A Shift in the Prevailing Winds
An exploration of current issues in the practice of upper cervical chiropractic
Michael D. Thomas, D.C., Jeffrey N. Scholten, D.C.
(This paper was originally published in The Upper Cervical Monograph, September 2004)
This paper is intended to act as a catalyst for an introspective examination of NUCCA (National Upper Cervical Chiropractic Association) and to a degree, upper cervical chiropractic as a whole. The authors believe it is critical to re-examine the assumptions and assertions that drive NUCCA both scientifically and socially. The percentage of chiropractors working from an upper cervical perspective continues to constitute less than 5% of the profession. The voice of upper cervical chiropractic is essentially silent outside of its own borders. The reasons are many and diverse: historical, technical, political, financial, and social. This isolation has however, resulted in a simplistic perspective that reinforces a sense that we are â€œrightâ€ and that the rest of the profession ought to â€œwake upâ€ or is â€œwrongâ€. This manner of communicating our work to the outside world has not worked for sixty years. We remain basically invisible.
The rest of the profession has not stood still in the intervening decades. Both the chiropractic field and healthcare itself have undergone tremendous changes in the past few decades. The rules are changing and what sufficed in the past is not going to be adequate to guarantee survival into the future. This paper is offered as the beginning of an analysis that can take us into the future. By clarifying our foundation we will improve our delivery of care while building the structure necessary to make our case to the world at large.
Most of you reading this paper owe your livelihoods to upper cervical chiropractic. The right to practice this work is precious and must be protected. You are on the front lines; there is no army in front of you. The need to validate the work we do is paramount and fortunately much work has already been done. Much of this work has however, been published only in upper cervical periodicals and/or passed down by word of mouth. Little has been published where we now need it, in peer reviewed, indexed literature. It is critical that we document what we know as well as what we know we donâ€™t know. Further research can then work to â€œfill in the gapsâ€ and make our case more objective and complete.
Upper cervical doctors tend to be highly principled, intelligent, thoughtful individuals. In fact, without those qualities, it is unlikely an individual would choose to become an upper cervical doctor. For historical reasons, we have not tended to make much use of this incredible brain trust. We would like to change that and the reader is invited to make one of several choices:
1) You may read this far and decide to toss the paper in the trash.
2) You may read the whole paper and then toss it in the trash.
3) You may wish to respond to one or two items that mean something to you.
4) You may sit down and analyze the paper, making comments (agreeing, disagreeing, perhaps shifting perspective) and adding other meaningful topics that you believe to be of critical importance to the future of this work.
Our plea is that you express your thoughts and opinions. In so doing, you may help to change the face of chiropractic and perhaps even healthcare.
We plan to publish this paper along with the responses we receive in a special issue of the Monograph. The responses will then engender the next step. We believe that a focused group of doctors working together may be more effective than the heroic efforts of a handful of individuals who by sheer force of will have driven this entire segment of our profession. We will always owe them our livelihoods but now the torch is being passed and along with it the responsibility to further this work.
Note: The paper is fairly long and contains a tremendous amount of material. It should probably be chewed slowly. Upper cervical chiropractic cannot be summed up in a â€œsound-biteâ€. Just as the work itself is complex, so any meaningful discussion of it will also likely be somewhat complex.
The Real and the Ideal
The Upper Cervical Monograph was launched in 1973 as a vehicle for NUCCA and NUCCRA (National Upper Cervical Chiropractic Research Association) to disseminate the ongoing findings from current investigation and research into the ASC (Atlas Subluxation Complex). It has served NUCCA well for over thirty years. When it was initiated, there was virtually no place in any peer reviewed, indexed journal for investigators in chiropractic to publish their findings. Medicine had simply shut us out. This made The Monograph a critical link in communicating new ideas. As venues have opened up in chiropractic, upper cervical work has still found it difficult to gain access to publication, often because our protocols involve radiating patients and the safety and efficacy of taking pre and post films has not been established in the literature. This has in some ways created a â€œCatch-22â€ kind of situation. So the problem has been that the only people who are aware of upper cervical chiropractic research findings are those within our own community. Anyone outside upper cervical work and certainly, any researcher who does a literature search on Medline, will not find any of these papers. As far as the work published in The Monograph is concerned, we are still invisible outside of our subscription population.
Any new research conducted should now be published in a journal, which will be available to the scientific community at large. This leaves The Monograph at a crossroads. The ever-decreasing frequency of Monograph publication is one symptom of this change in professional climate. There are, and will continue to be, still more articles that are of specialized interest only to orthogonally based upper cervical chiropractors which still make sense to publish â€œin houseâ€. At the same time, it may be time to examine other uses for The Monograph.
