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Wake Up – We’re in a Race for Scientific Ownership of Manipulation

Wake Up – We’re in a Race for Scientific Ownership of Manipulation

The Chiro.Org Blog


SOURCE:   Dynamic Chiropractic

By William Meeker, DC, MPH, FICC


For several years now, many have pointed out that our major clinical intervention, that family of procedures we call adjustments/manipulation, is no longer a “quack” remedy. That designation changed dramatically over a decade ago with the publication of the RAND appropriateness studies, the AHCPR guidelines on back conditions, and a fair number of randomized clinical trials.

Historically, those studies were very powerful in pulling manipulation out of the closet to where it now is – experiencing a great deal more exposure. As a result, we are seeing a renaissance of interest by osteopathic physicians and physical therapists. This in turn has led to a significant increase in the amount of research on manipulation by these professions. They are challenging chiropractic for pre-eminence in this field.

Professions, by definition, “own” their tools and their knowledge. This means that there is a cultural consensus in society that expertise in the use of professional knowledge is invested in a particular profession because that profession knows the most, is the most expert in, and can do the most good for the public with its unique tools. Lawyers know the most about laws because they make laws, study laws and apply laws. You wouldn’t go to a plumber if you had a legal case. Obviously, the situation is analogous for health care.

A citizen should not have any trouble deciding whom to consult for specific kinds of clinical expertise. But the situation for manipulation is becoming increasingly muddy, if the scientific publication record is any indication. We chiropractors do not enjoy an unassailable cultural consensus anymore when it comes to manipulation and adjustments. Chiropractors certainly have some authority by virtue of our history and training, but others are encroaching. We need to recognize that our authority in this area is under concerted and constant attack, and I fear that we may be losing ground.

First, a disclaimer: This is absolutely not an indictment of the extremely dedicated, highly skilled and largely underappreciated individuals who toil daily attempting to produce chiropractic science. I know these people, and they are special. And there are several chiropractic organizations that continue to fund research as best they can. There’s no doubt that significant sophisticated strides have been made in the past decade, including the advent of federal funding for research in some chiropractic institutions. The most recent ACC-RAC meeting has documented that development. But let’s face it, there are not many more people doing chiropractic research now than there were 10 years ago.

So … this is an indictment of this profession’s inability to grow its research enterprise. This is despite the fact that the need for research seems to be on everyone’s lips; how could you possibly be against it? But when it comes down to understanding just what it takes to make quantum leaps forward, there’s precious little to work with. We can’t even find jobs for promising young scientists in our institutions. Only a small number of grant applications are submitted to the National Institutes of Health, even though manipulation research is explicitly on their scientific agenda. [1] Our peer-reviewed scientific journals are in chronic financial trouble.

Here are some examples to illustrate why I think we are in a race for the professional ownership of manipulation. Look at what is coming out of the profession of physical therapy. Fritz, et al., [2] found that different classifications of patients with back pain benefited from manipulation or other approaches compared to treating all back pain patients alike. Fritz, et al., [3] found six patient factors that, when present, predicted a lack of success with manipulation. The same group of researchers also found six factors that predicted the clinical success of manipulation. [4, 5] Patients without at least some of these factors did not progress as well. These studies and others are starting to refine knowledge about what kinds of patients are most likely to benefit from manipulation, knowledge that could greatly affect clinical decision-making and our ability to provide accurate prognoses for patients and payers. Another interesting study concluded that the audible “pop” is not necessary for a successful outcome of a high-velocity manipulation. [6] Physical therapy researchers are also looking at the side-effects of manipulation and whether they can be predicted, [7] at the reproducibility of spinal palpation, [8] and at the effects of manipulation on weight-bearing and iliac crest symmetry. [9] This is just a sampling. Physical therapists were also involved, as were osteopathic physicians, in the recently published UK BEAM Trial that found a mild but significant benefit to manipulation over that of “best care” in general practice. [10]

Osteopathic physicians are in this race, too. They have come together politically and financially to support a major research center, which has successfully been awarded several grants from the NIH’s National Center for Complementary and Alternative Medicine to focus on osteopathic manipulation. A dedicated, skilled and highly motivated group of young osteopathic physicians is very serious about researching their approach to manipulation, and their contributions cannot be ignored.

