RCT Worshippers Rejoice! All Hail the RCT!

Recently I have noted in social media that straight chiropractors, who are partial to relying on anecdotal evidence and case studies to justify their treatments, have resorted to a new straw man attack against evidence based chiropractic.  They now like to utilize the phrase "RCT Worshipper" as a slur against evidence based chiropractors.  They do this when their claims of efficacy are challenged, or when asked for literature to back up the all too common outrageous statements made on social media.

The implication is that evidence based chiropractors only value the things that are found and can be verified by Randomized Control Trial evidence.  It is an absolute straw man argument, a false representation of an opponent's point of view.  This is nothing unusual for straight chiropractors, or particularly the ones who like to drive a wedge between the two factions of the profession.  In fact, straw man might be their number number one form of fallacious thinking.

The fact is, evidence based chiropractors, and evidence based clinicians from all fields, understand the value of all levels of evidence.  The RCT is just one piece of the puzzle and some levels are regarded much higher than others for their ability to control for bias and demonstrate true cause and effect.

The hierarchy of levels of evidence are as follows, from highest to lowest:

  • Systematic Reviews
  • Randomized Controlled Trials
  • Cohort Studies
  • Case Controlled Studies
  • Case Series and Case Reports
  • Editorials, Expert Opinions

 

Consider this analogy:

Levels of evidence are like the Richter Scale of seismic activity.  Registering a "1" on the scale (editorial, expert opinion) isn't going to get as much attention as a "6" (RCT).  Yet straight chiropractors tend to go limbic over every "1" they see that supports their confirmation bias, and use that information as proof that something truly seismic is going on.

Take a recent facebook post of chiropractor Lyle Koca.  It was posted on his personal page, but then shared into a public group.  Many times straight chiropractors use their social media pages as proxy advertisement for their practices.  The posting of testimonial and results not only can be construed as advertisement, but especially in the case of Lyle Koca specifically, the posts are then used as a soap box for anti-medicine or anti-science diatribes. The following post is no different (the poor grammar is his, not mine):

Mom just leaves...we checked and adjusted her 11 month old who has been constipated since day one...Peer reviewed and what our "other" side says we should become (I DISAGREE) says that is "normal"...Saturday night after her first Gonstead Adjustment to ONE specific vertebra, he pooped 3x and is going like "normal" now...so I ask the cmm's and other groups...I know you are constipated in thinking, but is it right to allow a child to be that way???

Now first, I will admit, it is very difficult to even understand what Lyle Koca is talking about.  But there are a few things to take from this nearly incoherent rant.  And for further clarification, it is relevant to this blog post because the commenter's below the original post referred to their professional colleagues who operate in an evidence based manner as "RCT Worshippers" and "RCT Luddites".  That's the theme of the message.  Lyle Koca has decided to take a child's personal medical experience, and twist it into an anti-evidence diatribe to drive a wedge between his approach to care and his colleagues.  Classy.

One thing to take away from the rant:  Lyle Koca is convinced that his one specific vertebral adjustment allowed a child who has been constipated since birth to poo regular.  Back to our levels of evidence folks.  That would be an expert opinion (yes I'm laughing as I type that) or an editorial opinion.  That's an even LOWER level of evidence than a case study.  It's a "1" on the Richter scale, but its an earthquake enough in Lyle Koca's mind to claim that the evidence based world is collapsing.

Remember, higher up the ladder, less chance of biased observation.  Is it plausible that a vertebral adjustment helped a constipated child poo regular?  Absolutely!  So why is there an argument?  Who cares?

That's a relevant question.  This is a clinical issue.  While it is important to help the person in front of you who is seeking an answer to their health concerns, that is still just one person.  And even if it happens often in your office, that is still just one office.  And even if it happens often amongst your peers who practice like you do, that's still a small percentage of all the practicing health care providers in the world, with the rest of the world not even knowing your strategy is even a possibility.

What if, instead of occupying your time as a clinician using these patients and their results as tools in your rants and attempts at personal aggrandizing on social media, what if you used your time to work these results up the evidence ladder?  Into case studies, even cohorts.  Like I said, it is important to help the person right in front of you.  Could you imagine how many people in the entire world you could help by showing an unbiased evidence base for what you do and the results you get?