The NUCCA landscape has changed in the fourteen years since Dr. Gregoryâ€™s death. The major concepts are set and the basic protocols established. Changes are much more incremental now. This is a natural evolutionary consequence of the success of the Grostic and Gregory investigations. At the same time, there has been tremendous change over the past several decades in the scientific community at large in understanding of complex and nonlinear systems. New mathematical models exist that were unknown and unavailable in the past. Biomechanics itself is undergoing rapid change in understanding. The frontiers of biology are approaching models that may accommodate orthogonally based upper cervical chiropractic and may, ultimately, greatly improve its application.
â€œNew ideas in science are not always right because they are new. Nor are the old ideas always wrong just because they are old. A critical attitude is clearly required of every scientist. But what is required is to be equally critical to the old ideas as to the new. Whenever the established ideas are accepted uncritically, but conflicting evidence is brushed aside and not reported because it does not fit, then that particular science is in deep trouble-and it has happened quite often in the historical past.â€
At this point, excellence has come to be defined by close and long term attention to detail and consistency in all of the various sub-protocols that comprise upper cervical chiropractic. This remains essential and probably always will, but it is no longer enough. As professionals, it is our duty to examine not only the new concepts that arise, but also to periodically re-examine the foundational concepts. When NUCCA was a handful of doctors meeting in Monroe, Michigan with Dr. Gregory, it was appropriate to defer to the decades of close examination of ideas that comprised the life of Dr. Gregory. No one else had the depth of experience, the methodical analytic abilities or frankly, the overriding brilliance that he demonstrated. He was able to explain in considerable detail his process and the rigor by which he arrived at the specifics of all the various components of the work.
We have grown beyond that handful of doctors. We are on the cusp of the next evolutionary step. Dr. Gregory was well aware of the requirements of a scientific endeavor. His work with Dr. Grostic and later individually, was the initial and perhaps most critical step. Individual investigation and experimentation are the genesis of any new scientific process. The issue today is that if we are to be taken seriously in the world at large, we can no longer validate our work by saying that Dr. Gregory (or Dr. Grostic) told us it is true. This is not meant as a refutation of their body of work. In fact, it is the reverse. The years since their deaths have only increased the clinical evidence as hundreds of practitioners have taken on this work and validated its results in the patients who have been adjusted by them. It is precisely for this reason that it is up to this next generation to take the next steps. We owe it to Dr. Gregory, Dr. Grostic and humanity.
The Burden of Proof and Impediments to Truth
Science is often discussed in an idealized form. Returning to Gold for a moment, here is his admittedly â€œnaÃ¯veâ€ definition of â€œwhat a scientist isâ€:
â€œHe is a person who will judge a matter purely by its scientific merits. His judgment will be unaffected by the evaluation that he makes of the judgment that others would make. He will be unaffected by the historical evaluation of the subject. His judgment will depend only on the evidence as it stands at the present time. The way in which this came about is irrelevant for the scientific judgment; it is what we know today that should determine his judgment. His judgment is unaffected by the perception of how it will be received by his peers and unaffected by how it will influence his standing, his financial position, his promotion â€“ any of these personal matters. If the evidence appears to him to allow several different interpretations at that time, he will carry each one of those in his mind, and as new evidence comes along, he will submit each new item of evidence to each of the possible interpretations, until a definitive decision can be made.â€(p. 245)
Gold asserts that there is probably no one who can actually fulfill this rigorous description. It is acknowledged that people have motivations beyond the abstract ideal of scientific methodology. He sees danger existing in those motivations that are more social in nature. He asks:
â€œâ€¦what are the communal judgment-clouding motivations? What is the effect of the sociological setting? Is our present day organization of scientific work favorable or unfavorable in this respect? Are things getting worse or are they getting better? That is the kind of thing we would like to know.â€ (p. 246)
Gold then describes two motivations that are deleterious to scientific progress -the unwillingness to learn, and the â€œherdâ€ instinct.
â€œToo many people think that what they learned in college or in the few years thereafter is all that there is to be learned, in the subject, and after that they are practitioners not having to learn anymore.â€
â€œWhen people pursue the same avenue all together, they tend to shut out other avenues, and they are not always on the right one.â€ (p. 246-7)
He heralds diversity and recognizes the danger of limiting our avenues of investigation.
Gold continues his paper with a devastating critique of the peer review system in science, which seems to him, designed to maintain the status quo actually squelching innovative ideas and dissenting voices. (The reader is encouraged to read the whole paper at: www.suppressedscience.net/inertiaofscientificthought.pdf ) Although we are not looking to overturn the peer review system, we are looking for access to the mainstream scientific community. The flaws of the system are not our greatest concern but they are instructive. We find ourselves entrenched in a process that we are not really examining with a critical eye, hoping to gain access to the â€œgreater herdâ€ which has its own inertia. Keeping our heads down and concentrating on optimizing our x-ray techniques and maintaining parallel forces in our adjustments is critical but not enough to assure the sustainability of this work beyond our generation.
