Thank you for the opportunity to reply to the Letter to the Editor by Puhl and Reinhart. As we read it, the authors have two main areas of concern with respect to our article that reviewed the clinical effectiveness of the activator adjusting instrument (AAI).1 These concerns can be distilled down to: (i) lack of discussion of the ‘clinical intent’ of the use of the AAI and; (ii) lack of discussion of the clinical effectiveness of Activator Methods Chiropractic Technique (AMCT) versus use of AAI.
With respect to the first issue, we assert the clinical intent of the practitioner was irrelevant. Nelson et al2 have opined that what differentiates the chiropractic profession from other professions is that chiropractors focus on the beliefs or values of the practitioner; elsewhere, Cooperstein and Gleberzon3 have suggested this is synonymous with differences in worldviews. Examples of differing clinical intents or worldviews include subluxation-based, functional-based, structural-based, pain-based, wellness-based and tonal-based. For the purposes of our study, however, the ideology of the practitioner was of no concern to us. This is because we were focusing on the clinical effectiveness of AAI treatments, not the purported ‘philosophical’ benefits envisioned by the operator.
It is possible that we misinterpreted this concern, and Puhl and Reinhart are referring to the determination of the clinical target by the practitioner. If so, perhaps a reiteration of our study’s conclusion is in order. Of the 8 clinical trials we reviewed that met our inclusion criteria, the only clinical intent of the practitioners that concerned us was whether or not clinically meaningful results were achieved for various diagnosed conditions when either an AAI was used or when its use was compared to the use of another treatment method. The main outcomes measured by the investigators of these 8 clinical trials range from pain to range of motion to general disability. Overall, use of the AAI resulted in similarly beneficial results when used by itself or when compared to other therapies among patient with acute or chronic low back or sacro-iliac joint pain, dysfunction of the TMJ or trigger points of the trapezius muscle.
Moreover, it was not our concern if the practitioner used the AAI at the site of pain or if it was used at a site distant from it. Our concern was reviewing the literature with respect to clinical effectiveness achieved using the AAI, regardless of how the clinical target was determined. This is not unlike many clinical trials investigating the effectiveness of interventions such as spinal manipulative therapy (SMT) for spinal pain. Typically, therapists in those kinds of studies are allowed to deliver SMT in whatever manner they choose (perhaps the only restriction is to have the patient positioned prone or side-lying) and the practitioner is often entitled to identify the site of care using whatever method they use in private practice (static palpation, motion palpation, joint play and so on). In these types of studies, the focus of investigation is the method of treatment for spinal pain, not how the site of care was determined nor the clinical intent the practitioner hoped to achieve by the intervention.
Along that train of thought, with respect to the concern that we did not differentiate the clinical effectiveness between AAI and AMCT, again we assert this was not necessary for the purpose our study. The purpose of the study was to review clinical trials that used the AAI. At times, these clinical trials were conducted by practitioners who substituted manual adjusting using the AAI and at other times the clinical trials were conducted by practitioners incorporating the diagnostic protocols of AMCT, which involve the isolation, stress and pressure tests to identify the putative ‘pelvic deficient leg.’4 It was not our concern how the chiropractor identified the clinical target. It was our concern that they used the AAI as the method of treatment. It is for this reason we discussed that some of the clinical trials involved AMCT, since that is the only technique system that advocates the exclusive use of the AAI; however, AMCT, as a technique system, was not itself the focus of our study.
Looked at another way, our study concerned itself with the treatment side of the clinical encounter, not the diagnostic side. In order to accomplish this goal, it was necessary to search both the AAI and AMCT literature. Our study did not explore the validity or reliability of the diagnostic tests used by AMCT and it would have therefore been inappropriate – and gone beyond our dataset - to comment on them.
That said, we can inform Puhl and Reinhart that a study that assessed the reliability and validity of all diagnostic inputs used by chiropractors (including the diagnostic tests of AMCT) used to identify the site of care has recently been completed by a team of investigators. This manuscript is being prepared for journal submission and one of the authors of that study (Gleberzon) anticipates publication of it by the end of 2012.
Respectfully submitted,
Brian J. Gleberzon, DC, MHSc
Tiffany Huggins, BA (Hons), BEd, DC
Ana Lubric Boras, BA, DC
References
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