- Email: [email protected]
Pushing back the frontiers, pushing back the boundaries: a new journal, a new paradigm
Clinical Chiropractic (2003) 6, 1Ð3
Editorial Pushing back the frontiers, pushing back the boundaries: a new journal, a new paradigm For those of you who have followed the British Journal of Chiropractic since 1997 and come to love±Ðor hate±Ðits content, variable production schedule and occasionally idiosyncratic spelling, then a few changes may be evident. The new cover, new name, new style and new publisher are not a case of 7-year itch but rather a development from co-habitation into marriage. So why the wedding bells? The story of the BJC was one of progression and development, edition by edition. The ®rst issue, preceding the formal inauguration of the College of Chiropractors by 2 years, was just 8-pages long, contained only two case studies and was littered with typographical errors. Five years later, the aim to improve the journal issue by issue had given rise to 36-page issues boasting a wide variety of article types; a strong clinical base; doubled blinded peer review; limited indexation and a glossy, unique image. However, in the past year, that progressive improvement faltered. Pressures of budget, resources and, more than anything else, time meant that the journal had ceased making progress1. The College had been talking to Churchill Livingstone (now an imprint of Elsevier) for several years and now seemed the time to take advantage of their marketing expertise, publishing knowledge and administrative know-how to relaunch the journal. Both parties were agreed that the existing product established an excellent platform for development and both were agreed that the two immediate aims should be to establish an international presence and to strive to gain early and maximal indexation. This journal aims to be the ®rst with ``Chiropractic'' in its title to be indexed by MEDLINE. This has been a major challenge to the chiropractic profession over many years, and nobody should underestimate the impact this will have on dissemination of chiropractic research to the health care professions at large. So what can Clinical Chiropractic offer to a profession of just 80,000 already supplied by some 20 or so existing journals? Firstly, most of those journals cater for a national rather than an international audience±Ðbut chiropractic prides itself on being an international profession and needs international publications. Secondly, most chiropractic journals are written by academics and researchers for academics and researchers. Nobody would question the need for this, but, with the vast majority of the profession involved in actual clinical practice, there is often a paucity of material with immediate and obvious clinical relevance gaining publication. The aim of the journal is speci®cally to address this need: . . . to provide authoritative information of use to the clinical chiropractor in advancement of their professional career; clinical skills and performance; and ability to deliver optimal patient care. The emphasis here is on patient care. The ultimate aim of any form of biomedical continuing professional development is to improve the delivery of care to the patient2. This comes not from propping up the bar at interminable conferences but from individual practitioners identifying their weaknesses or areas for potential development and undertaking a wide variety of activities. Conferences of course play a part, but of equal import are seminars, small group work, observations, clinical audit, literature review and, obviously, journal reading3. The embracing of evidence-based practice (EBP) has changed global attitudes to chiropractic and led, in many countries, to the recognition or even adoption of chiropractic by both private and, increasingly, government health schemes4. Evidence-based practice has been a friend to chiropractic, underpinning much of daily practice and being re¯ected in international consensus on areas such as acute, uncomplicated low back pain and whiplash5Ð10. However, its implementation is seriously hampered. 1479-2354/03/$30.00 ß 2003 the College of Chiropractors. Published by Elsevier Science Ltd. All rights reserved. doi:10.1016/S1479-2354(02)00008-1
2
Editorial
Only one chiropractic journal (Journal of Manipulative and Physiological Therapeutics) is comprehensively indexed and this makes access to chiropractic research dif®cult for those without knowledge of or access to specialist databases. In addition, there is paucity of research taking place and, in common with other health care professions, that research often falls short of the requirements of the clinical practitioner11. This, itself, begs several questions regarding chiropractic research itself. The majority of chiropractic research takes place in undergraduate institutions that frequently lack secure funding; dedicated researchers with dedicated research time and a signi®cant post-graduate infrastructure within which to operate. The majority of research to date has taken place in the United States in which chiropractic exists in a state of relative adversity with allopathic medicine and this, not surprisingly, has in¯uenced both the methodology and the rationale for research. The rationale has frequently been defensive, attempting to prove to sceptics that chiropractic can treat such-and-such complaint. This, inevitably, has lead to the adoption of the randomised controlled trial (RCT) as the gold standard for chiropractic researchers regardless of its actual