Dural Connection Internet Edition    Volume 4 Number 2


Can Our Chiropractic Techniques See the Road Aheadand Appreciate the Road Signs?

RE: Cooperstein R, Perle Stephen, “Condition-specific Indicationsfor Chiropractic Adjustive Procedures for the Low Back: Literature and Clinical Effectiveness Ratings of an Expert Panel” Top Clin Chiropr 2002;9(3): 19-29.

With the completion of two landmark papers, [1,2] which characterizepublished research studies and rate chiropractic technique procedures forlow back conditions, the study published recently in Topics in Clinical Chiropractic [3] warrants a review by all chiropractic technique organizations. Drs. Robert Cooperstein and Stephen Perle produced a summary paper from a 6-year study designed to characterize the quality and quantity of literature gathered foran expert panel, and rate various specific chiropractic adjustive procedures for common presentations of low back pain. They summarized that the “ratings for the effectiveness of chiropractic technique procedures are not equal. Those procedures that are rated the highest are supported by the highest qualityliterature.” [3]

I wish to share with you my interpretation of the study as a sacro occipital technique (SOT) practitioner interested in furthering SOT’s acceptance into the chiropractic community and ultimately improving patient health care. Aswith any study of this nature there will always be those dissatisfied withthe study, particularly those doctors identifying with a particular chiropractictechnique. The goal of anyone reviewing this study, in my opinion, shouldbe to determine where something can be learned, and how this information canhelp us, as a profession, to improve our work.

Panel Selection:

“The eight members of the expert panel that met in Chicago [1997] were chosen based on their broad knowledge of chiropractic technique procedures, active involvement in chiropractic leadership, and nonidentification with any system technique. They were balanced relative to academic and clinical representation, gender, philosophical orientation, and geographical location.” [3] There was, to my critical eye, a sincere attempt on the part of the panel to be open and unbiased throughout the evaluation process.

Literature Selection and Evaluation Process

They stated that, “We had expected a paucity of literature pertaining to some of the adjustive methods we had identified and that much of this literaturewould be of rather poor quality. We were not disappointed.” [3] “Althoughno doubt some relevant literature was missed, we believe the likelihood aresource was missed inversely proportional to its quality because the best materials were the most retrievable.” [3]

“Characterizing the literature by adjustive approach, there are manyarticles on [high velocity low amplitude] HVLA manipulation, many of themof high quality. We also see many articles on distraction methods, but feweron segmentally specific mobilization. Very little is available on other chiropracticadjustive methods, including mainstream procedures such as pelvic blocking,instrument-assisted adjusting, and drop-table methods.” [3]

“The expert panel did not, generally speaking, rate the clinical effectiveness of well-published methods more highly than methods that are essentially unstudied. For example, HVLA drop table adjusting and pelvic blocking were more highly regarded than instrument adjusting, even though there are dozens of (non-clinical) articles pertaining to the latter.” [3]

Obviously the expert panel had subjective opinions regarding chiropractic adjustive methods and it was noted in this study that, “we see that pelvic blocking and drop table methods are especially problematic, having achieved relatively high ratings [without] much [literature] support, suggesting a particular need for clinical research in that area.” [3] “In this project, we had to balance two concerns: panelist’s need to have enough expertise andknowledge about the procedures used by system techniques to rate their effectiveness,and yet not be so closely identified with any of them that even the appearanceof bias would exist.” [3]

Chiropractic Techniques Need to Justify Their Claims

“Claims by the proprietors of system techniques that their methods are ‘clinically validated’ must be carefully scrutinized because the proprietary jargon, theories, and treatment methods that do in fact distinguish them areusually unstudied, whereas the validated methods they use, such as side-posture manipulation and mobilization are in the common domain and are simply generic.” [3]