Of course I'm not directing this only at Lyle Koca, he's only an example.  But he does claim to be a leader in the profession, so he needs to be made example of.  Most chiropractors are woefully scientifically lazy.  Their only interest in science seems to be when it confirms something they already believed anyways, or when they can use it to get people in the door and keep them there.

For example, take case reports.  Recently, a case study was published in the "journal", Journal of Pediatric, Maternal & Family Health - Chiropractic, stating that spinal adjustment corrected the strabismus in a young Down's Syndrome patient (Chiropractic Care of a Down's Syndrome Patient with Vertebral Subluxation and Strabismus, JPM&FH Volume 2015, Issue 1, pages 46-50).  Oops, let me correct that so that Rob Sinnott, the author doesn't get upset.  The patient had a vertebral subluxation and strabismus.  In the case study the subluxation was corrected, and the strabismus resolved.  These slight technicalities in rhetoric will drive straight chiropractors completely limbic.

But I digress, that particular case report, since its release, has been shared and posted by straight chiropractor's as "evidence".  Evidence of what?  I'm not sure.  But typically they will use it for evidence of whatever pet belief about chiropractic they have.  And they are right, it is evidence.  A very low level of evidence with a high possibility of bias and not tested on a large enough population to make any assumptions about anything.  Yet it is, once again, a "1" on the Richter scale, maybe a "2" being treated as ground shaking and ground breaking.

But here's where relying on case reports and anecdote can come back to bite you:  If you are going to hold high regard for case studies and anecdotes that support your beliefs, you also have to hold high regard for case studies and anecdotes for the things you don't believe in as well.  If not, you are being intellectually dishonest.  Think about that.  Intellectually dishonest.

And in the great big world of things that chiropractors hate to admit, adjusting the upper cervical spine has a very high anecdotal and case report body of work that says it is dangerous and even life threatening.  A very high volume of such evidence exists.  Can you be an honest clinician when discussing anecdotal results, while ignoring other anecdotal results that say you shouldn't even be doing it in the first place?

For instance, let's take the above mentioned case study.  Adjusting a child with Down's Syndrome and noting a correction of strabismus.  You can't celebrate the anecdotal observation of the strabismus resolution while at the same time ignoring the higher volume of evidence that applying a high velocity, low amplitude thrust to a Down's Syndrome patient is a risky move.  Down's Syndrome individuals susceptible to atlantoaxial instability, up to 10-20% of Down's Syndrome individuals (Neurologic sequelae secondary to atlantoaxial instability in Down's Syndrome.  Implications in otolaryngologic surgery. Harley et al Arch Otolaryngol Head Neck Surg. 1994 Feb;120(2):159-65).  This is a higher evidence base, with less bias that would indicate that, although not a strict contraindication, a moderate contraindication exists when considering cervical adjustment of a Down's Syndrome patient.

If you ignore the higher level evidence, in order to accept the belief affirming lower level, you are in fact allowing your personal beliefs to put people at risk.  Rob Sinnott's case study shows a response in one patient, the one in front of him.  But with a 10-20% chance of atlantoaxial instability, you could say he got lucky.  Attempt to reproduce that study in 100 similar patients, and the results could indeed be disastrous.

So let's get back to Lyle Koca for a second.  Did his adjustment actually help the child as he claims?  Who knows?  Maybe.  Possibly.  Possibly not.  We do not know.  Even if he says it does, even if the child's patents say it did, we don't know.  In situations where we just don't know, how can someone honestly claim a moral and professional victory.  Correlation does not equal causation.  Yes, it could have indeed been the adjustment.  It could have been anything!  And it could have been the adjustment for 100 kids before that.  We don't know.  None of it was controlled for bias.  Just because you are certain, does not mean you are right.  But science have given us a beautiful gift, a tool for proving that your assertion is correct...  Evidence.

