Shaping the Future of Chiropractic Research & Practice
By Matthew McCoy, D.C.
During a recent discussion about the state of chiropractic clinical practice
and the scientific evidence supporting it, one chiropractor remarked that he
didn’t see any moral problems with “…a patient-initiated and
motivated course of continued manipulative care.” He reasoned that this
would be considered elective care, similar to buying a massage. To this chiropractor
an acceptable “sale” of this type of care is for the chiropractor
to say to patients when they have reached his version of MMI, “Some of
my patients enjoy the feeling of getting an adjustment so well that they come
weekly or monthly or whenever they like, similar to getting a massage. Although
getting an adjustment feels good, it is not the kind of care that our health
insurance system would or should pay for and thus must be paid out of pocket.”
There are other chiropractors within our profession that hold the opinion that
patients visit as needed based on the recommendations of the chiropractor. They
feel the benefit of the adjustment and learn how it affects their overall health.
Everyone is entitled to their opinion. But the real question is how are these
opinions formed and then how are they maintained and passed down to others?
The answers to these questions lie in the concept of worldview. Simply put,
a worldview is a set of foundational beliefs that may or may not be true or
may be held either self consciously or unconsciously. It is important to understand
that our worldview dictates our behavior and even our character. Groups of people
with certain dominate character traits and behavior come together to form cultures.
So a culture is really formed from these seeds of foundational beliefs and knowledge
about reality and depending on our worldview we could be carving out a world
that is something quite different from prime reality.
The colleague that I discussed above has a worldview of chiropractic based on
certain foundational beliefs that he holds. His chiropractic worldview is one
where subluxations have not been proven to lead to ill health effects or to
interfere with the innate intelligence of the body. Further, based on his chiropractic
worldview he has constructed a set of ethical imperatives that he believes should
apply to all chiropractors. So, because he believes that subluxations have not
been shown to interfere with health or innate intelligence, then all chiropractors
should refrain from telling patients about these concepts or recommending care
plans based on them.
What about other chiropractic worldviews? There is a chiropractic worldview
based on foundational knowledge about how the body works and how humans interact
with their environment. This worldview says that there is intelligence in all
matter and that, within living things, this intelligence is termed innate intelligence.
Some might call this innate intelligence within living things the process of
homeostasis. This worldview goes on to state that homeostasis is controlled
through the function of the nervous system, that interference may occur to the
nervous system and that this interference may affect the expression of the innate
intelligence in that person.
This chiropractic worldview says that this interference may or may not cause
symptoms, that the person may or may not be aware of the interference and that
the interference can be prevented, or if it already exists, can be corrected
or reduced. People who hold this, or similar chiropractic worldviews, tend to
feel a moral and ethical responsibility to educate the public on these views.
But is there evidence to suggest that this type of chiropractic worldview is
consistent with reality? Certainly we have evidence that homeostasis exists
and this is a worldview shared by more than just the culture of chiropractic.
The evidence that the nervous system controls and coordinates all functions
of the body is fairly compelling as well and is also shared by other professional
cultures such as physiology and neurology.
That brings us to the issue of the nervous system and the resultant interference
of human expression through the process of subluxation. Does that exist? The
debate regarding the actual existence of subluxation has died down to a large
extent. There are over 200 words to describe a subluxation and the term has
been around for centuries. Recent surveys indicate that the vast majority of
chiropractors address subluxations in their clinical practice and we have various
position statements from our colleges and organizations that attest to the central
prominence that subluxation holds within our chiropractic worldview.
Even outside our culture of chiropractic we find that other health professions
are making subluxation a part of their professional worldviews. We saw this
with the recent legal actions of the physical therapy community relative to
the HCFA lawsuit and we also saw it in the judge’s decision when he would
not allow the exclusive restriction of subluxation analysis and correction to
chiropractors. The judge felt that there was no compelling evidence to suggest
that only chiropractors should be able to care for subluxations. While they
may have a different term for it, go about reducing it a little differently
and apply similar or dissimilar attributes to it, we see it in the osteopathic
literature and their educational programs as well.
While there might be a few disbelieving chiropractors who continue to say that
there is no proof that subluxations exist, the real debate has shifted to the
clinical meaningfulness of subluxations. If a subluxation does exist and it
does interfere with the function of the nervous system and the expression of
human potential—how is that demonstrated clinically? Are these effects
consistent and repeatable? Further to this is the question of whether we are
able to consistently and effectively reduce or correct subluxations when we
do find them.
This is where we go from the black and white of homeostasis and neurological
control to the grayer areas of clinical meaningfulness. Let’s understand
that the shades of gray do not mean that evidence does not exist. In fact, much
evidence does exist to support such a chiropractic worldview, however it is
spread out over a vast expanse of studies and literature in several disciplines,
and no one has really taken the time or expended the effort to compile this
evidence in one place.
Perhaps the most significant research concerning the clinical meaningfulness
of the chiropractic adjustment can be found in the 1997 study by Blanks et al.
This study on self-rated health, wellness and quality of life published in the
Journal of Vertebral Subluxation Research, is significant for several reasons.
First, it is the largest study ever conducted in the history of the chiropractic
profession, involving 2,818 patients and over 150 chiropractic offices in four
countries. Second, the care intervals studied were from 1-3 months to over three
years, making it the longest study ever conducted as well. Third, and most significant,
is that the benefits of chiropractic care (improved physical and mental health)
were evident from as early as one month and showed continuing clinical improvements
over three years with “no indication of a maximum clinical benefit.”
In other words, these patients did not plateau but continued to show improvement
in their quality of life even after three years.
