[Editor's note: We received the following letter to the editor approximately 10 days before the Florida Board of Governors voted against the formation of a chiropractic school at Florida State University. For more about the board's decision, read "Florida Board of Governors Votes Down Chiropractic School" in the March 12, 2005 issue.]
Due to your informative articles on the possible development of a chiropractic program at Florida State University (FSU), I have remained interested in this momentous topic. However, I have recently come across an article in the Atlanta Journal and Constitution (AJC) (Sunday, Jan. 16, 2005), that also points out a darker underbelly to the program's development.
The article is titled, "FSU Profs Shun Chiropractic," and the tone of the article clearly demonstrates the prejudices, paranoia and flat-out misunderstanding the medical, research and academia communities still have of chiropractic. "More than 500 professors, including the university's two Nobel laureates, have signed a petition opposing the school, and a handful have even threatened to resign rather than teach alongside what they consider a pseudo-science." An anesthesiologist from Oklahoma places chiropractic in the realm of meditation and prayer for healing, since "there's no more evidence for chiropractic than there is for any of these therapies."
The fact that lawmakers in the Florida Senate are standing by the chiropractic proposal says a lot about the progress that chiropractic has made in its tumultuous history. It is true that if the college proposal goes through, there will be doors opened for chiropractic research and continued validation. I believe that in a way, these critics are scared of these breakthroughs, and of the money that will be funneled away from their projects.
Chiropractors constantly get reminded of the battles that have been won, including: Medicare and insurance company acceptance, the AMA being found guilty of conspiracy, and VA hospital acceptance. These reminders usually occur in chiropractic journals, magazines and newspapers and allow us to pat ourselves on the back for a job well done. Let me remind other chiropractors, are you reimbursed at the same rate as an osteopath? Are there not medical doctors from outside the state of Florida trying to dictate the future of chiropractic education? How much bureaucracy does a veteran have to go through to be treated by a chiropractor at a VA hospital?
I recently have been reminded about how much chiropractic emphasizes "integration." My alma mater's alumni journal stressed this point from cover to cover. After reading the AJC's article, I really have come out of my integration stupor and realized there is a good percentage of the medical and scientific field who believe chiropractic is just as effective as shaking chicken bones over a person! How much do they really want to integrate with us? We really do need to wake up as a profession, get behind this college proposal, make our association leaders stand by it, and once the school is functional, allow the research to validate the miracles we see in our offices every day!
Charles C. Jakubczak, DC
Powder Springs, Georgia
Type 1 Versus Type 2 Errors
[Editor's note: The following letter to the editor is addressed to DC columnist Dr. Arlan Fuhr. The letter is in response to Dr. Fuhr's Dec. 16, 2004 column, "Two Types of Unproven Claims" (www.chiroweb.com/archives/22/26/08.html).]
Dear Dr. Fuhr:
You are quite right to state that either a type 1 error (error of assuming an intervention was successful) or type 2 error (error of assuming that an intervention was not successful) is still an error. Your article pointed out that assuming an intervention had no effect in the absence of proof is a problem. Only study and testing will provide the proof we need of success or failure of an intervention. As an academic or research discussion, these two types of error would seem to be on equal footing. You also noted that such type 2 errors have traditionally been made more by our outside detractors, but are increasingly being made by our own. All of this is quite true.
However, there is a very large difference in the practical application of error. Yes, there is a definite practical application of type 1 errors and it occurs with great frequency within chiropractic. Type 1 errors are used as marketing tools. On a daily basis, patients are subjected to potential or actual faulty claims of benefit for chiropractic care. Advertising is present in many forms of chiropractic media which supports the use of potential type 1 error claims. Entire practices and techniques are based on potential type 1 errors. Millions of dollars are spent in chiropractic offices annually on potential type 1 errors. Thousands of patients are subjected to and charged for techniques and procedures that at best are experimental and at worst are simply already known to be ineffective. Reports of findings designed to do nothing more than convince patients of the need for care are frequently based on type 1 errors. Patients are subjected to potentially injurious interventions based on type 1 errors. Our standing as a not-very-well-respected profession in part stems from too many type 1 errors.
