I grew up in and around chiropractic and always took it for granted that people should have their spines checked on a regular basis. Most chiropractors I know make similar recommendations to their patients and to their own families.

Despite this there is a rogue, splinter group in the profession that believes otherwise. While it would be fine if they simply acknowledged that they have a different personal opinion about regular spinal hygiene – they don’t leave it there. Instead they contend that those chiropractors who make recommendations involving long term care are public health risks.      

We’ve seen this before and no doubt we will see it again. Here’s the latest attack:

Redwood D, Globe G. Prevention and Health Promotion by Chiropractors. American Journal of Lifestyle Medicine 2008; 2; 537

http://ajl.sagepub.com/cgi/content/abstract/2/6/537

After seeing it, I took the time to write and submit a Letter to the Editor offering another perspective.  Letters to the Editor of research journals serve as an extension of the peer review process and allow further clarification of issues – especially contentious ones.  A copy of my letter is below. The Editor responded and said simply that they didn’t have the space to run it.

What a shame. It will only be a matter of time until a chiropractor working for an insurance company, malpractice plaintiff or regulatory board uses this article to substantiate accusations of overutilization, malpractice or professional misconduct.

Please help me distribute this information to as many people as possible.

As always I look forward to your comments, feedback and suggestions.

Matthew McCoy DC, MPH
Editor - Journal of Pediatric, Maternal & Family Health - Chiropractic    
http://www.chiropracticpediatricresearch.net

James M. Rippe, MD
Editor
American Journal of Lifestyle Medicine
21 North Quinsigamond Avenue
Shrewsbury, MA 01545

RE: Redwood D, Globe G. Prevention and Health Promotion by Chiropractors. American Journal of Lifestyle Medicine 2008; 2; 537

Dear Editor,

Redwood and Globe offer a seemingly helpful review of the literature regarding the role of chiropractors and preventive activities. They include the common domain risk assessments and preventive measures utilized by anyone advancing public health issues.(1)

However, they fall short when it comes to the one thing that is unique to chiropractic – the adjustment. Further, they use the guise of an article about prevention to resurrect once again the tired old attack on chiropractors who offer extended care plans, or offer chiropractic adjustments for anything other than the treatment of head, neck and back pain. It is concerning because the authors offer criteria for referral to chiropractors in their paper starting with duration of care and the “potential for over treatment.” They go on to advise the reader that treatment plans involving extended courses of care “should be considered red flags” especially in cases where patients are asked to pay up front.

Personal autonomy issues aside, Redwood and Globe offer a very limited description for the justification of adjustment/manipulation in which joint fixation or “radiographically  demonstrable joint surface disrelationships” provide the rationale for intervention. The authors are perhaps unaware that clinical models of chiropractic exist that go well beyond such a limited application.(2) Interestingly, the authors did not include the demonstration of a neurological component to their model thus limiting vertebral subluxation to a purely mechanical, orthopedic definition. Of further concern is their apparent disregard for the differences between the chiropractic adjustment and the common domain modality of manipulation.     

Chiropractors have historically recommended initial care plans that involve a high frequency of visits as well as extended care plans of long duration to encompass corrective and wellness based care. Care plans that do not base care solely on the presence or absence of symptoms have as their basis some very fundamental scientific laws that govern connective tissue and neurological responses to abnormal biomechanical loads and neurological interference while also addressing quality of life issues. The goal of care becomes the reversal of these insidious processes and an enhanced sense of well-being so that any judgment of that care must take into consideration those outcomes as well as outcomes related to the technique being applied.(3)

Using a very limited review of the literature on the benefits of ongoing care the authors were able to retrieve only two articles.(4,5) Considering they limited their review to those papers indexed in Medline we should not be surprised. Interestingly, their own article is published in a non-Medline journal.

Had they expanded their search to all peer reviewed chiropractic research journals they would have stumbled upon quite a number of articles where longer term care and its related outcomes are addressed. Being this is a simple letter to the editor I’ll discuss just three. One such study by Blanks et al used a retrospective assessment of chiropractic care involving 2818 patients undergoing care in over 150 chiropractic offices in four countries.6 The care intervals studied were from 1-3 months to over three years and the most significant finding was that the benefits of chiropractic care were evident from as early as one month and showed continuing clinical improvements over three years – with no indication of a maximum clinical benefit.

The benefits included improvement in physical state, mental state, stress and life enjoyment. Most relevant to Redwood and Globe’s review is a follow-up paper from that study by Schuster et al which demonstrated that while chiropractic care had a direct effect on these outcomes the more significant finding was chiropractic’s effect on changing those lifestyle habits most commonly associated with preventive efforts such as quitting smoking, losing weight, and taking up exercise among others.(7)   

In another long term study of outcomes Campbell et al used a case controlled retrospective analysis to assess the effects of short and long-term chiropractic care on serum thiol levels in asymptomatic subjects.(8)  Serum thiol levels in subjects with active disease were compared to levels in primary wellness subjects with thiol levels shown to be highest in the group with greater than 52 weeks of chiropractic care. Serum thiol is a surrogate measure of DNA repair enzyme activity.

Finally, Hannon reviewed existing literature documenting objectively measured physiologic changes and their associated health benefits subsequent to chiropractic adjustments, primarily in asymptomatic individuals.( 9) More than twenty studies documented objective health benefits in subjects who were described as “asymptomatic,” “healthy,” “normal,” or “free from physical injury” and nearly an equal number of studies documented objectively measured health benefits in subjects where no symptomatic presentation was described.

The chiropractic clinical spectrum encompasses much more than the limited joint fixation or bone out of place model depicted by these authors and the application of chiropractic includes much more than manipulation for the alleviation of musculoskeletal symptoms or dysfunction. The depiction of chiropractic clinical strategies that go beyond this limited view as somehow below the standard of care and as “red flags” for deviant behavior is misleading. I hope the authors will entertain a more expansive and fair assessment of the literature in the future.

Sincerely,

Matthew McCoy DC, MPH

References

1. Redwood D, Globe G. Prevention and Health Promotion by Chiropractors. American Journal of Lifestyle Medicine 2008; 2; 537
2. Kent C. Models of Vertebral Subluxation. J. Vertebral Subluxation Res. Vol. 1 No. 1.
3. Clinical Guideline Number 1: Vertebral Subluxation in Chiropractic Practice. Council on Chiropractic Practice. Chandler, AZ  2003.
4. Rupert RL. A survey of practice patterns and the health promotion and prevention attitudes of US chiropractors. Maintenance care: part I. J Manipulative Physiol Ther. 2000;23:1-9.
5. Rupert RL, Manello D, Sandefur R. Maintenance care: health promotion services administered to US chiropractic patients aged 65 and older, part II. J Manipulative Physiol Ther. 2000;23:10-19.
6. Blanks, RH, Schuster TL, Dobson M. A Retrospective Assessment of Network Care Using a Survey of Self-Rated Health, Wellness and Quality of Life. J. Vertebral Subluxation Research. Vol. 1, No. 3.
7. Schuster TL, Dobson M, Jaurequi, Blanks RH. J Alt and Comp Med, 10(2):349-368, 2004
8. Campbell CJ, Kent C, Banne A, Amiri A, Pero RW. Surrogate Indication of DNA Repair in Serum After Long Term Chiropractic Intervention – A Retrospective Study. J. Vertebral Subluxation Res. February 18, 2005.
9. Hannon S. Objective Physiologic Changes and Associated Health Benefits of Chiropractic Adjustments in Asymptomatic Subjects: A Review of the Literature
J. Vertebral Subluxation Res. April 26, 2004.