A profession-wide goal is to see the chiropractors and chiropractic students become better clinicians through consistently achieving quality clinical results for their patients.
But the research indicates most chiropractors are unwilling or unable to apply their research clinically. This may be because research tends to focus on only a part of a patient’s treatment and not the entire visit as a whole.
Consider the numerous studies of the lumbar spine adjustment. Some of these studies use double- and even triple-blind randomized controlled trials to isolate the lumbar adjustment. But in practice, before and after the adjustment there is usually an assessment protocol, soft-tissue work, acupuncture, or other intervention. This is then followed by reassessment. So the adjustment is normally studied in isolation in the lab, but it is only one of the many other ingredients involved in the typical chiropractic visit.
A recent article in the Journal of Complementary and Alternative Medicine concludes chiropractors are not doing a good job of taking research and applying it to clinical practice, saying “much remains to be done for chiropractors to routinely apply evidence into practice.”1
What is perhaps being misunderstood is that research in manual medicine is generally not as applicable as research in conventional medicine. For instance, conventional medical research finds a drug that works when studied in the lab and then it is applied directly by physicians when they prescribe it to their patients.
In manual medicine, the JCAM article above found “most chiropractors have favorable attitudes toward evidence-based research” but are unable to apply it.1 This is because the clinical patient visit is full of other intangibles and variables that have not or cannot be studied in unison.
Some critics of chiropractic and alternative medicine contend that any positive clinical results obtained are likely due to chance (i.e., the patient was likely going to get better regardless of treatment). The well-known researcher David Colquhoun, PhD, has explained the false-positive rate in most alternative medical research based on innate intelligence is likely to be higher than in regular research.
Colquhoun wrote an article in Royal Society Open Science, a follow-up to the popular paper “Why Most Research Is False,” written by John Ioannidis, PhD.2 The Ioannidis piece is one of the most downloaded papers in history and it outlines the many flaws that skew research results. Factors such as confirmation bias, sample size, P- values, and the source of project funding are presented as some of the major reasons why generated research is likely false or misleading. At one point, the editor of the Lancet, Richard Horton, spoke out in support of Ioannidis by saying, “Much of the scientific literature, perhaps half, may simply be untrue.”
How are DCs interpreting research?
Some weeks ago I quoted the Ioannidis article in a post to a chiropractic evidenced-based Facebook page. The post received staunch opposition and criticism from the research-based
DCs who read it. Later, of the 26 commenting chiropractors, not one agreed to be interviewed for this article, preferring not to share their thoughts outside the confines of the online group. Indeed, we may never really know what the consensus is on this subject because the researchers and DCs employed by the schools and institutions that generate research prefer to remain silent to protect their own interests. This is understandable.
Scott Haldeman, DC, MD, PhD, contends research does not always provide the answers and sometimes new research informs us that prior findings were misinterpreted or even wrong. He also says the issue is simply whether a clinician wants to practice the best possible care based on current knowledge and therefore be evidence- based, or practice according to personal beliefs.
Beliefs in practice
This is where things get tricky because sometimes clinical beliefs can change depending on the context of the situation. For example, my wife was recently pregnant with my daughter and she went into labor. At the hospital, they discovered she was only 2 centimeters dilated and they were short-staffed, so they advised us to go home and return later that night once labor had progressed.
We questioned this because we were concerned about exposure of the baby to infection. The doctor on call told us of a research study that concluded women could go into labor for three or four days without having an infection to pass to the fetus. We went home, and 24 hours later a beautiful baby girl was born. While at the maternity ward, they began extensive testing on the baby and my wife to rule out infection. They said the research stated that anyone who gives birth after 18 hours of their water breaking is at high risk of infection.
So which is it? Both doctors were correct in the research they quoted but had completely different guidance.
If we really want to be unbiased, shouldn’t we explain both sides of the coin to our patients? Or is it too cumbersome to say “These studies state chiropractic works for condition A, but these other studies state that chiropractic doesn’t help condition A.”
Haldeman says it is not possible for most busy clinicians of any specialty to be completely up-to-date with the literature and able to quote every article. This is especially true if the literature is question is conflicting.
Improving research-based clinical results
Panels: Haldeman believes the best way to address this is to continue to create panels that review research and develop guidelines. He says it is increasingly recognized that patients should be part of the decision-making process and be informed as much as possible on the options for care and the basis for recommendations. This is why it is increasingly important to consider guidelines as determined by panels who review the literature.
Mentors: Furthermore, if DCs are going to learn how to deliver high- quality clinical results, where patients can see the difference between chiropractic and other manual types of medicine, then it is time we learned from those who are good at it. I have always been a firm believer in the existence of what I call “outlier chiropractors,” who are simply better than the majority of their peers at providing the results patients seek.
To do this, outliers must be willing to mentor those who are willing and open to concepts that could change the way they practice, as opposed to those searching for concepts that only reinforce their current thinking.
Long-time chiropractic critic Edzard Ernst, MD, told me that he does not believe in outliers, but if they do exist then they are phenomena that can and should be studied. Regardless of your beliefs, if you refuse to accept that there are some DCs you can learn from, then you must accept that your service is nothing more than a commodity.
Pradeep Kumar, MD, provides a different perspective. He was trained as a pediatrician in India and then studied at the Mind-Body Medical Institute at Harvard University. Kumar suggests there are three stages for a therapist or practitioner to grow through:
Technician: One who follows evidence- based practice and is dependent on external science; a follower of the system. This is where most practitioners are.
Healer: When evidence-based practice is combined with a person’s healing touch or energy; a changer of the system.
Philosopher: One who combines the science and the personal in a new form; a maker of the system.
The Healer and Philosopher use the best evidence available to enhance their clinical delivery. They would be considered outliers. Kumar went on to say that no matter how much science is developed, no one can replace one- to-one learning from a great teacher. A personal element always helps you understand the health and healing of your patients.
Anthony J. Lombardi, DC, is the creator of the eXStore assessment system. He is a consultant and treatment provider to professional athletes in the NFL, NHL, and CFL. He can be contacted firstname.lastname@example.org or through hamiltonbackclinic.com.
1 Bussières AE, et al. Evidence-Based Practice, Research Utilization, and Knowledge Translation in Chiropractic: A Scoping Review. BMC Complement Altern Med. 2016;16:216. Published online 2016 Jul 13. doi: 10.1186/s12906-016-1175-0.
2 Colquhoun D. An Investigation of the False Discovery Rate and the Misinterpretation of P- Values. R Soc Open Sci. 2014 Nov;1(3):140216. Published online 2014 Nov 19. doi: 10.1098/rsos.140216.