Chiropractic: A Profession Seeking Identity

The chiropractic profession is resisting changes that will establish it as a back-pain specialty while seeking an identity that will continue to allow chiropractors to treat a broad scope of health problems.

SAMUEL HOMOLA

Samuel Homola is a retired chiropractor. He is the author of fifteen books, including Inside Chiropractic (Prometheus, 1999) and A Chiropractor?s Self-Help Back and Body Book (Hunter House, 2002). This is his third article for Skeptical Inquirer.

In 1895, D.D. Palmer, a grocer and magnetic healer, announced that "Ninety-five percent of all diseases are caused by displaced vertebrae, the remainder by luxations of other joints" (Homola 1963). Palmer claimed that he had cured deafness and heart trouble by adjusting the spine (Wardwell 1992). He concluded that most diseases could be cured by adjusting vertebrae to remove interference with "nerve vibrations" that flowed from the brain to the spinal cord and out through openings between the vertebrae (Palmer 1914). Palmer's questionable and anecdotal claims gave birth to the profession of chiropractic.

Today, the chiropractic profession agonizes over the definition of chiropractic, which has changed little except in wording used to explain how adjusting the spine can restore and maintain health. For many years, the vertebral subluxation theory was explained in a very simple way: a vertebra out of its normal position encroached upon spinal nerves, interfering with the flow of nerve impulses to the tissues and organs supplied by the affected nerve. Certain spinal nerves supplied certain organs. Adjustment of a selected vertebra would release vital nerve flow so that so-called "innate intelligence" could heal the body (Wardwell 1992). This theory has since been rejected and ridiculed by the scientific community.
New Definition for an Old Approach

Facing the realization that pressure on a spinal nerve cannot be demonstrated to be a cause of organic disease and that slight displacement of a vertebra does not compress a spinal nerve, defenders of the subluxation theory further theorized that abnormal joint function could affect general health by triggering nerve impulses from proprioceptors, nociceptors, mechanoreceptors, and other monitors of joint function. There are no appropriately controlled studies, however, to indicate that any type of dysfunction in structures of the spinal column is a cause of organic disease (Nansel 1995).


D.D. Palmer

It is the consensus of the chiropractic profession's schools and leaders that chiropractic should not be limited to treatment of back pain and should focus on treatment of general health problems. In July 1996, the Association of Chiropractic Colleges (ACC), representing sixteen North American chiropractic colleges, drafted a new paradigm stating that "Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health" (Association 1996). Such a subluxation has never been proven to exist.

In 1997, the Foundation for Chiropractic Education and Research (FCER), supporting the vague, untestable, and all-inclusive ACC paradigm, published a monograph titled The Role of Subluxation in Chiropractic. Noting that a vertebral subluxation complex (VSC) "may not be detectable by any of the current technological methods," the monograph explained, "[The VSC] embraces the holistic nature of the human body, including health, well-being, and the doctor/patient relationship as well as the changes in nerve, muscle, connective, and vascular tissues which are understood to accompany the kinesiologic aberrations of spinal articulations" (Rosner 1997).

The ACC paradigm was endorsed by the International Chiropractic Association and the American Chiropractic Association in November 2000 and by the World Federation of Chiropractic in May 2001.

A random survey of 1,102 active North American chiropractors in 2003 revealed that 88.1 percent of 687 respondents believed that the term "vertebral subluxation complex" should be retained by the chiropractic profession. The respondents also believed that vertebral subluxation is a significant contributing factor in 62.1 percent of visceral ailments. The majority believed that spinal adjustment should not be limited to treatment of musculoskeletal problems (McDonald 2003).
Chiropractic Consensus versus Scientific Consensus

Scientific consensus does not support the theory that vertebral misalignment or "subluxation" is a cause of organic disease (College 1996, Crelin 1973, Jarvis 2001, National Council Against Health Fraud 2005). Spinal nerves primarily supply musculoskeletal structures. Organ function is governed by the autonomic nervous system in concert with psychic, chemical, hormonal, and circulatory factors. Autonomic cranial and sacral nerves that supply the body's organs do not pass through movable joints. Spinal nerves are commonly irritated or compressed by bony spurs, herniated discs, and other abnormalities in the spine. Even the most severe compression of a spinal nerve, however, which cripples the supplied musculoskeletal structures, does not cause organic disease. It is unreasonable to assume that slight misalignment of a vertebra or an undetectable vertebral subluxation complex can cause disease or ill health when those effects do not occur because of gross displacement of a vertebra or as a result of impingement of a spinal nerve.

