Len Siskin, DC
Promote Chiropractic,
Co-Chair ICA Best Practices
INTRODUCTION
Communication and honest reporting of scientific observations are the goal of healthcare research. In a recent overview of systematic reviews of randomized clinical control trials (RCT) using complimentary and alternative medicine (CAM) treatments, Katherine Hunt and Edzard Ernst of Peninsula Medical School in the UK point out that chiropractors, among other CAM professionals, have nearly failed to show RCT’s supporting claims of helping children1. I would like to thank Dr. Matthew McCoy for bringing this to paper to our attention2. The authors reinforce that they were simply using literature searches to overview existing reviews and did not actually read the original research papers themselves. They noted the failure of CAM professions, including chiropractic to produce adequate numbers of these types of reviews which are common in mainstream medicine. Be careful.
I am a practicing chiropractor and at first I became defensive when reading this paper. I was prepared to discuss the limitations of RCT’s in guiding clinical practice and the masses of research omitted by these authors. When I thought for a moment I realized the world of evidence based medicine values these types of evaluations so much they might not be so interested to know the volumes of research that exist. They are looking for a certain type of research performed by each healthcare profession and in the absence of reviews on chiropractic RCT’s they conclude that chiropractic care is ineffective for things chiropractors claim they can help in the pediatric population.
When looking at the numbers, 99 articles were located covering reviews of RCT’s spanning CAM professions of acupuncture/acupressure, Alexander technique, Aromatherapy, Bach Flower remedies, chiropractic, craniosacral therapy, herbal medicine, homeopathy, hypnotherapy/hypnosis, massage, naturopathy, osteopathy, spiritual healing, Tai chi, traditional Chinese medicine, and yoga. Twenty of these articles were included in this overview of which 4 appear to be chiropractic.
In their critical review aimed at assessing the effectiveness and safety of CAM for infants, children, and adolescents, the authors looked only at reviews of RCT’s to maximize reliability and validity of the review. Admittedly this excludes all other forms of evidence which is a problem when RCT’s are not available. The authors observe only one of three total RCT’s for colic using chiropractic was performed reasonably and showed no significant improvement with chiropractic treatment. This does not take into account the information in the ICA’s Best practices database which shows only 2 (not 3 because the third RCT reviewed has not yet been incorporated to the database) RCT’s and than 20 additional papers on colic and chiropractic where all papers showed improvement with chiropractic care and no adverse effects were noted.
It should be mentioned that because 19 of the 20 additional studies were case reports here a system of rating traits of the case report mathematically shows the data equivalent to .6 RCT value per paper on average and the total quality score is equivalent to about 12 RCT’s. Unfortunately for both our profession and for the understanding society has about chiropractic, the tendency in healthcare science is to ignore the lower profile and often more clinically representative research but in CAM professions, there has notoriously been little no funding with little emphasis for higher quality research so the lower quality research represents the vast majority of what exists for us to communicate the benefits of what we do to the scientific world.
The authors suggest claims about chiropractic helping otitis media are baseless as they were unable to find any reviews on this topic of RCT’s. Fifteen level III and IV studies were found in the ICA Best practices research database equivalent in point scores to nearly 10 RCT studies. Fourteen of the 15 papers showed positive treatment outcomes and one paper was inconclusive. No adverse effects were noted in any paper.
As for nocturnal enuresis, the authors found insufficient RCT reviews to suggest chiropractic can help. The ICA Best practices database shows 9 papers published on chiropractic helping this condition equivalent to 6 RCT’s in quality points where all papers showed positive outcomes and no adverse effects.
The truth of the matter is the Best Practices Database of the ICA shows about 290 papers on chiropractic treatment in children where all but 2 show positive outcomes and none show adverse effects. Many dozens of named medical conditions were shown to improve in these papers because of chiropractic care. The authors of the overview paper discussed here make the statement, “Our analyses do not reveal consistent evidence to suggest that CAM is effective for pediatric conditions.”
When I want to eat Chinese food in New York City I would not go to Little Italy even though it is across the street from Chinatown. If I want Chinese food I should cross the street to Chinatown! If I were looking for Chinese restaurants in Little Italy I might conclude that New York City is void of Chinese restaurants. Dr. McCoy recently urged chiropractors to subscribe to peer reviewed chiropractic journals to show that chiropractors are conscientious about the research in our profession and to prove to the world we care. Furthermore, he urged chiropractors and chiropractic organizations to publish more research. The discussed overview of reviews of CAM RCT’s written by professionals in mainstream medicine sadly conclude what this author found to be negative about the entire CAM industry. Without good quality chiropractic research and a vehicle to communicate and publicize that research our profession will continue to be represented in this negative light.
Problematically, insurance companies, guideline developers, and ‘other reviewers’ are likely to use papers like the Hunt and Ernst1 one which misrepresent our existing research and to some extent vilify CAM to deny payment for care. Consumers will be left with the personal financial responsibility without the real information behind what we do. If you are reading this and want to defend what you do a good step would be to go online to www.chiropractic.org and purchase a copy of the very readable ICA Best Practices Guidelines and also a copy of the ICA’s Practicing Chiropractors Committee on Radiology Protocols (PCCRP) Guidelines if you take chiropractic x-rays. The monies spent to purchase these materials go to educating accrediting bodies, law firms, state boards, malpractice insurance companies, etc.
These two ICA based Chiropractic practice guidelines also help defend chiropractors in lawsuits. The information in these resources will prove vital to any chiropractor writing a report to a patient, other professional or third party payer. Support our great profession and protect your practice by purchasing these materials and subscribe to a scientific journal! Join organizations within our profession who support your philosophy of chiropractic and be very careful when discounting what role research will play in your future ability to help the people who honor you with their trust and health status.
References
- Hunt, Katherine; Ernst, Edzard. The evidence base for complimentary medicine in children: a critical overview of systematic reviews; ADC Online July 6, 2010; 10.1136/adc.2009.179036 BMJ Publishing Group
- McCoy, Matthew Ernst Slams Chiropractic for Children; http://researchupdate.mccoypress.net/2010/07/29/dont-just-sit-there.aspx