Condition-specific Indications for Chiropractic ...

Cooperstein and Perle: Condition-specific Indications for Adjustive Procedures

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Condition-specific Indications for Chiropractic Adjustive Procedures for the Low Back: Literature and Clinical Effectiveness Ratings of an Expert Panel Purpose: A formal process to evaluate the literature and determine which specific types of manipulation and nonmanipulative methods are most effective for particular types of low back pain is undertaken. This is a summary paper from a 6-year study to characterize the quality and quantity of literature gathered for an expert panel convened to rate various specific chiropractic adjustive procedures for common presentations of low back pain. Methods: Systematic review of treatment-specific, condition-specific trials, studies, and case reports of chiropractic care for low back pain followed by convening of an expert panel to rate effectiveness of procedures for common types of low back pain. Statements related to the rating process and clinical practice were then developed through a facilitated nominal group exercise. Summary: The ratings for the effectiveness of chiropractic technique procedures are not equal. Those procedures that are rated the highest are supported by the highest quality literature. More evidence is necessary toward an understanding of which procedures maximally benefit patients for the various conditions. Key words: chiropractic, low back pain, peer review, review literature, spinal manipulation

Robert Cooperstein, MA, DC Professor; Coordinator of Technique and Research Palmer College of Chiropractic-West San Jose, California

Stephen Perle, DC Associate Professor of Clinical Studies University of Bridgeport Bridgeport, Connecticut

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PROJECT ENTITLED Guidelines for Utilization of Chiropractic Procedures in the Treatment of Low Back Pain was originally approved for support by the Foundation for Chiropractic Education and Research (FCER) in its 1996 funding cycle. This project consisted of two parts: (1) a systematic review of treatment-specific, condition-specific trials, studies, and case reports of chiropractic care for low back conditions; and (2) the convening of an expert panel to review this literature and draw on their own clinical experience, to rate the clinical effectiveness of these procedures and the quality of the literature on which their opinions were partially based. Ultimately, two articles were published, one characterizing the literature1 and the other providing and discussing the panel’s ratings and recommendations to the chiropractic profession.2 The idea for this project emerged clearly at a meeting of the Panel of Advisors to the American Chiropractic Association Council on Technique at New York Chiropractic College, September 21–23, 1995.3 Dr. Perle distributed a proposal calling for the creation of a group that would identify the questions deemed most relevant to a consensus process featuring the various chiropractic technique systems that would revisit previous efforts at clinical guidelines, such as the Mercy document4 Purchase reprints in quantities of 100 or more, contact Journal Reprint Services toll-free at 1-866-863-9726 (outside the U.S. at 610-586-9973) or visit their Web site at www.journalreprint.com. Funding support for this project was provided by the Foundation for Chiropractic Education and Research: Grant # 96-03-09. R. Cooperstein, Professor; Coordinator of Technique and Research, 90 East Tasman Avenue, Palmer College of Chiropractic-West, San Jose, CA 95134. Top Clin Chiropr 2002; 9(3): 19–29 © 2002 Lippincott Williams & Wilkins, Inc.

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TOPICS IN CLINICAL CHIROPRACTIC/VOLUME 9, ISSUE 3, 2002

and the Agency for Health Care Policy and Research (AHCPR) guidelines.5 The discussion eventually led to a proposal that the technique panel conduct some type of “consensus conference” (although consensus was not the primary aspect of what eventually transpired) toward that goal. The minutes of the meeting state: Preparatory work would involve selecting a condition (e.g., acute low back pain), exploring the scientific basis of the proposed treatment approaches, doing a literature search, describing the rationale for the treatment, and differentiating core adjustive from ancillary procedures.

