Edward F. Owens, Jr. MS, DC

Director of Research

Sherman College of Straight Chiropractic

This article first appeared in Today's Chiropractic, 1999; 28(6):94-99.

The end of the millennium is a good time to step back, take a look at where we are and consider redirecting our efforts to the future, not unlike making New Year’s resolutions, but on a much grander scale. Even though its title implies that this article will explore the future of research in chiropractic, we really have to look at chiropractic’s research endeavors in the broader context of the profession and the society in which it operates to fully understand this issue. Hence, we’ll take a broader view of professional chiropractic development in the future and how research can influence that development.

While I don’t believe in predestination — that we have no control over the future — I do believe strongly in a physical analog of it, inertia. If Newton was right about inertia, then objects at rest or in uniform motion will continue in that state, unless acted on by external forces. Great examples come from our space program. Where would we be if the astronauts reported "Houston, we’re headed straight for the moon, and, we fear, destined to crash into it?" Actually, the space program’s success depends on our ability to recognize the location and trajectory of a space craft in relation to other bodies in the solar system, and make course corrections using rockets burning at critical times in the correct directions.

Rather than succumb to inertia, our space program was built on a mission: to push the bounds of knowledge and come back safely, to use the knowledge gained to create tools to evaluate and control position, and then use the tools to further the mission. I think we can use this model to evaluate the position and course of the chiropractic profession.

Our leaders and practitioners have developed the mission for the profession. Research contributes to the profession as the knowledge gathering process that we can use as we see fit to discover or create new tools that will help us accomplish the mission. Our course for the future, then, depends on 1.) our mission, 2.) the forces acting on the profession, 3.) our trajectory, i.e. the recent course of events, and 4.) the tools we are willing to develop and use to achieve course corrections that fulfill our mission. Let’s look at each of these contributions in turn to help us predict our future.

There are currently two divergent missions being pursued in chiropractic today, each based on a different practice model. One mission, which I’ll refer to as therapeutic chiropractic, is to treat human ailments using manual manipulation or other physical therapeutics. The other mission is to detect and correct subclinical spinal deviations that act as stressors on the nerve system. Since these subclinical spinal problems are most often called vertebral subluxations, we can refer to this second mission as vertebral subluxation chiropractic. Like most complex systems, there are advantages as well as disadvantages to both models.

Kepler, a German astronomer, worked out how the gravitational attraction of heavenly bodies influences their motions in space in the 1600's. Those interactions seem simple compared to the forces acting within and upon the chiropractic profession today. Internal forces often involve conflict between the divergent missions, although sometimes such conflict can contribute to the progress of the profession as a whole. External forces are even more complex, involving the public, whom we seek to serve, the people who pay for the services provided, and the governmental agencies that regulate and/or encourage our activities. These forces have had significant impact on the profession during its first 100 years and we can expect that they will continue to shape it in the future.

There are several key historical developments, particularly having to do with research, that I’ve witnessed in the 25 years I’ve been associated with chiropractic. Research in the late 1970s and early 1980s was focused on developing and testing measures of spinal subluxation, such as x-ray analysis and thermographic instruments. The literature was replete with reliability studies, few of them favorable. By the mid-1980s, a lot of researchers seemed frustrated in their attempts to measure subluxation factors and were inclined to adopt a stance that subluxations existed not in spines, but in the minds of the beholder. Research turned from subluxation specific chiropractic research to therapeutic, outcomes-based research.

Even the terminology used to describe chiropractic care changed from spinal adjustment to spinal manipulative therapy (SMT). This was a key development because it helped therapeutic chiropractic "fit in" with medical manipulators and make use of advances in that field of research. The measures used to assess the effects of care in patients were oriented toward showing improvement in reported or measured symptoms of diagnosed conditions. Unfortunately, the practitioner’s motives and methods for detecting the segment to be manipulated were largely ignored.

Chiropractic and medical research of SMT was successful in attracting the attention of reviewers for the Agency for Health Care Policy and Research (AHCPR) who evaluated all types of care for acute low back pain in 1994. The AHCPR review suggested that SMT was the most efficacious active care for that condition. At about the same time, the National Institutes of Health (NIH) became interested in complementary and alternative medicine (CAM) because of the observation that many Americans were seeking alternative care, often in the form of chiropractic care. CAM was awarded its own office in the NIH. This office was recently upgraded to the National Center for Complementary and Alternative Medicine (NCCAM). Chiropractic attracted the attention of another federal agency, the Health Resources and Services Administration (HRSA). It believed that the chiropractic profession might help supplement the short supply of medical doctors in rural America. All this governmental attention toward SMT and CAM eventually led to more and more research money being granted for chiropractic demonstration projects and the establishment of the Consortial Center for Chiropractic Research (CCCR) as a branch of the NCCAM.

