The Race for Scientific Ownership of Manipulation

With the rapid dissemination via technology, I find it hard to believe that this article was published in April 2005 and that I first came across it this morning browsing around different chiropractic websites. This should be mandatory reading for all physical therapists - not because it references some of our work, but because it expresses why physical therapists have become such a threat to the chiropractic profession.

As much as I support the APTA, PT-PAC, and all the political efforts that go into supporting physical therapist practice (and every physical therapist should be an APTA member and contribute to the PAC!), the primary path to professional autonomy is through clinical research and support of organizations like the Foundation for Physical Therapy and the American Academy of Orthopaedic and Manual Physical Therapists. If you look at the studies referenced in this article, virtually all of them can be traced back to the Foundation. Our profession owes organizations like the Foundation and American Academy of Orthopaedic and Manual Physical Therapists and their supporters a great debt of thanks. If you have not made a donation this year, you should seriously consider doing so now! Our profession’s future hinges on growing physical therapist clinician scientists.

This article also summarizes why the chiropractic profession is in dire need of major reform. The underlying foundation of chiropractic – the vertebral subluxation complex – is a ‘house built of straw’. The problem for the chiropractors is there are not enough credible ones like Bill Meeker who get it. Organizations like the ACA are too busy writing letters to the editor defending their ‘turf’ rather than investing in the resources necessary to grow the science of their profession.

If you are a genuine evidence-based chiropractor, I would suggest you become a physical therapist. You are getting left behind by your profession, while other health care professionals readily understand that evidence is the ‘common currency’ that will drive health care for the foreseeable future. The chiropractic professional associations have invested thousands of your hard earned dollars in fruitless (they have had a few victories) political and legal efforts rather than growing scientists skilled in clinical research. I truly feel bad for those chiropractors out there demanding reform, only to be ignored by their professional associations’ ill informed agendas. This is why I continue to reiterate that our best days as a profession are ahead of us. Make your donation to the Foundation for Physical Therapy today. Combined with a membership in APTA if you are not already a member, it's the best investment you will make all year.

John

Comments

[Anthony Delitto]

Meeker has been preeching to the chiros for a while about their lack of research. I remember he once published a survey analysis that stated that over 70% of faculty at chiro schools have never published a single paper. Chiros have their own foundation (Foundation for Chiropractic Education and research). My previous dealings with them suggests a heavy dose of political contamination in their operations.

[John Goodrich]

Dear John, Thanks for the article. My concern at this point is that while we may be ahead in the research battle, it is very hard to keep up with the public relations wars. A recent article by Hurwitz in Medical Care was reviewed in the Back Letter with the lead in that "Physical therapy is an expensive add-on to standard medical care for low back pain but provides no demonstrable clinical benefit..." This should be our wake-up call to embrace the evidence and move to more standardized care. If you have not done so already, I wonder if you could post comments on this article and the editorial by Freburger (Medical Care, Vol 43(5)). Thanks, John Goodrich

[Britt Smith]

Sorry...inspired by e.e. cummings or a slow learning curve with technology.
britt

[Britt Smith]

