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October 2005, Vol. 15, Iss. 4
Table of Contents
A Time to Change • CBP® Annual Convention News • CBP® Performs Groundbreaking Car Crash Research • CCE Cited for Accreditation Violation • Dr Colloca Becomes a Reviewer for Spine and the European Spine Journal • ICA's Involvement in Hurricane Relief Efforts • JMPT Publications: Impulse™ Fairs Best Among Chiropractic Adjusting Instruments • Its Paul's Opinion • Letters to the Editor • Life University Opens Its Arms and Hearts to Katrina Victims • Micro-Reports Don't Work • PosturePrint™ Can Determine Axial Rotations • Quackbuster vs. Dr Ted Koren • The Chiropractic Genome • The Start of Something Big • The Unspoken • Updates on Aspertame
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It’s Paul’s Opinion
Triano Should Stop Bad Mouthing Harrison’s Work and Accept It
As Clinical Evidence for the CCGPP Guidelines
by Paul A. Oakley, MSc, DC
Dr. Oakley received a Bachelors Degree
in Kinesiology from Laurentian University,
Sudbury, Ontario, Canada in 1998, a Mas-
ter’s of Science Degree in Biomechanics
from Queen’s University, Kingston, Ontario
in 2000, and a DC Degree from PCC, Dav-
enport, Iowa in 2003. He is a contributing
author for two CBP®texts and has present-
ed research projects at several biomechan-
ics and chiropractic conferences as a stu-
dent. Dr. Oakley is a CBP®Certified Fellow
and is the first Chairperson for CBP®’s Case
Study Committee.
Recently, Dr. John Triano (Texas Back Institute) was in New Jersey giving a presentation on the new CCGPP guidelines (Council on Chiropractic Guidelines and Practice Parameters).1 There, he conveniently avoided a questioning period, however, he did not escape a bombardment of questions from a crowding audience following the presentation. According to witnesses, he did answer a few questions off-stage before boisterously exiting the scene!
One question was why the Harrison’s work on spinal modeling would NOT be included to be reviewed as evidence by the CCGPP ‘panel.’ Triano stated that the Harrison’s modeling studies were not appropriate. On other occasions, Triano has stated that the work by Don and Deed Harrison is ‘theoretical,’ that human modeling studies had been done in the 1940s, and that modeling of the spine couldn’t be done. By ‘theoretical’ Triano may have been referring to the Dr. Don Harrison’s first modeling paper published in Spine, 1996.2 This paper was not a true modeling paper per se, but rather a comparison paper of patients to an idealized cervical spine model based on several assumptions.3
Since Don’s first modeling paper in 1996, however, CBP® has published several true modeling papers on the cervical spine,4 thoracic spine,5,6 lumbar spine,7,8 and most recently, the whole spine.9 These papers represent some of the most sophisticated and clinically relevant and important studies ever done on human spinal posture. Further, due to the rigor of the methodology (i.e. use of reliable data extraction methods from x-rays and use of unique sophisticated computer iteration processes), it is now possible through rigorous means, to discriminate pain groups from normal, pain-free subjects. This was demonstrated in the lumbar spine (On average ARAs for chronic pain <40°, acute pain>40°, and normals=40°),7 as well as the cervical spine (On average ARAs for chronic pain =22°, acute pain=28.6°, and normals=34.5°).4 These findings are so powerful that they made the righteous statement: “our findings of reduced cervical lordosis in neck pain patients give credence to clinicians and researchers who seek to describe neck pain in mechanical terms and for the first time give meaning to the term cervical hypolordosis.”4 These are the modeling studies that are not ‘theoretical,’ have been done and published in Spine,4,6 The Spine Journal,9 Journal of Orthopedic Research,8 and the Journal of Spinal Disorders & Techniques.5,7
During his presentation, Triano stated “only proven studies and research would be used.” If the Harrison’s work is not going to be included, then apparently ‘proven’ must mean Triano’s opinion. I believe ‘proven’ should mean the quality of the study design that should automatically correspond to the impact factor of the scientific journal where that research was published. The CCGPP guidelines are supposed to differ from ‘guidelines’ in that they incorporate “the most current explicit evidence based practices.”1 If this is the case, then the CBP® clinical data10-15 should definitely be a dominating aspect of the chiropractic scientific evidence for the efficacy of chiropractic methods in achieving optimal patient outcomes.