We believe that many of our problems are simply representative of our current level of maturity. We have a very small number of practitioners, many of whom are isolated by geography. We have no real university funding and we have no real corporate sponsorship. Almost all of our investigation and research has been the product of selfless service by individuals, very few of who have any training in research methodology. Each of us is very busy with family and business life. And yet, somehow, upper cervical chiropractic remains a viable career path in chiropractic. Also, considering our scant numbers, we are well represented in the current chiropractic literature. None of this would or could, be true if it wasnâ€™t for the incredible power of the upper cervical adjustment.
It may have been necessary in the past to tightly control access to instruction and information in order to systematize it and create a series of protocols that could produce safe, effective and consistent care. This system is now well in place and has been comprehensively codified in the NUCCA seminars and in the NUCCA textbook. New students as well as long time doctors, all have clear guidelines regarding all of the sub-protocols. Restriction of conversation, ideas or innovations by doctors regarding aspects of the work only serves to disenfranchise the members of our community. Very often, behaviors that are appropriate at one point in time (to protect the work) become the very behaviors that restrict further evolution of it in the future. We believe this to be the case now. While class time at the seminar is not the proper time to delve into a diversity of viewpoints regarding the protocols, we believe there should be some venue for this process.
The Proof is in the Post
In numerous talks to chiropractic colleges, Dr. Gregory often noted that the use of any specific technique was unimportant to him; it was the results that mattered. By â€œresultsâ€, he meant post-films. He often said that he didnâ€™t care if someone adjusted the big toe if it could produce corrections on film. Our gold standard is the radiological measurement of maximal and proportional reduction (correction) of misalignment. Post film analysis ensures that the patient is not left with disproportionate, different or even greater misalignment factors than prior to intervention. Other techniques do not share this goal and therefore the offer to take a set of pre-films prior to some â€œotherâ€ intervention, have the patient â€œadjustedâ€ in whatever technique is being evaluated, and then posted to analyze whether misalignment factors have been reduced is not necessarily appropriate. The explicit assumption here is that if the misalignment factors are unchanged, reduced disproportionately, or increased, then the intervention has failed to improve the health of the patient. Outcome measurements for most other techniques do not include x-ray analysis of upper cervical spinal alignment. Apples are not oranges and demanding that an apple taste like an orange is unreasonable. There are more than 300 techniques now being utilized in chiropractic and many people have derived health benefits from the whole diversity of procedures.
The growth of chiropractic in recent years can certainly not be credited to the work of a handful of upper cervical chiropractors. All chiropractic procedures exist within their own context and the best ones are internally consistent. Outcome standards vary because our collective understanding of health is at best incomplete. Part of the current challenge upper cervical chiropractic faces as a minority, is in becoming able to enlarge our perspective and not demand that other procedures fit our mold. Instead, we need to work to more completely define and properly document what sort of physiological changes can be consistently expected under our care. When these physiological changes coincide with changes reported by other procedures then the efficacy of different interventions can be compared. The commonality may point to new directions. The upper cervical chiropractor has the burden of proof because of our minority status. Demanding that other techniques conform to the outcome standard of orthogonal upper cervical is not reasonable. There is a plethora of wonderful healing stories that come out of the chiropractic profession in every technique.
Considering the immaturity of our current physiologic understanding, the loss of continued development would be tragic. It is a near certainty that any procedure that does not take the upper cervical misalignment factors into account is not going to produce proportional reduction on post film analysis. Only when the complete reduction of misalignment factors on post film analysis equals a total and completely sustainable return to health in all people all the time will this standard be appropriate as a universal outcome measure for all chiropractic techniques. Health is multi-factorial and each practitioner and procedure brings different pieces of the puzzle to each individual case. Not everyone sees life in the same way however, and honest people take data in different directions. Just as light is both particulate and wave depending on the methods used by the observer there are different truths to each incomplete puzzle depending on the observerâ€™s vantage point.
Integration of our ideas into healthcare will not come from making everyone else â€œwrongâ€. We have empirically and repeatedly proved this point over the past sixty years. As mainstream chiropractic continues to move away from the specific structural subluxation concept all together, the very real possibility exists that we could become â€œrighteouslyâ€ extinct.
