EDITOR’S NOTE Today is a big grant deadline for me; at 5 PM EDT, the grant is due. As a consequence of working on my grant application into the wee hours of the morning last night, I didn’t have a chance to write my usual bit of logorrhea of the sort that I’ve laid down each and practically every Monday for the last three-plus years. Fortunately, retired chiropractor turned skeptic of chiropractic Sam Homola was ready to fill in admirably just for this week. Although I might throw up a post later this week, worst case scenario, I’ll be back here, same time, same day, same Bat Channel. In the meantime, take it away, Sam!

As a chiropractor, I am often asked why the image of chiropractic is so bad. “Why is chiropractic so often ignored by the media and ridiculed by physicians?” Journalists and health professionals tend to judge chiropractic by the worst of what they see, and what they see is often bad. This March 15, 2011, post from a chiropractic group asking for money to provide chiropractic services for earthquake and tsunami victims in Japan is a good example of why chiropractic has a bad image:

Please consider donating whatever you can to the SOTO-I/PAAC [Sacro Occipital Teaching Organization International-Pacific Asian Association of Chiropractic] Japan Relief Fund. 100% of your donation will go directly to helping the needy Japanese people through SOT Chiropractic treatments and services.

Please consider this avenue of donation rather than the Red Cross etc. While they are worthy organizations, we have ZERO overhead to administration and the funds will provide CHIROPRACTIC services to the needy. Please recommend this avenue of aid to your patients and friends also. Any and everything will help!

Practitioners of Sacro Occipital Technic (SOT) and SOT Craniopathy claim to restore innate healing capacity by removing neurological interference and improving the flow of cerebrospinal fluid (“craniosacral respiration”). Vertebral subluxations affecting certain organs are found by palpating tendon insertions at the base of the skull. Craniosacral respiration is improved by adjusting the bones of the skull and the sacroiliac joint.

There are dozens of such nonsensical chiropractic treatment methods foisted on the public through “press releases” and junk-science journals. NUCCA (upper cervical technique), which identifies slight misalignment of the atlas as a major cause of human ailments, is a commonly-promoted technique based on chiropractic vertebral subluxation theory.

This press release further illustrates the reason for chiropractic’s bad image:

A revolutionary neuro relief technique is being used by chiropractors across the United States and Canada to treat a wide-array of Symptoms and Chronic Disorders they were never before able to handle. This technique, when applied correctly performs absolute miracles for patients who have been suffering for an extensive period in their lives. Thus patients are happier and chiropractors are increasing their visibility and incomes!

Online PR News – 12-March-2011

An article titled “Second Opinion: Of Chiropractors & Christians,” published in a Baptist news magazine, describes an “inherently unbelievable” chiropractic message:

My back hurt, so I went to a chiropractor. He is helping my back pain. That’s a good thing.

But that is not what this article is about.

My chiropractor is an evangelist for his particular brand of chiropractic. Literally, he and his staff are religious about it. They preach the word. They offer written materials. They make promises of a greater life. I am unmoved. I just want him to make my back feel better.

I have a better understanding now of how nonbelievers may react to Christian witness. My reactions to the “message” I get at my chiropractor’s office could also be the reactions of someone you know to church, Christianity or the gospel message of Christ:

• These folks are extremely nice, and I appreciate that, but that does not mean I am going to believe what they believe or what they tell me to believe.
• They sincerely believe what they say. I do not doubt that. Their sincerity does not persuade me to change my mind.
• They walk the walk. They cleanse their toxins, go to burst training, take supplements and get regular adjustments. As far as I can tell, they are not hypocrites. But I am not moved.
• They go out of their way to educate me. They offer written information. They invite me to seminars, dinners and meetings. I do not have the excuse that “I don’t understand.”
• These folks care about me. I believe that.

So, why am I not fully sold? Why won’t I buy into the full program instead of just “settling” with having them make my back feel better?

• Their message is inherently unbelievable.
• Their message runs counter to what I know and to what I read and hear everywhere else.
• Their message is too demanding of my time, energies and commitments.

Sound familiar? Those are reasons why people routinely reject our Christian witness…

Published: March 11, 2011 (The Baptist Standard)

Sorting out a Few Good Apples

As illustrated by the above clips, it’s not hard to understand why chiropractic has such a bad image. If the chiropractic profession does not take steps to eliminate the nonsense in chiropractic, it may be difficult for ethical, science-based chiropractors to separate themselves from questionable treatment methods that have been traditionally supported by chiropractic subluxation theory. The practice-centered approach of chiropractors who disseminate misinformation, whether they are true believers or not, hurts the public as well as the profession. It is unlikely that unethical chiropractors will voluntarily give-up a faith-based or money-based approach they are using to make a living. Ethical chiropractors, many of whom are well-meaning but misinformed, struggle while pitch masters thrive. Guardians of public health feel compelled to issue warnings about chiropractic. Science-based chiropractors, as individuals, are forced to distance themselves from misguided colleagues and from purveyors of bogus methods based on the tenets of chiropractic. My heart goes out to those well-meaning chiropractors whose education left them totally dependent upon belief-based self-employment. Few of them have the faculties or the means needed to take a different path.

