- Email: [email protected]
Several pathways in the evolution of chiropractic manipulation
72
Letters to the Editor
Journal of Manipulative and Physiological Therapeutics January 2004
Jason W. Busse, DC Department of Clinical Epidemiology and Biostatistics McMaster University 1200 Main Street West Room 2C3 Hamilton, Ontario L8N 3Z5 Canada 0161-4754/$30.00
© 2004 National University of Health Sciences
REFERENCES 1. Pikula JR. The effect of spinal manipulative therapy (SMT) on pain reduction and range of motion in patients with acute unilateral neck pain: a pilot study. J Can Chiropr Assoc 1999; 43:111-9. 2. Parkin-Smith GF, Penter CS. A clinical trial investigating the effect of two manipulative approaches in the treatment of mechanical neck pain: a pilot study. J Neuromusculoskelet Syst 1998;6:6-16. 3. Korthals-de Bos IB, Hoving JL, van Tulder MW, Rutten-van Molken MP, Ader HJ, de Vet HC, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. BMJ 2003;326:911-6. 4. Licht PB, Christensen HW, Hojgaard P, Marving J. Vertebral artery flow and spinal manipulation: a randomized, controlled and observer-blinded study. J Manipulative Physiol Ther 1998; 21:141-4. 5. Rogers RG. The effects of spinal manipulation on cervical kinesthesia in patients with chronic neck pain: a pilot study. J Manipulative Physiol Ther 1997;20:80-5. 6. Heikkila H, Johansson M, Wenngren BI. Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study. Man Ther 2000;5:151-7. 7. Bracher ES, Almeida CI, Almeida RR, Duprat AC, Bracher CB. A combined approach for the treatment of cervical vertigo. J Manipulative Physiol Ther 2000;23:96-100. 8. West DT, Mathews RS, Miller MR, Kent GM. Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. J Manipulative Physiol Ther 1999;22:299-308.
SEVERAL PATHWAYS IN THE EVOLUTION OF CHIROPRACTIC MANIPULATION
To the Editor: Dr Joseph C. Keating1 demonstrates a considerable knack for gathering historic information, as evidenced by his citing of important works from as early as the 1800s. In his review of more contemporary technique innovations and evolution, however, his review is less than adequate. Keating concluded that “technique innovators have still not accepted responsibility for providing outcomes data related to their particular methods, nor for relating their assessment methods to their intervention.”1(p317) Related to only 3 techniques reviewed, namely Activator, flexiondistraction, and applied kinesiology, this criticism may be accurate. Other techniques, however, have made significant advances in these areas and were not mentioned, let alone given credit. Gonstead technique members, for example, have documented treatment outcomes,2-4 as well as evaluated their assessment methods.5 The most significant dem-
Table 1. CBP research articles published/in press by journal title as of 2003 Journal
Published
In press
JMPT Chiropractic Technique Spine Clinical Biomechanics Journal of Spinal Disorders European Spine Journal Archives PM & R Journal of Orthopaedic Research Totals
35 6 6 3 3 2 2 1 58
3
1
4
CBP, Chiropractic Biophysics; JMPT, Journal of Manipulative and Physiological Therapeutics; Archives PM & R, Archives of Physical Medicine and Rehabilitation.