In this chain of events, research has led the way in helping therapeutic chiropractic win the struggle to "fit" into the health care system. Several chiropractic colleges are striving to blend in to an even greater extent and have announced the adoption of wider curricula, offering other alternative therapies such as acupuncture, nutrition and massage therapy.

The therapeutic model of chiropractic has been bolstered by research showing its efficacy for low back pain, and perhaps neck pain. If we take this as the trajectory that chiropractic will follow in the next millennium, then the future will be shaped largely by the success of research to lengthen the list of conditions for which chiropractic manipulation is appropriate and effective. It will also be influenced by the market forces that act on it as chiropractors work their way into niches perhaps already occupied by other disciplines. Adopting a wider scope of practice by adding other alternative therapies will enable chiropractors to treat a wider array of conditions and compete more effectively in the therapeutic marketplace.

However, many in the profession, myself included, are not happy with this possible future and see a very different role for the profession. There is a sense that a large part of our professional identity and our patient base will be lost if we abandon the vertebral subluxation mission and restrict our practices to certain classes of sick people. There is compelling evidence, albeit mostly anecdotal, that regular spinal checkups can benefit people who are not even sick, helping to optimize physical performance and acting in an overall health-enhancing role. The ones who are most convinced of this potentially huge benefit to society are the practitioners who have witnessed such changes first-hand in their patients and/or themselves. Indeed, recent surveys of the profession reveal the existence of a vital and unmet interest in seeing research done to describe the vertebral subluxation at a basic science level.

It seems that the recent successes and future promise of chiropractic research are at odds with the wishes of the practitioners. The research being pursued is not contributing to the vertebral subluxation mission of the profession. On the other hand, to return to the space exploration analogy one last time, research bolstering the therapeutic mission of chiropractic has acted very much like a booster rocket, helping the profession gain credibility, governmental recognition and popular acceptance as an alternative to medicine. This is just the first stage, however, and we have not yet achieved a stable orbit. If we choose to make a course correction, it will take the ignition of a second stage of professional development. We will need to make use of all the tools at our disposal, particularly the internal and external forces that bear on our trajectory, to redirect it back toward the issues of vertebral subluxation chiropractic.

The HRSA has provided for us a perfect opening in the form of the Research Agenda Conferences (RACs), now in their fourth year. The original intention of the RACs was to figure out what our research focus should be. The researchers up to now have been mostly interested in doing research that was deemed fundable by agencies such as the NCCAM, essentially letting the funding agencies dictate to us what our research interests should be. Finally this year, there was some discussion at RAC-IV of possible ways that vertebral subluxation research could be renewed. New approaches to studying vertebral subluxation from basic and clinical viewpoints are needed. The medical treatment model of research does not well elucidate the effects of care when symptoms are not present.

I think that more researchers would gravitate toward vertebral subluxation investigations if the funding were made available. A decision to devote a reasonable portion of the federal funds earmarked for chiropractic research and administered through the CCCR for vertebral subluxation research would help. Developing new sources of funding dedicated to vertebral subluxation research, through practitioner-supported groups would be another avenue.

If our profession’s leaders, at the behest of their constituents, decide that both chiropractic missions and practice models, the therapeutic and the vertebral subluxation-centered, are vital to the growth of the profession and deserving of respect, then perhaps a unified profession would spring forth. Practitioners would be more likely to make themselves aware of and become more supportive of research. Awareness would come from reading research literature in which they had a professional interest, while support would take the form of donations to research foundations, participation in practice-based research networks, or publication of original research. Finally, the profession might be able to engage the support of a public that is becoming increasingly interested in enhanced performance and quality of life.

Taken together, we have the tools we need to change our course in the future, widening the applicability of chiropractic care and maintaining our identity as portal of entry health care providers specializing in the area of vertebral subluxation.

Owens EF, Vertebral Subluxation Hypothesis Tree. Presented at the 4^th Research Agenda Conference, Chicago July 23-25, 1999. Online at: http://www.sherman.edu/research/VS-hypothesis/index.htm

Gold, R. The Triune of Life, Sherman College of Straight Chiropractic, Spartanburg, SC, 1998.

Cassidy, CM. Unraveling the Ball of String: Reality, Paradigms, and the Study of Alternative Medicine, The Journal of Mind/Body Health Vol 10(1), 1994. Online at : http://www.healthy.net/LIBRARY/Articles/Advances/CASSIDY.htm

Jonas WB, Levin JS. Essentials of Complementary and Alternative Medicine, Lippincott, Williams & Wilkins; ISBN: 068330674X, 1999.