While personally I have no problem with the concept of evidence-based
medicine applied to what I do as a chiropractor, however, there are a few
difficulties with trying to use EBM as a way for my whole profession to
practice.
There are historical reasons why the following is true, but there is a
paucity of literature available to allow a chiropractor to determine which
of the various methods employed within the profession is most appropriate to
use with any given patient. (I suspect that others on this list would also
say there is a paucity of literature to support chiropractic care in general
without regard to the specific mode of chiropractic treatment.)
Cooperstein R, Perle SM, Gatterman MI, Lantz C, Schneider MJ. Chiropractic
technique procedures for specific low back conditions: Characterizing the
literature. J Manipulative Physiol Ther 2001;24(6):407-24.
Gatterman MI, Cooperstein R, Lantz C, Perle SM, Schneider MJ. Rating
specific chiropractic technique procedures for common low back conditions. J
Manipulative Physiol Ther 2001;24(7):449-56.
This of course allows one to invoke the oft used phrase "lack of evidence is
not evidence of lack." Obviously it is the responsibility of chiropractic
profession to step up to the plate (sorry for the American idiom) and to do
the research. To this I say we are trying but we lack the funds, personnel
and infrastructure. But we are working on it. See: www.c3r.org
If we look at the medical literature concerning chiropractic prior to, say
1980, very many papers were opinion pieces that discounted chiropractic's
effects without any substantive data. Thus, there are some within the
profession who say, "why should I believe what they publish now, they were
lying before?" or "they have shown themselves to be biased against us, so
why believe what they say?" The "they" of course is mainstream medicine.
Then there are elements of my profession that will not change their mode of
treatment based on the evidence because their personal experience tells them
the evidence is wrong. For example, there is a growing body of literature
that questions the effectiveness of chiropractic care in the management of
asthma:
Nielsen N, Bronfort G, Bendix T, Madsen F, Weeke B. Chronic asthma and
chiropractic spinal manipulation: a randomized clinical trial. Clin Exper
Allergy 1995;25:80-88.
Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O'Shaughnessy D, et al.
A comparison of active and simulated chiropractic manipulation as adjunctive
treatment for childhood asthma. N Engl J Med 1998;339(15):1013-20.
Bronfort G, Evans RL, Kubic P, Filkin P. Chronic pediatric asthma and
chiropractic spinal manipulation: A prospective clinical series and
randomized clinical pilot study. J Manipulative Physiol Ther
2001;24(6):369-77.
In an informal way I have surveyed hundreds of chiropractors at
post-graduate seminars around the US, asking two questions. "Have you
treated a patient with asthma that had a profound positive outcome from the
treatment? By profound positive outcome I mean has gone from a high level
of usage of medication to manage their asthma to requiring no medication."
Invariably a substantial number of hands go up. Then I ask, "Keep your
hands up if you have found that this kind of response is universal." And no
hands are ever left up.
Now I know that this is not a systematic survey but it has reinforced in my
mind two particular aspects of this issue:
1. That with almost all conditions that chiropractors have experience with
positive clinical effect there are patients who we could call responders and
non-responders. The problem is that we do not know on an a priori basis
which is which. Of course the skeptic might say that the responders are just
responding to the placebo effect. To which the doctor with this clinical
experience might respond, who cares if it is placebo or the manipulation
alone that is "working", isn't helping the patient get better the idea?
Regardless of why it happens, I believe that there is some way to identify
the responders from the non-responders prior to treatment. I suspect that
this will require research with much larger samples than have been used in
the past. Or is there another way?
2. A doctor of chiropractic has treated patients with manipulation only and
seen a patient using multiple medications and walking around with an inhaler
that they use, respond to manipulative treatment to the extent that they
never need any medication to maintain their airway. But the literature says
on average we can't help asthma. So I ask the list, are we to tell this
doctor that they did not really see the response they thought they saw? If
so, how do we get them to buy into the literature when their personal
experience is so different? Thinking from that doctor's perspective why
should they believe any of the evidence if they "know" that the evidence is
wrong when it comes to asthma, for example?
_____________________________________________
Stephen M. Perle, D.C.
Associate Professor of Clinical Sciences
University of Bridgeport College of Chiropractic
Bridgeport, CT 06601
www.bridgeport.edu/~perle
______________________________________________
"Be ashamed to die until you have achieved some
victory for humanity."
Horace Mann
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