There is considerable evidence that spinal manipulation can be helpful in treating some types of back pain (Bigos 1994, Shekelle 1991), but "there appears to be little evidence to support the value of spinal manipulation for nonmusculoskeletal conditions" (Shekelle 1998).
Choices for the Future

Back pain is one of this nation's most common medical problems, accounting for $50-100 billion in health costs annually (Pelletier 2002). Despite the need for a back-pain specialty that combines the use of spinal manipulation with physical therapy modalities, it does not appear that the chiropractic profession plans to take advantage of the growing back-pain market by specializing.

Spinal manipulation is only one treatment of many available in the treatment of back pain. A back-pain specialty would require the use of a variety of physical treatment methods in concert with various medical specialties. Chiropractors who adjust subluxations to restore and maintain health do not qualify as back specialists. Chiropractic as an alternative method of primary care for general health problems is far from being accepted by the scientific community.

A 2005 report by the Institute for Alternative Futures reported that the future of chiropractic is uncertain because of economic challenges and the limitations in chiropractic science and methods. The Institute predicted four possible scenarios for chiropractic: (1) slow, steady growth as support mounts for the use of manipulation in the treatment of back and neck pain; (2) a downward spiral from competition and healthcare costs; (3) evidence-based collaboration in the care of neuromusculoskeletal conditions; or (4) chiropractors will become healthy life doctors "specializing in preventing disease with health-management plans" (Institute 2005).

Concerned that the chiropractic profession "has failed to define itself in a way that is understandable, credible and scientifically coherent," a group of evidence-based chiropractors offered a model for "spine care" that focuses primarily on treatment for back pain. The purpose of the plan is to "help integrate chiropractic care into the mainstream delivery system while still retaining self-identity for the profession" (Nelson 2005). The plan was not well-received by the chiropractic profession at large, which is loathe to restrict chiropractic treatment to back pain, preferring instead to claim a broad scope of health problems as its purview.

On June 15, 2005, the World Federation of Chiropractic, at its Eighth Biennial Congress, unanimously agreed that chiropractors should be identified as "spinal health care experts in the health care system . . . with emphasis on the relationship between the spine and the nervous system" (World 2005). This definition fails to place proper limitations upon chiropractors who use spinal adjustments to treat general health problems, plunging the profession deeper into pseudoscience and away from establishing an identity for chiropractors as back-pain specialists. Most states continue to define chiropractic as a method of adjusting vertebral subluxations to restore and maintain health, allowing chiropractic treatment of almost any ailment.
Filling a Niche in Mainstream Health Care

If the chiropractic profession continues to define itself as a method of health care based on the relationship between the spine and the nervous system rather than as a method of treating back pain, it seems likely that physical therapists and other practitioners of physical medicine will step in and offer manipulation along with physical therapy modalities in the treatment of back pain. According to the American Physical Therapy Association, "Physical therapy, by 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists. Consumers will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services. Physical therapists will hold all privileges of autonomous practice" (American 2005).

Many physical therapists are already using manipulation/mobilization techniques. Of the 209 physical therapy programs in the United States, 111 now offer Doctor of Physical Therapy (DPT) degrees. About thirty-five states now grant physical therapists direct access to patients (Institute 2005), and there are nearly three times as many physical therapists (137,000) as chiropractors (49,000) (Bureau 2005).