Great post, John.
You would have thought the chiropractic profession would have alerted to the issues of 'scientific ownership of manipulation,' when Johnson & Rogers wrote, at the turn of the century (love that term), the editorial demonstrating that the AHCPR guidelines recommending manipulation for acute LBP was based on a majority of evidence from physical therapy studies and studies in which PTs performed the manipulations. Unfortunately, presenting the information as an editorial in Physical Therapy let the information slide under everyone's radar screen: PT community, chiropractors, and the general public.
The defense of PTs as providers of manipulation after the AHCPR guidelines in 1994, has often come from such unlikely persons as Richard Deyo MD. In a letter to the Sci. Amer. 1998 editor from a chiropractor stating “In the 1994 U.S. Agency for Healthcare Policy and Research (AHCPR), in a landmark study on back pain, found that the treatment of choice was chiropractic care.”
Deyo responded: “I was a member of the AHCPR panel that produced the report Walz mentioned.… It did not indicate that chiropractic therapy was the ‘treatment of choice.’" and he followed, “The guideline did, however, discuss spinal manipulation, which may be provided not only by chiropractors, but by osteopathic physicians and physical therapists among others.” (Sci. Amer. Dec. 1998.)
I believe the Systematic Review from Annals in 2004 greatly toned down recommendations for manipulation (and discounted the identification of a subgroup of responders), in part, as a political response to continued mis-representation of the evidence by the chiropractic community. Evidence: I believe the evaluators of the evidence were purged of any manipulators (previously all chiropractors)...Assendelft in 1995 stated “…a review of spinal manipulation is more likely to have a positive outcome if the review deals with spinal manipulation only, if a spinal manipulator was among the authors, & if a comprehensive search was described.”...but he further states, “It can be equally true that reviewers who were not spinal manipulators were biased against the therapy.” [Last sentence in monograph in JAMA, 1995]
Now, Shekelle (one of the Annals 2004 authors) has acknowledged that the reports of the death of the subgroup concept 'may be greatly exaggerated'[forgive me Mark Twain]: “There is a glimmer of hope in other publications that it might be possible to identify patients with LBP who respond preferentially to specific treatments. Childs et al 2004 showed that a simple rule anticipated a (+) response to treatment with manipulation. Furthermore, the CPR identified only about 35% of their patients as suitable candidates for manipulation…The positive outcome in this subgroup persisted at 6-months follow-up, under-scoring the potential efficiency of targeting such interventions more precisely.”(Shekelle, Delitto commentary on Hayes et al, Lancet 2005.
Keep up the great work on research and development of the treatment-based classification. Kudos to Delitto, Erhard, Fritz, Flynn, Wainner, Childs et al. for the terrific contributions to our profession. OUR colleagues and profession must also heed the clarion call to promote and develop sound scientific foundations for our clinical practice and implement, change, develop and refine our practice in accordance with the research.
Thanks again for a great posting and information.
Britt

[Jeff Hebert, DC]

Dr. Childs,

As is typically the norm, I find very little to disagree with in your post...with one exception. Having chiropractors pursue a second clinical doctorate (DPT) is not a reasonable course for the vast majority of my profession. What I would like to see is some type of "bridge" program for DC's practicing in a reasonable musculoskeletal model to transition into a DPT. Given that there is no shortage of P.T. students, I would not expect the P.T. profession to be overly enthusiastic of this option.

Dr. Meeker has been a voice of reason within the chiropractic profession for many years. There are also a number of others who are trying to steer the profession in a more reasonable direction, my hope is that one day, it will make a difference. Meanwhile, physical therapists have certainly been at the forefront of research in the realm of manual therapy, for which there are a number of reasons. I agree that the most significant factor is that chiropractors and the professional associations have not made this a true priority. I would also venture that your profession has greater resources, more access to mainstream funding sources/facilities, as well as closer ties to the academic community. Please do not view this as an excuse for chiropractic's research track-record, I just feel that the problem is multifaceted.

Jeff

[Selena Horner]

You know what hits me initially with what Dr. Meeker wrote... well, if the chiropractors are reading the research and if chiropractors tend to manipulate everyone that walks through their doors (this would be just an assumption on my part) - wouldn't it give them pause to think that via the evidence, not every patient responds to manipulation with a favorable outcome and that to reach the best outcomes manipulation should be done on the appropriate population?

[Michael DuPriest DC PT OCS DABCO]

Wow. This brings back memories to the mid 80's, as a young PT just entering chiropractic school. Yes, I did receive positive advice from Dick Erhard in 1984. For me, practicing in Arkansas, this has played out much better than I would have ever dreamed possible.

Having both degrees has essentially placed me on a professional fence. Having PT students rotate through my clinic for 10 + years I invariably was asked this question: "How can you practice both chiropractic and physical therapy? They are so different!" You know I never really could understand that question. Yes, I am probably not that smart, but the only differences I could see was based in philosophy and 1 specific procedure. Chiropractic was steeped toward patient dependence and PT toward independence. Chiropractors used manipulation and PT’s did not. Some of you will probably take exception to the latter but, in Arkansas that’s the status quo.