Recently, we have discovered16 that of all the decent clinical trials on spinal manipulative therapy (SMT),17 only about half of these trials have had the ‘manipulation’ provided by chiropractors. Further, there are only two randomized clinical trials using ‘diversified technique;’ that is, the technique taught at all chiropractic colleges! Even more surprising, is that we discovered that all the randomized clinical trials on manipulation for low back or neck pain leave the patient in a significant amount of pain and disability!
Specifically, as rated on a numerical rating scale (NRS: 0= no pain; 10= severe pain), on average, the best current evidence on manipulation has a before and after NRS of 4.7 and 2.6. Please note that a 2.6 out of 10 equates to somewhere between ‘Constant Minimal to Intermittent Slight Pain’ (2.0) and ‘Constant Slight Pain with some handicap’ (3.0). Alternatively, the CBP® clinical trial data reveal a before and after NRS of 4.0 and 1.0. A 1.0 out of 10 equates to ‘Minimal Pain or annoyance.’
The reader should note that the average number of treatments involved in the SMT studies was about 6-12, therefore, the average patient was left in chronic pain (NRS = 2.6) after up to 12 treatments of SMT. It is now obvious that while short-term usage of SMT reduces chronic pain intensity, it does not relieve it and in fact, these subjects would not be described as MMI. The recent studies by Haas et al.18 and Leboeuf-Yde et al.19 are good examples of this.
In a pilot RCT with a small number of subjects (n = 8 in each group), Haas et al.18 found that an increased number of treatments, up to 12, was associated with greater improvement of headache pain. However, even in the 12 treatment group, the headache pain was still less than 50% improved.18 Likewise, in a recent large multi-center trial, after 4 treatments of SMT for lower back pain, Leboeuf-Yde et al. found that subjects were left with a NRS of 2.6 (12 month follow up data). Leboeuf-Yde et al.19 also reported that these subjects still had significant levels of disability on the Oswestry scale (35-Moderate Disability down to 22.2-Moderate Disability).
In order for clinical research to be considered valid, the CCGPP Q & As1 state: “studies will have able to pass scrutiny by those within the chiropractic as well as outside the chiropractic profession.” As stated earlier, passing this ‘scrutiny’ should depend on the methods of a study and its journal of publication. The CBP® clinical trials have all been published in Index Medicus journals: European Spine J,15 two in the Archives of Physical Medicine & Rehabilitation,11,13 Journal of Rehabilitation Research and Development,14 and two in JMPT.10,12
Triano’s CCGPP guidelines, however, will not address technique “because of the exceptionally small amount of information available in the literature.”1 Apparently, as it looks now, likely none of the state-of-the-art CBP® research will even get the chance to be evaluated by Triano’s ‘panel.’ Further, the CCGPP document will also “provide benchmarks for intervening when the response is below average.”1 Thus, according to the best data on ‘above average chiropractic treatment,’ the CBP® patient data showing dramatically better outcomes than SMT-only patients (CBP=1.0 vs. SMT=2.6) will not even be conceived as existing because there is an ‘exceptionally small amount of (technique) information available in the literature.” One can see then, if a patient is not 50% better (Pre-NRS=4.7, Post-NRS=2.6) in 6-12 treatments, ‘benchmarks for intervening’ will undoubtedly result in CCGPP ‘evidence’ to support a loss of insurance coverage for the suffering patient! However, the accomplishment of a 75% improvement (Pre-NRS=4.0, Post-NRS=1.0) typically experienced by CBP® patients who have the causal factor of their complaints addressed (structural correction) will play no role in the ‘most advanced’ current guidelines despite having more evidence than Diversified technique16 as mandated by the CCE to be taught in all the chiropractic colleges!
One may wonder why Triano is even involved with the new CCGPP guidelines in the first place considering that it seems he has a conflict of interest. Not only is Dr. Triano an IME,20 he and his ASHN buddies have a very meager view of the profession as a whole.21 According to his (including 4 other ASHN co-authors) recent proposed model of the chiropractic profession (the article that Triano was very defensive about when questioned about its content while in New Jersey recently), we should limit our scope, adopt pain care-only, and all this because it is consistent with the current (incomplete) ‘evidence-base.’ Not only this, but they propose that chiropractors should sell their souls and become second-rate doctors in order to fit-in to the allopathic model! It is time for Triano and many of our other biased colleagues to recognize the expansive evidence-base that CBP® technique now has and start incorporating this data into current and evidence-based guidelines.
References
1. Council on Chiropractic Guidelines and Practice Parameters website (www.ccgpp.org).
2. Harrison DD, Janik TJ, Troyanovich SJ, Holland B. Comparisons of lordotic cervical spine curvatures to a theoretical ideal model of the static sagittal cervical spine. Spine 1996;21:667-675.
