Here's the problem with technique: It's the core of the manual skills one acquires for obtaining a professional degree in chiropractic, yet the word carries a stigma when debates ensue as to precisely how the T-word is to be incorporated into chiropractic teaching curricula. It's very much a lightning rod, just as the term subluxation has raised more than a few passionate voices in the past.
Even renowned authors have taken opposing viewpoints. Consider how the great mystery writer Raymond Chandler, out of Los Angeles, sized up the T-word: "The moment a man begins to talk about technique, that's proof that he is fresh out of ideas." Compare this to Ezra Pound: "Technique is the test of sincerity. If a thing isn't worth getting the technique … it is of inferior value." So, where does one go from here?
The problem isn't helped by the image – rarely deserved – of a technique developer flush with cash, posing as the highest bidder, gaining an inside track to a chiropractic teaching curriculum despite the lack of potential to make significant inroads in patient treatment. But what remains the top priority in chiropractic education is to put the most effective tools, both cognitive and manual, in the hands of students during their enrollment period at chiropractic institutions.
The difficulty is that in many instances, there has been evidence of an undercurrent of general disdain between chiropractic academia directed toward our chiropractic technique developers, and similarly, an overall sense of mistrust toward chiropractic academia by chiropractic technique developers and users.
Some chiropractic college departments have attempted to integrate chiropractic techniques by separating parts of a technique and integrating them into a whole "technique package," discounting how a part of said technique might relate to the whole enchilada. While it is evident that some chiropractic techniques may have made claims without substantive data, it is also obvious that there are positive aspects of chiropractic techniques that warrant greater study.
Working together, our chiropractic academics and technique representatives need to find avenues for greater cooperation in developing greater evidence, mutual respect and awareness of the appropriateness of given techniques, either partially or wholly. The concept is not unlike providing a suitable catalyst to lower the activation barrier, as envisioned by chemists for decades, in order to allow a reaction to proceed.
This is precisely why I took it upon myself to organize a workshop titled, "Enhancing the Integration of Chiropractic Technique, Academia, and Research," presented in March at the ACC-RAC 2013 conference in Washington, D.C. The structure of this presentation was to present the viewpoints of three technique developers / representatives (Dr. Arlan Fuhr on Activator, Charles Blum on sacro-occipital technique, and me representing applied kinesiology) and three researchers from academic institutions: Drs. Michael Schneider [University of Pittsburgh], Stephen Perle [University of Bridgeport] and Mitchell Haas [University of Western States].
Our goal was to lower this activation barrier produced by past biases and a few missteps, to achieve meaningful technique integration into a teaching curriculum. Moderator to the session was Dr. Robert Cooperstein, who has benefited from the dual perspectives of technique development and incorporation into a teaching program at an accredited chiropractic institution.
Before a packed ballroom at the conference, Drs. Schneider, Perle and Haas pointed out that the indicators for conditions such as back pain and headache used by chiropractors suffer from marginal reliability and validity. (As a note of encouragement and perhaps by contrast, I was able to point out that the reliability among three experienced diplomates in applied kinesiology, and validity as suggested by instrumentation of manual muscle testing of the middle deltoid muscle, was recently shown to be excellent.1) Schneider, Perle and Haas also outlined three requirements for a technique to be accepted: (1) clinical effectiveness of the treatment procedure; (2) determining comparative effectiveness of various treatment procedures; and (3) reliability and validity of examination procedures. They pointed out that there are instances in which treatment procedures may be clinically effective, while examination procedures within a technique system may be unreliable and invalid.
Representing the technique developers, Arlan Fuhr outlined a model first presented by Kaminski in 1987 to describe practices and procedures taught within a chiropractic curriculum, accounting for definitions, methods of observation, consistency of the science, and pertinent research.2 Fuhr stressed that key elements in any technique or instrument evaluation should include safety, legal issues, utilization, evidence, and support from a consensus process.
This point of view was largely echoed by Charles Blum from the perspectives of biological plausibility and weighing the evidence as he came to grips with the sacro-occipital technique (SOT). My own viewpoints emphasized that much in the manner of technique development needs to be added to the chiropractic curriculum in view of the observations that (1) the release of vertebral fixations by chiropractic adjustments may be largely short-lived;3 (2) the dose-response pattern of relief from chronic back pain by spinal manipulation appears to disappear from 4-12 weeks after the initiation of treatment if numerous adjunctive procedures (heat / ice, ultrasound, electrotherapy, soft-tissue treatments [massage and/or trigger-point therapy]) are omitted;4 and (3) important elements such as nutrition and the patient's psychological status have often been overlooked.
As moderator, Robert Cooperstein pointed out the need to recognize the difference between named and generic techniques, each representing the overlap of assessment and treatment procedures. Ways to bring techniques up to teaching standards are not a new issue, the topic having been embraced by the ACA Council of Techniques at least as far back as the early 1990s.
Long story short: It is very much in the interest of chiropractic institutions to provide a mechanism for recognizing and testing various techniques that attain a certain threshold of evidence supporting their safety, reliability, clinical effectiveness and utility. By the same token, technique developers must be able to recognize and adhere to minimum standards of rigorous research methodology in order to engage in productive dialogues with those academicians whose successful teaching ultimately will rely upon more advanced technique development. While a promising start to these discussions seems to have been offered by our recent ACC-RAC workshop, more intensive and detailed exploration of the topic is needed.
This is especially true in light of what seems to prevail nowadays as an axiom first advanced by Arthur Schopenhauer: "Every truth passes through three stages before it is recognized. In the first it is ridiculed, in the second it is violently opposed, in the third it is regarded as self-evident."
References
- Rosner AL, Leisman G, Gilchriest J, Charles E, Keschner M, Minond M. Reliability and Validity of Therapy Localization in Applied Kinesiology. Society for Neuroscience presentation, New Orleans, Oct. 13-17, 2012. Manuscript submitted for publication.
- Kaminski M, Boal R, Gillette RG, Peterson DH, Villnave TJ. A model for the evaluation of chiropractic methods. Journal of Manipulative and Physiological Therapeutics, 1987;10(2):61-4.
- Rosner AL, Conable KM, Edelmann T. Duration of effects of spinal manipulation as influenced by orthotics. Journal of Manipulative and Physiological Therapeutics, 2013. Submitted for publication.
- Haas M, Groupp E, Kramer DF. Dose-response for chiropractic care of chronic low back pain. The Spine Journal, 2004;4:574-583.
