Page 26 - BackSpace October 2017

Feature
Newell’s Notes: A bigger ‘Big Idea’ The chiropractor, not the treatment, makes the difference
THE EFFECTIVENESS of chiropractic interventions is
often articulated in the literature as being synonymous with spinal manipulation (SM). Vanishingly few articles compare such interventions with sham manipulation, some compare them with supposed inert interventions, and the majority compare them with other active interventions. These are then reported as evidence for or against spinal manipulative therapy and mostly there are few differences in outcomes between the groups(1,2).
However, the reality is that none of these trials actually compared SM alone to anything. What they compared were clinical encounters. These consist of a clinician with a patient, some communication, almost certainly some instruction, empathy and touch. These cues themselves are powerful in creating expectations in the patient and, of necessity, trust in the clinician and the experimenters. A whole history of ideas, world views, experiences and opinions that the patient brings to the study, impacts on the experience hoped for and subsequently reported. All these, and more, ‘contextual factors’ are present during the encounter and the idea that SM is delivered devoid of these things is unrealistic. So when evidence is presented of the supposed efficacy or otherwise of SM, what is being considered is a complex context of rich human interaction within which a manipulative thrust is delivered.
“A skilfully constructed package
of care... woven together with
language, stories, context and
expert listening”
You might say that these contextual cues would also be present in other arms of a trial; but if the comparator were group exercise the details of the encounters would be different – one patient alone with a practitioner, another in a group of patients, perhaps with an instructor in a gym. Additionally, what if the patients were given randomly- selected treatments that they were neither expecting nor wanting? What if the practitioner delivered a modality that they preferred or one they didn’t prefer? How do these things affect the final clinical outcome? One recent study reported that outcomes were not only changed by patient preference but also by practitioner preference.(3)
Clearly then, even if SM were the only physical modality delivered, there is much more going on in clinical encounters than simple manipulation of a spine. Why then does the chiropractic profession often characterise itself by manipulation, when manipulation is at best, only a part of what has been provided?
The issue of identity runs deep here. Some would say that without a manipulation-centric description of the profession we are no different to any other group delivering conservative care. This makes no sense, even at the simple level, because many other professions deliver manipulation and almost certainly, in many cases, as well as chiropractors.
Accumulated evidence suggests that for MSK conditions, particularly low back pain, a large range of interventions have similar efficacy. It is not only research that says this. Most
chiropractors already know colleagues who practise with a plethora of different approaches, using multiple different manipulative techniques, diagnostic routines and explanations of mechanism, each proclaiming undying loyalty and unswerving conviction in the efficacy of often divergent approaches. And yet it is common knowledge that these colleagues are frequently making a good living and presiding over substantive and repetitive improvements in the health of their patients. What might that tell you?
An obvious explanation suggests the common factor between all approaches is the clinical encounter itself and, perhaps more so, the clinician. This type of observation has been noted in other therapeutic arenas including psychotherapy(4).
If so, is the real identity of the profession not the delivery of
a manipulative thrust or other modality but how chiropractors construct a package of care, weaving together stories, conviction and skilful humanity with multiple interventions tailored to the patient before them? Chiropractic is a profession NOT a treatment.
So, if manipulation is merely one of many tools, where is the evidence for other modalities that chiropractors can provide? Exercise has recently been shown to be the only modality that has strong evidence of a substantive effect on pain, and it doesn’t really matter what type of exercise you prescribe as long as it’s a type that the patient is likely to undertake(1). Self-management, advice and talk, or elements of them, all seem to work. Massage and
soft tissue approaches work. Other potential modalities such as mindfulness, yoga and even Tai Chi are emerging as effective.(1,2). What is actually observed in trials is that a range of interventions from manipulation to mind management, from movement to massage are legitimate approaches to care.
The reality is that chiropractors have a big basket of building blocks and tools from which they may make a bespoke clinical encounter.
Take the example of a carpenter. When a carpenter uses multiple components and tools to build a bespoke object, do we cry: “But the carpenter’s uniqueness is their expertise with the plane, or saw. They did not use these enough in making this furniture, they are not a professional carpenter, they might as well call themselves a bricklayer”? How absurd that would be. No. The carpenter’s skills are knowing how, when, and with what to approach the chosen wood. Using the appropriate tools, they create a coherent, functional and perhaps beautiful object. We define the carpentry profession by the skill with which they use their knowledge, experience and expertise to wield a multiplicity of tools, not by one tool in their toolbox. Why then define a health care profession by a single tool?
Similarly, chiropractic is a profession whose members deliver a skilfully constructed package of care – multiple modalities, woven together with language, stories, context and expert listening. What emerges most of the time is a patient that is more well than when they first arrived. Moving away from a narrow and fragile identity centred on one modality not only makes us evidentially far stronger but leverages the effectiveness of multiple approaches. If we are more than manipulation does it matter then that research has found manipulation is equally effective to other approaches for some conditions?
26 BACKspace www.chiropractic-ecu.org October 2017