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Research Information
June 10, 2002
Dana J. Lawrence, D.C., Editor Journal of Manipulative & Physiological Therapeutics 200 E. Roosevelt Road Lombard IL 60 148 To the Editor: Reply to J.C. Smith, M.A., D.C. I thank Dr. Smith for bringing several issues into sharp focus. Dr. Smith misstates his own point, the one which I responded to, which was that the use of low-rated procedures amounts to malpractice. This is an extraordinary conceptual leap, and certainly not justified by the ratings project findings. Indeed, the authors advised that "Comparison of procedure ratings must be made with caution..." and that "Lack of evidence in the literature is not evidence of lack of effectiveness" (1). One wonders how they could have made these points any more clear, so that Dr. Smith could grasp the limitations inherent in the project and the literature available for review. My critic ignores Gatterman et al's admonitions, and would have readers believe that paucity of experimental evidence turns a clinical method into malpractice. Dr. Smith seems to interpret Gatterman et al.'s project to mean that lower-rated procedures are less effective than higher-rated procedures, and conversely that higher-rated procedures are more effective. He asserts, "Using low-rated methods may only add to the overall cost or delay positive outcomes." These speculations may or may not be correct; the Gatterman project did not address relative effectiveness or relative cost-effectiveness. Smith's misunderstanding of Gatterman et al.'s project is further reflected in his query "Why then would a chiropractic patient want to use a DC who used a low-rated method if, in fact, he knew there were superior methods available?" The ratings in Gatterman et al. (1) amount to judgments of the panel's confidence in each of the various methods; they are neither judgments nor evidence of "superior" effectiveness. To date, the one RCT (2) that has addressed the relative merits of instrument (Activator Adjusting Instrument) vs. manual adjusting for low back patients found no difference in immediate pain relief (see Table). Smith dismisses this as "not very impressive, poorly designed, and unconvincing to the study panel." [Unless he has spoken directly to the panel members, Smith cannot know how they interpreted this paper.] The study (2) was indeed limited (which is not equivalent to a poor design), both in sample size and in that it only looked at the immediate effect of adjusting. A sole clinician administered both types of adjustments, and he may have a predilection to lower force techniques. Yet patients in both groups reported statistically significant pain, reduction, and the difference in pain reduction between groups was almost zero. Of course, it is possible that a Type II error occurred, and the absence of a no-treatment control makes interpretation of clinical improvements difficult. However, if there is a difference in immediate outcome for manual vs. instrument adjusting, a much larger sample may be required to tease out such difference, which suggests that any relative advantage for either method may be clinically trivial. It should also be noted that a comparison of the short-term effects Activator vs. manual adjusting for neck pain also failed to find a difference between groups (3), although in this case the within-group improvements were not statistically significant. Table: Results of Gemmell & Jacobson's (2) comparison of the effects (patients' pain ratings on the Visual Analogue Scale) of a single Activator adjustment (n=14) to a single manual adjustment (n=16) in acute low back pain patients
Dr. Smith has an agenda. He would call a "moratorium" on Activator Methods Chiropractic Technique (AMCT), except in unspecified "unusual conditions" where he judges low-force may be necessary (and would presumably then not be malpractice). Although he calls for a controlled comparison of instrument vs. side-posture manual adjustment for low back pain, he is obviously satisfied that the ratings of eight panelists with scrappy data justify such a draconian step. And, following the allopathic tradition, he transforms an inadequate data base into "no evidence." Dr. Smith misstates my position by suggesting that l or Activator Methods International, Ltd. expect anyone to "fully accept" AMCT "without hard data." In fact, we offer clinical hypotheses concerning the assessment and treatment of human ills. These hypotheses (i.e., tentative assertions) are made credible (but not proved) by nearly 40 years of experience with AMCT , by papers considering the neurophysiology of the adjustment (e.g., 4-6), by the limited available outcome literature (7), and by the response of the profession, a majority of whom (estimated at 62.8%) makes use of these procedures in an estimated fifth (21.7%) of their caseloads (8). My company seeks to encourage a more critical attitude toward clinical theory and practice, and despite the recriminations it fosters, we have repeatedly acknowledged (e.g., 9) that AMCT lacks adequate scientific validation. We have accepted the challenge to investigate the merits, including effectiveness, of our procedures and will continue to do so within the constraints that limited resources impose. Sincerely, Arlan w. Fuhr, D.C., President Activator Methods International, Ltd. References: I. Gatterman MI, Cooperstein R, Lantz C, Perle SM, Schneider MJ. Rating specific chiropractic technique procedures for common low back conditions. Journal of Manipulative & Physiological Therapeutics 2001 (Sept); 24(7): 449-56 2. Gemmell HA, Jacobson BH. The immediate effect of Activator vs. Meric adjustment on acute low back pain: a randomized controlled trial. Journal of Manipulative & Physiological Therapeutics 1995 (Sept); 18(7): 453-6 3. Yurkiw D, Mior S. Comparison of two chiropractic techniques on pain and lateral flexion in neck pain patients: a pilot study. Chiropractic Technique 1996 (Nov); 8(4): 155-62 4. Evans DW. Mechanisms and effects of spinal high-velocity, low-amplitude thrust manipulation: previous theories. Journal of Manipulative & Physiological Therapeutics 2002 (May); 25(4): 251-62 5. Slosberg M. Effects of altered afferent articular input on sensation, proprioception, muscle tone and sympathetic reflex responses. Journal of Manipulative & Physiological Therapeutics 1988 (Oct); 11(5): 400-8 6. Slosberg M. Spinal Learning: central modulation of pain processing and long-term alteration of interneuronal excitability as a result of nociceptive peripheral input. Journal of Manipulative & Physiological Therapeutics 1990 (July/Aug); 13(6): 326-36 7. Fuhr AW. Reply to Drs. Perle, Cooperstein, Lantz & Schneider. Journal of Manipulative & Physiological Therapeutics, in press 8. National Board of Chiropractic Examiners. Job analysis of chiropractic. Greeley CO: the Board, 2000, p. 129 9. Osterbauer PJ, Fuhr A W. The status of Activator Methods Chiropractic Technique, theory and training. Chiropractic Technique 1990 (Nov); 2(4): 168-75 |