While it would be painful for chiropractors to point out and renounce obviously worthless diagnostic and treatment methods used by some of their colleagues, it might be prudent for chiropractic associations to do so to establish credibility in the eyes of the public. No other health profession has such a negative image. Good chiropractors are mixed in with bad chiropractors, like a crate of partially spoiled fruit that still contains a few good apples but is often discarded.

The chiropractic profession has to face the reality that chiropractic as a method of treating human ailments by adjusting vertebral subluxations is not acceptable in the scientific community and is unrelated to the generic spinal manipulation now being used by physical therapists and science-based chiropractors. A look at chiropractic journals, advertisements, and office procedures, however, reveals that a large number of chiropractors still cling to Palmer’s subluxation theory, some combining science with pseudoscience. I suspect that chiropractic has survived primarily because its use of manipulation in the treatment of back pain has provided a service not readily available in medical care, that is, symptomatic relief for mechanical-type neck and back pain or a good back-cracking back rub for providing pleasure and relieving tension. I believe the chiropractic profession today would be better off if it renounced the subluxation theory that gave it birth and concentrated on caring for back pain. So far, there is no indication that this will happen any time soon. Until the chiropractic profession does discard the vertebral subluxation theory, it will be difficult for the profession to condemn a multitude of popular, wacky chiropractic techniques based on a theory that defines the profession.

Entrenched Subluxation Theory

When the Council on Chiropractic Education (CCE) proposed new accreditation standards for chiropractic colleges, subject to take effect in January of 2012, all reference to “subluxation” was omitted. (“The CCE does not define or support any specific philosophy regarding the principles and practice of chiropractic, nor do the CCE Standards support or accommodate any specific or political position. The Standards do not establish the scope of chiropractic practice. They specify core educational requirements but do not otherwise limit the educational process, program curricular content, or topics of study.”) The American Chiropractic Association (ACA), the largest association in America representing the chiropractic profession, responded, in part, with this comment regarding the subluxation:

The document removes all references to the term “subluxation” – a core element of the practice of chiropractic that has been integral since the profession’s beginnings over 100 years ago. While the term “subluxation” and its role in the practice of chiropractic is sometimes misunderstood or not fully appreciated by all parties involved in medical related research and the delivery of health care, the term is one which is explicitly recognized in federal law (Section 1861(r) of the Social Security Act) and has been widely recognized by the courts, state legislative bodies and licensing authorities. The elimination of any reference to this term in the proposed standards will be viewed by many within the profession as a counter-productive action that will, in the long-term, likely weaken the profession’s collaborative strength and historic identity. We would propose placing “subluxation theory” back into Section 2, H. Educational Program for the Doctor of Chiropractic Degree and Vertebral Subluxation Complex into Section 3 Initial assessment and diagnosis as a required component.

As a chiropractor and a critic of chiropractic, I often found common ground with other health-care professionals by noting the value of generic spinal manipulation while providing guidelines to separate science-based chiropractors from subluxation-based chiropractors. Failure to point out obvious chiropractic nonsense may simply allow a believing public to assume that all chiropractors are the same, most of whom do not deserve to feed off the positive image projected by a few ethical, science-based chiropractors. Subluxation-based chiropractors peddle dubious services without opposition from their colleagues or from their associations, alienating chiropractic from the scientific community.

When I published my book Bonesetting, Chiropractic and Cultism in 1963, I renounced the vertebral subluxation theory and recommended that chiropractic be developed as a back specialty. It has always been my hope that chiropractic would become a form of physical medicine, a sub-specialty of medicine offering physical treatment methods for mechanical-type neck and back problems. If chiropractic aspires to become an independent, primary non-surgical specialty capable of accepting full responsibility for treating neck and back pain and related problems, it would have to have access to certain prescription medications and all available rehabilitative and physical treatment methods as well as access to hospital facilities, requiring changes in state laws and chiropractic college curriculum. As a back-pain specialty or sub-specialty, the chiropractic profession could be sustained by referrals from other health-care professionals.

Back Specialists?

In 2005, the World Federation of Chiropractic defined chiropractors as “…spinal health care experts in the health care system…with emphasis on the relationship between the spine and the nervous system…” This ambiguous definition fails to place proper limitations on the practice of chiropractic, leaving the door open for subluxation-based chiropractors who use spinal adjustments to treat general health problems. Such chiropractors, with only a hammer in their tool box, cannot qualify as a legitimate “back specialist” or “spine specialist.”