Polled on undertaking this project, the vote was nine in favor, four against, and one undecided. As one of those voting against, Dr. Cooperstein argued that there simply was not enough condition-specific, technique-specific information available to conduct such a conference. Having failed to persuade his colleagues on this point, Dr. Cooperstein then enthusiastically accepted his appointment, with Dr. Perle, to the team of chosen investigators: M. Gatterman (principal investigator), R. Cooperstein, C. Lantz, S. Perle, and M. Schneider. The conference took place in Chicago in 1997. Let us look at the historical backdrop against which the idea to conduct this conference arose. By 1996 that manipulation (meaning high-velocity, low-amplitude thrusting [HVLA]) had been established as a safe and effective treatment of low back pain, by the RAND reports,6-8 Mercy Guidelines,4 AHCPR guidelines,5 and of course by the clinical trials upon which the recommendations of these reports and clinical guide were based. Furthermore, chiropractors were known to perform most of the manipulations in the United States,9 so there could be little doubt that chiropractic care, broadly speaking, had been found effective for the conservative treatment of low back pain. But what type of chiropractic care? It is no exaggeration to state that during its century plus of existence, chiropractic has witnessed hundreds of different named system techniques, such as the Gonstead technique, the Palmer method, sacrooccipital technique, and so on.10 Most of these systems (e.g., brand name, proprietary, named) techniques claim to be superior to the others and to treat a great variety of (if not all) health problems without needing treatment methods that would be found in a different technique system.11 New techniques rename and add to rather than displace existing techniques, fostering the uncontrolled proliferation of clinical protocols and, alas, confusion among members of the public, health care personnel, and government administrators. After about a century of technique wars,12 it had become apparent to individuals both within and without the chiropractic profession that there were extensive variations in practice patterns, both in terms of the type and amount of treatment received for the same diagnostic entities. Furthermore, many

studies and reviews13 had shown poor concordance in the case of most of the examination procedures used by chiropractors, suggesting they were not treating the same diagnostic entities even when they thought they were. As all of this weren’t confusing enough, differences in terminology and the use of jargon among most of the system techniques meant that agreeing or disagreeing on what treatments were best for which conditions would be subject to wide variations in interpretation. The investigators deliberately and explicitly decided to identify relevant literature and convene an expert panel to rate not these system techniques, but rather the core adjustive procedures used by chiropractors everywhere. We thought it necessary, in identifying these procedures, to not confine them to HVLA methods because chiropractic adjustive procedures consist of a whole lot more than HVLA “manipulation” as understood by the RAND reports6-8 and the AHCPR guidelines.5 Likewise, looking at the diagnostic entities amenable to adjustive procedures, the investigators chose to go beyond the “low back pain” of AHCPR and RAND, made only slightly more expansive in the Mercy guidelines.4 These latter, as an example, state that high velocity thrusting is “established for the care of patients with mechanical low-back problems”4 and drop table procedures are “promising to established for the care of patients with neuromusculoskeletal problems,”4 only begging the questions: What mechanical low back problems, what neuromusculoskeletal problems? METHODS The project consisted of (1) identification of commonly employed chiropractic adjustive procedures for mechanical low back conditions, (2) selection of mechanical low back conditions chiropractors commonly treat, (3) nomination of an expert panel, (4) retrieval of relevant literature from both the chiropractic and allied health professions and distribution to the expert panel, (5) convening of the expert panel to rate both the clinical efficacy of these procedures for the given conditions and the quality of the literature upon which their ratings were partially based, and (6) publication and presentation of the results. Literature selection Granted, although the expert panel would be rating chiropractic adjustive procedures, some of them, such as sideposture manipulation, are used by other health professions. Therefore, we searched within biomedical databases in addition to chiropractic publications and databases, using Medline and Cumulative Index of Nursing and Allied Health Literature. The term biomedical is used loosely because these databases include some chiropractic publications, notably the Journal of Manipulative and Physiological Therapeutics


(JMPT) in Medline. Because the chiropractic literature is more difficult to retrieve electronically, computerized searching was supplemented by hand-searching publications starting from the year 1976 (date arbitrarily chosen). To search the chiropractic literature, we used the Chiropractic Research Archives Canada, the Index to Chiropractic Literature, and especially the Manual, Alternative and Natural Therapies Information System, which proved most useful. A secondary search was performed across the bibliographies of the journal articles retrieved, including the papers cited by RAND and AHCPR. The hand search included the symposia proceedings of the International Conference on Spinal Manipulation, the World Federation of Chiropractic, the Conference on Research and Education, chiropractic textbooks, technique manuals, and books published by technique organizations. Wellknown technique system developers were mailed a letter asking that they bring relevant studies to our attention. We had expected a paucity of literature pertaining to some of the adjustive methods we had identified and that much of this literature would be of rather poor quality. We were not disappointed. From the outset, we decided to adopt a more liberal inclusion criteria than those used by meta-analyses and most systematic reviews. Each article had to contain an operational definition of the technique procedure used, identify the low back condition being treated and provide an outcome measure of some kind (objective or subjective, with or without statistics). Of these, the primary inclusion criterion was the quality of the description of the adjustive procedure. Given our liberal inclusion criteria, the expert panel would be admonished to carefully weigh not only the content of the articles but also their credibility. We had no choice but to exclude otherwise sound studies that stated merely that “spinal manipulative therapy,” “osseous adjusting,” or “chiropractic manipulation”14,15 had been used. At the other extreme, studies of the form “we used sideposture manipulation on three patients with low back pain, who had less pain afterwards” (depending on the details) might have been included. Tables 1 and 2 provide detailed definitions of the adjustive procedures and diagnoses we selected, respectively. By necessity, we had to collapse various adjustive approaches to keep the investigation within manageable limits. Had we subdivided side-posture manipulation, for example, into methods that use or don’t use rotation, or separated out push and pull methods (these may be thought very different by their advocates) the project would have died on the vine. While we decided on the relevant “techniques” and “diagnoses” before the literature searches, the final list was developed based upon the literature that was actually found. As for the diagnostic entities, numbers 1 through 4 are functional in character (the precedent for their use in chiropractic may be found in references 16, 17), describing a sign-symptom complex,

