|
January 2006, Vol. 16, No. 1
Table of Contents
CBP® Non-Profit Matches Dr. Bill Harris' $25,000 Research Grant • Counter Point Round III • Dr Deed Harrison is the Most Published Chiropractor in the Index Medicus • Flawed Thinking • It's Don's Opinion • JCCA Publishes CBP® Structural Rehab Protocol • More Studies to Confirm the Validity and Reliability of PosturePrint™ • Thriving in the New Health Care Marketplace • Organic Chiropractic • Patient Education • Point Round III • The Purpose Driven Practice • Radiation Hormesis • Research Corner • Subluxation Update • System Failure • Ten New Year's Resolutions for Your Practice • Chiropractic: A Useful Component of Traumatic Brain Injury Rehabiitation • Triano is a Chiropractic Pariah •
back to front page
Point - Round III
A Final Few Comments
Support for a Connection Between Altered Cervical Lordosis and DJD
by John J. McDaniel, DC, DACBSP
Dr. John McDaniel received his DC degree in 1986 from Palmer College of Chiropractic-West. He studied CBP® at that time receiving instruction in the early stages of this technique from Don Harrison, DC in Sunnyvale, CA. After graduation, he followed CBP® protocols for a couple of years but discontinued using them. Since then, Dr. McDaniel has pursued teaching undergrad and continuing ed at Palmer-West, published some literature reviews and case studies, obtained his Diplomat from the American Chiropractic Board of Sports Physicians, served on committees for the CCA and the ACBSP, is the current president of the ACBSP, and maintained a private practice in Mountain View, CA. He has continued to follow the progress of chiropractic research in general and CBP® in particular.
Like an Olympic sport, let’s make it three rounds and call it a match. In reviewing my prior two letters I feel that I have made most of my points and further discussion becomes repetitious. If a reference in this letter seems obscure I would direct any reader to the two previous letters for clarification of my position.
I would like to thank you for providing this forum and your time. I have learned a few things, read some interesting articles and had a forum to voice some of my concerns regarding CBP® as practiced. Again, let me congratulate CBP® for its impressive body of work and encourage you to continue in your endeavors.
I do have a few issues to clarify from the previous two rounds.
I still maintain that it is imperative for writers in the literature to cite references which are timely, appropriate and accessible. Any citations to works which are in press or were observed in a poster presentation but which are not currently published and accessible deprive the reader of the ability to verify the content. I realize that you are convinced that your interpretation of the issues is always correct, but there is always room for error or simple misinterpretation. It is only through the reader’s ability to access the citations that they can verify or deny your interpretation.
Back to that pesky IRB issue. There remains some opinion on your part that both I and Dr. Perle have provided “Ad Hominem” statements about the CBP® IRB protocol. In particular, this is the quote I will be addressing,
“D) Dr. McDaniel did not make an ad hominem statement about CBP®’s IRB protocol. Dr. Perle does not remember doing this either at RAC 2004.
For Dr. McDaniel I have the following response: What was your purpose then, when you were questioning the informed consent procedure utilized and clearly stated in our manuscript7 in your first point article in the AJCC?
To Dr. Perle: I am sorry he’s having memory loss. I personally recall this exactly and to confirm this, I contacted three individuals who were present (one that was on the platform with me and two that were in audience attendance). Dr. Christopher Colloca (Phoenix, AZ), Dr. Paul Oakley (Canada), and Dr. Jason Haas (Windsor, CO.) were all present during this “Ad Hominem” comment made by Dr. Perle and they would be more than happy to assist his memory recovery.”1
In reviewing the first of my letters, I can find only one reference that is even close to asking about your IRB, “I have read many of your papers and it would seem that you rigorously follow research protocols including informed consent for research subjects. I note that in a recent paper utilizing both treatment and control groups, it was noted that, “Subjects gave informed consent.” Can I assume that this was informed consent to be a subject of biomedical research?”2
Regardless of my intention in asking this question, it clearly is only a very plain question and, in fact, does not even mention your IRB protocol.
On his own initiative Dr. Perle contacted Dr. Colloca to obtain some memory assistance. This is a quote from the email provided to Dr. Perle, you and as a CC to me.
“Hi Stephen,
I think they are referring to your questioning their IRB. I don’t remember any ad hominem, but rather you questioning their IRB, that’s all.
Best regards,
Chris. (Colloca)”3
So, it would seem that in this case, there is room for error or misinterpretation on your part. Similarly, I don’t accept your contention regarding obscure citations that, “I am privy to this information and can assure the reader and Dr. McDaniel the accuracy of my interpretation.”1 If there is room for the misinterpretation of the simple comments provided by myself and Dr. Perle, there is certainly room for errors interpreting the more complex issues dealt with in the scientific literature.