In another study involving the Blanks’ team that was published in the
Journal of Alternative and Complementary Medicine, they explored the dynamic
between wellness, health lifestyle practices and chiropractic. Following the
analysis of 2,596 patients, the authors concluded that patients under chiropractic
care tended toward practices associated with a positive health lifestyle, which
further led to reported improvements in physical and mental wellness.
Other studies have found improvement in the quality of life of patients under
chiropractic care. Coulter et al performed an analysis of an insurance database,
comparing persons receiving chiropractic care with non-chiropractic patients.
The study consisted of senior citizens over 75 years of age. It was reported
that the persons receiving chiropractic care reported better overall health,
spent fewer days in hospitals and nursing homes, used fewer prescription drugs,
and were more active than the non-chiropractic patients.
In a 2000 study, Rupert, Manello and Sandefur surveyed 311 chiropractic patients,
aged 65 years and older, who had received “maintenance care” for
five years or longer. Chiropractic patients receiving maintenance care, when
compared with U.S. citizens of the same age, spent only 31 percent of the national
average for health care services. There was a 50 percent reduction in medical
provider visits. The health habits of patients receiving maintenance care were
better overall than the general population, including decreased use of cigarettes
and decreased use of nonprescription drugs. Furthermore, 95.8 percent believed
the care to be either “considerably” or “extremely”
valuable.
In a 2000 study on attitudes of chiropractors in the United States, Rupert reports
that 79 percent of chiropractic patients have maintenance care recommended to
them, and nearly half of those comply. In an online survey with 3,018 respondents
by Miller in 2002, 62 percent responded affirmatively when asked, “Although
you feel healthy, would you follow your family member’s lead and visit
a doctor who focuses on wellness and prevention just so you can stay feeling
that way?” In addition to improved quality of life these studies, similar
to the Blanks’ studies, demonstrate that patients under chiropractic care
tend to make healthier lifestyle choices.
Two additional studies have addressed the issue of improved physical and mental
health of patients under chiropractic care. One of the studies by Holder et
al, published in the Journal of Molecular Psychiatry, consisted of a three arm
randomized clinical trial with two control groups (one of which was placebo
controlled). This was a single blind study utilizing subluxation-centered chiropractic
care implemented in a residential addiction treatment setting. A total of 98
subjects (14 female and 84 male) were enrolled in the year and a half study.
100 percent of the Active (chiropractic) group completed the 30-day program,
while only 24 (75 percent ) of the Placebo group and 19 (56 percent) of the
Usual Care group completed 30 days.
The Active group showed a significant decrease in anxiety while the Placebo
group showed no decrease in anxiety. The frequency of visits to the nurse’s
station was monitored during the course of the study and among the Active treatment
group only 9 percent made one or more visits, while 56 percent of the Placebo
group and 48 percent in the Usual Care group made such visits. This poor performance
by the placebo group suggests that the chiropractic care had no positive placebo
effect.
Treatment was five days per week over a period of 30 days, for a total of 20
treatment encounters. Therefore, a 100 percent retention rate was achieved in
a residential treatment setting using subluxation-centered chiropractic. The
possible mechanism for such a response is elaborated on in an earlier paper
by Holder et al published in the Journal of Psychoactive Drugs, in which they
describe the Brain Reward Cascade in relationship to vertebral subluxation and
its role in resolving (RDS) Reward Deficiency Syndrome.
The changes in quality of life, documented in numerous chiropractic studies,
are felt to have their foundation in physiological changes secondary to chiropractic
care and subluxation reduction. In a 2004 paper published in the Journal of
Vertebral Subluxation Research Hannon reviews nearly 40 studies that document
objective health benefits in subjects who are described as being asymptomatic,
normal or free from injury. These benefits included statistically significant
improvements in such things as:
Some of the most powerful evidence of the impact chiropractic has on health
is demonstrated in the literature showing a positive effect from chiropractic
on the immune system. This evidence includes studies that have shown: enhanced
respiratory burst, increased CD 4 counts, improvement in Crohn’s disease,
elevation of serum thiol levels, increased immunoglobulins and B-lymphocytes
and reduced cortisol levels in subjects under chiropractic care.
In a recent study that will hopefully lead to more of its kind, the effects
of long term chiropractic care on DNA repair was revealed. In the study by Campbell,
Kent, Banne, Amiri and Pero published in the Journal of Vertebral Subluxation
Research the team found that serum thiol levels (a measure of DNA repair activity)
were highest in the group with 52-312 weeks of chiropractic care. This study
has serious implications for patients and advocates of long term chiropractic
care.
Numerous other clinical and basic science studies provide support to segments
of the chiropractic profession that have developed a worldview of chiropractic
that expands on the narrow, symptomatic treatment of episodic musculoskeletal
disorders. This worldview drives their outward behavior and forms a culture.
This worldview is based on over one hundred years of anecdotal experiences that
chiropractors have had with millions of patients. The experience of chiropractors
is bolstered by the positive experiences of other types of “hands on”
practitioners and their patients over centuries. Adding to this empirical evidence
are the clinical and basic science research studies reviewed here along with
others that exist within the literature. This evidence forms the foundational
knowledge upon which a culture of vitalistic, performance-based chiropractic
builds its worldview.
In order for this worldview to gain further acceptance, additional extensive
research needs to be performed. Further, and just as critical—all of this
research must then be used to support a political and social agenda that drives
public policy in the area of health and human services. When consistent with
such a chiropractic worldview, these policy initiatives will expand the cultural
base that supports the positive and vitalistic portion of the profession. The
profession as a whole, and the patients and society we serve, will be the better
for it.
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