Principles and Practice of Chiropractic, Third Edition [3rd ed] 9780071811569, 0071811567, 9780071375344, 0071375341

Table of contents :
Contents......Page 6
Contributors......Page 12
Preface......Page 18
Acknowledgments......Page 22
1. History of Spinal Manipulation......Page 28
2. A Brief History of the Chiropractic Profession......Page 46
3. The Evolution of Vitalism and Materialism and its Impact on Philosophy in Chiropractic......Page 88
4. Philosophy in Chiropractic......Page 100
5. Communication in the Chiropractic Health Encounter: Sociological and Anthropological Approaches......Page 122
6. International Status, Standards, and Education of the Chiropractic Profession......Page 134
7. Integration of Chiropractic in Health Care......Page 158
8. The Clinical Effectiveness of Spinal Manipulation for Musculoskeletal Conditions......Page 170
9. The Treatment of Headache, Neurologic, and Non-Musculoskeletal Disorders by Spinal Manipulation......Page 190
10. Public Health Responsibilities for Chiropractic......Page 206
11. Professionalism and Ethics in Chiropractic......Page 224
12. Sensory Innervation of the Spine......Page 248
13. Muscle Spindles and Spinal Proprioception......Page 272
14. Central Projections of Spinal Receptors......Page 292
15. Peripheral Nerve Biology and Concepts of Nerve Pathophysiology......Page 312
16. Somatoautonomic Reflexes......Page 324
17. Clinical Biomechanics and Pathomechanics of the Cervical Spine......Page 338
18. Clinical Biomechanics and Pathomechanics of the Lumbar Spine......Page 358
19. The Theoretical Basis for Spinal Manipulation......Page 384
20. Pathophysiology of Disc Degeneration......Page 406
21. Pathophysiology of the Posterior Zygapophysial (FACET) Joints......Page 424
22. The Influence of Muscles in Spinal Pain Syndromes......Page 442
23. Biomechanics and Pathophysiology of the Sacroiliac Joint......Page 456
24. Headaches of Spinal Origin......Page 470
25. Risk Factors for Low Back and Neck Pain: An Introduction to Clinical Epidemiology and Review of Commonly Suspected Risk Factors......Page 488
26. The Clinical History......Page 510
27. The Physical Examination......Page 532
28. Neurologic Examination......Page 560
29. Orthopedic Examination......Page 584
30. Manual Examination of the Patient......Page 616
31. The Clinical Application of Selected Examination......Page 634
32. The Use of Measurement Instruments in Chiropractic Practice......Page 652
33. Indications for and Use of X-Rays......Page 684
34. Indications for and Use of Advanced Imaging Studies......Page 706
35. Indications for and Use of Laboratory Tests......Page 728
36. Documentation and Record Keeping......Page 748
37. Evolution and Basic Principles of the Chiropractic Adjustment and Manipulation......Page 768
38. High-Velocity Low-Amplitude Manipulative Techniques......Page 778
39. Mobilization Techniques......Page 790
40. Low-Force and Instrument Technique......Page 810
41. Soft Tissue Manual Techniques......Page 828
42. Traction and Distraction Techniques......Page 844
43. Medication-Assisted Spinal Manipulation......Page 864
44. The Use of Physical Modalities......Page 884
45. Acupuncture, Acupressure, and Trigger Point Techniques......Page 898
46. The Role of Rehabilitation and Exercise in Chiropractic Practice......Page 910
47. The Management of Low Back Pain and Radiculopathy......Page 934
48. Thoracic Spinal Pain Syndromes......Page 974
49. Management of Neck Pain and Related Disorders......Page 992
50. The Management of Headache......Page 1022
51. Disorders of the Peripheral Nerves......Page 1036
52. Management of Non-Musculoskeletal Disorders......Page 1060
53. Issues Specific in Pediatric Practice......Page 1072
54. Issues Specific to Geriatric Practice......Page 1102
55. Clinical Nutrition......Page 1122
56. Musculoskeletal Complications of Chiropractic Practice......Page 1160
57. Neurological Complications of Spinal Manipulation Therapy......Page 1172
58. Integration Of Chiropractic Into Multidisciplinary and Hospital-Based Settings......Page 1188
A......Page 1204
B......Page 1206
C......Page 1207
D......Page 1214
E......Page 1215
F......Page 1217
G......Page 1218
H......Page 1219
I......Page 1220
L......Page 1223
M......Page 1225
N......Page 1229
P......Page 1231
R......Page 1236
S......Page 1238
T......Page 1242
W......Page 1245
Z......Page 1246

Citation preview

PRINCIPLES AND PRACTICE OF CHIROPRACTIC

NOTICE Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The editors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the editors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs.

PRINCIPLES AND PRACTICE OF CHIROPRACTIC Third Edition Editor in Chief

Section Editors

Scott Haldeman, DC, MD, PhD, FCCS(C), FRCP(C)

Brian Budgell, DC, MSc

Clinical Professor, Department of Neurology University of California, Irvine Adjunct Professor, Department of Epidemiology University of California, Los Angeles Adjunct Professor, Research Division Southern California University of Health Sciences Whittier, California

Associate Professor School of Health Sciences, Faculty of Medicine Kyoto University Kyoto, Japan

Niels Grunnet-Nilsson, DC, MD, PhD Director of Studies for Clinical Biomechanics Faculty of Health Science University of Southern Denmark, Odense, Denmark

Associate Editor

Paul D. Hooper, DC, MPH, Dipl Erg

Simon Dagenais, DC Department of Environmental Health, Science, and Policy University of California, Irvine Clinical Research Manager, CAM Research Institute Irvine, California

Chair, Department of Principles and Practice Southern California University of Health Sciences Whittier, California

William C. Meeker, DC, MPH Director, Palmer Center for Chiropractic Research Vice President for Research Palmer Chiropractic University Foundation Davenport, Iowa

John Triano, DC, PhD Director, Chiropractic Division Co-Director, Conservative Medicine Texas Back Institute Plano, Texas

McGraw-Hill MEDICAL PUBLISHING DIVISION New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto

Copyright © 2005 by The McGraw-Hill Companies, Inc. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. ISBN: 978-0-07-181156-9 MHID: 0-07-181156-7 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-137534-4, MHID: 0-07-137534-1. All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs. To contact a representative please e-mail us at [email protected]. Previous editions © 1992 by Appleton & Lange; copyright c 1980 by Appleton-Century-Crofts The editors were Michael Brown and Karen Edmonson; the production supervisor was Richard Ruzycka; Pamela J. Edwards prepared the index; the text designer was Parallelogram/Marsha Cohen; the cover designer was Kelly Parr. Quebecor World/Versailles was printer and binder. TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.

Contents

Contributors Preface Acknowledgments

xi xvii xxi

I. INTRODUCTION TO CHIROPRACTIC PRINCIPLES / 1 William C. Meeker, DC, MPH 1.

History of Spinal Manipulation

5

Glenda Wiese, MA Alana Callender, MS 2.

A Brief History of the Chiropractic Profession

23

Joseph C. Keating, Jr., PhD 3.

The Evolution of Vitalism and Materialism and its Impact on Philosophy in Chiropractic

65

Reed B. Phillips, DC, PhD 4.

Philosophy in Chiropractic

77

Joseph C. Keating, Jr., PhD 5.

Communication in the Chiropractic Health Encounter: Sociological and Anthropological Approaches

99

Ian D. Coulter, PhD 6.

International Status, Standards, and Education of the Chiropractic Profession

111

David A. Chapman-Smith, LL.B (Hons) Carl S. Cleveland III, DC 7.

Integration of Chiropractic in Health Care

135

William C. Meeker, DC, MPH Robert D. Mootz, DC 8.

The Clinical Effectiveness of Spinal Manipulation for Musculoskeletal Conditions

147

Gert Brønfort, DC, PhD Mitchel Haas, DC, MA Roni Evans, DC, MS 9.

The Treatment of Headache, Neurologic, and Non-Musculoskeletal Disorders by Spinal Manipulation

Howard Vernon, DC, FCCS, FCCRS, FICC

167

vi

10.

CONTENTS

Public Health Responsibilities for Chiropractic

183

Michael G. Perillo, DC, MPH 11.

Professionalism and Ethics in Chiropractic

201

Robert D. Mootz, DC Ian Coulter, PhD Gary D. Schultz, DC, DACBR

II. INTRODUCTION TO CHIROPRACTIC THEORY / 221 Brian Budgell, DC, MSc 12.

Sensory Innervation of the Spine

225

Joel G. Pickar, DC, PhD 13.

Muscle Spindles and Spinal Proprioception

249

Barbara I. Polus, BAppSc(Chiropractic), MSc (UNE, Australia), PhD (Monash, Australia) 14.

Central Projections of Spinal Receptors

269

Xue-Jun Song, MD, PhD Ronald R. Rupert, DC, MS 15.

Peripheral Nerve Biology and Concepts of Nerve Pathophysiology

289

Geoffrey Bove, DC, PhD 16.

Somatoautonomic Reflexes

301

Akio Sato, MD, PhD Brian Budgell, DC, MSc 17.

Clinical Biomechanics and Pathomechanics of the Cervical Spine

315

Gary Greenstein, DC 18.

Clinical Biomechanics and Pathomechanics of the Lumbar Spine

335

Partap S. Khalsa, DC, PhD, FACO 19.

The Theoretical Basis for Spinal Manipulation

361

John Triano, DC, PhD 20.

Pathophysiology of Disc Degeneration

383

Michael A. Adams, BSc, PhD 21.

Pathophysiology of the Posterior Zygapophysial (FACET) Joints

401

Lynton G.F. Giles, DC, MSc, PhD 22.

The Influence of Muscles in Spinal Pain Syndromes

419

Mark T. Finneran, MD 23.

Biomechanics and Pathophysiology of the Sacroiliac Joint

433

Dale Mierau, DC, MSc 24.

Headaches of Spinal Origin

Simon Dagenais, DC Scott Haldeman, DC, MD, PhD, FCCS(C), FRCP(C)

447

CONTENTS

25.

Risk Factors for Low Back and Neck Pain: An Introduction to Clinical Epidemiology and Review of Commonly Suspected Risk Factors

vii

465

Jan Hartvigsen, DC, PhD

III. INTRODUCTION TO THE CLINICAL EXAMINATION / 485 Niels Grunnet-Nilsson, DC, MD, PhD 26.

The Clinical History

487

Palle Pedersen, DC, MPhil, DPMSA 27.

The Physical Examination

509

B. Kim Humphreys, DC, PhD Lisa Caputo, BSc, DC, FCCS(C) 28.

Neurologic Examination

537

Rand S. Swenson, DC, MD, PhD 29.

Orthopedic Examination

561

Edward Rothman, DC, FACO(US), FCC(UK) Haymo Thiel, DC, MSc(Ortho), FCCS(C), FCC(Orth) 30.

Manual Examination of the Patient

593

Donald R. Murphy, DC, DACAN Craig Morris, DC, DACRB 31.

The Clinical Application of Selected Examination and Diagnostic Instruments in Chiropractic

611

Keith Wells, DC, MA 32.

The Use of Measurement Instruments in Chiropractic Practice

629

Christopher J. Colloca, DC Tony S. Keller, PhD Gregory J. Lehman, MSc, DC Donald D. Harrison, DC, PhD, MSE 33.

Indications for and Use of X-Rays

661

Cynthia Peterson, RN, DC, DACBR, MMEd, FCCR(C) William Hsu, BSc, DC, DACBR, FCCR(C) 34.

Indications for and Use of Advanced Imaging Studies

683

Dennis R. Skogsbergh, DC, DABCO, DACBR 35.

Indications for and Use of Laboratory Tests

705

Robert W. Ward, DC 36.

Documentation and Record Keeping

Louis Sportelli, DC Gary Tarola, DC, DABCO

725

viii

CONTENTS

IV. INTRODUCTION TO SPECIFIC TREATMENT METHODS / 743 Paul D. Hooper, DC, MPH, Dipl Erg 37.

Evolution and Basic Principles of the Chiropractic Adjustment and Manipulation

745

Paul D. Hooper, DC, MPH, Dipl Erg 38.

High-Velocity Low-Amplitude Manipulative Techniques

755

Thomas F. Bergmann, DC, FICC 39.

Mobilization Techniques

767

John Scaringe, DC, DACBSP Craig Kawaoka, DC, DACBSP, CSCS 40.

Low-Force and Instrument Technique

787

Arlan W. Fuhr, DC 41.

Soft Tissue Manual Techniques

805

Stephen M. Perle, DC, MS 42.

Traction and Distraction Techniques

821

James M. Cox, DC, DACBR M.R. Gudavalli, PhD 43.

Medication-Assisted Spinal Manipulation

841

Frank J. Kohlbeck, DC 44.

The Use of Physical Modalities

861

Paul D. Hooper, DC, MPH, Dipl Erg 45.

Acupuncture, Acupressure, and Trigger Point Techniques

875

John A. Amaro, DC, FACC, FIAMA, DiplAc 46.

The Role of Rehabilitation and Exercise in Chiropractic Practice

887

Craig Liebenson, DC Clayton Skaggs, DC

V. INTRODUCTION TO MANAGEMENT OF SPECIFIC DISORDERS / 907 John Triano, DC, PhD 47.

The Management of Low Back Pain and Radiculopathy

911

Dennis R. Skogsbergh, DC, DACBO, DACBR Robert Cooperstein, MA, DC 48.

Thoracic Spinal Pain Syndromes

951

W. Mark Erwin, DC 49.

Management of Neck Pain and Related Disorders

969

Donald R. Murphy, DC, DACAN Michael Freeman, DC, PhD, MPH 50.

The Management of Headache

Rand Swenson, DC, MD, PhD Niels Grunnet-Nilsson, DC, MD, PhD

999

CONTENTS

51.

Disorders of the Peripheral Nerves

ix

1013

Rand S. Swenson, MD, DC, PhD P. Thomas Davis, MUP, DC 52.

Management of Non-Musculoskeletal Disorders

1037

Richard L. Sarnat, MD Brian Budgell, DC, MSc 53.

Issues Specific in Pediatric Practice

1049

Jesper M. M. Wiberg, DC Niels Klougart, DC 54.

Issues Specific to Geriatric Practice

1079

Jacqueline D. Bougie, DC, MS 55.

Clinical Nutrition

1099

G. Douglas Andersen, DC, DACBSP, CCN 56.

Musculoskeletal Complications of Chiropractic Practice

1137

Marion McGregor, DC, FCCS(C), MSc 57.

Neurological Complications of Spinal Manipulation Therapy

1149

Allan G.J. Terrett, DipAppSc(HumBiol), BAppSc(Chiro), MAppSc(Chiro), FACCS, FICC 58.

Integration Of Chiropractic Into Multidisciplinary and Hospital-Based Settings

1165

Deborah Kopansky-Giles, BPHE, DC, FCCS(C) Bruce Walker, DC, MPH, DrPH Scholar Sira Borges, DC, MD

Index

1181

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Contributors

Michael A. Adams, BSc, PhD

Alana K. Callender, MS

Senior Research Fellow, Department of Anatomy, University of Bristol, United Kingdom Pathophysiology of Disc Degeneration

Director, Palmer Foundation for Chiropractic History, Davenport, Iowa History of Spinal Manipulation

John A. Amaro, DC, FACC, FIAMA, DiplAc

Lisa Caputo, BSc, DC, MEd, FCCS (C)

Chiropractic Physician, Licensed Acupuncturist, International Academy of Medical Acupuncture, Inc, Carefree, Arizona Acupuncture, Acupressure, and Trigger Point Techniques

G. Douglas Andersen, DC, DACBSP, CCN Postgraduate Faculty, Southern California University of Health Sciences, Whittier, California; Certified Clinical Nutritionist; Private Practice of Chiropractic Nutrition, Brea, California Clinical Nutrition

Coordinator, Clinical Education (Acting) Division of Chiropractic, School of Health Sciences, RMIT University, Melbourne, Australia The Physical Examination

David A. Chapman-Smith, LLB (Hons) Attorney at Law, The Chiropractic Report, Toronto, Ontario, Canada International Status, Standards and Education of the Chiropractic Profession

Thomas F. Bergmann, DC, FICC Professor, Methods Department, Faculty Clinician, Northwestern Health Sciences University, Bloomington, Minnesota High Velocity Low Amplitude Manipulative Techniques

Carl S. Cleveland, III, DC President, Cleveland Chiropractic College, Kansas City and Los Angeles International Status, Standards and Education of the Chiropractic Profession

Sira Borges, DC, MD Clinic Director, Clinica Internacional da Coluna, Salvador, Brazil Integration of Chiropractic Into Multidisciplinary and Hospital-Based Settings

Jacqueline D. Bougie, DC, MS Associate Professor and Chair, Department of Integrative Procedures, Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic, Whittier, California Issues Specific to Geriatric Practice

Geoffrey M. Bove, DC, PhD Assistant Professor, Department of Anesthesia Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts Peripheral Nerve Biology and Concepts of Nerve Pathophysiology

Gert Brønfort, DC, PhD Research Professor, Director of the Neck and Back Research Program Northwestern Health Sciences University, Bloomington, Minnesota The Clinical Effectiveness of Spinal Manipulation for Musculoskeletal Conditions

Christopher J. Colloca, DC Graduate Student, Department of Kinesiology, Arizona State University, Tempe, Arizona; Postgraduate and Continuing Education Department Faculty, New York Chiropractic College, Seneca Falls, New York; Clinic Director, Owner, State of the Art Chiropractic Center, PC, Phoenix, Arizona The Use of Measurement Instruments in Chiropractic Practice

Robert Cooperstein, MA, DC Professor and Director of Technique and Research, Palmer College of Chiropractic West, San Jose, California The Management of Low Back Pain and Radiculopathy

Ian D. Coulter, PhD Professor, School of Dentistry, University of California, Los Angeles; Research Professor, Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic, Whittier, California; Senior Behavioral Scientist, RAND Corporation, Santa Monica, California Communication in the Chiropractic Health Encounter: Sociological and Anthropological Approaches; Professionalism and Ethics in Chiropractic

James M. Cox, DC, DACBR Brian Budgell, DC, MSc Associate Professor, School of Health Sciences, Faculty of Medicine, Kyoto University, Kyoto, Japan Introduction; Somatoautonomic Reflexes; Management of NonMusculoskeletal Disorders

Chiropractic Physician, Chiropractic Radiologist, Post Graduate Faculty, National University of Health Sciences; Private Clinical and Radiological Practice, Chiropractic Associates, Inc, Fort Wayne, Indiana Traction and Distraction Techniques

xii

CONTRIBUTORS

Simon Dagenais, DC

M.R. Gudavalli, PhD

Department of Environmental Health, Science, and Policy, University of California, Irvine; Clinical Research Manager, CAM Research Institute, Irvine, California Headaches of Spinal Origin

Associate Professor, Palmer Center for Chiropractic Research, Davenport, Iowa; Adjunct Associate Professor, National University of Health Sciences, Lombard, Illinois Traction and Distraction Techniques

P. Thomas Davis, MUP, DC

Mitchel Haas, DC, MA

Associate Professor, Northwestern Health Sciences University, Bloomington, Minnesota Disorders of the Peripheral Nerves

Professor and Dean of Research, Western States Chiropractic College, Portland, Oregon The Clinical Effectiveness of Spinal Manipulation for Musculoskeletal Conditions

W. Mark Erwin, DC Clinician and Clinic Director, Osgoode Health Centre, Toronto, Ontario, Canada

Scott Haldeman, DC, MD, PhD, FCCS(C), FRCP(C)

Thoracic Spinal Pain Syndromes

Clinical Professor, Department of Neurology, University of California, Irvine; Adjunct Professor, Department of Epidemiology, University of California, Los Angeles; Adjunct Professor, Research Division, Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic, Whittier, California Headaches of Spinal Origin

Roni Evans, DC, MS Associate Professor and Director, Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, Bloomington, Minnesota The Clinical Effectiveness of Spinal Manipulation for Musculoskeletal Conditions

Donald D. Harrison, DC, PhD, MSE Mark T. Finneran, MD Medical Director, Ashland Industrial Medicine Services Wooster, Ohio The Influence of Muscles in Spinal Pain Syndromes

Michael Freeman, DC, PhD, MPH Clinical Assistant Professor and Forensic Trauma Epidemiologist, Department of Public Health and Preventive Medicine, Oregon Health Sciences University, Salem, Oregon Management of Neck Pain and Related Disorders

Arlan W. Fuhr, DC President and Co-Founder, Activator Methods Phoenix, Arizona Low Force and Instrument Technique

Lynton G.F. Giles, DC, MSc, PhD Director, National Unit for Multidisciplinary Studies of Spinal Pain, The University of Queensland, Townsville Hospital, Townsville, Queensland, Australia; Adjunct Associate Professor, School of Public Health and Tropical Medicine, James Cook University Townsville, Australia Pathophysiology of the Posterior Zygapophysial (FACET) Joints

Gary Greenstein, DC Associate Professor of Clinical Sciences, University of Bridgeport College of Chiropractic, Bridgeport, Connecticut Clinical Biomechanics and Pathomechanics of the Cervical Spine

President of CBP Nonprofit, Inc., Evanston, Wyoming; Affiliated Professor, Biomechanics Lab, University of Quebec Three Rivers, Canada The Use of Measurement Instruments in Chiropractic Practice

Jan Hartvigsen, DC, PhD Senior Researcher, Nordic Institute of Chiropractic and Clinical Biomechanics; Associate Professor, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark Odense, Denmark Risk Factors for Low Back and Neck Pain: An Introduction to Clinical Epidemiology and Review of Commonly Suspected Risk Factors

Paul D. Hooper, DC, MPH, MSc Chair, Department of Principles and Practice, Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic, Whittier, California Introduction; The Evolution and Basic Principles of the Chiropractic Adjustments and Manipulation; The Use of Physical Modalities

William Hsu, BSc, DC, DACBR, FCCR(C) Associate Professor, Canadian Memorial Chiropractic College Toronto, Ontario, Canada The Indication and Use of X-Rays

B. Kim Humphreys, DC, PhD Dean, Graduate Education and Research Programmes, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada The Clinical Examination

Niels Grunnet-Nilsson, DC, MD, PhD Director of Studies in Clinical Biomechanics, Professor, Faculty of Health Science, University of Southern Denmark Odense, Denmark Introduction: The Clinical Examination; The Management of Headache

Craig Kawaoka, DC, DACBSP, CSCS Assistant Professor, Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic Whittier, California Mobilization Techniques

CONTRIBUTORS

xiii

Joseph C. Keating, Jr., PhD

Robert D. Mootz, DC

Secretary and Historian, National Institute of Chiropractic Research; Member, Board of Directors, Association for the History of Chiropractic, Phoenix, Arizona A Brief History of the Chiropractic Profession; Philosophy in Chiropractic

Associate Medical Director for Chiropractic, State of Washington Department of Labor and Industries, Olympia, Washington Integration of Chiropractic in Health Care; Professionalism and Ethics in Chiropractic

Craig Morris, DC, DACRB Tony S. Keller, PhD Professor and Chair, Department of Mechanical Engineering, The University of Vermont, Burlington, Vermont The Use of Measurement Instruments in Chiropractic Practice

Partap S. Khalsa, DC, PhD, DABCO Associate Professor of Biomedical Engineering, Neurobiology, and Orthopaedics; Vice-Chair and Graduate Program Director, Department of Biomedical Engineering, State University of New York (SUNY), Stony Brook, New York Clinical Biomechanics and Pathomechanics of the Lumbar Spine

Niels Klougart, DC Private Practice, Denmark Issues Specific in Pediatric Practice

Frank J. Kohlbeck, DC Associated Research Faculty, Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic, Whittier, California Medication Assisted Spinal Manipulation

Deborah Kopansky-Giles, BPHE, DC, FCCS(C) Associate Professor, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada Integration of Chiropractic Into Multidisciplinary and HospitalBased Settings

Gregory J. Lehman, MSc, DC Assistant Professor of Biomechanics, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada The Use of Measurement Instruments in Chiropractic Practice

Craig Liebenson, DC Post Graduate Faculty, Southern California University of Health Sciences, Director, L.A. Sports and Spine; Adjunct Professor, School of Chiropractic, Division of Health Sciences, Murdoch University; Private Practice, Los Angeles, California The Role of Rehabilitation and Exercise in Chiropractic Practice

Marion McGregor, DC, FCCS(C), MSc Associate Professor, Texas Chiropractic College, Pasadena, Texas Musculoskeletal Complications of Chiropractic Practice

William C. Meeker, DC, MPH

Associate Clinical Professor, Cleveland Chiropractic College, Los Angeles, California; Post Graduate Faculty, Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic, Whittier, California; Post Graduate Faculty, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Clinic Director, F.I.R.S.T. Health, Torrance, California Manual Manual Examination of the Patient

Donald R. Murphy, DC, DACAN Department of Community Health, Brown University School of Medicine; Postgraduate Faculty, University of Bridgeport College of Chiropractic, New York Chiropractic College, Southern California University of Health Sciences, Anglo-European College of Chiropractic; Clinical Director, Rhode Island Spine Center, Providence, Rhode Island Manual Examination of the Patient; Management of Neck Pain and Related Disorders

Palle Pedersen, DC, MPhil, DPMSA Senior Lecturer in Clinical Sciences (Chiropractic), The Welsh Institute of Chiropractic, University of Glamorgan Pontypridd, United Kingdom The Clinical History

Michael G. Perillo, DC, MPH Adjunct Professor in Public Health, University of Bridgeport College of Chiropractic, Bridgeport, Connecticut Public Health Responsibilities for Chiropractic

Stephen M. Perle, DC, MS Associate Professor of Clinical Sciences, University of Bridgeport College of Chiropractic, Bridgeport, Connecticut; Private Practice, Connecticut Chiropractic Specialists, L.L.C. Milford, Connecticut Soft Tissue Manual Techniques

Cynthia Peterson, RN, DC, DACBR, MMedEd, FCCR(C) Professor and Chairperson, Department of Radiology and Chief of Clinical Radiology, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada The Indication and Use of X-Rays

Reed B. Phillips, DC, PhD

Director, Palmer Center for Chiropractic Research; Vice President for Research, Palmer Chiropractic University Foundation Davenport, Iowa Introduction; Integration of Chiropractic in Health Care

President, Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic Whittier, California The Evolution of Vitalism and Materialism and its Impact on Philosophy in Chiropractic

Dale Mierau, DC, MSc

Joel G. Pickar, DC, PhD

Chiropractor, Saskatoon Musculoskeletal Rehabilitation Center Saskatoon, Saskatchewan, Canada Biomechanics and Pathophysiology of the Sacroiliac Joint

Professor, Palmer Center for Chiropractic Research Davenport, Iowa Sensory Innervation of the Spine

xiv

CONTRIBUTORS

Barbara I. Polus, BAppSci, MSc, PhD

Louis Sportelli, DC

Senior Lecturer and Coordinator of Research (Acting) Division of Chiropractic, School of Health Sciences, RMIT University, Melbourne, Australia Muscle Spindles and Spinal Proprioception

Past President, World Federation of Chiropractic; Private Practice, Palmerton, Pennsylvania Documentation and Record Keeping

Edward Rothman, DC, FACO(US), FCC(UK)

Rand S. Swenson, DC, MD, PhD

Senior Clinical Tutor, Anglo European College of Chiropractic, Bournemouth, Dorset, England The Orthopedic Examination

Ronald R. Rupert, DC, MS Director of Research, Research Institute, Parker College of Chiropractic, Dallas, Texas Central Projections of Spinal Receptors

Richard L. Sarnat, MD Alternative Medicine Integration, Highland Park, Illinois Management of Non-Musculoskeletal Disorders

Associate Professor of Anatomy and Neurology, Departments of Anatomy and Medicine, Section of Neurology, Dartmouth Medical School, Hanover, New Hampshire Neurological Examination; The Management of Headache; Disorders of the Peripheral Nerves

Gary Tarola, DC, DABCO Postgraduate Faculty of Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic, and National University of Health Sciences, Whittier, California; Clinic Director/Owner, Chiropractic Associates Fogelsville, Pennsylvania Documentation and Record Keeping

Akio Sato, MD, PhD Professor, University of Human Arts and Sciences Iwatsuki-City, Japan Somatoautonomic Reflexes

John Scaringe, DC, DACBSP Dean of Clinical Education, Chief of Staff, and Clinical Professor, Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic Whittier, California Mobilization Techniques

Gary D. Schultz, DC, DACBR Vice President of Academic Affairs and Professor of Radiology, Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic Whittier, California Professionalism and Ethics in Chiropractic

Clayton Skaggs, DC Research Associate, Logan College of Chiropractic; Adjunct Instructor, Department of Obstetrics, Washington University School of Medicine; Director, Clayton Physical Medicine, St. Louis, Missouri The Role of Rehabilitation and Exercise in Chiropractic Practice

Dennis R. Skogsbergh, DC, DABCO, DACBR Chiropractic Practice, Texas Back Institute, Plano Texas; Musculoskeletal Radiology, Quantum Diagnostic Imaging, Richardson, Texas Indications and Use of Advanced Imaging Studies; The Management of Low Back Pain and Radiculopathy

Xue-Jun Song, MD, PhD Associate Professor and Associate Director of Basic Science Research, Parker College of Chiropractic Research Institute, Dallas, Texas Central Projections of Spinal Receptors

Allan G.J. Terrett, DipAppSc(Hum Biol), BAppSc(Chiro), MAppSc(Chiro), FACCS, FICC Associate Professor, RMIT University, Bundoora, Australia Neurological Complications of Spinal Manipulation Therapy

Haymo Thiel, DC, MSc(Ortho), FCCS(C), FCC(Ortho) Associate Professor and Head of Clinic, Anglo-European College of Chiropractic, Bournemouth, Dorset, England The Orthopedic Examination

John J. Triano, DC, PhD, FCCS Director, Chiropractic Division, Co-Director, Conservative Medicine, Texas Back Institute, Plano, Texas; Research Professor, University of Texas, Arlington Biomedical Engineering, Arlington, Texas The Theoretical Basis for Spinal Manipulation; Introduction

Howard Vernon, DC, FCCS, FCCRS, FICC, PhD Professor, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada The Treatment of Headache, Neurologic and Non-Musculoskeletal Disorders By Spinal Manipulation

Bruce Walker, DC, MPH, DrPH Scholar Doctor of Public Health Scholar, School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia; Townsville Back Clinic, Townsville, Queensland, Australia Integration of Chiropractic Into Multidisciplinary and HospitalBased Settings

CONTRIBUTORS

Robert W. Ward, DC

Jesper M. M. Wiberg, DC

Associate Professor of Diagnosis, Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic, Whittier, California The Indication and Use of Laboratory Tests

Chiropractor, Private Practice, Kiropraktisk Klinik Ballerup, Denmark Issues Specific in Pediatric Practice

Glenda C. Wiese, PhD Keith Wells, DC, MA Professor, Southern California University of Health Sciences, Faculty of Los Angeles College of Chiropractic Whittier, California The Clinical Application of Selected Examination and Diagnostic Instruments in Chiropractic

Professor, Palmer College of Chiropractic Davenport, Iowa History of Spinal Manipulation

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Preface

The evolution of this text, Principles and Practice of Chiropractic over the last 20 years represents, to a large extent, the evolution of the chiropractic profession during this period. Over this relatively short period of two decades, chiropractic has seen rapid changes in its acceptance by the other health care professions. Interest in chiropractic on the part of clinical and basic science researchers has also grown exponentially during this time. This may be in part due to the growing interest in all complementary and alternative treatment approaches but is primarily the result of increasing research directly related to the theories and practice of chiropractic. The first edition of this text was the first time that a chiropractic textbook was published by a major medical textbook publishing company, and therefore marked the beginning of a new era for the sciences related to chiropractic and for the education of chiropractors. At the time the first edition was published, several medical associations around the world affirmed that it was unethical for medical physicians to cooperate with chiropractors. Chiropractors were, for the most part, excluded from major academic institutions and research facilities, and interdisciplinary practice was almost unheard of. Within this context, it was extremely difficult to convince the major publishing companies that not only did a market exist for chiropractic textbooks, but also that publishing such a text would not tarnish the reputation of the company considering such a venture. Despite these obstacles, the first edition of this text was eventually published in 1980. When developing the content of the text it was necessary to recruit a number of scientists and clinicians without any chiropractic background to write many of the chapters. There were simply too few chiropractors at that time with the advanced scientific and academic qualifications and experience necessary to write quality treatises in the basic and clinical sciences. Although the first edition was intended to be fairly comprehensive, it consisted of only 16 chapters and was 390 pages long. There were sections on social aspects of chiropractic and a number of scientific principles on which the practice of chiropractic was based at that time. In

retrospect it must be admitted that there were extensive gaps in the material presented and that the text did not cover the field adequately. Nonetheless, the text did provide some insight into chiropractic and provided a reference for students, practitioners, and scientists with an interest in the field. It also established that there was a lucrative market for textbooks on the topic of chiropractic and paved the way for the publication of future chiropractic textbooks by major medical publishers. The second edition of this text, published in 1992, was much more ambitious than the first, perhaps because the era was much more favorable to chiropractic than the early 1980s had been. Following the landmark 1987 Superior Court ruling against the American Medical Association, it became acceptable for medical physicians to communicate and interact with chiropractors. This cooperation marked the beginning of several important cross-disciplinary and joint research efforts, culminating with the publication of multidisciplinary guidelines for the management of back and neck pain that included input from chiropractic scientists and researchers. During this period there was a progressive increase in the number of chiropractors with advanced and graduate degrees in a variety of subjects, including the basic sciences, who could be called upon to write chapters on their fields of expertise. It was therefore possible to rely to a much lesser extent on authors without formal chiropractic training to write chapters. The second edition attempted to be much more comprehensive than the first by doubling the number of chapters to 32 and increasing the number of pages to 641. Again, retrospection allows us to appreciate the many aspects of chiropractic theory and practice that were not included in that text. With the publication of this, the third edition of Principles and Practice of Chiropractic, it is again time to reflect upon the position gained by the chiropractic profession over the past decade. Bolstered by the endorsement of spinal manipulation for low back and neck pain by several interdisciplinary guidelines both in the US and worldwide, chiropractic has developed a significant presence in the musculoskeletal

