Chiropractic is a controversial health-care system that has been legalized throughout the United States and in several other countries. In the United States in 1984, roughly 10.7 million people made 163 million office visits to 30,000 chiropractors [1]. More than three fourths of the states require insurance companies to include chiropractic services in health and accident policies. The federal government pays for limited chiropractic services under Medicare, Medicaid, and its vocational rehabilitation program, and the Internal Revenue Service allows a medical deduction for chiropractic services. Chiropractors cite such facts as evidence of "recognition." However, these are merely business statistics and legal arrangements that have nothing to do with chiropractic's scientific validity.

Although it has existed for nearly 100 years, the chiropractic health-care system has failed to meet the most fundamental standards applied to medical practices: to clearly define itself and to establish a science-based scope of practice. More disturbing is the fact that chiropractic has made no contribution to the worldwide body of knowledge shared by the health sciences and continues to isolate itself from the mainstream of the health-care community.

Spinal Manipulative Therapy (SMT)

An estimated 80% of adults will experience a severe bout with back pain and dysfunction at some time in their life. There is substantial evidence that spinal manipulative therapy (SMT) has value in relieving back pain and improving the range of impaired spinal motion at least temporarily. Although SMT is probably no more effective than other modalities in the long term, it appears to offer faster relief in about one third of patients [2-4] Further, because SMT involves the laying on of hands, a technique widely employed throughout history by folk and faith healers, it enhances suggestibility and the placebo effect [5,6]. Many people like SMT because of the direct contact it involves and the subjective relief it brings. Charles DuVall, Sr., D.C., reports that SMT can become addictive [7].

Chiropractic is commonly thought to be synonymous with SMT. In reality, SMT's history goes back at least to Hippocrates (400 B.C.), while chiropractic's roots go back less than 100 years. Folk healers ("bonesetters") and early osteopaths used SMT as a panacea. Today SMT is employed by medical specialists (physiatrists, orthopedists, sports medicine practitioners), osteopathic physicians, physical therapists, and athletic trainers, as well as by chiropractors.

A survey of back-pain sufferers revealed that physiatrists are the most effective at treating back problems [8]. Physiatrists are medical doctors who specialize in rehabilitation. Formerly they were called doctors of physical medicine. But physiatrists are few in number and can be difficult to find. (They often practice in connection with Veterans Administration hospitals.) Some hospitals now have back treatment centers that emphasize strengthening weak stomach musculature (a major cause of back problems) and improving the flexibility of the back. Many of these centers offer SMT either by a physical therapist or a chiropractor.

Chiropractors are the SMT practitioners most accessible to the public, and 85% of people who patronize them do so for neuromusculoskeletal problems [1]. Chiropractors point with pride to selected worker's compensation studies that show that chiropractic care got workers back on the job sooner and for less cost than did medical care. But these studies were not scientifically controlled for the severity of the injuries, and not all workmen's compensation studies have been favorable to chiropractic. Nonetheless, the studies do suggest that chiropractors can play a useful role in treating workers with musculoskeletal problems.

Chiropractic's Unique Theory

Chiropractic's uniqueness lies not in its use of SMT, but in its theoretical reason for doing so. just as prescientific osteopathy found its justification in the "rule of the artery" (the belief that manipulation improved circulation by reducing muscle spasms), chiropractic is based upon the "rule of the nerve" (the belief that SMT has important effects upon "nerve flow").

The word chiropractic literally means "done by hand." The term was adopted by chiropractic's founder, Daniel David Palmer. Palmer was a layman with an intense interest in metaphysical health philosophies such as magnetic healing (Mesmer's "animal magnetism"), phrenology, and spiritualism. In 1895, he claimed to have restored the hearing of a nearly deaf janitor by manipulating the man's spine.

Obsessed with uncovering "the primary cause of disease," Palmer theorized that "95 percent of all disease" was caused by spinal "subluxations" (partial dislocations) and the rest by "luxated bones elsewhere in the body." Palmer speculated that subluxations impinged upon spinal nerves, impeding their function, and that this led to disease. He taught that medical diagnosis was unnecessary, that one need only correct the subluxations to liberate the body's own natural healing forces. He disdained physicians for treating only symptoms, alleging that, in contrast, his system corrected the cause of disease.