clinical relevance. This is not a criticism; had this not been the case, it would have been impossible to publish anything in mainstream journals and little if any evidence for chiropractic would ever have emerged. But the opportunity now exists for chiropractic to move away from slavishly following the medical model and develop its own paradigm most suited to its own needs aiming to improve practice rather than to prove it12. Chiropractic lends itself well to modes of research other than the tried and tested RCT for which there will doubtless always be a signi®cant role. Case reports, studies and series and other more sophisticated models of qualitative research doubtless have a role to play. These direct themselves towards patients' responses and feelings, a key aspect of the holism that chiropractic professes to hold in high esteem and re¯ective of the vitalistic traditions of the profession13. Similarly, Best Evidence Topics (BETs) offer a new way of approaching clinical questioning distinct from the traditional literature review that, again, can fail to address the speci®c needs of the clinician14. But the best methodology in the world can still fail to deliver a quality end product unless the right questions are being asked. Again, chiropractic, often for reasons of pragmatism, has fallen into the allopathic trap of addressing symptomatology rather than underlying cause. So research questions will often ask ``Can chiropractic treat . . . (low back pain, headache, dysmenorrhea, asthma, etc.)? Apart from a small minority who believe chiropractic to uniquely act as a universal panacea, the vast majority would regard the question as irrelevant±Ðall the conditions mentioned are symptoms with multiple and complex aetiologies, not diseases in their own right. A more correct question would be ``can the chiropractic subluxation be a cause of . . .?'' Assuming that the right question is asked and the right methodology adopted, there remains one important research question for the profession to consider: who controls the agenda? Chiropractic research is usually a question of individual effort and thus often lacks collaboration (internal or external), coordination, integration or overall strategy. In the United Kingdom, efforts are being made to overcome this by utilising the patient-base of clinically based chiropractors with a background in or experience of research with doctoral programmes. This gives the potential for multi-centric trials investigating populations that are both suf®ciently large and in a clinical (rather than laboratory) setting using experienced (as opposed to student/intern) practitioners15. If chiropractors do not take control, then third parties will±Ðand it would be fatal to chiropractic to lose control of its own research agenda either to those with ill-will towards the profession or those ignorant of the questions that need to be asked. It is vital therefore that chiropractic research is taken forward in a positive, co-ordinated fashion. It is no less vital that quality research ®nds a publication outlet that has the widest possible audience. Clinical Chiropractic offers a new outlet with a potential to reach international audiences from both within and outside the profession interested in improving delivery of care to the patients that are Ãtre of health care professionals and researchers alike. the raison d'e
References 1. Young M. Report of journal editor. In: Minutes of College of Chiropractors Annual General Meeting, Royal College of Medicine, London, May 2002. 2. Bourdillion P. Continuing professional development: trying to match theory and practice. In: President's address, College of Chiropractors' Annual General Meeting, Royal College of Medicine, London, May 2002. 3. Hunt N. Continuing professional development: the why, the how and the when. Br J Chiropractic 1999;3:62Ð4.
Editorial
3
4. Copeland-Grif®ths M. Statutory regulation: the chiropractic experience. Br J Chiropractic 1999;3:68Ð73. 5. Bigos S, Bowyer O, Braen G, et al. Acute low-back problems in adults: clinical practice guideline no. 14. AHCPR Publication No. 950642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; 1994. 6. Clinical Standards Advisory Group. Back pain. London: Department of Health, Her Majesty's Stationery Of®ce; 1994. 7. Spitzer WO, Skovron ML, et al. Scienti®c monograph of the Quebec task force on whiplash associated disorders: rede®ning whiplash and its management. Spine 1995;20:8S. 8. Accident Rehabilitation and Compensation Insurance Corporation of New Zealand, National Health Committee New Zealand. In: New Zealand acute low back pain guide. Wellington, NZ; 1997. 9. Manniche C. Low back pain: frequency management and prevention from an HAD perspective. Danish Health Technol Assess 1999;1(1). 10. Royal College of General Practitioners. Clinical guidelines for the management of acute low back pain. London; 1999. 11. Freeman AC, Sweeny K. Why general practitioners do not implement evidence: qualitative study. Br Med J 2001;323:1Ð5. 12. Hawk C. Personal communication, Research Agenda Conference V, Chicago, 1999. 13. Stump JL. Health care paradigms in chiropractic. In: Masarsky CS, Todres-Masarsky MT, editors. Somatovisceral aspects of chiropractic: an evidence-based approach. Philadelphia, USA: Churchill Livingstone; 2001. 14. Bolton J. The case report±Ðtraditional and future directions. PRT National Seminar, Nottingham, UK, March 2002. 15. Young A. Council minutes; report from the research unit. Reading, UK: College of Chiropractors; September 2002.