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Table 1. Treatment definitions 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

HVLA, no drop table (side posture) HVLA, with drop table assist Pelvic blocking procedures Instrument adjusting Mobilization, segmentally specific Distraction techniques HVLA without drop table assist Upper cervical Nonthrust/”reflex”/low force Lower extremity adjustment

Source: Data from Gatterman MI, Cooperstein R, Lantz C, et al., Rating specific chiropractic technique procedures for common low back conditions, J Manipulative Physiol Ther 2001;24(7):449–456.

whereas numbers 5 through 8 are tissue-based, or structural. Some of the literature sources described multiple types of treatments, especially the case reports, which are practicedbased and do not pretend to be laboratory experiments attempting to identify the treatment impact of individual components of care. Likewise, many of the sources include patients with multiple clinical entities, such as case series that report outcomes in relation to multiple specific diagnoses. These are not design flaws, but simply complications that arose for us in categorizing the literature. Panel selection and process The eight members of the expert panel that met in Chicago were chosen based on their broad knowledge of chiropractic technique procedures, active involvement in chiropractic leadership, and nonidentification with any system technique. They were balanced relative to academic and clinical representation, gender, philosophical orientation, and geographical location. Each panelist rated the clinical effectiveness of each of the 10 adjustive procedures for each of the 8 diagnostic entities, Table 2. Diagnosis definitions 1. Low back pain 2. Low back pain with buttock or leg pain 3. Low back pain, with buttock or leg pain and neurological deficits 4. Buttock or leg pain (no low back pain) 5. Herniated disk 6. Spondylolisthesis 7. Posterior joint subluxation/syndrome 8. Sacroiliac joint dysfunction syndrome Source: Data from Gatterman MI, Cooperstein R, Lantz C, et al., Rating specific chiropractic technique procedures for common low back conditions, J Manipulative Physiol Ther 2001;24(7):449–456.

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separately (at their own insistence) for acute and chronic presentations, with one exception: they declined to rate adjustive procedures for acute spondylolisthesis. The expert panel also rated the quality of the literature base for each procedure-diagnosis couple, separately for acute and chronic presentations, and again excluding acute spondylolisthesis. The panelists were free to discuss their opinions and interpretation of the literature before assigning ratings, and all of the investigators were present and available to clarify various matters that came up. However, no attempt at achieving consensus was made. After group discussion each panelist independently rated each adjustive procedure’s effectiveness and literature support for each diagnostic entity by what amounts to a secret ballot. RESULTS Literature characterization In all, 143 articles were finally selected, making up more than 1,000 pages. Of these, 73 were retrieved from the biomedical literature (again, including JMPT) and 70 more from chiropractic sources. Although no doubt some relevant literature was missed, we believe the likelihood a resource was missed was inversely proportional to its quality because the best materials were the most retrievable. Therefore, any ultimate conclusions to be drawn about the appropriateness of the adjustive procedures are likely to be reasonable, even given the likelihood of some missed resources. The literature we retrieved is characterized by adjustive procedure (Figure 1), diagnosis (Figure 2), and type of study (Figure 3). The literature totals for Figures 1 and 2 exceed the grand total of 143 references because some studies used either multiple adjustive procedures or addressed multiple diagnoses. Table 3 (literature base for condition/treatment couples) is a matrix with 8 low back condition columns and 10 adjustive