Palmer did not employ the term subluxation in its medical sense, but with a metaphysical, pantheistic meaning. He believed that the subluxations interfered with the body's expression, of the "Universal Intelligence" (God), which Palmer dubbed the "Innate Intelligence." (soul, spirit, or spark of life). [9] Palmer's notion of having discovered a way to manipulate metaphysical life force is sometimes referred to as his "biotheology."

Scientific Shortcomings

Chiropractors commonly claim that their isolation from the health science mainstream results from organized medicine's opposition. Chiropractic propagandists have made much of a 1987 court decision that found the American Medical Association and others guilty of illegally boycotting chiropractors. But the Wilk case did not uncover any secret conspiracy by doctors to destroy chiropractic. It merely examined whether or not the AMA's ethical prohibition against voluntary professional association with nonscientific healthcare providers violated the Sherman Antitrust Act. On August 27, 1987, District judge Susan Getzendanner decided that it did. She stated in her decision, however, that the AMA's ethical prohibition was not economically motivated, but was based upon the AMA's belief that chiropractic care was did not serve the best interest of patients [10]

Palmer can be forgiven for his nineteenth-century misconceptions, but his followers cannot be excused for failing to avail themselves of the scientific advances of the twentieth century to test chiropractic theory and practice. In fact, chiropractors have never defined a subluxation in measurable terms, nor shown that it even exists. Despite the ability of neurophysiologists to measure nerve impulses, chiropractors have not shown that impinging a spinal nerve alters an impulse beyond the zone of impingement, nor have they shown that disrupting a nerve impulse produces disease. Yale University anatomist Edmund Crelin, Ph.D., demonstrated that only a disabling spinal injury could produce the impingement that Palmer posited as the basis for chiropractic [11].

But laboratory failings do not daunt chiropractors. They argue that no one fully understands the mechanisms of many effective medical procedures. As clinicians they feel capable of detecting subluxations subjectively, even if objective methods for doing so are lacking. However, chiropractors have yet to pass a test of interexaminer reliability. Studies of the ability of two or more chiropractors to find the same subluxation(s) on either the same x-ray film or in the same patients have demonstrated that chiropractors cannot even agree among themselves about what specific conditions need treatment [12-16].

In the mid-1960s, an official delegation of chiropractic representatives, including a radiologist of their own choosing, failed to identify a single subluxation on a series of 20 x-ray films that had been submitted for insurance reimbursement to the National Association of Letter Carriers [14]. In 1972, the Medicare law was amended to include chiropractic care for "subluxations demonstrated by x-rays to exist." A 1986 report by the Inspector General of the Department of Health and Human Services revealed that many payments for chiropractors do not meet this legal requirement [17]. The fact that the federal government does not enforce the rules it has established for chiropractors raises the question of a double standard. Is there one standard for science-based medicine and another for nonscientific practitioners with political savvy?

Chiropractors not only find subluxations as elusive as the mythical unicorn, but they also disagree wildly about how to go about treating them. Some believe that each vertebral level corresponds to a specific disorder. Others believe that it is necessary to manipulate only the seven cervical vertebrae to effect a cure. "Hole-in-one" (their term) practitioners believe that it is necessary to adjust only the atlas (topmost) vertebra. Basic sacral chiropractors agree that only one vertebra needs to be adjusted, but rather than the topmost, it is the sacrum, located at the bottom of the spine. Still another group adjusts both the atlas and sacral vertebrae. Others adjust the entire spine in a shotgun approach, while another group measures leg lengths in order to level up the spine. No scientific criteria have been applied to resolve these conditions.