If you really want chiropractic to dominate the health care scene, to be the primary source for health and wellness in the world (and I know straight chiropractors do), then put your money where your mouth is and prove it.  Work to design the studies that will bring your practice to the exalted level it deserves.  Stop only using low level information as a bias confirmation tool and then dropping its importance once you've reached your personal goal of getting someone to lay face down on the table.  Science is not a tool to help you meet your ends.  It has been a human discovery that has changed the entire world with its application.  Whether you despise it or embrace it, don't understand it or do, ignore it or love it, you are participating in science when you attempt to heal people, like it or not.

So no, evidence based chiropractors don't worship the RCT.  In fact, statements like that show how science inept many straight chiropractors are.  If we worshipped anything, it would be the meta-analysis, which is higher up on the evidence ladder!  We, like all other clinicians who understand research, just respect higher levels of evidence for what they're worth.  But all levels have some worth.  But I'm personally not going to give a level "1" earthquake the same respect as a level "6".  And you shouldn't either.

Recently, in a related incident, I was accused of practicing out of fear and not "thinking outside the box" by a straight chiropractor.  This was when I asked for evidence and reasoning for why a chiropractor would utilize Applied Kinesiology to help a 2 year old child with constipation after an abdominal surgery.  That's ok, I'm used to being insulted when asking for a reason for certain treatment approaches.  When your beliefs are questioned, respond with an insult or attack seems to be the second most common logical fallacy of the straight chiropractor.

My response was that I absolutely think outside the box.  And evidence based practice encourages that.  Evidence based practice encourages clinician experience and intuition.  But that is AFTER the box has been drawn.  You actually have to have a foundation for how you operate, before you know how to operate outside of it.  The name of the game is to get as many safe, conservative, positive results for as many people as possible.  Evidence based guidelines are an excellent box to start within, and let your experience guide you beyond that.  Establish a comfort zone, and work your way out of it.  

This individual seemed to think you should just AVOID THE BOX AT ALL COSTS.  The box isn't even defined.  Since vertebral subluxation has never been specifically defined or agreed upon (or reliably detected), there is no box!  It's a create your own adventure which amounts to not much more than believing in magic.

Those people have no business serving the public as healthcare providers.  They are the ones that think vaccines are dangerous beyond all cost, regardless of the levels of evidence available to the contrary.  They are the ones who think that all allopathic medicine is bad, and detrimental to humans, ignorant of the things that medicine can and does do for people throughout the world on a daily basis (unless of course they get sick themselves, then its off to the MDs for help and a swallowing of pride).  They are the ones that see less than 1% of the worlds population, and get some results in some of those people, but their run with the blinders on mentality has them thinking they are the answer to the world's ills.

They are the ones who may put their beliefs ahead of their patient's personal needs.  Because for many of these folks, the whole game is about setting up and surrounding themselves with a world that will only mirror back exactly what they want to hear.  Making confirmation bias the third most utilized logical fallacy in straight chiropractic.  With psychological projection being the fourth.  Yes, I know it's not a true logical fallacy.  But it should be.

The psychological projection, in this case, is for a group of professionals who ABSOLUTELY worship a certain ideology and rationale, to accuse another group of professionals of worshipping something like evidence, which is just organized information.  It's laughable.  It's enough to make a guy want to write a blog.  The organization of information is what has taken us from caves and peat bogs to the moon and beyond.  Information is just information.  How you interpret it or ignore it is what defines your course in history.

How we as a profession participate or ignore the world of information as it rapidly unfolds around us will define this professions course in history.  To use a new agey term that straight chiropractors will understand...  straights are not playing big enough when it comes to providing evidence for what they claim to do.  This isn't about proving it to yourself and your patients and friends, it's about proving it to the world.

So my challenge to straights is this:  Instead of ridiculing those of your peers who quest to make sense and expand our base of knowledge on how chiropractic can help humanity, can you participate in the conversation, become literate in the world of research and evidence, and help the world in ways that it so desperately needs?  If we do not participate in the process of saying who we are and what we do, someone else will make those determinations for us.  Whether you're lauging at them on social media or not.  Whether your office is full or not. No one ever talks about the last dinosaur that lived and how he was more successful than the others.  History only tells us that they all went extinct.

Posted on March 19, 2015 .