Type 2 errors do not have this problem.
So, as an academic point, it would seem that making a type 2 error is just as bad as a type 1 error. But, in practical application, the type 1 errors have taken over many facets of chiropractic. This reliance on potential or actual type 1 errors has had a negative effect on patients' disposable income, insurers' opinions, legislators' perceptions and the public's overall trust in chiropractic.
Making more type 2 errors and fewer type 1 errors in the practical application of chiropractic would likely reverse many of these problems.
John McDaniel, DC, DACBSP
Mountain View, California
Going Beyond the Subluxation-Degeneration Model
Is the subluxation-degeneration model wrong? Can it really be the other way around, whereby degeneration of joint integrity leads to the majority of subluxations? This profession needs to seriously look at the evidence we are accumulating on this paradigm shift.
Let's start with something many of us in practice have no doubt observed when we follow a patient with known disc lesions over a period of years. How much reversal of the spurring and joint space narrowing do you really see over the course of several years of chiropractic care? Sure, these signs may stabilize or even mildly improve using most manipulative techniques, but honestly, how many of you in practice over 20 years can truly reverse these lesions over decades of care without a traction and biochemical approach to specifically address the joint lesion? A few of our techniques can restore A-P curves and reduce lateral deviations with enough coaxing, and these successes can lead to some disc restoration and facet regenerations. However, I believe we are just adjusting a symptom most of the time!
Look at the studies coming out from weight-bearing spinal MRI. We see discopathy like we could never imagine, and at epidemic levels in America! What happens when a disc is compromised? The answer is primarily local spinal instability. This leads to those sudden drop-to-your-knees pain cases we see all the time. These are generally due to a large shift of the motor unit or a new fissure opening in the annulus. The body desperately tries to avoid this by recruiting muscles to do the job of the disc, but this soon leads to spinal ligament thickening and calcification as an energy-sparing consequence. Nonetheless, this "fixation" serves a purpose by restoring the local stability. And what do we do? We go charging into the "subluxation" to improve mobility and alignment! We've learned the resulting increased range of motion fires improved levels of local proprioception to the brain, which overrides many of the brain pathways in the CNS and thus makes the area "feel" better. We know the fresh irritation stimulates renewed fibroblastic activity and thus perhaps accounts for some of the regeneration we might get. But we also can create counterproductive debris which may not all clear the area with the improved blood and lymph circulation. Thus, we have seen so many low-force techniques promulgate throughout the profession.
Next is our profession's research on subluxation-degeneration. A recent experiment fusing rodent spine with hardware and waiting for degeneration (this got us some interesting national exposure when PETA protested at the institution) has again failed to conclusively prove the model. The experiment created an artificial fixation, but hardly in a manner that would have occurred naturally. Some facet degeneration did occur, but this could also have been an attempt by the rodent to accelerate the healing process of the invasive surgery!
Instead, we should focus on what causes the disc and facet degeneration beyond subluxation. Could trauma be a major factor, such as whiplashes (motor vehicles and amusement rides) and falls (the passion of extreme sports)? We know many discs have low-grade occult infections in them, or autoimmune destruction. What is the source of these immune-related inflammations? We see vast amounts of congenital anomalies in the facets and discs, created from simple maternal B-vitamin deficiencies, especially folic acid. Do these anomalies promote degeneration by altering tissue regenerative properties? We see numerous nutrient imbalances, such as with vitamin C, play roles in disc and cartilage degeneration. The body will often shift these limited resources away from the spinal motor unit into more vital systems, such as arterial walls. It would rather have you flat on the floor with a blown disc than dead on the floor with a blown artery!