Anyone visiting a number of chiropractors will be confronted with a bewildering variety of pseudoscientific diagnostic procedures. In 1981 Mark Brown, a reporter for the Quad City Times, spent five months visiting chiropractors in the Davenport, Iowa, area (the birthplace of chiropractic). Diagnostic methods included placing a potato on his chest and pressing down on his arm (applied kinesiology), projecting lines on his back to read body contours (Moire contour analysis), reading the iris and comparing markings with a chart (iridology), measuring leg lengths for unevenness (one chiropractor said Brown's right leg was shorter, another said his left leg was shorter) , measuring skin surface temperature differences, and palpation [16]. Other dubious diagnostic methods used by some chiropractors include pendulum divining, electroacupuncture, reflexology, hair analysis, herbal crystallization analysis, computerized "nutritional deficiency" questionnaires, a cytotoxic food allergy test, and the Reams urine and saliva test.

Chiropractors also employ a wide variety of pseudomedical therapies. Magnetic therapy (placing magnets on the body), homeopathy, herbology, colonics, colored-light therapy, megavitamin therapy, radionics (black box devices), bilateral nasal specifics (inserting a balloon in the nose and inflating it), and cranial manipulation are but a few of the unfounded therapies employed by various chiropractors.

A 1988 trade survey found that 74% of chiropractors in the United States use nutrition supplements in their practices [18]. Many prescribe and sell these directly to patients -- a practice that is generally regarded as unethical in the medical profession.

Chiropractors promote themselves as "drugless practitioners," capitalizing on the restrictions against the use of drugs or surgery that lawmakers have placed upon them. The word drug has several definitions. Included are: articles listed in several recognized official United States pharmacopoeias; articles intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or animals; articles (other than food) intended to affect the structure or any function of the body [19]. In 1987 the supreme court of Georgia ruled that because chiropractors were licensed as drugless practitioners, they could not prescribe dietary supplements for the prevention or treatment of any condition. Not long afterward, the legislature reacted to chiropractic lobbying by passing a law permitting chiropractors to recommend dietary supplements to their patients, but not to prescribe them as drugs.

The use of x-rays by chiropractors is a related issue. Chiropractors often expose the whole body trunk to x-ray radiation. Since radiation effects are cumulative, exposing patients to radiation always involves a serious benefit-risk evaluation. Chiropractors often justify their use of X-rays as a means of screening patients for serious disease, but a recent probability study by a chiropractic radiologist reveals that full-spine x-rays are twice as likely to induce cancer as to discover it in a patient [20].

One thing chiropractors excel at is satisfying their patients. Patients rank them above medical doctors in the concern exhibited about their problems, understanding their concerns, amount of time spent listening to a description of their pain, information provided about the cause of their pain, making them feel welcome, and other factors related to the art of fulfilling human needs [21,22]. Although it is important for physicians to differentiate between mere patient satis, faction and true clinical effectiveness, it seems that they could learnsomething from chiropractors about meeting the emotional needs of suffering patients.

Factions in Chiropractic

Only a minority of today's chiropractors adhere to Palmer's "one-cause-one-cure" theory, but most still believe that subluxations exist and may play an important role in the cause and treatment of diseases. Chiropractors who wish to be considered full-fledged physicians consider limiting the value of SMT merely to relieving pain and improving function as an affront.

Practitioners who limit their practices to analyzing the spine and correcting subluxations are called "straight" chiropractors. Those who believe that they are affecting Palmer's biotheological "Innate Life Force" are often called "superstraights." The straights label chiropractors who do more than SMT "mixers," because they mix other modalities. These various chiropractic factions have been at odds with each other throughout nearly all of chiropractic's existence. Each claims to be the true chiropractors and labels the others as cultists or "pseudomedical doctors." The strife between these factions has been fought out in courts and state legislatures and remains unresolved to this day.

Often the straight/mixer dichotomy is wrongly suggested as a useful criterion for separating rational from irrational practitioners. In fact, either type can be irrational. Straights may be cultists who overuse SMT, applying it to conditions for which it offers no benefit. And mixers have a propensity for espousing pseudomedical fads and are probably the major sources of nonsensical modalities in the health-care marketplace. Both straights and mixers have traditionally opposed scientifically based public health measures such as immunization, fluoridation, pasteurization of milk, modern food technology, prescription drugs, and surgery.