onstration of the insufficiency of Keating’s criticism is his exclusion of the published research by Chiropractic Biophysics (CBP) technique. CBP began in 1980, and in the last decade, the CBP nonprofit research group has published an extensive number of publications in chiropractic, orthopedic, and physical medical journals (Table 1). As presented by Harrison at the 2003 Association of Chiropractic Colleges/Research Agenda Conference meeting, practitioners of specific techniques attempting to validate their procedures should base their research agenda on 4 separate arms. They should: 1. Have a distinct and specific definition of subluxation with validation of its existence; 2. Evaluate the examiner reliability and validity of the assessment of (1); 3. Using measurements derived from (2), develop and evaluate technique treatment procedures aimed at correction of the subluxation defined in (1); and 4. Evaluate whether subluxation correction using procedures from (3) lead to improved patient outcomes. In meeting the requirements laid out in stage 1, CBP has published articles on its distinct and measurable definition of subluxation6; that is, translations or rotations of the head, thoracic cage, and/or pelvis in relation to the body mass below, as well as deviations from the normal lateral contours of the cervical,7 thoracic,8,9 and lumbar spine regions.10,11 The definition has received validation internally11-13 and externally.14-17 CBP technique utilizes 3-dimensional posture analysis and 2-dimensional radiograph analysis as the crux of its assessment procedures; since these methods require use of radiography, standardized patient positioning and use of established reliable and reproducible radiographic mensuration methods are necessary. The repeatability of radiographic positioning, radiographic line drawing analysis, and spinal posture have been established,18-28 satisfying stage 2. Development and assessment of unique methods used in CBP technique have been studied and demonstrated to correct cervical29-31 and lumbar sub-
Journal of Manipulative and Physiological Therapeutics Volume 27, Number 1
luxations/displacements;32,33 4 of these studies demonstrated long-term stability of spinal correction.29,30,32,33 These clinical trials satisfy stage 3, albeit not entirely, as many postural alterations are possible, as defined in stage 1. Stage 4 is the final and most important link, establishing whether the correction procedures lead to improved patient outcomes. Although research is ongoing, 4 completed clinical trials29-32 suggest that improvement in posture correlates with improvements in pain, as evaluated by visual analogue scale/numerical rating scale (VAS/NRS). While we acknowledge that some of the research manuscripts we cite herein were published later than the article by Dr Keating1 was written, most were available to him via a simple Medline search. CBP is currently at stage 4 of this research agenda/ hierarchy. What remains to be done is further refinement of technique protocols, as well as performance of the last and top of the evidence hierarchy, the much over-rated randomized clinical trial (RCT).34 As stated by Keating,1 “lack of scientific scrutiny has resulted in a proliferation of brand-name methods, each vying with the next for claims of superiority.” As illustrated, the extensive scientific scrutiny performed by the CBP research group may deservedly be considered superior in at least this consideration. Considering that CBP is the primary technique used by a larger number of practitioners,35 Keating1 has demonstrated research incompetence by his all-encompassing conclusion, as it does not apply to CBP. Keating1 states that chiropractors “have not refined their art by using clinical research methodology to separate the chaff from the wheat.” After evaluation of the evidence, CBP should be considered the closest thing to “wheat” this profession has. At the very least, other techniques should adopt this research agenda hierarchy to guide their scientific efforts, as many have not even satisfied stage 1. It is time for Dr Keating to give credit where credit is due. Paul A. Oakley Palmer College of Chiropractic 1000 Brady St Davenport, IA 52803 Deed E. Harrison, DC Private practice of chiropractic Elko, Nevada 0161-4754/$30.00
© 2004 National University of Health Sciences doi:10.1016/j.jmpt.2003.11.018
REFERENCES 1. Keating JC. Several pathways in the evolution of chiropractic manipulation. J Manipulative Physiol Ther 2003;26:300-21. 2. Alcantara J, Heschong R, Plaugher G, Alcantara J. Chiropractic management of a patient with subluxations, low back pain and epileptic seizures. J Manipulative Physiol Ther 1998;21: 410-18.
