Is our intervention actually doing anything?

An interview with Droctor Philip Bolton by Melanie Gibson

In this edition of COCA news we will take the opportunity to profile our Key Note speaker for the conference, Dr Philip Bolton.

Philip is an Associate Professor and Deputy Head of the School of Biomedical Sciences at the University of Newcast le. He works in a Faculty of Heal th that t rains medi cal doctors, a range of allied health care practitioners and biomedical scientists. The Faculty is internationally renowned in part for its biomedical research. Interestingly, Philip has also worked in clinical practice as a Chiropractor for over 10 years. He has two primary research interests; the somatosensory system particularly relating to the neck, and spinal manipulative therapy in general and the chiropractor’s subluxation hypothesis and adjustment in particular.

Philip’s presentation at the conference will address the question ‘is our intervention actually doing anything?’ Essentially his presentation will consider the current research evidence concerning the nervous system’s response to spinal manipulation and the chiropractic adjustment. He will then explore the likely-hood that these responses have a therapeutic benefit to the patient.

Dr Bolton, is a Chiropractor who has made the journey from clinician to scientist and senior academic. COCA recently asked Philip a number of questions covering a range of topics. The first part of that interview is presented here and the remainder of the interview will be published in latter editions of the COCA News.

COCA – What prompted you to become a chiropractor?

I trained as a chiropractor almost 30 years ago now but in fact my first exposure to chiropractic was more than 20 years earlier. I was born into a chiropractic family. My grandfather and grandmother were both chiropractors. In fact there have been more than 15 chiropractors in my immediate family. My grandfather was the founding secretary and treasurer of the Australian Chiropractors’ Association (now Chiropractors’ Association of Australia) which was formed in his practice in Sydney in 1938. My father, also a chiropractor, later became the President of both the NSW Branch and the Federal body of the Australian Chiropractors’ Association. Although I have had chiropractic care all my life, I have long had a interest to be on the land and indeed I initially started a degree in Rural Science. However, when returning home during a University vacation period I suffered a very significant neck injury. It was my father who was able to resolve the problem with chiropractic care and thereby avoid probable neck surgery. Although I had had good health under chiropractic care all my life, this latter experience with chiropractic was very impressive and so I decided to transfer from Rural Sciences in to a science degree with a major in physiology so I could better understand what had happened to me and concurrently prepare to become a chiropractor so I could help others as my father had helped me.

COCA - Does your chiropractic back-ground influence and sway you in your research and judgement?

Absolutely, when I was in clinical practice I applied my chiropractic principles, treatment and management strategies to assist my patients as I had been taught. Many of my patients would respond favourable, which was exciting and pleasing, but many of them didn’t respond as I had expected and I often wondered why. I also found while teaching in the chiropractic program at the Preston Institute of Technology (now RMIT) that I was constantly challenged by students to justify and explain biologically why and how chiropractic worked. But at the time, some 25 years ago now, there was essentially no research concerning chiropractic that I could refer to in order to answer these questions so I decided to get further training so I could scientifically investigate and better understand the biological aspects of what we as chiropractors actually do and from this hopefully how we could do it better. The focus of my research, that is, the questions that I’m investigating, are driven by my training as a chiropractor and my observations in clinical practice. To this extent I am strongly influenced by my chiropractic background. However, my training as a scientist assists me to appropriately test these research questions, but that is not to say that I am not in conflict from time to time. The reductionism of science is not always the most valid or appropriate way to test a research question.

COCA - What are your areas of research?

I have two main research focuses.

One of my research focuses concerns chiropractic and spinal manipulative therapy. This work involves investigations intended to try and understand two things; Firstly, to better understand what chiropractors actually do when they manipulate the spine in terms of its effects on the nervous system, and secondly to test the biological concept validity of the chiropractic vertebral subluxation hypothesis. That is, does the lesion described by chiropractors, and referred to by them as the vertebral subluxation, have an impact on the physiology of an individual to an extent that causes dysfunction sufficient to compromise the individual’s health. If you like, part of my research focus is intended to examine the validity of one of the fundamental theories on which the clinical practice of chiropractic has been based.

The other research focus I have concerns my interest in the physiology underlying whiplash associated disorders. In particular, I’m trying to enhance our understanding of how the central nervous system processes and integrates sensory information arising from a whiplash event and how this influences the nervous system and translates into signs and symptoms. So I am also involved in a series of studies and collaborations concerning the physiology of various aspects of proprioception, pain, posture and balance and the autonomic system.

COCA - how does your academic expertise add value for the Chiropractor in daily practice.

Most of my research questions are derived from my clinical experiences as a chiropractor and to that extent my research will provide the chiropractor in daily practice with a better understanding of the biological mechanisms associated with the practice of chiropractic and I dare say to the practice of osteopathy and others who use spinal adjustments or manipulative procedures as a therapeutic intervention.