“Although some of the system technique advocates have been active inperforming and sponsoring research on their methods, attempts to validatethe clinical appropriateness of their favored methods might best focus moreon clinical outcomes and less on peripheral matters (e.g., modeling, forcesgenerated, the reliability of diagnostic procedures.” [3] Cooperstein andPerle firmly believe that “the responsibility to fund and assist in the conductof outcomes research into proprietary chiropractic techniques rests withthe owners of those techniques.” [3] They continue with the statement thatan acceptable model of health care “must be credat emptor (let the buyerbelieve in us). Under such a model a doctor who promotes a technique thatlacks any evidence of effectiveness might be accused of violating their dutiesto their patients [3,4]. Likewise, those teaching a technique who do notfund and conduct the research to test the safety and efficacy of their methodsmight likewise be accused of an ethical lapse. Carl Sagan has written: ‘Ibelieve that the extraordinary should certainly be pursued. But extraordinaryclaims require extraordinary evidence.’” [3,5]

Quoting Sackett, Cooperstein and Perle note, “Good doctors use both individual clinical expertise and the best available external evidence, and neither aloneis enough [3,6]. Evidence based medicine is the conscientious, explicit, andjudicious use of current best evidence in making decisions about the careof individual patients. The practice of evidence based medicine means integratingindividual clinical expertise with the best available external clinical evidencefrom systematic research.” [3,7] Cooperstein and Perle conclude, “Moreover,as so many have said, lack of evidence does not constitute evidence of lack.”[3]

The Challenge to Chiropractic Techniques

The challenge to all chiropractic technique methods, and to SOT in particular for me, is that we must use clinical research to support, reject, improve, and/or delete those assertions and statements made in our literature and byour instructors. In other words, until we have produced sufficient evidence to justify our presumptions, we must be circumspect in what we state as “fact.” Clinical research is desperately needed to support our chiropractic techniques’ methods. Waiting for someone else to do this research is an exercise in optimistic futility.

If you personally are not going to sit down and write the literaturethen please consider supporting your technique organization, such as SacroOccipital Technique Organization (SOTO) – USA. For instance, SOTO-USA haspresented SOT-related studies at every chiropractic research conference thispast year, and is continually submitting papers to chiropractic peer reviewjournals. SOTO-USA has organized all the SOT-related research literatureto the year 2000, in three books: The SOT Compendium, The SOT Collection,and The SOT Collection: Supplement.

A few years hence, when someone undertakes a study of the magnitude of the Cooperstein & Perle review, I hope that there will be enough newly published SOT research to provide a more credible base for conclusions of efficacy. Hopefully, all chiropractic techniques will do likewise, with the ultimate goal of aiding patient care

Charles L. Blum, DC
[www.soto-usa.org]



References

1. Cooperstein R, Perle SM, Gatterman MI, Lantz C, Schneider MJ. Chiropractic technique procedures for specific low back conditions: characterizing the literature J Manip Physiol Ther 2001;24(6): 407-24.

2. Gatterman MI, Cooperstein R, Lantz C, Perle SM, Schneider MJ .Rating specific chiropractic technique procedures for common low back conditions J Manip Physiol Ther 2001; 24(7):449-56.

3. Cooperstein R, Perle SM, Condition-Specific Indications for Chiropractic Adjustive Procedures for the Low Back: Literature and Clinical Effectiveness Ratings of an Expert Panel Top Clin Chiropr 2002;9(3): 19-29.

4. Coulter ID The roles of philosophy and belief systems in complementary health care In WFC/ACC Conference on Philosophy in Chiropractic Education, 2000 Fort Lauderdale, FL: World Federation of Chiropractic: 2000, 1-10.

5. Sagan C, Broca’s Brain: Reflections on the Romance of Science New York: The Ballantine Publishing Group, 1993.

6. Sackett DL Evidence-based medicine Spine 1998;23(10): 1085-6

7. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996 Jan 13;312(7023):71-2.

Important Replys to this Dural Connection Internet Edition:

Dr. Robert Affolter
Dr. Gary P. Casper
Dr. Mark Filippi
Dr. Christopher Good
Dr. Cheryl Hawk
Dr. Kim Humphreys
Dr. Dana Lawrence
Dr. Thomas Milus
Dr. Robert Percuoco
Dr. Stephen Perle
Dr. Mark Pfefer
Dr. Reed Philips
Dr. Virgil Seutter
Dr. Igor Steiman
Dr. John Triano
Dr. Robert Ward
Dr. Ray Wiegand
Dr. Tim Young