Manual Healing Diversity and Other Challenges
to Chiropractic Integration

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

FROM:   J Manipulative Physiol Ther 2000 (Mar); 23 (3): 202–207 ~ FULL TEXT

Carl D. Nelson, DC, Daniel Redwood, DC, David L. McMillin, MA,
Douglas G. Richards, PhD, Eric A. Mein, MD

Carl D. Nelson, DC,
Meridian Institute,
1849 Old Donation Parkway, Suite 1,
Virginia Beach, VA 23454, (757) 496-6009

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Chiropractic has made significant strides in establishing itself as a leading contender for integration in the emerging health care system.  However, recent articles in prominent medical journals illustrate key issues that must be resolved for chiropractic to fully establish itself within the new health care model.  Manual therapy diversity and the corollary question of whether chiropractic care should be defined solely in terms of the high velocity-low amplitude (HVLA) adjustment, are issues in need of urgent attention and analysis. Other problematic areas affecting chiropractic's integration into the health care mainstream include research methodology issues, treatment of visceral disorders, and professional relationships.

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INTRODUCTION

Chiropractic has met many challenges in its development as a healing art.  Throughout most of its existence, the chiropractic profession has battled opposition from organized medicine, suffered financially as a result of exclusion from health insurance reimbursement, and been widely regarded as a marginal profession [1].  Despite these obstacles, chiropractic has flourished, becoming the third largest of the learned health care professions [2].  Although the quality and quantity of chiropractic research during the early years of the profession left much to be desired [3], modern research has contributed significantly to the success and acceptance of chiropractic.

With the rapidly changing political and economic aspects of health care delivery, chiropractic is well situated to make important contributions to the emerging health care paradigm.  However, to fully participate in this revolution, key issues must be addressed with regard to manual therapy diversity, research methodology, the treatment of systemic dysfunction, and professional relations.

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MANUAL THERAPY DIVERSITY

Chiropractic is one of the main branches of manual therapy. Historically, one of the major challenges of chiropractic has been to define and maintain its unique identity among the various manual therapy professions. This has often resulted in a competitive stance toward other forms of manual therapy.  Notably, the rift between chiropractic and osteopathy goes back to the founders of the professions, who openly debated the conceptual and clinical differences of their respective approaches [4].  Osteopathy has integrated a wide variety of modalities, most notably the practice of medicine, while chiropractic has remained primarily focused in the application of manual therapy.  While the role of manual therapy in osteopathy (osteopathic manipulative treatment or OMT) has decreased, the diversity of techniques practiced by osteopaths has increased. The minority of osteopaths who practice OMT utilize a broad spectrum of techniques including inhibitive pressure, soft tissue manipulation, and cranial/sacral treatment.

In chiropractic as well, the short lever high velocity/low amplitude (HVLA) thrust adjustment (typically associated with an audible cavitation or "cracking" sound) has been supplemented by a wide range of non-cavitating methods including flexion-distraction, sacro-occipital, Thompson, Activator, Applied Kinesiology, directional non-force, and dozens of others. Defining chiropractic strictly in terms of the HVLA adjustment fails to accurately describe the practice of contemporary chiropractic.

Historically, chiropractic has struggled with the dilemma of therapeutic diversity in a number of ways.  To some extent, the battle between "purists" and "mixers" continues to this day [5].  Some chiropractors offer a blend of diverse manual therapy techniques in addition to complementary and alternative medicine (CAM) options including nutrition, herbal medicine, energy medicine, and physiotherapy.  These DCs view themselves as chiropractic physicians qualified to address a broad range of disorders, including systemic dysfunction and visceral disease.  Many of these clinicians use methods from the full spectrum of manual therapy, including soft tissue manipulation. Other chiropractors limit their therapeutic methods to the hands-on adjustment but apply this method to both somatic and visceral complaints. Still others feel strongly that the role of chiropractic should be limited to treating somatic dysfunction, primarily back and neck pain.

Manual therapy diversity is more than an historical or academic issue.  Structuring research to reflect this diversity poses a significant methodological problem and, if recent, well-publicized studies are a harbinger of things to come, represents a potential major stumbling block to chiropractic's full integration into the mainstream of health care.

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ISSUES IN RESEARCH METHODOLOGY

Two studies reported in leading medical journals illustrate the potential methodological problems confronting chiropractic researchers.  In the New England Journal of Medicine, Balon et al. [6]  compared "active" and "simulated" chiropractic manipulation as adjunctive treatment for childhood asthma.

The active treatment consisted of "manual contact with spinal or pelvic joints followed by low-amplitude, high velocity directional push often associated with joint opening, creating a cavitation, or ‘pop’.”  This treatment is a standard direct technique used by a wide variety of manual therapy practitioners, primarily chiropractors and osteopaths.

