Daniel Redwood

Consensus process to develop a best-practice document on the role of chiropractic care in health promotion, disease prevention, and wellness.

OBJECTIVE The purposes of this project were to develop consensus definitions for a set of best practices that doctors of chiropractic may use for promoting health and wellness and preventing disease and to describe the appropriate components and procedures for these practices. METHODS A multidisciplinary steering committee of 10 health care professionals developed seed statements based on their clinical experience and relevant literature. A Delphi consensus process was conducted from January to July 2011, following the RAND methodology. Consensus was reached when at least 80% of the panelists were in agreement. There were 44 Delphi panelists (36 doctors of chiropractic, 6 doctors of philosophy, 1 doctor of naturopathy, 1 registered nurse). RESULTS The statements developed defined the terms and practices for chiropractic care to promote health and wellness and prevent disease. CONCLUSION This document describes the procedures and features of wellness care that represent a reasonable approach to wellness care and disease prevention in chiropractic clinical practice. This living document provides a general framework for an evidence-based approach to chiropractic wellness care.

Chiropractic Care and Public Health: Answering Difficult Questions About Safety, Care Through the Lifespan, and Community Action

The purpose of this collaborative summary is to document current chiropractic involvement in the public health movement, reflect on social ecological levels of influence as a profession, and summarize the relationship of chiropractic to the current public health topics of: safety, health issues through the lifespan, and effective participation in community health issues. The questions that are addressed include: Is spinal manipulative therapy for neck and low-back pain a public health problem? What is the role of chiropractic care in prevention or reduction of musculoskeletal injuries in children? What ways can doctors of chiropractic stay updated on evidence-based information about vaccines and immunization throughout the lifespan? Can smoking cessation be a prevention strategy for back pain? Does chiropractic have relevance within the VA Health Care System for chronic pain and comorbid disorders? How can chiropractic use cognitive behavioral therapy to address chronic low back pain as a public health problem? What opportunities exist for doctors of chiropractic to more effectively serve the aging population? What is the role of ethics and the contribution of the chiropractic profession to public health? What public health roles can chiropractic interns perform for underserved communities in a collaborative environment? Can the chiropractic profession contribute to community health? What opportunities do doctors of chiropractic have to be involved in health care reform in the areas of prevention and public health? What role do citizen-doctors of chiropractic have in organizing community action on health-related matters? How can our future chiropractic graduates become socially responsible agents of change?

A Case Study of Misrepresentation of the Scientific Literature: Recent Reviews of Chiropractic

Accurate use of published data and references is a cornerstone of the peer-review process. Statements, inferences, and conclusions based upon these references should logically ensue from the data they contain. When journal articles and textbook chapters summarizing the safety and efficacy of particular therapies or interventions use references inaccurately or with apparent intent to mislead, the integrity of scientific reporting is fundamentally compromised. Ernst et al.s publication on chiropractic include repeated misuse of references, misleading statements, highly selective use of certain published papers, failure to refer to relevant literature, inaccurate reporting of the contents of published work, and errors in citation. Meticulous analysis of some influential negative reviews has been carried out to determine the objectivity of the data reported. The misrepresentation that became evident deserves full debate and raises serious questions about the integrity of the peer-review process and the nature of academic misconduct.

The Health Reform Moment : Peril and Possibility in the Obama Era

1 For the first time in 15 years, a major national health reform initiative is moving forward in the United States. Those of us who recall the events of 1993–1994, when the Clinton administration failed to pass its version of coverage for all, know that numerous pitfalls lie ahead with the potential to undermine the best-laid plans. But for those of us who have seen the widespread and needless suffering caused by the dominant role of money in American health care, President Barack Obama’s clear commitment to change gives much cause for optimism. Currently, tens of millions of uninsured Americans lack adequate access to quality health services and uncounted millions more delay needed care for financial reasons. The men and women leading the health reform process, particularly at the interface of the executive and legislative branches of the federal government, appear to have learned from past failures. Also of considerable significance, the new president is a consensus builder with roots as a community organizer and is now applying his unprecedented grassroots-plus-online campaign model to the process of governance. Access to care and related budgetary issues tend to dominate the debate, but they comprise only one part of the equation. In the long run, financial issues may prove less important than questions about which services are being delivered to patients with newly increased access, as well as to those who already have access to health care but for whom it has failed to deliver health and wellness. Unless there are major changes in the health priorities of the nation, there will be no sustainable health care solutions. The stakes are extremely high. This commentary focuses on four areas: universal coverage; prevention and health promotion; chiropractic (I am a chiropractic educator who was in private practice for 26 years); and complementary and alternative medicine (CAM).

Improving preventive health services training in chiropractic colleges part II: enhancing outcomes through improved training and accountability processes.