Martin Young (Editor)* Clinical Chiropractic, Health Sciences, Elsevier Science Ltd., The Boulevard, Langford Lane, Kidlington, Oxford OX5 1HJ, UK Jenni Bolton (Director of Research) Anglo-European College of Chiropractic, Bournemouth, UK Antoinette Young (Director of Research Unit) College of Chiropractors, Yeovil Chiropractic Clinic, Somerset, UK *
Corresponding author. E-mail address: [email protected]
Editorial Pushing back the frontiers, pushing back the boundaries: a new journal, a new paradigm For those of you who have followed the British Journal of Chiropractic since 1997 and come to love±Ðor hate±Ðits content, variable production schedule and occasionally idiosyncratic spelling, then a few changes may be evident. The new cover, new name, new style and new publisher are not a case of 7-year itch but rather a development from co-habitation into marriage. So why the wedding bells? The story of the BJC was one of progression and development, edition by edition. The ®rst issue, preceding the formal inauguration of the College of Chiropractors by 2 years, was just 8-pages long, contained only two case studies and was littered with typographical errors. Five years later, the aim to improve the journal issue by issue had given rise to 36-page issues boasting a wide variety of article types; a strong clinical base; doubled blinded peer review; limited indexation and a glossy, unique image. However, in the past year, that progressive improvement faltered. Pressures of budget, resources and, more than anything else, time meant that the journal had ceased making progress1. The College had been talking to Churchill Livingstone (now an imprint of Elsevier) for several years and now seemed the time to take advantage of their marketing expertise, publishing knowledge and administrative know-how to relaunch the journal. Both parties were agreed that the existing product established an excellent platform for development and both were agreed that the two immediate aims should be to establish an international presence and to strive to gain early and maximal indexation. This journal aims to be the ®rst with ``Chiropractic'' in its title to be indexed by MEDLINE. This has been a major challenge to the chiropractic profession over many years, and nobody should underestimate the impact this will have on dissemination of chiropractic research to the health care professions at large. So what can Clinical Chiropractic offer to a profession of just 80,000 already supplied by some 20 or so existing journals? Firstly, most of those journals cater for a national rather than an international audience±Ðbut chiropractic prides itself on being an international profession and needs international publications. Secondly, most chiropractic journals are written by academics and researchers for academics and researchers. Nobody would question the need for this, but, with the vast majority of the profession involved in actual clinical practice, there is often a paucity of material with immediate and obvious clinical relevance gaining publication. The aim of the journal is speci®cally to address this need: . . . to provide authoritative information of use to the clinical chiropractor in advancement of their professional career; clinical skills and performance; and ability to deliver optimal patient care. The emphasis here is on patient care. The ultimate aim of any form of biomedical continuing professional development is to improve the delivery of care to the patient2. This comes not from propping up the bar at interminable conferences but from individual practitioners identifying their weaknesses or areas for potential development and undertaking a wide variety of activities. Conferences of course play a part, but of equal import are seminars, small group work, observations, clinical audit, literature review and, obviously, journal reading3. The embracing of evidence-based practice (EBP) has changed global attitudes to chiropractic and led, in many countries, to the recognition or even adoption of chiropractic by both private and, increasingly, government health schemes4. Evidence-based practice has been a friend to chiropractic, underpinning much of daily practice and being re¯ected in international consensus on areas such as acute, uncomplicated low back pain and whiplash5Ð10. However, its implementation is seriously hampered. 1479-2354/03/$30.00 ß 2003 the College of Chiropractors. Published by Elsevier Science Ltd. All rights reserved. doi:10.1016/S1479-2354(02)00008-1
2
Editorial
Only one chiropractic journal (Journal of Manipulative and Physiological Therapeutics) is comprehensively indexed and this makes access to chiropractic research dif®cult for those without knowledge of or access to specialist databases. In addition, there is paucity of research taking place and, in common with other health care professions, that research often falls short of the requirements of the clinical practitioner11. This, itself, begs several questions regarding chiropractic research itself. The majority of chiropractic research takes place in undergraduate institutions that frequently lack secure funding; dedicated researchers with dedicated research time and a signi®cant post-graduate infrastructure within which to operate. The majority of research to date has taken place in the United States in which chiropractic exists in a state of relative adversity with allopathic medicine and this, not surprisingly, has in¯uenced both the methodology and the rationale for research. The rationale has frequently been defensive, attempting to prove to sceptics that chiropractic can treat such-and-such complaint. This, inevitably, has lead to the adoption of the randomised controlled trial (RCT) as the gold standard for chiropractic researchers regardless of its actual clinical relevance. This is not a criticism; had this not been the case, it