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PREFACE

literature of the 1990s. During this period, the focus slowly shifted from defending the practice of chiropractic to studying its appropriateness for a number of specific conditions. Helping this effort is a growing number of chiropractors who have gone on to obtain Masters and Ph.D. degrees in various fields of research related to chiropractic. Their efforts have served to greatly increase the quality of the science on which chiropractic theory and practice are based and to develop new and increasingly interesting theories to explain the results observed in chiropractic clinical studies. The number of scientists with a chiropractic background is now such that all but 6 of the 58 chapters contained in this edition were written by chiropractors with graduate degrees in such subjects as biomechanics, epidemiology, neurophysiology, and public health, to mention just a few. This shift of expertise to individuals with training and expertise in both the clinical aspects of chiropractic and the basic sciences has resulted in a more comprehensive, critical, and practical discussion to the topics in each chapter. This text is divided into five sections. Section I presents the history of spinal manipulation and chiropractic followed by a discussion of some of the traditional and modern philosophical issues that have dominated much of the discussion of chiropractic such as the relationship of vitalism and science. This is followed by a series of chapters that discusses some of the more important sociological factors that have influenced and continue to influence the growth and behavior of chiropractic as a profession. The expansion of chiropractic legislation and educational facilities outside of the North American continent is seriously impacting chiropractors within its traditional strongholds of Canada and the United States. This has been brought about by the publication of clinical trials that are described in Chapters 8 and 9. The last two chapters in this section focus on the public health responsibilities and the importance of professionalism and ethics in the practice of chiropractic. This section aims to provide a background from which chiropractic as a discipline can be evaluated and appreciated for what it has accomplished in its century of existence. Section II is devoted to reviewing the basic sciences that increasingly influence chiropractic theory and practice. The innervation of spinal structures and manner in which neuronal input to and from spinal tissues can impact spinal function have been of growing interest to all clinicians who treat patients with spinal disorders. The neurophysiological processes that are the source of much of this research have been reviewed in some depth in the first five chapters of this section. The neurophysiology chapters are then followed by the second component of chiropractic theory, namely spinal biomechanics. It is not possible to

understand the theories on which chiropractic is based without understanding both spinal neurophysiology and biomechanics and how these two sciences interact with each other. It is not, however, sufficient to review normal physiology to understand the etiology of symptoms coming from the spinal structures. Abnormal physiology or pathology within these structures also impacts the manner in which treatment might have an effect. It is for this reason that a series of chapters on the pathophysiology of the intervertebral disc, the posterior zygapophysial joints, the muscles and the sacroiliac joint have been included. The inclusion of chapters on headaches related to the spine and risk factors for low back pain and neck pain conclude this section by introducing come basic epidemiological principles and illustrating how clinical and theoretical principles can be integrated. Section III is an introduction to the clinical skills a chiropractor needs to evaluate a patient and develop a treatment plan. The process of reaching a diagnosis is dependent on a complex integration of the clinical history, basic physical examination, the neurological and orthopedic examinations, and the use of a variety of diagnostic tests. There is an increasing incorporation of advanced diagnostic tools including imaging and electrodiagnostic tests that are becoming part of the chiropractic diagnostic armamentarium and are included in chapters on these topic. The final chapter in this section is devoted to documentation and record keeping and gives some of the principles necessary to build a practice that can integrate with other healthcare professionals, as is increasingly being required by governmental and insurance agencies. Section IV is devoted to the most common treatment approaches used by chiropractors for their patients. It is not possible to discuss each of the over 100 manipulation and adjustive techniques that are currently used and taught within chiropractic institutions. Instead, the chapters in this section have focused on differentiating specific subgroups of manipulative techniques such as mobilization, high velocity low amplitude, low force, instrument, traction, and distraction techniques. There are also specific chapters on treatment approaches that are gaining increasing interest within chiropractic such as medication- assisted manipulation, physical modalities, acupuncture, and rehabilitation. Section V is an attempt to integrate the prior chapters into a logical clinical approach to the most common conditions seen by chiropractors in practice. The majority of patients who seek chiropractic care do so for low back pain, thoracic pain, neck pain and headaches. There are also, however, a small percentage of patients who seek care for non-musculoskeletal symptoms and a discussion of some of the research on these conditions is necessary to put recommendations

PREFACE

on these conditions in context. There are also unique characteristics in the pediatric and geriatric patient populations that can impact management that warrant specific chapters on these topics. There is no treatment approach that is without some risk. Although the risk of the most commonly used chiropractic treatment approaches is very small, it is nonetheless important that those rare complications be discussed. It is for this reason that two chapters were devoted to these issues. The final chapter in this test is devoted to the integration of chiropractic into interdisciplinary spinal clinics. It is probable that a fourth edition of this text will devote considerable more time on the integration of chiropractic into mainstream healthcare. Although a more thorough understanding of chiropractic may be achieved by reading the book in the order it is presented, each chapter is in fact nonsequential and may thus be read independently of the

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others as a stand-alone reference on the topic. Due to constraints on volume length, it remains impossible to include chapters on every important aspect of chiropractic theory and practice. What we have presented here is a comprehensive overview of the topics deemed most relevant to chiropractic clinicians and students at this time. Although specific objectives are listed in each chapter, the general purpose of a chapter is to present a condensed review on a particular topic. For those wishing to gain deeper understanding in a field, these chapters are simply a starting point for further learning and discussion. Key references are provided in each chapter to help guide the reader through the literature. We hope that readers will enjoy this text and use it as an opportunity to learn more about the very interesting and rapidly evolving discipline that is chiropractic. SCOTT HALDEMAN SIMON DAGENAIS

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Acknowledgments

This book is a team effort and has become too complex to be written or edited by one person. The wide scope of knowledge and understanding that is necessary to write and edit a book that adequately covers this topic requires people with qualifications and experience in a number of backgrounds that include the social and basic sciences, as well as clinical practice. For this reason, multiple authors from around the world were recruited to impart their knowledge and expertise on a particular topic, and I wish to thank them for their efforts. The task of corresponding with authors and ensuring that a quality manuscript was written that would contribute to the each of the sections fell on the shoulders of the section editors. All five of these individuals are amongst the most respected and experienced scientists and clinicians within the field of chiropractic. I count each of them amongst the closest of my friends and wish to thank them for accepting this challenge. This text also received input from a number of other individuals who contributed to reading, editing, and correcting individual chapters. In particular,

I would like to thank Frank Kohlbeck for his input on a number of chapters. This text, however, could not have been completed without the intense effort of Simon Dagenais, the associate editor, who personally reread and edited every chapter after it had passed through my hands and that of the section editors to ensure that the final product was legible, accurate, and of high quality. A text of this scope that requires several years of intense work cannot take place without the sacrifice of the families of the authors and editors. In particular I want to thank my wife Joan for her support and understanding of the weekends and evenings spent in the preparation of this text. Finally, there is always considerable amount of work that has to be done once the text is submitted to the publisher. The energy and skill of the editorial staff at McGraw-Hill, including Michael Brown, Barbara Holton, and Andrew Hall, who transformed our manuscript into the book you now see today. To everyone who played a part in the production of this book, whether or not I remembered to include your name here, thank you. SCOTT HALDEMAN

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S E C T I O N

I

INTRODUCTION TO CHIROPRACTIC PRINCIPLES

manipulation. The historical context, especially during the formative years of chiropractic, is particularly important for understanding the current competition for eminence in the field of manual therapies. It is also important to understand the reasons behind the development of chiropractic. The history of spinal manipulation is picked up in the second chapter when it intersects with the dramatic birth of the profession of chiropractic. Joe Keating, a well-known and highly published chiropractic historian, provides the reader with an image-filled narrative about the strong-willed pioneers of chiropractic, most notably the Palmer family and their many important contemporaries, and the profound and durable effect they had on the future of the profession. Starting with a section describing the intellectual milieu surrounding the founder of chiropractic, D. D. Palmer, the story unfolds with a chronological look at the various forces and personalities at work in a turbulent time. Readers will well appreciate the challenges chiropractic had to overcome to reach its current state of development. After this introduction to chiropractic philosophy in the historical context, the chapter by Reed Phillips provides a more detailed discussion of the underlying concepts and propositions of vitalism, which was a dominant component of chiropractic theory in the first 50 years of the profession, and which has been a source of much of the controversy surrounding the incorporation of chiropractic into the mainstream health care system. Beginning with an examination of the ancient giants of formal philosophy, the chapter then deals with the progression of intellectual thinking on vitalism that came before the term chiropractic was coined and influenced chiropractic philosophy. This is followed by a discussion by Joe Keating in Chapter 4 of the various philosophical positions that have been taken by chiropractors over the years and the role of philosophy in the development of chiropractic theory. He points out that much of the controversy

The profession of chiropractic has a unique history and evolution. It is not possible to understand the factors that are currently driving the scientific and clinical developments within chiropractic and to place the profession in the broader perspective of the health care community without describing its historical context. Thus, the first section of this text is devoted to a brief review of the history of spinal manipulation and chiropractic. It would be inappropriate not to discuss some of the more controversial components of the theory of chiropractic, especially its earlier reliance on vitalistic concepts, and its philosophical principles, as is done in Chapters 3 and 4. The chapters on history are followed by an important look at the current state of the profession, its organizations, and its educational systems from an international perspective. This flows naturally into an examination of the extent to which chiropractic has managed to “integrate” with the overall health services system, especially in the United States. These quantitatively focused chapters give way to a qualitative discussion of the nuances and importance of the chiropractic patient “encounter,” in Chapter 5. Chapters 8 and 9 change tone to describe the most important randomized clinical trial evidence regarding spinal manipulation for both musculoskeletal and nonmusculoskeletal conditions. The last two chapters of this section provide important information about the role of chiropractic in the wider domains of public health and social and personal ethics. Together, this set of introductory chapters gives the reader a thoughtful context within which to understand the more detailed and clinically focused information that follows. The first chapter is written by Glenda Wiese and Alana Callender, both eminently qualified by virtue of their long professional involvement in historical scholarship to present a precise history of spinal manipulation through the ages. Beginning with prehistorical evidence, the authors describe early theories underlying manipulation and go on to emphasize the role that many professions have played in adopting and adapting spinal 1

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CHIROPRACTIC PRINCIPLES

surrounding chiropractors has come from the historical isolation of the profession and the legal necessity to differentiate chiropractic from the practice of medicine. He points out, however, the potential pitfalls of maintaining untenable theoretical or philosophical positions to the future of chiropractic and points out the shortcomings of some traditional chiropractic concepts. Chapter 5 contains a discussion of the interaction between chiropractors and their patients. Ian Coulter has a long and influential career in chiropractic scholarship. With expertise in many areas, Dr. Coulter brings his years of experience, research, and training in sociology to an important discussion regarding the chiropractic encounter. Along with several social scientists who study health care, Dr. Coulter believes that there is a unique communicative power in the chiropractic style of case management. He applies the concepts, analytical tools, and models developed through medical sociology and anthropology to provide a compelling argument supporting the unique chiropractic approach to health care. Rather than the dry and limited picture of chiropractic that might emerge from the quantitative studies on manipulation, the social sciences provide a much richer palette from which to view chiropractic. The patient– practitioner relationship is an area of intense interest from a scientific point of view, and one that will likely bear much fruit down the road. David Chapman-Smith is in a unique position to provide in Chapter 6 an overview of chiropractic worldwide. As the chief executive of the World Federation of Chiropractic, he has been directly involved in the rapidly evolving international spread of chiropractic. The most important professional organizations are described as well as the various laws governing the right to practice chiropractic. The recent evolution of chiropractic education worldwide is a fascinating movement to observe. In the last two decades, enormous strides have been made in research, professional literature, and in the development of clinical guidelines. In the closing sections of Chapter 6, Chapman-Smith introduces readers to the important and controversial development of complementary and alternative medicine (CAM), and its implications for chiropractic acceptance and future growth. The international flavor of Chapter 6 sets the stage for a discussion on the integration of chiropractic into the health delivery system. “Integration” is currently a major buzzword on the lips of many discussing the large interest in CAM. “Integrative medicine” is the rallying cry of those who would transform conventional medicine to a more humane style of care. What does all this mean for chiropractic? How is it to be viewed? William Meeker and Robert Mootz have had excellent vantage points from which to observe and interpret this important social movement. Beginning with definitions of the several roles that chiropractors fill in the health system,

two models of integration are presented in Chapter 7. One deals with the complex and overlapping levels within the overall health system and society where integration is occurring. The other model is a useful breakdown of clinical behavior and relationships that practitioners can use to describe their own situation. The authors go on to place the current position of chiropractic in each model, drawing the potential implications for each reality. Readers will be able to appreciate the context as they contemplate their own clinical and professional goals. Gert Bronfort, Roni Evans, and Mitch Haas are among the preeminent clinical scientists of the profession; in Chapter 8 they describe the current state of the scientific evidence for spinal manipulation for the treatment of several common and important musculoskeletal conditions. Back pain, neck pain, and extremity conditions comprise the overwhelming majority of complaints that bring patients to chiropractic, and there is more evidence for the effectiveness of spinal manipulation for these conditions than there is for many other treatment approaches. Yet, despite several decades of scientific effort, there are still many clinical questions left unanswered. The reader will gain an understanding for the complexity and difficulty of conducting clinical trials, as well as an appreciation for study designs and different levels of evidence. In Chapter 9, Howard Vernon tackles a similar evidence base regarding the effectiveness of spinal manipulation for headache and nonmusculoskeletal conditions. Dr. Vernon has had an influential career as a chiropractic scientist and is well qualified to articulate the state of the evidence in this area. Starting with a brief overview of some of the proposed mechanisms by which spinal manipulation could affect visceral, or nonsomatic, functions of the body, the chapter quickly moves into a succinct recitation of the results of a review of the scientific literature. There are sections on headache and vertigo, and one on all other disorders. The discussion closes with the appropriate statement about the lack of definitive clinical trial evidence, but also proposes a reasonable algorithm for how to empirically deal with these conditions in the course of chiropractic care. There is an obvious need to marshal resources for additional research on the effect of manipulation and chiropractic on nonsomatic disorders. One of the great opportunities for chiropractic is to become more formally involved in the public health arena. Chapter 10, authored by Mike Perillo, provides an excellent overview of a vast and complex topic. Dr. Perillo has been active with the American Public Health Association for many years and has a wealth of knowledge to impart. The perspective of public health is somewhat different from that of the individual health practitioner in that the health of an entire population is considered as opposed to one patient at a time. Despite the distinction, there is little doubt that practitioners and

INTRODUCTION TO CHIROPRACTIC PRINCIPLES

public health workers must collaborate for the greater good. As so many chapters in this section do, this one also provides a broader context for understanding the role and potential of chiropractic in the overall health care system. Although focused on many details related to the situation in the United States, the concepts of public health apply worldwide. Robert Mootz, Ian Coulter, and Gary Schultz complete Section 1 with a very important chapter on professionalism and ethics in chiropractic. In an increasingly complicated world with a plurality of social norms, customs, and rules that always seem to change, knowledge about the basic concepts that underlie health care ethics is extremely important. As chiropractic matures, a great deal of attention will be paid to areas of ethical controversy that must be sorted out not only by the

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profession at large, but also by each individual practitioner on a daily basis. In summary, Section 1 sets the stage for understanding the role of chiropractic in the delivery of health care. It is the broad overview, providing the overarching perspective of chiropractic from a historical, social, evidentiary, and professional point of view. Chiropractic is clearly entering a new stage of its development and the details as well as the broad sweep of what is described here will change, sometimes dramatically, even as this book is being published. If anything, this section should give readers a point of departure and a clear warning that in order to progress, members, critics, and students of the chiropractic profession should keep their eyes on the horizon. William C. Meeker

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C H A P T E R

1 HISTORY OF SPINAL MANIPULATION Glenda Wiese and Alana Callender

O U T L I N E THE TWENTIETH CENTURY AND BEYOND Osteopathy Naprapathy Manual Medicine Physical Therapy SUMMARY QUESTIONS ANSWERS KEY REFERENCES REFERENCES

INTRODUCTION PRIMITIVE HEALING EASTERN HEALING HEALING IN THE WESTERN WORLD Greece to the Renaissance (100 bc to 1600 ad) The Age of Enlightenment (1600 ad to 1800 ad) The Age of Medical Dissent (1800 ad to 1900 ad) Bonesetting Spinal Irritation Magnetic Healing

meanings over different historical periods that extreme care is needed to avoid error.1 The Palmers (the founders of the profession of chiropractic) used the word “adjustment” for their spinal manipulative technique, and gave it a precise meaning. On the other hand, “manipulation” is a generic term with a broader meaning than the chiropractic adjustment, and is not limited to the spine. Variation on the purposes of manipulation also exists, and can include reduction of a fracture or dislocation, mobilization to increase the range of motion of a limb or joint, promotion of circulation, or the stimulation or inhibition of nerve function. The prechiropractic literature on spinal manipulation can be categorized in several ways. The first includes the manipulative practices of primitive peoples; the second, manipulation by ancient Eastern civilizations; and the third, manipulative healing in the Western world. We will also review the history of the manipulative healing movements whose development is concurrent with chiropractic. These include osteopathy, naprapathy, manual medicine, and physical therapy. With the exception of naprapathy, which has declined in recent decades, there is now a resurgence of traditional interest in spinal manipulation in these other health care professions.

OBJECTIVES 1. To place spinal manipulation in its proper historical context. 2. To understand the development of early theories underlying the use of manipulation. 3. To describe how several health professions other than chiropractic have adopted and adapted spinal manipulation.

“Beyond all doubt the use of the human hand, as a method of reducing human suffering, is the oldest remedy known to man; historically no date can be given for its adoption.” John Mennell

INTRODUCTION Alfred North Whitehead, in his book The Organization of Thought, said: “Everything of importance has been said before by somebody who did not discover it.” The same can be said of spinal manipulation. One reason may be that words have had so many different

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PRIMITIVE HEALING In many respects the healing practices of primitive peoples are often accompanied by religious ritual or magic, especially when the cause of disability is not apparent or easily treatable. Gaucher observes how throughout history bones and joints have been invested with a symbolic and mystical significance.2 Captain Cook relates how the women of Tahiti pummeled and squeezed him to relieve him of the effects of his rheumatism. 3 Many early inhabitants of North, South, and Central America practiced some form of spinal manipulation, and the custom of having children walk on troubled backs has been reported from both America and from Polynesia, as well as being a peasant healing practice in Bohemia.4,5 Robert Anderson, an anthropologist with training in both chiropractic and medicine, observed a contemporary practitioner of traditional lomilomi who also practiced massage and employed backwalking in Hawaii.6 Anderson also reported a contemporary Mexican

FIGURE 1–1. Manipulation of the thoracic spine by a contemporary folk practitioner in Mexico. (Courtesy of Robert Anderson.)

folk healer who used massage, stretching, and manipulation of the spine and extremities with considerable success for his clients (Fig. 1–1).7 Many of the early natives of North, Central, and South America performed spinal manipulation as well. Gaucher cites a Jesuit missionary in northern Canada in 1724, J. F. Lafitau, who observed the Abnaki Indians perform surprising cures: “The Savages are equally successful with ruptures and prolapses, dislocations, luxations and fractures.”2 The gauchos of South America practiced a technique called “abrazo del ranchero” on one another, which was comprised of one individual lifting another from behind after he had folded his arms across his chest.8 Thus, it appears that even in preliterate cultures, joint manipulation, including spinal manipulation, has been a part of traditional healing methods for many, many years. EASTERN HEALING A form of manipulation was practiced in China as early as 2700 bc, according to the Kung Fou document, and there is evidence of similar practices in India.9 About 2000 years ago, the Han dynasty classic The Yellow Emperor’s Classic of Internal Medicine described massage and exercises, which may well have included mobilization and manipulation.2,9 Joint manipulations were known to be widely used in China (Fig. 1–2). They were extensively developed during the Mongol dynasty and were recorded by We Yilin in the Shiyi dexiao fang. In one section he wrote on various luxations and fractures, and gave specific advice on manipulation.10 Several centuries later, evidence suggests that spinal manipulation was still being practiced. One illustration in the Golden Mirror of Medicine (I Tzung Chin Chien) shows a form of gravity traction used to treat the lumbar spine (Fig. 1–3).11 The patient is standing on a pile of tiles, with the tiles being pulled from under him as a practitioner appears to be applying force to the lumbar region of the patient’s spine. Robert Anderson maintains that traditional Chinese medicine and chiropractic are remarkably alike in their underlying theories. “Through deep massage at the occiput, for example, (contemporary) Chinese practitioners find that they can bring down high blood pressure, a practice analogous to that of chiropractors.”12 In India, joint manipulation was practiced by bath attendants, not as a medically advised prescription but as an act of hygiene. Anqutil-Duperron, a French orientalist who translated the Zend Avesta in the eighteenth century, relates how in Bombay he was given no peace until his bath attendant had made his spine crack. “He kneels on the small of your

HISTORY OF SPINAL MANIPULATION

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back, grasps your shoulders, and makes your spine crack by moving all the vertebrae.”10 Additionally, Gaucher describes the ancient Arabic culture of healing, whose theories had to undergo the rigor of scientific analysis, and the results were impressive: Over 1000 medical treatises were produced or translated into Arabic during this period. One of these texts, written by as-Zahrawi, better known as “Albucasis,” describes spinal manipulative techniques that were considered part of surgery. Other sources cited include Oribasius, Paul of Aegina, Appolonius of Kitium, and Sushruta.10

HEALING IN THE WESTERN WORLD

FIGURE 1–2. A patient receiving manipulation of the shoulder. Joint manipulation has always been an important feature of Chinese medical treatment. (By permission The Wellcome Institute, London.)

FIGURE 1–3. A gravity traction technique used to manipulate the lumbar spine in China. (Courtesy of Dr. Huang Min-der and the Free China Review, vol. 37, no. 2, p. 21.)

Greece to the Renaissance (100 BC to 1600 AD) According to Anderson,9 the first physician to clearly describe techniques of spinal manipulation in the Western literary tradition was Hippocrates (460– 377 bc), in his book On Joints, who identified two contrasting techniques of spinal manipulation. The first, known as succussion, consisted mainly of gravity traction carried out in a forceful manner while the second used a special table to adjust the spine. This table was equipped with poles at each end, to which straps were attached for the leverage for applying traction; wheels and axles could be used if more force was necessary. While the patient was under traction, the physician or assistant administered a spinal thrust (Fig. 1–4). It is noteworthy that Hippocrates referred to the above technique (rachiotherapy) as one of the cornerstones of healing, on a par with drug therapy and surgery. Hippocrates wrote three books on bones and is often cited by chiropractors for his aphorism, “Look well to the spine for the cause of disease.”13 According to Waerland,14 and Ligeros,15 Hippocrates repeatedly pointed out the importance of knowing about the spinal column, since so many disorders were apparently related to it, “He [Hippocrates] evidently studied very closely the mechanism of the spinal column and understood thoroughly its importance and significance. He appears to have known well its relation and application to and effects upon the nervous system, and also its influence upon the whole organism.”15 Ligeros and Homola agree that Hippocrates recognized different degrees of displacement in the spinal joints and attempted correction accordingly.13,15 Hippocrates is quoted as saying that manipulation of the spinal column was an ancient art and that he thought highly of those who first discovered its importance.16 One feature in Hippocrates’ writings that is especially compatible with chiropractic

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affected part.17,18 Wardwell cites Gaucher when discussing the changing perceptions of the desirable human form: “In the Middle Ages the only requirement for the spine was that it should be straight . . . a straight back was an attribute of nobility and a sign of valour. . . . The cultural image of the Renaissance encouraged manipulation of the spine . . . but only in order to impose upon it the desired form!”1 Ambroise Par´e (b. 1517–d. 1590), often called the “Father of Surgery,” refers to dislocations or luxations in the Workes of Ambrose Parey and describes the following manipulative technique: “The dorsal vertebrae outwardly dislocated, when as they stand bunching forth. . . . Then must you lye with your hands upon the extruberancyes, and force in the prominent vertebrae. . . . You may know that the vertebrae are restored by the equal smoothness of the whole Spine” (Fig. 1–6).18 The Age of Enlightenment (1600 to 1800 AD)

FIGURE 1–4. The Hippocratic method of manipulating the spine relied on traction combined with a thrust or sustained pressure. (Courtesy Biblioteca Universitaria, Aarchiginnasio de Bologna, Bologna, Italy.)

theories is “that man must be treated as a whole, that the ultimate curative forces are within, that we should study the entire patient and his environment” (Fig. 1–5).9 Hippocrates’ influence on medicine was immense, and his method of adjusting vertebral subluxations using an adjusting table persisted for more than 2000 years.9 In the East this method became part of Islamic medical practice, and Avicenna of Baghdad included the technique in his voluminous medical encyclopedia, the Qanun. At the end of the Middle Ages a translation of Avicenna’s work was published in Europe, which contributed to Western medicine’s renaissance. During the sixteenth century references to Hippocrates’ manipulative techniques also appeared in works by influential Western European medical authorities, such as Ambrose Pare and Guido Guidi.9 Another influential Greek physician, Galen (c. 130– c. 200 ad), referenced spinal manipulation for a patient following trauma to the neck. In his Fourth Book of di loci affectis, Galen cites the importance of knowing the points of emergence of spinal nerves to an

AD

Gaucher finds that during the seventeenth century the classical theory of bodily humors brought a greater interest in the musculature of the body rather than its frame. As a result, “massages and frictions became the recommended treatment, and articular reductions were condemned.”1 However, a physician might still encounter a brief reference to manipulation of the extremities in Mouton’s The Compleat Bone-Setter or in The Surgeons Store-House, by Johannis Schultetus (Fig. 1–7).12 In spite of the venerable age of Hippocrates’ method of spinal manipulation, adjusting soon went into a decline, and by the nineteenth century surgeons had largely abandoned it for the treatment of subluxations.9 Even though a French surgeon wrote in 1837 of an “almost immediate cure” of cases of lumbago when treated with spinal manipulation, such references were unusual.19 The medical literature then began to be openly critical of spinal manipulation. In 1833, a London physician described the Hippocratic adjusting table and recommended that it be used with great caution.20 As late as 1841, a British physician observed that manipulation was objected to on the grounds that it could be potentially harmful.21 Although it is not clear why nearly all physicians and surgeons abandoned spinal manipulation, Anderson speculates that it was probably given up because they perceived it as dangerous.9 Nineteenth century physicians worried about applying manipulative pressure to tubercular vertebrae that might disintegrate, a condition of endemic proportions at the time.22 They also worried about being exposed to syphilis as a result of direct contact with the

HISTORY OF SPINAL MANIPULATION

9

FIGURE 1–5. Minor spinal displacements may be the modern counterparts of Aesculapian manipulations. (Courtesy Logan College of Chiropractic, Chesterfield, MO.)

patient, a disease that frequently resulted in disfigurement, sickness, and death.12 The Age of Medical Dissent (1800 AD to 1900 AD) According to Wardwell “most disputes over therapy in the nineteenth century involved much heat and

little light.”1 Early in the century, the practice of bloodletting was still being used. Bloodletting, blistering, cupping (leeching), sweating, and purging, as well as heavy dosing with calomel and other toxic chemicals often produced more harm than good. Not surprisingly, patients often preferred the less painful and less harmful remedies of unorthodox healers. Herbalists

FIGURE 1–6. This sixteenth century woodcut describes a method being used by Ambroise Pare (1517–1590) to “restore a thoracic vertebra in its proper place.” (From Beale LJ: A treatise on the distortions and deformities of the human body. Exhibiting a concise view of the nature and treatment of the principal malformations and distortions of the chest, spine, and limbs. London: John Churchill, 1833.)

10

CHIROPRACTIC PRINCIPLES

FIGURE 1–7. A notable evolution resulted from the introduction of a spring-loaded apparatus fixed to a bed that allowed for traction and thrust to be performed by a single person. (From Schultetus J. The surgeons store-house, 1674. Courtesy of Yale Medical Library.)

and other folk practitioners were often consulted and enjoyed considerable local reputations. Many kinds of health care practices began and flourished in this pluralistic environment of medical opinion and dissent. Samuel Thomson (b. 1769–d. 1843) developed the most popular system of herbal treatment. After patenting his remedies in 1813, he marketed them widely, wrote a compendium in 1822, and organized his adherents into “societies” that lobbied legislatures against medical licensing laws. They were so successful that by the 1840s, most of the statutes dealing with regular physicians had been repealed.23 Two branches of botanical medicine developed from the Thomsonians: the physiomedicalists and the eclectics. Each branch had its own active adherents, schools, associations, and journals, but after 1900 their impact on health care became minimal.24 Bonesetting Although regular physicians might have retreated from manipulation during the nineteenth century, patients did not. People suffering from sciatica, lumbago, and rheumatism sought practitioners who could provide relief, and ultimately found their way to lay bonesetters. Bonesetting has had a long traditional history, but the earliest known text by the name was published by the friar Moulto in 1656. Anderson reports, “Bonesetting became identified with the humble, oral tradition of uneducated peasant and working people. That identification became a stigma. . . . ”12 As a result, bonesetters were soon refused access to hospitals,

even when treating cases relevant to their specialty. Nevertheless, bonesetting continued as a folk healing art well into the nineteenth century, when it again attracted the attention of medical doctors. Dr. Edward Harrison reported that bonesetters outnumbered medical doctors nine to one in Lincolnshire, England.25 In England, doctors Harrison, Little, Hood, Paget, and Dods all incorporated some variant of spinal manipulative therapy into their practices, even though spinal manipulation was still regarded as risky by orthodox practitioners.1 Perhaps the best-known English bonesetter was Sir Herbert Barker, who was knighted for his efforts, and who, by 1906, was calling himself an osteopath.12 The literature on bonesetting is extensive. In Germany bonesetting was called “Knocheneinrichter” or “Wundarzt.” In France the term was “reboutage” or “bailleul,” in Czechoslovakia, “napravit,” in Spain, “algebrista.”26 Whatever it was called, the practice of bonesetting became widespread during the eighteenth and nineteenth centuries. Dintenfass writes, “The art of manipulation, often called ‘bonesetting,’ was handed down from father to son, or mother to daughter, and was practiced by at least one supposedly ‘gifted’ person in most communities in Europe and Asia . . . The results obtained by these individuals were so unusual that the people believed that they inherited a divine gift to heal the sick!” (Figs. 1–7 and 1–8).27 Anderson speculates that the “Little Tradition” of unlettered villagers—bonesetting—coexisted for

HISTORY OF SPINAL MANIPULATION

11

FIGURE 1–8. This photograph shows a bonesetter manipulating the low back. It was taken near Vannes in Brittany, France, circa 1880. (Courtesy Mus´ee des Arts et Traditions Populaires, Paris.)

centuries with the “Great Tradition” of the literate urban elitists—medicine and surgery. He hypothesizes that each practiced a form of spinal manipulation “in a complex and fluctuating give-and-take of imitation and differentiation.”9 By the end of the nineteenth century physicians harbored ambivalence toward bonesetters. Anderson asserts that it was a well-established part of the medical culture to express disdain for bonesetters, but physicians also acknowledged bonesetters’ popularity with their patients.9 One of the most famous surgeons of the day, James Paget, recommended in The British Medical Journal that physicians should learn what is good from bonesetting and avoid what is bad.28 Another physician, Wharton Hood, defied the medical ethics of the time and apprenticed himself to a bonesetter. Publishing in The Lancet, he offered the medical professions a basic primer in extremity adjusting, but failed to describe spinal manipulation.9 In the United States well-known bonesetters were Bonesetter Reese, of Pennsylvania and Ohio, and the Sweet family, who practiced in Rhode Island, Massachusetts, Connecticut, and New York. The Sweets attracted patients from all over the East Coast, and even received many referrals from medical doctors. Joy attributes the open-minded attitude on the part of the medical profession to the Sweet’s skill and to the fact that they did not exploit their patients. The last of the Sweets practiced in Rhode Island until 1917 (Fig. 1–9).26

While the descendants of the Sweet family went on to become orthopedists, descendants of a popular bonesetting family in South Dakota, the Tieszens, went on to become chiropractors, as did the descendants of the South Dakota Orton family, who were so successful that they built a four-story, 72-room hotel with an attached clinic to accommodate their many patients.23 Joy attributes the decline of the bonesetters to the fact that orthopedic knowledge was becoming more and more a part of the general physician’s skills.26 In the 25-year period between Paget’s and Hood’s publications on bonesetting and D. D. Palmer’s performing the first chiropractic adjustment, very little was written about spinal manipulation.19,29 An occasional endorsement would appear, including one 15 years after Palmer’s discovery that stated: “It is very remarkable that the medical profession should so long have neglected such a wide field of therapeutics.”19 Interestingly enough, only 11 years before the first chiropractic adjustment was to be administered, E. Dailly writes of manipulating the bony framework of the body, “grasping the spinous processes with the fingers.”2 Dailly goes on to say, “The treatment should therefore be directed either at the articulations or the nervous system.”2 According to Gaucher, “It would seem that those who objected to the concept of vertebral subluxation as proposed by Palmer ten years later had not assimilated all the data that the classic scientific medical discourse placed at their disposal.”2

12

CHIROPRACTIC PRINCIPLES

FIGURE 1–9. A nineteenth century migrant from Bohemia (Czechoslovakia) administering a spinal adjustment. (From Smith, et al., 1906, p. 11. Courtesy of David D. Palmer Health Sciences Library, Palmer College of Chiropractic.)

FIGURE 1–10. This early medical drawing illustrates the awareness of the relationship between spinal nerve roots and distant parts of the body. (From Monell CG. Rheumatism, Acute and Chronic. 1845, p. 20.)

