Evidence-based practice has never been a hotter topic of conversation; unfortunately, much of the debate has centered around what constitutes ‘evidence’ and this has highlighted the widening chasm between researchers, who disregard anything that is not, randomized, controlled and, preferably, double-blinded, and clinicians who are far more interested in clinical outcomes for the individual patients they observe and treat every day than p-values. This problem has beset the medical profession for many years1; now, it appears, chiropractors are falling into the same trap.
The term ‘evidence-based’ therefore, and increasingly, has different meanings for the two groups: for researchers, the only evidence that matters is that derived from randomised controlled trials (RCTs) and the subsequent systematic reviews and meta-analyses; for clinicians, the traditional model of a knowledge base working in harmony with their own clinical experience and patients’ expectations, is what matters. A clinician is far more likely to pay attention to a cohort study, case control study or even case series if it gels with their own experiences than to heed a large RCT that contradicts them; this problem is often compounded by the fact that RCTs are often based away from the ‘real life’ situation of clinical practice and, for the sake of homogeneity, excludes significant sub-populations.
Even more germane is the nature of the research questions being asked: as the recently commissioned review by Bronfort et al.2 has demonstrated, researchers have been singularly poor at asking the right questions; although chiropractic has, up until now, benefited from this, the time has now come to ensure that the profession's future scope of practice is not threatened by research that is as meaningless and it is detrimental.
Firstly, there is the widely held assumption that all manual therapy is equal – osteopathy, physiotherapy, chiropractic … it's all the same thing: how frequently do we see trials on one profession's interventions being extrapolated to cover spinal manipulation in general or even manual therapy as a whole without any evidence to show that this is valid? Conversely, a recent trial showing no benefit when comparing manipulative physiotherapy to non-steroidal anti-inflammatory drugs for low back pain, was widely interpreted – and reported – as “Chiropractic doesn’t work for back pain”.
I am not a spinal manipulative therapist; I am a chiropractor – and I seem to recall learning an awful lot at College (and even more since) that did not merely involve cavitating patients’ joints. To limit chiropractic to spinal manipulative therapy is preposterous; to assume that one profession's education standards, diagnostic capabilities, treatment ethos and approach can be unquestioningly equated to another's equally so – yet where are the trials on ‘chiropractic management’? The reductionism of the RCT has limited the investigation to a single intervention.
The RCT also has limited value when looking at sub-populations; for chiropractic this has not mattered too much in the past – there are enough sub-populations in the low back pain group that can be helped by chiropractic management to produce positive results. How about infantile colic though? Here we have a perfect – and currently highly controversial – example of an intervention for which there is ‘no evidence’,2, 3 an opinion that flies in the face of many practitioners’ experiences and a large number of observational reports. Leaving aside the validity of comparing chiropractic treatment with ‘sham’ manipulation, there is one blindingly obvious reason why the research base is not only inadequate but is actually meaningless: infantile colic is not a disease, it is a symptom and its diagnosis is purely clinical, based on the ‘rule of threes’ – paroxysms of crying and fussing lasting for a total of three hours a day and occurring more than three days a week for at least three weeks.
It does not take a healthcare professional to realise that there are a variety of reasons as to why babies cry, ranging from gastrointestinal pain to sheer bloody-mindedness – as any parent can testify. It is entirely probable that any babies with a vertebrogenic (and/or cranial) aetiology to their symptoms are being masked by the large numbers of patients who do not have such an aetiology.
Based on my own clinical experience of treating several hundred cases of infantile colic with a 95%
+success rate, I find it improbable that so many cases spontaneously self-resolved within hours of a first or, more commonly, second treatment although, as a researcher, I also appreciate I may be deluding myself as to cause and effect, as are the dozens of colleagues who report the same experiences to me.
My own clinical experience also tells me that parental reassurance, ergonomic consideration, diet, feeding habits and environment are also important considerations and that babies with displacement of the external occipital protuberance (EOP) and the axis to the left are far more likely to respond to treatment than other presentations and that, when accompanied by fixations in the mid- to lower-thoracic spine, resolution is more likely to take two treatments than one.
What I would now like to see is an RCT on chiropractic management of the sub-population of babies suffering from the ‘rule of three’ with left displacement of the axis and EOP – only when that proves negative will I stop advising parents to bring in their babies!
This issue does offer some hope to the beleaguered and bewildered clinician, the second part of the proceedings of the European Chiropractic Convention offers a partial snapshot of the current state of play of European research. There is a refreshing lack of inappropriate RCTs; instead observational, qualitative and cohort studies are investigating new areas of chiropractic intervention and identifying the sub-groups that do and do not show response to chiropractic management. Hopefully, such insightful research will lead to the changes in research ethos that will move away from the search for ‘magic bullet’ cure for symptoms and instead inform and improve chiropractic practice rather than confound and homogenise manual medicine.
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