Can Our Chiropractic Techniques See the Road Ahead and Appreciate the Road Signs?
RE: Cooperstein R, Perle Stephen, “Condition-specific Indications for Chiropractic Adjustive Procedures for the Low Back: Literature and Clinical Effectiveness Ratings of an Expert Panel” Top Clin Chiropr 2002;9(3): 19-29.
With the completion of two landmark papers, [1,2] which characterize published research studies and rate chiropractic technique procedures for low back conditions, the study published recently in Topics in Clinical Chiropractic  warrants a review by all chiropractic technique organizations. Drs. Robert Cooperstein and Stephen Perle produced a summary paper from a 6-year study designed to characterize the quality and quantity of literature gathered for an expert panel, and rate various specific chiropractic adjustive procedures for common presentations of low back pain. They summarized that the “ratings for the effectiveness of chiropractic technique procedures are not equal. Those procedures that are rated the highest are supported by the highest quality literature.” 
I wish to share with you my interpretation of the study as a sacro occipital technique (SOT) practitioner interested in furthering SOT’s acceptance into the chiropractic community and ultimately improving patient health care. As with any study of this nature there will always be those dissatisfied with the study, particularly those doctors identifying with a particular chiropractic technique. The goal of anyone reviewing this study, in my opinion, should be to determine where something can be learned, and how this information can help us, as a profession, to improve our work.
“The eight members of the expert panel that met in Chicago  were chosen based on their broad knowledge of chiropractic technique procedures, active involvement in chiropractic leadership, and non identification with any system technique. They were balanced relative to academic and clinical representation, gender, philosophical orientation, and geographical location.”  There was, to my critical eye, a sincere attempt on the part of the panel to be open and unbiased throughout the evaluation process.
Literature Selection and Evaluation Process
They stated that, “We had expected a paucity of literature pertaining to some of the adjustive methods we had identified and that much of this literature would be of rather poor quality. We were not disappointed.”  “Although no doubt some relevant literature was missed, we believe the likelihood a resource was missed inversely proportional to its quality because the best materials were the most retrievable.” 
“Characterizing the literature by adjustive approach, there are many articles on [high velocity low amplitude] HVLA manipulation, many of them of high quality. We also see many articles on distraction methods, but fewer on segmentally specific mobilization. Very little is available on other chiropractic adjustive methods, including mainstream procedures such as pelvic blocking, instrument-assisted adjusting, and drop-table methods.” 
“The expert panel did not, generally speaking, rate the clinical effectiveness of well-published methods more highly than methods that are essentially unstudied. For example, HVLA drop table adjusting and pelvic blocking were more highly regarded than instrument adjusting, even though there are dozens of (non-clinical) articles pertaining to the latter.” 
Obviously the expert panel had subjective opinions regarding chiropractic adjustive methods and it was noted in this study that, “we see that pelvic blocking and drop table methods are especially problematic, having achieved relatively high ratings [without] much [literature] support, suggesting a particular need for clinical research in that area.”  “In this project, we had to balance two concerns: panelist’s need to have enough expertise and knowledge about the procedures used by system techniques to rate their effectiveness, and yet not be so closely identified with any of them that even the appearance of bias would exist.” 
Chiropractic Techniques Need to Justify Their Claims
“Claims by the proprietors of system techniques that their methods are ‘clinically validated’ must be carefully scrutinized because the proprietary jargon, theories, and treatment methods that do in fact distinguish them are usually unstudied, whereas the validated methods they use, such as side-posture manipulation and mobilization are in the common domain and are simply generic.” 
“Although some of the system technique advocates have been active in performing and sponsoring research on their methods, attempts to validate the clinical appropriateness of their favored methods might best focus more on clinical outcomes and less on peripheral matters (e.g., modeling, forces generated, the reliability of diagnostic procedures.”  Cooperstein and Perle firmly believe that “the responsibility to fund and assist in the conduct of outcomes research into proprietary chiropractic techniques rests with the owners of those techniques.”  They continue with the statement that an acceptable model of health care “must be credat emptor (let the buyer believe in us). Under such a model a doctor who promotes a technique that lacks any evidence of effectiveness might be accused of violating their duties to their patients [3,4]. Likewise, those teaching a technique who do not fund and conduct the research to test the safety and efficacy of their methods might likewise be accused of an ethical lapse. Carl Sagan has written: ‘I believe that the extraordinary should certainly be pursued. But extraordinary claims require extraordinary evidence.’” [3,5]
Quoting Sackett, Cooperstein and Perle note, “Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough [3,6]. Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” [3,7] Cooperstein and Perle conclude, “Moreover, as so many have said, lack of evidence does not constitute evidence of lack.” 
The Challenge to Chiropractic Techniques
The challenge to all chiropractic technique methods, and to SOT in particular for me, is that we must use clinical research to support, reject, improve, and/or delete those assertions and statements made in our literature and by our instructors. In other words, until we have produced sufficient evidence to justify our presumptions, we must be circumspect in what we state as “fact.” Clinical research is desperately needed to support our chiropractic techniques’ methods. Waiting for someone else to do this research is an exercise in optimistic futility.
If you personally are not going to sit down and write the literature then please consider supporting your technique organization, such as Sacro Occipital Technique Organization (SOTO) – USA. For instance, SOTO-USA has presented SOT-related studies at every chiropractic research conference this past year, and is continually submitting papers to chiropractic peer review journals. SOTO-USA has organized all the SOT-related research literature to the year 2000, in three books: The SOT Compendium, The SOT Collection, and The SOT Collection: Supplement.
A few years hence, when someone undertakes a study of the magnitude of the Cooperstein & Perle review, I hope that there will be enough newly published SOT research to provide a more credible base for conclusions of efficacy. Hopefully, all chiropractic techniques will do likewise, with the ultimate goal of aiding patient care
Charles L. Blum, DC
1. Cooperstein R, Perle SM, Gatterman MI, Lantz C, Schneider MJ. Chiropractic technique procedures for specific low back conditions: characterizing the literature J Manip Physiol Ther 2001;24(6): 407-24.
2. Gatterman MI, Cooperstein R, Lantz C, Perle SM, Schneider MJ .Rating specific chiropractic technique procedures for common low back conditions J Manip Physiol Ther 2001; 24(7):449-56.
3. Cooperstein R, Perle SM, Condition-Specific Indications for Chiropractic Adjustive Procedures for the Low Back: Literature and Clinical Effectiveness Ratings of an Expert Panel Top Clin Chiropr 2002;9(3): 19-29.
4. Coulter ID The roles of philosophy and belief systems in complementary health care In WFC/ACC Conference on Philosophy in Chiropractic Education, 2000 Fort Lauderdale, FL: World Federation of Chiropractic: 2000, 1-10.
5. Sagan C, Broca’s Brain: Reflections on the Romance of Science New York: The Ballantine Publishing Group, 1993.
6. Sackett DL Evidence-based medicine Spine 1998;23(10): 1085-6
7. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996 Jan 13;312(7023):71-2.