Given a choice, it seems likely that informed consumers who seek treatment for back pain would prefer the services of a physical therapist whose therapeutic armamentarium is limited to treatment of musculoskeletal problems rather than the controversial services of a chiropractor who adjusts the spine to restore and maintain health. In 2002, only about 7.4 percent of the population was seeing a chiropractor annually (Tindle 2005). I suspect that this percentage would increase if the chiropractic profession identified itself as a specialty that deals with back pain and related problems.

References

American Physical Therapy Association. 2005. APTA Vision Sentence and Vision Statement for Physical Therapy 2020. Available at www. apta.org/About/aptamissiongoals/visionstatement. Accessed October 1, 2005.

Association of Chiropractic Colleges. 1996. A position paper on chiropractic. Journal of Manipulative Physiological Therapeutics 19:633-37.

Bigos, S., O. Bowyer, G. Braen, et al. 1994. Acute Low Back Problems in Adults. Clinical Practice Guidelines No. 14. AHCPR publication No. 95-0642. Rockville, Md.: Agency for Health Care Policy and Research.

Bureau of Labor Statistics, U.S. Department of Labor. 2005. Occupational Outlook Handbook. Washington, D.C.: Office of Occupational Statistics and Employment Projection, 2004-2005.

College of Physicians and Surgeons of the Province of Quebec. 1996. A scientific brief against chiropractic. The New Physician, September.

Crelin, E.S. 1973. A scientific test of the chiropractic theory. American Scientist 61:574-80.

Homola, S. 1963. Bonesetting, Chiropractic, and Cultism. Panama City, Fla.: Critique Books.

Institute for Alternative Futures. 2005. The Future of Chiropractic Revisited 2005-2015. Available at www.altfutures.com. Accessed October 1, 2005.

Jarvis, W.T. 2001. NCAHF Fact Sheet on Chiropractic. National Council Against Health Fraud. Available at www.ncahf.org/articles/c-d/chiro.html. Accessed October 1, 2005.

McDonald, W., K. Durkin, S. Iseman, et al. 2003. How Chiropractors Think and Practice. Ada, Ohio: Ohio Northern University.

Nansel, D., and M. Szlazak. 1995. Somatic dysfunction and the phenomenon of visceral disease simulation: A probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. Journal of Manipulative Physiological Therapeutics 18:379-97.

National Council Against Health Fraud. 2005. Position Paper on Chiropractic. Available at www.ncahf.org/pp/chirop. Accessed October 1, 2005.

Nelson, C., D. Lawrence, J. Triano, et al. 2005. Chiropractic as spine care: A model for the profession. Chiropractic and Osteopathy 13:9. Available at www.chiroandosteo.com/content/13/1/9. Accessed October 1, 2005.

Palmer, D.D. 1914. The Chiropractor. Montana: Kessinger Publishing Company.

Pelletier, K.R., and J.A. Astin. 2002. Integration and reimbursement of complementary and alternative medicine by managed care and insurance providers: 2000 update and cohort analysis. Alternative Therapies in Health and Medicine 8:38-39.

Rosner, A. 1997. The Role of Subluxation in Chiropractic. Des Moines, Iowa: Foundation for Chiropractic Education and Research.

Shekelle, P.G., A.H. Adams, M.R. Chassin, et al. 1991. The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review. Santa Monica, Calif.: RAND

Shekelle, P.G. 1998. What role for chiropractic in health care? New England Journal of Medicine 339:1074-1075.

Tindle, H.A., R.B. Davis, R.S. Phillips, and D.M. Eisenberg. 2005. Trends in use of complementary and alternative medicine by U.S. adults: 1997?2003. Alternative Therapies in Health and Medicine 11:42-49.

Wardwell, W. 1992. History and Evolution of a New Profession. St. Louis, Mo.: Mosby Year-Book.

World Federation of Chiropractic. 2005. WFC Consultation on the Identity of the Chiropractic Profession, June 15, 2005. Available at www.wfc.org, Identity Consultation. Accessed October 1, 2005.

