By Anthony L. Rosner, PhD, LLD.(Hon.)

Of what value is research? At one extreme there is a quotation in a publication from a recently dedicated modern art museum in Vienna which reads:

"Proof of the existence of information does in fact not exist in actuality, but is based on probability."(1)

And where does probability take us? Cynics would point out the recent defeat of Smarty Jones, the race-horse who went off as a prohibitive 2-5 favorite at the Belmont Stakes on June 5, 2004. In other words, probability is never to be confused with certainty, or as has been heard so often at the racetrack: There is no such phenomenon as a sure thing. At the other extreme is the quotation from the renowned science fiction author Isaac Asimov who once provided an answer to the following question: If mankind is capable of developing an elegant theory which appears to encompass all the information known to date, why is it necessary to perform the experiment? Asimov's answer: To convince the idiots.(2)

Between these two polarities is what we consider to be valid, empirical scientific information. This is the only means by which what chiropractors have performed can ever be reproduced, refined and appreciated by others. Indeed, research in the chiropractic profession was clearly lacking just 30 years ago such that in some quarters it was considered to be something of an oxymoron, "falsely conceived and rather clumsily executed...(with a text)...that should never have been accepted, on a subject that should never have been chosen, by (those) who never have attempted it." A depiction of chiropractic researchers? No, a description of George Gershwin's now immortal opera, Porgy and Bess, by the music critic Virgil Thompson.

On the subject of chiropractic research, I am both joyful and dismayed. Joyful, due to the exceptional strides that have been accomplished only within a short period of time to document with full scientific peer review much of what the chiropractic profession has performed in words and deeds over the past century.

Despite the fact that chiropractic has existed as a formal profession worldwide for over a century, most of what we consider to be rigorous, systematic research in support of this form of healthcare has emerged in just the past two-and-a-half decades. In 1975, Murray Goldstein of the National Institute of Neurological Diseases and Stroke concluded that there was insufficient research to either support or refute chiropractic intervention for back pain and other musculoskeletal disorders.(3)

Nearly 30 years later, we now can review with great satisfaction how back pain management has been assessed by government agencies in the United States,(4) Canada,(5) Great Britain,(6) Sweden,(7) Denmark,(8) Australia,(9) and New Zealand.(10) All of these reports are highly positive with respect to spinal manipulation. Now we could argue that chiropractic care, at least for back pain, appears to have vaulted from last place to first as a treatment option.

In just the last 20 years, at least 73 randomized clinical trials involving spinal manipulation have made their appearance in the English literature. Even more remarkable is the fact that the majority of these have been published in general medical and orthopedic journals.

These trials address not only back pain, but also headache and neck pain, the extremities, and a surprising variety of nonmusculoskeletal conditions. When spinal manipulation is employed, the majority of these trials have shown positive outcomes with the remainder yielding equivocal results. There are 43 trials addressing acute, subacute, and chronic low back pain with 30 showing us that manipulation is more effective than control or comparison treatments and the remaining 13 reporting no significant differences between treatment groups. None of these studies appears to have produced a negative outcome and none indicate that manipulation is any less effective than any comparison intervention.(11),(12)

Other major accomplishments?

1. The appearance of a variety of favorable systematic literature reviews;(13-15)

2. The establishment of the first federally funded chiropractic Center for Excellence at Palmer University by NIH's National Center for Complementary and Alternative Medicine in 1997;

3. The publication of the Headache Report by Duke University in 2001;(16)

4. The securing of over $10M in federal grants within the past decade when in 1991 this accomplishment was considered to be unlikely;(17)

5. The establishment of chiropractic services within the military; and

6. The historic signing of Public Law 107-135 on January 23, 2003, mandating the establishment of a permanent chiropractic health benefit within the Department of Veterans Affairs health care system.

Even more noteworthy is the efficiency of chiropractic research. When compared to the NIH budget of nearly $20B, the $10M investment in federal funds is substantially less than a tenth of 1 percent, which makes it less than a rounding error or, as a couple of wags have offered in the past--obviously, the federal government must believe in alternative medicine because it has given chiropractic researchers homeopathic doses of money to work with.

If you were to sum up my attitudes about how far chiropractic research seems to have come, I'd have to resort to a pithy quotation from a baseball hero that many of us grew up with: Yogi Berra. When asked as manager of the New York Yankees whether one his star players exceeded his expectations during a banner season, Yogi's remark was, "I'd say he's done better than that!"

