:306-13.
- Billis EV, Foster NE, Wright CCT.Reproducibility and repeatability: errors of three groups of physiotherapists in locating spinal levels by palpation. Man Ther 2003;8(4):223-32.
- UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomized trial: effectiveness of physical treatments for back pain in primary care. BMJ 2004;329(7479):1377.
William Meeker, DC, MPH, FICC
Consortial Center for Chiropractic Research
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