would have been impossible to publish anything in mainstream journals and little if any evidence for chiropractic would ever have emerged. But the opportunity now exists for chiropractic to move away from slavishly following the medical model and develop its own paradigm most suited to its own needs aiming to improve practice rather than to prove it12. Chiropractic lends itself well to modes of research other than the tried and tested RCT for which there will doubtless always be a signi®cant role. Case reports, studies and series and other more sophisticated models of qualitative research doubtless have a role to play. These direct themselves towards patients' responses and feelings, a key aspect of the holism that chiropractic professes to hold in high esteem and re¯ective of the vitalistic traditions of the profession13. Similarly, Best Evidence Topics (BETs) offer a new way of approaching clinical questioning distinct from the traditional literature review that, again, can fail to address the speci®c needs of the clinician14. But the best methodology in the world can still fail to deliver a quality end product unless the right questions are being asked. Again, chiropractic, often for reasons of pragmatism, has fallen into the allopathic trap of addressing symptomatology rather than underlying cause. So research questions will often ask ``Can chiropractic treat . . . (low back pain, headache, dysmenorrhea, asthma, etc.)? Apart from a small minority who believe chiropractic to uniquely act as a universal panacea, the vast majority would regard the question as irrelevant±Ðall the conditions mentioned are symptoms with multiple and complex aetiologies, not diseases in their own right. A more correct question would be ``can the chiropractic subluxation be a cause of . . .?'' Assuming that the right question is asked and the right methodology adopted, there remains one important research question for the profession to consider: who controls the agenda? Chiropractic research is usually a question of individual effort and thus often lacks collaboration (internal or external), coordination, integration or overall strategy. In the United Kingdom, efforts are being made to overcome this by utilising the patient-base of clinically based chiropractors with a background in or experience of research with doctoral programmes. This gives the potential for multi-centric trials investigating populations that are both suf®ciently large and in a clinical (rather than laboratory) setting using experienced (as opposed to student/intern) practitioners15. If chiropractors do not take control, then third parties will±Ðand it would be fatal to chiropractic to lose control of its own research agenda either to those with ill-will towards the profession or those ignorant of the questions that need to be asked. It is vital therefore that chiropractic research is taken forward in a positive, co-ordinated fashion. It is no less vital that quality research ®nds a publication outlet that has the widest possible audience. Clinical Chiropractic offers a new outlet with a potential to reach international audiences from both within and outside the profession interested in improving delivery of care to the patients that are Ãtre of health care professionals and researchers alike. the raison d'e
References 1. Young M. Report of journal editor. In: Minutes of College of Chiropractors Annual General Meeting, Royal College of Medicine, London, May 2002. 2. Bourdillion P. Continuing professional development: trying to match theory and practice. In: President's address, College of Chiropractors' Annual General Meeting, Royal College of Medicine, London, May 2002. 3. Hunt N. Continuing professional development: the why, the how and the when. Br J Chiropractic 1999;3:62Ð4.
Editorial
3
4. Copeland-Grif®ths M. Statutory regulation: the chiropractic experience. Br J Chiropractic 1999;3:68Ð73. 5. Bigos S, Bowyer O, Braen G, et al. Acute low-back problems in adults: clinical practice guideline no. 14. AHCPR Publication No. 950642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; 1994. 6. Clinical Standards Advisory Group. Back pain. London: Department of Health, Her Majesty's Stationery Of®ce; 1994. 7. Spitzer WO, Skovron ML, et al. Scienti®c monograph of the Quebec task force on whiplash associated disorders: rede®ning whiplash and its management. Spine 1995;20:8S. 8. Accident Rehabilitation and Compensation Insurance Corporation of New Zealand, National Health Committee New Zealand. In: New Zealand acute low back pain guide. Wellington, NZ; 1997. 9. Manniche C. Low back pain: frequency management and prevention from an HAD perspective. Danish Health Technol Assess 1999;1(1). 10. Royal College of General Practitioners. Clinical guidelines for the management of acute low back pain. London; 1999. 11. Freeman AC, Sweeny K. Why general practitioners do not implement evidence: qualitative study. Br Med J 2001;323:1Ð5. 12. Hawk C. Personal communication, Research Agenda Conference V, Chicago, 1999. 13. Stump JL. Health care paradigms in chiropractic. In: Masarsky CS, Todres-Masarsky MT, editors. Somatovisceral aspects of chiropractic: an evidence-based approach. Philadelphia, USA: Churchill Livingstone; 2001. 14. Bolton J. The case report±Ðtraditional and future directions. PRT National Seminar, Nottingham, UK, March 2002. 15. Young A. Council minutes; report from the research unit. Reading, UK: College of Chiropractors; September 2002.
Martin Young (Editor)* Clinical Chiropractic, Health Sciences, Elsevier Science Ltd., The Boulevard, Langford Lane, Kidlington, Oxford OX5 1HJ, UK Jenni Bolton (Director of Research) Anglo-European College of Chiropractic, Bournemouth, UK Antoinette Young (Director of Research Unit) College of Chiropractors, Yeovil Chiropractic Clinic, Somerset, UK *
Corresponding author. E-mail address: [email protected]