Letters to the Editor
3. Alcantara J, Plaugher G, Thornton RE, Salem C. Chiropractic care of a patient with vertebral subluxations and unsuccessful surgery of the cervical spine. J Manipulative Physiol Ther 2001;24:477-82. 4. Plaugher G, Cremata EE, Philips RB. A retrospective consecutive case analysis of pretreatment and comparative static radiological parameters following chiropractic adjustments. J Manipulative Physiol Ther 1990;13:498-506. 5. Plaugher G, Hendricks AH, Doble RW, Bachman TR, Araghi HJ, Hoffart VM. The reliability of patient positioning for evaluating static radiographic parameters of the human pelvis. J Manipulative Physiol Ther 2003;16:517-22. 6. Harrison DD, Janik TJ, Harrison DR, Troyanovich SJ, Harrison DE, Harrison SO. Chiropractic biophysics technique: a linear algebra approach to posture in chiropractic. J Manipulative Physiol Ther 1996;19:525-35. 7. Harrison DD, Janik TJ, Troyanovich SJ, Holland B. Comparisons of lordotic cervical spine curvatures to a theoretical ideal model of the static sagittal cervical spine. Spine 1996;21:66775. 8. Harrison DE, Janik TJ, Harrison DD, Cailliet R, Harmon S. Can the thoracic kyphosis be modeled with a simple geometric shape? J Spinal Disord Tech 2002;15:213-20. 9. Harrison DD, Harrison DE, Janik TJ, Cailliet R, Hass JW. Do alterations in vertebral and disc dimensions affect an elliptical model of thoracic kyphosis? Spine 2003;28:463-9. 10. Janik TJ, Harrison DD, Cailliet R, Troyanovich SJ, Harrison DE. Can the sagittal lumbar curvature be closely approximated by an ellipse? J Orthop Res 1998;16:766-70. 11. Harrison DD, Cailliet R, Janik TJ, Troyanovich SJ, Harrison DE, Holland B. Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. J Spinal Disord 1998;11:430-9. 12. Harrison DE, Harrison DD, Janik TJ, Jones EW, Cailliet R, Normand M. Comparison of axial flexural stresses in lordosis and three buckled configurations of the cervical spine. Clin Biomech (Bristol, Avon) 2001;16:276-84. 13. Harrison DE, Jones EW, Janik TJ, Harrison DD. Evaluation of axial and flexural stresses in the vertebral body cortex and trabecular bone in lordosis and two sagittal cervical translation configurations with an elliptical shell model. J Manipulative Physiol Ther 2002;26:391-401. 14. Korovessis P, Dimas A, Ilipoulos P, Lambiris E. Correlative analysis of lateral vertebral radiographic variables and medical outcomes study short-form health survey. J Spinal Disord 2002;15:384-90. 15. Ganju A, Ondra SL, Shaffrey CI. Cervical kyphosis. Tech Orthop 2003;17:345-54. 16. Lind LR, Lucente V, Kohn N. Thoracic kyphosis and the prevalence of advanced uterine prolapse. Obstet Gynecol 1996;87:605-9. 17. Milne JS, Williamson J. A longitudinal study of kyphosis in older people. Age Ageing 1983;12:225-33. 18. Jackson BL, Harrison DD, Robertson GA, Barker WF. Chiropractic biophysics lateral cervical film analysis reliability. J Manipulative Physiol Ther 1993;16:384-91. 19. Troyanovich SJ, Robertson GA, Harrison DD, Holland B. Intra- and inter-examiner reliability of the chiropractic biophysics lateral lumbar radiographic mensuration procedure. J Manipulative Physiol Ther 1995;18:519-24. 20. Troyanovich SJ, Harrison DE, Harrison DD, Holland B, Janik TJ. Further anaylsis of the reliability of the posterior tangent lateral lumbar radiographic mensuration procedure: concur-
73
74
Letters to the Editor
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
rent validity of computer aided x-ray digitization. J Manipulative Physiol Ther 1998;21:460-7. Troyanovich SJ, Harrison SO, Harrison DD, Harrison DE, Payne MR, Janik TJ, et al. Chiropractic biophysics digitized radiographic mensuration analysis of the anteroposterior lumbaroview: a reliability study. J Manipulative Physiol Ther 1999;22:309-15. Harrison DE, Harrison DD, Cailliet R. Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis. Spine 2000;25:2072-8. Troyanovich SJ, Harrison DE, Harrison DD, Harrison SO, Janik TJ, Holland B. Chiropractic biophysics digitized radiographic mensuration analysis of the anteroposterior cervicothoracic view: a reliability study. J Manipulative Physiol Ther 2000;23:476-82. Janik TJ, Harrison DE, Harrison DD, Holland B, Coleman RR, Payne MR. Reliability of lateral bending and axial rotation with validity of a new method to determine axial rotation on anteroposterior cervical radiographs. J Manipulative Physiol Ther 2001;24:445-8. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. Reliability of Centroid, Cobb, and Harrison posterior tangent methods: which to choose for analysis of thoracic kyphosis. Spine 2001;26:E227-34. Harrison DE, Harrison DD, Cailliet R, Janik TJ, Holland B. Radiographic analysis of lumbar lordosis: Centroid, Codd, TRALL, and Harrison posterior tangent methods. Spine 2001; 26:E235-42. Harrison DE, Holland B, Harrison DD, Janik TJ. Further reliability analysis of the Harrison radiographic line-drawing methods: crossed ICCs for lateral posterior tangents and modified Risser-Ferguson method on AP views. J Manipulative Physiol Ther 2002;25:93-8. Harrison DE, Harrison DD, Colloca CJ, Betz J, Janik TJ, Holland B. Repeatability over time of posture, radiographic positioning, and radiograph line drawing: an analysis of six control groups. J Manipulative Physiol Ther 2003;26:87-98. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial. Arch Phys Med Rehabil 2002;83:447-53. Harrison DE, Harrison DD, Betz J, Colloca CJ, Janik TJ, Holland B. Increasing the cervical lordosis with seated combined extension-compression and transverse load cervical traction with cervical manipulation: non randomized clinical control trial. J Manipulative Physiol Ther 2003;26:139-51. Harrison DD, Jackson BL, Troyanovich SJ, Robertson G, De George D, Barker WF. The efficacy of cervical extensioncompression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study. J Manipulative Physiol Ther 1994;17: 454-64. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. Changes in sagittal lumbar configurations with a new method of extension traction: nonrandomized clinical controlled trial. Arch Phys Med Rehabil 2002;83:1585-91. Harrison DE, Bula JM, Harrison DD. Nonoperative correction of the flexible flat back using lumbar extension traction: a case study of three with follow-up. J Chiropr Educ 2003;17:13-14. Kaptchuk TJ. The double-blind, randomized, placebo-controlled trial: gold standard or golden calf? J Clin Epidemiol 2001;54:541-9. Hawk C, Long CR, Boulanger KT. Prevalence of nonmusculoskeletal complaints in chiropractic: report from a practice-
Journal of Manipulative and Physiological Therapeutics January 2004
based research program. J Manipulative Physiol Ther 2001; 24:157-69.
In Response: I can well appreciate Mr Oakley’s and Dr Harrison’s chagrin with my conclusion that “technique innovators have still not accepted responsibility for providing outcomes data related to their particular methods, nor for relating their assessment methods to their intervention.”1 This is a serious overstatement of the situation, and I apologize. Had I prefaced this comment with, “For the most part,” or if I had asserted instead that brand-name technique innovators have not validated their outcomes data nor yet validated relationships among their assessment methods, their interventions, and clinical outcomes, I would have been on safer ground. I wish to acknowledge the extensive research conducted by the Drs Harrison and the Chiropractic Biophysics (CBP) group and thank them for exercising their “crap-detectors.” I suspect that they agree with my conclusion that “there is much work ahead.” I wish to acknowledge also the 4-point agenda for technique validation/invalidation that they present; it is reminiscent of strategies for the clinical investigation of chiropractic techniques and subluxation that have been offered elsewhere.2,3 I suggest, however, that validation of the existence of subluxation (eg, misalignment or fixation of joints), as suggested in their first step, may not be essential (albeit may be desirable) to determining whether the “correction” of subluxation (by whatever operational definition) is predictably associated with improved patient outcomes. As well, determination of the reliability of any particular subluxation detection strategy is a nonessential step in the process, since determination of validity can reasonably be assumed to encompass reliability as well. Nonetheless, reliability studies can serve an important screening