I have been hearing and reading a lot of negative comments about chiropractic lately, mostly from chiropractors. It seems many e-mail discussions have centered on negative research studies, bashing of "out-of-touch" trade organizations, media slams, and tug-of-wars among some of the chiropractic "factions." Oh, and let's not forget the challenge of staying in business with all the competition for patients and an abusive managed care reimbursement environment.
Fortunately, in the midst of the morass, there was some very good news this summer. For the first time in my professional career, I witnessed firsthand a maturation of our profession take place that rivaled the scientific evolution of other health care disciplines. Between July 23-25, 1999, a federally sponsored chiropractic research conference brought together one of the largest gatherings ever of chiropractic researchers, college faculty and administrators, and practitioners to consider the development and implementation of a chiropractic research agenda.
The fourth Research Agenda Conference (RAC IV), organized by the Palmer Center for Chiropractic Research and funded by the U.S. Department of Heath and Human Services, offered research design, grant-writing and scientific writing courses for both new and established chiropractic researchers, faculty and practitioners. However, what really inspired me was a day-long exploration by a diverse spectrum of chiropractic scholars on the development and role of chiropractic theory.
The program included an afternoon presentation examining what chiropractic theory is all about by Dr. Bill Meeker, along with an incredibly eloquent and insightful deconstruction of recent research studies by Dr. Howard Vernon, illustrating how
inappropriate application of chiropractic theory to research designs can result in negative findings. Dr. Craig Nelson,
chiropractic's consummate skeptic's skeptic, offered a thought-provoking talk that challenged the very nature of
chiropractic theory. I contributed a good bit less than two cents worth with a rather rushed overview of how our profession has used our theory in some useful (and not so useful) ways over the years.
The next morning, Drs. Ed Owens and Cheryl Hawk offered examples of approaches to developing, articulating and refining chiropractic theory, including identification of key research questions for chiropractic clinical encounters and the vertebral subluxation model. Dr. Owens' "hypothesis tree" for subluxation laid out quite well the extent and magnitude of research questions that need to be answered. Dr. Hawk's view of the entire chiropractic clinical encounter as a basis for theory development emphasized the relevance of the context in which we deliver care.
What followed was a panel session of esteemed discussants representing a diverse spectrum of beliefs and expertise posing
answers to the question, "Where do we go from here?" There were many eloquent statements of strong opinions, many expressions of frustration regarding the value (or lack thereof) of theory in chiropractic. A question and answer session with attendees punctuated dilemmas and anxieties that practitioners, faculty, students and researchers have with our models, with research itself, and with the medically dominated health care system at large.
And what made this all so inspiring to me? It was the first time in my 22-year affiliation with chiropractic that such reasoned and critical introspection has been focused on chiropractic theory and subluxation. Most of the usual attention chiropractic theory and subluxation receive seems polarized between all-or-none political factions that call for complete abandonment of subluxation altogether, or some kind of subluxation-only practice and professional identity.
Theories are designed to explain observable phenomena. In actuality, the "subluxation model" that postulates a relationship
between body structure, physiological function and health is an inherently viable one. The precise biomechanical,
neurophysiological and/or psychosocial mechanisms that may or may not come into play remain to be elucidated through research. As more becomes known, chiropractic models should rightly be refined to better explain clinical observations. Well-developed theories help pose research questions and study designs that do a better job at finding out information that can improve our practices and benefit the patients we are here to serve.
Subluxation theory still isn't "quite there" yet. However, based on the provocative discussions and insightful commentary from the presenters above and panel discussants (such as Drs. David Koch and Ian Coulter), I believe the seeds of the kind of critical review were planted that will lead to strengthening and appropriate refinement of chiropractic subluxation theory.
A detailed review of the known and unknown neurophysiological attributes of spinal joint dysfunction and subluxation by Dr.
Joel Pickar made me experience some professional pride for how far we have come, yet underscored (with dismaying awe) how far we have to go. Much greater understanding of the biomechanics of spinal motion and spinal adjusting is coming from work at universities in the U.S. and Canada, and from practitioners in private practice.
It is almost a historical constant that there will always be those that see such critical review and debate of existing
theories as a "the sky is falling" sort of proposition. However, models and theories subjected to review and refinement become stronger for the wear. I was gratified to see chiropractic theory given such attention, even if some of my favorite cages were rattled.
Although I probably found just as much to disagree with as I found to agree with at RAC IV, for the first time, I saw
chiropractic theory elevated to the level of importance it should have in our scientific evolution as a profession. Theory is a tool, not a truth, and theory must consider diverse perspectives, clarifying and refining assumptions upon which it is
Blaise Pascal wrote, "Plurality which is not reduced to unity is confusion. Unity which does not depend on plurality is tyranny." I think those who call for abandoning chiropractic subluxation theory are missing the point just as much as those who promote the conceptualizations of chiropractic models from decades past as absolute truth. For too long, chiropractors have hunkered down at one end of Pascal's "plurality spectrum" or the other. What happened at RAC IV represents a beginning to the critical intellectual discussions and investigations that will help find that balance between chiropractic "confusion" and "tyranny" that can carry us into the next millennium.