July 2006

No 'Perles' of wisdom here

by Dr. Terry Rondberg

When Stephen Barrett (aka the "Quackbuster") puts misleading or erroneous information about chiropractic on his website, chiropractors are justifiably enraged. The same goes when a so‑called "stroke victims" group pays for anti‑chiropractic bus ads and billboards. After all, we can't tolerate lies and innuendo about our profession.

But where's the outrage when lies and innuendo are directed at a portion of the profession by someone within the profession?

Is it any less offensive when a DC spreads false information about other chiropractors? Why should we tolerate that kind of behavior?

A case in point was a recent column by Stephen Perle, DC, who teaches mechanical engineering at the University of Bridgeport's School of Engineering. He also teaches courses for the University's College of Chiropractic although his concept of chiropractic is so different from that held by most subluxation‑based chiropractors, it almost doesn't qualify for that name.

Underscoring the difference in Perle's professional perspective are his "research interests" as posted on the Bridgeport University website:

***  Human performance effects of manipulation of the extremities

***  Biomechanics of manipulation

***  Measurement of therapeutic 'dosage' of manipulation used in the treatment of low back pain

***  Comparative evaluation of chiropractic treatment methods

Dr. Perle has admitted that "there are no prospective studies, that I am aware of, showing that people without subluxations are healthier than those with subluxations. Further, in my experience, the clinical trials that have examined spinal adjusting have not tracked changes in health with changes in indicators for the presence of subluxations."

Since he apparently has little interest in conducting such research (as opposed to the best "therapeutic dosage" for back pain) one would think he would support legitimate efforts by others to do so. But that isn't the case.

In his latest column on "ethics" for Dynamic Chiropractic, he displays a total lack of ethics by using lies and innuendo to attack the subluxation‑based research agenda of RCS (Research & Clinical Science).

He drags me into his latest mud‑slinging fest by referring to a research effort I started back in the 1980s, the Vertebral Subluxation Research Institute (VSRI). That effort is totally unrelated to RCS, but apparently served as a convenient way to confuse the issue.

Perle calls VSRI "unprincipled and disgraceful" and labels it a "bait and switch" scam. What nonsense! At the instigation of several ACA "leaders" who were also attacking every element supportive of subluxation‑centered chiropractic. VSRI was investigated by several state boards and state Attorneys General. Despite such aggressive attacks, not a single board action was ever taken against the program. In fact, the Alabama and Arizona Board of Chiropractic Examiners both officially declared the program legal and said there was "no basis for action" against it.

Perle doesn't mention that in his article. Nor does he state that the program was initially developed with the legal advice of nationally noted attorney Paul F. Eckstein or that the research was conducted by Barbara Nienstedt, DPA, then a research methodologist for the Auditor General of the State of Arizona and a research associate and guest lecturer at Arizona State University.

Instead, Perle blithely labels the program a "scam" and hopes readers will be gullible enough to take him at his word. He even points out that no actual research was ever conducted by VSRI, but doesn't bother noting that this was due to the extreme pressure put on the program from organizations and individuals opposed to subluxation‑based research at the time (Perle was only out of school for three years when VSRI was started, so he wasn't involved in the attacks back then. To write his column, he obviously had to read all the anti‑VSRI material still in the Dynamic Chiropractic archives. Too bad he didn't bother reading the information in The Chiropractic Journal archives as well to get a balanced view. But I guess "ethicists" don't have to worry about fairness.)

But this column isn't about VSRI, which ‑‑ as I said ‑‑ has absolutely nothing whatsoever to do with RCS despite Perle's insinuation.

However, since Perle has pulled me into this argument about RCS, I think it's only fair for me to respond to some of his more blatantly misleading statements.

The purpose of research

First of all, Perle says that, in chiropractic, there seems to be confusion about the purpose of research. Really? Perhaps he's confused but the rest of us know very well that the purpose ‑‑ the sole purpose ‑‑ of chiropractic research is to discover the truth about chiropractic.

For me (and the vast majority of chiropractors, according to every recent survey of the profession) that means finding out the extent of the impact of subluxations on general health and wellness, and the efficacy and cost‑effectiveness of chiropractic adjustments.

Notice that I didn't say it's to verify whether or not subluxations exist. That has already been adequately proven through scientific research. We no more have to "prove" that than medical research has to "prove" hypertension exists.

Nor did I say it's to figure out the dosage of chiropractic manipulation for back pain. That may be Perle's interest, but it isn't the area RCS (or most doctors) are concerned about.

Perle says, "Many think it is to prove chiropractic works, to help us get reimbursed, or to help us build our practices." He gravely underestimates chiropractors if he honestly thinks they don't know the difference between the reason we conduct research and the ways research can, ultimately, help individual practitioners.

When the medical and pharmaceutical industries conducts research, they don't let that knowledge sit isolated in a laboratory. They use it to help formulate treatment guidelines, sell drugs, ensure insurance coverage, and win bigger research grants. I'm surely not saying we should model ourselves after them, but we have to have a realistic understanding of the many benefits of research, aside from knowledge for knowledge sake.

