For more than 114 years, chiropractors have struggled with the issues of cultural authority, identity, legitimacy and professional autonomy. Throughout these struggles, our profession has not merely survived, but also flourished because of the enthusiastic support of the patients we serve.As we face the uncertainty of health care reform, it is imperative we not succumb to the delusion that we can substitute political strategy for evidence. In today's evidence-based world, that just won't cut it.
A previous column [Oct. 7, 2008 DC] discussed the need to exercise caution when approaching the issue of evidence-based practice.1 Perhaps Baruss said it best: "If we are serious about coming to know something, then our research methods will have to be adapted to the nature of the phenomenon that we are trying to understand. The purpose of science should take precedence over established methodologies ... Similarly, belief in a universal, inflexible scientific method that can guarantee truth belongs to scientism. If one is authentic, one's effort to develop one's understanding by changing opinions into questions may cut so deeply that traditional research methods themselves are called into question and are replaced by others that serve one's purpose better. One may need to draw on the totality of one's experience and not just on that subset that consists of observations made through the process of traditional scientific discovery."2
Larry Dossey, MD, coined the word methodolatry to describe "[t]he obsession with a particular method of investigation and the willingness to disfigure a therapy to preserve the sanctity of the method of inquiry."3 In this context, "therapy" may refer to a profession as well as a treatment. Dossey correctly notes that the method of evaluation should be tailored to the clinical practice being evaluated, not the other way around.
Martin Young, editor of a chiropractic research journal, notes: "This entrenched attitude runs right through the medical world, as well it might, because the methodology was designed for and is perfectly suited to pharmacological trials. If it is not an RCT [randomized controlled trial], it is not worth considering. It has even proved the major stumbling block to clinical chiropractic securing MedLine indexation; if we published nothing but RCTs, it is likely we would have secured indexation some considerable time ago. I have nothing against the RCT, I have conducted them myself and will doubtless continue to do so; indeed we are publishing one herein. I am, however, pleased to announce that we are also publishing a literature review, a cohort study, an evidence-based case report, a qualitative investigation, a standard case report and a case challenge; a case report dressed up to get your diagnostic brain cells firing. Different questions, different methodologies. All appropriate, all contributing to the chiropractic knowledge base (and beyond), all clinically useful so long as the limitations are understood."4
A Double Standard
One flawed premise that has resulted in a cultural barrier to the broader application of distinctively chiropractic principles and methods is the belief that allopathic interventions universally enjoy strong research support for their safety and effectiveness. Chiropractic, along with other non-allopathic approaches, are dismissed as lacking scientific support. Thus, allopathic medicine has become the de facto standard and enjoys largely uncritical acceptance by policy-makers.
Pelletier wrote, "To provide a baseline against which to measure CAM, it is important to point out that as much as 20 percent to 50 percent of conventional care, and virtually all surgery, has not been evaluated by RCTs."5 An analysis was published in the journal Clinical Evidence.6 Of 2,404 treatments used in medical practice, 360 (12 percent) were rated as beneficial, 538 (23 percent) likely to be beneficial, 180 (8 percent) as a trade-off between benefits and harms, 115 (6 percent) unlikely to be beneficial, 89 (4 percent) likely to be ineffective or harmful, and 1,122 (46 percent) as unknown effectiveness. In other words, only 35 percent of conventional therapies were found to be beneficial or even likely to be helpful.
This isn't gratuitous medical-bashing; it's merely an acknowledgement of the current state of the art. We cannot allow policy-makers to demand a more burdensome standard for chiropractic than is demanded of allopathic medicine. On a level playing field, we will establish our rightful place in the culture.
Appropriate Chiropractic Research
The disease treatment model is ill-suited to chiropractic. Even if it were appropriate, we do not have the resources to investigate the effectiveness of every known chiropractic technique for every condition. What we can do is focus our limited resources on designs that are feasible, affordable and focus on chiropractic's unique contribution to society: a subluxation-centered wellness approach to human health. This requires a focus on the global benefits of chiropractic care on such processes as immune system function, DNA repair and oxidative stress, and somatic and autonomic nervous system function. Another important area is cost-effectiveness research, showing how chiropractic care saves money and results in improved quality of life.
A growing number of visionary chiropractic organizations are supporting chiropractic research. One study investigated the feasibility of monitoring immune status as a means of assessing physiological health to ascertain changes in patient health status. It was concluded that such an approach was feasible.7 This was followed by a pilot study evaluating the immune status of a small population. "This pilot study has provided some preliminary information regarding chiropractic care and possible links to immune status and improved aspects of health and quality of life. Limited numbers of subjects, however, preclude definitive conclusions. Larger studies, including ill and healthy populations, to investigate the parameters presented herein and others such as killer cell activity will be necessary to test the conclusions presented."8
Another study was a retrospective, case-control investigation that looked at serum thiol levels as a surrogate indicator of DNA repair and oxidative stress. The study noted: "Asymptomatic or primary wellness subjects under chiropractic care demonstrated higher mean serum thiol levels than patients with active disease and produced some values that were higher than normal wellness values."9
This study resulted in some coverage in the popular media, where it was reported: "Chiropractors collaborating with researchers at the University of Lund found that chiropractic care could influence basic physiological processes affecting oxidative stress and DNA repair. These findings offer a scientific explanation for the positive health benefits reported by patients receiving chiropractic care."10,11
These are baby steps in the right direction, but one thing is clear: If we are to secure our rightful place in society, we must produce the data to back our claims. How about you taking a small step in that direction by publishing a case report in a peer-reviewed journal or participating in a research project? It will make you feel good and help secure the future of the profession.
- Kent C. "Where's the Evidence for Evidence-Based Chiropractic?" Dynamic Chiropractic, Oct. 7, 2008;26(21).
- Baruss I. Authentic Knowing. The Convergence of Science and Spiritual Aspiration. Lafayette, Ind.: Purdue University Press, 1996, pp 40-1.
- Dossey L. "Mind-Body Medicine: Whose Mind and Whose Body?" Explore, 2009;5(3):127.
- Young M. "Methodological Madness." Clin Chiropr, 2008;11:171.
- Pelletier K. "Mind as Healer, Mind as Slayer: Mindbody Medicine Comes of Age." Advances, 2002;18:4-15.
- "How Much Do We Know?" Clin Evidence; available at www.clinicalevidence.com/ceweb/about/knowledge.jsp.
- Boone WR, Oswald P, Holt K, et al. Physical, physiological, and immune status changes, coupled with self-perceptions of health and quality of life, in subjects receiving chiropractic care: a pilot study. J Vertebral Subluxation Res, July 5, 2006:1-6.
- Boone WR, Oswald P, Holt K, et al. Long-term assessment of blood indices and immune panel profiling of subjects receiving chiropractic care: a pilot study. J Vertebral Subluxation Res, June 7, 2006:1-11.
- Campbell CJ. Kent C, Banne A, et al. Surrogate indication of DNA repair in serum after long term chiropractic intervention: a retrospective study. J Vertebral Subluxation Res, Feb. 18, 2005:1-5.
- "Chiropractic Influence on Oxidative Stress and DNA Repair." Medical News Today, March 7, 2005.
- "Doctors Crack Code on Chiropractic Care." April 27, 2005; available on Mercola.com.
Click here for previous articles by Christopher Kent, DC, Esq..