So then why am I dismayed? I could share with you just one example out of many which typifies our problem. A recent report on workers' compensation claimants from Florida is particularly galling. It pointed out that for industrial musculoskeletal injuries, chiropractic care demonstrates lower costs and shorter durations in both reaching maximal medical improvement and return to work.

Incredibly, over the same seven-year period, the frequency of specific musculoskeletal related cases treated by chiropractors in 1999 was only 25 percent of the level seen in 1994 (the date that managed care was introduced into the Florida workers' compensation system).(18) In other words, just when access of workers to chiropractic care should be increased to result in significant direct and indirect cost savings (as previously shown by Manga) (19) we are witnessing precisely the opposite.

Chiropractic care seems to be getting squeezed out of the system. Look at the neighboring state of Georgia, in which chiropractic workers' compensation cost recoveries were just 0.8 percent of the benefits disbursed to physicians in 1997 and 1998.(20),(21) Again one suspects the exclusion of chiropractic services.

Is this paranoia? Not when you consider that, despite the wealth of its research information with such little funding, it has been necessary time and time again for the chiropractic profession to seek both legislation and legal recourse to achieve its earned recognition with the most meticulous of research, ironic in light of a recent report which shows that chiropractic practices in at least one locale can demonstrate that a higher percentage of its treatments are evidence-based than found in medical interventions.(22) Yet we still endure the opinions of past editors of such trusted sources as The New England Journal of Medicine who have debunked alternative medicine as "unscientific," often basing their own theories upon the same type of anecdotal evidence that they condemn in various branches of nonorthodox medicine.(23),(24)

Add medical journal articles on cerebrovascular accidents of questionable scientific validity(25-30) plus an onslaught of negative press regarding the safety of manipulation(31-36) that could only be described as approaching hysteria rather than reasoned discourse. The issue of stroke, alone, ignores a wealth of information which suggests that the majority of cerebrovascular dissections thought to produce stroke are brought on by spontaneous events rather than those associated with spinal manipulation.(37-39) Instead of abiding by false or incomplete information, we accordingly have to level the playing field instead of the patient. The only way that this can ever be achieved is through properly designed and conducted research.

Importance of chiropractic research:

As indicated earlier, the Department of Defense mandate, the Veterans Administration legislation, installation of outstanding practitioners on Capitol Hill, the Bethesda Naval Center, and Walter Reed Hospital would never have happened in the United States without the research efforts having been published in the peer-reviewed journals. On a worldwide basis, the issuance of 8 positive government guidelines and recent legislation recognizing chiropractic in France likewise could not have occurred without ongoing research programs.

In today's environment, the chiropractic physician has the responsibility to be able to understand and utilize chiropractic research. First, he or she must be able to explain the strengths and weaknesses of studies to insurers, potential collaborators in other health professions, and particularly to the patient. Secondly, he or she must rely upon research methods (at the case study level) in order to be able to maintain patient records which do not become a liability in cases of litigation--whether involving direct malpractice lawsuits or in offering testimony for other purposes.

As evidence-based medicine becomes more the rule in today's healthcare, the recent Medicare legislation and any other provisions of third-party reimbursement that can offer anything near equitable allocations for chiropractic services will become primarily dependent upon the research information that can be generated.

Such data, for example, must be able to distinguish chiropractic intervention from that provided by other manual therapists--such as osteopaths, physical therapists, manual therapists, physiatrists, bonesetters, orthopedists, and massage therapists. Clearly, this has a direct implication in being able to identify, preserve, refine and develop chiropractic practice in the future.

It is apparent, also, that only research can guide the physician as to the optimal forms of interventions, lengths and frequencies of treatment for specific conditions--which themselves need to be better understood in relation to specific types of patients in order to optimize the outcomes with maximum efficiency.

To add a sobering corollary: The only way in which risks to the patient perceived to have been brought on by the chiropractor may be reduced (other than by eliminating this perception altogether by abandoning treatment altogether, which in the final analysis does not necessarily abolish all risk to the patient) is if research is allowed to flourish and guide the physician in identifying components which may be producing problems. Obviously, in terms of patient care, the only way in which improvement in any of the health professions in treatment is ever going to be realized is through research.

