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PROLIFERATION OF CLINICAL MYTHS

A letter, entitled Philosophy sparks outbursts at Stratford, appears in the September issue of Contact. It has prompted this response by staff at the University of Glamorgan. It is, they say, meant to be a general response to the theme of the letter plus a reply to a number of the author's comments.

Philosophical opinion within the chiropractic community is an embroiled and contentious issue. This situation is not solely limited to the UK, but encompasses several international jurisdictions, as reported time and time again in a number of trade documents. Nothing could be more detrimental than internal polarisation of the membership as a result of both misunderstanding and misinterpretation of fundamental professional tenets. Short-term gains at the expense of long term credibility and position are unjustifiable. The "us and them" scenario sends out the wrong message to the public and to other partners in the health care delivery system. As a profession we should be striving to improve inter-professional communication by employing common language, similar clinical guidelines and validated outcomes. This hard-earned process could easily be thwarted with irresponsible statements such as, "Does this make us so different from all other chiropractors out there", implying lack of unity and both intra-and inter-professional isolation. These are views, if broad enough, that could potentially impair growth and influence the nature of future integration and recognition within the primary health care delivery infrastructure. History does repeat itself. Therefore, we should learn from the mishaps encountered in other regions. The leadership of this profession should not permit these misguided powerplays by those bent on attempting to re-shape the future of this profession based on misconceived principles and self interest.

Philosophy, by its very nature, is an intellectual pursuit underpinned by rational investigation, current knowledge and debate. We don't believe there is a chiropractor alive who wouldn't sign on to such a fair process. However, our instincts and experience lead us to believe that there are those who are seemingly blessed with "the philosophy" who are breaking this fundamental rule of the game due to their narrow minded and outdated principles. There aren't too many out there driving Model T Fords or watching black and white television sets. So why should we continue to embrace unfounded principles laid down at the turn of the century when knowledge and science were less understood. More alarming are the sycophants who buy into "the philosophy" because it sounds good, maybe not realising that it is simply another banner for practice building and financial supremacy.

Furthermore, the chiropractic belief system essentially emphasises two basic characteristics. The first is a testable principle whereby the structure and condition of the body influences how the body functions and heals. Well documented neurobiomechanical laws fortify this view. The second is an untestable metaphor that describes the mind-body relationship as instrumental in maintaining health and solely responsible for the healing process (holism). This is clearly problematic. We would be interested to see what steps "the philosophers" are taking to address this claim. If in fact the chiropractic profession is the third largest healthcare provider (certainly not here in the UK) as the author of this article states, then we would dare to say that chiropractors could be guilty of achieving such status by sheer numbers and not by professional achievement. Indeed, does the term "health care provider" also include PTs, massage therapists, aromatherapists and osteopaths? If so are we really the third largest? Fame and merit are two completely different concepts and should not be confused on the scientific playing field.

Notwithstanding, we can only conclude that the author of this article sounds somewhat confused. The author alludes to the fact that chiropractors employ numerous management interventions beyond the adjustment including exercise and rehabilitation protocols. These therapeutic interventions have gained significant support in the literature and provide the framework for a number of recently published clinical guidelines. However, most chiropractors practising today have been poorly educated as to how best to deal with many of these issues. For instance, in order to achieve a successful therapeutic outcome, would it not be prudent to have some idea of the patient's prior knowledge base before embarking upon an explanation of the cause of their ill health; the elusive subluxation, the complexities of which have evaded intellectuals for many decades. Furthermore, reviews of the literature reveal little more than anecdotal evidence with regard to evidence-based patient education strategies for in-office programmes. There is convincing educational research which indicates that in order to influence attitudes and beliefs, strategies have to be directed toward the affective domain. Most in-house educational programmes address the cognitive domain only. Many pamphlets are misleading and at best confuse patients. Moreover, it has been reported that chiropractors tend to view patient education simply (consciously or unconsciously) as a potent marketing tool to assist professional survival, promote financial growth and ensure a place in the health care arena rather than being for the patient's best interest. Business is business and we know that the patient education industry is big business worth millions annually, though sadly, with little regard for supporting or conducting appropriate research. If those who sell educational materials are truly interested in the welfare of patients, then their tariff should be set to cover the cost of reproduction only.

The author goes on to say "we know we are doing something more powerful", which is a totally unsubstantiated, meaningless anecdote and diametrically opposes his reference to evidence based protocols. More powerful than what? More powerful than the body's ability to preserve itself, more powerful than to think and make logical decisions, more powerful than saving a human life or more powerful than leaping a tall building in a single bound? We would really like to know how he proposes to measure the power of such a clinical entity. It's so easy to make these bold statements when it has been shown on numerous occasions that most of our patients are presenting with non-specific, non-life threatening, yet socially relevant low back pain, neck pain or headaches. Furthermore, we know patient satisfaction scores are usually quite favourable following chiropractic care, but it has also been shown that patients are very pleased and satisfied with chiropractic care whether they get better or not. Is it so bad that patients get well despite what we do or is it too much of a blow to the "philosophical" ego to consider such a heresy. There is something special about providing care and enjoying success, but it has to be put into perspective. Playing doctor is a very responsible and accountable position.