function by weeding out those presumed subluxation indicators that are unlikely to be valid if they lack reliability (these are small points). That said, I cannot recall ever reading a randomized, controlled clinical trial in which putative segmental indicators of subluxation were monitored alongside clinical outcomes variables (eg, patients’ complaints of pain or dysfunction), such that a correlation between “subluxation correction” and improved clinical outcomes could be demonstrated. Such studies would be needed to: (1) validate the clinical meaningfulness of “subluxation syndrome,”4 and (2) relate subluxation assessment methods to their interventions. (Actually, these are more or less the same thing.) To the best of my knowledge, Activator Methods, Chiropractic Biophysics, Gonstead procedures, and many if not most chiropractic brand-name techniques are based on the notion of detecting and correcting subluxations (Cox’s flexion-distraction method may be an exception; I am not sure), so as to address patients’ concerns (eg, symptoms of disease and dysfunction, better health). Given the current state of
Letters to the Editor
Journal of Manipulative and Physiological Therapeutics January 2004
Jason W. Busse, DC Department of Clinical Epidemiology and Biostatistics McMaster University 1200 Main Street West Room 2C3 Hamilton, Ontario L8N 3Z5 Canada 0161-4754/$30.00
© 2004 National University of Health Sciences
REFERENCES 1. Pikula JR. The effect of spinal manipulative therapy (SMT) on pain reduction and range of motion in patients with acute unilateral neck pain: a pilot study. J Can Chiropr Assoc 1999; 43:111-9. 2. Parkin-Smith GF, Penter CS. A clinical trial investigating the effect of two manipulative approaches in the treatment of mechanical neck pain: a pilot study. J Neuromusculoskelet Syst 1998;6:6-16. 3. Korthals-de Bos IB, Hoving JL, van Tulder MW, Rutten-van Molken MP, Ader HJ, de Vet HC, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. BMJ 2003;326:911-6. 4. Licht PB, Christensen HW, Hojgaard P, Marving J. Vertebral artery flow and spinal manipulation: a randomized, controlled and observer-blinded study. J Manipulative Physiol Ther 1998; 21:141-4. 5. Rogers RG. The effects of spinal manipulation on cervical kinesthesia in patients with chronic neck pain: a pilot study. J Manipulative Physiol Ther 1997;20:80-5. 6. Heikkila H, Johansson M, Wenngren BI. Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study. Man Ther 2000;5:151-7. 7. Bracher ES, Almeida CI, Almeida RR, Duprat AC, Bracher CB. A combined approach for the treatment of cervical vertigo. J Manipulative Physiol Ther 2000;23:96-100. 8. West DT, Mathews RS, Miller MR, Kent GM. Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. J Manipulative Physiol Ther 1999;22:299-308.
SEVERAL PATHWAYS IN THE EVOLUTION OF CHIROPRACTIC MANIPULATION
To the Editor: Dr Joseph C. Keating1 demonstrates a considerable knack for gathering historic information, as evidenced by his citing of important works from as early as the 1800s. In his review of more contemporary technique innovations and evolution, however, his review is less than adequate. Keating concluded that “technique innovators have still not accepted responsibility for providing outcomes data related to their particular methods, nor for relating their assessment methods to their intervention.”1(p317) Related to only 3 techniques reviewed, namely Activator, flexiondistraction, and applied kinesiology, this criticism may be accurate. Other techniques, however, have made significant advances in these areas and were not mentioned, let alone given credit. Gonstead technique members, for example, have documented treatment outcomes,2-4 as well as evaluated their assessment methods.5 The most significant dem-
Table 1. CBP research articles published/in press by journal title as of 2003 Journal
Published
In press
JMPT Chiropractic Technique Spine Clinical Biomechanics Journal of Spinal Disorders European Spine Journal Archives PM & R Journal of Orthopaedic Research Totals
35 6 6 3 3 2 2 1 58
3
1
4
CBP, Chiropractic Biophysics; JMPT, Journal of Manipulative and Physiological Therapeutics; Archives PM & R, Archives of Physical Medicine and Rehabilitation.
