To the editor:
Grod, Sikorski and Keating's recent article¹ is both commendable in its quest for accuracy and vexing in its literal readings of various statements that exist in a sampling of patient brochures. The heart of the matter seems to arise in the article's fixed definition of what constitutes “making claims for methods that have not been scientifically validated,” which the authors rightfully distinguish from the use of unproven methods for healing which “is often quite appropriate.”

There is little doubt that chaotic, sweeping, and emphatic statements in patient brochures without any real basis for their veracity leave the chiropractic profession exposed to well-founded criticisms. If the evidence points toward (rather than explicitly identifies) a specific causative agent or set of causes, it is important to describe it as a model or conjecture rather than as a clinical fait accompli. Regarding the subluxation as such, there indeed is a consensus as to its general definition² but not, as yet, an absolute set of detailed attributes. Thus, it may be referred to as a defining characteristic of what chiropractors pursue, but it needs to be interpreted with caution.

On the other hand, the authors may have defined their criterion of substantiated claims with too narrow a lens. What precisely, after all, is “scientific validation?” With the goal of substantiating claims from any health care provider, it would be of interest to the authors to consult a recent assessment of the clinical guidelines for the management of low back pain developed in 11 countries. Here, one would expect that, given that the available scientific evidence is a fixed quantity, the guidelines should be similar, irrespective of their country of origin. In terms of such features as diagnostic triaging or the recognition of psychosocial factors in low back pain, they are. In terms of patient information, muscle relaxants, exercise therapy, or (most importantly for this discussion) spinal manipulation, however, major disparities exist.³ This would suggest that, despite the best of intentions, an absolute gold standard of scientific validation may not exist— although attempts to achieve this goal must not be discouraged.

This type of variability and subjectivity, which the authors decry, is actually quite rampant in the medical literature, let alone the patient brochures they have described and decried in their article. Concerning what one would imagine would be a far less politically charged subject (differing preparations of heparin, for example), one finds that depending on which of 25 individual scoring systems different investigators have devised for methodological quality, one can come up with diametrically opposing conclusions.⁴ In yet other studies involving antifungal agents, inappropriate administration of 1 of 2 agents that have been manufactured by the pharmaceutical company competing with the product sponsored by the firm funding most of the researchers involved leads to a foregone conclusion and an obviously rigged conclusion—the superior performance of the sponsoring company's own medication.⁵

The point of all this is to make it clear that bias, subjectivity, and disagreement extend far beyond patient brochures into the rarefied echelons of randomized clinical trials, meta-analyses, and actual clinical guidelines. Interestingly, what had been considered to be a lower stratum of evidence in quality (observational studies) compared with randomized clinical trials may not be such—as it has been recently reported that in terms of treatment effects, estimates from observational studies conducted since 1984 do not appear to be consistently larger or qualitatively different from those obtained in more fastidiously constructed randomized clinical trials.⁶ Indeed, the entire pecking order of the quality of scientific clinical evidence as it appears to have been envisioned by Grod et al has been seriously questioned, such that observations taken in the doctor's office assume a far greater value in establishing an evidence base with external as well as internal validity.⁷

Under these circumstances, we believe that the quotations cited in patient brochures from the Foundation for Chiropractic Education and Research (FCER) represent responsible extensions and generalizations from both the scientific literature and a large number of repeated clinical observations. They are important starting points for health care consumers to raise appropriate questions about their health care. It is understood that the scientific literature supporting chiropractic theory and practice is scanty, but it is fortunately growing at a rapid pace as a result of efforts by the FCER for the past 56 years. Indeed, as David Eisenberg once remarked, Chinese medicine endured into the 20th century without documentation from clinical trials because it was substantiated by 3000 years of case studies. Indeed, only 15% of what we regard as modern medicine appears to have been supported by any scientific evidence at all,⁹ and only 1% has been described as sound.¹⁰ Within this framework, therefore, we feel that responsible statements such as ours, which engender public inquiry and research while assessing the orientation of what both published scientific studies in the journals and careful clinical observations are telling us, is the most productive course to follow. Indeed, FCER, in its promotion of the acquisition and dissemination of pertinent research data, appears to have successfully followed the dictates laid down over 90 years ago by no less an authority than D.D. Palmer:

If the author of this and other schemes would put in as much time and energy in developing the science, art, and philosophy of Chiropractic as he does in enveloping them, he would advance instead of retard them.⁸



© 2002 by JMPT

0161-4754/2002/$35.00 + 0 76/1/124415

doi:10.1067/mmt.2002.124415

Anthony L. Rosner, PhD
Foundation for Chiropractic Education and Research 1330
Beacon Street, Suite 315
Brookline, MA 02446-3202, USA


References

1.  Grod JP, Sikorski D, Keating JC. Unsubstantiated claims in patient brochures from the largest state, provincial, and national chiropractic associations and research agencies. J Manipulative Physiol Ther 2001;24:514-9.

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ABSTRACT

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2.  The ACC chiropractic paradigm: issues in chiropractic, position paper #1. Association of Chiropractic Colleges; July 1996.

3.  Koes BW, van Tulder MW, Ostelo R, Burton AK, Waddell G. Clinical guidelines for the management of low back pain on primary care. Spine 2001;26:2504-14.

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CROSSREF


4.  Juni P, Witsch A, Bloch R, Egger M. The hazards of scoring the quality of clinical trials for meta-analysis. J Am Med Assoc 1999;282:1054-60.

5.  Johansen HK, Gotzsche PC. Problems in the design and reporting of trials of antifungal agents encountered during meta-analysis. J Am Med Assoc 1999;282:1752-9.

6.  Benson K, Hartz AJ. A comparison of observational studies and randomized controlled trials. N Engl J Med 2000;342:1878-86.

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7.  Jonas WB. The evidence house: how to build an inclusive base for complementary medicine. West J Med 2001;175:79-80.

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8.  Palmer DD. The chiropractor's adjustor: the science, art and philosophy of chiropractic. Portland (OR): Portland Printing House; 1910. p. 870.

9.  Smith R. Where is the wisdom: the poverty of medical evidence. BMJ 1991;303:798-9.

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10.  Rachlis N, Kuschner C. Second option: what's wrong with Canada's health care system and how to fix it. Toronto: Collins; 1989.