November 11, 1998
CNN Medical Division
1 CNN Center
Atlanta, GA 30348
Dear Ms. Rowland:
Thank you for the opportunity to express my views regarding CNN features. This letter is a commentary on a recent news report you made regarding chiropractic research. It is understandable to be curious about any latest developments regarding chiropractic, a field that is certainly misunderstood and somewhat of a mystery to many. When a research project presents important results it is often the nature of the media to jump on the story, but sometimes this can be done without a thorough investigation of possible weaknesses in the study, or of possibly contradictory research. What I saw as perhaps the biggest flaw in the Low Back Pain Comparison study that you featured was in the treatment protocol. It is certainly unreasonable to assume that ceasing chiropractic treatment after a 4-week period could continue to produce results a year or two later. This is due to the non-invasive nature of chiropractic adjustments, which, unlike surgery or drugs, take time for the permanence of their effects to be realized. Chiropractic produces cumulative changes while drugs and surgery produce immediate changes with greater permanence, so studies like this shouldn’t be based on pre-conceived designs. Furthermore, since an educational pamphlet creates a type of long-term, continued approach to care of the problem, I believe it should not be compared in this way to short-term application of techniques which were originally meant to be applied over longer periods of time. An analogy might be giving the patients the pamphlet and then taking it out of their hands before they could finish reading it. That chiropractic may have achieved superior results if carried out to completion (as in real-life situations) is clear in that the preliminary outcomes of the study after 4 weeks were very favorable for the chiropractic group, rather than the long-term outcomes after absence of chiropractic care. The nature of chiropractic care is often in the way of gradual, progressive change and restoration of wellness. This wellness approach is why many chiropractors feel they can benefit other problems besides back pain. However, since I know of no chiropractor who would agree to a treatment protocol of 1 month of care and then none for 2 years, how can you argue that this particular research project really tests the integrity of chiropractic?
Apparently, this study indeed had a poor comparison group methodology. Comparison groups are difficult to create in some studies, since in cases like surgery for example, one cannot estimate placebo effects. Perhaps the flaw of the second study on chiropractic and childhood asthma that was featured, and as Dr. Williams pointed out, was that the placebo group may well have been too similar to certain chiropractic methodologies in existence today. Some may even conclude that control-based research can never completely reproduce the "in-vivo" effect that goes on in the casual clinical setting. I would say that I am a proponent of clinical-based research myself as an alternative. Of course we need both.
I would like to offer an article from our recent issue of the Chiropractic Research Journal which offers some promise for chiropractic in the light of science. It is an ongoing project through our research center and uses the SF-36 questionnaire as a means to assess an overall wellness state of a patient. This standard test offers a level of consistency of measurement and objectivity in a diagnostic area (pain and overall health status) that by its nature must remain in the subjective arena. It thus allows research of this type to progress. This study (attached), in its early stages, is already beginning to demonstrate the value of chiropractic. As you will notice, the visit protocol was to continue care until maximum improvement was achieved (MCI), unlike the study that was covered in your news broadcast. So far the MCI point has averaged 1.5 months, demonstrating that most patients need more than 1 month of care. In comparing these results with the NEJM Low Back study mentioned earlier, one could conclude that length of chiropractic treatment is likely a key factor in the determination of its effectiveness. There is no doubt a long list of additional research that supports the benefits of chiropractic care. My goal is to give you some insight into the progress here at Life University.
An additional note is deemed necessary in regard to cost studies. It is agreed that the "cost of care" factors included in the study were accurate within the realm of the followed treatment protocol. The suggestion of lengthening the care phase of the study would have only increased the gap of cost comparison. However, when one weighs in the normal costs of general back care treatment, including common surgical intervention, chiropractic and/or physical therapy present great cost reductions over surgery, with research showing similar, if not better, results than surgery (Manga, etc.). Therefore generalized remarks about higher costs with chiropractic care may be inappropriate or inaccurate in this light.
Should you have further questions or comments and wish to contact our Research Center, please do not hesitate to do so.
James Provoost, DC