onstration of the insufficiency of Keating’s criticism is his exclusion of the published research by Chiropractic Biophysics (CBP) technique. CBP began in 1980, and in the last decade, the CBP nonprofit research group has published an extensive number of publications in chiropractic, orthopedic, and physical medical journals (Table 1). As presented by Harrison at the 2003 Association of Chiropractic Colleges/Research Agenda Conference meeting, practitioners of specific techniques attempting to validate their procedures should base their research agenda on 4 separate arms. They should: 1. Have a distinct and specific definition of subluxation with validation of its existence; 2. Evaluate the examiner reliability and validity of the assessment of (1); 3. Using measurements derived from (2), develop and evaluate technique treatment procedures aimed at correction of the subluxation defined in (1); and 4. Evaluate whether subluxation correction using procedures from (3) lead to improved patient outcomes. In meeting the requirements laid out in stage 1, CBP has published articles on its distinct and measurable definition of subluxation6; that is, translations or rotations of the head, thoracic cage, and/or pelvis in relation to the body mass below, as well as deviations from the normal lateral contours of the cervical,7 thoracic,8,9 and lumbar spine regions.10,11 The definition has received validation internally11-13 and externally.14-17 CBP technique utilizes 3-dimensional posture analysis and 2-dimensional radiograph analysis as the crux of its assessment procedures; since these methods require use of radiography, standardized patient positioning and use of established reliable and reproducible radiographic mensuration methods are necessary. The repeatability of radiographic positioning, radiographic line drawing analysis, and spinal posture have been established,18-28 satisfying stage 2. Development and assessment of unique methods used in CBP technique have been studied and demonstrated to correct cervical29-31 and lumbar sub-
Journal of Manipulative and Physiological Therapeutics Volume 27, Number 1
luxations/displacements;32,33 4 of these studies demonstrated long-term stability of spinal correction.29,30,32,33 These clinical trials satisfy stage 3, albeit not entirely, as many postural alterations are possible, as defined in stage 1. Stage 4 is the final and most important link, establishing whether the correction procedures lead to improved patient outcomes. Although research is ongoing, 4 completed clinical trials29-32 suggest that improvement in posture correlates with improvements in pain, as evaluated by visual analogue scale/numerical rating scale (VAS/NRS). While we acknowledge that some of the research manuscripts we cite herein were published later than the article by Dr Keating1 was written, most were available to him via a simple Medline search. CBP is currently at stage 4 of this research agenda/ hierarchy. What remains to be done is further refinement of technique protocols, as well as performance of the last and top of the evidence hierarchy, the much over-rated randomized clinical trial (RCT).34 As stated by Keating,1 “lack of scientific scrutiny has resulted in a proliferation of brand-name methods, each vying with the next for claims of superiority.” As illustrated, the extensive scientific scrutiny performed by the CBP research group may deservedly be considered superior in at least this consideration. Considering that CBP is the primary technique used by a larger number of practitioners,35 Keating1 has demonstrated research incompetence by his all-encompassing conclusion, as it does not apply to CBP. Keating1 states that chiropractors “have not refined their art by using clinical research methodology to separate the chaff from the wheat.” After evaluation of the evidence, CBP should be considered the closest thing to “wheat” this profession has. At the very least, other techniques should adopt this research agenda hierarchy to guide their scientific efforts, as many have not even satisfied stage 1. It is time for Dr Keating to give credit where credit is due. Paul A. Oakley Palmer College of Chiropractic 1000 Brady St Davenport, IA 52803 Deed E. Harrison, DC Private practice of chiropractic Elko, Nevada 0161-4754/$30.00
© 2004 National University of Health Sciences doi:10.1016/j.jmpt.2003.11.018
REFERENCES 1. Keating JC. Several pathways in the evolution of chiropractic manipulation. J Manipulative Physiol Ther 2003;26:300-21. 2. Alcantara J, Heschong R, Plaugher G, Alcantara J. Chiropractic management of a patient with subluxations, low back pain and epileptic seizures. J Manipulative Physiol Ther 1998;21: 410-18.