Even Perle admits this, although he tries to remain cloistered in his ivory tower by dismissing any other considerations as "secondary."

Research shouldn't prove anything

He next calls RCS leaders to task for stating up front that their aim is to prove that chiropractic works. After all, he chides, "research should never be seen as a way to prove anything, for if our intent is to prove something, what happens if the data from our research disproves our hypothesis?"

Unlike Perle, I have a hard time envisioning a research project that would end up "proving" that chiropractic is useless, and I think the RCS leaders share my optimism about the results of the project. We know ‑‑ from personal and clinical experience ‑‑ that it has a beneficial impact. We need the research to determine just how much of an impact it has.

But, still, the actual research proposal spells out the objectives in proper scientific terms:

"The three‑year research plan calls for the use of the electronic data capture network to evaluate the contents of the central data repository in a variety of research formats (retrospective, case reports, time series, and controlled clinical trials). These research designs will allow analyses of health outcomes across the large pool of patients required to provide control for the hundreds of clinical, sociodemographic, socioeconomic, and health lifestyle variables encountered in clinical practice. Of course, all of these functions will have required approvals (IRB, HIPPA). Public health surveillance strategies will be employed to sample: 1) incidence of clinical sign (vertebral subluxation), 2) primary and secondary benefits of chiropractic, 3) optimal duration and frequency of care, 4) health conditions benefitted by chiropractic, and 5) effects of age, sex, ethnicity and prior existing conditions. Multivariate statistical analyses will be used to identify the relationships between variables; structural equation modeling will be used to provide operational models relating to health interventions, health behaviors and health outcomes (Schuster et al., 2004 a, b). We will begin with an analysis of chiropractic in years 1‑3, but our long‑term goal will be to expand the network to include other selected fields in medicine and nursing thereafter. This comprehensive program permits a comparison of health outcomes and cost‑effectiveness across and between (co‑therapies) health disciplines. These strategies will ultimately improve the quality of health care service delivery, radically advancing the evidence‑based documentation of the fields under study, and promote the re‑establishment of a rationale, information technology‑based, national health policy."

Ironically, Perle never contacted RCS to request a copy of the actual proposal before condemning it. I hope that's not the same type of thorough literature search he conducts for his research on chiropractic "dosage."

At the Bridgeport U site, he provides students with a "sample" research proposal with this objective:

Chiropractors have long claimed that the chiropractic adjustment, also called a manipulation, has an ergogenic effect. There have been no comprehensive literature reviews of this topic published in the peer‑reviewed indexed literature.

Perhaps RCS would have received Perle's approval had its objective been stated as:

Chiropractors have long claimed that the chiropractic adjustment, to correct vertebral subluxations, has a beneficial impact on human health and wellness. There has been no comprehensive clinical research on this topic published in the peer‑reviewed indexed literature.

If Perle had bothered to read the actual RCS proposal objective, he would have seen that it says pretty much the same thing, except in more detail.

So much for his bogus criticism.

Another critical piece of information Perle fails to give readers is that RCS research is not being conducted by the DCs who, in their foolish optimism, are apparently fairly certain chiropractic can help people.

The actual research is done by a group of highly respected medical researchers including MDs and PhDs who have been published in hundreds of scientific journals around the globe. Each month, The Chiropractic Journal has been featuring profiles of these panel members, so there's no excuse for Perle not to know about them and their credentials. For him to lecture them in proper research techniques is, at the very least, arrogant.

Of course, arrogance is something of a trademark for Perle, who once stated: "I love being a chiropractor ... even though I often feel embarrassed about being one. I am not embarrassed because of chiropractic, but because of chiropractors."

Maybe that's why he seems opposed to chiropractors enjoying any kind of success. In his Dynamic Chiropractic columns, he's labeled as unethical just about every marketing tool used by chiropractors: advertising, free screenings, health fair booths, etc.

"I could go on and on about the various practice‑building methods that the public views as unethical," he said in one column. And he does! He may have won the 2004 "Academician of the Year" title from the American Chiropractic Association, but he won't win many accolades from doctors around the country struggling to get patients in order to stay in practice.

In addition, Perle never mentions the fact that the RCS research proposal was approved by an independent Institutional Review Board. Following guidelines set down by the FDA, this IRB examines every facet of the research program, including objective, methodology, informed consent, confidentiality, etc. It even looks into even the least hint of financial impropriety. RCS won IRB approval with flying colors.

I suppose it's possible that the entire IRB committee, the members of the International Scientific Advisory Panel, the RCS leadership, RCS Authorized Clinical Investigators, and RCS supporters around the country, all fail to live up to Perle's ethical standards, or are part of a massive conspiracy.

More likely, the criticism is merely part of Perle's elaborate but ultimately transparent 'smoke and mirrors' crusade.

Paying for research

The next criticism Perle aims at RCS is that it is a private‑sector research company that derives its revenue from membership fees rather than government grants or institutional funding.

Robert Blanks, PhD, president of RCS, addresses this issue very well in an article in this issue of The Chiropractic Journal so I won't repeat what he says.