HISTORY OF SPINAL MANIPULATION

13

Spinal Irritation The link between a problem with a spinal vertebral segment and pain or a diseased organ at some distance away was unfamiliar to most doctors by the nineteenth century (Fig. 1–10). Monell wrote in 1845, “This symptom has been carefully noticed by a few, superficially by several, but totally neglected by the great majority of Practitioners.”6 Other authors in the early part of the nineteenth century noted the relationship between the spine and organic disorders. Stanley observed, “The internal organs, specifically of the abdomen and pelvis, variously participate in the nervous derangements ensuing from disease in the spine.”30 The theory of spinal irritation was promulgated early in the nineteenth century. It originated with Dr. Thomas Brown in Glasgow in 1828, and was mentioned 4 years later by Dr. Isaac Parrish of Philadelphia.22,31 In 1843, J. Evans Riodore, a Fellow of the Royal College of Surgeons, wrote A Treatise on Irritation of the Spinal Nerves. Gaucher quotes Riodore, claiming that he had to read the quotation twice to ascertain that it had really been written in 1842, “The cause is never suspected to be in the spine, and the latter is never examined; the subluxated vertebra is never replaced in its original lineal direction.”10 Riodore goes on to declare that, because spinal nerves reach out to every organ and muscle in the body, “We cannot be otherwise than prepared to hear of a lengthened catalogue of maladies that are either engendered, continued or the consequence of spinal irritation.”19 Magnetic Healing Influential in the development of both osteopathy and chiropractic was the practice of magnetic healing. D. D. Palmer practiced magnetic healing for nine years before formulating his theory of chiropractic. “Andrew Taylor Still, Magnetic Healer” was how Still, the founder of osteopathy, was billing himself in 1875.32 But what was most significant was the fact that practitioners of magnetic healing, faith healing, and mental healing often made bodily contact with their hands when treating patients (Figs. 1–11 and 1–12). According to Homola, the Mormon leader, Joseph Smith, Jr. practiced faith healing, using bonesetting techniques. One of his elders advertised that while setting bones, “they came together, making a noise like the crushing of an old basket.”10 Since only the joints of the spine give such a sound, Homola concludes that the laying on of hands was conducted with some force, not unlike that of chiropractic adjustments. Others were using magnetic healing techniques. Andrew Jackson Davis (b. 1826–d. 1910), a leading exponent of spiritualism, placed emphasis on healing, with his hands, which consisted of vigorous rubbing

FIGURE 1–11. This shows position of hands in treating heart or lungs. Right hand over upper dorsal plexus, left hand over heart or lungs. (From Weltmer SA. Revised Illustrated Mail Course of Instruction in Magnetic Healing, 1901.)

FIGURE 1–12. A. T. Still, the founder of osteopathy. (Courtesy Still National Museum of Osteopathy, Kirksville, Missouri.)

14

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the rotated spinous and transverse processes into a more favorable position.”1 Another mention of using the spinous process as a lever is presented by Gaucher, citing Warner’s treatment for scoliosis: “Where the deviation is not very advanced a degree of correction can be obtained by grasping the spinous processes with the fingers.”1 Gaucher concludes that Palmer was not familiar with Dechambre’s Dictionary, or he would not have claimed to be the first to use the spinous process to effect a correction. Wardwell concludes that there was more conceptual continuity between Palmer and his predecessors than previously believed, and that “chiropractic was not such a radical break with the past, but rather the product of a long evolutionary development.”1

THE TWENTIETH CENTURY AND BEYOND

FIGURE 1–13. A. P. Davis, MD, DO, DC (1835–1915), performing an osteopathic manipulation. (From Davis AP. Osteopathy Illustrated, a Drugless System of Healing, 1899.)

along the spine (Fig. 1–13).32 Warren Felt Evans (b. 1817–d. 1889) wrote that “By the friction of the hand along the spinal column an invigorating life-giving influence is imparted to all the organs within the cavity of the trunk.”1 A. T. Still, the founder of osteopathy, was able to synthesize some of the major components of bonesetting and magnetic healing into one unified theory.32 D. D. Palmer did so, too, although his chiropractic theory was based on different concepts than osteopathy. Palmer was adamant about the influence magnetic healing had on chiropractic, declaring he never would have been able to conceive his chiropractic theory without his experience as a magnetic healer. Palmer wrote, “I saw fit to date the beginning of chiropractic with the first adjustment, although quite a portion of that which now constitutes Chiropractic I had collected during the previous nine years.”33 Although Palmer never claimed to have been the first to replace subluxated vertebrae, he did claim to be the first to use the spinous and transverse processes as levers. Wardwell suggests otherwise.1 He refers to the British surgeon W. J. Little, who mentions Harrison’s technique of “endeavoring to press

Osteopathy Gevitz concludes that manipulation and massage did not make the transition from their early roots to the armamentarium of the medical practitioners of Still’s time because “most American and English MDs felt it was beneath them to administer treatment with their hands.”32 Mennell stated that massage and manipulative therapy were passed over because it was “impossible for conscientious practitioners” to employ them when they lacked faith in the philosophy espoused by those who did.34 The neglect of orthodox medicine allowed manipulation’s efficacy to be “discovered” by Andrew Taylor Still, by Daniel David Palmer, and by others, because no one disputes the healing power of touch whether the mechanism by which it works is understood, accepted, or even important to those who seek its relief. Andrew Taylor Still was a frontier doctor in Kansas. His experiences as a Union field doctor in the Civil War followed by the loss of three children to typhoid after the war left him disenchanted with the state of orthodox medicine. He was fascinated by human anatomy, and most particularly the bony structure. Still was influenced by the spiritualist fervor sweeping the country and practiced as a magnetic healer for a time. He added bonesetting to his list of talents and by the 1880s was advertising himself as the “lightning bonesetter,”32 a designation that seems to denote great speed. In 1874, Still announced a new medical theory, osteopathy, which was greeted with such derision that he was “read out” of the Methodist church,35 barred from presenting his concepts at Baker University, a school his family had helped found,32,35 and run out of town. He relocated to Kirksville, Missouri, where the populace welcomed him. On October 3, 1892, he and William Smith, a European-trained medical doctor,

HISTORY OF SPINAL MANIPULATION

welcomed the first students to the American School of Osteopathy. Founded on spinal manipulation in place of materia medica, osteopathy was supposed to reform medicine, not replace it.36 The conceptual basis of osteopathy was that the body was a machine and the physician an engineer.37 Still postulated the rule of the artery in 1870 while many early osteopaths subscribed to the nerve pressure theory.17,38 Osteopaths have been described by Helminski as the “Protestants of orthodox medicine.”37 Still’s early osteopathic concepts included the supremacy of blood flow,39 surgery only in the case of emergencies, and a complete disavowal of drugs. Previous manual systems were thought to use a “shotgun method” of general manipulation, while osteopathy “works with the definite aim of finding the obstruction to health and removing it.”32 Although claiming specificity, osteopaths still worked to restore physiologic harmony even in the absence of palpable anatomic displacement. Still and his followers added a focus on the spine. The early faculty was able to lay a scientific basis for Still’s work, integrating it with medical discoveries of the time.32 Clinicians awaited the millennium when “regular” medicine would discover the accuracy of osteopathic teachings and adopt them. Their work done, DOs would then be reunited with MDs in the “Truth.”37 Toward the end of the nineteenth century, legislatures and courts started tightening up on the unregulated practice of medicine. Under common law, anyone could practice medicine in the absence of a statute requiring licensure or other qualifications. The purpose of law is to protect society, and it was believed that few members of the public were able to judge for themselves the qualifications of medical practitioners.37 With a national association founded in 1847, the regulars or orthodox physicians were in a position to influence legislation. When established, state boards of medical examiners were frequently dominated by traditional physicians.37 In the 1870s and 1880s, several states granted allopaths, homeopaths and eclectics separate boards. Boards were then combined and a representative of each sect was placed on a single board.32 After this experience, legislatures were reluctant to empower separate boards, so osteopaths found it difficult to obtain separate licensing. Medical boards required that candidates be proficient in surgery and materia medica, subjects not be taught in osteopathic colleges. The first attempt at osteopathic legislation was in its home state, Missouri, in 1895. Although the bill passed both houses, it was not signed by the governor.40 In 1896, Vermont licensed osteopaths.37 In its 1897 medical practice act, Illinois included osteopathy and magnetic healing under the definition of medicine. Other states were not as open to the new

15

“branch” of medicine. In those states where osteopathy did not have its own separate legislation, osteopaths could be charged with practicing medicine without a license. In a 1900 case (Nelson v. State Board of Health) where an osteopath was charged with practicing medicine without a license, the court found for the osteopath, reasoning that the law did not apply to the appellant at all, as what he did could not be construed as the practice of medicine; he was likened to a nurse. This became a landmark case, cited by other courts to show osteopathy was not medicine.37 The definition of “practice of medicine” became the primary legal point at issue. Orthodox medicine wanted the interpretation to be as broad as possible; osteopathy wanted the interpretation to be the practice of administering drugs.32 The courts tended to use a narrow interpretation. The courts also tended to interpret osteopathy as it had been at its founding, giving no credence to developments made in education and practice. The profession had to appeal to legislatures for relief and by 1900, several states had osteopathic statutes either exempting DOs from the medical practice acts or establishing separate licensing mechanisms. In the legislatures, the medical drive was that osteopathy be specifically outlawed while osteopaths were campaigning for separate licensing boards.35 The National School of Osteopathy was established in Kansas City in 1895,32 and was headed up by Drs. Elmer and Helen Barber. Elmer Barber wrote the first book ever published on osteopathy and in it, he claimed that Still was wrong on a number of important theoretical issues (Fig. 1–14).32 The text was used by medical physicians as an illustration of their contention that osteopathy was a fraud. By 1900, there were 13 osteopathic schools in the United States.32 The relations between the new colleges and the American School were at best polite “and at worst, openly hostile.”32 Still believed that the other schools “stole” students that were rightfully his and that his graduates had neither the training nor practical experience to teach osteopathy on their own.32 Although Still was to remain the revered figurehead of osteopathy throughout his lifetime, his followers started broadening their scope of practice as soon as the early 1900s,37 first adding obstetrics and then surgery. This was the first philosophical split, but these two additions were eventually endorsed by Still. Those who remained loyal to the tenets of Still became known as “lesion” osteopaths, and those who campaigned for routine surgery and materia medica became “broad” osteopaths.32 Adjuncts such as hydrotherapy, suggestive therapeutics, and electrotherapy were the next additions sought by the broad osteopaths, and Still and the lesionists considered these and pharmacology as heresy.32

16

CHIROPRACTIC PRINCIPLES

FIGURE 1–14. Elmer Barber founded the National School of Osteopathy in Kansas City in 1895. (From Barber E. Osteopathy Complete. Kansas City, MO: Hudson-Kimberly Pub. Co., 1898.)

In the early part of the twentieth century, osteopaths found themselves caught on the horns of a dilemma. Their predecessors had used a “straight” argument to exempt themselves from medical legislation. State licensing laws often excluded surgery,32 but when later practitioners tried to establish osteopathy’s equality with medicine, asserting that they were qualified in the use of drugs and surgery, the earlier arguments of purely manipulative practice would rise up against them.37 In 1915, the restrictions against the teaching of materia medica in the schools was lifted but a reported great success during the influenza epidemic of 1918–1919 once again gave credence to osteopathic fundamentalism and materia medica was removed from the curricula, not to reappear until 1929, when a curriculum for pharmacology was approved.32,37 During the 10 years between 1897 and 1907, the number of osteopathic graduates rose from 63 to 2765.37 Manipulative therapy remained an integral part of most osteopaths’ practices, as they believed this modality gave them a decided edge over their medical counterparts. In obstetrics, manipulation was thought to “shorten hours of labor, lessen accompanying pain, prevent mastitis and secure a more rapid convalescence of the patient.”35 Between the world wars, the profession moved from using the label “osteopath” to “osteopathic physician.” DOs progressed in legal status and the variety of functions they performed. With separate boards and a general recognition of the quality of

the colleges, osteopathic physicians took on more of the functions associated with medical physicians (e.g., surgery, prescription of drugs, issuance of birth and death certificates, and the filling of offices such as coroner and school physician).37 Denied commissions during the wars but exempt from the draft, osteopathic physicians filled the void left by the very medical physicians who had campaigned against their appropriateness in the military, assuming their civilian patient loads.32 When osteopathy was able to practice under its own set of licensing boards, the MDs began lobbying for basic science examinations that would be taken prior to the state boards, thus circumventing profession-specific boards. In 1930, the pass rate for the seven state basic science exams in effect was 88.3% for MDs, 54.5% for DOs, and 21.9% for DCs.32 Manipulative therapy as an integral part of osteopathic patient management began a steady decline after 1930.32 Gevitz attributes this to institutional changes (i.e., alterations in the social structure of the colleges, hospitals, and office practice) and to scientific changes (i.e., transformations in the osteopaths’ knowledge base). Basic science instructors did not necessarily have osteopathic backgrounds and as more time was spent on pharmacology and surgery, less was available for osteopathic instruction. The DOs started to adopt more and more allopathic practices and standards.41 Osteopathic surgeons began to argue that manipulative therapy was only appropriate in an ambulatory setting. The shift from chronic to broad-based practices increased the demand for care and thus reduced the frequency and length of osteopathic treatments. The Spinalator and pharmacotherapy replaced hands-on practice. Patients not socialized into the traditional osteopathic approach were less likely to expect or desire manipulation.32 By the end of the 1950s, most Journal of the American Osteopathic Association (JAOA) articles failed to mention osteopathic manipulation therapy/treatment (OMT) and when they did, the mention was brief and the OMT was an adjunct to other treatment within the sphere of medicine. The use of manipulative therapy was decreasing in colleges of osteopathy and increasing in the orthopedic and physiatry departments of medical schools.32 A 1954 survey of all DOs graduating between 1948 and 1953 found that only 44% used OMT on more than half their patients, citing lack of training in palpation and manipulation along with the growing number of internships in allopathic settings.41 Approximately 10% of active DOs still confined themselves to distinctive osteopathic procedures, either by choice or by state law, but this group steadily shrank each year32 and DOs officially remained cultists in the eyes of the American Medical Association (AMA).

HISTORY OF SPINAL MANIPULATION

In 1962, osteopathy achieved the nadir of its professional history when the California Osteopathic Association, after 19 years of negotiation, merged with the California Medical Association. California was a stronghold for broad osteopaths. The contract of merger stipulated that DOs would become MDs in the state of California and that they should cease identifying themselves with the osteopathic profession. The osteopathic college would be immediately converted into a medical college. The MDs favored the merger because they saw the DOs as an inferior group that was lowering the general quality of health care in the state. The upside of the merger was the perception that if California considered DOs and MDs were equivalent, they must be. In 1963, the Civil Service Commission said that for its purposes, the MD and DO degrees were to be considered equivalent.32 DOs began to be called upon to give expert testimony in court, circumventing the longstanding “conspiracy of silence” in which MDs refused to testify against each other.37 The Michigan State University College of Osteopathic was chartered in 1964, the first osteopathic school associated with a state university.37 Helminski, in his 1981 master’s thesis, stated that the “equation of osteopathy with manipulation has plagued the movement throughout its life . . . it has given rise to the present myth that osteopathy began as a cult of manipulation, and later somehow outgrew its origins to embrace ‘scientific medicine.’”12,37 He later uses the word “tainted” in referring to the emphasis on manipulation.37 In the twenty-first century, manipulation has become a specialty within osteopathy, the same role it appears to be headed for in orthodox medicine. A position statement of the American Osteopathic Association (AOA) directs its members to refer to themselves as osteopathic physicians and to use “osteopathic manipulative treatment” in place of “osteopathic manipulative therapy,” presumably to avoid confusion with physical therapy.42 In 1998, Guglielmo reported that DOs are becoming too much like MDs in an effort to achieve parity and that distinctive practices like OMT are being lost. What does make the osteopathic physician unique is doctor-patient connectedness. Dr. Patricia Roy describes it more graphically as “touchy-feely.”42 Louisiana, the last state to recognize chiropractic, still won’t accept the osteopathic profession’s national licensing exams. Although the osteopathic profession is represented by its professional organization, the AOA, the practitioners of osteopathic medicine are recognized by the AMA as physicians with full qualifications.43 The research on spinal manipulation therapy is led today by chiropractors, with OMT being studied to a lesser degree.39 The need for research is still paramount, but the manipulative equivalent of a

17

placebo remains elusive.42 A uniquely American product, osteopathic medicine has spread around the world. The British College of Naturopathy and Osteopathy, founded in 1936, offers a Bachelor of Science Degree in Osteopathic Medicine.44 The regulation of practice is not as formalized as in the United States. Naprapathy Naprapathy, formulated in 1905 by Oakley Smith,4 was based on the principle that “ligatites” caused the vertebrae to draw too closely together, obstructing nerves and blood vessels, which resulted in disease (Fig. 1–15). The ligaments could be stretched back to normal by manual adjustments.4,36 Smith founded the Chicago College of Naprapathy in 1905. He devised a system of charting areas of tension of the spine and classified physical disorders by symptoms. Both Palmer and Smith denied that naprapathy was a branch of chiropractic.4 Naprapaths were originally eligible for licensure under the Illinois Practice Act. In 1949, another college

FIGURE 1–15. Oakley G. Smith, DC (1880–1967), an 1899 graduate of D. D. Palmer, named the ligatite that became the basis of his healing art: naprapathy. (Courtesy Palmer College of Chiropractic Archives, Davenport, IA.)

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CHIROPRACTIC PRINCIPLES

of naprapathy was formed in Chicago and the two schools merged in 1971.4 The Naprapathic Practice Act of 1995 allows for limited doctoral licenses similar to those granted to optometrists or dentists and has been the impetus for a dramatic growth in the profession.45 In 1986, there were an estimated 800– 1000 naprapaths practicing in Illinois.4 The practice of naprapathy today concentrates on connective tissue manipulation and includes exercise, postural and nutritional counseling, and other therapeutics.45 Manual Medicine Manipulation does not have a clear identity within orthodox medicine in North America. Medicine comes to manipulation through the back door, if not from the cellar. European medical doctors, however, did not share the disdain for manual medicine evidenced by the Americans and British. In 1903, Naegeli, a Swiss doctor, used traction manipulation on the cervical spine in the treatment of headache.46 In 1945, a group of German doctors became interested in manipulation,46 after a series of lectures by members of the European Chiropractic Union. During the same era, The London College of Osteopathy offered training in manipulation to qualified allopaths. Graduates of this program have played an important part in developing manipulative medicine throughout Europe. Robert Maigne gave courses in manipulation at the Medical Faculty of the University of Paris, attended mainly by specialists in physical medicine.16 A prominent pioneer of medical manipulation in the 1950s was James Mennell, an outspoken protagonist of osteopathic techniques which he also taught, mainly to physiotherapists.36,46 He explained the reluctance of medical physicians to employ massage or manipulative because it would have been “impossible for conscientious practitioners to do so when they lacked faith in the creed which has been so commonly attached to the performance of those outside of the [medical] profession.”34 By 1955, training in manipulative therapy was decreasing in colleges of osteopathy but was increasing in the orthopedic departments of medical schools.32 Writing in the 1960s, John M. Mennell opined, “The condition of joint dysfunction is the only pathologic condition that will respond to the treatment of manipulation. . . . Manipulating joints is an art and, as with so many arts, not everyone can expect to be able to learn to use it.”44 In Europe, the reluctance to include manipulation within orthodox medicine lies in the universities.47 Postgraduate courses taught outside the universities are generally recognized by insurance companies as adequate training to qualify for reimbursement.46 The discovery of the mechanical role of disc prolapse in root syndromes made doctors aware of the

possibilities of traction and even of other methods of mechanical treatment, including manipulation. In this way a somewhat paradoxical situation developed: While the osteopaths and chiropractors, who were regarded by the medical profession as “quacks,” were elaborating sophisticated manipulation techniques, medical doctors also began to include spinal manipulation methods, sometimes employing anesthesia.48 A number of medical physicians in Europe and the United States have promoted the idea that manipulation should be performed by qualified medical doctors only, striving to keep the monopoly for the profession.16,36,46,47 Manual medicine has been included within the specialties of general practice, physical medicine and rehabilitation, rheumatology, orthopedics, and neurology.47 The first international meeting of those practicing manual medicine took place in Switzerland in 1958. At the second meeting in 1962, it was decided to form an international body and in 1965, the International Federation of Manual Medicine (F´ed´eration Internationale de M´edicine Manuelle, or FIMM) was formed.46 Today, there are 21 national associations affiliated with FIMM, mainly from Europe and Australia.16 Great Britain and the United States have lagged behind in developing a well-defined specialty of manual medicine.48 In the United States, the physician with manipulative skills can often be found working with professional and amateur athletes.49 In the 1970s and 1980s, the field of manual medicine began to analyze its successes and failures, searching for neurophysiologic explanations.47 In 1975, the National Institute of Neurological and Communicative Disease and Stroke of the National Institutes of Health appropriated funding for a workshop on the status of chiropractic which evolved into the research status of spinal manipulative therapy. The 1975 conference, held in Bethesda, Maryland, was attended by 58 scientists and clinicians from the United States and eight other countries, and included doctors of medicine, osteopathy, and chiropractic, along with specialists in 11 basic sciences. One of the tasks they set for themselves was the search for the neural biologic basis for manipulative therapy.36 Mainline medical journals are increasingly reporting and analyzing the results of research into manipulation,50–53 but orthodox medicine is finding many of the same hindrances to manipulative research that has hamstrung osteopathic and chiropractic research for so long.54 Physical Therapy Massage developed as a profession around 1900, as did physiotherapy. Physiotherapists originally used massage and exercise as the primary treatment

HISTORY OF SPINAL MANIPULATION

approach.55 The first professional association for physiotherapists was founded in 1921 as the American Women’s Physical Therapeutic Association. Members were known as “Reconstruction Aides.” Membership was opened to men in the 1930s and the name was changed to the American Physiotherapy Association, then changed to the American Physical Therapy Association (APTA) in the late 1940s. The polio epidemic of the 1940s and 1950s increased the demand for physiotherapists (the term is interchangeable with physical therapists).56 Historically, physiotherapists have worked under the guidance of medical authority.47 They have been functioning as primary evaluators of neuromusculoskeletal conditions in the army since the early 1970s and are assuming greater responsibility for the initial assessment and management of patients.29 The diagnostic skills of physical therapists, however, have been under attack by many medical practitioners of manipulation. In 1984, Dvorak wrote, “The physical therapist is neither trained nor authorized to discern the contraindications to classic manipulation procedures. The physician only can judge if and what further work-up is in order and follow up accordingly.”47 In 1992, the journal Physical Therapy published a special issue devoted to manual/manipulative therapy. In the editorial for the issue, Rothstein wrote, “This approach to the management of musculoskeletal disorders has become mainstream, a part of every curriculum, and for some the raison d’ˆetre for much of our practice.” He bemoaned the lack of research appearing in credible, peer-reviewed journals, stating, “There has been little maturation and very little scientific development in this area. It has been as if popular opinion precluded the necessity of research and refinement.”57 Other articles in that issue dealt with treatment for back and joint pain by manual therapy,58 and the efficacy of manual therapy.59 Farrell and Jensen assessed the role of manual therapy in the physical therapy profession. “Manual techniques include massage, distraction and traction techniques, specific (specific to one vertebral motion segment, such as L4-5) or general (specific to a region of the spine, such as L1-S1), high-velocity manipulation and joint mobilization, and what is called ‘adverse neural tissue mobilization.’” Hours of classroom instruction in manipulative therapy are on the rise.60 In the United States today, the physical therapist has shown the strongest interest in mobilization techniques.36 Farrell and Jensen proposed that the choice of the term “mobilization” was to avoid strong association with the word “manipulation” within the chiropractic profession.60 Mobilization is already an accepted term in some physical therapy state practice acts.60 Low back pain is the condition most frequently

19

treated in outpatient settings.61 Most authors, however, differentiate between mobilization, manipulation, and manual therapy. The Practice Affairs Committee of the Orthopaedics Section of the APTA assumes the following position: 1. Manipulation in all forms is within the scope of practice of the licensed physical therapist. 2. The force, amplitude, direction, duration, and frequency of manipulative treatment movements is a discretionary decision made by the physical therapist on the basis of education and clinical experience and on the patient’s clinical profile. 3. Manipulation implies a variety of manual techniques which is not exclusive to any specific profession.60 As part of the 2001 Balanced Budget Refinement Act, Congress lifted the Medicare $1500 cap on physical therapy services. To address the utilization of physical therapy services, Congress mandated the Centers for Medicare and Medicaid Services to develop utilization guidelines for physical therapy services. The PT guidelines include language that could allow physical therapists to perform spinal manipulation. In a current draft, for Current Procedural Terminology (CPT) code 97140 (manual therapy techniques), “manipulation may be medically necessary for the treatment of painful joint or soft tissue restrictions of the spine or extremities.”62 SUMMARY 1. Spinal manipulation has been practiced for over two millennia. A Chinese text written two thousand years ago describes massage and exercises, and centuries later, another Chinese text illustrates a form of gravity traction. In the Western World Hippocrates describes a technique of spinal manipulation in the fifth century, bc. During the Middle Ages Hippocrates’ technique was diffused through the influential work of Avicenna of Baghdad, and reappeared in Western Europe through the writings of Ambroise Par´e. A tradition of folk healing or unschooled healers using manipulation coexisted with the manipulation of the urban practitioners for centuries. By the middle of the nineteenth century, urban practitioners viewed spinal manipulation with ambivalence, but it continued to be championed by a few medical practitioners, notably James Paget and Wharton Hood. Into this milieu appeared Daniel Palmer, who performed the first chiropractic adjustment in 1895.

20

CHIROPRACTIC PRINCIPLES

2. As early as Hippocrates, physicians were attempting to treat man as a whole. Hippocrates is quoted as saying curative forces come from within and that we should study the patient. Galen emphasized knowing the points of emergence of the spinal nerves and how they affect the body. By the seventeenth century, the interest in bodily humors brought an increased interest in musculature, rather than the skeletal system, with a concurrent interest in massage and friction, rather than manipulation. Physicians began to believe that manipulation was dangerous, perhaps because of the widespread occurrence of tuberculosis. In the first half of the nineteenth century Brown, Parrish, and Riodore promulgated the theory of spinal irritation and the relationship between a problem with a vertebral segment and a diseased organ. Magnetic healing developed the theory that the friction of the hand along the spinal column imparted a life-giving influence. Osteopathy, developed by Andrew Still in the late nineteenth century, theorized that blood flow or the lack of blood flow was decisive in causing or curing disease. Palmer focused on the nervous system as his rationale for spinal adjustment, and taught a specific adjustment of a particular segment to correct a specific subluxation. 3. Although long a part of healers’ art, manipulation became a distinct entity within health care in the late nineteenth century with the founding of osteopathy. The theory behind manipulation’s success in treating ailments varies from profession to profession, as do the purposes for which it is used. The practice and the outcomes remain similar, governed by the body’s structure and reaction to the manipulation. Osteopathy considered the body as a machine and the physician as an engineer, employing specific long lever movements to restore physiologic harmony. Naprapathy was based on the theory that ligatites caused the vertebrae to draw together and obstruct nerves and blood vessels. Relief was considered granted through connective tissue manipulation. Physical therapy used mobilization techniques for the treatment of painful joint or soft tissue restrictions of the spine or extremities.

4. Briefly discuss the role of manipulative therapy in the practice of osteopathy from its inception to the present. 5. What has been the evolution of manipulation by physical therapists during the past century?

ANSWERS 1. The Kung Fou document describes a form of manipulation practiced in China as early as 2700 bc. Centuries later, the Golden Mirror of Medicine shows a form of gravity traction being used to treat the spine. 2. Hippocrates described two forms of early manipulation, gravity traction and rachiotherapy. He repeatedly stressed the importance of knowing the spinal column, and is often cited as the source of the aphorism, “Look well to the spine for the cause of disease.” 3. Although bonesetting had a long tradition prior to the nineteenth century, during the nineteenth century it became identified with the humble traditions of the working class. The lay public continued to seek out bonesetters for conditions like sciatica, lumbago, and rheumatism, even though bonesetters were refused access to hospitals. A few medical doctors, Harrison, Hood, and Paget, continued to study and incorporate bonesetting techniques into their practice and published the results of their work. 4. Osteopathy was originally based on manipulation, but manipulative practice began to decline as osteopaths moved closer to their allopathic brethren, incorporating materia medica and surgery in the era between the world wars. By the end of the 1950s, manipulative therapy appears to be an adjunct to other traditional medical treatments. Today, manipulation has become a specialty within osteopathy. 5. Although manipulation may have been a part of the armamentarium of the physical therapist from its earliest times, it was not separated out as a distinct treatment until the 1990s. In the short time since then, the physical therapy profession has shown a strong interest in mobilization, suggesting that manipulation in all forms is within their scope of practice.

QUESTIONS 1. Give two examples of manipulation in Eastern healing. 2. Describe the contribution Hippocrates made to the tradition of manipulation. 3. Discuss the role of bonesetting in the nineteenth century.

KEY REFERENCES Anderson RT. On doctors and bonesetters in the 16th and 17th centuries. Chiropr Hist 1983;3(1):13–14,20–21. Gaucher-Peslherbe PL. Antecedents to chiropractic. In: Peterson DR, Wiese GC. Chiropractic: An illustrated history. St Louis: Mosby, 1995.

HISTORY OF SPINAL MANIPULATION

Gaucher-Peslherbe PL. Chiropractic: Early concepts in their historical setting. Lombard, IL: National College of Chiropractic, 1993. Gevitz N. The DO’s: Osteopathic medicine in america. Baltimore: Johns Hopkins Press, 1982. Harris D. History and development of manipulation and mobilization. In: Basmajian JV, Nyberg G. Rational manual therapies. Baltimore: Williams and Wilkins, 1993. Lewit K. Manipulative therapy in rehabilitation of the locomotor system, 3rd ed. Oxford: Butterworth-Heinemann, 1999. Ligeros KA. How ancient healing governs modern therapeutics. New York: Putnam, 1937. Lomax E. Manipulative therapy: A historical perspective from ancient times to the modern era. In: The research status of spinal manipulative therapy: A workshop held at the National Institutes of Health, February 2–4, 1975. DHEW Publication No. (NIH) 76-998; Bethesda, MD: 1975. Schiotz EH, Cyrix J. Manipulation past and present. London: William Heinemann Medical Books, 1974. Wardwell WI: Before the Palmers: An overview of chiropractic’s antecedents. Chiropr Hist 1987; 7(2):27–33. Wardwell WI. Chiropractic: History and evolution of a profession. St. Louis: Mosby, 1992.

REFERENCES 1. Wardwell WI. Before the Palmers: An overview of chiropractic’s antecedents. Chiropr Hist 1987;7(2):25–33. 2. Gaucher-Peslherbe PL. Chiropractic: Early concepts in their historical setting, p 12. Lombard, IL: National College of Chiropractic, 1993. 3. Wilk CA. Chiropractic speaks out: A reply to medical propaganda and ignorance. Park Ridge, IL: Wilk Publishing Co., 1973. 4. Zarbuck MV. A profession for ‘Bohemian chiropractic’: Oakley Smith and the evolution of naprapathy. Chiropr Hist 1986;6(1):78. 5. Riley JS. Science and practice of chiropractic with allied sciences. Washington, DC: self-published, 1925. 6. Anderson RT. Hawaiian therapeutic massage. WorldWide Report 1982;24(5):4A. 7. Anderson RT. The treatment of musculoskeletal disorders by a Mexican bonesetter (Sobador). Soc Sci Med 1987;24:43–46. 8. Eisenberg AM. Medicine vs. chiropractic: A rhetorical analysis. DCE 1990;33(2): 106–107. 9. Anderson RT. Spinal manipulation before chiropractic. In: Haldeman S. Principles and practice of chiropractic. Norwalk, CT: Appleton & Lange, 1992. 10. Gaucher-Peslherbe PL. Antecedents to chiropractic. In: Peterson DR, Wiese GC. Chiropractic: An illustrated history. St Louis: Mosby, 1995. 11. Mindich JH. Five millennia of medical practice. Free China Rev 1987;37(2):10–27. 12. Anderson RT. On doctors and bonesetters in the 16th and 17th centuries. Chiropr Hist 1983;3(1):13–14, 20–21. 13. Homola S. Bonesetting, chiropractic, and cultism. Panama City, FL: Critique Books, 1963.