Upper cervical chiropractic is simple in initial concept but difficult to truly understand at the level of practical competence. It is also difficult to perform as a consistent and accurate physical act. After six decades of evolution, there are still very few doctors who can be called masters of the work. If the only benefit humanity can derive from upper cervical chiropractic is from this (literal) handful of masters, then the work is of minimal practical significance, perhaps, an asterisk in the history of chiropractic at best. But the truth is that right now many hundreds of upper cervical doctors do their very best everyday and make incredible differences in hundreds of thousands of lives. A twenty percent decrease in misalignment factors can, at times, produce dramatic results. It may take several adjustments to obtain the best possible reduction. Some practitioners find they are unable to produce the results they know are possible with hand adjusting and begin to use an instrument. Any given individual or instrument (mechanical or manual) has greater and lesser qualities that need to be assessed and evaluated but not just discarded out of prejudice. It has been shown time and again that blinded division and unproven prejudice only serves to dilute our pool of talent, frustrate innovation and stall progress. To avoid this righteousness we must be willing to speak from and to share our own experience and allow others to speak from their own experience and observations. The â€œopen forumâ€ is certainly a step in this direction.
The Map and the Terrain
The association between maximal, proportional correction on post film analysis and restoration of health in a multitude of people has astounded upper cervical practitioners and gratified untold numbers of patients for several decades. The correlation between correction on film and return to health is so profound that it has led to the use of post-film analysis as an equal synonym for return to health, among upper cervical doctors. As great as this correlation may be (and we certainly do not dispute this), the post film remains merely a reflection of this potential for the restoration of health in an individual. It is not the transformation itself and it is not inclusive of all the myriad factors that are responsible for optimum health. The map must not be confused with the terrain itself.
This error occurs in the deep-seated conviction among many upper cervical chiropractic practitioners that restoration of health cannot occur without reduction of the upper cervical misalignment factors as measured on film analysis. This may seem to be a trivial point since we are not debating that there is a high correlation. This error in logic has however, in our opinion, created nearly irreparable harm to our standing in the chiropractic community and in healthcare at large.
In the world at large, this has translated into a tiny group of practitioners with the firm conviction that they are â€œrightâ€ and everyone else is â€œwrongâ€ if they donâ€™t conform to the outcome measure delivered by the post film analysis. This social impediment to widespread acceptance appears unassailable if we maintain our present course. We are not questioning the foundation of using the post film analysis as our main outcome measure; in fact we heartily endorse it. We are questioning the oversimplification that mistakes the map for the terrain and in so doing, dismisses the veracity of all other work.
A map can only take a person into areas that have been explored and charted by others. It is only as accurate as the knowledge and abilities of the maker of the map can allow. Of course, reading the map and orienting the map with the terrain is always a function of the knowledge and abilities of the map-reader, too. There is great comfort (and safety) in following a map that has long proven its worth. When Columbus looked at his map, it told him he could sail west across the Atlantic and find India. What he found, of course, was the Western Hemisphere -a little something that had been left off his map.
Preconceptions necessarily guide even the questions we ask. We canâ€™t know what we donâ€™t know. Samuel Clemons once noted that it wasnâ€™t what people didnâ€™t know that scared him; it was what they â€œknewâ€ that wasnâ€™t true. What we â€œknowâ€ can also be our current knowledge of what is â€œpossibleâ€. The routine resolution of dis-ease after correction of the upper cervical subluxation complex remains outside the realm of â€œpossibilityâ€ for both the medical community and for the general population at large. How often have your patients shook their head as they talked with you about their friends who â€œknowâ€ that it isnâ€™t possible to deal with an issue (sciatica for instance) by touching the afflicted behind the ear?
Paralysis by Analysis
Historically, NUCCA seems to have arisen out of the reaction of Dr. Gregory to the complex biomechanical problems requiring additional understanding and training that had not been available. For Dr. Gregory, the complexity of the issues involved required not just the memorizing of formulas, but a complete biomechanical understanding of the ASC. He believed that a more comprehensive understanding of the various components of upper cervical work would allow a doctor to circumvent or at least correct the problems that arose on post films.
NUCCAâ€™s certification process continues as a successful attempt to develop this biomechanical, kinesthetic and intellectual understanding of our work and is essential to produce a more competent practitioner. This solution has however, created another problem, which is social in context. Our methods of awarding competence to the certified doctors have created a presumptive incompetence among uncertified doctors. The result has been a very small number of doctors charged with tremendous responsibility and a general sense of disconnectedness, even disenfranchisement, among the rest of the membership. The burnout among (and loss of) these few seems to occur faster than the creation of new certified doctors.
The disenfranchisement of the internal membership has a parallel in NUCCAâ€™s relations to chiropractic in general. Essentially in isolation, upper cervical work has, over several decades, consistently and methodically evolved into a sophisticated set of effective protocols. Even so, it continues to remain hidden from public and professional view.