OBJECTIVE Over the past decade, chiropractic colleges have introduced clinical prevention services (CPS) training. This has included an updated public health curriculum and procedures for student interns to determine the need for preventive services and to provide these services directly or through referral to other health professionals. The purpose of this study was to evaluate the effect of a program to train chiropractic interns to deliver CPS to patients. METHODS Program evaluation used retrospective chart review, comparing the proportion of patients receiving CPS recommendations before and after implementation of the program. The main outcome measures were the percentage of appropriate CPS recommendations based upon chart reviews. RESULTS Chart reviews in 2006 indicated appropriate CPS recommendations in 47.4% of cases (295/623). Chart reviews in 2007, after an additional year of sustained implementation of procedures to ensure intern and faculty accountability, showed appropriate counseling recommendations in 87% of files (137/156). CONCLUSIONS Requiring interns to attend didactic presentations on CPS had no measurable effect on their performance. Major improvements occurred after a series of clinically relevant training interventions; new forms and audit procedures were implemented to increase intern and clinical faculty accountability.

Prevention and Health Promotion by Chiropractors

Chiropractic care includes a variety of minimally invasive approaches, with both treatment and prevention as essential elements of clinical practice. Although chiropractic adjustment (manipulation) is the signature therapy and best-known identifier of the profession, the practice of chiropractic involves more than manual therapeutics. In general, chiropractors seek to bring a holistic worldview to the doctor—patient encounter, seeking not only to relieve pain and restore neuromusculoskeletal function but also to support the inherent self-healing and self-regulating powers of the body. Aside from applying their diagnostic training to the evaluation of a variety of physical disorders and delivering manual adjustments and related therapeutic interventions, many chiropractors encourage patients to take an active role in restoring and maintaining health, with particular emphasis on doctor-guided self-care through exercise and nutrition. In this review, the authors summarize the peer-reviewed literature on chiropractic and prevention, describe health promotion and wellness approaches currently taught at chiropractic colleges and used in chiropractic clinical settings, discuss duration of care, emphasize the importance of interprofessional cooperation and collaboration, and address the hypothesis that chiropractic adjustments yield preventive effects.

Methodological Changes in the Evaluation of Complementary and Alternative Medicine: Issues Raised by Sherman et al. and Hawk et al.

5 The quest for methodologies appropriate for evaluating complementary and alternative medicine (CAM) continues to challenge the research community. Two papers in this issue, Sherman et al.’s “Description and Validation of a Noninvasive Placebo Acupuncture Procedure,” (pp. 11–19) and Hawk et al.’s “Issues in Planning a Placebo-Controlled Trial of Manual Methods: Results of a Pilot Study,” (pp. 21–32) demonstrate efforts by thoughtful investigators to develop legitimate placebo interventions and to address standardization of delivery. Sherman et al. show great ingenuity in their use of a toothpick and a plastic insertion tube to mimic acupuncture needling. In their first experiment, the toothpick insertions were perceived as slightly more like real needling than the real needling itself; in the second, a still impressive 53% of those receiving the simulated needling believed it “definitely” or “probably” was real acupuncture, compared to 65% of those receiving actual acupuncture. Further supporting the legitimacy of this method as a placebo or control is the difference in reported therapeutic response: 33% of subjects receiving real acupuncture reported significant improvement in their back pain compared to only 4% receiving imitation acupuncture. Yet questions remain. The ideal placebo should be therapeutically inert; a reasonable placebo should be reasonably inert. But the authors note that noninsertive needling is actually practiced as part of some styles of acupuncture and that the effects of gentle stimulation are not well understood at this time. Therefore, they suggest that the toothpick method be considered a “minimal sham treatment,” which should not be assumed to be inert. Nonetheless, based on the efficacy of patient blinding and the differences in therapeutic response to toothpick versus acupuncture needling, they recommend their method as a “reasonable control treatment for acupuncture-naïve individuals in randomized controlled trials assessing the efficacy of acupuncture for low-back pain.” Although Sherman and colleagues are clearly conscious of the subtleties in these distinctions among placebos, shams, and minimal shams, other investigators using this method in the future may lack this awareness or fail to convey it to consumers of their research. Unless a clear disclaimer to the contrary is noted in the abstract as well as the text of an article, most readers assume that methods used as placebos, controls, or shams are actually inert. A broader context for interpretation may be achieved by including a “no treatment” and/or a conventionally treated group along with the minimal sham and real acupuncture groups. In the Hawk et al. trial, a multidisciplinary team of researchers began with the assumption that fundamental differences exist between the administration of medications and the application of manual procedures. They designed a multisite pilot study on chiropractic care for women with chronic pelvic pain, seeking to address the methodological challenges inherent in these differences. They also hoped to lay the groundwork for a larger randomized controlled trial (RCT).

