"Those dang scientists - they haven't proven that the bumblebee can fly!" Do you remember this quote from a prominent chiropractic leader a few years back? This lament and similar disparagements of the scientific enterprise have echoed down through the decades.
For many years and perhaps still today, DCs have responded to charges of quackery from political medicine by insisting that "chiropractic is not quackery - it works!" This sort of self-defeating rebuttal may suggest that too many of us have operated under the misconception that "scientific" and "effective" are somehow synonymous. We ought to know better by now.
Whatever else "scientific" may mean, it refers to the process of critical questioning and the search for answers from Nature herself. "Philosophizing" is part of this process: We contemplate a clinical issue and hope we're asking the right questions. Yet the scientific method means more: We pose questions (hypotheses or tentative assertions), collect systematic and representative answers (empirical evidence or data), and hope that our part of the clinical universe (e.g., a patient sample) represents the larger population to which we'd like to extrapolate the results (answers) we get.
Keep in mind, however, that when we put questions to Mother Nature (test our hypotheses), the answers we get back may or may not confirm our expectations. If we think a particular clinical method is effective and we test it scientifically, we might find out that it doesn't work! "Scientific" doesn't equal "effective"; scientific means carefully and well-studied.
Of course, neither does "effectiveness" equal "scientific." Bumblebees do fly (in my experience), whether or not the scientific community has been able to explain the mechanisms by which this occurs. The bees have an effective flight apparatus that has long eluded our capacity to understand (although I understand the flight of birds is explainable in scientific terms), but we hope that our plodding methods of investigation may eventually pry open this mystery. In the meanwhile, we can enjoy the flight of the critters while we wait for science to "catch up."
When we turn to clinical matters, however, it's a different story. Although the flight of the birds and the bees is universally acknowledged, the clinical value of many methods of aiding patients to overcome their health problems is indeterminate (never mind explainable). It required some 20 years of randomized, controlled clinical trials to establish (more or less) the value of spinal manipulative therapy (SMT) for the relief of patients with low back pain (LBP). We have enough quality information at this point to argue the usefulness of these methods in the scientific arena, yet we still don't know why SMT relieves LBP.1 In this instance, we might argue that the effectiveness of SMT is scientifically validated for LBP relief (there are a few researchers who still contest this), but how this happens, much like the flight mechanisms of certain critters, remains uncertain.
When it comes to the value of instrument adjusting for patients with musculoskeletal problems, we have less data than for the broader category of SMT.
Yes, the Activator instrument and similar thrusting devices have enjoyed and continue to enjoy a growing body of scientific evidence (support), and I have been pleased to contribute to organizing this information for the consumption of the scientific community.2 Although the number of randomized, control group trials is expanding, the sample sizes in most of these is still small (a limiting factor). We can legitimately say that the available data suggest the efficacy of instrument methods of adjusting, and the interactive physics of instruments and the spine are proceeding (instrument adjusting is "scientific"), but robust substantiation is still a goal.
Similarly, when we question the value of adjusting for patients with nonspecific neck pain, we find less data than for the broader category of SMT for LBP. Yes, these data suggest the value of SMT for patients with headache and neck pain disorders,3 and in this sense, we might say that this area of clinical research and practice is "scientific." However, the clinical usefulness of the manual healing arts for these patients is less than fully substantiated; "scientific" doesn't equal "proven." This is most certainly not a problem unique to chiropractic.
There are many areas of healing that will never be thoroughly, scientifically validated, if only because the research process itself would violate ethical principles. Take placebo-controlled trials for many forms of surgery, for instance, or no-treatment/waiting-list comparisons for exquisitely painful disorders; our desire for certainty would not justify the individual patient's anguish. The realities of a health problem will not always allow the ideal research designs the scientific process calls for. In these circumstances, we do not concern ourselves excessively that the healing method has not been scientifically "proven." We proceed based upon the best scientific understanding we can muster (this is partly what is meant by evidence-oriented practice), but always within the confines of the Hippocratic tradition. When Mrs. Jones presents with an agonizing migraine, we do the best we can for her, despite our less-than-optimal understanding of the problem and our imperfect methods of helping. Science is important, but the patient always comes first!
The limitations of the scientific method and scientific understanding have become ever more apparent as we wrestle with clinical guidelines, standards and "best practice" recommendations. Little by little, we have realized that science provides only a platform upon which we clinicians can base our diagnostic and treatment hypotheses. Yet that platform will never replace the doctor, who still must exercise judgment in choosing and fitting clinical interventions to meet the idiosyncratic needs and preferences of the patient. We have come to appreciate that guidelines, standards and best practices are not (and cannot be) equivalent to strictly scientific determinations.
Let us resolve to mature. We wish to maximize our effectiveness, and we believe that the scientific method provides a potent tool to accomplish this worthy goal. We also recognize that chiropractic is not a "basic" or "pure" science, but rather a clinical discipline. Our "clinical science" involves a technology and art constructed for a social purpose: to help sick people get well and stay well. I believe we will better orient ourselves to this challenge by recognizing the differences between "science" and "effectiveness."
References
- Haldeman S. Neurologic effects of the adjustment. Journal of Manipulative & Physiological Therapeutics Feb 2000;23(2):112-4.
- Fuhr AW, Menke JM. Status of Activator Methods chiropractic technique, theory and practice. Journal of Manipulative & Physiological Therapeutics Feb 2005; 28(2):135.e1-135.e20. doi:10.1016/j.jmpt.2005.01.001.
- Coulter ID, Hurwitz EL, Adams AH, et al. The Appropriateness of Manipulation and Mobilization of the Cervical Spine. Santa Monica, CA: RAND Corporation, 1996. RAND MR-781-CCR.
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