The reasons for this continuing anonymity have long been debated. Perhaps the major reason for this lack of entry into the public domain is that upper cervical chiropractic has demanded a shift in understanding that has no context within the (earlier, as well as) current healthcare paradigm. Only now are some in biology beginning to take on a holistic viewpoint that can accommodate the upper cervical perspective.
There have been no large granting institutions funding upper cervical chiropractic research at the university level across the globe, as there is in medicine. There is no army of PhDâ€™s who have been educated in research methodology critically examining the various aspects of the field. Primarily, any progress that has been made has come from individuals working within their own practices over decades of time. The diversity of protocols in upper cervical work may simply illustrate the level of current maturity of the field. Tremendous gratitude should be rendered to those who have toiled in relative obscurity and who have laboriously developed the current protocols. We simply would not be here without them. This work of decades has been handed over to the current generation. We have much work to do if this work is to be passed on to subsequent generations.
Though the literature now contains ample information to validate the importance of the upper cervical spine to health, communicating this news to a general audience has largely failed. Publication has been difficult until the last decade or so. Aside from JMPT (The Journal of Physiological and Manipulative Therapeutics), we still have no peer reviewed, Medline indexed journal in chiropractic. Any publishing we do in our own journals is seen primarily by upper cervical doctors, and interested students.
This cloistered existence has led to the (decades long) evolution of a shared perspective among a fairly small community that cannot be easily transmitted to others outside of this shared body of knowledge. It has also led to a â€œself evidentâ€ sense of proof that also cannot be shared with others outside of the upper cervical community that have not shared the same experiences. Upper cervical chiropractic has essentially lost its voice in the chiropractic profession, which itself has a very small voice in the overall scheme of healthcare. It took several decades to develop the current protocols, which now provide a method to safely and consistently correct the upper cervical spine. We roughly estimate that upper cervical doctors constitute between 1 and 4 percent of the chiropractic profession and the number of organizations representing this voice presents a challenge to cohesive progress.
The aspirations of the upper cervical chiropractic profession remain essentially the same as they were in the 1940â€™s. A quote from the Council Bulletin-Official Organ of the Palmer Standardized Chiropractic Council in December of 1944 revealed much of the same frustration still felt today in the field. Dr. Roy Labachotte, in a personal letter to a colleague (and then republished in the Bulletin) wrote:
â€œWe have been going along for years hoping against hope that something would happen which would bring Chiropractic to the front as it deserves. We have during this period watched, only to see that the enemies of Chiropractic have from within been tearing the very foundation out from under our science. We have worried ourselves sick about it but we have been unable to do ANYTHING about it.â€
We remain the best-kept secret in healthcare. There are aspects of the work that cannot be changed without loss of the integrity of the work itself. These must be kept clear and inviolate. In our desire to hold onto our legacy, we may lose the flexibility required to move us forward.
The upper cervical approaches are truly a distinct form of chiropractic. As with any specialty, it is neither critical nor appropriate that the entire profession practice the same way we do, but it is critical that they understand how what we are doing is different. As a group, it is essential that we realize that to gain respect, we must give respect. Some of our historical positions have turned out to be self-defeating the most damaging of which has been that we are â€œrightâ€ and until proven to us differently, everyone else is â€œwrongâ€.
We have become truly a minority component of the chiropractic profession, and as such the burden of proof is ours. We need more than the post radiograph to convince the rest of the world. It is also critical to our survival that awareness of scientific methodology be propagated amongst the average upper cervical clinician. It is time to create an environment that encourages inquiry and evaluation.
A strictly hierarchical model of organization is the traditional form of coordinating a group of people engaged in a process. It is certainly present in the Darwinian natural selection process, and most business and political models. Biology itself has historically been modeled this way assigning ultimate â€œcontrolâ€ of the organism to some discrete area within the brain. At one point in history the pineal gland was assigned this ultimate role but newer models, unable to find any physical location, began to talk about the â€œghost in the machineâ€. The supposition is that without some ultimate authority (and controller), only chaos can result. Deeper study of biological and other complex systems has clearly shown that stability arises out of â€œchaosâ€ although it is not the same kind of stability that arises out of equilibrium. Two children on opposite ends of a teeter-totter may â€œbalanceâ€ out in a stable equilibrium that leaves the teeter-totter level and unmoving. The balance that occurs at equilibrium is static. The kind of stability that occurs in living systems is however, of a very different kind.
Ilya Prigogine, a Nobel laureate (Chemistry, 1977) for his work with complex systems, wrote in Modern Thermodynamics: from heat engines to dissipative structures (Wiley, 1998, p. 409):
â€œIn nature, far from equilibrium, systems are ubiquitous. The earth as a whole is an open system subject to the constant flow of energy from the sun. This influx of energy provides the driving force for the maintenance of life and is ultimately responsible for maintaining an atmosphere out of thermodynamic equilibriumâ€¦every living cell lives through the flow of matter and energy.