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14. Waerland A. Die chiropraktik und ihre erfolge im lichte der menschheitsentwicklung. Bern: Blume, 1960. 15. Ligeros KA. How ancient healing governs modern therapeutics. New York: Putnam, 1937. 16. Lewit K. Manipulative therapy in rehabilitation of the locomotor system, 3rd ed. Oxford: Butterworth-Heinemann, 1999. 17. Drummer TG, Mahe A. Out on the fringe: Osteopathy, chiropractic and naturopathy. London: Parrish, 1963. 18. Morell E. Manipulation as a curative factor. London: Methuen & Co., 1931. 19. Schiotz EH, Cyriax J. Manipulation past and present, pp 59–60. London: William Heinemann Medical Books, 1974. 20. Beale LJ. A treatise on the distortions and deformities of the human body. Exhibiting a concise view of the nature and treatment of the principal malformations and distortions of the chest, spine, and limbs. London: John Churchill, 1833. 21. Tuscon EW. The cause and treatment of curvature of the spine, and diseases of the vertebral column. London: John Churchill, 1841. 22. Lomax E. Manipulative therapy: A historical perspective from ancient times to the modern era. In The research status of spinal manipulative therapy: A workshop held at the National Institutes of Health, February 2–4, 1975. DHEW Publication No. (NIH) 76-998; Bethesda, MD: 1975. 23. Wardwell WI. Chiropractic: History and evolution of a profession. St. Louis: Mosby, 1992. 24. Rothstein W. American physicians in the nineteenth century: From sects to science. Baltimore: Johns Hopkins University Press, 1972. 25. Harrison E. Pathological and practical observations of spinal diseases: Illustrated with cases and engravings. Also an inquiry into the origin and care of distorted limbs. London: T & G Underwood, 1827. 26. Joy RT. The natural bonesetters with special reference to the Sweet family of Rhode Island: A study of an early phase of orthopedics. Bull Hist Med 1954;28:416–441. 27. Dintenfass J. Chiropractic: A modern way to health, p 36. New York: Pyramid House, 1970. 28. Paget J. Cases that bone-setters cure. Br Med J 1867; 1:1–4. 29. Smith KL, Tichenor CJ, Schroeder M. Orthopaedic residency training: A survey of the graduates’ perspective. J Orthop Sports Phys Ther 1999;29(11):635–655. 30. Stanley E. Treatise on diseases of the bones. Philadelphia: Lea and Blanchard, 1949. 31. Parrish I. Remarks on spinal irritation as connected with nervous diseases. Am J Med Sci 1832;10:293–314. 32. Gevitz N. The DO’s: Osteopathic medicine in America. Baltimore: Johns Hopkins Press, 1982. 33. Palmer DD. Text-book of the science, art and philosophy of chiropractic. Portland: Portland Printing House, 1910. 34. Mennell JB. Manual therapy. Springfield, IL: Charles C Thomas, 1951. 35. Gevitz N. Osteopathic medicine. From deviance to difference. In: Gevitz N. Other healers. Baltimore: Johns Hopkins University Press, 1988. 36. Harris D. History and development of manipulation and mobilization. In: Basmajian JV, Nyberg G. Rational

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37. 38. 39.

40. 41. 42.

43.

44.

45.

46.

47. 48. 49. 50.

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manual therapies. Baltimore: Williams and Wilkins, 1993. Helminski FJ. The legal creation of osteopathic medicine. Detroit, MI: Wayne State University, 1981. Facts about osteopathy. Society for the Advancement of Osteopathy, 1922. Andersson GBJ, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med 1999;341(19):1426–1431. Hildreth AG. The lengthening shadow of Dr. Andrew Taylor Still. Macon, MO: self-published, 1938. Guglielmo WJ. Are DOs losing their unique identity? Med Economics 1998; April 27. American Osteopathic Association. Position statement. OMT–Osteopathic manipulative treatment. 1999. www.aoa-net.org. Accessed September 20, 2001. American Medical Association. Physician education, licensure and certification. www.ama-assn.org/aps/ physcred.html. Accessed September 20, 2001. British College of Naturopathy and Osteopathy. www.bcno.ac.uk/college.htm. Accessed September 20, 2001. Chicago National College of Naprapathy. www.naprapthy.edu/naprapathy.html. Accessed September 25, 2001. Lewit K. Manipulative therapy in rehabilitation of the locomotor system, 2nd ed. Oxford: Butterworth Heinemann, 1991. Dvorak J, Dvorak V, Scheider W. Manuelle medizine. Berlin: Springer, 1984. Paterson JK, Burn L. Introduction to medical manipulation. Lancaster: MTP Press Ltd., 1985. Haldeman S. Spinal manipulative therapy in sports medicine. Clin Sports Med 1986;5(2):277–291. Curtis P, Carey TS, Evans P, Rowane MP, Jackman A, Garrett J. Training in back care to improve outcome

51.

52.

53.

54. 55.

56.

57. 58.

59. 60.

61.

62.

and patient satisfaction. J Fam Prac. Jfponline.com/ content/2000/09/jfp 0900 07860.asp. Accessed July 8, 2001. Koes BW, Bouter LM, van Mameren H, Essers AHM, et al. The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints. Spine 1992;17(1): 28–35. Knipschild P, Kleijnen J, Ter Riet G. Belief in the efficacy of alternative medicine among general practitioners in the Netherlands. Soc Sci Med 1990;31(5):625–626. Ottenbacher K, DiFabio RP. Efficacy of spinal manipulation/mobilization therapy. A metaanalysis. Spine 1985;10(9):833–837. Grieve GP. Modern manual therapy of the vertebral column. Edinburgh: Churchill Livingstone, 1986. Gross AR, Aker PD, Quartly C. Manual therapy in the treatment of neck pain. Rheum Dis Clin North Am 1996;22(3):579–597. American Physical Therapy Association. www.apta. ort/about/apta history/history. Accessed September 25, 2001. Rothstein JM. Manual therapy: A special issue and a special topic. Phys Ther 1992;72(12):839–841. Twomey LT. A rationale for the treatment of back pain and joint pain by manual therapy. Phys Ther 1992;72(12):885–892. DiFabio RP. Efficacy of manual therapy. Phys Ther 1992;72(12):853–864. Farrell JP, Jensen GM. Manual therapy: A critical assessment of role in the profession of physical therapy. Phys Ther 1992;72(12):843–852. Sullivan MS, Kues JM, Mayhew TP. Treatment categories for low back pain: A methodological approach. JOSPT 1996;24(6):359–364. American Chiropractic Association. Executive VicePresident email weekly report Aug. 17, 2001.

C H A P T E R

2 A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION Joseph C. Keating, Jr.

O U T L I N E INTRODUCTION BEFORE CHIROPRACTIC A TRADITION OF PROTEST FROM MAGNETISM TO ADJUSTMENT THE CHIROPRACTIC PROTEST THE SPREAD OF CHIROPRACTIC PROSECUTION, PHILOSOPHY, AND LEGISLATION BASIC SCIENCE: THE NEW BATTLEFIELD EDUCATIONAL REFORM RESEARCH IN THE MIDDLE ERA:

SCIENCE AND PUBLICITY PUSH FOR RECOGNITION SUDDEN VICTORY MORE MOUNTAINS TO CLIMB THE RECENT PAST AND NEAR FUTURE CONCLUSION SUMMARY QUESTIONS ANSWERS KEY REFERENCES REFERENCES

OBJECTIVES

INTRODUCTION

1. To understand the historical context of the founding of chiropractic and to describe D. D. Palmer’s original experience and thinking. 2. To summarize the genesis of the struggle between “mainstream” medicine and chiropractic, and the efforts of chiropractic to obtain legal, institutional, and social legitimacy. 3. To describe and understand the initiation of various competing strands of thought and politics within chiropractic. 4. To identify the major individuals, events, and milestones in chiropractic history. 5. To appreciate the past and its effect on the current and future history of chiropractic and its institutions, educational and licensing processes, professional status, and science.

When historian Russell W. Gibbons quoted Brian Inglis (above) in the first edition of this book, historical scholarship bearing on chiropractic was still very much in its infancy. Two decades later, the saga of the profession remains largely unknown to the wider scholarly community, and only slightly more familiar to doctors of chiropractic (DCs) themselves. However, the intervening 20 years have seen a burgeoning of historical literature, encouraged largely by the efforts of Gibbons, William Rehm, DC, and others (see sidebar “Founders of the Association for the History of Chiropractic, 1980”) who organized the Association for the History of Chiropractic (AHC), created its periodical, Chiropractic History, and established the annual Conference on Chiropractic History.2 A much richer understanding of how chiropractic began and what the profession has come through is now possible. A way of thinking about the origins and development of a profession is as a series of steps toward legitimacy and cultural authority. The saga of chiropractic can be viewed in this fashion, with the caveat

The rise of chiropractic . . . has been one of the most remarkable social phenomena in American history . . . yet it has gone virtually unexplored.1 23

24

CHIROPRACTIC PRINCIPLES

Founders of the Association for the History of Chiropractic, 1980 Cheri D. Alexander, DC Eleanore Blaurock-Busch Fern L. Dzaman Leonard E. Fay, DC, ND Russell W. Gibbons Vern Gielow A. Earl Homewood, DPT, DC, ND, LLB Herbert K. Lee, DC Joseph E. Maynard, DC Ernest G. Napolitano, DC Arthur L. Nickson, DC Viola Nickson, DC James F. Ransom, DC William S. Rehm, DC James M. Russell, DC Richard C. Schafer, DC

that special circumstances have applied. This profession’s quest for recognition has been drawn out and complicated by an extended struggle for security (the right to exist). Confronted by a powerful adversary determined to “contain and eliminate” it,3 and by strenuous disagreements within its own ranks over the purposes and methods of chiropractic, legitimacy has been slow in coming and cultural authority remains beyond the horizon. Chiropractors’ historic isolation from the wider health services and scientific communities, although now beginning to lessen, has also delayed legitimization by retarding the interdisciplinary cross-fertilization that other health care providers have enjoyed. It has been, as Inglis and Gibbons point out, a remarkable story.

others. And, in the waning days of the nineteenth century, several of these alternative methods would be drawn together under one umbrella and combined with European hydrotherapy by German immigrant Benedict Lust, MD (1872–1945) (Fig. 2–1).10 Lust’s “naturopathy” (now often referred to as naturopathic medicine) would be a thorn in the side of chiropractic purists and the orthodox medical profession for decades to come. Proprietary or “patent” medicines were unregulated in this earlier era. The best ones were inert, while the more potent concoctions frequently contained liberal doses of alcohol or opiates. Unlike the heroic and highly toxic preparations of the “regular physicians,” patent medicines might well provide symptomatic relief, if only by deadening the senses. Any individual was at liberty to purchase whatever medicine the person preferred; patent medicines flourished. Various mechanical and electrical apparatuses, each claiming to build health or to relieve various diseases, vied with regular physicians for customer-patients. As well, the populist movement in the first half of the century had succeeded in repealing what licensing laws for doctors that had previously existed, and by 1852 anyone who

BEFORE CHIROPRACTIC Health care in the United States in the nineteenth century was a patchwork quilt of providers and remedies with very little regulation by government.4 Doctors of medicine (MDs) included heroic practitioners, homeopaths, eclectics, and practitioners of botanical medicine. Vying with the MDs for patients’ business were an assortment of what today are called complementary and alternative medicine practitioners. Among these were herbalists, vegetarians, faith healers such as Mary Baker Eddy (1821–1910) and the Christian Science movement, Ellen G. White (1827– 1915) and the “medical evangelism” of the SeventhDay Adventists, Bernard Macfadden (1868–1955) and the “physical culture” movement of body builders,5 magnetic6,7 and phrenomagnetic healers, bonesetters, mechanotherapists,8,9 electrotherapists, and sundry

FIGURE 2–1. Benedict Lust, MD, ND, father of naturopathy in America. (Courtesy of Friedhelm Kirchfeld, MLS.)

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

FIGURE 2–2. Benjamin Rush, MD.

cared to might hang a shingle and practice the healing art. One of the motivations for the formation of the American Medical Association (AMA), in 1848, was to seek methods of bringing order out of chaos. With little if any scientific understanding of disease, therapeutic anarchy prevailed. The dominant healing sect in America was heroic medicine, a tradition championed by Benjamin Rush, MD (1746– 1813), a signer of the Declaration of Independence in 1776 and a strong opponent of medical hegemony (Fig. 2–2). Adherents to heroic medical concepts recommended that the harshness of a remedy should be in proportion to the severity of the patient’s condition. Strong emetics and cathartic preparations were used to “purify” the digestive tract, and preparations of mercury and other toxic substances were liberally administered.11 Bloodletting, from which the British journal Lancet drew its name, was employed to purge the blood of the impurities thought responsible for disease. George Washington would die from the best care his physicians could provide—a gross depletion of his blood in an effort to cure an infection. The German tradition of homeopathy, established by Samuel Hahnemann, MD (1755–1843), offered a gentler alternative. Based on Hahnemann’s theory of “similars,” homeopathic doctors prescribed weak dilutions of substances that produced symptoms like those of the disease to be treated. If remedies based on the notion that “like cures like” did not improve the patient’s condition, neither did they distress the invalid nor impair the individual’s endogenous healing ability. Hahnemann’s followers brought homeopathy to America, where it found an eager following in the

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early 1800s. He also coined the term “allopathy” to describe the dominant heroic tradition of prescribing drugs to combat symptoms. The label stuck, but even today some MDs find the term offensive. Herbal and botanic remedies were similarly justified, if only by their relative safety. Samuel Thompson, a self-trained American healer, organized “friendly botanical societies” throughout the former colonies, and marketed his plant-based remedies through them. Thompson and his followers decried medical treatment and insisted that every family should provide for its own health care. His writings offered guidance to the common man. The option to go to a hospital (if any were available) was very much a last resort; hospitals were places where the most seriously ill went to die. Homeopathic physicians, who were often European, university-trained immigrants, were usually better educated than their allopathic competitors in America. But as medical statutes were gradually reintroduced in the latter half of the century (Table 2–1), homeopaths often found it necessary to establish their own schools and licensing authorities, owing to the hegemony practiced by the politically dominant and more numerous allopaths. Eclectic physicians, whose guiding principle involved using the best available treatments regardless of theoretical source, likewise suffered from the political machinations of the emerging medical establishment. The heroic/allopathic tradition had much to be humble about. Although MDs might rail against the unrestrained advertising of the patent medicine vendors and competition from sundry “quacks” (i.e., nonallopaths), the cultural and legal authority that an embryonic biomedical science would one day confer still eluded them.12 The pioneering research of Lister, Koch, and Pasteur was only just under way in the latter half of the century, and the germ theory was a popular target of humor. The surgical innovations (such as appendectomies) that the Mayo brothers would foster were still considered quackery.13 Not until 1906, when President Theodore Roosevelt signed the first Pure Food and Drug Act, would the first regulations be imposed on patent medications. Not until 1910, when Abraham Flexner, PhD, issued his devastating report to the Carnegie Foundation14 on the sorry state of medical education in the United States and Canada, did the first sustained and well-financed efforts to reform how doctors were trained begin. Medical education in the nineteenth century was meager at best. Many MDs had little more than an apprenticeship before hanging their shingles. Most medical schools were proprietary, and laboratory training in the basic sciences was often not available. A few university-based medical schools along the eastern seaboard began to teach the newer concepts of

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CHIROPRACTIC PRINCIPLES TABLE 2–1.

Reintroduction of Medical Statues in America, 1873–1899

Year

State/Territory

1873 1874

Arizona Territorial Act Missouri

1875

Nevada

1875–1876 1876

California Vermont

1878 1879 1881 1886

Cherokee and Choctow Nations in Indian Territory Kansas,Texas Colorado Iowa

1889

Idaho, North Carolina, Tennessee

1890

Florida, Washington

1891 1892 1893 1894

Alabama, Nebraska, North Dakota Maryland, Mississippi Connecticut, Kentucky, New York, Pennsylvania, South Dakota Georgia, Louisiana, Massachusetts, Maryland amended, New Jersey, South Carolina, Utah, Virginia Arkansas, Delaware, Indiana, Maine, Minnesota, Montana, Oregon, Rhode Island, New York amended

1895 1896 1897 1899

District of Columbia, Ohio New Hampshire, Wisconsin Illinois, Michigan, Wyoming (no date listed, but defined; also not listed are Alaska and Hawaii)

From Wilder A. History of medicine. New Sharon, ME: New England Eclectic, 1901:775–835 (Synopsis of Medical Statutes). Courtesy of Robert B.Jackson, DC, ND, June 20, 1996.

sanitation, hygiene, and gentler medical treatment, but the influence of their graduates would take decades to spread across the continent. When licensing laws first reappeared in the 1870s, educational credentials were often not required. Anyone who paid the licensing fee and registered with the county clerk could receive a certificate as a “physician and surgeon.” Populist sentiments still prevailed, and the right of the individual to employ the doctor or method of his or her choice discouraged enforcement of medical statutes. Public health measures were often viewed as government intrusion upon individual liberty. The right of the sick to get well became a rallying cry of alternative medicine practitioners and their patients for decades to come. The Civil War devastated the nation, and few families escaped the human scars of war. Spiritualism, a method of communicating with the deceased, brought solace to some and intellectual curiosity to many. Darwin’s novel biology made its debut in the 1860s, and added a new type of causality to the push–pull thinking of the machine age. Theosophical societies, which asserted that the laws of God and the laws of the physical world were but reflections of one another, gained enthusiasts. Into this popular intellectual soup was added a pinch of phrenology, which

involved an understanding of the individual’s psyche by palpation of cranial bumps, and the animal magnetism of Anton Mesmer, MD. Like homeopathy and herbalism, magnetic healing was not likely to hurt the patient, regardless of its efficacy or lack thereof (Fig. 2–3). Phrenology opened up the possibility of understanding individual human behavior; phrenomagnetism suggested that a more precise and scientific control of behavior was also possible. Americans were teased by the possibilities science might bring. In this climate of public probing emerged the mechanical healing metaphors of Andrew Taylor Still.15–17 The son of a circuit preacher and frontier doctor, Still (1828–1917) and his family were passionate Methodist abolitionists who served with their state militia in the Civil War. The young man worked as a hospital orderly and perhaps also as a battlefield surgeon, eventually rising to the rank of major. In the decade following the war he lost several children to spinal meningitis, despite the ministrations of his medical peers. Determined to find effective alternatives to the heroic medical practices of his era, Still practiced as a magnetic healer before unfurling his “banner of osteopathy” in 1874.18 As a “lightning bonesetter,” he likened the body to a machine and developed manipulative procedures to keep its parts

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

27

the osteopathic curriculum would eventually loosen the ideological grip that he initially imposed. In the United States, today’s doctor of osteopathy (DO) is a “physician and surgeon” in the broadest legal sense of the term. A TRADITION OF PROTEST The early roots of chiropractic were planted in the rich soil of late nineteenth century enlightenment and liberty. The hazards of the heroic medical tradition were widely appreciated, as were the possibilities for a more scientific healing art. The populist sentiments of early nineteenth century, including an aversion to medical orthodoxy and the rallying cry of “medical freedom,” were still in evidence. When Daniel David Palmer opened his first clinical office in Burlington, Iowa, in 1886,19 the future founder of chiropractic could reasonably expect to practice without interference from the local medical community (Fig. 2–4). If he had begun practice 5 years earlier, he might even have secured a license as a physician, had he chosen to.19 In the 1860s and 1870s, Burlington had been home to famed magnetic healer Paul Caster, and in the late 1880s, Caster’s son continued the family tradition.20 Palmer reestablished his magnetic practice in Davenport, Iowa, in 1887,20 perhaps in search of a less competitive venue. The father of chiropractic was born a few miles east of Toronto at Brown’s Corner, then an agricultural region in the town of Pickering, and was raised there and

FIGURE 2–3. Nineteenth century caricature of the magnetic practitioner.

in working order. Anticipating the later discovery of endorphins, enkephalins, and neurotransmitters, Still believed that the brain manufactured the body’s own healing substances. Health, he proposed, could be maintained and restored by keeping the various channels (circulation and nerves) from the brain to the end organs free of obstructions. It was a mechanical theory of health and illness, yet harkened back to medieval humoral theories. Conceived as a reformation of medical methods, Still and his osteopathy were rebuffed by the “regular” (allopathic) medical community.15 Undeterred, he practiced as an itinerant healer in several midwestern states before settling in Kirksville, Missouri, where he built his clinic and opened the American School of Osteopathy in 1892. The medical members of his faculty sought to broaden the scope of instruction to include pharmaceuticals, but the “old doctor” would have none of it. However, his inclusion of surgery in

FIGURE 2–4. Seated left to right: D. D. Palmer and his father, Thomas; standing left to right: brothers Thomas J. and Bartlett D. Palmer, circa 1890.

28

CHIROPRACTIC PRINCIPLES

further east in Port Perry, Ontario.21 D. D. Palmer did not attend school beyond the sixth grade, but developed a hunger to learn, which he attempted to satisfy as an avid reader. He was the eldest of six children, and matured in a culture that valued industriousness, independence, respect for elders, and a free market. The family was of Scotch, Irish, English, and German stock,22 and worshipped as fundamentalist Christians (known as Millerites or Adventists). When jobs in Ontario grew scarce owing to the influx of draft evaders during the Civil War, D. D.’s father, unsuccessful in business, relocated the clan to rural, midwest America along the Mississippi River circa 1865.21 During the 1870s and early 1880s, D. D. made his living as a farmer, beekeeper, and school teacher, and kept meticulous records of his crops, business dealings, and lesson plans. His was an ordered but inquisitive mind. Palmer could have practiced his magnetic techniques quietly in Davenport, but that was not his style. As was the custom of the day, he assumed the title “Doctor,” thereby implicitly challenging the status and credentials of the allopathic community. Dr. Palmer widely advertised to “Cure Disease Without Medicine,” and distributed newspaper-size fliers, successively known as The Educator and The Magnetic Cure, to reach prospective patients (and later, students). Palmer’s fliers were full of testimonials and taunts directed at his allopathic competition (see sidebar “Examples of Dr. Palmer Taunting the Competition in The Magnetic Cure, 1896”). Among the conditions he claimed success with were “Diseases of the Head, Throat, Heart, Lungs, Stomach, Liver, Spleen, Kidneys, Nerves, and Muscles, ten times quicker than any one can with medicines”.23 Palmer competed directly with the medical establishment, and rubbed their noses in it. Examples of Dr. Palmer Taunting the Competition in The Magnetic Cure, 1896 A QUACK doctor is one who cures by irregular means what a regular doctor cannot cure. MY MOTTO I give such balms as have no strife With nature or the laws of life; With blood my hands I never stain, Nor poison men to ease their pain. MEDICINE A SCIENCE (?)

their use, even to self-destruction. These misguided unfortunates, half-living witnesses of medical incompetency, can be seen everywhere. Wasting diseases and premature deaths grow more frequent, in open defiance of medical skill. (?) The simplest forms of fevers invade the family circle and leave death and desolation, as they did two thousand years ago, when the science (?) of medicine was in its infancy. It is no wonder that the sick leave the regular medical fraternity and go to the “quacks” for relief. Every man and every woman who can cure is divinely ordained to heal, and their duty to God and humanity demands that they do it. The license of all such is a natural license, which no legislature nor bigoted board of medical monopolists may revoke. Legislation (?) Wanted Yes, by all means let us have more stringent medical laws. We all admit that class legislation leads to tyranny, but that is what we need in this land of personal liberty. The people are cursed with too much freedom, especially in their choice of medical advisers and constant resort to the counter-prescriber. Surely all sensible physicians will admit, without argument, that all medicines not prescribed by regular graduates is damaging (to the profession) and should be prohibited by law. Surely, now that class legislation is running to seed, we doctors ought to lobby for a law to protect the profession and prevent such a shameful robbery of the physician. Can’t we have the druggists fined for selling medicines to such patients? Or, perhaps, it would be better to have such foolish people arrested and placed under the care of the doctor who owns the largest number of diplomas. This would give a great impetus to the diploma business, and enable some of the “mills” to add another course of lectures to their tyrannous exactions. There are but two horns to the dilemma. We must either have the medical profession so hedged about by legal enactments that it will be harder to get into than a burglar-proof safe, or we must take more medical journals, buy more books, and study harder than we ever did before. Let us have the law; the more tyrannical the better. It is much easier to get laws enacted than to sit up nights reading medical literature. . . . The Constitution of the United States says: “No state shall pass any law abridging the privileges or immunities of any citizen of the United States; nor deprive any person of life, liberty or property without due process of law.”

For many years there has been growing in the public mind a suspicion that medicine is not a science, but that it is most experimental guesswork.

Can Drugs Cure Disease?

This ancient system of poisoning the sick has a lawful right to fill our poorhouses, Keeley institutes, and asylums with their poisoned victims. They are dosed with stimulants, sedatives, and narcotics until they must continue

source must be a source of life. In the case of “drug action,” is the life in the drug or in the patient? Drugs have no effect on a dead body. Being in the live patient, the action is necessarily from it and upon the drug. Medicines, when

All action must come from an active source, and an active

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

taken into the stomach, are treated by it as an enemy, a poison which is to be gotten rid of, either by vomiting or purging. The medical fraternity express it clearly when they say, “our most powerful remedies are our most virulent poisons.” Why the most powerful? Because they call forth the greatest amount of vital action from the patient to throw off the poison. All chemical compounds, called medicines, are dead, lifeless, and are powerless to sustain life. Compulsory Vaccination is Criminal If there is virtue in vaccine virus, the vaccinated are amply protected against the unvaccinated. If there is no virtue in vaccination, coercion is vile and villainous. Who will contend that the old systems of healing are the best, and should have exclusive Legal rights. New discoveries are the order of the day in mechanics, science, and arts, why not in healing the sick? Is there not a demand for more light in this direction?

FROM MAGNETISM TO ADJUSTMENT Palmer prided himself on a unique form of magnetic treatment that involved the same anatomic specificity that would subsequently characterize his chiropractic methods. He used his sensitive magnetic fingers to palpate the patient for the site of inflammation; Palmer believed that inflammation was the essential feature of TABLE 2–2.

29

disease and was always deleterious. He would “cool off” the hot, inflamed tissue by pouring his personal, excess, vital magnetic force into the identified lesion. D. D. considered his method superior to that of other magnetic healers because he did not waste his vital energy by distributing it diffusely over the entire body of the patient. During his years of magnetic practice, the inquisitive Palmer arrived at the theory that inflammations were caused by displaced anatomic parts: arteries, veins, nerves, muscles, bones, ligaments, and joints. Such displacements, he reasoned, created friction, heat, and inflammation. The first of his three theories of chiropractic (Table 2–2) was an extension of his magnetic rationale.24–26 Although the self-styled “magnetic manipulator”27 was initially quite secretive about his clinical procedures, in July 1896 he incorporated his Palmer School of Magnetic Cure28 to teach and spread his clinical insights. The following January he offered to teach “the chiropractic” to any “intelligent person.”27 Early training involved little more than an apprenticeship at Palmer’s 40-bed infirmary and clinic in downtown Davenport. Likening his role in the profession to that of Mary Baker Eddy, the founder of Christian Science, “Old Dad Chiro” similarly claimed that the principles of chiropractic theory had been revealed to him by spiritual sources.29 However, the origins of D. D.’s unique, segment-specific thrusting manipulations are not known. He acknowledged that he had studied osteopathy and a variety of other alternative healing

D. D. Palmer’s Theories of Disease, 1896–1914 1897–1902†

1904–1906‡

1908–1910¶

1914§

Concept

1896*

Therapeusis

Yes

Yes

No

No

No

Method of intervention Foraminal occlusion Circulatory obstruction

Magnetic ? ?

Manipulation ? Yes

Adjustment Yes No

Adjustment No No

Adjustment No No

Nerve pinching

?

Yes

Yes

No

No

Nerve vibration Nerve stretching Machine metaphor Tone

? ? ? (Vital)

? Yes Yes (Vital)

? Yes Yes Absent

Yes Yes Yes/no Yes

Yes Yes Yes/no Yes

Innate/educated

Absent

Absent

Nerves;

Intelligence

Intelligence

Absent

Intelligence Absent

Optional

Obligatory

Religious plank

Yes

* From The Magnetic Cure, a newspaper-sized advertiser published by D. D. Palmer. †

From The Chiropractic, which was a continuation of D. D. Palmer’s magnetic advertiser during the early years of his chiropractic practice.

‡

From The Chiropractor, which was a journal published by D. D. Palmer and his son, B. J. Palmer, beginning in December 1904 at the Palmer School in Davenport. ¶

From The Chiropractor Adjuster, which was D. D. Palmer’s journal published in Portland by the D. D. Palmer College of Chiropractic, and The Chiropractor’s Adjuster, which was the title of his 1910 book.

§ From The Chiropractor, a collection of D. D. Palmer’s essays posthumously published by his wife.

30

CHIROPRACTIC PRINCIPLES

TABLE 2–3.

Comparison of D. D. Palmer’s 1897 and 1904 Theories of Cancer Theory, 1897*

. . . The cause is an obstruction to the blood circulation and an injury to certain nerves. Show us a case of cancer—no matter in what portion of the body that cancer may be—and we will at once show you two injuries that obstruct the blood circulation and injure certain nerves. It is this combination of injured nerves and obstructions that cause cancers.

Theory, 1904† Cancers are but the symptoms of impinged nerves. We no longer wonder that there are so many kinds when we consider that no two of us sense alike. All cancers, no matter in what part of the body, have one and the same cause; they are all produced by injured nerves, but the effect of these irritated nerves show their dissimilarity in the great diversity of cancers.

* Palmer DD. Cancers: Their cause and cure. Chiropractic 1897;17:2. †

Palmer DD. Cancers: Their cause and cure. Chiropractor 1904;1(1):15.

systems,30 but adamantly denied that he had ever visited or been treated at Andrew Still’s Kirksville institution. The traditional anecdote of Palmer’s first chiropractic adjustment has several variants; the earliest known account was authored by the patient, Harvey Lillard, a janitor in the building where D. D. practiced. Palmer published Lillard’s testimonial in the January 1897 issue of his renamed advertiser, The Chiropractic: Deaf Seventeen Years: I was deaf 17 years and I expected to always remain so, for I had doctored a great deal without any benefit. I had long ago made up my mind to not take any more ear treatments, for it did me no good. Last January Dr. Palmer told me that my deafness came from an injury in my spine. This was new to me; but it is a fact that my back was injured at the time I went deaf. Dr. Palmer treated me on the spine; in two treatments I could hear quite well. That was eight months ago. My hearing remains good.31 With the assistance of a patient, Reverend Samuel Weed, Palmer named his new method from Greek stem words, meaning “done by hand.” As disciples increased in the early years of the twentieth century, chiropractors’ hand maneuvers multiplied even more rapidly (including adjusting by instruments).32 By 1911 the founder’s son, Bartlett Joshua Palmer, included “An Exposition of Old Moves” in texts distributed by the Palmer School of Correspondence; in this he enumerated more than 170 adjustive procedures that had blossomed in the profession’s first 15 years.33,34 Yet this early technique proliferation only foreshadowed the continuing creation of new chiropractic procedures throughout the coming decades. Hundreds of “brand name” chiropractic techniques have been offered over the course of the profession’s first century. There has also been considerable

“borrowing” of manual methods among professions (e.g., chiropractic, manual medicine, naturopathy, osteopathy), although this cross-fertilization tends to be ignored for political reasons. D. D. Palmer’s chiropractic continued to evolve, as can be discerned by comparing two distinct explanations for cancer, the first offered in 1897 and the second in 1904 (Table 2–3). In 1903, he reduced his clinical concern to the relief of nerve compression secondary to subluxation of joints.26 It was this second of his theories that would prevail throughout much of the chirocentury. However, by this time Palmer had developed methods of adjusting all the joints of the body, including those of the feet, where neural compression was not possible. The founder’s 1910 volume22 revealed still further metamorphosis in his thinking: nerve stretching and slackening as the critical factor in disease production. Old Dad Chiro now denied that nerves were “pinched” in the intervertebral foramina, insisting instead that any subluxated joint could alter the tension in nerves, and thereby modify their effective message to end organs. From this tensionregulation point of view,35 , it mattered not whether a nerve passed between bones; a classic quotation captures some of this theoretical rethink: “I have never felt it beneath my dignity to do anything to relieve human suffering. The relief given bunions and corns by adjusting is proof positive that subluxated joints do cause disease.”22

THE CHIROPRACTIC PROTEST Palmer’s feisty style and direct verbal assault on his medical competitors prompted retaliation. A war of words erupted in the Davenport newspapers and in Palmer’s advertiser. The Chiropractic in 1899 devoted much of its space to refuting the charges of Heinrich

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

Matthey, MD, a local allopath who disputed the profession of osteopaths as the “basest of swindlers.”36 Matthey’s antipathy toward Palmer may have also operated behind the scenes in a dispute that erupted in 1900 between Palmer and one of his students, H. H. Reiring, who had voiced dissatisfaction with the curriculum of the Palmer School and demanded a return of his $500 tuition. Palmer had the police remove the young man from the campus but failed to press charges, prompting Reiring to file suit for false arrest.37 This episode may have been part of the impetus for Palmer’s departure for California in the spring of 1902. Palmer’s stay in Pasadena was brief, and marked by his indictment for practicing medicine without a license following the death of a patient under his care. The charges were dropped owing to a legal technicality, and D. D. moved on to Santa Barbara, where he continued to teach and practice. However, by December 1904 he was back in Davenport (Fig. 2–5), were he and son B. J., who had revived and managed the Palmer School in D. D.’s absence, commenced publication of The Chiropractor. It was this periodical, and the claims for chiropractic made therein, that served as the basis for the founder’s trial for unlicensed practice in 1906.19 The father of chiropractic offered a meager legal defense, calling no witnesses on his behalf and claiming only that the practice of chiropractic did not constitute the practice of medicine. The jury promptly convicted, and the judge imposed the choice of a fine

31

or time in jail. Outraged, Palmer refused to pay the fine and was incarcerated (see sidebar “How to be Happy in County Jail”). It was the first of many voluntary “martyrdoms” for chiropractic in the next seven decades.

“How to be Happy in County Jail” Be sure you are in the right. Keep busy; always have something to do. Keep your person and room clean and neat. Don’t worry. Let the fellow who committed the injustice do that. If you are in the right, you can afford to hold your temper; if in the wrong, you can’t afford to lose it. Be thankful for small favors, hoping to receive larger ones. Have no regrets. Take your medicine with a smile. Jails have contained some of the best, as well as the worst, men. Treat the sheriff, turnkey, and guards with due respect; they have their duties to perform. Have a clear conscience and a good appetite. Feel that your cause is just, that you are imprisoned for righteousness. Thus does time pass quickly and pleasantly. Others have suffered for conscience sake and the uplifting of their fellow men. Persecution or prosecution creates sympathy, sympathy generates investigators, investigation produces followers, who become more zealous and persistent in spreading their peculiar doctrines. Thousands will be benefited by my incarceration. It has already been copied in hundreds of newspapers, and stimulates the growth of our business. Radical changes cannot be made “on feathery beds of cane;” new thoughts of great importance cannot be born without labor. “Truth crushed to earth will rise again.” DR. D. D. PALMER, Discoverer and Developer of Chiropractic. From Palmer DD. Davenport Democrat & Leader, 6 April 1906:6.