One might say in alarm, what can we do to protect our scientific “turf?” The first thing to understand is that there is really no such thing as scientific “turf” that can be protected. It cannot effectively be defended by legal means or references to history and tradition. New knowledge is owned by those who produce it; thus, our only solution is to produce the most and the best knowledge about manipulation and related topics. This means that our profession’s research capacity must take a significant leap forward, and all chiropractors must understand and apply the fruits of scientific evidence.

This is easy to say, and I have said it for years. But it is a truly difficult challenge. It takes people with curiosity, knowledge, skills, motivation, time, and lots and lots of money. All of these things have always been in short supply. My opinion is that we must start and change our own professional culture. When the profession truly values research, and when our institutions and organizations understand the potential impact and deep responsibility they have, then the material resources are more likely to be found. I hope this happens soon.

We, at Chiro.Org are 100% in agreement with Dr. Meeker, and for the last decade we have donated 50% of our annual income back into chiropractic research, first through FCER, and now through the various chiropractic school research centers. We strongly recommend that every field doctor tithe a portion of your income to support research studies at the school level, because that’s where most of our infrastructure resides. The time for snoozing on the sidelines is over!

References:

  1. http://nccam.nih.gov/about/plans/2005/index.htm

  2. Fritz JM, Delitto A, Erhard RE.
    Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain.
    Spine 2003;28(13):1363-72.

  3. Fritz, JM, Whitman JM, Flynn T, Wainner RS, Childs JD.
    Factors related to the inability of individuals with low back pain to improve with spinal manipulation.
    Physical Therapy 2004;84(2):123-90.

  4. Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, et al.
    A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation.
    Spine 2002;27:2835-43.

  5. Childs JD, Frita JM, Flynn TW, et al.
    A Clinical Prediction Rule To Identify Patients With Low Back Pain Most Likely To Benefit from Spinal Manipulation: A Validation Study
    Annals of Internal Medicine 2004 (Dec 21); 141 (12): 920–928

  6. Flynn T, Fritz JM, Wainner RS, Whitman JM.
    The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain.
    Arch Phys Med Rehabil 2003;84:1057-60.

  7. Cagnie B, Vinck E, Beernaert A, Cambier D.
    How Common Are Side Effects of Spinal Manipulation And Can These Side Effects Be Predicted?
    Man Ther. 2004 (Aug); 9 (3): 151–156

  8. Childs JD, Piva SR, Erhard RE.
    Immediate improvements in side-to-side weight bearing and iliac crest symmetry after manipulation in patients with low back pain.
    J Manipulative Physiol Ther 2004;27:306-13.

  9. Billis EV, Foster NE, Wright CCT.
    Reproducibility and repeatability: errors of three groups of physiotherapists in locating spinal levels by palpation.
    Man Ther 2003;8(4):223-32.

  10. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomized trial: effectiveness of physical treatments for back pain in primary care
    British Medical Journal 2004 (Dec 11); 329 (7479): 1377


William Meeker, DC, MPH, FICC
Principal Investigator,
Consortial Center for Chiropractic Research
Davenport, Iowa

8 comments to Wake Up – We’re in a Race for Scientific Ownership of Manipulation

  • This is why chiropractic should not be defined as a ‘crack’. We are diagnosticians with many tools at our disposal in order to treat conditions, one of which may be the spinal manipulation. If anyone wants to distinguish themselves as the pre-eminent manual adjustor, or ‘cracker’, then they are missing the entire point of chiropractic

  • Alan Dinehart, DC

    Unfortunately, the Chiropractic profession does not ‘Own” manipulation. The Osteopathic profession is as old as the Chiropractic profession and has used Manipulation in their practice since its inception. Now, more and more occupations (PT’s, NP’s, PA’s…) are starting to utilize manipulation as one of their many tools. Our only hope of continuing to exist is to expand our scope into the realm of medicine and fill the gap in Primary Care.