Commentary on Anderson: Turf Protection or Interprofessional Cooperation?

203 In Robert Anderson’s intriguing article, “The Fugelli Tactic” (this issue, pp. 197–201), he describes the variety of health practitioners from which citizens of Iceland and Denmark can access manual therapy services (Anderson, 2002). Anderson, who is a professor of anthropology, a medical physician, and a chiropractor, depicts the ancient family lineage tradition of the lay bonesetters, the century-old chiropractic profession, and the more recent phenomenon of medical physicians (and physiotherapists) practicing manipulation after taking short postgraduate courses. Contrary to the expectations of many, rather than threatening the survival of chiropractic, increased medical participation in manual therapy appears to have contributed to (or at least coincided with) a significantly enhanced status for chiropractors in Denmark. What Anderson calls the Fugelli tactic involves subsuming into conventional medical practice successful aspects of the practices of complementary and alternative practitioners. Thus defined, the Fugelli tactic is manifest when medical physicians learn to apply manual manipulation of the spine, or emulate the kinds of interpersonal connection skills that writers such as Kaptchuk and Eisenberg (1998) have attributed to chiropractors. The implications of Anderson’s presentation extend beyond the specific case of the bonesetters, chiropractors, and manual medicine practitioners. The borderlines where one profession ends and another begins are always in flux and a constant source of controversy. When professional groups seek to influence public policy on licensure and qualifications, the desire for turf protection and expansion often underlies pronouncements of concern for public safety. What is especially encouraging about “The Fugelli Tactic” is its implication that self-centered attempts to protect one’s turf may ultimately prove counterproductive. A win-win scenario may be possible. At least since the time of the medieval guilds, professionals of all types have sought government-sanctioned monopolies in their areas of expertise. In the area of spinal manipulation, medical physicians fought a long and ultimately unsuccessful political battle to contain and eliminate chiropractors, who they claimed were infringing on the practice of medicine. In like manner, organizations representing chiropractors in the United States currently oppose the practice of spinal manipulation by physical therapists as well as efforts to allow patients to directly access physical therapists without a medical referral. Not to be outdone, national organizations representing physical therapists and osteopathic physicians recently joined forces with the American Medical Association, in late 2001, to oppose legislation to include chiropractic services in Veterans Administration health benefits. Congress accurately assessed the motivation behind their opposition to the bill and enacted it over their heated objections. In the age of information, with open public hearings and records, turf protection is increasingly transparent. Even when temporarily successful, it does its practitioners no credit.

Chiropractic Management of Chronic Low-Back Pain: Commentary on Wilkey et al.

451 Anew study by Wilkey et al. in this issue (pp. 465–473), “A Comparison Between Chiropractic Management and Pain Clinic Management for Chronic Low-Back Pain in an NHS Outpatient Clinic: A Preliminary Study,” in which chiropractic care for chronic low-back pain (CLBP) significantly outperformed medical pain clinic care in an outpatient setting within the National Health Service (United Kingdom), may provide the basis for a breakthrough in the way large health care systems handle CLBP cases. It comes at a moment when chiropractors’ ability to provide adequate courses of care for CLBP is under fire on several fronts, including managed care and worker’s compensation boards in the United States. The core question is whether chiropractic is judged to be effective (and therefore reimbursable) for acute cases only or for chronic cases as well. A corollary issue is whether chiropractic is being required to meet a higher standard of evidence than medical treatments for the same condition. The first wave (1975–2005) of research on chiropractic treatment of low-back pain dealt primarily with acute cases and focused on comparing spinal manipulation to a comparison treatment or placebo. A strong majority of these studies (there are now over 40 randomized controlled trials1 of spinal manipulation for low-back pain) found that manual manipulation outperformed competing options; in no study did a comparison treatment or placebo outperform manipulation. Moreover, not a single participant in any of the trials experienced a major negative reaction to chiropractic care. The evidence supporting spinal manipulation for acute low-back pain is broad and deep, leading government consensus panels in the United States, Canada, Great Britain, Sweden, Denmark, Australia, and New Zealand to recommend spinal manipulation in their low-back pain guidelines, as did recent guidelines jointly developed by the American College of Physicians and the American Pain Society.2 Chronic low-back pain has generally been seen as a separate clinical entity, reflecting the very real challenges posed by chronicity across the spectrum of human illness and across the range of treatments delivered by the various professions. In essence, the longer someone has suffered from a problem, the steeper the climb toward recovery. Overall, guidelines and reviews that endorse spinal manipulation for acute low-back pain have been more hesitant in their conclusions about its efficacy for chronic cases. This has also been true of guidelines evaluating other interventions for low-back pain. We are now entering a second wave of low-back research related to chiropractic. Two major questions at the forefront of researchers’ attention are: