Dear Colleague and/or other reader:
The evidence for chiropractic should neither be exaggerated nor unfairly downgraded. The evidence can and should speak for itself and the evidence, when available, can and must guide our clinical decision-making. When as a profession we choose to become fully aware of the evidence, and, most importantly, practice according to it, we will not only best serve our professional interests we will, most importantly, best serve the public interest. This is, of course, true for all healthcare professionals.
Practicing evidence-based chiropractic does not require abandoning the chiropractic adjustment or chiropractic spinal manipulative therapy, rather, being evidence-based demands a central focus upon chiropractic adjustment/SMT. Compared to any other intervention, chiropractic adjustment/SMT is, without any scientific debate, the most evidence-based intervention available within the scope of chiropractic practice and, based on the available evidence, should fairly be considered the most evidence-based intervention within any scope of practice.
Chiropractic adjustment or chiropractic thrust SMT, based on the available randomized controlled intervention trials, comparative trials, and comparative analyses, can, and in my opinion should, be considered the most evidence-based spinal healthcare intervention currently available with respect to effectiveness, cost-effectiveness, and safety.
A fair, unbiased interpretation of the available peer-reviewed literature provides high
quality evidence that chiropractic adjustment/SMT has always been, and remains, the best option for patients with non-traumatic instability, non-infectious, non-cancerous spinal health problems and should be, as many others have concluded, the preferred, if not mandated, first option for patients suffering with such spinal health issues.
I contend that the only thing that has any chance to unite us is a commitment to evidence-based practice and to the chiropractic health paradigm of addressing the cause/correcting function rather than simply treating symptoms. Both “camps” are guilty of bias and dogma based on ignorance of the literature or a refusal to objectively apply available evidence. One extreme tends to exaggerate the evidence and blindly accept virtually any claim regarding the benefits of chiropractic adjustment. The other extreme tends to exaggerate and blindly accept the validity of disproven passive physical therapy modalities and virtually any other non-evidence-based allopathic interventions while too often rejecting and/or downplaying the evidence regarding chiropractic adjustment compared to other alternatives. Not a great environment to grow our beloved profession so that we can best serve the public interest!
We all have our biases. The only remedy is an honest appraisal and acceptance of the evidence and an honest dedication to research unanswered questions. Lack of research showing ineffectiveness is not evidence of effectiveness. Similarly, lack of research is not proof of lack of benefit. Lack of research evidence is simply evidence that we lack evidence and that we need to do research to compile evidence. If we lack valid evidence of effectiveness, then we lack the ethical right to make claims regarding effectiveness – this seems an easily understood and uncontroversial concept to me. Again, this is not proof of lack of benefit and it is not disproof or discredit of clinical experience, case studies or patient experience/testimonials. It is simply a lack of valid evidence of a cause and effect relationship between intervention and benefit and public claims of effectiveness should be based on valid evidence of a cause and effect relationship between intervention and benefit.
We can be bold in our hypotheses but we must be conservative and evidence-based regarding our public claims. There is, and must always be, room for clinical experience and clinical judgement and trials of care, but there is no room for false or unsubstantiated claims, especially in the public domain. False or unsubstantiated claims are the straw men we build ourselves which invite the attacks of skeptics. Even when skeptics of chiropractic are biased and dogmatic and unscientific and outright dishonest as they have so often have proven to be, when we make a false claim we validate these skeptics and we do great harm to ourselves.
The result is people who could benefit from chiropractic care get either turned off or turned away and that is the greatest tragedy of all. Millions needlessly suffer because they don’t get the chiropractic care they need and/or because they get ineffective, expensive, and/or harmful care they don’t need. False claims represent not just an unethical violation of our Chiropractic Oath, they represent harm to our profession and to the public interest.
Billions and billions of dollars are spent on ineffective and/or harmful treatments each year and nearly as much or more is spent on adverse effects. Think about the economic and human costs of proven ineffective, dangerous, often harmful back surgeries which are now performed more often than hip surgeries. Think opioids, think Vioxx, think about the fact that, according to a study out of Quebec, Canada, for every dollar spent on NSAIDS, sixty-six cents is spent on the side-effects (which ironically is spent on other, ineffective, harmful drugs).
Think about the fact that paracetamol or acetaminophen or Tylenol was considered the Gold Standard for medical care of low back pain for decades even though there was not a single RCT study to show its effectiveness and that in the latest guidelines (Chou 2017) they now admit it has never had evidence of effectiveness and is thus now considered guideline-discordant. Yes, you read that correctly, the intervention considered the Gold Standard in medical clinical guidelines around the world for decades never had a shred of valid evidence and is now considered guideline-discordant.
Think about the passive physiotherapy modalities and specialized back exercise programs that have been standard of care for decades, again without any valid evidence, that are now considered guideline-discordant due to strong evidence of ineffectiveness but yet are still provided to millions on a daily basis.
Think about how often the aforementioned treatments have been recommended, referred for, and reimbursed to the exclusion of chiropractic with the false, biased excuse that this was because chiropractic lacked evidence or was dangerous. It is HEARTBREAKING. Not just for chiropractors, but, more importantly, for the millions of needlessly suffering patients.
No field of healthcare practices exclusively evidence-based care. Evidence-informed trials of “off label” or experimental care based on clinical experience/evidence are commonplace in all fields of healthcare – even for infants – think colic. However, there must be a clear distinction made between an honest communication to an individual patient regarding clinical experience and an honestly communicated possibility of benefit from a reasonable trial of care, and publicly made false claims or promises. The former is reasonable, defensible and ethical; the latter is unreasonable, indefensible, and unethical.
Strange and amazing things outside the realm of musculoskeletal benefits happen in chiropractic offices – about this there is no reasonable doubt – it is an absurd notion to suggest that thousands of patients are simply lying. However, more evidence is needed before we can make ethical, valid claims about being able to reliably elicit such benefits – about this there is no doubt.
Be reasonable, be ethical, be evidence-based – it’s not that hard, and it is the best way to build the practice both you and your patients want and it’s the best way to build the trust and cultural authority we need to increase the number of people who seek the chiropractic care they need and that they will benefit from.
These are a few of the questions I have spent my professional life searching the peer-reviewed literature looking to provide answers to in my books and other writings, at my seminars, and in my Evidence-Based Chiropractic and Lifestyle Protocols practice systems:
- What are the most evidence-based explanations regarding the effectiveness of chiropractic adjustment/SMT?
- What is the known neurophysiological, sensory-motor, structural, functional, and metabolic/autonomic importance and/or role of segmental joint motion and what are the known neurophysiological, sensory-motor, structural, functional, and metabolic/autonomic consequences of a loss of normal segmental joint motion?
- What are the landmark studies, reviews, and government inquiries showing the effectiveness, cost effectiveness, and safety of chiropractic adjustment/thrust SMT and how can we best utilize these to educate ourselves, our patients, the public, and other healthcare professionals?
- What is the level of evidence regarding safety, effectiveness, and cost-effectiveness for chiropractic compared to surgery for low back pain and other spinal health issues?
- What is the level of evidence regarding safety, effectiveness, and cost-effectiveness for chiropractic compared to usual medical care for low back pain and other spinal health issues?
- What is the level of evidence regarding safety, effectiveness, and cost-effectiveness for chiropractic compared to physical therapy for low back pain and other spinal health issues?
- Why is there such heterogeneity amongst the conclusions of systematic reviews, even amongst those published within a very similar time frame and thus reviewing the same body of literature?
- What methodological variables explain the heterogeneity of conclusions of systematic reviews of SMT and, when variables such as frequency and duration of care, proper differentiation between mobilizations versus thrust adjustments/manipulations, and maintenance care provided in gaps between outcome measures in the post-treatment period, are accounted for, does this change the level of evidence for SMT? In other words, are the quality and strength of evidence from valid studies of SMT/adjustment invalidly and unfairly diluted in systematic reviews by pooling such data with data from invalid studies of SMT?
- Is there evidence of bias against chiropractic in the peer-reviewed literature, in systematic reviews, and in clinical guidelines and, if so, how is this best identified and best exposed in a rational, scientific manner?
- According to the available evidence, with respect to the treatment of low back pain and other neuromusculospinal health issues, which would, according to a valid, unbiased assessment, be considered the most evidence-based education – medical, physical therapy, or chiropractic?
- Are commonly proffered public opinions about chiropractic education and practice by skeptics and entities such as Friends of Science in Medicine or Quackwatch reflective of an honest, scientific review of the available evidence or of dogmatic, unscientific, and deliberate bias?
- Does the evidence support the commonly held view, often included in clinical guidelines, that the majority of low back pain is self-limiting within a few weeks with or without care?
- Is there any valid clinical evidence that maintenance chiropractic adjustments/SMT provides benefit to patients? If so, why is such care not provided in studies looking at long-term outcomes of chiropractic adjustment/SMT?
- What represents an evidence-based chiropractic spinal health exam? According to the peer-reviewed literature, what spinal exam findings are required to indicate clinical need for chiropractic adjustment/SMT and what clinical spinal exam findings regarding segmental joint dysfunction or vertebral subluxation complex are considered most reliable and valid?
- Is pain itself a legal or valid clinical indicator for the need of chiropractic adjustment/SMT or is a segmental spinal exam finding the legal and valid clinical indicator for the need of chiropractic adjustment/SMT?
- How can we ever validly study the detrimental effects of, or the benefits of correcting, segmental joint dysfunction/vertebral subluxation complex if we do not standardize our clinical findings around the most reliable and valid clinical methods to determine its presence, improvement, and/or resolution?
- What should be considered an evidence-based claim regarding the effectiveness or benefits of chiropractic care based on the current available evidence?
- What should be considered evidence-based care recommendations, patient education, and public
communication?
- Are there any valid studies determining frequency and duration of care or must this be determined during a course of care by valid clinical exam findings at regular and reasonable time periods which measure both progress or benefit, and any further required care to achieve resolution or maximal benefit?
- If we do not earn public trust can we ever earn cultural authority and if we do not earn trust and authority will we ever reach the millions of suffering patients who erroneously choose other, less evidence-based, less effective care options?
- If we, as a profession, are not willing to practice and communicate in an evidence-based way how will we ever standardize our clinical findings, standardize our care recommendations, and gain public trust and cultural authority?
- What is the cause of the current chronic illness pandemic and what are the most evidence-based solutions for prevention and/or management/resolution?
- What lifestyle habits are required by humans to epigenetically express their inborn genetic potential for quality and quantity of life?
- For the human species, what represents evidence-based eating, moving, and thinking/social interaction choices; what represents evidence-based lifestyle habits or choices; what represents ‘Living Right for Your Species Type’.
I truly believe that a focus on evidence-based care is the greatest thing to ever happen to chiropractic regardless of what “camp” you belong to and that the implementation of evidence-based care represents the greatest chance we have to standardize, unite, and mature into the profession the world so desperately needs us to be.
I hope this has been some food for thought and I hope it provides an insight into what I am trying to accomplish and contribute to our profession, to healthcare, and to humanity.
I hope to see you at a seminar. All are welcome, all questions and polite, respectful viewpoints are welcome. Please, no dogma, no vitriol, no arrogance, and no bias. Please come with an open mind to learn what you might not know, share what you do know, and a willingness to let an objective analysis of the available evidence build your knowledge, shape your beliefs, guide your clinical behaviors, and provide common ground with your colleagues and with other evidence-based, ethical healthcare providers.
To subscribe to my Monthly Research Review or for more information to register for a seminar or get more information on my evidence-based practice protocols systems please visit www.thewellnesspractice.com
Yours in evidence-based, compassionate, ethical healthcare,
James Chestnut B.Ed., M.Sc., D.C., C.C.W.P.
THEWELLNESSPRACTICE.COM
Dr. Chestnut’s – The Wellness Practice
We define ethical practice success as the exchange of evidence-based care that elicits documented patient outcomes for a fair fee. We believe that every chiropractor and every chiropractic patient benefits from this ethical model. Numbers of patients does not define ethical practice success.