I will, however, mention that Perle's information on this matter is so full of errors and out of date that I really have to wonder when he wrote his column (and why Dynamic Chiropractic chose to print it now). I spoke with David Jackson, DC, the CEO of RCS, and confirmed that RCS does not lease the program nor does it charge $400/month ‑‑ and it hasn't offered that arrangement for several months. Dr. Jackson also told me that Perle never called him to verify the information in his column.

Perle says, "We would challenge those involved with the RCS program to provide examples of any other major research institutions in which the researchers themselves are paying a fee to participate in such research."

First of all, I wonder who the "we" is. His use of that pronoun confirms my suspicions that he's being used as a mouthpiece for others of like mind.

To answer his question, though, I don't know of any other profession where the practitioners are willing to pay for the privilege of collecting data for research. Maybe we're the first and we're going to be the model the others will follow. Of course, medical researchers hardly need to follow RCS' example, do they? They have billions of dollars in government grants and drug company money to fund their research.

Perle should ask himself what's wrong with being innovative. What are the alternatives? He says the money doctors pay to participate in RCS would "have a far more positive impact on our profession if the doctor would commit this amount of money as a monthly donation to FCER."

Why should they? So the FCER can pay Perle to do a research project on the proper therapeutic "dosage" of manipulations? So it can hire another ACA academician to do a literature search on low back pain? They know very well that the FCER's 2005 teleconference series was called "Back to the Future ‑‑ New Perspectives in Back Pain Research."

FCER has no interest in doing the kind of research most chiropractors want and frankly, it hasn't been able to scrape up enough funds to do much research at all. In the Spring/Summer 2005 issue of the FCER publication Advance, Dr. William Meeker complained, "there are not many more people doing chiropractic research now than there were 10 years ago... We can't even find jobs for promising young scientists in our institutions. Only a small number of grant applications are submitted to the National Institutes of Health, even though manipulation research is explicitly on their scientific agenda. Our peer‑reviewed scientific journals are in chronic financial trouble."

And Perle wants the profession to keep doing what it's been doing rather than try something new?

That sounds to me like Einstein's definition of insanity: "Doing the same thing over and over again and expecting different results."

Ad hominem ho hum

No doubt, Perle will categorize this column of mine as an ad hominem attack, all the while failing to admit that calling the VSRI program a "scam" is, in essence, a personal attack. Or that accusing the RCS researchers of "bait and switch" is equally personal. He likes to hide behind a sanctimonious veil of false civility.

And note that he has stated: "There is one situation in which ad hominem is a valid argument ‑‑ when it is used to attack the credibility of a person who is the sole source of information, not on the validity of their deduction, for there is none. For example, one chiropractor wrote me: 'You are the most unprincipled man on earth and should do the profession a favor and jump off a cliff.' Since he presented no logical argument or evidence that I am unprincipled, attacking his credibility is a valid argument."

Actually, I think Perle's column on RCS provides ample evidence that its author is unprincipled, since it contains the same kind of lies and misinformation we see on Barrett's "Quackbuster" site all the time. It's not surprising that many of Perle's articles are posted on the Quackbuster site in support of Barrett's consistently misleading (and often outrageous) claims!

My column, then, is no ad hominem attack but simply a way to expose Perle's lack of credibility.

Let's tell the truth

I think it's clear that there's more going on here than just one disgruntled, "embarrassed" chiropractor trying to destroy a research program he wasn't invited to participate in. A lot more.

When a state board tells subluxation‑based chiropractors they can't discuss innate intelligence or nerve interference in their ads, but approves ads from "chiropractic physicians" that display a laundry list of pain symptoms and complaints, there's more going on.

When American Chiropractic Association representatives to the government advisory committees vote in favor of having medical gatekeepers and against references to subluxation correction, and then hypocritically wastes $7,000,000 on a law suit to Save Our Subluxation, there's more going on.

When the same people who developed the Mercy Guidelines try to foist their "next generation of limited back pain treatment guidelines" CCGPP "Best Practices" document on the profession, regardless of massive opposition from subluxation‑based chiropractors, there's more going on.

You don't have to be a research scientist to look at the mounting evidence and see that the attack on RCS is part of a larger campaign against subluxation‑centered chiropractic. The opponents don't have the guts ‑‑ or the ethics ‑‑ to just come out and say it, but Perle came pretty close when he sent an e‑mail last year stating: "Now we must undertake the effort to weed the fringe out of the profession (CCE's decision on Life should help reduce their breeding rate). This I believe is an ethical obligation of the profession to the public."

Well, listen up Dr. Perle. Subluxation‑based chiropractors are NOT the "fringe" of this profession. We ARE the bulk of this profession and we will not allow you and your comrades in arms to weed us out. We will continue to support RCS because it's the one sure way we have of proving that chiropractic's unique subluxation correction service has a long‑term beneficial effect on health.

And if that gives Perle even more reasons to be embarrassed to be a chiropractor, then I wish him well in whatever less shameful profession he wishes to join. Perhaps there's a full time opening on Bridgeport University's mechanical engineering staff?