The simulated treatment involved:

• "soft-tissue massage and gentle palpation" to the spine, paraspinal muscles, and shoulders
  

• "turning the subject's head from one side to the other"
  

• "a nondirectional push, or impulse" to the gluteal area with the subject lying on one side and then the other
  

• with the subject in the prone position, "a similar impulse was applied bilaterally to the scapulae"
  

• the subject in a supine position "with the head rotated slightly to each side, and an impulse applied to the external occipital protuberance"
  

• "low-amplitude, low-velocity impulses were applied in all these nontherapeutic contacts, with adequate joint slack so that no joint opening or cavitation occurred"

Jongeward [7] questioned the appropriateness of the simulated treatment, noting that that standard chiropractic practice commonly includes soft tissue work. Furthermore, the sham treatment in the Balon et al. study bears a marked similarity to a traditional general osteopathic treatment [8–10].  The Early American Manual Therapy website provides easy access to several such examples from the traditional manual therapy literature [11].

The authors of the Balon et al. study summarized the simulated treatment by stating, "Hence, the comparison of treatments was between active spinal manipulation as routinely performed by chiropractors and hands-on procedures without adjustments or manipulation."  Apparently, these investigators were unaware of the early osteopathic works addressing asthma [8–10] and more recent literature on OMT for respiratory problems in general, particularly as cited in Osteopathic Considerations in Systemic Dysfunction [12]. The methodological limitations of the Balon et al. study with regard to manual therapy were noted by Richards et al. [13]. Balon et al. [14] responded that they were unconvinced by the evidence supporting the efficacy of the simulated treatment.

The results as reported by the researchers were, "Symptoms of asthma and use of ß-agonists decreased and the quality of life increased in both groups, with no significant differences between the groups."  Based on this equality of improvement, the authors concluded, "the addition of chiropractic spinal manipulation to usual medical care provided no benefit," [6]. In our view, this is unfortunate, because the data clearly indicate that the subjects in both groups improved after being treated by diverse forms of manual therapy.

Another article, reported in the Journal of the American Medical Association, also fails to accurately portray and interpret manual therapy diversity.  In certain respects, "Spinal Manipulation in the Treatment of Episodic Tension-Type Headache" [15] duplicates the questionable methodological choices in the Balon et al. study.  The researchers compared two forms of manual therapy for the treatment of tension headache.  The experimental treatment consisted of HVLA chiropractic adjustments and deep friction massage plus trigger point therapy (if indicated).  The subjects receiving this intervention were designated as the "manipulation" group.   The "active control" group received deep friction massage plus low-power laser light (considered not to be efficacious for tension headache).  Thus, as in the asthma study, one form of manual intervention was compared to another.

The researchers observed that "by week 7, each group experienced significant reductions in mean daily headache hours" and mean number of analgesics per day." But because both groups benefited equally from the diverse forms of manual therapy, the authors concluded that, "as an isolated intervention, spinal manipulation does not seem to have a positive effect on episodic tension-type headaches." [15, p. 1576]. Unlike the Balon study, this carefully worded conclusion is technically correct, though it would also have been technically correct to conclude that both massage and manipulation plus massage resulted in measurable improvements for tension headache sufferers.

Both the headache and the asthma studies were widely reported in the mass media as demonstrating that chiropractic fails to help patients with childhood asthma and tension headache. In our view, a more informative conclusion is that diverse forms of manual therapy appear to be at least mildly helpful for these conditions. Although the favorable outcomes could have resulted from chance or placebo effects, a reasonable person might also justifiably conclude that various forms of manual medicine can be helpful for these conditions. The diversity and potential validity of the full spectrum of manual therapy applications significantly confounds the issue.

Although less publicized, Nilsson [16] used the same methodology in an earlier study on cervicogenic headache (n=39). Standard chiropractic (HVLA spinal manipulation) was compared to deep massage, trigger point therapy and light therapy (control treatment).  The subjects in both the experimental and control groups showed notable improvement.  There was no statistical difference in the outcomes between the two groups. Ironically and disconcertingly, Nilsson specifically noted in this earlier article that, "the control group in the present study (massage/trigger points) is normally assumed to have some effect on this group of headaches."  He further noted the inherent methodological shortcomings of using such a group as a control: "Future studies need necessarily include higher numbers of experimental subjects, but should take care to use an absolutely inert control treatment (for example, low-level laser only)." [16, p. 440]  One can only wonder why Nilsson elected not to follow his own clearly stated recommendation, and instead used the same admittedly questionable methodology in the later tension-headache study.

Future research must seriously consider the full spectrum of diverse manual therapy options rather than assuming that some forms are ineffective and can therefore be used as sham treatments. Legitimate alternative methodologies exist, particularly direct comparisons of chiropractic procedures (allowing the full range of methods typically used by chiropractors in real-world practice settings) versus standard medical care. Some comparative studies [17–21] have shown chiropractic equal or superior to conventional medical procedures, with fewer side effects. If fairly constructed, future studies of this type will yield data that allow health practitioners and the general public to place manual therapy procedures in proper context. Comparing manual therapy to highly questionable placebos confuses the issue, and delays the advent of a level playing field [22].

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