3. Harrison DD, Janik TJ, Troyanovich SJ, Harrison DE, Colloca CJ. Evaluation of the assumptions used to derive an ideal normal cervical spinal model. J Manipulative Physiol Ther 1997;20:246-256.
4. Harrison DD, Harrison DE, Janik TJ, et al. Modeling of the sagittal cervical spine as a method to discriminate hypo-lordosis: results of elliptical and circular modeling in 72 asymptomatic subjects, 52 acute neck pain subjects, and 70 chronic neck pain subjects. Spine 2004; 29(22):2485-2492.
5. Harrison DE, Janik TJ, Harrison DD, Cailliet R, Harmon S. Can the thoracic kyphosis be modeled with a simple geometric shape? The results of circular and elliptical modeling in 80 asymptomatic patients. J Spinal Disord Tech 2002;15:213-220.
6. Harrison DD, Harrison DE, Janik TJ, Cailliet R, Hass JW. Do alterations in vertebral and disc dimensions affect an elliptical model of thoracic kyphosis? Spine 2003;28:463-469.
7. Harrison DD, Cailliet R, Janik TJ, Troyanovich SJ, Harrison DE, Holland B. Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. J Spinal Disord 1998;11:430-439.
8. Janik TJ, Harrison DD, Cailliet R, Troyanovich SJ, Harrison DE. Can the sagittal lumbar curvature be closely approximated by an ellipse? J Orthop Res 1998;16:766-770.
9. Keller TS, Colloca CJ, Harrison DE, Harrison DD, Janik TJ. Influence of spine morphology on intervertebral disc loads and stresses in asymptomatic adults: implications for the ideal spine. The Spine J;5:297-309.
10. Harrison DD, Jackson BL, Troyanovich SJ, Robertson G, De George D, Barker WF. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study. J Manipulative Physiol Ther 1994;17:454-464.
11. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: A nonrandomized clinical controlled trial. Arch Phys Med Rehab 2002;83:447-453.
12. Harrison DE, Harrison DD, Betz J, Colloca CJ, Janik TJ, Holland B. Increasing the cervical lordosis with seated combined extension-compression and transverse load cervical traction with cervical manipulation: Nonrandomized clinical control trial. J Manipulative Physiol Ther 2003;26:139-151.
13. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. Changes in sagittal lumbar configurations with a new method of extension traction: Nonrandomized clinical controlled trial. Arch Phys Med Rehab 2002;83:1585-1591.
14. Harrison DE, Cailliet R, Betz J, et al. Conservative methods for reducing lateral translation postures of the head: A non-randomized clinical control trial. J Rehab Res Dev 2004; 41(4): 631-640.
15. Harrison DE, Cailliet R, Betz JW, Harrison DD, Haas JW, Janik TJ, Holland B. A non-randomized clinical control trial of Harrison mirror image methods for correcting trunk list (lateral translations of the thoracic cage) in patients with chronic low back pain. Eur Spine J 2005; 14(2):155-62.
16. Oakley PA, Harrison DD, Harrison DE, Haas JW. Evidence-Based Protocol for Structural Rehabilitation of the Spine and Posture: Review of Clinical Biomechanics of Posture (CBP(r)) Publications. J Canadian Chiro Assoc 2005;49(4);In Press for Dec.
17. Bronfort G, Haas M, Evans R, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J 2004; 4:335-356.
18. Haas M, Groupp E, Aicki M, et al. Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: a randomized pilot study. J Manipulative Physiol Ther 2004;27:547-553.
19. Leboeuf-Yde C, Gronstvedt A, Borge JA, Lothe J, Magnesen E, Nilsson O, Rosok G, Stig LC, Larsen K. The Nordic back pain subpopulation program: A 1-year prospective multicenter study of outcomes of persistent low-back pain in chiropractic patients. J Manipulative Physiol Ther 2005; 28(2):90-96.
20. Chiropractic Journal. Washington State lawsuit targets Mercy Guidelines. Judge says denial based on Triano’s opinions is ‘arbitrary and capricious.’ Chiro J. Apr 1996. (www.worldchiropracticalliance.org/tcj/1996/apr/apr1996g.htm).
21. Nelson CF, Lawrence D, Triano JJ, et al. Chiropractic as spine care: A model for the profession. Chiropractic & Osteopathy 2005, 13:9 (www.chiroandosteo.com/content/13/1/9).
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