As you all probably know in Arkansas PT’s are not allowed by statute to perform manipulation. I am sure you are aware of Michael Teston’s situation with the Arkansas State Board of Chiropractic Examiners. In the mid 90’s I received a number of inquires by politically active PTs regarding the Arkansas PT law. My advice was and has been that until manipulation is made a part of the education a PT receives then you will have a hard time convincing state policy makers to write this into the PT scope of practice. DC’s will point to the level of training they receive (extensive) and that PT’s receive (variable or none) and the rest is history.

I may be wrong and please correct me but, I believe that a lot of the current research relative to manipulation in PT circles is being produced by military PTs. Different world than out her where I live.

The PT students I come in contact with from the local Arkansas PT school, a DPT program, seem to be fairly clueless about how to treat acute nonspecific LBP. When you put an x-ray up they can tell you the views, but not much else. Forget MRI, they do not understand what a T1 or T2 weighted image means. You would think that when I do manipulation in their presence I was practicing voodoo. They would be much more comfortable if I applied heat and EMS.

What really bothers me is that we have 2 professions (DC and PT) that have not stepped fully forward to fill the gap between family practice and orthopedic surgery. DC’s continue to perform the bulk of manipulative therapy and PT’s are trying to become doctors. I guess you do that first and then you add your skills.

In 1985 I had the opportunity to become involved in the National Association of Chiropractic Medicine. I was a PT in DC school and was drawn to the goals the NACM proposed. Dr Ron Slaughter, who wrote the position paper, founded the organization with the intent to make positive change, i.e. to encourage the profession to move from philosophy and pseudo-science to evidenced based practice. The term EBP was not used then but, inherent in what Dr Slaughter was saying.

The chiropractic profession viewed Ron as a heretic and coined the term to describe him as a “medi-practor”. He took a lot of crap for many years from a profession that did not appreciate or grasp the consequ3eces of the road they were choosing.

I would like to present some excerpts from Dr Slaughters paper as they are applicable to both professions.

“Because of the failure of philosophical approaches to health delivery, divergent views come into being. To accept that the philosophy is wrong and science is right would be to abandon the reason to be a chiropractor. Therefore, when philosophy fails to answer real problems of patient handling the tendency is to resort to natural methods of healing; i.e. naturopathy, herbology, homeopathy, etc. Acceptance is great for anything that is natural and non-medical. Hence, the anti-science, anti-medicine, anti-surgery and anti-drug mentality is perpetuated in chiropractic education. Adulteration by natural methods, then leads to further fractionation of the profession, further non-standardization and lack of diagnostic methodology.”

“There is a huge gap in medicine today between the general practitioner and the orthopedic surgeon. If one has a musculoskeletal condition of a non-surgical nature, there is little lat medicine has to offer to the general population. Just as dentistry, podiatry, and optometry filled gaps in medicine, so could have chiropractic filled this area as a physician specializing in non-surgical conditions. Dentistry, podiatry, and optometry took the sciences that developed and circumscribed their practices to become skilled in their respective areas. Chiropractic did not do this. Only because of its skills developed in manipulative therapy have they something of value to offer to the public today. Ironically, because of chiropractic insistence on the universal use of this therapy, medicine ignored this treatment and allowed the chiropractor the means to continue existence. “

“Now spinal manipulative therapy is receiving the attention is so richly deserves in many areas of the sciences. Will medicine finally offer the competition in this area so vital to chiropractic? Unquestionably so- the trend has already begun. Will chiropractic see the the handwriting on the wall and move to correct its past failing in time to avert total annihilation? This is the question I must ask as a Doctor of Chiropractic. The incidence of back pain in the developed nations today demands rational and effective treatment. A part of this treatment will unquestionably be SMT. The question is, what degree will the spinal manipulator hold in the future; A DC or MD?”

I forwarded this discussion to Ron and received this response:

“I do not remember what I wrote yesterday much less back in the 80's (I wrote so much stuff that nobody ever paid any attention to it became irrelevant). What you do not know is that I BEGGED Pres. of TCC to offer a D. C. degree to any licensed P. T. in the State of Texas back in the late 70's for an 18 month course in manipulative therapy. My argument being----"take an enemy and make them a 'partner'". Of course----nobody listened. In fact---as always---I was regarded a 'turncoat', "no-hopper", "defeatist" and, of course, a "medi-practor".

