“Studying real world results is a ‘messy’ business. But it is important to study not only how patients could be treated but also how they are being treated.”
Coleman et. al. JMPT 2003
That was true when I first wrote those words, and it’s still true today. What does that have to do with our story? Well, many of you have given suggestions about what studies we should do at G.C.S.S. First, we want to hear those ideas, because you may be the person that has the idea that revolutionizes chiropractic. When we bring up some things that may be obstacles to a particular study, it doesn’t mean that it is not something that would be good to do or even something that future events may make it become something that must be done. It just means that there are difficulties with that particular study at this time. So let’s go through some of them and see if we can show some things that may make them complex to accomplish—i.e., complex at this time. The world changes quickly, and tomorrow, it may be a whole different matter.)
So here are some of the suggestions and some things that make them difficult to get published in a science journal that is listed in PubMed.
1. Menstrual pain due to SI instability/misalignment.
Thoughts: This is a human study, therefore, reviewers will point out that you took radiographs to look at the spine for a non-red flag reason. The idea that SI joints move very little under normal circumstances would be difficult to overcome, due to the sophisticated imaging that is used in good studies to evaluate this motion. It is a very expensive endeavor. But the human being x-rayed is what will probably get the editor to start feeling queasy. contiguous vertebrae of the 3-joint complex.
2. Vertebral disc degeneration due to hypomobility of contiguous vertebrae of the 3-joint complex.
Thoughts: We would need proof of hypomobility, meaning radiographs or fluoroscopy and then a follow up many years later. We would need a large enough number of individuals, probably at least 30, to get any meaningful data, which wouldn’t be enough for extrapolating to other populations. This would be difficult, if not impossible, to get through the IRB (Institutional Review Board), which is necessary for permission just to get started, or it would not be published. This study would cost tens of thousands of dollars, at least.
3. Hypertension due to sympathetic hyperactivity.
Thoughts: Recently, there has been an article that indicated that chiropractors could not show that their care substantially improved hypertension. I’ve certainly seen personal evidence in my practice that convinced me that chiropractic can make changes in at least some cases. As it stands right now, we’d have to overcome some literature, but I think this one is quite promising, and I’d like to see it done. The challenge would be testing and monitoring sympathetic activity. One could use blood tests, skin temperature or galvanic skin response or some other marker. The bigger picture suggests that the mechanism is not as simple as ‘sympathetic hyperactivity’ alone, but the balance in the autonomic function overall. These are interesting and complicated at the same time.
4. Sympathetic vs. Parasympathetic conditions.
Thoughts: I always like it when someone frames a problem broadly, because it gives me a lot of room to pick out a part that can be studied. This is one of those times. You’d have a really hard time looking at this in one bite, but in many, many small bites, you might have something.
5. Frequency of adjusting (what is appropriate, what is excessive, possible side effects).
Thoughts: There have been a number of studies that mentioned the side effects that they found from SMT. Fortunately, these statements on side effects are generally not too bad for us. There are exceptions, but many authors have approached the side effects issue in a reasonable manner. I would love to address the frequency of adjustments issue, but I admit that I have a huge bias. I personally think that a patient should be adjusted every time you find a subluxation. If you need to adjust them every day, that’s great with me—two times a day, and I’m still happy. Every 15 minutes? I know of a child that had spinal meningitis as a boy whose father was a chiropractor. They had a chiropractor stay with him 24 hours a day, and every time he needed an adjustment, he got one. His father told me that at the worst, it was about every 15 minutes. That boy became my best friend, and he’s 63 now. His father was my doctor of chiropractic. So I’m biased, and I’m pretty sure that I’d have hard time getting a paper published with my present thoughts. As a general rule, I feel that chiropractors don’t adjust often enough.
This is very doable. We could use the Diplomates and Fellows to collect data retrospectively and outcome measures, such as, soft data forms (SF-36, Oswestry, etc.). We could see what is being done and if there is an association of outcomes with ranges in visits frequency, etc. There have been some studies already that looked at this issue in different ways, but we could do one with Gonstead specifically, even if we just published it in-house, but it could be publishable in a reputable journal as well.
6. The importance of specificity.
Thoughts: I would really love to do one. I think it is really true and important, but it would be very difficult. We have a lot of basic science stuff to do before that. Some examples are: a) show you can actually locate the vertebrae you want to adjust in clinical practice; b) how how many vertebrae move when you adjust; and c) how you can move the segment(s) in the direction that you desire. These are just some of the challenges. It amazes me that the chiropractic profession has looked at so many things and skipped over so many basic questions that are fundamental to understanding what we do. We should have done this long ago. So why do you continue to donate money to colleges that neglect this basic type of research? Want to change a world? Then get on the board of directors of a college and make these types of statements.
7. Treatment of visceral conditions.
Thoughts: Read the article in the journal Chiropractic History on type O disorders by Stephan Troyanovich. It very accurately sums up the present situation on that subject. This is a long but difficult subject that once again should have been studied long ago. (Refer to the part above about getting on a college board of directors.)