Fig. 1. Literature totals by adjustive procedure

Fig. 2. Literature totals by diagnosis

procedure rows. Each cell in the matrix indicates the number of studies satisfying the following 2 conditions: the quality of the procedure description is relatively high (according to a rating system we had devised), and the outcome description measure includes some level of quantification. (In constructing Table 3, we generously decided not to take into account the type of study, as might have been done, whereby a randomized clinical trial would have been rated of higher quality than a case report.) This table enables the reader to rapidly identify treatment-condition combinations that are sparse in highquality literature evidence. Only 17 of the 80 cells have any entries at all, meaning only 22% of the condition-treatment pairings have any reasonably high quality evidence to support them. Characterizing the literature by diagnoses, there are many studies on the manual treatment of unspecified low back pain, much of it of high quality. We also see a number of articles on low back pain with concurrent leg pain, and a few involving

Fig. 3. Literature totals by type of study

Low back pain

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—

1

3

9

3

3

—

1

—

Rating Scale: 0–10 Means (SD)

1. HVLA, no drop table (side posture)

2. HVLA, prone, with drop table assist

3. Pelvic blocking procedures

4. Instrument adjusting

5. Mobilization, segmentally specific

6. Distraction technique

7. HVLA, prone, without drop table assist

8. Upper cervical

9. Non-thrust/reflex/ low force

10. Lower extremity adjusting —

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5

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3

Low back pain w/buttock or leg pain

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5

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Low back pain with buttock or leg pain and neurological deficits

Table 3. Literature base for condition/treatment couples

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Buttock or leg pain only (no low back pain

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2

2

—

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3

Herniated disk

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—

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Spondylolisthes is

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Posterior joint subluxation/ syndrome

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2

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1

—

3

—

—

2

Sacroiliac joint dysfunction syndrome


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neurological deficits. Among the tissue-specific diagnoses, only herniated disk has much of a literature base, and sacroiliac dysfunction to a lesser extent. Characterizing the literature by adjustive approach, there are many articles on HVLA manipulation, many of them of high quality. We also see many articles on distraction methods, but fewer on segmentally specific mobilization. Very little is available on other chiropractic adjustive methods, including mainstream procedures such as such as pelvic blocking, instrument-assisted adjusting, and drop-table methods. Side-posture HVLA procedures are best studied, followed distantly by instrument-assisted, low force, and distraction techniques. Most of the included techniques procedures (6 of 10) have no reasonably highquality literature basis at all. Panelists’ ratings Although which diagnoses were thought most amenable to treatment varied according to the treatment approach, and which technique procedures were thought most effective varied according to the diagnosis (Figures 4 and 5), a few generalizations can be made. The conditions generally considered most amenable to adjustive treatment were: nonspecific low back pain, sacroiliac dysfunction, and posterior joint subluxation; and least amenable to treatment were buttock and leg pain only and herniated disk. The adjustive approaches most generally supported were side-posture high HVLA, distraction, and drop-table methods; and those least generally supported were upper cervical technique, nonthrust/low-force/ reflex, and lower extremity adjusting. Ratings for the quality of the literature tended to covary with clinical effectiveness ratings, and are further discussed in the section on the difference matrix. Figures 4 and 5 show the panel’s ratings for clinical effectiveness and literature quality, respectively, for each adjustive procedure and each diagnostic entity. Although the ratings tended to be higher for acute than chronic states, we present the numbers for acute only, since the differences were not statistically significant. (Because the panel did not rate spondylolisthesis for acute presentations, the figures use data for chronic presentations). The very similar sigmoid shape seen for most of the curves in Figures 4 and 5 confirm that panel’s ratings of the quality of the literature closely mirrored its ratings of the clinical effectiveness, a matter of some interest. DISCUSSION Lest this project be misinterpreted, it must be understood to have constituted neither a consensus process, nor the production of clinical guidelines. Although the expert panel did develop some consensus statements that were intended to clarify their ratings, this was not the crucial part of this study. The ratings of clinical effectiveness for each technique proce-

