Oakley et al. want to compare CBP to what they label “Diversified Technique.” It doesn’t take long for their methodology to collapse. Their non-referenced definition of Diversified appears in Table 1. Briefly, it says Diversified is a technique system where the doctor uses x-ray and motion palpation to obtain a listing, then delivers a “specific line of drive opposite the spinal listing.” Problem is, whether this is a good or a bad definition, it remains their
definition. Apparently, Oakley et al. did not notice that the CBP definition of Diversified would apply just as well to Gonstead Technique. Thus, the strategy of searching for studies on “Diversified” exactly as they define it will not locate the many studies where Gonstead Technique was used, which the investigators would have to admit would be relevant. By comparison, a Gonstead Technique website7
includes some relevant research involving Gonstead-like
Leaving aside the issue that several chiropractic colleges do not concern themselves with listings at all, this definition of Diversified is completely arbitrary, unsupported by historical and contemporary fact, and is used by Oakley et al. to make Diversified a straw man that would be shown to be inferior to CBP. Not only is the definition in Table 1 ad hoc
in relation to the diverse usages deployed by others in chiropractic, it is inconsistent with CBP’s own usage, as in a 1994 publication concerning one of their clinical trials. In it, they write: “treatment group 1 consisted of diversified spinal manipulations in lateral flexion and or axial rotation.”8
This contradicts the comment in their Table 6 that Diversified was not used in this study.1
More importantly, if CBP researchers and practitioners have been using the terms spinal manipulation and diversified adjusting more or less interchangeably over the years, what’s the point of drawing a distinction at this time, other than their current need to hammer down a straw dog?
The more narrowly a treatment method is defined, the less information will be retrievable in a literature search. Two of us had to deal with this problem when we and our collaborators studied the literature and clinical evidence for specific chiropractic procedures, stratified by specific low back conditions.9–11
We had to collapse the plethora of chiropractic adjustive methods available down to only 10. Only one-third of the chiropractic data (exclusive of the Journal of Manipulative and Physiological Therapeutics) was retrievable through electronic searching, since chiropractors do not excel in choosing the best keywords, and many of the publications we consulted were not indexed anyway. It is very likely that many researchers doing studies in which the treaters might have defined their adjustments as “Diversified” did not use that keyword, which is not even available in the MeSH system.
What happens if we apply Oakley et al.’s type of search strategy to their own technique? Doing a search for CBP clinical trials using the search term “Clinical Biomechanics of Posture” does not result in a single citation, since that term has just been invented. Although “CBP Technique has over 80 publications in Index Medicus Journals”12
only 17 show up searching using the former name of the technique, Chiropractic Biophysics. Of those 17 only 5 are labeled in MEDLINE as clinical trials and only one is classified as a nonrandomized clinical control trial.
Since it is unlikely that most chiropractors distinguish Diversified adjusting from manipulation, just as Oakley et al. may not have until this current publication, it makes no sense to classify literature as pertinent to one or the other. Oakley et al. state: “Surprisingly, there is [sic] little data existing on Diversified technique (as defined in Table 1).” Given how limited their classification of Diversified is, the CBP investigators should not be surprised by the result. If, as they state in the abstract, the evidence for SMT exceeds that for CBP, the difference would appear even more pronounced were studies they classify as Diversified combined with SMT studies in their review, as they should have done. Actually, we don’t think this is much of a problem, since we don’t think (however paradoxically) the CBP studies should be included in their own systematic review, or any other, for reasons discussed below.
Cooperstein and Gleberzon14
(p.143-9), and Peterson15
(p.495) have written extensively on the historical roots of Diversified Technique; as have Green and Johnson.16
What becomes apparent is that Diversified has a dual nature, in which “Diversified” (capitalized) denotes a brand-name technique system and “diversified” (lower case) denotes a more eclectic grouping of diagnostic and therapeutic procedures used by any and all practitioners throughout the chiropractic profession. There are reasons to believe that Diversified developed in part as a response to the rigidity and dominance of the Palmers. Cooperstein and Gleberzon wrote: “Ironically, as the years went by, DT, which originated as a liberating, eclecticizing response to the myriad of narrowly defined and often cultistic technique systems of the day, found itself more than just occasionally arranged alongside of, rather than alternative to them – as yet another technique system. However paradoxically, it appears that modern DT is chiefly distinguished from all of the others by its poor distinction from any one of them”14
(p.147). Indeed, “Diversified is too global to describe succinctly, whereas as a named technique, it too eclectic to describe distinctly”14
(p.143). The data from the NBCE Job Analysis3
also support a very broadscope sense of Diversified in the chiropractic profession, very much at odds with Oakley et al., in that 96.2% of chiropractors claim to use Diversified some of the time, on 71.5% of their patients.
The comment that the CCE mandates the teaching of Diversified, however defined, is entirely inaccurate. The word “diversified: does not appear in the CCE Standard.17
Although we would prefer to not speculate about Oakley et al.’s motivations in writing their paper, a major error of fact like this suggests a possible wish to demonstrate CBP procedures are superior to the eclectic and integrated methods of chiropractic technique taught at many of the chiropractic colleges. This would in turn have potential implications for third party payment, not warranted by the facts as we see them.