FIGURE 2–5. D. D. Palmer, circa 1906.

D. D. Palmer and his son parted company following the father’s release from jail. The elder headed to Oklahoma and later Oregon, where he established several chiropractic schools. Meanwhile, young Dr. B. J. Palmer (1882–1961) took complete charge of the Palmer School of Chiropractic (PSC). Recognizing the legal jeopardy faced by his growing alumni body, in 1906 he organized the Universal Chiropractors’ Association (UCA), a protective society that provided attorneys’ services to member DCs charged with unlicensed medical practice. The UCA’s first test came in 1907, when PSC graduate Shegatoro Morikubo, a naturalized American citizen practicing in LaCrosse,

32

CHIROPRACTIC PRINCIPLES

FIGURE 2–6. Tom Morris, LLB. (Courtesy of Cleveland Chiropractic College of Kansas City, Library Archives.)

Wisconsin, was arrested for practicing medicine, surgery, and osteopathy without a license. The indictment was brought at the request of the osteopathic member of the state medical board, and there were strong racial overtones as well. The Japanese navy had defeated a Russian fleet in 1902, and the “yellow scare” was widespread in the United States. As secretary of the UCA, B. J. Palmer hired state senator and former district attorney Tom Morris to represent Morikubo (Fig. 2–6). It was a fortunate choice, for the Canadian-born Morris brought a number of skills to the task. He had studied medicine briefly before turning to the law, and delighted in championing the underdog. As well, the prosecutor, Otto Bosshard, was a personal friend and prot´eg´e. Morris approached the district attorney to suggest that charges of the unlawful practice of medicine and surgery be dropped, because Dr. Morikubo had used only his hand (no drugs, no surgery) to heal. When Bosshard acquiesced and agreed to try the Japanese American chiropractor solely for the unlicensed practice of osteopathy, a weak legal precedent was created. Now the challenge for Morris was to convince a

jury that the practice of chiropractic was not the practice of osteopathy.38 To accomplish this, Morris relied on expert witnesses who held degrees in both manual healing disciplines. These osteopath-chiropractors testified to the dissimilarity in theory and technique between the professions. Chiropractors, it was argued, were only interested in the nervous system, whereas the osteopathic “rule of the artery” focused DOs solely on the circulation. This contention was not true, but was consistent with the revised and reduced theory of chiropractic that the founder had introduced in 1903.26 The experts’ testimony was buttressed by the introduction into evidence of the first textbook of chiropractic, Modernized Chiropractic, authored by several Palmer alumni and competitors in the school business: Oakley Smith, Minora Paxson, and Solon M. Langworthy.39 Modernized Chiropractic declared that chiropractors had a “separate and distinct” philosophy and practice. The jury took less than an hour to return a verdict of “not guilty.” Morris was hired as chief legal counsel for the UCA, a post he would hold until his death in 1928.40 Young Dr. Palmer, delighted by the way that “philosophy” had saved the day, had his faculty at the PSC award him the first ever “PhC” (Philosopher of Chiropractic) degree in 1908. Armed with chiropractic’s separate and distinct philosophy, chiropractors argued their case in thousands of trials, and usually prevailed when cases were heard by juries. As well, the “separate and distinct” contention formed the centerpiece of DCs’ petitions to state legislatures for chiropractic licensing laws. Thanks to Morris, who subsequently served as lieutenant governor of Wisconsin, the chiropractic protest had a fighting chance. THE SPREAD OF CHIROPRACTIC The earliest diplomas in chiropractic issued by D. D. Palmer authorized his graduates to “teach and practice” the new healing art. The father of chiropractic must have been chagrined when several of his first graduates took this mandate literally and competed with him for students. One such example was that of Solon Massey Langworthy, DC, a 1901 Palmer graduate who organized the American School of Chiropractic & Nature Cure in Cedar Rapids, Iowa, and drew Palmer alumni Oakley Smith and Minora Paxson to his institution as dean and chair of obstetrics and gynecology, respectively.39 But it was just the beginning of a fairly rapid proliferation of chiropractic schools, including at least three established by the founder (Table 2–4). The schools would collectively produce some 12,000 practicing chiropractors by 1930. Early chiropractic schools were strictly for-profit ventures, with great variations in the breadth and

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION TABLE 2–4.

33

Several of the Earliest Schools of Chiropractic

Founding Date

Institutional Name

Location

Founder

1896 1903

Palmer School of Magnetic Cure American School of Chiropractic

Davenport, IA Cedar Rapids, IA

D. D. Palmer Solon Massey Langworthy, DC

1904 1904

& Nature Cure Marsh School of Chiropractic Pacific School of Chiro-Practic

Portland, OR Oakland, CA

John E. Marsh, DC Harry D. Reynard, DC

1905 1905 1906

American School of Chiropractic Parker School of Chiropractic Carver-Denny School of Chiropractic

New York Ottumwa, IA Oklahoma City, OK

Benedict Lust, MD, ND, DC Charles Ray Parker, DC Willard Carver, LLB, DC, and Lee L. Denny, DC

1906

National School of Chiropractic

Davenport, IA (relocated to Chicago in 1908)

John F. A. Howard, DC

1907

Palmer-Gregory College of Chiropractic

Oklahoma City, OK

1908

D. D. Palmer College of Chiropractic

Portland, OR

1908

Texas Chiropractic College

San Antonio

D. D. Palmer and Alva Gregory, MD, DC D. D. Palmer and L. M. Gordon, DC J. N. Stone, MD, DC

1908 1908

Michigan Clollege of Chiropractic Ratledge System of Chiropractic Schools Wichita College of Kiropractic Robbins Chiropractic Institute Pacific College of Chiropractic New Jersey College of Chiropractic &

Grand Rapids, MI Guthrie, OK

N. C. Ross, DC T. F. Ratledge, DC

Wichita, KS Sault Ste. Marie, Ontario Portland, OR Newark, NJ

J. G. Wilson, DC W. J. Robbins, MD William O. Powell, DC Frederick W. Collins, DO, DC

San Diego Los Angeles

F. B. C. Eilersficken, DC T. F. Ratledge, DC

Los Angeles Portland, OR

Charles A. Cale, DC John E. LaValley, DC

Los Angeles

1909 1909 1909 1910 1910 1911 1911 1911 1911

Naturopathy San Diego School of Chiropractic Ratledge System of Chiropractic Schools Los Angeles College of Chiropractic Oregon Peerless College of Chiropractic & Neuropathy

1913

Bullis & Davis School of Neuropathy, Ophthalmology & Chiropractic California Chiropractic College

Los Angeles

Benson Bullis, DC, and Andrew P. Davis, MD, DO, DC Albert W. Richardson, DC

1914

Canadian Chiropractic College

Hamilton, Ontario

Ernst DuVal, DC

depth of biological and clinical subjects taught. The original Palmer curriculum was only 3 months in duration. Twenty years later, consensus had formed around a course of 18 months, and the Palmer School would maintain this length of training into the 1950s. However, even this minimum curricular standard seemed substantial in comparison to the “correspondence schools” that sprang up in the first few decades of the chirocentury. These mail-order diploma mills, most prominently the American University of Chicago,41 would stain the integrity of chiropractic education for decades to come. But in those early years, even some of the better schools, including the National in Chicago and the Palmer School,

dabbled in correspondence training for at least part of the curriculum (Fig. 2–7). The growth in the chiropractic ranks is attributable to additional factors. Like several other “irregular” healing sects, chiropractors offered a gentle alternative to the harsh remedies of allopathic medicine. Many early chiropractors marketed themselves as “drugless doctors,” although this was frowned upon for ideological reasons by the “purists” such as B. J. Palmer and T. F. Ratledge.42 The extensive marketing examples set by the Palmers, although considered unethical by orthodox medicine, broadcast the “gospel of chiropractic” far and wide. In addition to advertising in the popular media and in

34

CHIROPRACTIC PRINCIPLES

least for a few years. Not until the 1974 recognition of the Council on Chiropractic Education (CCE) by the US Office of Education, which brought with it eligibility for federally guaranteed student loans, would a steady stream of students become available. A final and paradoxical factor in the expansion of the chiropractic ranks involves the persecution of the profession. Organized medicine’s persistent attempts to “contain and eliminate” chiropractic created a solidarity among the besieged. Beset by criminal prosecutions, chiropractors rallied to defend their healing art and their livelihoods. The passions created by repeated arrests, prosecutions, and jailings created a bond among doctors and a determination to resist. How chiropractors adapted and overcame this onslaught is part of the larger story of their quest for legitimacy, but in the short term, DCs’ campaigns to win their own licensing laws and regulatory boards also aided in the growth of the profession by keeping the fires of missionary fervor well stoked and fueled.

FIGURE 2–7. Early advertisement for correspondence training from the Palmer School.

alternative healing journals (e.g., Benedict Lust’s Naturopath & Herald of Health), chiropractors were enthusiastic publishers of their own magazines, pamphlets, and brochures. Early periodicals included The Chiropractor and the Fountain Head News (published by the Palmer School), the Backbone (published by the American School in Cedar Rapids), and the American Drugless Healer (published by the American Chiropractic Association of Oklahoma City). These magazines carried clinical anecdotes and theoretical discourses, news of chiropractic events, reports of prosecutions, and, in later years, reviews of legislative and lobbying activities related to chiropractors’ quest for licensure. Their contents supplemented the evangelical zeal taught at the schools, extending it into doctors’ offices and on to patients and prospective students. It also seems likely that the intuitively appealing theory of spinal nerve pinching and manual correction that these periodicals spread was itself a stimulus to growth in the chiropractic ranks. Perhaps the biggest boon to chiropractic education and the growth of the profession in the first eight decades of chiropractic was the two world wars. Vocational training benefits offered by the Veterans Bureau (after World War I) provided federal funds for the students’ tuition. The Palmer School reported more than 3000 students in 1922, and by 1925 as many as 82 schools may have been in operation.43 The economic depression of the 1930s saw a drastic decline in number of schools and sizes of student bodies. However, the GI Bill (following World War II) once again flooded the chiropractic institutions with new enrollments, at

PROSECUTION, PHILOSOPHY, AND LEGISLATION The glue that bound the profession together during its early struggles was the “philosophy of chiropractic”

FIGURE 2–8. Dr. John F. A. Howard, founder of the National School of Chiropractic. (Courtesy of National College of Chiropractic.)

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

that won the first acquittal in 1907. Its “separate and distinct” character sprouted wings as B. J. Palmer elaborated upon his father’s notions of Universal Intelligence (God), Innate Intelligence (an individualized portion of Universal residing within the patient and controlling her/his physiology), and Educated Intelligence (the repository of knowledge acquired by individuals through experience and learning). Cosmic in its implications, pragmatic in its courtroom and clinical applications, B. J. Palmer’s philosophy became both defense and explanation of all things chiropractic. Terms such as diagnosis and treatment were banned as “medical” from B. J.’s “straight” lexicon, replaced by “spinal analysis” and “adjustment.” Broadscope or “mixer” dissenters from Palmerian chiropractic, such as John Howard, DC (Fig. 2–8), later acknowledged that this new jargon amounted to “garments to protect the child until legal clothing could be secured,”44 but many chiropractors accepted the new terminology as requisite truths. The chiropractor’s sole concern, argued the purists, was the detection and manual correction of subluxation, so as to free obstructed nerves and allow Innate Intelligence to direct healing messages from the brain through the

35

nerves to the end organs. Any care beyond this was branded “medical,” and, as B. J. would say, “whether you like it or not.” B. J. Palmer wrapped himself in the new chiropractic philosophy, and as secretary of the UCA and in concert with the protective society’s chief legal counsel, Tom Morris, organized the defense of thousands of chiropractors arrested for unlicensed practice. Although several other protective societies competed with the UCA for members and dues, not until the 1922 establishment of the Chicago-based American Chiropractic Association (ACA) was there any serious and enduring rival to the UCA’s preeminence. From the time of his father’s death in 1913, and notwithstanding unfounded charges of patricide,45 B. J. Palmer was truly a “majority leader” in the profession (Fig. 2–9). Trials of chiropractors frequently took on carnivallike features. The UCA could call upon an extensive team of specialized attorneys and experienced, expert witnesses to make their legal points, and if the courtroom proceedings were within a convenient distance by train from Davenport, the PSC would pack the courtroom with students. Even when held at a

FIGURE 2–9. Students and faculty of the Palmer School, circa March 1910, who traveled to Montezuma, Iowa, to attend the trial of State of Iowa vs. Corwin, a chiropractor. The two men standing center, front are the local sheriff and the defendant; C. Sterling Cooley, DC, is fourth and B. J. Palmer is fifth from left in rear row. Note the “PSC” armbands. (Courtesy of Texas Chiropractic College.)

36

CHIROPRACTIC PRINCIPLES

distance, the chiropractors could often depend upon throngs of loyal patients, who strenuously demonstrated on behalf of their local doctor. Although political medicine succeeded in bringing about the prosecutions of an estimated 15,000 chiropractors by 1930,46 the DCs prevailed in nearly 80% of these cases. The likelihood of acquittal was greatly increased if the case was tried by a jury (rather than by a judge), because public sentiment rejected the legal monopoly that allopathy held. If the state would not license chiropractors, juries would not convict them for practicing medicine. Palmer and Morris were initially opposed to licensing statutes for chiropractors (see, e.g., references 47–49). They argued that separate and distinct licensing laws and boards of examiners, hard won by the strenuous efforts of straight chiropractors, would eventually be compromised when “mixers” were appointed to such boards. Palmer also contended that licensing of all healers, MDs, DCs, DOs, or otherwise, was inappropriate on the grounds that it usually failed to provide protection to the public, the justification for passage of such laws. Health care, he insisted, was a commodity like any other—the marketplace, he believed, would weed out the incompetent. Palmer and the UCA leadership were out of step with the profession-at-large on this point. Kansas passed the first chiropractic statute in 1913, and North Dakota issued the first chiropractic license, to Guy G. Woods, DC, in 1915. (The governor of Kansas had refused to appoint a chiropractic examining board on the grounds that the available DCs in the state had practiced illegally, and were therefore ineligible to serve.) In less than a decade more than half of the then 48 American states followed suit (Table 2–5). Bowing to the inevitable, Palmer and Morris redirected their efforts, and sought to organize the emerging state boards of chiropractic examiners. One of the earliest meetings of these licensing authorities took place at the Palmer School in 1919 (Fig. 2–10), and subsequent meetings were held in conjunction with the annual lyceum (homecoming) of the PSC and convention of the UCA. In 1921, Palmer proposed a National Board of Chiropractic Examiners (the first of three so-named agencies), whose purpose was to examine and issue certificates to license applicants, and with the hope that the examination results would be accepted by the various state boards of examiners. By this time also, the UCA had introduced its “Model Bill” for implementation in those states that had not yet passed chiropractic statutes. The Model Bill called for an 18-month curriculum in a chiropractic school and a “straight” scope of practice. Many chiropractic educators considered 18 months of training a minimum standard,37 but Palmer insisted it was a maximum, and continued to offer doctorates for “three years of six months

Early Chiropractic Practice Acts in the United States

TABLE 2–5.

Date of Enactment

Jurisdiction

1913

Kansas, Michigan

1915

Arkansas, North Dakota, Ohio, Oregon, Wisconsin* Colorado Connecticut, Illinois, North Carolina

1916 1917 1918 1919

Montana Florida, Idaho, Minnesota, Nebraska, Vermont, Washington

1920 1921

Kentucky, Maryland Arizona, Georgia, Iowa, New Hampshire, New Mexico, Oklahoma

1922 1923 1924 1925

California, Nevada, South Dakota Tennessee, Utah Maine West Virginia

1927

Indiana, Missouri

* The Wisconsin law did not license chiropractors per se, but permitted them to practice if the DC hung a sign indicating the absence of licensure.50,51 Data from American College of Chiropractors. Medical education versus chiropractic education. National publicity series no. 3 (pamphlet). New York: The College, 1927.

each” training into the 1950s. These early disagreements over scope of practice and curricular standards foreshadowed decades of intense and sometimes bitter feuding within the profession. But the chief antagonist was organized medicine, which prevailed upon the state attorneys general and district attorneys to prosecute DCs in those jurisdictions that did not yet license chiropractors. Charles Lemly, DC, of Waco, Texas (Fig. 2–11) supposedly was arrested 66 times, although he never spent more than a few nights in jail. Herbert Reaver, Sr., DC, of Ohio may hold the record for greatest number of incarcerations; after his tenth stint behind county bars he was warned that the next time he would be considered a felon, whereupon he relocated to Florida.52 In California, prior to the 1922 law passed by the voters, the state medical society reportedly adopted a policy of keeping at least one chiropractor behind bars in each county, so as to set a vivid example. Chiropractors in the Golden State reacted by adopting the Palmer-advocated policy of “Go to Jail for Chiropractic.”53 When convicted, the DC refused to pay any fine (which money would have furthered the medical board’s harassment of chiropractors), electing instead to serve time. When offered a pardon in 1916 if he would accept a license as a drugless practitioner

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

37

FIGURE 2–10. Gathering of representatives of state boards of examiners and UCA officers at Palmer School of Chiropractic, 11–12 January 1919. (Courtesy of James Edwards, DC.)

from the state medical board, T. F. Ratledge, DC, founder of what is today the Cleveland Chiropractic College of Los Angeles, replied to the governor that such a license would be fraudulent, because the medical board knew nothing about chiropractic. Ratledge served out his 90-day sentence for unlicensed practice in Los Angeles County Jail and continued his vigorous campaign for a chiropractic law. The “Go to Jail” strategy had the effect of creating “martyrs” for the profession and generated more widely favorable sentiment within the press and the public. In other states, different strategies won the day for chiropractors. Iowa’s 1921 statute is attributed to the efforts of Frank W. Elliott, DC, business manager and registrar of the PSC, who was first elected to the Iowa legislature in 1919 (Fig. 2–12).54,55 In Missouri, credit for passage of the first chiropractic statute (in 1927) goes to attorney-physician Jones Parker, speaker of the state assembly and former member of the AMA board of trustees.56 When the mother of a chiropractor lamented the harsh treatment DCs received at the

hands of the medicos during a conversation with the owner of a mortuary, the mortician summoned Parker (who was obligated for undisclosed reasons to the undertaker), and the legislator promptly reversed his previous opposition to chiropractic licensure. Not only did Parker marshal a majority of both houses of the Missouri legislature in favor of the chiropractic bill, but he became a popular speaker at state and national chiropractic conventions. Continuing criminal prosecutions in the unlicensed jurisdictions produced a number of strong state chiropractic societies committed to defending their members and to establishing “separate and distinct” chiropractic licensing laws. The state societies were frequently at odds with Palmer (Fig. 2–13) and his UCA and its “straight” policies. The UCA’s “clean house” edict, which demanded that state associations purge mixers from their ranks, further antagonized the rank and file. Those state societies that failed to comply with the UCA mandate were confronted by UCA-initiated rival associations, thereby

38

CHIROPRACTIC PRINCIPLES

FIGURE 2–11. Charles Lemly, DC, stands second from right in this 1943 photo taken as Texas Secretary of State Latham (seated) signs the recently passed chiropractic statute. Others in the photo are (from left) Dr. Hugh Warren, President of the Texas Chiropractic Association; Dr. Roy LeMond, President of the Texas Research Society and cochair of the Legislative Committee; and standing far right is Dr. Ernest Chaney. (National Chiropractic Association photo collection.)

weakening the profession’s voice with state legislators. Dissatisfaction with Palmer and the UCA grew so great that a rival national society, the American Chiropractic Association (ACA), was organized in Chicago in 1922 and quickly attracted state society affiliates in Colorado, Montana, New York, and Oregon. By 1930, the list of ACA-affiliated state societies also included Alabama, California, Idaho, Michigan, Minnesota, North Dakota, Ohio, Tennessee, Washington, and Wyoming. Palmer’s former majority support in the profession was further eroded in 1924 when he introduced his two-prong, spinal heat-sensing device, the neurocalometer (NCM).37,57 Henceforth, declared the self-proclaimed “Developer of Chiropractic,” practice without an NCM would be considered unethical, because no palpating chiropractor, not even “B. J. himself,” could detect a subluxation as accurately as the

new instrument. The NCM could not be purchased, but was available exclusively through a 10-year lease from the PSC at a cost of more than $2000 (a fabulous sum in 1924). Palmer used his weekly periodical, the Fountain Head News, to repeatedly warn that he would sue NCM patent infringers, both those who manufactured and distributed rival devices and those DCs who purchased them. The NCM, Palmer insisted, would save chiropractors from themselves by enforcing a revival of “straight” chiropractic theory and practice. Patient histories and symptoms would no longer be of much, if any, importance, for the NCM would find “THE CAUSE OF ALL DISEASES OF THE HUMAN RACE.”58 Dissatisfaction with the Davenport leader was swift and sustained. A massive exodus of members from the UCA was accompanied by drastic declines in students referred to the PSC. Enrollments at the

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

FIGURE 2–12. Frank W. Elliott, DC, circa 1925.

mother school, which had once numbered 3000, dwindled to 400–500 by the end of the decade. (The decline was also attributable to the expiration of vocational benefits for World War I veterans and the onset of the Great Depression). During 1925–1926, several disaffected faculty members (Harry Vedder, Stephen Burich, James Firth, Arthur Hinrichs, and

39

Ernest Thompson), discouraged by what they considered the NCM’s infringement upon their academic freedom, departed the Davenport mecca and organized the Lincoln Chiropractic College (LCC) in Indianapolis in 1926. They took with them the good will of many Palmer alumni and a continuing commitment to straight chiropractic (i.e., no instruction in physiotherapy and other modalities). However, the LCC also offered a strong curriculum in the basic sciences and in diagnosis, and soon lengthened the course of instruction beyond the 18-month standard at the PSC. Lincoln’s position was a middle ground in the ongoing war of “philosophies” in chiropractic. The school exerted influence in the profession until its merger (for financial reasons) with the National College in 1971.59 With hostility mounting, in 1925 Palmer resigned the post he had held as secretary of the UCA since 1906, and, following an unsuccessful reelection bid the following year, organized the Chiropractic Health Bureau (CHB), forerunner of today’s International Chiropractors’ Association (ICA). Now there were three national protective societies (ACA, CHB, UCA) for chiropractors to choose from, and three voices clamoring for authority in professional affairs. This intolerable situation was lessened somewhat when the ACA and UCA merged in 1930 to form the National Chiropractic Association (NCA). And if the new

FIGURE 2–13. B. J. Palmer, DC, PhC, during a visit to the Ratledge College homecoming in Long Beach, California, in 1931. (Courtesy of Paul Smallie, DC.)

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CHIROPRACTIC PRINCIPLES

society could not claim majority support (then as now, most DCs are not members of a national association), it nonetheless spoke for the largest membership in the profession. BASIC SCIENCE: THE NEW BATTLEFIELD While the chiropractors feuded among themselves over the appropriateness of diagnosis, physiotherapy modalities, and curriculum standards, organized medicine devised new strategies to frustrate them. By the mid-1920s it was clear that the tide of licensing legislation had eroded medicine’s former legal monopoly in health care; indeed, by 1927, 39 of 48 American states had authorized the practice of chiropractic.60 To be sure, chiropractors were not always satisfied with their practice acts, which often called for “mixed” state boards of examiners, as in Rhode Island, where the licensing authority was comprised of two allopathic physicians and one chiropractor. As well, in those states that authorized chiropractic practice, political medicine sought to limit the DCs’ scope of practice as much as possible. Nonetheless, even these less than satisfactory statutes were a foot in the door and provided some relief from the arrests, prosecutions, and jailings that continued in so-called “open” states (i.e., those lacking chiropractic licensure). However, 1925 saw a new challenge introduced when Wisconsin and Connecticut passed the first effective basic science laws.61,62 Basic science legislation required that anyone wishing to sit for examination in chiropractic, medicine, naturopathy, or osteopathy must first pass a basic science examination administered by a separate, and ostensibly impartial, board of basic science examiners. Tests were administered in subjects such as anatomy, chemistry, pathology, physiology, and, occasionally, hygiene and public health. Chiropractors complained bitterly that inappropriate “medical” subjects were included, such as bacteriology and, in at least two states, diagnosis.63,64 They objected also to the composition of the basic science boards (see, e.g., reference 65), whose members were usually drawn from nonclinical faculty at state universities affiliated with medical schools, but sometimes also included licensed practitioners.64 The DCs objected also to the pretense that examiners did not know whether the applicant was a graduate in medicine, chiropractic, or other healing art. The obvious and stated (see, e.g., reference 66) purpose of basic science examinations, they argued (with justification; see, e.g., reference 67), was to “contain and perhaps eliminate”51 the ranks of nonallopathic doctors. Chiropractors and MDs alike were often distressed about the limitations that basic science legislation exerted upon reciprocal licensing across states.

FIGURE 2–14. Dr. John Nugent. (From the cover of the National Chiropractic Journal, November 1941.)

Ironically, the Connecticut basic science law was crafted and brokered by John J. Nugent, DC (Fig. 2–14),68 an Irish-born chiropractor with a university education, who had clashed with B. J. Palmer while a student at the PSC in 1922.69 Palmer would later refer to Nugent as the “anti-Christ of chiropractic” for his efforts to upgrade chiropractic schools as NCA director of education (1941–1959). But in 1925, faced with a nationwide scandal over medical diploma mills and the lenient licensing practices of the state’s eclectic medical board,51 the pressure for a basic science act was simply too strong to resist. A quarter century later, Nugent indicated that he wished he might have written all the basic science acts in those jurisdictions where they could not be avoided.70 Basic science legislation frequently accomplished its intended purpose. Chiropractors were often unable to create a compelling argument against the seeming reasonableness of the basic science laws (i.e., that all doctors of whatever persuasion should have the same basic competence in fundamental subjects) (Fig. 2–15). The profession suffered a slow but cumulative battering. For instance, the basic science barrier erected in Nebraska in 1927–1928 meant that the state’s Board of Chiropractic Examiners (BCE) issued

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

41

FIGURE 2–15. Chiropractors’ view of basic science legislation. (From the NCA’s Chiropractic Journal, April 1936.)

no new licenses during 1929–195071,72 because no DCs sat for the basic science test. In other jurisdictions, chiropractors were exceptionally unsuccessful in passing the exams.70 Gevitz51 notes that new chiropractic licenses in Minnesota dropped from an annual average of 39 during 1922–1926 to 1.4 during 1927–1937 following passage of the basic science act; in Washington State only 42 DCs passed the basic science exam during 1927–1953, for an average of only 1.6 per year. And as the number of states requiring basic science testing expanded (Table 2–6), the ranks of licensed chiropractors dwindled. Palmer blamed the spread of basic science legislation on the mixers, claiming that it was broad-scope DCs’ encroachment on the medical scope of practice that had encouraged the proliferation of the scourge. Homer Beatty, DC, ND, president of the University of Natural Healing Arts (UNHA) in Denver, laid the blame squarely on the “low educational standards” of the chiropractic colleges.73 When the chiropractors of Oregon, led by W. A. Budden, DC, ND, of Western States College, attempted to amend their practice act to return testing in the basic sciences to the

BCE, they were dismayed to find that B. J. Palmer had sided with the medicos to defeat the new legislation.74 However, political medicine was not always victorious in its basic science campaigns. In Arizona the basic science act was temporarily voided when the state supreme court ruled that the legislation should have been submitted to voters for approval.75 In Arkansas, the BCE ignored the basic science law by licensing DCs without the prerequisite basic science certificate; when the state supreme court challenged these licenses, the legislature grandfathered those who had been licensed inappropriately.51 In Tennessee, the basic science law was finally repealed through the effort of state representative Elbert T. Gill, DC, who pointed out the inequitable administration of the basic science process by professional licensing authorities.76 In Florida, the basic science statute was repealed in 1967 at the request of the state medical society, but only with the political support of chiropractors and osteopaths.51 Perhaps the most dramatic challenge to political medicine’s basic science campaign came in California,

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CHIROPRACTIC PRINCIPLES

Enactment and Revocation of Basic Science Legislation in the United States*

TABLE 2–6.

Dates of Enactment and Revocation

State

1925/1975

Wisconsin

1925/1975 1927/1974 1927/1975 1927/1979

Connecticut Minnesota Nebraska Washington

1929/1977 1929/1978 1933/1973

Arkansas District of Columbia Oregon

1935/1973 1936/1968 1937/1973 1937/1976

Iowa Arizona Oklahoma Colorado

1937/1972 1939/1967 1939/1975 1940/1971

Michigan Florida South Dakota Rhode Island

1941/1968 1943/1976 1946/1970 1949/1979 1951/1975 1957/1969 1959/1979

New Mexico Tennessee Alaska Texas Nevada Kansas Utah

1959/1975

Alabama

* States listed in chronological order of enactment. Data from Gevitz N. “A coarse sieve”; Basic science boards and medical licensure in the United States. J Hist Med Allied Sci 1988;43:36–63; and Sauer BA.: Basic science—Its purpose, operation, effect. Unpublished letter to the officers of the NCA and state chiropractic associations, 10 June 1932. Archives, Cleveland Chiropractic College of Kansas City.

president of the AMA, was singled out for vilification. When the basic science initiative went down to defeat (972,641 opposed vs. 507,421 in favor), chiropractors’ political clout at the state capitol in Sacramento was greatly increased (Fig. 2–16). As well, DCs facing the basic science threat in other states could point to California as an example of the only time the issue had been placed before the voters, and with a resounding result.51 However, by 1940, a number of chiropractic leaders had begun to change their views on basic science examinations. George E. Hariman, DC, a National College alumnus who operated a small hospital in Grand Forks, North Dakota, and would soon join the NCA’s board of directors, opined, “We may not like it that Basic Science is apparently here to stay but the sooner we accept it perhaps the better. . . . ”77 Hariman’s alma mater, the National College, had long since advocated and provided better than average instruction in the basic sciences as a means of defeating political medicine’s licensing barrier.78 School leader Beatty of UNHA opined, “Basic Science Laws can be a boon to the improvement and progress of Chiropractic,” provided such laws were coupled to state funding for all healing arts colleges preparing students for the basic science tests.79 C. O. Watkins, DC, 1935 founder and first chairman of the NCA’s Committee on Education (forerunner of today’s Council on Chiropractic Education [CCE]) and subsequently chairman of the NCA board of directors (Fig. 2–17), who had earlier referred to the “damnatory [sic] Basic Science laws,”80 later softened his stance as he realized the impetus these statutes provided to educational improvements within the profession.

EDUCATIONAL REFORM where, in 1942, the chiropractors won a nearly 2:1 victory against the proposed new law.51 The Golden State’s BCE and licensing law had been established by the voters through the initiative process in 1922, which meant the legislature could not pass a basic science bill that would interfere with the chiropractic initiative law. Medical forces in the state were therefore obliged to mount a costly public campaign to place basic science testing directly before the electorate. Straights and mixers who had feuded incessantly for decades came together at this point to meet the common foe. In what has been described as a “tough and at times dirty campaign,”51 chiropractors raised twice the campaign money that the California Medical Society was able to, and spent it on direct mail, newspaper advertisements, and radio announcements. The traditional cry of “medical freedom” was once again sounded, and the chancellor of Stanford University, a former

The standards and curricula of the chiropractic colleges had been an official agenda item at least since 1912, when the short-lived National Federation of Chiropractic Associations was organized in Kansas City.81 The issues were taken up again in 1926 by the newly formed International Congress of Chiropractic Examining Boards (ICCEB), just a year after the first basic science laws were introduced. A forerunner of today’s Federation of Chiropractic Licensing Boards, the ICCEB sought to inspect chiropractic schools and require a greater number of hours of instruction as a qualification for licensure. The ICCEB and its 1934 successor, the Council of State Chiropractic Examining Boards (COSCEB), soon found that its member boards were reluctant to relinquish their authority as agents of sovereign states.69 Standardization and higher standards would have to be sought through other mechanisms.

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

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FIGURE 2–16. Cover of the Chirogram for November 1942 sported a “V” for victory in California’s initiative vote against basic science.

The COSCEB’s president, Dr. John Nugent, was recruited in 1939 to inspect all chiropractic schools and to prepare formal criteria82 for evaluating these institutions. Appointed NCA’s first director of education in 1941, for the next 20 years Nugent led the profession’s efforts to raise the quality of instruction at the colleges and thereby to help establish greater legitimacy for chiropractors. It was a rocky road. Alarmed by what they perceived as threats to straight chiropractic principles and to the financial stakes they held

in the proprietary colleges, leaders of a number of schools banded together as the Allied Chiropractic Educational Institutions (ACEI) to challenge the NCA’s educational reforms.70 Nugent was repeatedly vilified in print and by word of mouth. It was not only the straight colleges that gagged on Nugent’s and the NCA’s innovations. Although the broad-scope schools were committed in concept to lengthening their curricula, improving basic science laboratories and instructional facilities, upgrading

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CHIROPRACTIC PRINCIPLES

FIGURE 2–17. Dr. C. O. Watkins appeared on the March 1940 cover of NCA’s journal.

the pool of faculty, and raising admissions criteria, these were expensive reforms. Most chiropractic schools, straight and mixer, were still proprietary and all were heavily tuition-dependent. As well, World War II and the military draft was diminishing the available pool of prospective students. (The Universal Chiropractic College of Pittsburgh, founded in Davenport in 1910, was forced to close its doors in 1944 as a consequence of enrollment shortfalls.) Even those schools allied with Nugent and the NCA complained bitterly about the demands for costly improvements and the absence of any significant financial support from the national association. “It cannot be done on tuition alone,” was the repeated lament from the NCA Council of Educational Institutions. Nugent, however, had a plan. He would seek the amalgamation of the many small, for-profit schools into a smaller set of larger, financially sounder, nonprofit colleges in selected cities around the nation. His first major achievement in this respect came in 1944, when the Eastern Chiropractic Institute merged with the Standard Institute of Chiropractic and the New York School of Chiropractic to form the nonprofit

Chiropractic Institute of New York. Three years later Nugent repeated this feat on the West Coast, with the merger of the nonprofit Southern California College of Chiropractic and the for-profit Los Angeles College of Chiropractic (LACC) to create today’s nonprofit LACC.83 And by this time, the newly created National Chiropractic Insurance Company (NCIC; precursor of today’s National Chiropractic Mutual Insurance Company), a spin-off of the NCA’s legal protective services,40 had made the first small donations to the NCA-affiliated schools.84 Also in 1947, the NCA education director and leaders from the COSCEB organized the NCA-allied schools into the Council on Education (forerunner of today’s CCE). The Council’s formation marked the birth of the modern accreditation movement. The war’s end aided Nugent in his consolidation efforts. For the next few years the colleges enjoyed a flood of students, veterans of the World War II (Fig. 2–18)and subsequently the Korean War, whose tuition was paid by the federal government under the GI Bill. Uncle Sam provided further, indirect support to the schools in 1951, when chiropractic students were exempted from the draft.85 Chiropractor-veterans, known as “chirons,” were encouraged to return to the schools for “refresher” courses. Meanwhile, Nugent repeatedly cautioned prospective freshmen to spend their tuition dollars in NCA-accredited colleges which he contended, was the only way to ensure their eventual license eligibility.86 The straight colleges and practitioners, meanwhile, organized as the ICA-friendly North American

FIGURE 2–18. Returning chiropractor-veterans were welcomed back to the National Chiropractic Association at war’s end in this 1946 cartoon. (From the National Chiropractic Journal.)