According to the Agency for Healthcare Policy and Research, low-back trouble is the second most common reason for office visits to primary care physicians and the most common reason for office visits to orthopedic surgeons, neurosurgeons, and occupational medicine physicians. Back problems are the most common cause of disability among persons under the age of 45 (Acute Low Back Problems in Adults, 1994). Despite the fact that back pain is one of this nation’s most common ailments, the niche for a back-pain specialty remains unfilled. With changes, chiropractic could have filled this niche (specializing like optometry or chiropody), but instead chose to be defined as a form of alternative medicine with a limited treatment method and an unlimited scope of practice .

Most people think of a chiropractor as a “back doctor.” And most people who go to a chiropractor go for treatment of a neck or back problem. It is certainly ironic that many chiropractors consider it demeaning to be called a “back specialist,” preferring to “treat human ailments without use of drugs and surgery.” Unfortunately, most state laws define chiropractic in this way, resulting in scientific and societal suspicion that hinders change and keeps utilization of chiropractic low.

Today, 48 years after publication of my Bonesetting book, I am still of the opinion that the chiropractic profession is not properly defined and limited. Chiropractic associations continue to tolerate implausible theories that provide an umbrella for inappropriate use of spinal manipulation and a variety of proprietary treatment methods applied to the gamut of human ailments. Many subluxation-based chiropractors seek support in the camp of alternative medicine where they are more readily accepted and where quackery is rampant. They are not representative of chiropractors who follow the guidelines of science in limiting their scope of practice. The uncontested proclamations of chiropractors who make vague and all-inclusive claims continue to drag the profession down, as indicated by figures showing that the percentage of the population seeing chiropractors annually decreased from 9.9% in 1997 to 7.4% in 2002 (Altern Ther Health Med. 2005;11:42-49), despite increasing popularity of alternative medicine.

Scientific presentations will not eliminate a belief system such as homeopathy or subluxation-based chiropractic, nor will the actions of a few science-based chiropractors. It seems likely that there will always be subluxation-based chiropractors. Until the majority of chiropractors make a clean break from what has traditionally been known as chiropractic (adjusting the spine to restore and maintain health), changes for the better in the profession as a whole will be problematic. Chiropractic associations will tend to represent the views of the majority, even if these views are scientifically indefensible. And the definition of chiropractic will continue to be based upon consensus rather than upon science.

Since physical therapy as a sub-specialty of medicine is now incorporating use of science-based manipulation in an armamentarium designed for treatment of neck and back pain and other musculoskeletal problems, it might be too late for the chiropractic profession to establish itself as a preferred back-pain specialty or sub-specialty. Forty-six states now allow direct access to the services of a physical therapist without physician referral. According to the American Physical Therapy Association, physical therapy, by the year 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists.

The Majority Rules

Chiropractors who use manipulation appropriately may be in the minority, making it necessary for them to seek refuge and camaraderie in small groups of like-minded chiropractors who voluntarily follow the guidelines of science in offering patient-centered care. It would certainly be nice if these chiropractors could be separated from the herd with a special degree in a separate camp until they become a majority and the national associations are forced to follow suit.

Until then, I hope that good chiropractors will offer their patients (and the public) tips on how to recognize questionable claims so that good judgment can be exercised in selecting a chiropractor. It may be necessary for chiropractors themselves to openly criticize esoteric techniques used to locate and correct the mysterious, asymptomatic, and undetectable chiropractic vertebral subluxations alleged to be a cause of disease. Scientifically indefensible theories and treatment methods must be labeled as such to discourage use by the public as well as by chiropractors. As the undesirable aspects of chiropractic (e.g., “killer subluxations”) become less acceptable in the eyes of the public, fewer chiropractors will tout such nonsense. When science-based chiropractors are in the majority, if that ever happens, chiropractic associations might then define chiropractic properly and make appropriate changes in state laws.

Finding a Good Chiropractor

Here are the guidelines I offer patients who might want chiropractic treatment for back pain:

• While a good chiropractor can do a good job treating back pain, not all chiropractors are the same; some follow the guidelines of science, some do not.
• Look for a chiropractor who limits his/her practice to care of musculoskeletal problems and who uses hands-on generic spinal manipulation in combination with physical therapy modalities. Such a chiropractor can often be found working in a multi-disciplinary back-pain clinic.
• Avoid chiropractors who propose to locate and adjust “vertebral subluxations” as a treatment for disease or to “restore and maintain health.”
• Avoid chiropractors who ask for payment in advance for a long course of treatment. As a general rule, treatment should be discontinued if symptoms worsen after one week or have not improved after two weeks.
• Avoid chiropractors who routinely x-ray new patients or who do full-spine x-rays on every patient. Remember that simple back strain will usually resolve on its own in a few weeks and does not require an x-ray exam.
• Do not accept the services of a chiropractor who refuses to share his/her records with your family physician or a medical specialist. An orthopedist who has exchanged office notes with chiropractors can often offer guidance in selecting a chiropractor.
• Persons who want manipulative therapy for a back problem but are reluctant to see a chiropractor should ask for a referral to a physiatrist, a physical therapist, or an orthopedic manual therapist who has been trained in the use of spinal manipulation.