    • Alan

      I beg to differ. Osteopaths used to be much more like us, in using SMT as a primary form of TX, but if you look at their curricula today, they only take about 25% of the hours that DCs do in SMT, and many of their schools now only offer SMT as an “elective”.

      Needless to say, this is because they chose the same path you recommend…that is, studying up on the allopathic model. As for the rest of those professions, I ask…how many hours did they invest in learning this complex manipulative ART, and who would YOU rather have check your spine?

      Wouldn’t you rather see someone who’s PRIMARY specialty is SMT, rather than someone who takes the occasional weekend seminar, with zero feedback, like we received while taking the same classes over a whole SEMESTER??? I say, better a MASTER of one, rather than a Jack-of-all, Master-of-NONE.

      If you want to offer medical services, that IS your right. But expect significant blow-back from organized medicine, for poaching, not to mention from the ultra-conservative DCs for “dilution”.

  • I have been in practice for over 33 years and most of my patients have been medical failures. We are able to help most of these patients whereas their medical doctors have struggled. We definetly need more restrictions placed on who can provide chiropractic manipulation and this comes from research and credibility.

  • karl

    Personally, I’ve been talking/writing about this for over fifteen years. Often I was looked at as worrying about something that didn’t/doesn’t exist. Well, physical therapists and their tight/driven association has goals to dramatically change their position/identity. This why they have this fast track program for obtaining D.PT. They will be major competition in the physical medicine arena. Why? They use language allopathes can put they can understand. And of course they’re in the system. They also, at least in philosophy instruct/prescribe corrective exercise and McKenzie of course. They also provide manipulation. Which is doing very well in the literature. We’ve been doing what physical therapists are doing now for years. But a perceived short coming is providing self care and corrective exercise. I think Craig Liebenson would agree with me. I read/cruise through physical therapy and osteopath journals at the Northwestern library. Often there’s info. about osseous/soft tissue manipulation.
    It’s true many osteopath students don’t take beyond minimal manipulation requirements. But I will say this,it’s becoming alittle more popular. I recently read in the osteopath journal where an medical officer D.O. was saying in an opinion article on how the military needs more osteopathes that have manipulation experience/skills.This D.O. did recognize chiropractors becoming available, but he mentioned the limited scope of practice as a short coming for chiropractors.
    This topic is especially interesting to me. I do think we need to understand and speak the language M.D.’s understand ie. kinetic chain, McKenzie, corrective exercise, evidence-based, outcome based, subgrouping.etc. We may or may not “own” manipulation but neither do the PT’s and they don’t own kinetic chain, functional movement, corrective exercise. We need to beat them at their own game.

    • Hi Karl

      PTs traditionally were an appendage of medicine, the garbage dump for patients unresponsive to drugs or surgery. It’s only natural for them to want to distance themselves from medical dominance and to carve out their own credibility as doctors.

      I was fortunate to take McKenzie (cervical and lumbar) in Liebenson’s rehabilitation diplomate program during the 90s. Several patients with severe radiculopathy stated that their PTs used McKenzie on them to no effect, but it turned out that whatever it was the PT did to them, it wasn’t even remotely like what I was taught.

      I believe that PT doctoral programs will not seriously harm our profession, because the underlying philosophy of their care will continue to rely on medical nostrums, rather than structural correction. All too often their patients fail to improve because they were being given exercises out of phase. If you have a sprained ankle, jogging is NOT the first treatment for recovery. DUH

      The one benefit of this external threat is what Darwin referred to as natural selection. Certain practices will close if they can’t provide a genuine alternative to medical, and now DPT care. But the Profession will continue and strengthen as it did in our early history. No therapy will ever challenge the benefits provided by a good adjustment to the right segment. To me, specificity means adjust the subluxation and leave the rest alone.

  • If every profession embraced manipulation then no one would be fighting .

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