Future trends in chiropractic research

It is remarkable to this date that all the recognition of chiropractic through its research has been accomplished with very little description having been provided of the type, number and frequency of what has most recently been described as nearly 300 chiropractic techniques(40) having been reported. In order to achieve parity with what are ordinarily uninterrupted reimbursements for medications which are routinely changed if they are unproductive or incur intolerable side effects, the effects of various frequency distributions of at least the more commonly applied chiropractic techniques will have to be studied in the near future.

In addition to the elegant neurological, electrophysiological, and histological attributes of both spinal manipulation and what chiropractors have historically referred to as the subluxation, one must also be aware of the importance of stress and the hormonal system.(41)

Already we have witnessed changes in cortisol levels following either massage(42) or manipulation;(43) the same was proposed for prostaglandins immediately following side-posture adjustments.(44) Since hormones play the role of chemical messenger and elicit an enormous range of physiological responses in and of themselves, their alterations following spinal manipulation may in fact provide an essential bridge for understanding the systemic changes which have been proposed for decades to be a consequence of spinal manipulation. Their study thus becomes mandatory if the actual mechanisms of spinal manipulation and its consequences are ever to be fully understood.

What would the future trends in chiropractic research indicate? In clinical research, one would assume that with the increasing reliability of observational research and the vulnerability and expense of the more fastidious randomized clinical trials that there will be a turn toward practice-based research in the actual setting of the doctor's office, together with renewed interest in case studies.

In terms of basic research, we should be able to understand not only at the tissue and cellular level but at the molecular as well in more precise terms what accompanies what chiropractors have defined as the subluxation, as well as the effects of manipulation. This is largely due to the fact that those individuals performing the current research represent many diverse fields in the biological, chemical, physical, and mathematical sciences. Indeed, such a convergence of interests gave rise to the birth of molecular biology and our concepts of DNA nearly 50 years ago, and it stands to reason that under the most favorable circumstances that chiropractic research could experience a similarly bright and dynamic future.

REFERENCES

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(2) Asimov I. Lecture at Dunster House, Harvard University, Cambridge, MA, May 1969.

(3) Goldstein M (ed): Monograph No. 15. The Research Status of Spinal Manipulation. Washington, 1975, U.S. Department of Health, Education, and Welfare.

(4) Bigos S, Bowyer O, Braen G, et al. Acute Low Back Pain in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, 1994, Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.

(5) Manga P, Angus D, Papadopoulos C, Swan W. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain. Richmond Hill, 1993, Kenilworth.

(6) Rosen M. Back Pain: Report of a Clinical Standards Advisory Group Committee on Back Pain. London, 1994, HMSO.

(7) Commission on Alternative Medicine, Social Departemente. Legitimization for Vissa Kiropraktorer. Stockholm, 12: 13-16, 1987.

(8) Danish Institute for Health Technology Assessment. Low-back pain, frequency, management, and prevention from an HTA perspective. Danish Health Technology Assessment 1(1), 1999.

(9) Thompson CJ. Second Report, Medicare Benefits Review Committee. Canberra, 1986: Commonwealth Government Printer, Chapter 10 (Chiropractic).

(10) Hasselberg PD. Chiropractic in New Zealand: Report of a Commission of Inquiry.. Wellington, 1979, Government Printer.

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(13) Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: A systematic review of the literature. Spine 21(15): 1746-1760.

(14) Kjellman GV, Skagren EI, Oberg BE. A critical analysis of randomised clinical trials on neck pain and treatment efficacy: A review of the literature. Scandinavian Journal of Rehabilitative Medicine 1999; 31: 139-152.

(15) Bronfort G, Assendelft WJJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headache: A systematic review. Journal of Manipulative and Physiological Therapeutics 2001; 24(7): 457-466.

(16) McCrory DC, Penzien DB, Hasselblad V, Gray RN. Evidence Report: Behavioral and Physical Treatments for Tension-Type and Cervicogenic Headache. Des Moines, IA: Foundation for Chiropractic Education and Research, 2001.

(17) Corporate Health Policies Group. An Evaluation of Federal Funding Policies and Programs and Their Relationship to the Chiropractic Profession. Arlington, VA: Foundation for Chiropractic Education and Re-search, 1991.