â€œâ€¦far-from-equilibrium states can lose their stability and evolve to one of the many states available to the systemâ€¦these new states can be highly organized states. In this realm of instability and evolution to new organized structures, very small factors, often beyond laboratory control, begin to decide the fate of a system. As for the certainty of Newtonian and Laplacian planetary motion and the uniqueness of equilibrium states, both begin to fade; we see instead a probabilistic Nature that generates new organized structures, a Nature that can create life itself.â€
The parallel here with the subluxated state is cogent, but is a subject for another paper. For living systems, stasis (or equilibrium) is death. Life is dynamic and always moving. In a social organization, stasis, or the attempt to concretize process into some â€œfinalâ€ rigid form causes a loss of vitality. It results in a lack of innovation and evolution. Socially, a great deal of energy must be expended to â€œholdâ€ the form in place. The underlying assumption is that the work is in a â€œfinalâ€ form and must be formalized in order to prevent loss of the foundation. While it is obviously true that one should not â€œthrow the baby out with the bath waterâ€, it is also true that this â€œbabyâ€ is not yet mature. If it were possible, stopping the growth of our â€œbabyâ€ might ensure preservation of its life, but it also prevents the untold possibilities that maturation into adult form holds. Indeed, the locking up of one area of the spine is defined by chiropractors as a deleterious circumstance that is at least a fixation if not a subluxation.
It is fear of chaos and loss of meaning that is at the heart of the urge to control and limit change. A hierarchical system that maintains control in an elite and centralized way ultimately alienates the majority who find themselves without a voice and unable to be a part of the process. Some form of organization is however, necessary to coordinate activities and assist in the evolution of a process. An interesting possibility for innovative organization leading to enhancement of the goals of the group has surfaced in the design of computer software. We would like to discuss the solution as a possibility for future innovation in our work.
Eric Raymond wrote about this development in a seminal paper entitled â€œThe Cathedral and the Bazaarâ€, which can be found at http://www.catb.org/~esr/writings/cathedral-bazaar/cathedral-bazaar/. This paper compares two different methods of organizing the development of software. Raymond describes the hierarchical model as a â€œcathedralâ€, in which complex undertakings needed to be â€œbuilt like cathedrals, carefully crafted by individual wizards or small bands of mages working in splendid isolation, with no beta to be released before its timeâ€. (p. 2.) He notes that his prior assumption had been that â€œthere was a certain critical complexity above which a more centralized, a priori approach was requiredâ€. (p.2)
Raymond then introduces another model based on a parallel systems approach. He terms it â€œthe bazaar modelâ€. In a bazaar, there are many people interacting together with many different â€œagendas and approachesâ€. It would seem that such uncontrolled diversity would lead to little more than chaos. On the contrary, open source software development has now led to several successful outcomes. One of Raymondâ€™s main examples is the Linux kernel (an open source software operating system)
Linus Torvald was the originator of the Linux kernel. Instead of trying to build a proprietary system in the usual â€œcathedralâ€ style, Torvald put all of his source code on the Internet for everyone to see. By approaching development in this way, â€œthe Linux community seemed to resemble a great babbling bazaar of differing agendas and approachesâ€. â€œThe fact that this bazaar style seemed to work, and work well, came as a distinct shockâ€. The development process â€œseemed to go from strength to strength at a speed barely imaginable to cathedral builders.â€ (p.3)
We are a community of upper cervical chiropractors. The protocols we use and the science and philosophy behind them are the glue that binds us together. It is in our common interest to develop greater understanding of all phases of our work to make it easier to learn and perform as well as becoming more effective in optimizing our patientsâ€™ health. To this end, a closer examination of a parallel systems approach may be helpful. Raymond made a number of points in his paper, many of which seem important to our theme.
Raymond took the lessons he learned with Linux and applied them to a project of his own. He also put his source code onto the Internet so it could be examined by anyone with an interest. He notes: â€œGiven a bit of encouragement, your users will diagnose problems, suggest fixes, and help improve the code far more quickly than you could unaided.
The reason it is so important to have many people involved is Raymondâ€™s next major point: â€œGiven enough eyeballs, all bugs are shallow.â€ I dub this â€œLinusâ€™s Lawâ€.
In Linusâ€™s Law, I think lies the core difference underlying the cathedral-builder and bazaar styles. In the cathedral-builder view of programming, bugs and development problems are tricky, insidious, deep phenomena. It takes months of scrutiny by a dedicated few to develop confidence that youâ€™ve winkled them all out. Thus the long release intervals, and the inevitable disappointment when long-awaited releases are not perfect.