Letters to the Editor
3. Alcantara J, Plaugher G, Thornton RE, Salem C. Chiropractic care of a patient with vertebral subluxations and unsuccessful surgery of the cervical spine. J Manipulative Physiol Ther 2001;24:477-82. 4. Plaugher G, Cremata EE, Philips RB. A retrospective consecutive case analysis of pretreatment and comparative static radiological parameters following chiropractic adjustments. J Manipulative Physiol Ther 1990;13:498-506. 5. Plaugher G, Hendricks AH, Doble RW, Bachman TR, Araghi HJ, Hoffart VM. The reliability of patient positioning for evaluating static radiographic parameters of the human pelvis. J Manipulative Physiol Ther 2003;16:517-22. 6. Harrison DD, Janik TJ, Harrison DR, Troyanovich SJ, Harrison DE, Harrison SO. Chiropractic biophysics technique: a linear algebra approach to posture in chiropractic. J Manipulative Physiol Ther 1996;19:525-35. 7. Harrison DD, Janik TJ, Troyanovich SJ, Holland B. Comparisons of lordotic cervical spine curvatures to a theoretical ideal model of the static sagittal cervical spine. Spine 1996;21:66775. 8. Harrison DE, Janik TJ, Harrison DD, Cailliet R, Harmon S. Can the thoracic kyphosis be modeled with a simple geometric shape? J Spinal Disord Tech 2002;15:213-20. 9. Harrison DD, Harrison DE, Janik TJ, Cailliet R, Hass JW. Do alterations in vertebral and disc dimensions affect an elliptical model of thoracic kyphosis? Spine 2003;28:463-9. 10. Janik TJ, Harrison DD, Cailliet R, Troyanovich SJ, Harrison DE. Can the sagittal lumbar curvature be closely approximated by an ellipse? J Orthop Res 1998;16:766-70. 11. Harrison DD, Cailliet R, Janik TJ, Troyanovich SJ, Harrison DE, Holland B. Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. J Spinal Disord 1998;11:430-9. 12. Harrison DE, Harrison DD, Janik TJ, Jones EW, Cailliet R, Normand M. Comparison of axial flexural stresses in lordosis and three buckled configurations of the cervical spine. Clin Biomech (Bristol, Avon) 2001;16:276-84. 13. Harrison DE, Jones EW, Janik TJ, Harrison DD. Evaluation of axial and flexural stresses in the vertebral body cortex and trabecular bone in lordosis and two sagittal cervical translation configurations with an elliptical shell model. J Manipulative Physiol Ther 2002;26:391-401. 14. Korovessis P, Dimas A, Ilipoulos P, Lambiris E. Correlative analysis of lateral vertebral radiographic variables and medical outcomes study short-form health survey. J Spinal Disord 2002;15:384-90. 15. Ganju A, Ondra SL, Shaffrey CI. Cervical kyphosis. Tech Orthop 2003;17:345-54. 16. Lind LR, Lucente V, Kohn N. Thoracic kyphosis and the prevalence of advanced uterine prolapse. Obstet Gynecol 1996;87:605-9. 17. Milne JS, Williamson J. A longitudinal study of kyphosis in older people. Age Ageing 1983;12:225-33. 18. Jackson BL, Harrison DD, Robertson GA, Barker WF. Chiropractic biophysics lateral cervical film analysis reliability. J Manipulative Physiol Ther 1993;16:384-91. 19. Troyanovich SJ, Robertson GA, Harrison DD, Holland B. Intra- and inter-examiner reliability of the chiropractic biophysics lateral lumbar radiographic mensuration procedure. J Manipulative Physiol Ther 1995;18:519-24. 20. Troyanovich SJ, Harrison DE, Harrison DD, Holland B, Janik TJ. Further anaylsis of the reliability of the posterior tangent lateral lumbar radiographic mensuration procedure: concur-
73
74
Letters to the Editor
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
rent validity of computer aided x-ray digitization. J Manipulative Physiol Ther 1998;21:460-7. Troyanovich SJ, Harrison SO, Harrison DD, Harrison DE, Payne MR, Janik TJ, et al. Chiropractic biophysics digitized radiographic mensuration analysis of the anteroposterior lumbaroview: a reliability study. J Manipulative Physiol Ther 1999;22:309-15. Harrison DE, Harrison DD, Cailliet R. Cobb method or Harrison posterior tangent method: which to choose for lateral cervical radiographic analysis. Spine 2000;25:2072-8. Troyanovich SJ, Harrison DE, Harrison DD, Harrison SO, Janik TJ, Holland B. Chiropractic biophysics digitized radiographic mensuration analysis of the anteroposterior cervicothoracic view: a reliability study. J Manipulative Physiol Ther 2000;23:476-82. Janik TJ, Harrison DE, Harrison DD, Holland B, Coleman RR, Payne MR. Reliability of lateral bending and axial rotation with validity of a new method to determine axial rotation on anteroposterior cervical radiographs. J Manipulative Physiol Ther 2001;24:445-8. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. Reliability of Centroid, Cobb, and Harrison posterior tangent methods: which to choose for analysis of thoracic kyphosis. Spine 2001;26:E227-34. Harrison DE, Harrison DD, Cailliet R, Janik TJ, Holland B. Radiographic analysis of lumbar lordosis: Centroid, Codd, TRALL, and Harrison posterior tangent methods. Spine 2001; 26:E235-42. Harrison DE, Holland B, Harrison DD, Janik TJ. Further reliability analysis of the Harrison radiographic line-drawing methods: crossed ICCs for lateral posterior tangents and modified Risser-Ferguson method on AP views. J Manipulative Physiol Ther 2002;25:93-8. Harrison DE, Harrison DD, Colloca CJ, Betz J, Janik TJ, Holland B. Repeatability over time of posture, radiographic positioning, and radiograph line drawing: an analysis of six control groups. J Manipulative Physiol Ther 2003;26:87-98. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial. Arch Phys Med Rehabil 2002;83:447-53. Harrison DE, Harrison DD, Betz J, Colloca CJ, Janik TJ, Holland B. Increasing the cervical lordosis with seated combined extension-compression and transverse load cervical traction with cervical manipulation: non randomized clinical control trial. J Manipulative Physiol Ther 2003;26:139-51. Harrison DD, Jackson BL, Troyanovich SJ, Robertson G, De George D, Barker WF. The efficacy of cervical extensioncompression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study. J Manipulative Physiol Ther 1994;17: 454-64. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. Changes in sagittal lumbar configurations with a new method of extension traction: nonrandomized clinical controlled trial. Arch Phys Med Rehabil 2002;83:1585-91. Harrison DE, Bula JM, Harrison DD. Nonoperative correction of the flexible flat back using lumbar extension traction: a case study of three with follow-up. J Chiropr Educ 2003;17:13-14. Kaptchuk TJ. The double-blind, randomized, placebo-controlled trial: gold standard or golden calf? J Clin Epidemiol 2001;54:541-9. Hawk C, Long CR, Boulanger KT. Prevalence of nonmusculoskeletal complaints in chiropractic: report from a practice-
Journal of Manipulative and Physiological Therapeutics January 2004
based research program. J Manipulative Physiol Ther 2001; 24:157-69.
In Response: I can well appreciate Mr Oakley’s and Dr Harrison’s chagrin with my conclusion that “technique innovators have still not accepted responsibility for providing outcomes data related to their particular methods, nor for relating their assessment methods to their intervention.”1 This is a serious overstatement of the situation, and I apologize. Had I prefaced this comment with, “For the most part,” or if I had asserted instead that brand-name technique innovators have not validated their outcomes data nor yet validated relationships among their assessment methods, their interventions, and clinical outcomes, I would have been on safer ground. I wish to acknowledge the extensive research conducted by the Drs Harrison and the Chiropractic Biophysics (CBP) group and thank them for exercising their “crap-detectors.” I suspect that they agree with my conclusion that “there is much work ahead.” I wish to acknowledge also the 4-point agenda for technique validation/invalidation that they present; it is reminiscent of strategies for the clinical investigation of chiropractic techniques and subluxation that have been offered elsewhere.2,3 I suggest, however, that validation of the existence of subluxation (eg, misalignment or fixation of joints), as suggested in their first step, may not be essential (albeit may be desirable) to determining whether the “correction” of subluxation (by whatever operational definition) is predictably associated with improved patient outcomes. As well, determination of the reliability of any particular subluxation detection strategy is a nonessential step in the process, since determination of validity can reasonably be assumed to encompass reliability as well. Nonetheless, reliability studies can serve an important screening function by weeding out those presumed subluxation indicators that are unlikely to be valid if they lack reliability (these are small points). That said, I cannot recall ever reading a randomized, controlled clinical trial in which putative segmental indicators of subluxation were monitored alongside clinical outcomes variables (eg, patients’ complaints of pain or dysfunction), such that a correlation between “subluxation correction” and improved clinical outcomes could be demonstrated. Such studies would be needed to: (1) validate the clinical meaningfulness of “subluxation syndrome,”4 and (2) relate subluxation assessment methods to their interventions. (Actually, these are more or less the same thing.) To the best of my knowledge, Activator Methods, Chiropractic Biophysics, Gonstead procedures, and many if not most chiropractic brand-name techniques are based on the notion of detecting and correcting subluxations (Cox’s flexion-distraction method may be an exception; I am not sure), so as to address patients’ concerns (eg, symptoms of disease and dysfunction, better health). Given the current state of