I contend that your interpretation of the Hohl article as well as others may be similarly skewed as noted in my prior letters. Further discussion of my v. your interpretation would create a circular, “did so,” “did not,” comedy routine. I would refer the reader back to prior letters and encourage them to read the citations for themselves for clarification.
I’m not sure of the correct citation but whoever said, “The man who claims to be always right is surely wrong” was correct. I apologize for not having a current and accessible citation for this quote.
Without digging too deeply into the articles used to compare pain relief levels, I can point out a few issues which may make any comparison of the pain relief afforded by CBP® v. that used in the cited studies an apples and oranges comparison. First, most of those studies were designed to see if there was ANY positive effect from adjusting. The Hurwitz study applied only one adjustment searching for any measurable result. These studies were not designed to determine the optimum effect. Only one was designed to test that hypothesis. The Haas study examined the effect after 3, 9 and 12 visits searching for the optimum. Second, there was a huge difference in the number of treatments. Those in the Bronfort et al cited studies had an average of only 10 visits v. 37 for the Harrison studies.1 One of the cited studies provides support for the idea that more is better. This quote comes from the Haas, M study, “Findings give preliminary support for the benefit of larger doses, 9 to 12 treatments, of chiropractic care for the treatment of cervicogenic headache.”4 It’s highly possible that the differences in pain relief in your comparison of the CBP® studies to the literature were due simply to the number of visits and not to the particular technique. Third, the Bronfort, et al cited studies were randomized trials v. the non-randomized trials of Harrison.1 It’s possible that the selection bias inherent in a non-randomized trial can account for the differences observed. Fourth, the patients in the studies cited by Bronfort, Jordan, Giles, Hurwitz and Skargren all started at a higher pain level. Those in the cited studies averaged 4.8 on the 10 scale v. 4.0 for the Harrison studies.1 Taken together, these issues would seem to make any comparisons of the two data groups difficult if not impossible. As a whole, chiropractic does need more inter-technique comparison studies to help sort these issues. However, at this time, claiming technique superiority would seem premature.
I appreciate the more complete ROF provided in your last reply. This is where I feel there is an issue. This is where my question about informed consent comes into play. This is actually one of the central issues which started this entire Point/Counter Point discussion as it originated on the CCA’s discussion board before being drawn to this venue.
In true informed consent, patients are given full information and are then asked for consent to proceed with therapies. Your report to my hypothetical patient notes quite convincingly that there IS a direct correlation between altered cervical curves and neck pain, early DJD and increased damage during an auto accident. You also convincingly note that CBP® WILL provide superior pain relief. You leave no room for doubt. However, I maintain that the only truly supported connection is to the neck pain. Your arguments drawing a connection to the early and progressive DJD fall short of convincing. This issue remains controversial. I realize that you feel your interpretation of the evidence is correct, but, as has been demonstrated, errors may be made. The superiority of CBP® in pain is likewise short of convincing. Further, the connection between variations in cervical curvature and increased damage in an automobile accident is very preliminary and tenuous as noted below.
I did manage to track down the article by Bertrand Fréchède which was cited as evidence of an altered cervical curve’s increased propensity for damage in an MVA.5 He emailed the study directly to me. This study was simply a mathematical modeling study consisting of only two pages which was presented as a poster with insufficient detail to truly evaluate the process. As an example, the article did not say whether or not a head rest was used in the modeling. I guess I would not feel comfortable convincingly informing a patient of a risk of increased damage based solely on one unpublished, two page, poster presentation of an in-vitro modeling study which is preliminary in nature. The study itself is acceptable for what it is. However, it should not be relied upon for clinical decision making or patient information. Again, I would cite this as an example of misinterpretation. This article is well done for what it is but hardly sufficient to provide assurances to a patient that proceeding through a CBP® protocol would provide protection in the event of an MVA.
It is not the point of informed consent to give the patient the doctor’s interpretation of the information, especially when the information is so conflicting. It is not the point of the informed consent phase to convince the patient of the need for the pre-selected care. That is a practice management increase-your-PV’s protocol. The point of informed consent is to clearly discuss all the issues, positive and negative, supportive and contradictory, surrounding the procedure and allow the patient to interpret it for their own benefit.
In my opinion, a more appropriate ROF would be as follows:
Inform the patient that this is a CBP® office. Let them know that there is some evidence to show that altered curves may be a source of pain and they MAY experience greater pain relief with these CBP® procedures although no true head to head comparison has been done. Inform them that there is conflicting evidence of long term effectiveness against DJD but this office BELIEVES that there is sufficient evidence to be convincing. However, there are others who believe that the evidence is unconvincing. If they wish to see the evidence provide something from both sides of the issue. I would suggest one by yourself and one by Gore, et. al. Omit the entire notation of the protective benefit in the event of an MVA. Then provide the three options of no care, relief care or corrective care.