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

Association of Chiropractic Schools and Colleges (NAACSC) in 1952, and later as the ICA’s Chiropractic Education Commission, vehemently opposed NCAfostered instruction in physiotherapy, diagnosis, and other “medical” subjects. Particularly vexing was the quest for a broader scope of practice sought by chiropractors in California, as suggested in the ICA’s International Review of Chiropractic.87 Many chiropractors’ fears about the consequences of “mixing” were further enhanced during 1960–1962, when the California Medical Association absorbed both the California Osteopathic Association and the state’s only osteopathic school (now the College of Medicine at the University of California at Irvine). Straight practitioners and leaders saw this as an ominous sign of what might happen to chiropractic if efforts to maintain a “separate and distinct” identity were not reinvigorated. In the late 1950s, with veterans’ benefits expired, the chiropractic colleges began to contract once again. The increased admissions standards that the NCA Council on Education had pushed (involving 2 years of prechiropractic study in liberal arts colleges) were withdrawn by those few schools that had dared to implement them when competition from schools without such requirements necessitated it. The local monopolies that the NCA-affiliated schools anticipated had not materialized. The NCA-accredited Chiropractic Institute of New York continued to compete with the Columbia Institute of Chiropractic for students, while in California the LACC lost students to both the Cleveland Chiropractic College (descendant of the Ratledge Chiropractic College) and the Hollywood College of Chiropractic.83 Meanwhile the PSC, although diminished in enrollments like the rest, continued as the largest chiropractic institution and as a thorn in Nugent’s side. When B. J. Palmer, president of the PSC and president of the ICA, died in 1961, there was hope that the incessant war of words between the straights and mixers might abate. Although the Developer’s passing probably encouraged the reorganization of the NCA into today’s ACA during 1963–1964, there was still no reconciliation among the schools. Nugent’s services to the NCA were terminated in 1961 when he fell into disfavor with the board of directors over his harsh and frank comments. Stepping in to fill the vacuum in leadership in educational reform was George H. Haynes, MS, DC, since 1953 the administrative dean and CEO of the LACC. Haynes assumed the post of president of the NCA (later ACA) Council on Education, and oversaw its conversion to the independently chartered CCE in 1971. He served one term as the CCE’s first president, and then headed the committee that negotiated with the US Office of Education (USOE) for recognition of the Council as the accrediting authority for chiropractic schools.83

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RESEARCH IN THE MIDDLE ERA: SCIENCE AND PUBLICITY Chiropractors since D. D. Palmer22 have claimed that theirs is a scientific discipline, and some have considered it the “only truly scientific healing art.”88 Since identification as a science has been a progressively more important component of legitimacy and professional identity throughout the past century, medicine’s long-held contention that chiropractic is quackery has not only stigmatized the profession, but cut to the heart of chiropractors’ sense of identity. At the start of the twentieth century, universitybased medicine was just emerging from the descriptive and intuitive epistemology of Darwin into the laboratory experimentation of Koch and Pasteur. But this transformation would take decades to fully develop; nearly 40 years would pass before the widespread introduction of antibiotics. The average medical practitioner muddled on with the remedies of old. Chiropractors, meanwhile, found much to criticize, both with medicine and the emerging field of public health. Inoculation against various infectious conditions seemed a vile and dangerous form of poisoning with no more apparent logic than the proverbial “hair of the dog that bit you” (Fig. 2–19). Laws that required citizens to submit to these shots were viewed as a clear violation of “medical freedom.” Old Dad Chiro (D. D. Palmer) had railed against vivisection, immunization, and the trial-and-error empiricism of orthodox medical practice. Chiropractic, he insisted, was scientific and superior because it was theory-driven. What’s more, Palmer claimed, chiropractic theory united the “material” and the “immaterial” (his theory of Universal and Innate Intelligence), in contrast to the sterile atheism of the new scientific medicine. In time, asserted the founder, the science of chiropractic would “lift the veil which obstructs the view of the life beyond.”22 While such rhetoric sounds decidedly and disturbingly unscientific today, it could strike a plausible and sympathetic chord in the public of that earlier time. Although allopathy had much to be humble about, the neophyte science of chiropractic was a homegrown ideology harkening back to the populism of the early nineteenth century. Chiropractors were fearless in the face of pathology, keen to test their methods in all manner of disease, and often administered hope where a still generally impotent medicine could offer only despair. The “deductive science” offered by the chairman of the philosophy department at the PSC seemed to obviate empirical data collection89 ; chiropractic was “scientific” by fiat, because its methods were consistent with and/or derivable true “first principles.” And following the tradition established by D. D. and his son, they were bold in the public

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CHIROPRACTIC PRINCIPLES

FIGURE 2–19. The Statue of Liberty flees her pedestal in this newspaper cartoon from 1904, which depicts a legislator restraining an unwilling citizen while a medical practitioner injects a vaccine.

claims made for their new method. Chiropractic was unabashedly offered as a panacea. B. J. Palmer excelled in his marketing campaign in chiropractic, and proudly declared that he had built the chiropractic science “with printer’s ink.” Early on political medicine found that DCs themselves provided ample ammunition to use against the new healing sect. Isolated from universities and centers of scholarly and scientific activity, and badgered as quacks by the MDs, chiropractors developed their own conceptions of the meaning of science. Their “data” lay in the many satisfied patients and the testimonials these grateful clients offered; chiropractic was scientific because “it works.” As the new century progressed, however, the role of systematic, experimental research gradually replaced the museum displays of old as markers of scientific prowess. When Palmer introduced his NCM in 1924, he claimed (but apparently did not publish) experimental studies involving hundreds of patients.90 He poured hundreds of thousands of dollars (millions in today’s economy) into clinical data collection in the B. J. Palmer Clinic at the PSC; unfortunately, the mountain of data collected is largely uninterpretable, owing to Palmer’s lack of familiarity with the rules of evidence in clinical science. The title of the Developer’s 1951 tome, Chiropractic Controlled Clinical Trials,91 seemed to suggest a marginal awareness of the advances in clinical research methodology, but was devoid of any experimental findings. By the early 1920s, however, chiropractors had begun to show interest in accumulating clinical outcome data beyond the testimonials that so often graced their

promotional literature. Perhaps the earliest sustained effort at clinical data collection was undertaken by the ACA’s Bureau of Research.92 Established by Leo J. Steinbach, DC, dean of the Universal Chiropractic College in Pittsburgh, the directorship of the Bureau passed through several hands during 1924–1929, including A. B. Chatfield, LLB, DC, John Monroe, AM, DC, and, finally, Clarence W. Weiant, DC. The Bureau published a monthly report that featured quantitative outcomes from thousands of cases. Unfortunately, no details on the definitions of diagnoses, methods of data collection, or the criteria for reporting “improvement” were given, and no comparisons to untreated patients or to patients treated by other methods were made. In short, these investigations could not be replicated, and the absence of controls rendered interpretation of outcomes dubious at best. Nonetheless, chiropractors, generally unfamiliar with the scientific method, believed the reports lent great credence to their clinical work. The Bureau of Research did not continue when the ACA merged with UCA to form the NCA in 1930. However, the leadership of the new society recognized the need to develop some sort of research infrastructure. Rebuffed in its grant seeking by the Rockefeller Foundation, which pointed out the lack of a nonprofit foundation to receive any philanthropy, the NCA organized the nonprofit Chiropractic Research Foundation (CRF) in 1944 (forerunner of today’s Foundation for Chiropractic Education and Research).92 With small sums derived from the NCA’s newly formed malpractice insurer, the CRF

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

47

• The problem of recording objective clinical results and or correlating these with the data obtained in the pursuit of problems one through four.93

FIGURE 2–20. Cover of the August 1943 issue of the National Chiropractic Journal featured Dr. Clarence Weiant.

appointed the ACA’s former research bureau chief, Clarence Weiant (Fig. 2–20), to be its first director of research and gave him free reign to use these research dollars as he saw fit. Weiant, who by this time had earned a PhD in anthropology from Columbia University, organized a small team of scholars at the Chiropractic Institute of New York (CINY). His list of important research issues included: • The problem of defining and recognizing the forms of anatomical relationship to which the skeleton is subject. • The problem of determining to what extent these forms are fixed, or to what extent they vary with alterations of posture and other physiological activity. • The problem of recording the anatomical changes produced by the application of the various chiropractic techniques. • The problem of determining the physiological effects resulting from the application of chiropractic techniques.

This was an ambitious set of research goals, by any standard. During the next several years Weiant’s small group at CINY, with the assistance of several others, turned out a remarkable seven dozen scholarly papers and data reports.92 Although clinical outcomes were still almost totally uncontrolled, the seeds of programmatic investigation were clearly in evidence. Unfortunately, funding from CRF did not continue, largely due to the Foundation’s loss of several hundred thousand dollars in an ill-conceived fundraising appeal to the general public. By 1950, research had become something of a dirty word within NCA/CRF circles, and continuing discussion of the need for clinical outcomes data was relegated to the NCA’s Committee on Research. Although some dollars continued to be directed to the NCA’s college reform program, especially after the CRF’s reorganization as the Foundation for Accredited Chiropractic Education (FACE) in 1958,94 a serious commitment to scientific investigation would be deferred for several more decades. Chiropractors continued to promote their research discoveries and inventions throughout the 1950s. However, these efforts were generally far below the standards set by Weiant and his cohort at CINY, and often involved local and unsophisticated “research groups” of doctors, or technique entrepreneurs intent on marketing their clinical innovations to fellow practitioners. Relatedly, instrument manufacturers had proliferated since the introduction of the NCM 25 years before. By mid-century the variety of devices (Fig. 2–21) and the marketing claims made for them brought increasing scrutiny from the US Food and Drug Administration, whose 1938 expanded authority included therapeutic devices; a few of these apparatuses were confiscated. In the 1950s chiropractic contributions to the treatment of polio were widely disseminated, along with disparagement for the Salk vaccine. However plausible their work with this neuromusculoskeletal condition (like that of Sister Kenny), no hard evidence to support their contentions was proffered. And the DCs sometimes let politics supersede legitimate attempts at scientific research, such as in 1965, when Carl S. Cleveland, Jr., DC, dean of the Cleveland Chiropractic College in Kansas City, was refused permission to present his animal model of subluxation at the California Chiropractic Association’s annual convention. Carl Jr.’s father had taken over the Ratledge College in Los Angeles more than a dozen years before, and had infuriated broad-scope doctors by competing with the LACC and by maintaining only the minimum

48

CHIROPRACTIC PRINCIPLES

FIGURE 2–21. The photoelectric visual nerve tracer, an alternative to the NCM derived from Clarence Weiant’s “Analyte,”95 was marketed by George Adelman, DC, of Brockton, MA.

standards necessary to meet California’s educational and licensing requirements. This was reason enough, unfortunately, to ignore the research that the son had conducted.

PUSH FOR RECOGNITION As George Haynes took the reins of the NCA Council on Education in the early 1960s, voices within the Council and the NCA governance structure were growing in their insistence on federal recognition for chiropractic schools. The absence of this imprimatur had grown increasingly troublesome for the profession and its quest for legitimacy; political medicine had made chiropractic education a primary target of its criticisms.70,96,97 Indeed, Dewey Anderson, PhD, who succeeded John Nugent as director of education, warned the profession that the AMA had “a definite program to destroy chiropractic, root and branch, by 1970,”98 and the schools could expect much of the onslaught. With the 1963–1964 reorganization of the NCA to form today’s ACA, determination to meet the higher training standards grew stronger; the ACA committed 40% of membership dues to college upgrading.93

However, several school leaders within the ACA Council on Education resisted making some of the tough but necessary choices. Janse of the National College, for instance, was reluctant to replace DCs who had taught the basic sciences for years with more appropriately credentialed instructors (i.e., those with masters’ and doctoral degrees in biology). Others were alarmed by Anderson’s intention to focus ACA and FACE funding on one institution, so as to “push one college ahead of all the rest as a sort of spearhead” in the accreditation effort.99 By this time, all of the ACA-affiliated schools offered 4-year curricula and had converted to nonprofit status, but still relied almost exclusively on tuition revenues to support operations. Circumstances would shortly persuade them of the necessity of meeting even greater demands. Chiropractors in Louisiana had endured an especially odious status for years. Court decisions in this unlicensed jurisdiction had construed the practice of chiropractic to be the practice of medicine (Fig. 2–22). This meant that DCs were not allowed to advertise, and were subject to arrest, prosecution, and jailing at any moment. Led by Palmer graduate Jerry England and with the financial assistance of the NCA and ICA, practitioners in Louisiana challenged the constitutionality of the medical practice act and sued the state

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

49

vow. Janse bit the proverbial bullet, made the hard decisions, and created the higher standard. Despite a vigorous, national antichiropractic campaign involving public disparagement (see sidebar “Antichiropractic Articles Appearing in Popular Magazines During 1963–1970”) and back room politics, organized medicine was unable to prevent the NCC’s accreditation by the New York State (NYS) Education Department in 1971. Antichiropractic Articles Appearing in Popular Magazines During 1963–1970105 Foot in the door. Newsweek, April 8, 1963 Smith M. If your back is out, you’re in. Life, April 9, 1965 FIGURE 2–22. Mr. J. Minos Simon (left), chief legal counsel for the Louisiana chiropractors in the England case, and Dr. Paul J. Adams, member of the Legal Action Committee, are shown standing in front of the Federal Court Building in New Orleans. (Journal of the NCA, December 1959, p. 9.)

medical society and the Board of Medical Examiners in federal and state courts. One of the issues to be argued was the integrity of chiropractic education. The case underwent a tortuous process over 8 years, but came to a head in 1965, when school administrators Joseph Janse, DC, ND, of the National College of Chiropractic (NCC), and William Harper, MA, DC, of the Texas Chiropractic College, took the stand in federal district court in New Orleans. Chiropractic journals of the day painted a rosy picture of their testimony,100,101 but the reality was something different: At the trial, Dr. J. J. was raked over the coals so badly by the medical attorneys over the issue that no DC college had any accreditation status with USOE or any regional accreditation agencies, that our education was therefore in fact inferior to medical schools and that we were all a bunch of uneducated so-and-so’s. J. J. was so stimulated by his handling, he became the driving force, along with Geo. Haynes of LACC, to get an accreditation agency for the profession, and we know what happened. J. J. then went for regional accreditation and I believe was first to receive this type of status. . . . 102 The case was lost, and Dr. England was again subjected to harassment and arrest.103 Meanwhile, Janse had departed Louisiana bruised and humiliated by the experience, but determined to establish federal recognition of chiropractic education “or leave the profession” (Janse, quoted in reference 104 at p. 111). And during the next 6 years, he made good on this

Smith RL. Chiropractic: Science or swindle? Today’s Health, May 1965 Fineberg H. Chiropractic education [letter]. Science, June 3, 1966 Sabatier JA. Chiropractic education [letter]. Science, June 3, 1966 The medical dispute about treatment by chiropractors. Good Housekeeping, May 1967 Smith RL. Golden touch for chiropractors. Today’s Health, June 1968 Smith RL. Visit to a bizarre world—Chiropractic alma maters. Today’s Health, July 1968 HEW rejects chiropractic. Today’s Health, April 1969 Smith RL, Sabatier JA. Chiropractic: Issues and answers. Today’s Health, January 1970

While most if not all chiropractic colleges enjoyed recognition from their state education agencies, the Illinois-based National College’s achievement in New York held special significance. The education department in New York had established regional accrediting status with the USOE in order to facilitate supervision of its multicampus university system. New York DCs, after 50 years of lobbying, had won their first licensing statute in 1963, but there was a catch. Although chiropractors already in the state were “grandfathered” into legal practice, new license-applicants were required to graduate from a chiropractic college recognized by the federal government. When the NCC achieved accredited status in New York, despite strenuous protest from the NYS medical society,106 its graduates (and its graduates only) became license-eligible in that jurisdiction. Students at the NCC were also among the first to become eligible to receive federally guaranteed student loans for their chiropractic training. As well, because the NCC was also accredited by the ACA Council on Education, its status with the NYS regional accreditor lent greater credibility to the Council’s efforts to gain USOE standing as a professional accreditor. A few years later, the NCC gained

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CHIROPRACTIC PRINCIPLES

Numbers of Students Enrolled in US Chiropractic Colleges circa 1974, According to the Association of Chiropractic Colleges108

TABLE 2–7.

Schools Accredited by ACC Cleveland Chiropractic College/Los Angeles*

Number of Students 485

Schools Accredited by CCE

Number of Students

Los Angeles College of Chiropractic

337

Cleveland Chiropractic College/Kansas City Columbia Institute of Chiropractic Logan College of Chiropractic Palmer College of Chiropractic

340 260 410 1965

National College of Chiropractic Northwestern College of Chiropractic Texas Chiropractic College Western States Chiropractic College

600 130 145 140

Total students in ACC schools

3460

Total students in CCE schools

1352

Percent of total US chiropractic students

71.9%

Percent of total US chiropractic students

28.1%

* Candidate for accreditation by the Association of Chiropractic Colleges. Data from: ACC accredited colleges represent more than 71% of chiropractic students. Association of Chiropractic Colleges, news release, 18 July 1974.

regional accreditation with the North Central Association of Schools and Colleges.107 The larger goal would not come easily. As had so often been the case in campaigns to establish licensing laws, chiropractors jousted not only with organized medicine, but also with themselves. The USOE, which insisted on recognizing only one accrediting agency per profession, was confronted by two claimants for federal recognition: the ICA-friendly Association of Chiropractic Colleges (ACC; no relationship to today’s organization by the same name) and the CCE. The CCE, formerly a division of the ACA, was

independently chartered in 1971 to meet the stipulations of USOE. Now each agency contended that it was the appropriate choice for recognition by USOE. Although the ACC was not a viable candidate for this designation (because at least one of its accredited straight schools was still for-profit), the ACC could justly claim to represent a majority of all students enrolled in chiropractic colleges (Table 2–7). During 1971–1974 the Council of State Chiropractic Licensing Boards made repeated attempts to merge the two agencies or arbitrate an agreement for a unified petition to USOE. All of these efforts failed, but the issue was rendered moot in August 1974, when CCE was recognized by the USOE (Fig. 2–23).

SUDDEN VICTORY

FIGURE 2–23. Dr. George Haynes, president of LACC, is congratulated in 1975 by Leonard Fay, DC, ND, president of CCE and vice president of the National College of Chiropractic, for his successful efforts in winning USOE recognition of CCE. (Reproduced from CCE awards announced. ACA J Chiropr 1975; 12(5):19.)

The 1970s were a remarkable period for chiropractic, marked by the lowering of many barriers to broader acceptance, an abrupt shift in intraprofessional politics, the birth of several new schools, and the emergence of a research community within the profession (see sidebar “Several Milestones in Chiropractic History, 1971–1978”). Accreditation brought some quick changes in the colleges’ fortunes. Students at all schools recognized by the CCE were now eligible for federally guaranteed student loans, and the colleges were eligible, in principle, for federal grants for research and education.109 Enrollment increased, ACC-accredited schools applied for standing with the CCE, and the ICA was invited to take a seat on the CCE’s governing board. State boards of examiners, encouraged by the Federation of Chiropractic Licensing Boards (FCLB; successor to the COSCEB), revised eligibility for chiropractic licensure by requiring graduation either from a CCE-accredited school or from

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

a chiropractic college accredited by an agency recognized by USOE. Organized in 1963 by the FCLB, the tests administered by the National Board of Chiropractic Examiners (NBCE) gradually replaced the basic science examinations that had strangled the profession for decades. In 1979, the last three states (Texas, Utah, and Washington) eliminated basic science boards altogether (see Table 2–6). Several Milestones in Chiropractic History, 1971–1978 1971: Council on Chiropractic Education (CCE) is independently chartered 1971: National College of Chiropractic gains regional accreditation from the New York State Department of Education 1973: Sherman College of Chiropractic is chartered in South Carolina 1973: International College of Chiropractic Neurovertebrology (subsequently renamed Pasadena College of Chiropractic) is chartered in California 1973: US Congress authorizes payment for chiropractic services under Medicare 1974: CCE is recognized by the US Office of Education as the accrediting agency for chiropractic education 1974: Life Chiropractic College is chartered in Georgia 1974: Final American state (Louisiana) passes a chiropractic law 1975: Conference on the research status of spinal manipulation is convened at the National Institutes of Health 1975: College of Chiropractic Sciences (Canada) seeks certification from the Canadian Memorial Chiropractic College 1976: Pacific States Chiropractic College (later renamed Life Chiropractic College West) is chartered in California 1977: ADIO Institute of Straight Chiropractic (later renamed Pennsylvania College of Straight Chiropractic) is chartered in Pennsylvania 1978: First issue of the Journal of Manipulative and Physiological Therapeutics is published 1978: Parker College of Chiropractic is chartered in Texas 1978: Northern California College of Chiropractic (later renamed Palmer College of Chiropractic West) is chartered in California

The US Congress authorized payment to chiropractors for services rendered to Medicare patients in 1973. The legislation was not satisfactory in several respects; for example, although radiological demonstration of “subluxation” was required to justify treatment, chiropractors were not permitted to bill for the x-rays. Nonetheless, the new law supplanted the conclusions delivered to Congress in a 1968 report by the secretary of the Department of Health, Education,

51

and Welfare (DHEW), which had advised against chiropractic inclusion in the health plan.56,110 This turnaround at the federal level constituted a moral victory for chiropractors, who suspected the long arm of the AMA had been at work behind the scenes. (Subsequent revelations proved them correct.3 ) Wardwell56 notes that working together for perhaps the first time, the ACA and ICA prepared a rebuttal to the DHEW’s report, and solicited 12 million letters to Congress in support of their petition for Medicare reimbursement. The following year saw passage of a chiropractic law in the last holdout state, Louisiana. As though to reenact the struggle for chiropractic licensure, two final chiropractic “martyrs” were jailed for defying a court order against practice (as had been the custom throughout the chiropractic century). Arrested for unlicensed practice before the new law was passed, Drs. Brutus D. Mooring and Ellis J. Nosser of Caddo Parish were fined and incarcerated 6 months after the statute took effect for defying Judge Jack Fant’s injunction.111 Like so many DCs before them, they spent their time treating fellow inmates and their jailers. The magistrate was forced to reconsider their lockup when the sheriff’s switchboard was flooded by citizens calling in to see about the welfare of their doctors. The judge threw in the towel when the local press picked up the story; Mooring and Nosser were released after serving only 3 days behind bars. And in 1975, after several years of lobbying the US Congress, a small grant ($2 million) for chiropractic investigations culminated in a novel research conference on spinal manipulation.70,112,113 Held at the National Institutes of Health in Bethesda, Maryland, this historic 3-day meeting brought together clinicians, scientists, and political activists from several disciplines, including chiropractic, osteopathy, and allopathic medicine (see sidebar “Participants in the National Institutes of Health’s Workshop”). The monograph that resulted, entitled The Research Status of Spinal Manipulative Therapy,114 reviewed what quantitative data bearing on spinal manipulative therapy (SMT) then existed, and concluded that the scientific validity of manual therapies had yet to be established (Fig. 2–24). The gathering marked the first time that practitioners of manual therapy from diverse professions had met face-to-face to share their knowledge and skills. Although chiropractors would continue to experience discrimination in their scientific endeavors (e.g., their research papers were rejected ad hominem),115 the assembly was a turning point for the science of chiropractic.116 And though a few in the profession had repeatedly bemoaned the dearth of empirical evidence in chiropractic,117,118 the importance of controlled clinical trials of manual therapies was now officially brought to the wider profession’s consciousness.119

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CHIROPRACTIC PRINCIPLES

Scott Haldeman, DC, PhD Joseph W. Howe, DC, DACBR Joseph Janse, DC, ND. Martin Jenness, DC, PhD William L. Johnston, DO Christopher B. Kent, DC Igor Klatzo, MD Andries M. Kleynhans, DC Irvin M. Korr, Ph.D Elizabeth Lomax, MD, PhD Horace W. Magoun, PhD Robert Maigne, MD Peter A. Martin, ND, DO, DC Joseph P. Mazzarelli, DC Fletcher H. McDowell, MD James H. McElhaney, PhD John McM. Mennell, MD William D. Miller, DO Alf Nachemson, MD, PhD George W. Northup, DO, FAAO Sidney Ochs, PhD Harry D. Patton, MD, PhD Edward R. Perl, MD

FIGURE 2–24. Scott Haldeman, DC, PhD, MD, FCCS (Canada), FRCP (Canada), participant at the 1975 conference on the research status of spinal manipulation.

Participants in the National Institutes of Health’s Workshop on Spinal Manipulative Therapy, Bethesda, Maryland, 2–4 February 1975114

David E. Pleasure, MD Santo F. Pullella, PhD Richard Remington, PhD Akio Sato, MD, PhD Herbert H. Schaumburg, MD Robert Shapiro, MD Seth Sharpless, PhD Chung Ha Suh, PhD Sir Sydney Sunderland, MD Peter Tilley, DO Donald B. Tower, MD, PhD Walter I. Wardwell, PhD Edmund B. Weis, Jr., MD Henry G. West, Jr., DC

Thomas H. Ballantine, Jr., MD

Augustus A. White, III, MD

William Bromley, DC Robert E. Burke, MD Thomas N. Chase, MD Carl S. Cleveland, Jr., DC Jerome Cornfield

Andrew B. Wymore, DC

James Cyriax, MD, MRCP William S. Day, DC John S. Denslow, DO Giovanni DiChiro, MD David Drum, DC Gustave Dubbs, DC Karl Frank, PhD Lyle A. French, MD, PhD Ronald Gitelman, DC, FCCS(C) Murray Goldstein, DO, MPH Philip Greenman, DO E.S. Gurdjian, MD, PhD Lloyd Guth, MD

Chiropractors’ preparation for the research conference was facilitated by faculty members of the Canadian Memorial Chiropractic College (CMCC), who compiled the first extensive bibliography of books and scientific papers on SMT. The compendium was later expanded and published by Williams & Wilkins (a medical publisher) as the Chiropractic Research Abstracts Collection (discontinued in 1985). Several of CMCC’s academics also took the initiative to establish a scholarly society, the College of Chiropractic Sciences, for the explicit purpose of preparing future chiropractors for careers in research and education.120 In collaboration with the CMCC, the new organization established a hospital-based residency program in orthopedics at the University of

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

Saskatchewan, and many of its graduates subsequently became productive in chiropractic research. Among the early participants in this training were Drs. J. David Cassidy, Don Henderson, Silvano Mior, and Howard Vernon.

MORE MOUNTAINS TO CLIMB The 1970s saw the profession cross a number of significant thresholds. The subsequent decade, not surprisingly, was a period of consolidation and new challenges, some of which derived from chiropractors’ newly won status. With federal recognition of the CCE, for example, came increasing demands for scholarship and scientific investigation, a responsibility that the profession had never truly accepted before. It was a challenge made all the more formidable by the still largely tuition-driven financial base of the chiropractic schools. Meanwhile, unheralded and largely unappreciated at its 1978 inception, the National College’s Journal of Manipulative and Physiological Therapeutics (JMPT), a peer-reviewed periodical, became the center stage in the emerging research enterprise.120 Although the magazine never achieved a subscription base of more than 10% of the nation’s chiropractors, its 1981 acceptance for inclusion in the National Library of Medicine’s Index Medicus provided enhanced legitimacy for the profession and international and interdisciplinary visibility for the data it published. The JMPT and its founding editor, Roy W. Hildebrandt, DC, created a high standard and a model for others to emulate (Fig. 2–25). The JMPT continues today as the preeminent scholarly journal in the profession.

FIGURE 2–25. Dr. Roy W. Hildebrandt, circa 1966.

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Dissatisfaction with the standards and purposes of the CCE prompted the formation of a second accrediting agency for chiropractic schools, this one focused on straight chiropractic education. The Straight Chiropractic Academic Standards Association (SCASA) was organized in 1978 by the Federation of Straight Chiropractic Organizations (FSCO) and two member schools: Sherman College of Straight Chiropractic in South Carolina and the ADIO Institute of Straight Chiropractic in Pennsylvania. Founded by 1957 Palmer graduate Thomas Gelardi, DC, in 1973, Sherman College was refused accreditation by CCE in 1975, ostensibly on the grounds that it did not provide instruction in human dissection (Fig. 2–26). However, the contentious issues between the school and the CCE ran deeper: Sherman rejected as “medical” the notion that chiropractors diagnose and treat human illness. A number of lawsuits were filed by SCASA and the straight colleges against various agencies and associations in the profession to protect the institution’s vision of a nondiagnostic and nontherapeutic chiropractic. Drawn into the dispute were the ACA, CCE and its accredited schools, FCLB, ICA, NBCE, the South

FIGURE 2–26. Dr. Thom Gelardi, circa 1980.

54

CHIROPRACTIC PRINCIPLES

Carolina Chiropractic Association, and the US Commissioner of Education.70,121,122 Accreditation was critical to the new schools, because it determined the eligibility of their students for federally guaranteed loans, and the eligibility of their graduates for licensure in most states. Sherman College achieved regional accreditation from the Southern Association of Colleges and Schools in 1984, which gained its alumni license eligibility in a few states. When SCASA, which accredited both Sherman and ADIO, was recognized by US Secretary of Education William Bennett in 1988, the cause of the new straight schools was strengthened. However, SCASA’s federal status was not renewed in 1993, and Sherman College lost its regional accreditation. The South Carolina school eventually reached an accommodation with CCE, and was accredited in 1995. The ADIO Institute, later renamed the Pennsylvania College of Straight Chiropractic, closed its doors that same year. While the new straight schools struggled with much of the profession, the two major national membership societies (ACA and ICA) attempted to merge. The formation of the ACA in 1963 had itself been an attempt at organizational unity, and although it drew members from the NCA and the ICA, it fell short of the larger goal. (The resources of the NCA were transferred to the new society.123 ) Unsuccessful attempts at merger in the 1970s were followed by a more promising initiative that commenced in 1982. By 1984, the two organizations had established a joint committee to explore the issues involved in combining the resources and activities of ACA and ICA; a debate between leaders of the groups was held on July 3, 1987. Whereas the spokespersons for ACA and the ICA’s president, Michael D. Pedigo, DC, were in favor of combining the two societies, ICA board chair Sid E. Williams, DC, who was also founder and president of the largest chiropractic school, voiced his concern that ICA’s mission to preserve chiropractic’s unique identity would be lost in any such amalgamation (Fig. 2–27). Like B. J. Palmer before him, Dr. Williams was committed to preserving the “purity” of traditional straight chiropractic thought. The ICA’s Board of Control (executive body) chose to put the issue before the membership, and did so on two occasions, in 1988 and 1989. Each time a majority of ICA members were in favor of amalgamation, but because the ICA’s articles of incorporation required a two-thirds majority to effect the merger, the issue was defeated.123 The two organizations have since worked cooperatively in several arenas, most importantly involving national legislative issues (e.g., chiropractic care for veterans and active duty servicemen, Medicare reform), but continue to duplicate services in many areas. And the greater legitimacy that could

FIGURE 2–27. Dr. Sid Williams. (Courtesy of Dr. Williams.)

derive from a consensus of opinion and a single voice speaking for the profession remains elusive. The ACA and ICA also threw their combined support behind a lawsuit against the medical establishment brought by chiropractors Chester A. Wilk, Patricia Arthur, James Bryden, Steven Lumsden, and Michael D. Pedigo. Filed in federal district court in Chicago in 1976, the DCs charged the AMA and 14 codefendants (see sidebar “Defendants in the Wilk Antitrust Lawsuit”) with a conspiracy to restrain trade, a violation of the Sherman Anti-Trust Act.124,125 Although the AMA’s efforts to “contain and eliminate” the chiropractic profession were many decades old, the suit was based on the more recent activities of AMA’s Committee on Quackery, which was organized in 1963 and patterned after similar efforts of the Iowa Medical Society and its legal counsel, Robert B. Throckmorton.126 The “Iowa Plan,” as it was known, involved antichiropractic publicity distributed by AMA members and various public agencies, so-called “ethical” prohibitions against professional association between MDs and chiropractors, and exercise of behind-the-scenes influence within local, state, and federal agencies that regulated health care (e.g., health departments, state education officials, DHEW).