The Reformers

Among the newer factions are several reform groups. One group publishes the Journal of Manipulative and Physiologic Therapeutics, which is indexed by Index Medicus. They publish results of tests of various modalities, and they publish articles dealing with chiropractic's scientific inadequacies. They hope to reform chiropractic quietly from within.

A more outspoken group, the National Association for Chiropractic Medicine (NACM), is composed of chiropractors who use only SMT and treat only functional back disorders that are not disease-related. NACM believes that chiropractic pseudomedicine and cultism are too well entrenched, and that the moral responsibility for public well-being is too serious to merely hope and patiently wait for self-reform. NACM members publicly renounce the subluxation theory and other forms of chiropractic pseudomedicine. They do not present chiropractic as an alternative to regular medicine, but offer their skills as SMT specialists in cooperation with mainstream medicine.

Reformers have a difficult time because they find themselves ostracized by the chiropractic guild for breaking ranks and openly criticizing chiropractic, but they may have difficulty being accepted by regular medical practitioners. These reformers, particularly NACM's leaders, exhibit rare, selfless courage. The first outspoken reformer, Samuel Homola, D.C., published his observations in 1963 in Bonesetting, Chiropractic, and Cultism, which is posted on this Web site.]

The dilemma reformers face is that chiropractors do not perform any service or deal with any condition not covered by some other health profession. State laws that enable them to practice either specifically mention the subluxation theory or describe it as the basis for chiropractic as an entity. Renouncing chiropractic's theoretical basis would eliminate its justification for existing as a separate profession.

Reformers acknowledge that they offer mainly the specialized skill of SMT. They believe that SMT is underutilized and that a substantial market exists for their skills. Although other health professionals can legally perform SMT or treat functional back disorders, most do not. To become skilled at SMT requires more time and effort than most physicians or physical therapists are willing to invest, especially when they feel that they may achieve the same clinical results over the long term with less demanding modalities.

Consumer Guidelines

The SMT skill of chiropractors varies among individual practitioners. Chiropractic is a cottage industry without an arena that permits critical peer review like that hospitals provide for medical doctors.

When evaluating a chiropractor's claims, it is useful to ask him or her what diseases chiropractic adjustments cannot benefit. A rational practitioner will readily admit to great limitations in treating anything other than musculoskeletal problems. A less rational chiropractor may answer by dodging the question with a response such as "I treat only people who have spines," or "I don't treat diseases; I treat people." Such answers avoid the question and/or represent a belief in the subluxation theory.

There is no agency that can tell how good an individual chiropractor is as a spinal manipulative therapist. Consumers must generally rely upon the practitioner's local reputation. When choosing a chiropractor, consumers should exercise great caution and consider the following guidelines.

1. Have the problem evaluated by a medical doctor first. Have underlying serious illnesses ruled out before deciding that the problem is neuromusculoskeletal. Heart disease, cancer, kidney dis' ease, and other serious problems that need prompt medical care may manifest themselves as back pain and dysfunction. Don't allow an overzealous, inadequately trained chiropractor to keep you from prompt diagnosis and care. If the chiropractor recommends X-rays, have them done by a radiologist.

2. If you decide to try SMT, inform your doctor. Ask if there is any reason you should not have SMT (osteoporosis is one common contraindication). if not, ask for his or her help in locating the most skillful practitioner in the area (physiatrist, physical therapist, chiropractor, etc.). Some doctors feel that SMT hasn't been scientifically proven effective, but most are willing to go along with a patient who wishes to give it a try.

3. Remember that the main value of SMT lies in the rapidity of the relief it provides. If you have not experienced significant relief within three weeks, discontinue SMT. Do not submit to long-term care. Do not sign a contract. And do not accept the idea of preventive chiropractic care. Education about how to prevent back problems by safe lifting techniques, proper exercise, and ergogenics (analyzing and redesigning the workplace to avoid injuries) is valuable.