In the bazaar view, on the other hand, you assume that bugs are generally shallow phenomena -or, at least, that they turn shallow pretty quickly when exposed to a thousand eager co-developers pounding on every single new release. Accordingly you release often in order to get more corrections, and as a beneficial side effect you have less to lose it an occasional botch gets out the door.
Raymond introduces a phenomenon identified in sociology as the â€œDelphi Effectâ€ to explain the idea that â€œGiven enough eyeballs, all bugs are shallowâ€. The concept is that given a population of observers, the averaged opinion of these observers is much more reliable than that of any single (randomly chosen) observer within the population. Raymondâ€™s article contains much more cogent information much of which may relate to our topic but this is enough to make the main point.
So how does this relate to upper cervical chiropractic? We acknowledge that since the 1930â€™s, several different concepts regarding upper cervical work have come forward. Maintaining the metaphoric parallels, the operating system kernel, (the orthogonal Grostic based approach) was developed in the traditional Cathedral style of inquiry. In the intervening decades, many eyes have looked at it and there are now several variations of practice based on divergent perspectives. The science has always been empirical. Different investigators have taken their empirical data in different directions. But within the orthogonal approaches, the protocols are more similar than different.
This generation of upper cervical doctors finds itself in a dilemma. The clinical results of the work point to possibilities that could profoundly improve delivery of healthcare in the world. At the same time, the publication of the specific components of the work in peer reviewed, indexed journals have not been done so that the scientific community at large continues to be unaware of our existence. In addition, the work is full of unexamined assumptions and unproven assertions. Having made this distressing statement, it seems only reasonable to acknowledge that orthogonally based upper cervical chiropractic has done as much or more to validate itself through investigation as any other work in chiropractic. Dr. Eriksenâ€™s new text (Upper Cervical Subluxation Complex: a review of the chiropractic and medical literature. Lippincott Williams & Wilkins, 2004) makes this point in an extremely thorough fashion.
As valid and important as it is for individuals to improve their accuracy in the various protocols, it is even more important to begin to examine our assumptions and prove our assertions. Even extreme accuracy in the application of (at best) incomplete protocols still results in real limitations for the potential improvement of patient care delivery.
The current NUCCA assertion seems to be that extremely consistent accuracy is required to deliver adequate patient care. Today we find a NUCCA culture that essentially assigns a verdict of incompetence at every level to those who have not become part three certified. The fear is that the incompetence of the uncertified doctors leads to potential changes that are the result of incomplete understanding, wrong thinking, or attempts to make a process easier. All of this is thought to arise because the disciplined rigor necessary to master the particular aspect in question has not been undertaken, leading to poor or incomplete results. This is undoubtedly true at times.
Those doctors who have been in practice for a while have all received films and adjustments from multiple other doctors. Questionable films and poor adjustments are not the territory of the uncertified alone. No one has ever said that certified doctors are perfect but only that the whole certification process is an attempt to minimize this possibility. As noted above, we applaud this process and encourage everyone to participate. At the same time, it should be noted that, â€œThe Emperor wears no clothesâ€. We are all doing the best we can with what we have, but no one is perfect.
We posit that the winnowing process that results in the actual formation of an upper cervical doctor is rigorous enough to guarantee a caliber of practitioner that is unusual in the general population. A parallel systems structure for ongoing inquiry into the diverse aspects of the work can offer hundreds of sets of eyes to the process; -eyes that are connected to years of study and practice. If one hundred people with ten years experience look at a topic, they form a collective pool of a thousand years of expertise. Within those thousand years of experience, someone among those one hundred is very likely to be able to make a cogent suggestion, ferret out an error, or come up with a possible solution. We are not suggesting some chaotic version of anarchy. Torvalds had a core group (perhaps analogous to the NUCCRA Board) that analyzed the plethora of comments and suggestions and using their own expertise, were able to find the solutions to problems that had been untenable in the past.
The Road Ahead
How did we come to our protocols? Where are our assumptions? What are we ignoring? What do we still need to know? What have we forgotten? This paper is offered as a beginning step toward opening up this conversation to our whole community. We can together, create an open forum for individual effort to be supported, critiqued, argued over, celebrated, modified and enhanced.
In order to successfully do this, we all have some learning and some â€œunlearningâ€ to do. There is nothing quite so polar as â€œrightâ€ and â€œwrongâ€. This judgment leaves no room for maneuverability. It leaves no room for modification of your position. Real science does not make polarized stands without massive and long term overwhelming data in favor of a proposition. Even so, concepts like Newtonian physics that remained â€œbedrockâ€ for hundreds of years have been greatly modified by new findings. Areas like relativity, quantum mechanics, and string theory have greatly enlarged our basic conception of the universe and changed our sense of what is possible.