Dr. James Cox has pioneered a focus on the disc most of his career. I would like all of you to think of the disc first in any case that doesn't substantially clear up in a few visits. And don't expect to see these disc lesions on standard MRI; only weight-bearing MRI is capable of revealing the subtleties of an early, primary disc pathology. I want to see every spur on our X-rays as a cry out for help from the body to focus on the disc, even if it currently isn't a classic "clinical" disc. A stable desiccating disc can still blow up in your face any day, as easy as any quiescent volcano is capable! Use office and home traction techniques first, coupled with nutritional support for these joints. As a chiropractor, become a disc and joint expert. When you fix these articulations, you stop treating symptoms and get back to the roots of chiropractic by finding the cause of most spine pain in America.
I think it is very possible that the profession's continued division on what we are supposed to do as chiropractors goes right to this very concept. Our model of subluxation-degeneration has been a powerful force in even how our political goals and agendas evolved. Doctors, over a hundred years is enough! Let's show orthopedic and conventional medicine we can get people out of our offices much faster than we currently average. Yes, this model will require all the pure adjusters out there to learn nutritional protocols. It will take more than pop-and-pray maneuvers 20-50 times per patient. It will make us more worthy of the title, "doctor," by using the skills our colleges have been pounding into our heads. If we fix the cause of degeneration first, then the subluxation is at our bidding.
James Denito, DC
"I Implore and Challenge Our National Leaders"
I was intrigued to read the "Insider's Insight" column by Dr. James Edwards in your 1/15/05 issue regaling the success of the Trigon Blue Cross/Blue Shield suit. [See "Teddy Roosevelt and the ACA Lawsuits" in the Jan. 15 issue or online at www.chiroweb.com/archives/23/02/10.html.] I am afraid that all Dr. Edwards attempted to do was "put lipstick on a pig" and at the end of the day, all we still have is a big, ugly pig.
I was a member of the ACA from 1984-2003 and contributed several thousand dollars to the Trigon suit, so I did not just stand on the sidelines. In my opinion, the suit was a dismal failure and we wasted a significant amount of money that could have been better-spent positioning chiropractic as the number-one drugless health care profession in the country. Once again, our national leadership seems to be more interested in chasing after the pennies (i.e., back pain) while the dollars (i.e., health and wellness) sit on the table, ignored.
In his article, Dr. Edwards bragged about getting federal Blue Cross/Blue Shield coverage for chiropractic as a result of this suit. Whenever we have a patient come to our office with federal Blue Cross/Blue Shield, their insurance does not pay for exams, does not pay for X-rays, does not pay for chiropractic adjustments, and pays anywhere from $8 to $14 for physical therapy services only. Since I am a chiropractor and not a PT, I find nothing to cheer about in this supposed victory.
Where was our national leadership during the Vioxx/Celebrex/Bextra disclosure? We missed a perfect opportunity to not only jump on the bandwagon, but to drive it and let the public know that chiropractic has stood for safe, drugless health care since 1895. We should have communicated to the disillusioned American people that the drugs they had been taking are not the answer and that it is time to give chiropractic another look for safe and effective treatment. I, in fact, called both the ACA and the ICA the day after the Celebrex news came out, suggested such a tactic, and asked for a response. I have yet to hear back from either association.
I think it is time for a grassroots effort among chiropractors to demand better from our national leaders, and to make it clear to them that we will no longer join ineffective national associations. Our leaders fight among themselves to protect their sacred turfs. They try to legislate our way to popularity or litigate our way to better acceptance. These are failed strategies and it is time for a change. The great leaders of history (e.g., Jesus, Buddha, Ghandi, Alexander) had a vision and attracted countless multitudes of followers. I have been told by our state and national leaders that "as soon as we increase our membership and have the money, then we'll have a vision." It doesn't work that way! You need to be, then you'll do and then you'll have (thank you, Larry Markson). We should demand unity (without uniformity) so that chiropractic can speak with one powerful voice, and pool our limited resources.
We need a big vision and leadership in our profession to take us to the next level. I implore and challenge our national leaders to create that compelling vision and to lead us forward.
Elliot Eisenberg, DC