REDWOOD: Does this mean that it isn’t effective over the long term, or that there haven't been enough studies to determine this? I know that the study by the orthopedic surgeon Thomas Meade, published in British Medical Journal, showed excellent long term outcomes for chiropractic care of low back pain.

MEEKER: Based on studies that have been done so far, we don't really know for certain about long-term outcomes. For example, measuring outcomes a year out—so many things happen to a patient in a year. Frankly, we don’t ask that question about aspirin.

REDWOOD: Is that true?

MEEKER: It's a real bias, I think. No one ever looks at the effect of a course of aspirin a year later. So why are we worried about the long-term effect of manipulation?

REDWOOD: This raises an important question. Do you feel that chiropractic and other complementary and alternative methods are sometimes held to a higher standard than conventional methods?

MEEKER: Yes, absolutely.

REDWOOD: Why?

MEEKER: There are two reasons, though it varies a bit from procedure to procedure. All of CAM has its problems, but it varies within CAM. First of all, for many CAM methods including manipulation, the mechanism by which it has its effect is not well understood. So without a logical, physiological mechanism with which to explain the results, it's harder to believe the results. It's just harder psychologically, for some reason. So I think we do need to put some effort into explaining why manipulation works, not just that it does. That’s a challenge; it's hard to do.

Second, because there is a cultural dominance to so-called "conventional" methods, when you're number two, you’ve simply got to try harder. The burden of proof is on the new, untried, untested, innovative strangers who have to come in and prove themselves. The burden of proof for something new is different than the burden of proof for something that has become a habit. So the playing field is not exactly level. You put those two reasons together, and you’ve got a higher bar. It's just a fact of life. Wayne Jonas [Wayne Jonas, M.D., the former director of the NIH Office of Alternative Medicine] has pointed this out.

REDWOOD: I've seen him talk about homeopathy in this regard. The Journal of Alternative and Complementary Medicine just published a commentary by Dr. Jonas on this topic.

MEEKER: Homeopathy has the same problem.

REDWOOD: Probably worse, because its theoretical mechanism is much tougher for people to conceive of than spinal manipulation's mechanism.

MEEKER: I've got a problem with it. Yet I know that there are plenty of randomized trials where homeopathic remedies are more effective than a placebo. Yet I still say to myself, "I don't know if I really believe this." So it's the same thing. We’re all guilty of this to one extent or another.

REDWOOD: What are some models you've seen of chiropractic integrating with conventional medicine, either in practice, research, or education? What are some of the trends here?

MEEKER: In terms of practice, I think there's a grassroots integration going on that health services researchers and policy makers have totally missed. It's going on right under our very eyes. If we did a survey of the profession, and asked how many of you are in practice with some other kind of provider—whether it's a medical doctor, physical therapist, or whatever—I think we’d be amazed at the number of practices out there involving business relationships with combined providers, interdisciplinary or multidisciplinary. It may be sharing office space or actually working together on patients. There are all these different models that exist. I think we’d be astounded at the amount that's going on at the grassroots level. No one's done that survey yet. It would be a very illuminating project.