When Research Challenges Our Assumptions

SOURCE: ACA News ~ Sept 2012

By Daniel Redwood

When new research, research reviews or practice guidelines support our current beliefs and practices, enthusiasm comes easily. When the 2007 medical practice guidelines on low back pain (LBP) jointly prepared by the American Pain Society and the American College of Physicians recognized spinal manipulation as the only non-pharmacologic method providing “proven benefits” for acute LBP and as one of several methods (including exercise, rehabilitation, acupuncture and yoga) proven effective for chronic LBP, the American Chiropractic Association and doctors of chiropractic (DCs) everywhere welcomed this as a long-overdue recognition of the value of our primary treatment methods.

But when research challenges our assumptions, our responses are understandably mixed. Such findings, if confirmed in multiple studies, may create pressure to change our practice patterns or threaten reimbursement from insurance companies. Like members of other health professions, DCs do not find such developments pleasant. How we and members of other health professions respond to such research says a great deal about who we are, how fully we practice what we preach, and the depth of our commitment to providing the best possible care to our patients.

In recent years, new studies on the effectiveness and cost-effectiveness of central aspects of chiropractic care (particularly spinal manipulation and exercise) have brought a mixture of welcome and challenging news. In a previous ACA News article, [1] I described many of the studies showing clear benefits from spinal manipulation and chiropractic care.

It is equally important for us to be familiar with research that challenges us. Fathoming its meaning and charting a course for how best to respond sometimes requires us to face difficult facts and thoroughly ponder their implications. Just as social change is far more sustainable when it percolates up from the grassroots rather than being imposed in a top-down fashion, practice or policy changes necessitated by research are ultimately better integrated and more long-lasting if they grow organically from our own enlarged understanding, rather than being forced upon us by external powers we may perceive as hostile. Particularly in the United States, where practice guidelines are voluntary, our willingness to engage this sometimes difficult process is crucial to fulfilling our responsibilities to our patients.

Using recent examples of research that challenges DCs, along with other research that challenges medical physicians, insurers and policy makers, let’s explore this rocky terrain, starting with two 2012 studies from researchers at Northwestern University of Health Sciences (NWUHS) and the Berman Center for Outcomes and Clinical Research.

1. Manipulation Yields Better Pain Outcomes than Medication for Acute and Subacute Neck Pain, with Results Essentially Equivalent to Home Exercise Plus Advice
Annals of Internal Medicine, 2012 [2]

Over the past two decades, there have been several head-to-head randomized trials in which chiropractic care achieved outcomes superior to those of conventional medicine. For LBP, the 1990 Meade et al. study, [3, 4] published in the British Medical Journal, the flagship journal of the British Medical Association, was arguably the most influential. For headaches, the award-winning [5] Boline et al. trial, [6] published in the Journal of Manipulative and Physiological Therapeutics in the mid-1990s, still stands out as a noteworthy model for rigorous research structured in a pure chiropractic-versus-medicine format. Had the 2012 Bronfort et al. trial [2] been structured similarly, the take-home message would have been received with unalloyed satisfaction by DCs, since the spinal manipulation group fared significantly better on pain reduction (the primary outcome) than the group treated with medication (NSAIDs, acetaminophen or both).

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