My laboratory and studies are somewhat removed from day the day practice of chiropractic and although I’ve had opportunities to take up appointments from time to time in institutions with chiropractic programs and thereby an opportunity to more directly influence the daily practice of chiropractic, I’ve been trained as a scientist and subsequently stayed in institutes with medical programs up to now primarily because I felt the opportunities to learn and assist the chiropractic profession by working in these institutes outweighed the, albeit strong, desire to be directly involved in a chiropractic program. In particular, the institutes with medical programs often have the best resources for the sort of research I currently do which involves laboratory based animal and human neurophysiology studies. I also know that I will be constantly challenged in this environment to do my research at the highest level. Importantly for the practicing chiropractor, this will ensure the validity of my chiropractic related research and thus its credibility. Scientists are well aware it often takes some time for research findings arising from the sor t of fundamental research I do to be translated into significant changes in clinical practice so I’m always happy to speak to practicing chiropractors at meetings such as yours so I can stimulate practitioners to consider if and how they should modify their practice procedures based on the current research evidence. At the very least, my research will test and clarify the concept validity of some fundamental theories that underlie the clinical practice of chiropractic and osteopathy. However, I hope that it will also provide insights and cues about how we might offer better care and management to our patients. So in short, I’m contributing to the knowledge base on which the chiropractic and osteopathic profession can fine tune and improve their clinical practice.

COCA - As a chiropractor with a foot in both camps what is your SWAT analysis of the chiropractic and osteopathic professions today

Strengths: The members of the chiropractic and osteopath professions in Australia have well developed skills in the application of manual techniques and procedures used as therapeutic intervention in the clinical setting. Furthermore, they have the potential to significantly influence the health of the community that consult them.

Weakness: The biggest weakness is the failure of the professions to provide the scientific and clinical evidence on which they have a basis or right to provide health care services. The community and third part payers, in particular, demand more than anecdotal evidence and hear say evidence any more. In the Chiropractic profession we have also failed to nurture and support the best and brightest in the profession so they can go on to contribute, in addition to their contribution as practitioners, to both the profession and the community at large. In addition, it seems to me that the chiropractic profession at least is composed of a lot of individuals who care passionately about their practice and profession but who are often pulling in different directions which significantly detracts from the professions contribution and worth to the community. This latter issue is perhaps not a unique situation to the chiropractors but it needs to be addressed and resolved if the profession is to move forward and be sustainable.

Advantages: The primary advantage is that the professions involve a relatively small group of people and therefore they have the potential to change rapidly if and when change is necessary.

Threats: The continued failure to provide appropriate evidence of outcomes that justify and define their role as health care providers. The credibility and integrity of the Chiropractic profession, in particular, is under grave threat from the continued engagement in and use by many of its members of practice strategies based on prepayment contracts, financial incentives etc and promises of health benefits that are yet to be evidenced, in order to offer so called better chiropractic or service to their patients – This is just unacceptable behaviour and is bringing the profession into considerable disrepute.

COCA - For chiropractic to be fully integrated into the mainstream health system, what does it have to do?

At the end of the day the chiropractic profession must provide to the community at large whether it be the individual patient, the third party payer in the private sector, or the Department of Health in the case of government, with the evidence that as a profession we offer a service that is safe, effective and of significant benefit to the community.

The second thing the profession needs to do is to ensure that the clinical experience that a patient receives and the subsequent professional interactions with other health care providers when they interact with a chiropractor is of the highest professional standard and is reasonably homogeneous across the profession. That is, that when a patient or other health care practitioner consults or interacts with the chiropractor in one location or another, that they receive essentially the same core experience in terms of an appropriate case history, examination and recommendation of findings and, importantly, a willingness and ability to interact and cooperate with other health care providers so the patient can access all the relevant information to make a decision as to what their best options are. At the moment because we don’t have the research in chiropractic that we should, we’re actually not able to reasonable predict for patients or healthcare provider what the likely outcome will be. We simply have no real idea about our efficacy for all the things we claim to assist or resolve. Until that’s resolved we won’t as profession, in contrast to any individual practitioner, be seen to be able to make a legitimate contribution to the mainstream healthcare system. That is not to say of course that individual practitioners do not make contributions to the health care system either locally in their community or to the broader community. We have recently seen a couple of fine chiropractors receive Australian honours for their work in this way. But alas the public will remain confused, indeed the medical and health community remain confused about when they should be referring and what sorts of patients they should refer to chiropractors and therefore when and how to involve the profession in the mainstream health care system here in Australia.

Dr Bolton will be a Keynote speaker at our National Conference ‘Beyond Musculo Skeletal Medicine’ Friday 24 to Saturday 26 October. For more information about our National Conference visit coca.com.au.