My first ever Chiro was an "old man" - Dr. Lloyd Garrison. He had retired, but did adjustments on the side. When I met him he was in his 80's and that was back in the late 70's when I met him. He said that he had learned the Palmer method - from Palmer himself.

Everyone called him "Doc". He could simply look at you and tell you where you were blocked, as far as blood flows and energy. He could have you just stand up in front of him and he could tell what to adjust in a quick look. He never used an X-ray machine.

This man literally saved my life. I saw him save one man's "limb" from having to be operated on and cut off completely. He straightened out my "newborn" baby's eyes. He straightened out the back and head of a stray dog I had found and the animal was like "night and day". During an earlier period, he helped me to walk again as I had had a serious injury to my atlas and it was making me too dizzy to walk. I could go on and on about this guy. He wasn't gentle by any means, but he got the job done.

He eventually died and I did find another chiro who wasn't quite as good, but he got the job done as well. I knew him about 8 years and he died too (wonder if its me - lol!)

I then got another "older" chiro and he was really good but then his house burned down when we had those bad fires in So. CA and now he lives in Kansas (at least he didn't die).

All in all, I'd say that one has to be careful about the chiros they choose. I've had some really bad ones. I've ones that were extremely good and didn't charge you an arm and a leg (so to speak). I sometimes found ones that sucked and charged way too much.

Its really worth finding a good one and if you can find one that's inexpensive, that's good too. If you don't need one - then this post is pretty moot for you :).

Kozee

We often overlook a holistic approach to health. We are a society that holds individualism sacred.
For that reason everyone wants to be a specialist; the best one on the block. Look how long it's taken for Osteopathic medecine to be recognized. Why? Because they want to be a team. They believe in treating the whole person and if specially trained doctors are required, they are also required to work as a team with the individuals regular Doctor and any other treatment facilitator.

If a person is in enough pain for a long enough period, there are physiological effects in the body. Anemia is an indicator of severe and/or long term pain. Any malfunction within the body can cause disruption in neuro-transmitter functions, as well as causeing hormone imbalnaces.
This can cause diseases as organs may not function properly.

The spinal column is central for the nervous system and a healthy spinal column helps to maintain interal organ health as well.

Part of the holistic approach includes undestanding the nature of deep rooted beliefs. Give a person a placebo for almost anything and they will experience what they have been told to expect after taking it.

Some people respond exceedingly well from a well given message. Zenaandnow has probably witnessed such responces from her own clients.

I think Chiropractice should be recognized as a viable alternative for some people on many fronts. However, overall, I would really like to see better team work between all the people who offer healing services. They all contribute to the well-being of individuals and every person who offers any kind of health related service should be concerned enough, about the individual they serve, to be involved in whatever options the individual chooses to pursue. That's when people will start to be healthier because that's when indivuduals will be treated as a whole person and not a "special case" for a "special doctor".

Alternative does not mean less, it means a different approach. Chiropractors take a different approach, and there are many who claim it has been effective. Just as one drug may not be the answer for every person suffering from the same malfunction, one specific course of treatment is not going to be right for everyone either.

All of the medical field evolves and it may be time for the Chiropractic field to make a change.

Moral of my story go find a really good physical therapist and a neurosurgeon if you want real science behind your spine recovery.

bushi, whether you meant your story to be funny or not, I laughed. I laughed becasue I know you are right, I do believe your experience, but let me address your statment:



I have many, stories about 'physical therapists' from personal experience and experiences of people close to me that match your own with Chiropractors.

I also have some great stories that 'glorify' the work of "some" Chiropractors.

Like anything else, as you say, one must seek a 'good one'. I also believe that Chiropractors have limitations, and that many of them are not capable, but I also believe the same thing of any other field of 'medicine'.

Even in psychology there are specific theories, but no one has proven infallible, only together do they seem to be most effective.

How are you now? Did you last round of surgery and therapy provide relief for you? What is your prognosis, if I might ask? As a student, I know what it is to 'sit' for l o n g periods of time, reading, studying, and projects. I do hope you are comfortable now and that you continue to keep strong.

Red