Dural Connection Internet
Edition Volume 5
Number 2
SOT Entering the 21st Century: Developing an Evidenced Base Approach
The relationship between research findings and actual practice in the clinical environment is something that has led to conflict in all fields of healthcare. Chiropractic is no different and often times there have been schisms between its research and clinical worlds. Ultimately research should be about helping the clinician develop the best, most effective, low risk, and high benefit diagnosis and treatment.
This struggle of developing an evidence base and having it embraced
by practicing clinicians is not independent to chiropractic or SOT.
For instance in the February 28, 2004 issue of the British
Medical Journal , Annette Tuffs discussed how, "Only
6% of drug advertising material is supported by evidence."
As far back as 1991 Smith
noted in the British Medical Journal that a considerable
number of covered medical services have limited research support.
This isn't about medicine bad - chiropractic good. This isn't about showing that medicine has its lack of evidence so that makes it okay for chiropractic or SOT to not be concerned with developing a greater evidence base. This is about being a part of an interdisciplinary healthcare continuum which will be accountable helping to build a strong evidenced based foundation for SOT practitioners, continuing the attempt by Dr. DeJarnette. Even chiropractic, in order to move forward into the alternative healthcare arena, will need to develop an ever growing and evolving evidence base to support the procedures we are using to help patients in our clinics or private practices. It is clear that chiropractic research needs greater financial support and a focused direction of study.
Major Bertrand DeJarnette, DC, DO, was a strong proponent of developing an evidence base to build the foundation of a method of care called Sacro Occipital Technique (SOT). While he apparently followed a "scientific" process to the development of the various aspects of SOT, he did not follow a process of sharing his statistical data, the design of all his studies, and explanations at all times leading to a clear biological plausibility. His authoritative nature, the biological plausibility he did share , and the consistency of the clinical outcomes for practitioners, has guided SOT to the position it has now in the field of chiropractic. The question is at this point in 2006 is,"Is that enough?" Or do we need to further develop, at the very least, a biological plausibility for ALL the SOT procedures we currently use?
Biological plausibility is the lowest form of evidence needed to propel a method of diagnosis or treatment. However even within biological plausibility there is a hierarchy of the information. That means that the opening step could be developing some rational why or how a procedure is employed for treatment or diagnosis. Then the next step would be determining has there been any corroborating studies that support that opening premise.
For instance, we might propose that a reflex or body reaction is due to a purported neurological pathway. The next step would be to ask, "Does this connection exist anatomically?" Then after it has been found anatomically we need to ask, "Just because it is there anatomically, are there any studies that support that these types of neurological patterns are actually taking place?"
Imagine that you want to travel to an imaginary town (point B) from where you currently live (point A). Someone without a descriptive map suggests that you could drive your car from point A to point B. The next step would be to determine if there are any roads that travel between point A and B. Then the step following would be to determine are those roads functional, is there high terrain so that I need a high terrain vehicle, or even do I have enough gas in my car for the drive?
The point is that while many SOT practitioners for many decades have found SOT protocols: diagnostic and treatment procedures, to be a helpful means to evaluate and treat, and ultimately leading to predictable outcomes. Regretfully there is a paucity of data or research to support many of the SOT procedures commonly taught and used clinically by SOT doctors; such as occipital or trapezius fiber analysis, category one crest or dollar signs, chiropractic manipulative reflex techniques (CMRT), and category one cranial indicators.
The irony is that while SOT has relatively minimal research and has limitations, such as protocols lacking biological plausibility, it is one of the highest studied chiropractic techniques. Comparatively we have quite a bit of data when compared to other chiropractic techniques. Yet that does not really help us when making a reasonable and "hard cold" self-assessment. According to a recent National Board of Chiropractic Examiners' "Job Analysis 2005" found that close to 50% of chiropractors in the United States practice some form of SOT. Logically SOT must be doing something to assist chiropractors achieve good patient outcomes, but without publicizing these SOT related outcomes, we are left with anecdotal stories.
Before we will ever have a hope of stepping proudly into the 21st century's era of evidenced based chiropractic and SOT, we need to take an account of where we are and what is "reality." SOT doctors and many other clinicians have confused the word research with investigations. While research does involve the word investigation it misleads doctors and students what actually is, and has been taking place with, SOT research. To say that SOT has "research" implies that there is solid biological plausibility, significant published peer reviewed high quality studies, and that the academic world acknowledges that there is some reason to consider and appreciate SOT's efforts in the research community.
For a clinician to be investigating various SOT procedures in their office with patients and then not publish these investigations in the peer reviewed scientific community prohibits that clinician from calling their efforts "research." It is personal investigation and nothing more. This is not to denigrate this worthy endeavor but we need to be very clear what is research, what aspects of SOT has research, and develop a path towards a positive future. Walking these paths we should acknowledge that SOT has methods of care that are unique in healthcare and can offer humanity methods of diagnosis and treatment that offers a low risk and high benefit. SOT doctors and their representative organizations are mandated humanistically to pursue research and publication so that future generations do not lose the gift we have been bestowed.
To move forward we need to ask ourselves some questions:
• Where are we?
• Where do we want to go?
• How do we get where we want to go?
Where are we?
We need to honestly acknowledge that with regard to SOT research we
are at the beginning. We have more than most chiropractic
techniques, as witnessed by some of our published studies. [See SOT
Compendium 1984-2000 or www.soto-usa.org SOT
Literature Section] However we need to note that:
(1) our research is not of extremely high quality,
(2) many of our methods lack biologically
plausible explanations, and
(3) internationally we do not have a clear research agenda to further SOT into the 21st century.
Where do we want to go?
Ideally we need to begin the process of insuring that our methods have some substantiated biological plausibility and acknowledge that we are in a process. We need to accept what we do not know as being a part of this process and accept that we might need to modify or expand what we have come to know as SOT. We need to improve the level of research that we are publishing and develop ongoing relationships with the research community. These research relationships will assist our publications and develop the necessary political connections associated with our literature helping SOT to gain credibility and acknowledgment.
How do we get where we want to go?
First we need to acknowledge this will take time, that we have years of work ahead of us, and attempt to develop a consistent vision of where we need to go internationally. It is not feasible to expect without a long-range goal that a focused forward direction can be achieved. We need to support those who are doing SOT research, sacrificing their time and efforts. We need to develop a research mentality that helps us make sure we know whether something has or has not been researched, so that we do not make empty proclamations about SOT.
But, it would NOT seem logical or prudent to stop using SOT techniques that have been used successfully for decades until research suggests otherwise. With only 0-2% of the research in on most of chiropractic and much of it not related to chiropractic techniques any definitive statement "for or against" is too premature. Since 2000 SOTO-USA has been in attendance and/or presented research at the major chiropractic related research conferences such as the ACC/RAC , ICSM, IRAPS, CCR, ICCR, and ICAMCP.
Our recent research conference exposure is a good start but not enough. We need to be present at all chiropractic and related interdisciplinary conferences worldwide where a platform for SOT can be achieved. We need to assist anyone who could attend these conferences with production of an abstract or study they would like to share. We need to gather all SOT doctors who have writing skills and encourage them to help write papers for publication. We need to begin the process of making sure our research efforts and funds are reaping adequate dividends. Lastly all SOT doctors and organizations need to work together with a common theme of furthering the growth of SOT, preserving its prominence in the chiropractic community and substantiating (or when necessary modify) SOT protocols we teach and use in our practices.