Furthermore, it has been said that chiropractic's greatest contribution to health care has been the development of a solid doctor-patient relationship. So, let's not kid ourselves. It may not be what we say (subluxation, pinched nerve, tilted pelvis, herniated disc, sacroiliac syndrome, etc.), but simply the way in which we say it that stimulates some measurable change in patient's general health care status. Some studies support this view. The public have the right to hear the truth about their health and what they can do about it. This is the responsibility of any regulated primary health care professional. We don't think that the intent by which one chiropractor delivers an adjustment is that dissimilar from another practitioner who boasts a strong philosophical approach. Is the author implying that a "philosophical adjustment" is potent than a "mechanistic adjustment"? A blinded randomised trial would challenge that view. Notwithstanding, there is a plethora of evidence which suggests that the physical parameters including force, amplitude and time differs significantly between practitioners. To the best of our knowledge there have been no studies comparing these specific parameters between those with a philosophical or mechanical slant.

Health care is rapidly moving towards a more integrated patient-centre approach as opposed to the antiquated physician-centred "I'll tell you what you need" and "you need to see me for the rest of your life if you want to experience optimal health" paradigm. There is absolutely no evidence to support maintenance or preventative care other than anecdote in most professions. Manipulation, like other therapeutic modalities, is time dependent. Without a doubt, there has been a clear shift in treatment philosophy from passive to active care and from long term sick listing to any early return to work. There is substantial evidence to support this paradigm shift. Moreover, it has been well documented that repeated use of acute care therapeutic interventions (manipulation included) may contribute to chronicity and dependency. Rather, we should be attempting to eradicate these parametres by promoting independent activity and "self sufficiency" together with supportive chiropractic care when clinically indicated as per evidence-based guidelines. However, it would appear that the profession in this country is still very much divided on the issue of evidence-based care and commitment to this shift in health care delivery.

It is offensive to imply that some chiropractors are not providing patients with good care simply because their approach is symptomatic and mechanical, an approach well supported by multidisciplinary expert consensus. They are just as enthusiastic and attentive in their management as the next practitioner. The only difference resides in their conscious endeavour to provide patients with the best available and up to date information concerning the patient's condition in terms they understand. It is also unwise to imply that because of the way some chiropractors practise they are incapable of being driven on by philosophical thought and reasoning. This is both preposterous and na´ve.

In our opinion it is not the chiropractor's role to impose on the public unproven and untestable health care beliefs, which, by the way, don't represent the consensus view of mainstream chiropractic care or health care generally, at least in this country. Implying ignorance of the evidence and disassociating from best practice methods as a way forward for this profession is absolutely absurd and dangerous. Other jurisdictions are addressing some of these issues. For example, the College of Chiropractors of Ontario has recently published a draft proposal concerning their immunisation policy. The policy clearly indicates that the chiropractic profession accepts vaccination as a cost effective and clinically efficient public health preventative procedure. It also stipulates that immunisation is not within the scope of practice of chiropractic but if chiropractors disseminate information it has to be balanced and accurate including scientific research documentation. It is timely that the General Chiropractic Council (GCC) has been sanctioned to develop, regulate and impose professional standards and competency. It is also reassuring that the GCC has set down stringent guidelines for disciplinary action as a result of incompetent practice methods.

It would seem that the regularity of such outbursts by numerous authors in Reflex on many previous occasions is not constant. They seem to increase in times when scientific/medical acceptance is itself increasing and might be seen as a gut reaction as something being lost or taken from the profession by such acceptance. This is psychologically understandable, especially where there is a gap between what a practitioner sees and what science can easily explain. This does not however justify embracing unsubstantiated theories to compensate for clinical incertitude.

In conclusion, our role as educators is to instil a rational sense of inquiry and encourage critical appraisal in our future chiropractors based upon science, common sense, reason and a strong knowledge base. This takes considerable time (4 years minimum) and effort just to initiate the process and the approximately another decade through continuous professional development to refine these skills to specialist level. To view primary health care as eliminating discrete little lesions (subluxation) is truly missing the point and shouldn't take more than a couple of weekends to master. To continue in the proliferation of clinical myths and assumptions regarding patient care is, in our view, professionally unsound.

David Byfield

Susan King

Peter McCarthy

University of Glamorgan

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