8. Mixing systems.
Thoughts: First, we would need to show that treatment can be system specific, as minor studies suggest but don’t show well. Then, we would need conditions thought to be system specific, deliver both mixed and specific system care, and view the outcomes with reliable measures. This is a multi-layer project that would take specific types of patients, with lots of time and money required.
9. Chiropractic effects on children.
Thoughts: We really don’t have the money to get into very far into this arena. It is being studied by a much better funded group (ICPA). But it is a great area of inquiry.
10. Knee chest vs. other types of adjustments.
Thoughts. This can certainly be done. There are some technical problems, but it can be done. Finding reviewers who don’t merely scoff at the idea of comparing one type of adjustment to another as opposed to just calling it SMT or finding an editor who is actually interested in the subject and would give it the space in their journal might be the biggest problems.
We would have to do with simple outcomes: patient satisfaction, relative symptom responses on soft data measures or something like that, or we probably couldn’t get it approved, since x-raying people for this type of experiment would get challenged by the IRB.
11. Need to differentiate us and explain “why” we do “what” we do.
Thoughts: I would love to see that one done really well. I go back to the need for a lot of basic research to be answered before that can be done really well. In the end, that’s a question that needs to be answered.
This can also be done in a position paper type of editorial format by anyone with a mind to do so. Someone could write up what it is to be a Gonstead practitioner vs. other types of chiropractors and submit it to Dynamic Chiropractic or other trade-type publication, versus, a peer-reviewed journal. This kind of writing is very important and just requires, experience, deep thinking, and literature review as needed. It requires good writing skills, as well as, the motivation and time to do so. Oh, a thick skin is also helpful and be sure to remember the phrase, “we would like to thank the reviewers for their helpful comments.”
12. Overall health improvement and/or overall healthcare, costs of patients under wellness care (2 or less adjustments per month).
Thoughts: It’s a good subject, and there has been some work done in this area that was encouraging, although, not as broadly defined as you have here. But this is certainly doable and important. Refer to number 5.
13. Postural improvement with adjustments.
Thoughts: For a few years, I did a pre- and post-G.S.A. (a postural measuring device) reading for each adjustment. Yep, I got changes. I did it as part of care, and I became convinced that chiropractic made postural changes. Now the G.S.A. was never validated for accuracy. There are other methods, and we could certainly do such a study. It would be a good idea. It takes time, planning, prioritizing (which at this time may be not soon), and see number 5.
14. Scoliosis studies: pre and post films.
Thoughts: I worked on an article like that. Michael Menke and Greg Plaugher put it together but couldn’t get it published in JMPT. There were some problems, because we were taking a second look at data from a prior study. But it did get published in the Journal of the Arizona-Nevada Academy of Science. It was later presented at the 50th. Annual meeting of the Arizona-Nevada Academy of Science where it received an award. Just goes to show, you don’t have all the knowledge in the world locked up in JMPT. (OK, so the movie buffs among you will recognize the fact that I just reworked a line delivered by Henry Fonda in Spencer’s Mountain, but it’s true.) However, we might be able to redo the whole study. As radiographs are used to track scoliosis cases we might avoid that objection. It’s a great field for inquiry.
18. Subluxation correction demonstrated on post- radiographs and lab indices.
Thoughts: Great idea. Please see number 1 about x-rays. It would have to be retrospective study to be within budget and to pass IRB. We are doing something like this now with post-radiograph and posture changes.
19. Resolution of clinical conditions pitted against pharmaceuticals, surgery, and P.T. (randomized controlled trials, double blind studies, etc)
Thoughts: I’ve seen some things in this vein, and it’s a good idea. But these type of studies are not about specific Gonstead adjustments; they are about SMT. That just drives me crazy, but that’s just me. This is a huge undertaking and unrealistic for our small budget. But we do find much to be said in favor of BJ’s statement, “Chiropractic first, medicine second and surgery last.”
We have taken the suggestions that we received and tried to make a quick note on each one, because we respect your thoughts, which is much different than a lot of college research departments that research things that have little interest to you. But all of your suggestions have one thing in common: they take time and money. They take a lot of time, because we have very limited money. Our whole budget is probably less than what it costs a major study to employ a full-time secretary. But considering everything, we’ve done pretty well so far, and we hope to do even better in the future.
For those of you who made these suggestions, we probably didn’t answer your particular suggestion in sufficient detail for you. Please feel free to call Roger at any time and talk about your thoughts. But, we really do have to “crawl before we walk and walk before we run.” Although, frankly, we’re already crawling well. So thanks for all your suggestions and all your support. We are the mice that roar, and we’re proud of what we’ve accomplished.
Another year is coming to an end, we’ve done a lot, and a lot is already scheduled for 2013. We’ll talk about that next time. For now, thank you so much for your support and thoughts, and in this season of joy, God bless you, every one.
Roger R. Coleman, DC
Mark A. Lopes, DC
Ed: A 2012 issue of Journal of Manual & Manipulative Therapy stated that PTs drove thrust-manipulation research—food-for-thought and shame on us.