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.
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).
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.
- 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.