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Chiropractic Journal of Australia : CJA March 2013
Chiropractic Journal of Australia Volume 43 Number 1 March 2013 7 THE DOUBLE STANDARD If the same standard of evidential proof demanded of chiropractic was to be applied to medicine, a double standard would be revealed. In its basic form, there are the numerous drug withdrawals from markets that occur on a monthly basis, published papers critical of author independence, not to mention the medical adoption of the terms adverse events, side effects and iatrogenic disease. On this basis, it is submitted that there is more of a positive foundation for chiropractic care, and in particular its raison d'être, the VSC. The following quote from Scientifc American is notably relevant: We could accurately say, Half of what physicians do is wrong or Less than 20 percent of what physicians do has solid research to support it. Although these claims sound absurd, they are solidly supported by research that is largely agreed upon by experts. Yet these claims are rarely discussed publicly. It would be political suicide for our public leaders to admit these truths and risk being branded as reactionary or radical. Most Americans wouldn't believe them anyway. Dozens of stakeholders are continuously jockeying to promote their vested interests, making it diffcult for anyone to summarize a complex and nuanced body of research in a way that cuts through the partisan fog and satisfes everyone’s agendas. That, too, is part of the problem.59 At least the more recent Scientifc American fgure seems an improvement on the British Medical Journal's editorial in 1993 which stated ...only 15% of medical interventions are supported by solid scientifc evidence...(and)...only 1% of the articles in medical journals are scientifcally sound ... many treatments have never been assessed at all ...60 To complicate health issues further In a review of studies published in The Cochrane Library, researchers found that both doctors and patients are largely unaware of these different and equally accurate ways of presenting the same information, and that the format in which data is presented can have a profound infuence on health care decisions.61 The concept of evidenced based medicine is also under question. It would appear that it does have shortcomings. Rosner states that Evidence-ba sed medicine (EBM) is beset with numerous problems. He concludes that Finally, the blinding concept of randomised controlled trials is particularly problematic in applications of physical medicine. Examples from the research literature in physical medicine highlight conclusions which are ope n to debate. Mo re progressive components of EBM are recommended, together with greater recognition of the varying audiences employing EBM.62 But Rosner is not the only one to raise reservations about EBM. Pring cites a very relevant quotation by noting ... that the defnition of evidence remains contested, and there has not been enough attention to values, perceptions and the consumer perspective.63 In discussing the appropriateness of EBM, Borgerson noted that The validity of evidence-based medicine (is) the subject of ongoing controversy.64 In 2010 Kerridge raised the issue of neutrality in EBM.65 This is not to say that EBM does not have a role, but that it may not be the total answer.66,67 Pirotta claims that It is estimated that as little as a quarter of conventional medicine is based on Level-1 evidence.68 It can be noted that although an evidence base is essential, patients must still be content with the treatment and the outcome. It is possible that they may at times prefer other forms of treatment in achieving satisfactory results. It should also be noted that If the chiropractic approach to low back pain had been abandoned early on due to the lack of research data, we would never have known its superiority to other conservative treatments.69 Within medicine itself, there is divided opinion, as more than 50% of Australians seek some form of alternative health care annually. A past president of the AMA, and current president of the Australasian Integrative Medicine Association, Dr Kerryn Phelps, states that opposition to evidenced-based complementary medicine options is prejudice dressed up as opinion and that it is ... completely unbalanced, completely out of touch, and it's in denial; of the level of scientifc research … Dr Phelps goes further in response to recent criticism by Prof Dwyer by claiming that He doesn’t work in this area and doesn’t know what we do. The published data is there. He is either unaware of it, or he’s not looking she says.70 Most pertinently, the statement by Knipschild in the Lancet in 1993 carries as much importance today as ever. He stated It is a pity that the message does not appear to have been heard…. They (patients) continue to choose the treatment that they expect to give them the best overall beneft.71 One must mention an episode of tacit acceptance of chiropractic by politico-medical forces in California in the late 1950's. At that time the chiropractic (and osteopathic) professions were offered to merge with the medicinal profession by means of a simple swap of certifcates, and medicine would therefore drop all opposition to the two professions. Osteopathy accepted that offer - chiropractic did not. Such a takeover would suggest political expediency to the extent that any claim of a lack of scientifc validation was false, compromised, or more likely, used conveniently to protect a monopoly.72 In the US chiropractors are now have positions in medical hospitals, so it would appear that the Australian signatories are quite out of date and out of step.73 Chiropractic health care is also provided through St Michael's medical hospital in Toronto Canada.74 THE POSSIBLE SOLUTION In order to avoid future confusion, a modifed term such as VSC, or perhaps another satisfactory compromise may clarify the situation. Because of its widespread use, VSC would be the preferred terminology. It would be a Herculean task to change the profession's lexicon. There may be however, other elements which could serve to ameliorate the situation. • That the term Vertebral Subluxation Complex (VSC) be defned within the introduction of all papers where it is used for perhaps fve years – or at least until it is widely recognised and adopted • The ICD to be amended to include the Vertebral Subluxation Complex (VSC) COMMENTARY ROME
CJA December 2012
CJA June 2013