2015/12/01 by Nick D. Jeffery · 1 citation
Medicine · #Complementary and Alternative Medicine Studies #Clinical practice guidelines implementation #Medical and Health Sciences Research
paper · pdf · doi:10.1111/jsap.12427
openalex publication_date 2015/12/01 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/15
The purpose of medicine is to alleviate disease. We take it for granted nowadays that human medical interventions will be effective and, although this is a slightly naïve assumption (see Schork 2015), most will at least have undergone rigorous trials before being widely applied. However, during much of history the efficacy of many medical interventions was highly questionable and, instead, it is probable that physicians were largely held in esteem because of the psychological aid they provided to sick patients. The two strands of the art and science of medicine remain readily discernible in current practice. Conventional Western medicine, building on the successful introduction of various drugs in the early 20th century, seeks to use interventions that have been rigorously tested and proven to be beneficial in large trials. On the other hand, a bespoke individualised service based on personal contact and devotion of time to the patient is largely the province of so-called alternative therapies. The differences between these two approaches create many sources of conflict between practitioners and adherents of each. The designation “alternative” has been applied to a large range of therapies, including homoeopathy, aromatherapy and chiropractics; a uniting feature is that these rely more on personal interaction between physician and patient (or owner for veterinary patients) to design the prescription than does conventional medicine. Most “alternative therapies” have not undergone tests of efficacy through the recognised methods usually applied to conventional medicine and it is arguable that those that have demonstrated benefit in clinical trials (e.g. acupuncture) have been absorbed into “conventional” medicine. This has led to the statement that “there is no such thing as alternative medicine: either it works, in which case it is medicine, or it doesn't, in which case it isn't!”* A claim that is frequently made regarding some alternative therapies (notably homoeopathy) is that they cannot be tested using conventional methods, although this is a highly contentious viewpoint. Furthermore, it is often hinted that there is a conspiracy by the “medical establishment” to prevent publication of articles that support the claims of alternative practitioners. The opposing view is that alternative practitioners and their therapies get an easy ride in assessment of their claims in the lay press where they are not held to the same standards as conventional medicine. Therefore, it is pleasing to be able to contribute to this ongoing discussion by the inclusion in this month's issue of JSAP of a case series on chiropractic diagnosis (Thude 2015). In this study, which was accepted after routine peer-review, Dr Thude reports the use of chiropractic diagnostic techniques in dogs that were presented with incontinence. The main finding is that there was a far higher probability of finding specific chiropractic disorders in the caudal lumbar region than would be expected through pure chance. Such a finding suggests the value of chiropractic training in localising spinal disorders in this group of patients. However, a closer examination of the methods suggests another possible explanation: the physical examination was carried out after a routine interview with the client about the animal and its problems, during which the owner informed the veterinarian about the presenting sign of incontinence. Since both the initial interview and physical examination were conducted by the same veterinarian, it is also plausible that the diagnosis of a specific chiropractic disorder was in some way guided by the prior interview. In the jargon of conventional medical trial design, the observer was not blinded to patient category, and observations of this type would not be regarded as reliable in a conventional clinical trial. A further anomaly regarding this report is that the nature of the incontinence is not described in detail – no neuro-anatomic localisation is reported. While it could be argued that this may not be relevant because specific findings were detected on physical chiropractic exam, it might detract from the biologic plausibility if the chiropractic abnormalities were distant from the site of a conventionally-diagnosed lesion (say, a tumour in the pons). Nevertheless, there may be much that could be learned from the subtleties of chiropractic examination and interview by veterinarians practising conventional medicine. Although conventional medicine practitioners may feel that this report on chiropractic does not yet convince them of its value, there are also some wider implications of this report with regard to conventional therapies in veterinary medicine. This article underwent routine peer-review and was accepted based on the positive reports of the reviewers. While peer-review is the gold standard for acceptance of scientific articles, it does not imply that every peer-reviewed article must be regarded as containing sacrosanct information and this applies just as much to publications on conventional medicine as to those on alternative therapies. Even the most high-profile articles in the most high-profile biomedical journals will have their flaws and it is an important aspect of being a reader of scientific literature to take a critical view of published findings. There is a recent tendency, perhaps in part engendered by the need to have a “canon of established facts” for clinical specialist examinations, for a rather uncritical acceptance of “facts” as reported in veterinary publications – and, most especially, to regard P values as providing proof of these facts (see Jeffery 2015). A more sophisticated approach is that publication of data (and perhaps the authors’ interpretation of that data) should be considered to be the beginning of a dialogue about the topic, rather than the last word. In summary, data on chiropractic diagnosis in dogs have been published and the origin of that data has been clearly stated. It is up to the reader to decide what message is being conveyed – the information is simply provided by the JSAP as a service to readers!