dure for each low back condition were not developed by consensus, although the panelists did have an opportunity to discuss each cell. The literature characterization and panelist’s recommendations described here do not constitute clinical guidelines, despite the title of the original grant proposal. Although those whose purpose is to develop guidelines may find the data useful, in and of itself this study cannot directly lead to guidelines. Eddy defines a guideline thus: “A practice policy is considered a guideline if the outcomes of the intervention are well enough understood to permit decisions about its proper use, and if it is preferred (or not preferred) by an appreciable but not unanimous majority of people.”18 Our literature search failed to find a body of literature that would allow any policy to be promulgated at a level where we could confidently say the outcome is well enough understood to permit decisions about its proper use. As can be seen in Table 3, 63 of the 80 possible treatmentdiagnosis couples lack any high-quality evidence. Therefore, it is fair to state that there is a dearth of information on the effectiveness of specific chiropractic procedures for specific low back diagnostic entities. Claims by the proprietors of system techniques that their methods are “clinically validated” must be carefully scrutinized because the proprietary jargon, theories, and treatment methods that do in fact distinguish them are usually unstudied, whereas the validated methods they use, such as side-posture manipulation and mobilization, are in the common domain and are simply generic. The expert panel did not, generally speaking, rate the clinical effectiveness of well-published methods more highly than methods that are essentially unstudied.2 For example, HVLA drop table adjusting and pelvic blocking were more highly regarded than instrument adjusting, even though there are dozens of (nonclinical) articles pertaining to the latter. Although clinical effectiveness and literature quality ratings tended to covary (r = .737, p = 0.0001)2 we cannot tell from this fact alone whether panelists tended to highly support procedures simply because they were relatively well-studied and thus familiar to them, whether investigators tend to study procedures that are generally regarded to be clinically effective, or if there is some other explanation. Figure 6 represents the difference matrix obtained by subtracting the literature quality rating from the clinical effectiveness rating. The quantitative relation of effectiveness and literature quality scores may allow us to assess at a glance situations which clinical opinions are closely related to the evidence base and those where they are not, thus helping us prioritize what is to be done from a research point of view. Peaks in the line drawings merit concern because they suggest that raters find the adjustive procedure, for a particular diagnostic entity, effective in spite of little supportive evidence.


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Fig. 4. Clinical effectiveness ratings

Troughs are more difficult to interpret, because they occur when a well-regarded procedure has an ample supportive literature (e.g., side-posture manipulation for low back pain), when a poorly regarded procedure has little supportive literature (e.g., upper cervical for leg pain only), or anything in between (e.g., instrument adjusting for most any condition). Scrutinizing the peaks, we see that pelvic blocking and droptable methods are especially problematic, having achieved relatively high ratings minus much support, suggesting a particular need for clinical research in that area. Again, this project was not about guidelines because it relied on expert opinion in an implicit way, which Eddy notes is “vulnerable to personal biases such as partiality and wishful thinking.”18 The credibility of any ratings process clearly

hinges on the judiciousness of expert panel selection. In this project, we had to balance two concerns: panelists need to have enough expertise and knowledge about the procedures used by system techniques to rate their effectiveness, and yet not be so closely identified with any of them that even the appearance of bias would exist. During the ratings process itself, a panel member was permitted to abstain as necessary when asked to rate procedures in which he or she lacked expertise or knowledge. Future projects like this one might be able to improve upon our panel selection process by having potential members complete a survey that rates their system technique proficiencies and preferences beforehand, and incorporate that information into both panel selection and eventually the interpretation of the data.

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Fig. 5. Literature ratings

CONCLUSION Our study should be in part a call to arms of those who believe that their favored chiropractic treatment method is clinically effective and yet did not fare well, either because little clinically relevant literature was identified, the expert panel did not rate their methods highly, or both. Although some of the system technique advocates have been active in performing and sponsoring research on their methods, attempts to validate the clinical appropriateness of their favored methods might best focus more on clinical outcomes and less on peripheral matters (e.g., modeling, forces generated, the reliability of diagnostic procedures). At the current time, there are precious few studies that establish any difference in the

treatment benefits or the relative risk of adverse consequences of any adjustive methods for any of the conditions featured in this study. Table 4 describes technique procedure-related research challenges. In a letter to the editor concerning this project, Fuhr correctly asserts that the expert panel was left to make “clinical judgment without empirical evidence [which] amounts to guesswork by experts.”19 However, it is important to note that the primary responsibility for this situation rests squarely upon the shoulders of Fuhr and other advocates of system techniques. We firmly believe that the responsibility to fund and assist in the conduct of outcomes research into proprietary chiropractic techniques rests with the owners of those techniques, just as the manufactures of proprietary medications


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Fig. 6. Difference matrix

fund studies on their clinical effectiveness. To allow for a more formal explicit guidelines development, the profession needs to conduct more research so that meta-analysis can be conducted and compelling data developed on the effectiveness of the various technique procedures. Despite the holes in our knowledge basis, patients continue to come in and clinicians must continue to treat based upon imperfect knowledge. In this situation, as Sackett has stated, “Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough,”20 Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.21

Moreover, as so many have said, lack of evidence does not constitute evidence of lack.