I don't care anymore. The P.T.'s should get their Doctorate. THAT IS THE FUTURE. I NOW and ALWAYS will believe that MANIPULATION has a huge role to play in the relief of spinal pain. Go back to my paper at the FDA sponsored Health Fraud Conference at St. Mary's Hospital in Kansas City in 1987. I chaired two workshops (the most highly attended at the entire workshop) and I BLAMED the A.M.A. as much as the Chiropractic profession for the quackery in spinal manipulation because of the lack of real investigation of it. After my talk I was met in the hall by M.D.;s of the AMA education council who told me they agreed with what I had to say. It was not long thereafter that the Rand Study was done.

Oh well.

Hell.

I did what I could

Hx. will tell

Rs”

What you should note is that PT’s were not even on the radar screen when Ron wrote this. I am sure now he would have inserted “ PT or DC.” If the trend continues knowledge is power and PT’s will be on top. However, PT must make changes in the educational process.

Mike

[Ben Hando]

Michael- thanks for that interesting post. I think most would agree that we need more focus on manipulative Rx during PT education, and thank goodness for the great effort by the manip task force and others to remedy this. However, a big part of educating future clinicians comes from the clinical ed. portion. Most of us that teach manipulation to our students would also report the kind of initial reaction from students you described here (voodoo)-but by the end of their rotation, this confusion ideally has been replaced by competence in a few basic techniques and a new found confidence in managing low back pain.

I realize you have a difficult situation in Ark., but I think C.I's should make manipulation a focus of their mentoring/instruction. This isn't something that academia should bear alone.

-Ben

p.s. I would contend that interpreting x-rays of patients with acute-nonspecific LBP is probably not one of the more important skills needed to manage these pt's.

[Britt Smith]

Mike,
Very interesting comments, thank you. Ron Slaughter DC is to be lauded for his vision on changing the chiropractic profession. Unfortunately for him, he was ostricized by his peers. J.J. Nugent (1891-1979) was a student and faculty at Palmer Chiropractic College in the early 1900's. He attempted to reform chiropractic education and was booted out by B.J. Palmer, who called him the 'Anti-Christ' of chiropractic. Nugent went on the be a major force in the reformation of the chiropractic education system, forming the National Council on Chiropractic Examining Boards in 1935, which Palmer resisted until his death, as a very wealthy man, in the early 1960s.
Some of the chiropractic profession are reasonable and enlightened and some are 'a tough audience'. Most telling about the little vignette is the use of the term 'Anti-Christ'...not quite a term one would use with a scientific argument. The difficulty of the chiropractic history, which has been an asset at time, is this quasi-religious fervor and anti-scientific, or perhaps a 'scientism', view.
Thanks again, Britt

[Jason Silvernail]

Great comments, everyone.
Mike- thanks for your perspective.

However, for every DPT student you say has no clue about how to treat LBP, I have another one (yes, from civilian programs) who comes with basic knowledge and a few techniques they have a passing familiarity with. If anyone's education system needs revamping, surely you don't mean the PT side of the house?

Ben- you're right in that we, as clinical instructors of these students, need to be the ones demanding that they have these (let's be honest, very basic) treatment skills. In my clinic, a student can no more choose not to use manipulation than they can choose not to provide strengthening exercise to a postop ACL reconstruction patient. Research (by civilian as well as military PTs) has really stripped this basic therapeutic modality of it's mysticism and secrecy. But I don't blame the chiros for being upset, I'd be mad too if I went to school for four years just to do one thing. Something that turns out to be a lot more general, nonspecific, and simple to perform than anyone ever imagined.

I think Mike's comment about the management of nonsurgical musculoskeletal conditions and bridging the gap between family medicine and orthopedic surgery is a great point, and something we all should be ascribing to do.

I just spent all of 15 minutes teaching a PT student just today how to do the basic lumbosacral manipulation from the CPR study. And to think some people spend years at school for that... how ridiculous.

J