Such a report of findings provides more complete information to the patient and allows them to evaluate that information when giving consent.
As I have in the past and I did on the CCA chat list, I maintain that the connections noted above are unproven and controversial. I maintain that misinterpretations of the evidence have led to excessive and premature confidence in the ability of CBP® to manage and control these conditions. This has led to improper information being transmitted to patients during the informed consent phase of patient care leading them to also have excessive confidence in the procedure. Further, this plus the melding of CBP® with practice management protocols have lead to an overutilization of CBP® as a matter of course and practice.
This was my initial opinion as presented on the CCA discussion board prior to being drawn over to this forum. Although I have read much since then, I do not see sufficient evidence of support or an adequately complete informed consent protocol to change my opinion. I’m sure I have not altered your opinion, either. However, it is for the reader’s, the patient’s and the profession’s benefit that we discuss such issues.
I thank you for your suggestion that I utilize a practice management group. However, I won’t be following up on that suggestion. Not to digress too much, but I would like to briefly address this issue. I have yet to find one which places the patient’s interests above the business’ interests. They all seem to rely on questionable methods of patient coercion to build PV’s and cash flow at the expense of the patient’s time and disposable income. I find that they tend to be less practice management and more patient manipulation and not in a good way. I could be wrong, but I have investigated several and found them all to be very similar in their approaches. The philosophy of most could be summed up in a few words, “Do whatever it takes to convince the patient to come in a bunch of times, get them to pay up front, hold them to the schedule and never release anyone.” From that basis, they only seem to vary based on the, “..whatever it takes...” methods, some worse, some better but all I have investigated are questionable.
There is currently a patient class action suit against one practice management group. The reader can view information about this at http://www. wandrolaw.com/ClassAction.shtml or simply, http://www.wandrolaw.com/. I am watching this closely as it could be successful and would ripple throughout the chiropractic and practice management community. It would be a PR mess and financially devastating in the short term but healthy for the profession in the long run.
Again, thank you for your time. This will be my last letter. You will have the last word. Before I finish and while I have your attention, I would like to ask a couple of other questions regarding CBP® which have been on my mind. Please indulge me with a few answers.
1) If the patient is scheduled for relief care of 12 visits but has a VAS scale of 0 after only 2 treatments, do you require that they finish the 12 visit schedule prior to embarking on a corrective schedule? If yes, why?
2) There are many devices now on the market which are prescribed for home use for curve restoration. Some of these devices are sold by Harrison Chiropractic Supply and advertised in this journal. Why is it necessary for the patient to come into the office for the suggested post-relief frequency of care when it can be done at home at far less cost and time? It would seem to me that after the initial 12 visits of relief care, the patient could be sold a home traction unit and brought back into the office on a weekly or monthly or bimonthly basis to check compliance. Such use could alter the treatment plan from an additional 24 visits over 6 weeks to only one or two. Plus, the patient could use the device daily instead of only 4 times per week. This would certainly lower the overall cost and frequency of visits and have the added benefit of daily use. A patient scheduled for 36 visits but pain free after 2 and then sent home with a traction unit could receive all the benefits of CBP® in only 6-8 visits.
3) With the availability of these devices, their promotion by Harrison Chiropractic Supply and given the number of studies produced by CBP® on curve restoration methods, why are there no studies demonstrating and comparing the effectiveness of these devices? Should they be found to be as or more effective than in-office procedures their broad inclusion into CBP® practice would lower the overall cost and frequency of visits. If there are studies and I have just missed them, please cite them and I will do more homework on CBP®.
In any case, I expect to do more homework on CBP®.
1) -Harrison, D, Selective Reviews, Misrepresentation of Studies, & Side Stepping Biomechanics Lead to an Inappropriate Characterization of CBP® Technique. Part II, AJCC, vol. 15(2), Apr. 2005, pg. 23-26
--2) -McDaniel, J, An Opinion of the Shortcomings of CBP® Technique Research and Practice Protocols, AJCC, vol. 15(1), Jan. 2005, pg. 22
3) -Personal communication via Email between Dr.’s Perle, Harrison, Colloca and myself, Sent: Wednesday, June 15, 2005
4) -Haas M et al, Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: a randomized pilot study. JMPT 2004 Nov-Dec; 27 (9):547-53
5) -Frechede B, Saillant G, LaVaste F, Skalli W. Risk of injury of the human neck during impact: role of geometrical and mechanical parameters. Paper A29; Presented at the European Cervical Spine Research Society Annual Meeting; 2004 Porto, Portugal, May 30-June 5.
| 