Although all this is certainly true, this does raise some interesting questions. Under what circumstances would a clinician choose a largely unstudied adjustive procedure over a validated adjustive procedure for mechanical low back pain, such as side-posture manipulation? Clearly, clinicians cannot and should not practice under the yoke of pure evidence-based chiropractic, drawing upon clinical trials that by their design may not be clinically relevant, at the expense of their own clinical experience and that of their colleagues. On the other hand, the individual clinician’s right to practice as he or she sees fit, as if there were no studies validating certain treatment options under certain circumstances, is at best questionable. Unlike as is the case for other goods and services, caveat emptor (let the buyer beware) is not an acceptable model of health care, which must be credat emptor (let the buyer believe in us). Under such a model a doctor who promotes a technique that lacks any evidence of effectiveness might be accused of violating their duties to their patients.22 Likewise those teaching a technique who do not fund and conduct the research to test the

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Table 4. Technique procedure-related research challenges Current problem

Proposed solution

Current overemphasis on researching reliability and validity of assessment procedures, construct validity, and modeling

Place more emphasis on outcomes research

Many studies simply report pain reduction

Better-quantified outcome measures, even in case reports: visual analog scale, etc.

Some well-designed studies simply state “chiropractic manipulation,” or “osseous adjusting” was used

Carefully describe adjustive procedures used

Some studies are conducted or reported in terms of a system (named) technique, confounding mechanical factors with ideology, patient communication style

Study core procedures, not system techniques per se, if goal of study is to determine mechanical impact of intervention

Use of jargon and atypical uses of terminology

Where terms (e.g., “subluxation” or “manipulation”) continue to be used in different ways, provide operational description

Study design bias (e.g., preferring the randomized controlled clinical trial (RCT) under all circumstances)

Recognize that case reports and non-controlled studies may be of redeeming value due to their clinical relevance, and RCTs may have methodological flaws

Inappropriate study design, such as using RCT to study an intervention that is never used, or is unsafe to use, in isolation in typical clinical settings

Careful selection of study design relative to problem under investigation

Careless documentation/description of diagnostic entity under investigation

Careful description of functional diagnoses; appropriate choice of confirmatory procedure for structural (morphological) diagnoses

Competitive, proselytizing subplot in purported “research” articles and other publications of system technique advocates

Strive to cast aside system technique affiliation to avoid actual or appearance of research bias

Much relevant literature is published in nonindexed journals, not entirely electronically retrievable

Continue efforts to index all relevant chiropractic literature (e.g., Chiropractic Research Archives Canada; Manual, Alternative and Natural Therapies Information System)

safety and efficacy of their methods might likewise be accused of an ethical lapse. Carl Sagan has written: “I believe that the extraordinary should certainly be pursued. But extraordinary claims require extraordinary evidence.”23 To use the previous example, if side-posture manipulation were contraindicated or otherwise unlikely to get a good outcome in a specific case (e.g., previous bad outcome, severe osteoporosis, very large patient), then a less studied treatment procedure is not only acceptable but required. However, if there are no such contraindications or other reasons to predict treatment failure, clinicians must realize that their practice choices are being scrutinized by health care administrators, and increasingly by savvy patients and their level of accountability is higher than ever. We must be careful, in disestablishing

the tyranny of randomized clinical trials, not to establish a new tyranny, the unfettered wisdom of the experienced clinician. Those who would defend the clinician’s right to practice as he or she sees fit irrespective of the evidence, no matter how limited, have overreacted to an evidence-based practice extremism. Somewhere in the mix “reasonable people should be able to strike a balance between imperfect knowledge and the exigencies of practice.”1 ACKNOWLEDGMENTS The National Chiropractic Mutual Insurance Company and The Foundation for Chiropractic Education and Research for financial support and administration that made this work


possible through grant number 96-03-09. We thank the members of the expert panel for their participation; Anthony Rosner for overseeing the research and for editorial assistance; the library staffs at Palmer College of Chiropractic West (Pat McGrew), the University of Bridgeport College of Chiropractic (Mary Ellen Bowen and Krystyna Kossarska), and Western States Chiropractic College (Pam Bjork and Lynn Attwood); and Research Assistants Jennifer Veit and Kay King for help with the literature searches.

9. 10. 11. 12. 13. 14.

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