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

Defendants in the Wilk Antitrust Lawsuit127 American Academy of Orthopedic Surgeons American Academy of Physical Medicine and Rehabilitation American College of Radiology American College of Surgeons American Hospital Association American Medical Association American Osteopathic Association Chicago Medical Society Illinois Medical Society Joint Commission on Accreditation of Hospitals Medical Society of Cook County H. Thomas Ballantine, MD, chairman, AMA Committee on Quackery Joseph A. Sabatier, MD, chairman, AMA Committee on Quackery James H. Sammons, MD, AMA executive vice president H. Doyl Taylor, chairman, AMA Department of Investigation

The lawsuit lingered in the courts for 14 years, led by antitrust attorney George McAndrews, brother of Palmer College’s president, Jerome D. McAndrews, DC (Fig. 2–28). Several defendants settled with the chiropractors out of court, but the AMA persevered. An initial jury verdict against the plaintiffs was overturned, and the matter was finally settled by federal

55

judge Susan Getzendanner, who found in favor of the DCs, awarded damages to plaintiffs, and issued an injunction against further abuse by political medicine. As well, she ordered that her ruling be distributed to all AMA members and be published in the AMA’s Journal.128 Several subsequent appeals by the AMA to higher courts were unsuccessful, and the ruling held. While the case was in the courts, the AMA decided (in 1980) to rescind its prohibition against interprofessional cooperation between chiropractors and allopathic physicians. No longer was it considered unethical for the two provider groups to refer patients to one another, and for the first time AMA members were at liberty to collaborate with chiropractors and their institutions (e.g., as faculty members at chiropractic schools and as coinvestigators in research). And though the Joint Commission on Accreditation of Hospitals, which had previously subscribed to the AMA’s ethical guidelines, was found not liable by Judge Getzendanner, its previous refusal to allow hospital privileges for DCs fell by the wayside. The Wilk case changed the interaction between DCs and MDs at both the national political and local/individual levels. The AMA has grown reluctant to publicly criticize chiropractors, although the federal court order does not prohibit such expressions of opinion. (Several independent groups, most especially the National Council for Reliable Health Information, have taken up where the AMA left off.) The evolving economics of the health care marketplace have encouraged greater cooperation between chiropractic and medical physicians, including the formation of interdisciplinary practices and greater crossreferrals between practitioners than had been the case.

THE RECENT PAST AND NEAR FUTURE

FIGURE 2–28. George McAndrews, 1989.

The past quarter century has seen a number of progressive steps in the chiropractic profession’s long pursuit of legitimacy. Chiropractic statutes have been enacted in a number of foreign nations,129 and chiropractic colleges are now more numerous beyond American borders than within. This international spread of chiropractic education has been fostered by the creation of state-university-based training programs in Australia, Brazil, Canada, Denmark, Great Britain, and South Africa, and educational accrediting agencies have been established in Canada, Europe, and Australasia.129 These governmentfunded schools, which lessen the otherwise heavy tuition dependence of chiropractic education, also significantly enhance the interdisciplinary dialogue and collaboration between chiropractors and other health service providers. The trend promises to lessen the traditional stigmatization of chiropractors.

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The era has also witnessed considerable growth in the quantity and quality of chiropractic scholarship.130 The emergence of a rigorous literature of controlled clinical trials of spinal manipulation, many of them conducted by chiropractors, has strongly suggested the clinical usefulness of the manual arts in patients with low back, head, and neck pain.131–133 Studies of the costs of chiropractic care have similarly suggested somewhat of an advantage,134 and most studies of patients’ perception of chiropractic care speak to the satisfaction that these doctors generate.129,135 This body of evidence has elevated the esteem of the chiropractic art in the eyes of legislators, government policymakers, and segments of the health science community.136 At least one book,137 authored by chiropractic radiologists Terry Yochum, DC, DACBR, and Lindsay Rowe, DC, MD, DACBR, has been very well received in the allopathic community. An important example of this change in perspective is the evidence-based clinical practice guidelines for the treatment of low back pain issued by the federal Agency for Health Care Policy and Research.138 Another is the emergence of chiropractic services for active duty members of the armed forces, albeit within the context of a demonstration project.139 And in just the last decade, members of the profession have been, for the first time, recipients of sizable federal grants for clinical investigations, and federal funds have been used to establish a Consortial Center for Chiropractic Research (located at Palmer College of Chiropractic). Chiropractors have also gained respect for their initiative in creating their own clinical practice guidelines.140,141 Despite these achievements and the gain in respect and esteem for chiropractic methods, a great many century-old problems persist, and prevent the profession from achieving the cultural authority for which it thirsts. Among these impediments are (a) lack of consensus about the nature of chiropractic; (b) lack of organizational unity; (c) lingering stigmatization and ostracism, as well as self-imposed isolation from the wider health science and academic communities; and (d) lack of epistemological consensus and vestiges of dogma in theory and practice. Several of these factors limiting chiropractic legitimacy interact with one another, but it is useful to consider each. Chiropractors do not all agree on their own identity: what methods they use, what clinical goals are appropriate, and to which sort of patients and problems their healing art is appropriately applied (Table 2–8). Verbal battles continue to erupt over whether DCs should be considered “physicians,” whether clinical targets other than the traditional “chiropractic lesion” should be attended to, whether intervention methods in addition to adjustive procedures should be employed, and whether diagnosis (other than the

identification of “subluxations”) is acceptable practice. While state laws provide some boundaries within which the chiropractor must perform, the variability across chiropractic statutes in terms of what they permit and mandate142 is, itself, a source of confusion. Beyond the profession’s borders the question of whether chiropractic should be considered “mainstream” or “alternative care” is complicated by a multiplicity of opinions from the profession itself. (Some accept that chiropractic methods have become mainstream with respect to musculoskeletal problems of the head, neck, and back, but remain alternative for all other disorders.) Although some consensus on methodology is implicit in the creation of clinical practice guidelines,140,141 “straight” chiropractors have disagreed with these guidelines and ventured to create their own alternatives.143 There is unfortunate veracity in the observation by the late Stanley Martin, DC, that “for every chiropractor there is an equal and opposite chiropractor.” The diversity of views about the nature of the chiropractic art continues to sustain a number of national societies, none of which can claim a majority of the nation’s chiropractors as members. Among these are the ACA (largest of all, with about 20,000 full, associate, and student members), the ICA (about a third the size of the ACA), and two much smaller groups: the National Association of Chiropractic Medicine (which advocates chiropractors’ subordination to allopathic diagnosticians) and the World Chiropractic Alliance (propounder of exclusively subluxation-based chiropractic practice). These divergences of opinion are also reflected in several jurisdictions, where multiple state associations vie for legislators’ attention and the public’s ear. The self-defeating character of speaking with multiple voices is a recurrent problem throughout chiropractic history that, even if understood, has not been overcome. The recent, broad endorsement of the “paradigm” offered by the Association of Chiropractic Colleges144 constitutes a step toward greater agreement, but as has been suggested elsewhere,145 may create more problems than it solves. A strong belief in vitalism and the so far scientifically unsubstantiated “subluxation complex” and its clinical implications has aided the profession’s opponents in maintaining the stigma against chiropractic. Political medicine’s traditional charge that chiropractors are quacks (i.e., pretenders to medical knowledge) seems particularly hypocritical in light of the gross deficiency of medical training in the area of musculoskeletal disorders. Although the voice of the AMA has been generally silent with respect to chiropractic since its defeat in the Wilk antitrust case, others have found that DCs and their organizations continue to provide examples of scientifically unsubstantiated claims for the chiropractic art (see, e.g., reference 146).

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION TABLE 2–8.

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Suggested Roles and Scopes of Clinical Practice Among Chiropractors

DC’s Role

Assessment Target(s)

Assessment Methods

Intervention Target(s)

Intervention Methods

Advocates*

Primary care family physician, internist

Whole-person orientation:

X-ray and noninvasive methods, diagnosis

Whole-person orientation:

Manipulative and physiological

ACA, CCE, ACACDID

Musculoskeletal specialist

unlimited Primary contact provider: unlimited

X-ray and noninvasive methods, diagnosis

unlimited Musculoskeletal problems

therapeutics Manipulative and physiological

ACCO, ACA, CCE

Chiromedical specialist

Primary contact provider: unlimited

X-ray and noninvasive methods, diagonsis

only Musculoskeletal problems only

therapeutics Analgesics and topical medicines,

NACM

manipulative and physiological therapeutics Radiologist or other diagnostic specialist Adjustor (1) Adjustor (2) Adjustor (3)

Adjustor (4)

Unlimited

X-ray and noninvasive methods, diagonsis X-ray and noninvasive

N/A

N/A

Whole person,

Adjusting only

provider: unlimited Primary contact provider: unlimited Subluxations only

methods, diagnosis X-ray and noninvasive methods, diagnosis X-ray and noninvasive subluxation detection only; no diagnosis

all “diseases” Whole person, all “diseases”

Spinal adjusting only

ACA, ICA, CCE

Whole person, all “diseases”

Adjusting only

FSCO, SCASA

Spinal subluxations only

Spinal x-rays and noninvasive subluxation detection only; no diagnosis

Whole person, all “diseases”

Spinal adjusting only

FSCO, SCASA

Primary contact

ACCR, ACA, CCE ACA, ICA, CCE

* Abbreviations: ACA: American Chiropractic Association; ACCO: American Council on Chiropractic Orthopedics; ACCR: American College of Chiropractic Radiologists; ACA-CDID: ACA Council on Diagnosis and Internal Disorders; CCE: Council on Chiropractic Education; FSCO: Federation of Straight Chiropractic Organizations; ICA: International Chiropractor’s Association; NACM: National Association of Chiropractic Medicine; SCASA: Straight Chiropractic Academic Standards Association.

The recent defeat of the CMCC’s bid for university affiliation seems to be a consequence of this sustained antichiropractic sentiment. However, the isolation of the profession from the wider scholarly community is also, to a considerable extent, self-imposed. Like the fear that the prospect of clinical research once generated in some corners of the profession,92 university affiliation and stateuniversity-based chiropractic education have also generated anxieties. Apprehensions that chiropractic might lose its “separate and distinct” identity and autonomy recently resurfaced, as seen in the efforts of Palmer University to prevent the formation of a chiropractic college at Florida State University. Chiropractors remain unsure just how “mainstream” they wish to be, and so perhaps miss out on the benefits that scientific and professional cross-fertilization might offer.

At the root of many of the “philosophical” and professional dilemmas confronting chiropractors is the lack of agreement on epistemology, that branch of classical philosophy that deals with the nature of knowledge. Chiropractors have traditionally advocated a wide range of methods of determining the usefulness of their healing art (see sidebar “Historic and Contemporary Epistemologies in Chiropractic”).147,148 Although visionary chiropractic philosopher C. O. Watkins, DC (Fig. 2–29), long ago suggested that the profession’s means of choosing patient care methods was the most important determiner of chiropractic’s future, the message has not been widely heard nor taken to heart. Whereas most other health disciplines agree on the scientific method as the most appropriate means of determining clinical validity, chiropractic epistemologies are all over

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Uncritical Empiricism Cause and effect relationships in clinical practice are considered “validated” by private (unpublished), unsystematic (casual observation), and/or uncontrolled (nonexperimental) data. The classical fallacy of reasoning known as “post hoc ergo propter hoc” is exemplary (e.g., we know that the Logan Basic technique was effective because the patient’s pain was decreased). Other Fallacious Reasoning Various classical fallacies of reasoning have been offered in support of clinical theories and practice. Among these are appeal to authority (e.g., we know upper cervical adjusting works because B. J. Palmer said so), appeal to ignorance (e.g., we know chiropractic works because it has never been disproved), and the non sequitur (e.g., we know subluxations are real because otherwise there would be no need for chiropractors). Spiritual Inspiration This method of knowing is a special case of an appeal to authority; in this method, the authority figure is some supernatural being such as Innate Intelligence. For example, D. D. Palmer claimed that the principles of chiropractic were revealed to him by Dr. Jim Atkinson, who was apparently a deceased physician.

FIGURE 2–29. C. O. Watkins, DC, circa 1955. (Courtesy of Robert Watkins.)

the map.149 The profession’s recent commitment to developing evidence-based practice guidelines is a hopeful sign of some convergence around scientific standards. Historic and Contemporary Epistemologies in Chiropractic Clinical Science Method Sometimes also called the “hypothetico-deductive” method, this epistemology makes use of inferential and deductive reasoning. Hypotheses (i.e., testable propositions about cause and effect) are derived from many possible sources (e.g., basic science knowledge, clinical experience, previous research) and tested repeatedly in controlled experiments. Uncritical Rationalism The validity of theories and effectiveness of clinical interventions are thought to be established by their consistency with or derivability from some prior knowledge (premise) such as basic science information or a metaphysical assumption. Stephenson’s (1927) “deductive science” is exemplary of this method.

A deleterious consequence of the profession’s lack of consensus about epistemology is demonstrated in public communications by individual DCs and their representative state and national organizations. Scientifically unsubstantiated (i.e., untested by random clinical trials) claims for the chiropractic art are frequently offered in marketing materials,150 professional and educational web sites,146 trade journals, and other public forums. Many chiropractors have not distinguished between the use of unproved methods of healing (which is authorized by state licensure) and the making of assertions for the value of these procedures (which is protected by the First Amendment, but considered unprofessional beyond chiropractic’s borders). Chiropractors’ harshest critics continue to draw upon the chiropractic literature for ammunition to be used against the profession.

CONCLUSION Doctors of chiropractic have traveled far in their first 100 years, from their humble frontier roots in animal magnetism and alternative healing in the nineteenth century to their regulated status as one of the largest health care provider groups in the United States, and by far the most frequent providers of manual therapies. Chiropractors have carried the torch of populism and medical liberty, and built a loyal clientele who recognize a benefit not usually obtainable from orthodox

A BRIEF HISTORY OF THE CHIROPRACTIC PROFESSION

physicians. With no assistance from government they have built an educational system that, if not ideal, has nonetheless achieved federal recognition and serves its primary purpose: basic training for future generations of DCs. And they have accomplished these goals while enduring an abusive and hypocritical medical establishment. The underdog’s survival has been its victory. Along the way, DCs have acquired most if not all of the symbols of legitimacy available to a health care profession. Beyond legitimacy, however, lies the issue of cultural authority. Despite the recent growth in popularity of alternative medicine, chiropractors’ traditional “philosophy” (e.g., vitalism) and theory (e.g., subluxation complex) have not been accepted by a majority of the public and the wider health science community. The profession’s core mode of intervention, manipulation, has fared well in scientific trials of its application for certain musculoskeletal problems. However, the broader utility chiropractors have traditionally claimed and currently claim for spinal adjusting (i.e., effectiveness for visceral or internal disorders and for disease prevention) is at least as likely to produce scorn as acceptance. Continued expansion of chiropractic research can go far toward demonstrating the usefulness (or lack thereof) of chiropractic care for nonmusculoskeletal conditions, but greater skepticism about things chiropractic and greater caution in claims for the healing art will be necessary for the profession to earn the broader respect it craves. SUMMARY 1. Chiropractic emerged in the late nineteenth century as one of several alternatives to the heroic medical practices in the emerging “machine age.” Despite D. D. Palmer’s mystical roots in spiritualism and magnetic healing, chiropractic was conceived as a drugless, mechanical means of relieving inflamed tissue. Subsequent versions of the founder’s chiropractic focused more narrowly on mechanical effects on the nervous system and reintroduced the vitalism of his magnetic practices. 2. Palmer’s feud with the local allopathic community in Davenport, Iowa, foreshadowed a century of conflict between chiropractors and organized medicine. Thousands of DCs were arrested and tried for “practicing medicine without a license.” When tried by juries, most chiropractors were acquitted, but one in four was convicted and fined or imprisoned. This persecution motivated vigorous legislative campaigns, and by 1935 some 40 American jurisdictions had passed licensing laws for DCs. However, these early victories were undermined in half the states by the spread of basic science legislation, which erected a medically

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influenced barrier to licensure. Louisiana was the last state to license chiropractors (1974), and not until 1979 was the last of the basic science statutes repealed. 3. Schisms within the profession were in evidence as early as 1903 when the first significant competitor to the Palmer School of Chiropractic was established. Competition bred ideological disputes, while courtroom struggles with the allopathic establishment encouraged novel terminology for describing the chiropractic art. Chiropractors’ inability to reach consensus over their role, epistemology, and scope of practice hampered their effectiveness in legislative campaigns and delayed the creation of a substantive research enterprise. These “philosophical” differences also interfered with efforts to upgrade and establish federally recognized accreditation for chiropractic colleges. 4. The profession was built by strong-willed, often charismatic individuals who pursued their dreams tenaciously. The founder’s son, B. J. Palmer, took over his father’s institution in 1906, and with the assistance of veterans’ benefits following two world wars, turned out tens of thousands of practitioners. Chiropractors’ courtroom victories were guided by the Canadian-born lieutenant governor of Wisconsin, Tom Morris, whose law firm partners and successors defended DCs in thousands of criminal cases and sired the National Chiropractic Mutual Insurance Company, a malpractice insurance provider. The tradition of “rational chiropractic” is credited to John F. A. Howard, founder in 1906 of the National School of Chiropractic, and to his successor, William C. Schulze, MD, DC. Credit for the 40-year struggle to improve and accredit chiropractic education belongs largely to two men: 1922 Palmer alumnus John J. Nugent and 1936 Ratledge College graduate George H. Haynes. Chiropractors’ successful antitrust law suit against the American Medical Association and a dozen other coconspirators, brought to federal court in 1976 by Chester Wilk, DC, and four coplaintiffs, is largely attributable to the untiring labors of their legal counsel, George McAndrews. During the last quarter of the chiropractic century the emergence of meaningful research in the profession has been strongly influenced by scholars and clinicians such as Bernard A. Coyle, PhD, Scott Haldeman, DC, PhD, MD, and John J. Triano, DC, PhD. The National College of Chiropractic provided a major forum for chiropractic science in 1978, when it established the Journal of Manipulative and Physiological Therapeutics. 5. The chiropractic profession in America has acquired most if not all of the formal characteristics

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of legitimacy (e.g., licensure, accredited schools, third-party and government reimbursement for services). Cultural authority, on the other hand, continues to elude chiropractors in this country for several reasons, including lack of internal consensus about the role and scope of practice of DCs, and extraordinary diversity in epistemologies. Aversion to the epistemology of science adopted in most other healing arts is a significant barrier to internal consensus and research development. As well, continuing commitment to dogma perpetuates conflict with many other stakeholders in the health care marketplace (e.g., allopathic medicine, insurance companies and health maintenance organizations [HMOs], government). Chiropractors’ willingness to “lower their guard,” for example, by establishing state-university-based colleges of chiropractic, could go a long way toward developing a broader financial and scientific infrastructure for training and research.

ACKNOWLEDGMENTS

My thanks to Arlan W. Fuhr, DC, Bart N. Green, DC, MSEd, Robert B. Jackson, DC, ND, Jerome McAndrews, DC, and Glenda Wiese, PhD, for their assistance in retrieving materials, and to the National Institute of Chiropractic Research for its financial support of work related to the completion of this chapter.

QUESTIONS 1. The early 1970s were a turning point for the chiropractic profession, owing to: A. Passage of licensing legislation in the final (fiftieth) American state. B. Inclusion of chiropractic services in Medicare. C. Recognition of the Council on Chiropractic Education by the US Office of Education. D. The first federally sponsored conference on the research status of spinal manipulation. E. All of the above. 2. Who is credited with originating the “rational chiropractic” tradition in the profession? A. John F. A. Howard, DC B. Dr. D. D. Palmer C. Scott Haldeman, DC, PhD, MD D. Hugh B. Logan, DC E. Tom Morris, LLB 3. True or false: D. D. Palmer’s first theory of chiropractic (1897–1902) proposed that vertebral subluxations shut off the flow of Innate Intelligence to the body, thereby altering tone and producing disease.

4. Among the purported consequences of the diversity of epistemologies in the chiropractic profession are: A. Acquittal of 75% of chiropractors arrested for unlicensed practice and tried by juries. B. Rejection of homeopathic remedies as acceptable practice by chiropractors. C. Tardiness in developing a substantive program of clinical research. D. Repeal of basic science laws. E. Appointment of Tom Morris as chief legal counsel for the Universal Chiropractors’ Association. 5. Which of the following most significantly influenced the growth in numbers of the chiropractic profession? A. Passage of the Sherman Anti-Trust Act B. Passage of California’s chiropractic statute in 1922 by vote of the citizens C. Repeal of basic science statutes D. Federal educational benefits for veterans following two world wars E. Formation in 1926 of the earliest ancestor of today’s Federation of Chiropractic Licensing Boards (the International Congress of Chiropractic Examining Boards)

ANSWERS 1. 2. 3. 4. 5.

E A False C D

KEY REFERENCES Beideman RP. A short history of the chiropractic profession. In: Lawrence DJ, ed. Fundamentals of chiropractic diagnosis and management. Baltimore: Williams & Wilkins, 1990. Bigos S, et al. Clinical practice guideline number 14: Acute low back problems in adults. Rockville, MD: Agency for Health Care Policy and Research, December 1994 (AHCPR Publication No. 95–0642). Chapman-Smith D. The Wilk case. J Manipulative Physiol Ther 1989;12(2):142–146. Cherkin DC, Mootz RD, eds. Chiropractic in the United States: Training, practice and research. Rockville, MD: Agency for Health Care Policy and Research, December 1997 (AHCPR Publication No. 98-N002). Gevitz N. The chiropractors and the AMA: Reflections on the history of the consultation clause. Perspect Biol Med 1989;23(2):281–299. Goldstein M, ed. The research status of spinal manipulative therapy: A workshop held at the National Institutes of Health, February 2–4, 1975. Bethesda, MD: DHEW Publication No. (NIH) 76–998, 1975.

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Keating JC, Green BN, Johnson CD. “Research” and “science” in the first half of the chiropractic century. J Manipulative Physiol Ther 1995;18(6):357–378. Martin SC. “The only truly scientific method of healing”: Chiropractic and American science, 1895–1990. Isis 1994;85:207–227. Moore JS. Chiropractic in America: The history of a medical alternative. Baltimore: Johns Hopkins University Press, 1993. Peterson D, Wiese G, eds. Chiropractic: An illustrated history. St. Louis: Mosby-Year Book, 1995. Wardwell WI. Chiropractic: History and evolution of a new profession. St. Louis: Mosby, 1992.

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42. Keating JC, Brown RA, Smallie P. Tullius de Florence Ratledge: The missionary of straight chiropractic in California. Chiropr Hist 1991;11(2):26–38. 43. Ferguson A, Wiese G. How many chiropractic schools? An analysis of institutions that offered the DC degree. Chiropr Hist 1988;8(1):26–36. 44. Beideman RP. Seeking the rational alternative: The National College of Chiropractic from 1906 to 1982. Chiropr Hist 1983;3:16–22. 45. Gibbons RW. “The witnesses” in Davenport: Was Brady and Third Chiropractic’s “Dealey Plaza” in August, 1913. Chiropr Hist 1992;12(2):10–12. 46. Turner C. The rise of chiropractic. Los Angeles: Powell Publishing, 1931, p 294. 47. Morris T. Legislation and what kind? Presentation at the twelfth National U.C.A. Convention, August 1917, Davenport, Iowa (Ashworth papers, Cleveland Chiropractic College of Kansas City). 48. Palmer BJ. Legislation #48. Fountain Head News 24 May 1913;2(20):7. 49. Palmer BJ. This makes me laugh. Fountain Head News 13 July 1918 [A.C. 23];7(44):1–2. 50. American College of Chiropractors. Medical education versus chiropractic education. National publicity series no. 3 (pamphlet). New York: The College, 1927. 51. Gevitz N. “A coarse sieve”; basic science boards and medical licensure in the United States. J Hist Med Allied Sci 1988;43:36–63. 52. Kimbrough MJ. Jailed chiropractors: Those who blazed the trail. Chiropr Hist 1998;18(1):79–100. 53. Gibbons RW. “Go to jail for chiro.” J Chiropr Hum 1994;4:61–71. 54. Dr. Elliott to legislate for the chiros. Fountain Head News 27 December 1919 [A.C. 25];9(14–15):2. 55. Hat in the ring. The Hawkeye Chiropractor April 1928;3(5):6. 56. Wardwell WI. Chiropractic: History and evolution of a new profession. St. Louis: Mosby, 1992. 57. Keating JC. Introducing the neurocalometer: A view from the Fountain Head. J Can Chiropr Assoc 1991;35(3):165–178. 58. Palmer BJ. Fountain Head News 1924;13(25):6. 59. Janse J. National-Lincoln Colleges sign affiliation agreement. Dig Chiropr Econ 1971;14(2):56–57. 60. Legislatively speaking: Recent enactments pertaining to chiropractic. Bull Am Chiropr Assoc 1927; 4(4):3. 61. Legal status of the states. J Natl Chiropr Assoc 1931;1(2):6. 62. News bits. The Hawkeye Chiropractor November 1926;1(11):6. 63. Adams AA. Basic science data: The first compilation of pertinent basic science information. ICA Int Rev Chiropr 1957;11(11):14–16. 64. Barad AD. Basic science—Friend or foe? Natl Chiropr J 1948;18(7):31–32, 68. 65. Burwell DH, Spears LL. Basic science: Its evil purposes and disastrous effects. Natl Chiropr J 1934; 3(12):9–10, 31. 66. Bierring WL. An analysis of basic science laws. JAMA 1948;137(1):111–112.

67. Sauer BA. Basic science—Its purpose, operation, effect. Unpublished letter to the officers of the NCA and state chiropractic associations, 10 June 1932. Archives, Cleveland Chiropractic College of Kansas City. 68. Cleveland CS Jr. Letter to B. J. Palmer, 1 May 1959 (Cleveland papers, Cleveland Chiropractic College of Kansas City). 69. Gibbons RW. Chiropractic’s Abraham Flexner: The lonely journey of John J. Nugent, 1935–1963. Chiropr Hist 1985;5:44–51. 70. Keating JC, Callender AK, Cleveland CS. A history of chiropractic education in North America: Report to the Council on Chiropractic Education. Davenport, IA: Association for the History of Chiropractic, 1998, pp 201– 203. 71. Metz M. Fifty years of chiropractic recognized in Kansas. Abilene, KS: Author, 1965. 72. Nebraskan seeks license. ICA Int Rev Chiropr 1950;4(8):4. 73. Beatty HG. Basic principles: A stable middle ground is sought for future. Natl Chiropr J 1940;9(6):23–24. 74. Budden WA. Medical propaganda, aided by B. J. Palmer, defeats healing arts amendment. NCA Chiropr J 1935;4(2):9–10, 38. 75. Rogers LM. Arizona Supreme Court voids basic science law [editorial]. NCA Chiropr J 1936;5(7):6. 76. State reports: Tennessee: Science law repeal boosted by ruling. ICA Int Rev Chiropr 1976;30(4):6. 77. Hariman GE. Basic science acts: Are they a professional benefit or bugaboo? Natl Chiropr J 1940;9(4):10. 78. Natl (College) J Chiropr 1928;5(14):12. 79. Beatty HG. Basic science laws: Shall we use them to our benefit or detriment? Natl Chiropr J 1940;9(8):27. 80. Watkins CO. The new offensive will bring sound professional advancement. NCA Chiropr J 1934;3(6):5, 6, 33. 81. Carver W. History of chiropractic [unpublished, mimeographed]. Oklahoma City: Author, 1936. 82. Nugent JJ. Chiropractic education: Outline of a standard course. Webster City, IA: National Chiropractic Association, 1941. 83. Keating JC, ed. A history of the Los Angeles College of Chiropractic. Whittier, CA: Southern California University of Health Sciences, 2001. 84. Answers of National Chiropractic Insurance Company to interrogatories of plaintiff (No. 122,533), Triton Insurance vs. Committee on Chiropractic Welfare, NCIC, et al., January 1962 (NCMIC Archives). 85. Nugent JJ. How chiropractic was recognized by Congress in the National Draft Act. J Natl Chiropr Assoc 1951 (Aug); 21(8):9. 86. Important. Natl Chiropr J 1948;18(9):27. 87. Naturopathic scandals threaten chiropractic! ICA Int Rev Chiropr 1957;11(11):6–12. 88. Martin SC. “The only truly scientific method of healing”: Chiropractic and American science, 1895–1990. Isis 1994;85:207–227. 89. Stephenson RW. Chiropractic text book. Davenport, IA: Palmer School of Chiropractic, 1927. 90. Fountain Head News 8 November 1924 [A.C. 30]; 14(7):13.

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91. Palmer BJ. Chiropractic controlled clinical trials. Davenport, IA: Palmer School of Chiropractic, 1951. 92. Keating JC, Green BN, Johnson CD. “Research” and “science” in the first half of the chiropractic century. J Manipulative Physiol Ther 1995;18(6):357–378. 93. Schierholz AM. The Foundation for Chiropractic Education and Research: A history [unpublished]. Arlington, VA: The Foundation, 1986:7. 94. Timmins RH. FCER—Its history and work. ACA J Chiropr 1976;13(4):19–20. 95. Keating JC. Clarence W. Weiant, DC, PhC, PhD, an early chiropractic scholar. Chiropr Hist 2000;20(2):49– 79. 96. Homola S. Bonesetting, chiropractic and cultism. Panama City, FL: Critique Books, 1963. 97. Stanford Research Institute. Chiropractic in California. Los Angeles: Haynes Foundation, 1960. 98. Anderson D. Dig Chiropr Econ 1964;6(5):24–25. 99. Martin RJ. Federal recognition of chiropractic accreditation agency: A story of vision and supreme effort. Chirogram 1974;41(11):6–21. 100. Adams PJ. Trial of the England case. ACA J Chiropr 1965;2(5):13, 44. 101. Harper WD. In tribute to Dr. Joseph J. Janse. ACA J Chiropr 1965;2(5):18, 44, 46. 102. Jackson RB. Letter to J. C. Keating, 25 February 1993. 103. England JR. The England case: A battle for licensure. Today Chiropr 1995;24(6):84–89. 104. Beideman RP. In the making of a profession: The National College of Chiropractic, 1906–1981. Lombard, IL: National College of Chiropractic, 1995. 105. Moore JS. Chiropractic in America: The history of a medical alternative. Baltimore: Johns Hopkins University Press, 1993. 106. Beideman RP. A short history of the chiropractic profession. In: Lawrence DJ, ed. Fundamentals of chiropractic diagnosis and management. Baltimore: Williams & Wilkins, 1990. 107. Beideman RP. From millstone to milestone. ACA J Chiropr 1975;12(1):16–17. 108. ACC accredited colleges represent more than 71% of chiropractic students [news release]. Association of Chiropractic Colleges, 18 July 1974. 109. CCE awards announced. ACA J Chiropr 1975;12(5): 19. 110. Cohen WJ. Independent practitioners under Medicare: A report to Congress. Washington DC: US Department of Health, Education and Welfare, 1968. 111. Cleveland CS, Keating, JC. The postwar years, 1945– 1975. In: Peterson D, Wiese G, eds. Chiropractic: An illustrated history. St. Louis: Mosby-Year Book, 1995. 112. Hart FD. Report from Congress of State Associations. N Engl J Chiropr 1975 (Spr);9(1):9–10. 113. Macdonald ME: Chiropractic attends NINDS Conference. N Engl J Chiropr 1975;9(1):5–8. 114. Goldstein M, ed. The research status of spinal manipulative therapy: A workshop held at the National Institutes of Health, February 2–4, 1975. Bethesda, MD: DHEW, 1975, Publication No. (NIH) 76–998. 115. Curtiss PH Jr. Letter to John W. Frymoyer, 23 July 1987.