In any scientific endeavor, the goal is to move toward progressive clarification of understanding regarding our observations. This is accomplished by observation, development of a hypothesis, implementation of an experiment designed to test the hypothesis, and evaluation of results. Proof and what constitutes â€œproofâ€ is harder to come by. In fact, scientific methodology can ultimately falsify a proposition but it cannot ultimately make the case for the absolute truth of the hypothesis. Evaluation leads to three possibilities: equivocal results requiring further (and possible modification of) the experiment, falsification of the hypothesis by experimentally disproving it, or statement of apparent support of the hypothesis, possibly within certain constraints. The conclusion may also ask more questions which arise out of the experimental results. It is also important for others to duplicate the experiment to validate the results. Within our own work, each practitioner should be able to revalidate the results for themselves in their own experience.
The premature attempt to concretize the upper cervical protocols actually has an ultimately anti-scientific effect. This formalization of the protocols has not taken place for strictly scientific reasons, but also for important social ones. The teaching of the protocols requires some uniformity of action so that a core of shared knowledge can be created and so that the teachers have a depth of common experience to help the student master the task at hand. At the same time, the rote repetition of the task begins with the assumption that this answer is the â€œbest fitâ€ for the accumulated data. Any inquiry is directed only at doing the task as defined in an optimum manner. Again, this is very appropriate for those beginners who are engaged in learning the common body of knowledge. From the wider perspective, it is always necessary to examine our assumptions.
Chiropractic has a scientific aspect, but like all healthcare systems, it also has aspects, which fall under the categories of art and philosophy. Our own interactions as a group of practitioners are not a strictly scientific endeavor as our relations with patients in our practices hinge as much on art and philosophy as they do the scientific. To reiterate our position, we believe that these protocols so far appear to constitute the best way yet found to help our population of adjustors deliver safe and effective care to their patients. The danger lies in our unexamined assumptions and assertions.
The scientific method constitutes a way to logically and systematically understand the material world. The upper cervical procedures are a systematic method for adjusting people. The two concepts are related but not identical. It is certainly logical that the extent of our scientific inquiry would extend past the current protocols used in adjusting people. The official protocols will always lag behind the cutting edge. It is important to realize that the beauty of the current protocols is that they are an unbroken chain of procedures that together, allow effective care while minimizing any potential harm. Creating a way to move forward while maintaining the integrity of the work and ensuring patient safety is imperative. We are still struggling, fourteen years after Dr. Gregoryâ€™s death, to find a systematic way to do this.
So What Does it Look Like?
Upper cervical chiropractic has not yet made an incontrovertible case in the accepted scientific literature for its proposition that correction of the upper cervical subluxation complex is a major factor in restoration of health. We cannot expect others to uncritically accept the presently (meager) published data (in the indexed journals) as adequate proof necessary to sweep aside the current segmentally based chiropractic paradigm.
There are many in upper cervical work that much prefer to focus solely on improving accuracy and consistency in their own practice of the upper cervical protocols. This is laudable and even necessary in every upper cervical practice, but it is not enough to sustain the profession. The shifting healthcare environment can no longer be ignored if upper cervical work is to be kept alive in coming generations. We would like our children and their children to be able to receive an orthogonally based upper cervical adjustment.
NUCCA and upper cervical chiropractic in general faces challenges on many fronts. We do not pretend to understand all of the challenges we face nor do we have the definitive answers to them. This paper was designed for a different task. Instead, we make an offer to the reader. Upper cervical doctors are usually of definite opinions. We are asking you to look at your experience and relate your understanding of our current standing. We believe that the solutions are within our grasp, especially if we grasp loosely to what we think we know while stretching our sense of what is possible.
This paper will be disseminated as widely as possible so we can test the idea of developing a parallel system of upper cervical doctors. The paper is meant to serve as an open door not as an exhaustive list of current issues and/or problems. Our request of you as a committed member of our community is to seize this opportunity to respond to these topics and/or whatever you believe to be of critical importance to upper cervical chiropractic. We have written this paper as two NUCCA doctors. Some of these issues apply only to the NUCCA organization. Others are of wider practicality. We intend to distribute this paper beyond the NUCCA membership because we believe Linus Torvald was correct: â€œGiven enough eyeballs, all bugs are shallow.â€
Our intent is to gather all of your responses and publish them along with this paper in a special edition of The Monograph. These various responses will hopefully engender an ongoing cumulative process of organized but dynamic dialogue within our community providing an additional use for The Monograph. By its nature, we will likely find several different issues that are of interest to different segments of our population. Like minds can find each other and dialogue can greatly accelerate the learning process. The form this takes will depend on the issues that are developed by your responses.