(18) Folsom BL, Holloway RW. Chiropractic care of Florida workers' compensation claimants: Access, costs and administrative outcome trends from 1994 to 1999. Topics in Clinical Chiropractic 2002; 9(4): 33-53.

(19) Manga P. Enhanced chiropractic coverage under OHIP as a means for reducing health care costs, attaining better health outcomes and achieving equitable access to health services. Report to the Ontario Ministry of Health, 1998.

(20) www.ganet.org/sbwc/about/

(21) Smith JC. email notice of August 11, 2000.

(22) Wenban AB. Is chiropractic evidence based? A pilot study. Journal of Manipulative and Physiological Therapeutics 2003; 26(1): 47 (Full text is online at www.mosby.com/jmpt.).

(23) Angell M, Kassirer JP. Editorial: Alternative medicine--The risks of untested and unregulated remedies. New England Journal of Medicine 1998; 339(11): 839-841.

(24) Bunk, S. "Is Integrative Medicine in the Future? Debate between Andrew Weil, M.D., and Arnold Relman, M.D." The Scientist 1999; 13(10): 1,10-11.

(25) Dalen JE. Is integrative medicine the medicine of the future? A debate between Arnold S. Relman, M.D., and Andrew Weil, M.D. Archives of Internal Medicine 1999; 159: 2122-2126.

(26) Lee KP, Carlini WG, McCormick GF, Walters GW. Neurologic complications following chiropractic manipulation: A survey of California neurologists. Neurology 1995; 45(6): 1213-1215.

(27) Bin Saeed A, Shuaib A, Al-Sulaiti G, Emery D. Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients. The Canadian Journal of Neurological Sciences 2000; 27(4): 292-296.

(28) Hufnagel A, Hammers A, Schonle P-W, Bohm K-D, Leonhardt G. Stroke following chiropractic manipulation of the cervical spine. Journal of Neurology 1999; 246(8): 683-688.

(29) Norris JW, Beletsky V, Nadareishvilli ZG, Canadian Stroke Consortium. Canadian Medical Association Journal 2000; 163(1): 38-40.

(30) Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: A population-based case-control study. Stroke 2001; 32(5): 1054-1060.

(31) Brody J. When simple actions ravage arteries. New York Times, April 30, 2001.

(32) Bill Carroll Show, CFRB 1010 radio, February 6, 2002, posted on the internet.

(33) Evenson B. National Post, February 7, 2002.

(34) Hamburg J, Medical Minute, WOR AM 710 radio, February 22, 2002.

(35) Jaroff L. Back off, chiropractors! TIME.com, February 27, 2002.

(36) A different way to heal. Episode of Scientific American Frontiers Public Broadcasting System telecast, June 4, 2002.

(37) Rosner A. Spontaneous cervical artery dissections: Another perspective. Journal of Manipulative and Physiological Therapeutics 2004; 27(2): 124-132.

(38) Rosner A. CVA risks in perspective. Manuelle Medizin 2003; 41: 215-223.
(39) Haneline MT, Croft AC, Frishberg BM. Association of internal carotid artery dissection and chiropractic manipulation. The Neurologist 2003; 9: 35-44.

(40) Cooperstein R, Gleberzon BJ. Technique Systems in Chiropractic. New York, NY: Churchill Livingstone, 2004.

(41) Rosner AL. Endocrine disorders. In Masarsky C (ed), Somatovisceral Aspects of Chiropractic: An Evidence-Based Approach. St. Louis, MO: Mosby, 2001, pp. 187-202.

(42) Field T, Henteleff T, Hernandez M. Martinez E, Mavunda K, Kuhn C, Schanberg S. Children with asthmahave improved pulmonary functions after massage therapy. Journal of Pediatrics 1998; 32(5): 854-858.

(43) Ali S, Hayek R, Holland R, McKelvey S-E, Bryce K. Effect of chiropractic treatment on the endocrine and immune system in asthmatic patients. Proceedings of the 9th International Conference on Spinal Manipulation, Toronto, Ontario, CANADA, October 3-5, 2002, pp. 57-58.

(44) Kokjohn K, Schmid DM, Triano JJ, Brennan PC. The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea. Journal of Manipulative and Physiological Therapeutics1992; 15(5): 279-285.

Anthony L. Rosner, PhD, LLD(Hon.) is director of research and education for the Foundation of Chiropractic Research and Education, www.fcer.org.