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Chiropractic Journal of Australia : CJA December 2013
Chiropractic Journal of Australia Volume 43 Number 4 December 2013 133 responses, usually called somato-autonomic refexes, is, however, essential to developing a truly scientifc understanding of the mechanisms underlying most forms of physical therapy, including spinal manipulation (emphasis added) and traditional as well as modern forms of acupuncture and moxibustion.” 34 These authors reviewed the “…somato-autonomic refex responses in the cardiovascular, including cerebral and peripheral nerve blood fow, digestive, urinary, endocrine and immune systems following somatic sensory stimulation in animals anesthetized to eliminate emotional factors." 35 They state further that "the decreases in blood pressure and renal activity during manipulation of the spine are thought to be supraspinal refexes,” and that there were "changes in adrenal nerve activity induced by thoracic spine stimulation in chloralose/urethane-anesthetised rats." 36 One cannot help but wonder if critics are aware of the published papers outlining the neurophysiological basis of the manipulative sciences before expressing their opinion. A summary of the role of the ANS and its potential underlying somato-autonomic concepts can be found in the literature.10 In addition, such authors as Bolton P,37 Budgell B,38 Carrick F,39 Haavik-Taylor H,40 Henderson C et al.,41 Pickar J,42 Pollard H,43 and others, have published widely on the concepts. There are also many textbooks covering the general principles of chiropractic and osteopathy by such authors as Cramer GD,44 Gatterman MI,45 Haldeman S,46 King HH et al,47 Korr IM,48 Kuchera et al,49 Leach RA,50 Patterson MM,51 Redwood and Cleveland,52 Schafer,53 and others. Of note is the fact that these published authors essentially base their evidence on available medical references. One could hardly express an informed opinion on the topic of the manipulative sciences without familiarity with these works. It should also be recognised that chiropractic is not just spinal manipulation. The practitioners generally incorporate into their regime other natural modalities in health management such as exercise, diet, massage, muscle balance, posture assessment, nutritional and life style advice. These are nominated here as incorporating a management and health maintenance supportive care. CASE REPORTS, EMPIRICAL & ANECDOTAL EVIDENCE Perhaps one argument about the manipulative sciences is that too great a proportion of its records is not level 1 evidence. Some have argued that in the case of the clinical healthcare sciences, supporting data requires a different form of evidence due to the individuality of patients.54,55 There is however, the mounting clinical evidence as well as formal scientifc research, especially neurophysiological studies substantiating the manual health professions' concepts. To date, the writer is not aware of any primary research that contradicts the fundamental hypotheses upon which they are based. Until recent times, the same doubts had been expressed about the value of manipulation for musculoskeletal conditions, and even about the lesion that is addressed by manual procedures -- the vertebral subluxation. Events have overtaken these reservations to the extent that SMT for those conditions is now widely sought and adopted within professions other than chiropractic and osteopathy. Less formal clinical evidence alone may be insuffcient to justify a primary contact role in health care. However, that evidence can be seen as positive and supportive as one of the elements in justifying such a role - as in patient-centred care.55-57 Gatterman emphasises this by stating "Implicit in the worldview of the patient-centred paradigm is the belief that the patient is the most important stakeholder." 55 It is submitted that if a treatment is scientifcally justifed but does not work clinically, it should be dismissed. On the other hand, if particular therapeutic procedures are clinically successful, they deserve recognition even if the rationale for them has yet to be fully explored. It seems easier for some to dismiss a particular model of care than to accept a different one - or even to rationally consider research into the underlying premises behind that regimen. How much of health care is based on the patient response? It is offered here that in practical clinical terms, there is a signifcant percentage. A patient’s own observations and satisfaction could be nominated as a regular form of effcacy assessment, as this forms a part of practical clinical protocols in everyday practise in all health professions. To dismiss empirical and anecdotal evidence of aspects of the clinical sciences is diffcult to substantiate due to the unique presentation of each patient.57 It is submitted that all health care professions have been substantially based on anecdotal evidence in clinical practice throughout history. Due to patient variables in the health care sciences, the practicality of establishing a consistent evidence base of clinical observations in health care is important but diffcult. Gatterman encapsulates this when she states that "Evidenced- based medicine that accepts only randomised controlled trials tends to devalue the individuality of patients, shifts the focus of clinical practice away from care of the individual toward the care of populations, with the complex nature of sound clinical judgements not fully appreciated. While RCTs may establish strong causality through the enhancement of internal validity, generalisability is sacrifced.” 55 It is apparent that clinical applications require different criteria than for the pure sciences such as mathematics, chemistry and physics. But even the clinical guidelines need to be fexible as practitioner judgement is also a variable.58 In underlining the role of anecdotal evidence, Bogen from Stanford University presents the following comment on its web site. "Scientists obtain a great deal of the evidence they use by observing natural and experimentally generated objects and effects. Much of the standard philosophical literature on this subject comes from 20th century logical positivists and empiricists, their followers, and critics who embraced their issues and accepted some of their assumptions even as they objected to specifc views. Their discussions of observational evidence tend to focus on epistemological questions about its role in theory testing. This entry follows their lead even CONTRADICTIONS ROME
CJA September 2013