4. Avoid practitioners who:

• Appear overconfident or cultist in their zeal for chiropractic care
• Disparage regular medicine as jealously antichiropractic
• Criticize prescription drugs or surgery in an ideological manner
• Attack immunization, fluoridation, pasteurization, or other public health practices
• X-ray all of their patients, or routinely use full-spine x-rays.
• Use scare tactics such as claiming that the failure to undergo chiropractic care could lead to serious problems in the future
• Sell herbs or dietary supplements
• Perform colonic irrigations. These have no medical value and can be dangerous [23].
• Claim that subluxations exist and that their correction is important.

5. Children should not be treated by chiropractors. There are no childhood conditions that chiropractors are better qualified than physicians to treat.

References

1. Chiropractic: State of the Art. American Chiropractic Association, 1986.

2. Farrell J, Twomey L. Acute low back pain, Comparison of two conservative treatment approaches. Medical Journal of Australia 1(4):160-164, 1982.

3. Haldeman S. Spinal manipulative therapy: A status report. Clinical Orthopedics and Related Research Oct (179):62-70, 1983.

4. Moritz U. Evaluation of manipulation and other manual therapy. Criteria for measuring the effect of treatment. Scandinavian Journal of Rehabilitative Medicine 11(4):173-179, 1979.

5. Neher A. The Psychology of Transcendence. Englewood Cliffs, NJ: Prentice-Hall, 1980, pp 49-52, 244

6. Homola S. Bonesetting, Chiropractic, and Cultism. Panama City, FL: Critique Books, 1963, pp 95, 96.

7. DuVall CE Sr. Facts on SMT. in DuVall CE Sr. Chiropractic Claims Manual. Akron, Ohio: Charles E. DuVall Sr, 1984), p. 3.

8. Klein AC, Sobel D. Back Relief. New York: New American Library, 1980, p 402.

9. A. E. Homewood AE. The Neurodynamics of the Vertebral Subluxation. Canada: Chiropractic Publishers, 1973, p. 80.

10. Getzendanner S: Memorandum opinion and order in Wilk et al v. AMA et al. 671 F Supp 1465, U.S. District Court for the Northern District of Illinois, Eastern Division, September 25, 1987.

11. Crelin ES. A scientific test of the chiropractic theory. American Scientist 61:574-580, 1973.

12. Barrett S. The Spine Salesmen. In The Health Robbers, Second Edition. Philadelphia: George F. Stickley Company, 1980, pp. 143-145;

13. Smith RL. I get the treatment. In Smith RL. At Your Own Risk: The Case Against Chiropractic. New York: Simon and Schuster, 1970, pp. 27-37.

14. Deely JP. Report of director, health insurance, to the officers and delegates of the forty-fifth national convention of the National Association of Letter Carriers. Aug1966, p 53A.

15. London WM. Free chiropractic spinal exams, consultations, and literature: An empirical investigation. resented at the Chiropractic Forum, American Public Association Annual Meeting, Chicago, Oct 24, 1989.

16. Brown M. Chiro: How much healing? How much flim-flam? Davenport, IA: Quad-City Times, December 13, 1981.

17. Moran WC et al. Inspection of Chiropractic Services Under Medicare. Chicago: OIG Office of Analysis & Inspections, 1986, pp 9-12.

18. How DCs in the USA practice. Dynamic Chiropractic 6(17):3, 1988.

19. United States Food, Drug, and Cosmetic Act, Section 201.

20. Fickel TE. An analysis of the carcinogenicity of full spine radiography. ACA Journal of Chiropractic 23(5):61-66, 1986.

21. Cherkin DC, MacCornack FA. Patient evaluations of low back pain care from family physicians and chiropractors. Western Journal pf Medicine 150:351-355, 1989.

22. Kane RL and others. Manipulating the patient: a comparison of the effectiveness of physician and chiropractor care. Lancet, June 29, 1974, pp 1333-1336.

23. Kizer KW. The case against colonic irrigation. California Morbidity, Sept. 27, 1985.

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This article was origianlly published as "Chiropractic: Controversial Health Care" in the May 1990 issue of Ministry magazine (pp 25-28)

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This article was revised on February 9, 2000.