Examining Exams – Are They Reliable?
chiropractor. After being warned that chiropractors “crack your bones,” fear of iatrogenic fractures made this no small feat.
Thankfully, I knew several apparently rational and ambulatory individuals who emerged from chiropractic offices unscathed and apparently pleased with the ministrations they received. Still, I was skeptical and concocted the ruse that I was doing a report on chiropractic for school and wanted to interview the doctor. This seemed a reasonable strategy for testing the waters without risking life and limb.
The doctor exuded confidence and enthusiasm. He seemed to love what he was doing. The clinic had an upbeat energy I had never experienced in the office of any other doctor I had visited. He invited me into his office for the interview and I asked him that question we have all been asked: “What is it that chiropractors do?” The answer I received remains the most concise and elegant description of chiropractic I have ever heard. It changed the course of my life. He said chiropractic is based upon four simple concepts:
The body is a self-healing mechanism. Cut your finger; it heals. Cut the finger of a corpse; it does not. Life heals.
The nervous system is the master system of the body. Every aspect of the human experience is processed through the nervous system.
When there is interference with the function of the nervous system, not only can it compromise your physical well-being, but it also can have psycho-emotional consequences because it distorts your perception of the world and limits your ability to respond to the environment. When this happens to a significant number of people in a society, you have a sick society.
What I do as a chiropractor is locate and correct the cause of that interference.
He then proceeded to explain vertebral subluxation and adjustment. I became a patient and experienced firsthand the benefits of chiropractic care. It became obvious I would become a chiropractor. Now, in my 35th year as a doctor of chiropractic, I ask, “Where, as a profession, are we going? What happened to that elegant vision my first chiropractor shared with me?”
A disturbing trend is the willingness of some chiropractic leaders to abandon chiropractic terminology and analytical strategies. The generic moniker spinal manipulation or spinal manipulative treatment is becoming a replacement for the term chiropractic adjustment. What’s wrong with that? They aren’t the same thing. There are techniques of chiropractic adjustment, such as basic, upper-cervical and low-force techniques, that simply do not fall under the medical definition of manipulation.
A popular definition of manipulation is “a manual procedure that involves a directed thrust to move a joint past the physiological range
A grave error is made in many studies of the effects of manipulation by lumping together all “hands-on” techniques while failing to address key issues, such as the examination criteria used to determine the presence of “manipulable lesions” and how the investigators determine the “manipulative treatment” was successful.
Would it not be absurd for medicine to test the efficacy of drug therapy for a given disease without defining the diagnostic criteria for the disease and specifying which drug is given and at which dosage? It is no less absurd to collectively refer to all chiropractic adjusting techniques as “manipulative treatments” without defining the technique used, the force applied, the direction of the force and the criteria for pre- and post-adjustment analysis. Some researchers acknowledge that the side manipulated in their “studies” is determined by random assignment. Others arbitrarily “manipulate” a vertebral segment, whether or not a “lesion” is present.
Many doctors of chiropractic employ orthopedic and neurological examinations as the core elements of their clinical examinations. They often do so because that is what they were taught to do in school and what they were tested on during their licensing examinations. However, the fact that a procedure is popular, taught in school or tested on examinations does not magically confer reliability and validity.
Walsh reviewed the available literature on orthopedic tests common in chiropractic and concluded: “The use of orthopedic tests has been an integral part of the physical examination for a long time. They have remained a part of the examination more by virtue of common use than on the basis of any scientific demonstration of their validity and clinical significance. To make a judgment on the clinical worth of a test, its validity, reliability, sensitivity and specificity should ideally be known. Unfortunately, for most, if not all, orthopedic tests, these measures have not been determined.”2 Perhaps the most damning aspect of reliance on orthopedic tests is that such tests are not congruent with the clinical objective of vertebral subluxation assessment.
Even traditional neurological tests have limited utility. Neurological tests in patients with no neurological symptoms serve little purpose. Deyo wrote, “In reality, if the patient has no neurological symptoms (including sciatica) in the history, the yield of this is close to zero.”3 If your clinical objective is the detection and correction of vertebral subluxations, and you are relying on orthopedic and neurological examination findings, you would do well to consider whether those examinations have been shown to be reliable and valid for that purpose.
Thankfully, there are reliable and valid procedures for measuring functional changes and clinical outcomes associated with vertebral subluxation. These include biomechanical assessments (X-ray spinography, ROM), neurophysiological assessments (somatic, surface EMG, autonomic, skin temperature analysis, heart rate variability) and health-related quality-of-life instruments.
These technologies are no longer confined to the laboratory; they are available now for clinical use. But what about that vision shared with me as an idealistic, albeit naïve, teenager? These tools represent important steps in developing the clinical strategies that are making the dream a reality. Thankfully, although some chiropractic politicians may not yet have noticed, the profession has achieved a high level of unity. A survey of North American chiropractors found, “For all practical purposes, there is no debate on the vertebral subluxation complex. Nearly 90 percent want to retain the VSC as a term. Similarly, almost 90 percent do not want the adjustment limited to musculoskeletal conditions. The profession as a whole presents a united front regarding the subluxation and the adjustment.”4
The scope of chiropractic’s influence on the human condition is as broad as the scope of the influence of the nervous system. How broad is your vision, doctor? Seize the vision and change the world.
Dr. Chritopher Kent
Bartol KM. Osseous Manual Thrust Techniques. In: Foundations of Chiropractic Subluxation, Gattermann MI. St. Louis: Mosby, 1995.
Walsh MJ. Evaluation of orthopedic testing of the low back for nonspecific lower back pain. JMPT, 1998;21(4):232.
“The Search for Serious Disease: What Is the Best Strategy?” The Back Letter, 2003;18(9):102.
McDonald WP, Durkin KF, Iseman S, et al. How Chiropractors Think and Practice. Ada, Ohio: Institute for Social Research, Ohio Northern University, 2003.