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116. Gitelman R. The history of chiropractic research and the challenge of today. J Aust Chiropr Assoc 1984;14(4):142–146. 117. Vear HJ. The validity of clinical chiropractic: A critical look. Address to the Western Canada Convention, 7 June 1974, Saskatoon, Saskatchewan. 118. Watkins CO. The basic principles of chiropractic government. Sidney, MT: Author, 1944. Reprinted as Appendix A in Keating JC. Toward a philosophy of the science of chiropractic: A primer for clinicians. Stockton, CA: Stockton Foundation for Chiropractic Research, 1992. 119. Dallas WH. Clinical trials: A new chiropractic research priority. ACA J Chiropr 1975;12(7):13–14. 120. Keating JC. Toward a philosophy of the science of chiropractic: A primer for clinicians. Stockton, CA: Stockton Foundation for Chiropractic Research, 1992. 121. Armstrong KS, Moore L, Wise LM. A report on chiropractic politics and education. Atlanta: Chiropractic Foundation of America, 1979. 122. Strauss JB. Refined by fire: The evolution of straight chiropractic. Levittown, PA: Foundation for the Advancement of Chiropractic Education, 1994. 123. Plamondon RL. Mainstreaming chiropractic: Tracing the American Chiropractic Association. Chiropr Hist 1993;13(2):305. 124. Chapman-Smith D. The Wilk case. J Manipulative Physiol Ther 1989;12(2):142–146. 125. Gevitz N. The chiropractors and the AMA: Reflections on the history of the consultation clause. Perspect Biol Med 1989;23(2):281–299. 126. Simpson JK. The Iowa plan and the activities of the Committee on Quackery. Chiropr J Aust 1997;27(1):5– 12. 127. Wardwell WI. Alternative policies adopted by organized medicine toward osteopaths and chiropractors: History and analysis. Res Soc Policy 1996;4:209–239. 128. Getzendanner S. Special communication: Permanent injunction order against AMA. JAMA 1988;259(1):81– 83. 129. Chapman-Smith DA. The chiropractic profession: Its education, practice, research and future directions. West Des Moines, IA: NCMIC Group, 2000, p 30. 130. Keating JC, Caldwell S, Nguyen H, Saljooghi S, Smith B. A descriptive analysis of the Journal of Manipulative and Physiological Therapeutics, 1989–1996. J Manipulative Physiol Ther 1998;21(8):539–552. 131. Bronfort G. Spinal manipulation: Current state of research and its indications. Neurol Clin North Am 1999;17(1):91–111. 132. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brook RH. The appropriateness of spinal manipulation for low-back pain: Project overview and literature review. Santa Monica, CA: RAND Corporation, 1991 (Document #R-4025/1-CCR/FCER). 133. Shekelle PG, Adams AH, Chassin MR, et al. The appropriateness of spinal manipulation for low-back pain: Indications and ratings by a multidisciplinary expert panel. Santa Monica, CA: RAND Corporation, 1991 (Document #R-4025/2-CCR/FCER). 134. Manga P, Angus D, Papadopoulos C, Swan W. The effectiveness and cost-effectiveness of chiropractic

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management of low-back pain. Ottawa: Pran Manga & Associates, University of Ottawa, 1993. Cherkin D, MacCormack FA. Patient evaluations of low back pain care from family physicians and chiropractors. West J Med 1989;150:351–355. Cherkin DC, Mootz RD, eds. Chiropractic in the United States: Training, practice and research. Rockville, MD: Agency for Health Care Policy and Research, December 1997 (AHCPR Publication No. 98-N002). Yochum TR, Rowe LJ. Essentials of skeletal radiology. Baltimore: Williams & Wilkins, 1987. Bigos S, Bowyer O, Braen G, et al. Clinical practice guideline Number 14: Acute low back problems in adults. Rockville, MD: Agency for Health Care Policy and Research, December 1994 (AHCPR Publication No. 95–0642). Jensen GA, Mootz RD, Shekelle PG, Cherkin DC. Insurance coverage of chiropractic services. In: Cherkin DC, Mootz RD, eds. Chiropractic in the United States: training, practice and research. Rockville, MD: Agency for Health Care Policy and Research, December 1997 (AHCPR Publication No. 98-N002). Haldeman S, Chapman-Smith D, Petersen DM, eds. Guidelines for chiropractic quality assurance and practice parameters. Gaithersburg, MD: Aspen Publishers, 1993. Henderson D, Chapman-Smith D, Mior S, Vernon H, eds. Clinical guidelines for chiropractic practice in

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Canada. Glenerin Inn, Mississauga, Ontario: Canadian Chiropractic Association, 1993. Lamm LC, Wegner E. Chiropractic scope of practice: What the law allows. Am J Chiropr Med 1989;2(4):155– 159. Practice guidelines for straight chiropractic. Chandler, AZ: World Chiropractic Alliance, 1993. Association of Chiropractic Colleges. The ACC chiropractic paradigm. J Manipulative Physiol Ther 1996;19(9):634–637. Keating JC. Commentary: The specter of dogma. J Can Chiropract Assoc 2001;45(2):76–80. Grod J, Sikorski D, Keating JC. The unsubstantiated claims of the largest state, provincial and national chiropractic associations and research agencies. J Manipulative Physiol Ther 2001;24(8):514–519. Keating JC. Chiropractic: Science and antiscience and pseudoscience, side by side. Skeptical Inquirer 1997;21(4):37–43. Keating JC. Philosophy and science in chiropractic: Essential, inseparable and misunderstood. Eur J Chiropr 2001;46(3):51–60. Keating JC. A survey of philosophical barriers to technique research in chiropractic. J Can Chiropr Assoc 1989;33(4):184–186. Keating JC, Hansen DT. Quackery vs. accountability in the marketing of chiropractic. J Manipulative Physiol Ther 1992;15(7):459–470.

C H A P T E R

3 THE EVOLUTION OF VITALISM AND MATERIALISM AND ITS IMPACT ON PHILOSOPHY IN CHIROPRACTIC Reed B. Phillips

O U T L I N E VITALISM IN CHIROPRACTIC AND THE TWENTIETH CENTURY CONCLUSION SUMMARY DEFINITIONS KEY REFERENCES REFERENCES

INTRODUCTION CLASSICAL GREEK PHILOSOPHICAL THOUGHT RENAISSANCE AND SEVENTEENTH CENTURY THOUGHT EIGHTEENTH CENTURY THOUGHT NINETEENTH CENTURY THOUGHT

influenced by subsequent followers, not the least of whom was B. J. Palmer, his son. This philosophy was greatly influenced by the prevailing thoughts at the end of the nineteenth century, when belief in vital forces governing life and action were increasingly challenged by the advancing knowledge of scientific investigation. Allopathic medicine was a strong supporter of the reductionistic approach to scientific inquiry, aiming to explain health and medicine in terms of purely physical, measurable phenomena. This clash in philosophy between chiropractic and allopathic medicine was an early source of friction between the professions, and was only heightened when legal maneuvering made chiropractors cling to this difference. Chiropractors’ conflict with allopathic medicine encouraged reliance upon vitalistic explanations for advancing the profession. The “life–matter relationship” debate happening in philosophy at that time also disposed chiropractors to emphasize deductive reasoning as a means of justifying and explaining chiropractic theory and practice. To better understand the roots of philosophical explanations in chiropractic, we must first travel the dusty roads of its predecessors. Appreciation of the philosophical debates over the centuries builds a

OBJECTIVES 1. To explain the historical roots and evolution of the philosophy of chiropractic. 2. To understand the meanings and the implications of the concepts of vitalism and materialism. 3. To describe how ideas about vitalism have evolved over time and who contributed to this discussion. INTRODUCTION The chiropractic profession is more than 100 years old. From its early beginnings to the present, an internal struggle over the philosophical underpinnings of the profession has resulted in a spectrum of beliefs and related behaviors. Many chiropractors have long held to beliefs in forces necessary for life, forces that are nonphysical and therefore unmeasurable, such as Universal Intelligence and Innate Intelligence, the vital forces that direct and govern life. Treatment with chiropractic adjustments in the past has been described as exerting a positive influence on the flow of Innate Intelligence, thereby leading to better health. The philosophical roots of chiropractic originated with its founder, D. D. Palmer, and were heavily 65

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context for understanding our current struggles. Our focus is on this “life–matter relationship,” also known as vitalism. CLASSICAL GREEK PHILOSOPHICAL THOUGHT The objective of this discussion is to gain an understanding of how ideas about life forces have evolved from the ancient Greeks to the present day. With this understanding one can appreciate more fully the reasons for the diversity of thought that exists today. In the space allotted, one can only trace the major strains of philosophical thought and lightly touch on some of the more notable contributors. The focus is on the development of thought as it relates to the origin, purpose, and meaning of life. The first point in need of clarification is that thoughts may change. The very definition of matter was a point of discussion for the early Greeks, to whom biology was built upon a dual concept of life—life as action in a physiological sense, and life as soul, inducing or permitting active life. Believing that life was simpler than the diversity presented to the senses, the Greeks sought a simplistic (reductionistic) explanation of life. Water was the first substance considered to have a “real existence”; other substances were added later, such as air, fire, and earth. Everything in the natural world was simply a combination of these elements. Thus life, as a soul, was part of what was defined as matter.1 Five fundamental theories developed to explain the relationship between life and matter: 1. Life is identical to some element. That is to say air and life are identical or fire and life are identical. 2. Life is immanent (contained within). Life is immanently present in the basic substances such as air or fire. 3. Life is imposed. Life is a distinct but nonmaterial entity bonded to certain objects and inducing in them a characteristic ensemble of behaviors (life as action). Plato was a strong proponent of this view. 4. Life is organization. Life is a special arrangement of matter that permits it to behave in a “lively” fashion, such as to eat or move. 5. Life is an emergent consequence of organization. This differs from the previous theory in that life is a result of the organization, and not the organization itself. Systems have characteristics that are absent from their isolated components, characteristics that only appear when the parts are assembled.1 Plato (427–347 bc), in his writing of Timaeus, taught that life occurred in a system subject to simultaneous

depletion and repletion. In his review of Plato’s work, Hall suggests that If that proper equilibrium of assimilated elements which is so necessary to life be disturbed, the results can be catastrophic. A disproportion of elements—and especially of the triangles in marrow—can bring on diseases and death. Such disproportion is caused specifically by irregularities in the rate of flow of substance [blood] into or out of the affected part of the body.1 This description is very similar to the chiropractic concept of subluxation, whose presence has been described as disturbing the equilibrium necessary to maintain health. Aristotle (384–322 bc) taught that natural bodies consisted of a primordial entity composed of two elements: the matter and the form. Form was the element capable of giving a specific determination to the matter and of transforming it into specific things. Aristotle believed that every living thing had a purpose toward which it spontaneously tended. The soul was part of the living body, and could not be separated from living matter.2 In fact, Aristotle spoke of three types of soul: (a) the vegetative, required for nutrition and reproduction, also found in plants and other living things; (b) the sensitive, found in all animals which appear to possess tactile sensation; and (c) the rational, possessed by man alone.3 Galen (129–189 ad) was heavily influenced by Aristotle’s concepts. He taught that the primary cause of any object is its final purpose, that is, the function or role for which it has come into existence.1 For Galen, life depended on breathing, which was the action of taking in spirit from the general world soul. The liver was the center for the veins, the heart for the arteries, and the brain for the nerves. From each of these organs the appropriate “spirits” were sent to the body not by circulation, but by an ebb and flow up and down a single series of channels. Blood from the liver and pneuma from the lungs mingled in the left ventricle and became vital spirits. The vital spirits that reached the brain were turned into animal spirits, which then traveled to all parts of the body through hollow nerves. From 200–1628 all followers of medicine and biology were Galenists and hence vitalists.3 RENAISSANCE AND SEVENTEENTH CENTURY THOUGHT Galen’s concept of vitalism remained mostly unchanged until the seventeenth century, when the Renaissance ushered in new ways of thinking. These new thoughts clashed with the dominant doctrine of the

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church, and acceptance of change was not without challenge. William Harvey (1578–1657) disregarded current notions about spirits. He proposed that the heart gave motion to the blood and that there was only one system of circulation in the body. The comingling of blood from the liver and the lungs to create vital spirits could not be demonstrated, which left this part of Galen’s work in question. However, Harvey’s work did not address the possibility of animal spirits associated with the function of the brain and nervous system. Thus, the belief in some sort of nervous spirits lingered and merged into the modern belief in nonmaterial impulses that pass along the nerves.3 Galileo Galilei (1564–1642), condemned by the church authorities in Rome, has been called the father of modern science. He was instrumental in the formulation of a new scientific methodology. Galileo asked not why objects move, but how they move. He was content to describe how phenomena progress, and he completely ignored questions about the purposes they serve, which he saw as irrelevant to the problems in which he was interested. The questions Galileo asked of nature were fundamentally different from those considered in the Middle Ages. Interest was directed not to final causes operating toward the future, nor to formal causes in the essence of the object, but to efficient causes. In all these ways, Galileo’s work embodied the approach typical of modern science, and it led to a new ideal of what it means to explain something.4 With the work of Galileo, the process of replacing God as First Cause began. God became merely the original creator of the interacting atoms in which resided all subsequent causality. Nature was considered to be independent and self-sufficient; God’s role was gradually relegated to that of First Cause only.4 Ren´e Descartes (1596–1650) attempted to show that man consisted of an earthly machine inhabited and governed by a rational soul not unlike that of Aristotle. In fact, the existence of God was essential for the creation and maintenance of nature and of the spirits of men. This duality of body and mind (or soul) ultimately depended upon God’s intervention to bring harmony to the two different entities. It became only too easy to omit the spiritual side of this duality and turn to a system of monism of a mechanistic nature.4 Descartes as a mechanist is considered the father of modern reductionism. His influence on biology and medicine led to efforts by others to explain all biological and chemical phenomena via the laws of mechanics. His concept of spirits, especially in man, amounted to nothing more than bodies with no properties, extremely small and moving at a very high speed like the parts of a flame.2 Georg Ernst Stahl (1660–1734) is probably best remembered for what are considered scientific errors.

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These were his ideas about phlogiston, a substance supposedly set free by burning objects, and his notion of a biomedical soul. Phlogiston influenced the history of biology by deflecting it temporarily from a forwarddirected understanding of biological oxidation.1 Stahl’s vitalism saw the soul as an external principle penetrating the inert body and vivifying it in a way that generated movement and hence life: The principle of life is the soul, not a special soul, but the rational soul, that which alone constitutes man, and is manifestly united to his body. . . . The soul is not the life of the body; it cannot even be said to be alive, but only to give life; and it accomplishes this task of vivification, not by simple union with the body, but by real action. . . . This life-giving act, the soul performs with complete intelligence in all details; it performs it by acting on all the organs, directing all their functions, using every appropriate means to arrive at its goal. . . . The organs, thus, are not, as the name organ might suggest, merely simple instruments; it is the soul that makes the lungs breathe, the heart beat, the blood circulate, the stomach digest, the liver secrete; it is the soul that, while preserving the body, also makes it live and that, in order to preserve it, maintains corruptible matter in its [condition of] essential corruptibility yet keeps it from the act of corruption; and it is the soul, finally, that, to protect the body against actual corruption and to restore its losses, nourishes it and assimilates foreign substances to it, and makes repose follow movement and sleep follow waking.1 The above definition is quite similar to the definition of Innate Intelligence given by Stephenson in 1927 (see “Definitions” below). And yet, as science progressed, Stahl’s views were eventually considered false and misleading by most thinkers. Rounding out the seventeenth century was Isaac Newton (1642–1727). As a mathematician, he furthered the work of Galileo in that he insisted that the scientist’s job was to describe phenomena and not to make unfounded speculations about why certain phenomena existed. Scientific research, he believed, should seek to explain how gravity worked, not why it existed. Newton’s laws of motion and gravity seemed applicable to all objects, from the smallest particle to the farthest planet. His theory painted an image of the world as an intricate machine following immutable laws. Here was the basis for the philosophies of determinism and materialism. Newton believed that the world machine was designed by an intelligent Creator

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and expressed God’s purposes. The properties that could be treated mathematically, such as mass and motion, were alone considered to be characteristic of the real world. Efficient causes replaced final causes, and all causality was assumed to be reducible to forces between particles and all changes reducible to the rearrangement of particles.4 EIGHTEENTH CENTURY THOUGHT While the science of mathematics and astronomy prospered during the seventeenth century, the development of the field of chemistry lagged. During the eighteenth century, science greatly expanded its explorations into new lands around the world. Scientific effort focused more upon collecting and classifying new forms of plants and animals than observing such things in their native habitat. While chemists and physicists made remarkable laboratory experiments, the distinction between living and nonliving entities remained unchanged. Life remained the unexplainable mystery regardless of the many varied forms that were discovered and classified. In spite of the growing momentum of mechanistic explanations of phenomena, vitalistic beliefs held sway because of the failure of mechanistic explanations to answer some fundamental biological questions. Partly because of the alleged shortcomings of mechanism and chemism, new solutions—new causae vitae—were called for. They carried appellations, varying with their authors, which were not new: “faculties,” “properties,” “principles,” “forces,” and “powers,” all characteristically preceded by the qualifying adjective “vital.”5 With the development of the microscope in the seventeenth century, a new field for the vitalist argument appeared. Embryology under the microscope opened the way for the great “evolution–epigenesis” controversy. Evolution was defined as the unfolding or development in the embryo of structures already present in the generative element or cells. To avoid confusion with Darwinian concepts, this definition of evolution is more correctly referred to as preformation. In contrast, epigenesis taught that new structures developed from undifferentiated structures that were not present in the original ovum or spermatozoon.3 Paul Joseph Barthez (1734–1806), a practicing physician, posited a causal “principle of life.” With this he sought to differentiate within the living system that which permits the organism to feel from that which allows it to move. It was this vital principle that led to the general use of the term “vitalism” after 1773. Barthez was unsure if his vital principle was (a) a definite substance, (b) a mode of the body, or (c) a mode of a special substance another of whose modes is the thinking soul. He considered the vital principle

to be separate from the body because the body could be killed with poisons without any physical disorganization of the body. He concluded that if the vital principle is separate from the body, then at death the vital principle may return to the universal principle that was created by God to animate the cosmos.5 In the latter half of the eighteenth century, vitalism retained its influence in scientific thought. This may have been related to the revival of the influence of religion in England and France, where an increased reverence for the Bible occurred. The general antirevolutionary movement after the excesses of the French Revolution may have also served to support vitalistic concepts.3 The second half of this century saw new models put forward and a general popular acceptance of the term “vitalism.” These models had in common the agencies or powers they evoked as preconditions of life at a point where they could not be explained or reduced any further. These principles, then, were primitive elements that acted as the cause of life, but of themselves were not interpretable in terms of organization or any other identifiable cause.5 NINETEENTH CENTURY THOUGHT The nineteenth century saw a proliferation of revisions in every branch of biology. The most radical were (a) the rise of organic chemistry and biochemistry, (b) the growth of cell doctrine, and (c) the establishment and acceptance of the theory of evolution.5 For a number of chemists during this century, it was apparent how far short their chemistry fell in explaining the phenomena of life. They recognized causal forces in living systems but could not explain them. Today, many of those forces have been explained as enzymes and peptides. Although the complexity of the molecular world was yet to be elucidated, this new knowledge began to weaken philosophic reliance upon unexplainable vital forces.5 T. Schwann (1800–1840) conceptualized the cell, albeit imperfectly. He described the cell as a vesicle with a cavity inside. The nucleus inside the cell was also thought to be a vesicle. As imperfect as his description might have been, he demonstrated that the ultimate living units of animals and plants contained the basic structural and developmental sameness.5 Nineteenth century vitalism left many unanswered questions. For example, was this “vital force” a specific nonmaterial, nonmechanical entity? What made it take action? What effects was it to produce? Was it matter or a force? Was it natural or supernatural? Does it have sentient or psychic properties? Was it the cause or the consequence of physical organization? The term “vitalist” represented a wide variety of ideas and was also applied to ideas from earlier eras. Hall

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organized the theories of vitalism in the nineteenth century into the following four areas:5 1. Life appeared as an ensemble of activities occurring when ordinary chemical elements were arranged in an extraordinary way. Thinkers in this group were called vitalists because of their insistence on life’s emergent uniqueness. 2. Vital properties consisted of certain unexplained and presumably inexplicable capacities or predispositions of living bodies to exhibit life as action. This group considered the vital cause not only unknown but unknowable. 3. The uniqueness of life seemed to demand the presence in living things of some extraordinary component, some special plastic principle, or entropyopposing force, or unique substance. 4. Matter itself is immanently alive and is the outward expression of the immanent animation of the organism’s substance. This theory was not well accepted. In summary, the term vitalism requires a clarification. Does it refer to an imposed causal agent or an inscrutable property of some sort, or is it the presumed immanent animateness of the organism’s substance or the emergent uniqueness of extraordinary organized matter? And, finally, why posit vitalism at all when progress in scientific discovery was bringing to light so much new knowledge? In the nineteenth century, vitalism retained its role for two reasons. The first was the apparent “irreducibility” of vital phenomena; the second was the apparent orderliness of the world, an organization that otherwise defied explanation.5 It was not common for the thinkers of the day to consider that the irreducibility of biological phenomena was a result of their own ignorance and not the existence of an inexplicable causal vital entity or agent. Giacomo Andrea Giacomini (1796–1849) was a vigorous supporter of vitalism in the nineteenth century. He taught that vital strength was a primary force of the living being, which stood as a power in opposition to the physicochemical laws and influences that could bring harm or even death to the organism: It is nature that cures disease. And by the term “nature” we mean an activity, a force within the living organism, called by different people mediating force, organic resistance. . . . To deny an activity of the organism which counteracts disease and keeps the body healthy against thousands of hazards is intellectual blindness. The mediating force of nature is the same force that renders this organism alive, develops it, and maintains it; it is the force which establishes

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and maintains the organic milieu and makes it no longer susceptible to nature’s laws, but to laws in opposition to these. . . . 2 This view is very similar to that of many early chiropractic practitioners, who believed that the body will heal itself if properly supported. Vitalistic concepts were opposed by the physicists and chemists of the day. They claimed “vital force” was a useless concept that added nothing new to a growing body of knowledge derived from observation and experimentation. In fact, they argued, many vital phenomena could now be explained by physical and chemical knowledge. Claude Bernard (1813–1878) sought to bring the opposing positions of the vitalists and mechanists together. He reaffirmed the existence of a finality in the internal units of the living being, but held that biologic dualism was only possible when the organism was considered as a whole: . . . [I]n physiology the knowledge of the properties of isolated elementary units cannot give anything more than an incomplete synthesis . . . in a word, when physiologic elements are combined new properties, which could not be appreciated in each single element, appear. . . . This shows that the elements, although different and independent, do not simply associate with one another, but their unification expresses something more than the simple addition of their separate properties . . . the vital force directs phenomena which it does not produce and physical agents produce phenomena which they do not direct. Among naturalists, and even more among physicians, there are some who in the name of vitalism formulate the most erroneous judgments. . . . They consider life a mysterious and supernatural force which acts arbitrarily and releases itself from any determinism, and consider as materialists all those who try to lead all vital phenomena to causes determined organically or physicochemically. . . . The vitalistic ideas, in the sense we have discussed, are nothing more than faith in the supernatural. . . . I would agree with vitalists only if they limited themselves to admitting that living beings present manifestations absent in the inanimate world and, for this reason, constitute a peculiar character of it.2 Rudolph Virchow (1821–1902) viewed the cell as the ultimate unit of life and life as the sum of activities that active cells have in common. He considered

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himself a new vitalist because of his refusal to acknowledge life at a level lower than the cell, even though he recognized a life force. He taught that: . . . the molecular properties of the cell are necessary for life but not in themselves sufficient. What was needed in addition was a vital force—a composite summation of all forces through which the motion that is life is communicated and maintained . . . that individual cells are the loci of disease and, in fact, of normal life processes too. The cell is the place where disease occurs, and it is also the place where life occurs. It is the unit of life and the precondition of life’s uniqueness . . . life-force is nonpsychic, nonteleological, and nontranscendental. . . . Life is only a special kind of the Mechanical, the most complex form thereof in which the usual mechanical laws occur under the most unusual and multiform conditions.5 Charles Darwin (1809–1882) had an enormous effect on the vitalism–mechanism controversies, although he tended to remain neutral. His theory of natural selection embraced the concepts of random variation, struggle for survival, and the survival of the fittest. He was a classical scientist of his day, and recognized that [n]o amount of data constitutes a scientific theory unless it is unified by the creative invention of an imaginative hypothesis; but no theory is of use in science unless it can be tested against individual observations and can guide the further collection of data.4 It was not until later in Darwin’s career that his theories expanded to explain the origin of man. What had been considered sacred was brought into the sphere of natural law and was analyzed in the same categories applied to other forms of life. His work emphasized that all of nature was constantly changing, that nature was a complex of interacting forces in organic interdependence, that the rule of law extended into new areas of biology and nature, and that nature now included humans along with other species.4 This transition of thought undermined the vitalist perspective by placing man under the governing laws of nature, and therefore likely devoid of a specially ordained vitalistic governance. The second half of the nineteenth century saw the vitalists’ traditions struggle with the definition of what was really alive and thus governed or at least influenced by a vital force. The argument was between those who believed the cell was the smallest living

unit and those who believed something smaller than the cell contained “life”: If life is a complex ensemble of nutritive, reproductive, and behavioral responses, then the least part of an organism that can be properly acknowledged as living will be the cell as a whole. But if life is more narrowly defined as, for example, replication through division, or molecular assimilation, or even a fairly complex combination of these, then it is arguable that something less than a cell—a molecule, or multimolecular particle or mixture—could be regarded as “living.”5 Herbert Spencer (1820–1903) defined life as follows: Life consists . . . in correlated, heterogeneous, simultaneous series of changes that adjust the organism to changes in its environment. Since every change is in some sense a change in relations, “the broadest and most complete definition of life will be—The continuous adjustment of internal relations to external relations.”5 The similarity of Spencer’s definition of life to that of chiropractic as given by Stephenson (1927) (see “Definitions” below) is not inconsistent with the transition of thought from one generation of thinkers to the next. Stephenson defined life “. . . as the movement of everything in the universe and governed by a Universal Intelligence.”6 VITALISM IN CHIROPRACTIC AND THE TWENTIETH CENTURY In 1895, vitalistic thinking was waning under the weight of scientific discovery. Mechanistic thinking paved the road to improved living conditions that began to reduce the rabid effects of disease and prolong life. It was in this same time period that medical education began to consolidate its “cultural authority”7 by drawing upon the findings of science to enhance the practice of medicine. In just two decades, medical education underwent significant changes that improved its quality and raised standards required to become a physician. D. D. Palmer, the founder of chiropractic, identified himself as a “magnetic healer.”8 Much of what D. D. taught in the early years was consistent with the prevailing vitalistic thinking. Many of his ideas were perpetuated at the Palmer School of Chiropractic under the leadership of his son B. J. These early years of chiropractic quickly saw conflict among a growing medical profession, a rivaling osteopathic profession,

THE EVOLUTION OF VITALISM AND MATERIALISM AND ITS IMPACT ON PHILOSOPHY IN CHIROPRACTIC

and Palmer’s followers. In Wisconsin in 1907, Palmer graduate Shegetaro Morikubo was charged with practicing medicine without a license. B. J. and legal counsel Tom Morris rushed to his aid. In Morikubo’s defense they declared that “chiropractic” was not the practice of medicine. The Morikubo case spawned a successful legal rhetoric which distinguished “chiropractic” from medicine and osteopathy.9 “We don’t treat disease” was the cry. Chiropractors cared for their patients by removing the cause for their disease, a state of being brought on by the presence of a “subluxation.” Allopathic notions of “subluxation” were much more narrow than those offered by chiropractors. Given these theoretical differences, it was argued, no real basis for criminal prosecution existed; chiropractors did not practice medicine, but merely detected and corrected subluxations of the spine. This approach kept many (but not all) chiropractors out of jail. From these beginnings, and driven by survival needs, B. J. and his followers developed a paradigm rooted in vitalistic concepts. The subluxation, freed from its restricted medical meaning, was the focus of chiropractic practice. Subluxations impeded the flow of vital life force (Innate Intelligence) through the body, and thereby caused disease. Chiropractors corrected these obstructions to life force by applying segment-specific chiropractic adjustments. Innate Intelligence was considered a fraction of the Universal Intelligence that governed all.10 The protective legal shield of “chiropractic philosophy” won many court battles by enabling chiropractors to successfully assert that they were not practicing medicine. As well, the vitalism of chiropractic philosophy was coupled to a restricted reasoning process. B. J. Palmer and Ralph Stephenson insisted that the “deductive science”6 of chiropractic was based upon derivations from a true first principle (the “Major Premise”), essentially an assertion of the existence of a Universal Intelligence. Chiropractic is a deductive science. The deductions are based upon a major premise that life is intelligent; that there is an Intelligent Creator, Who created matter, attends to its existence and gives to it all that it has. . . . Deductive reasoning is exactly suited to Chiropractic. By assuming a major premise that there is a Universal Intelligence which governs all matter, every inference drawn from that major premise and subjected to specific scrutiny stands the test. . . . We wish to make it clear that at no time does Chiropractic deny laboratory findings or discredit them as science, but Chiropractic reasons deductively instead of

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inductively upon them; seeing therein the action of intelligence, every finding being more proof of its Major Premise.6 This dismissal of the inferential reasoning of mechanistic science denied the essential value of empirical observation that natural philosophers since Galileo had pioneered, and served to further alienate the profession from the wider field of science. To be sure, B. J. Palmer was responsible for extensive data collection (e.g., his research clinic), but his intent was to confirm preconceived ideas rather than to explore the natural world. Any fact not found in support of the Major Premise was discounted in some fashion. Vitalism had found a shelter in which it seemed unassailable. Thus, in the developing years of chiropractic, when much oppression from the prevailing medical establishment existed, B. J. led a segment of the chiropractic profession into a then dying field of scientific endeavor, namely vitalism and metaphysics, initially to secure a measure of protection from legal harassment. This action spilled over into the developing thought patterns of the young profession and the desire for the security of an idealistic, isolationistic posture. However, it also unwittingly caused many elements of the profession to evolve an antiscience, antiintellectual attitude that impeded scientific thinking and the development of a research basis for the practice of chiropractic. Meanwhile, scientific discovery in the twentieth century surpassed all previous periods. Vision expanded into the heavens to distances difficult to comprehend and into microscopic degrees never before imagined. Yet, the search for the essence of life, that “vital force,” was not to be “scientifically” defined. Dix11 defined “life” as “the power by which a system of molecules acts so as to avoid equilibrium.” He felt that thought was impossible to explain by the laws of physics and chemistry. Even if the genetic code were fully understood, he argued, particular thoughts were not coded in the deoxyribonucleic acid (DNA) and these thoughts drive the organism toward maximum benefit, something he felt was a survival principle. This drive toward maximum benefit was termed by Dix as the vitalistic principle. Scientific inquiry into the cellular world led to an increasing focus on the mechanisms by which cells communicate with each other. Zweifach speaks of “the terminal mesh of microscopic sized vessels within the tissue . . . [and] the capacity to behave as an independent organic entity in response to local changes in the metabolic status of tissues. . . . [T]he basic functional attribute of this all-pervasive entity can best be described as the maintenance of tissue homeostasis. . . . [H]omeostatic controls have been relegated

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for the most part to the ultrastructural molecular domain.”12 Pischinger expanded the concept of the extracellular matrix as part of the controlling mechanism of the body and considers its vitalistic relationship:13

Cartesian view, because by definition, information belongs to neither mind nor body, although it touches both.”14 She also suggests the therapeutic potential of this informational model, and seems to provide support for the traditional vitalism of chiropractic:

Since the extracellular matrix is connected to the endocrine gland system via the capillaries, and to the central nervous system via the peripheral vegetative nerve endings with their blind endings in the extracellular matrix, and both systems are connected to each other in the brain stem, superior regulatory centers can be influenced by the extracellular matrix. Since capillaries, vegetative nerve fibers, and the connective tissue cells that wander through the connective tissue and regulate the extracellular matrix (macrophages, leukocytes, mast cells) are mutually “informative” through released cell products (prostaglandins, lymphokines, cytokines, proteases, protease inhibitors, etc.), the result is a vast, complex, intermeshed humoral system, whose historical scientific predecessors are to be found in the classical vital juice theory. The advantage of such an intermeshed system is a significant increase in the adjustment and performance capacity, and the possibility of more and properties that cannot be attained through simple addition of the single properties of the components. In this way, relationships between the psyche and the immune system (“psychoneuroimmunology”) can be understood.

So, if the flow of our molecules is not directed by the brain, and the brain is just another nodal point in the network, then we must ask— Where does the intelligence, the information that runs our body mind, come from? We know that information has an infinite capability to expand and increase, and that it is beyond time and place, matter, and energy. Therefore, it cannot belong to the material world we apprehend with our senses, but must belong to its own realm, one that we can experience as emotion, the mind, the spirit—an inforealm! This is the term I prefer, because it has a scientific ring to it, but others mean the same thing when they say field of intelligence, innate intelligence, the wisdom of the body. Still others call it God.14

The work of Candace Pert also addresses the life– matter discussion and reintroduces modern-day vitalistic concepts that have enjoyed some degree of respect within the scientific community. Pert observes the interconnectedness and communication among physiological systems, and locates the mind in this internal dialogue: The mind as we experience it is immaterial, yet it has a physical substrate, which is both the body and the brain. It may also be said to have a nonmaterial, nonphysical substrate that has to do with the flow of that information. . . . With information added to the process, we see that there is an intelligence running things. It’s not a matter of energy acting on matter to create behavior, but of intelligence in the form of information running all the systems and creating behavior.14 Information, she believes, “is the missing piece that allows us to transcend the body–mind split of

CONCLUSION From the classical Greek philosophers to present-day molecular biologists, the relationship between life and matter continues to elude precise scientific description, but likewise continues to persist as an element of our being that is not easily dismissed. The birth of chiropractic at the end of the nineteenth century with its emerging philosophical foundations presents plausible explanations for professional divisiveness. Allopathic hegemony attempted to eliminate the budding profession using legal means. Unable to withstand the frontal assault, chiropractic leadership sought refuge under the shield of an alternative vernacular. B. J. Palmer argued that the practice of chiropractic was different from the practice of medicine and, therefore, a chiropractor could not be punished for practicing medicine without a license. This protective shield apparently prompted a segment of the profession to extend its comfort zone by adopting not only an antimedicine position but an antiscientific stand. Chiropractors remained isolated from the scientific and academic community. Science, for B. J., meant sustaining the Major Premise and derivative theory and technique. The Major Premise (and other lesser premises) needed no explanation, because they were derived from a higher source and could not be questioned. Although this antiintellectual position persists in a small percentage of chiropractors in this twentyfirst century, the profession never developed a broadbased consensus around Stephenson’s 33 principles.

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The current spectrum of thought ranges from these traditional concepts espoused by B. J., Stephenson, and their adherents to an equally dogmatic and complete denial of vitalistic concepts at the other end of the spectrum. Fortunately, the spectrum contains a great deal of space between the two anchoring ends, a space wherein may be found many types of principles, such as vitalism, holism, naturalism, therapeutic conservatism, critical rationalism, and thoughts from the phenomenological and humanistic paradigms.15 A critical review of philosophy and its impact remains both a challenge and an opportunity for the profession. Diversity is generally healthy when it generates new ways of seeing the world. However, when diversity divides the world into warring camps, genocide is often the end result. On a shrinking planet, populated with a global community that embraces a diversity of thought, especially in the healing arena, chiropractic is confronted with an unprecedented opportunity to obtain its own “cultural authority” through enlightened and collegial intellectual exploration of its basic premises.

SUMMARY 1. The philosophical roots of chiropractic originated with its founder, D. D. Palmer, and were heavily influenced by subsequent followers, not the least of whom was B. J. Palmer, son of D. D. Their ideas, and those of other early chiropractic writers, were greatly influenced by prevailing thought at the end of the nineteenth century. Belief in vital forces governing life and action was increasingly challenged by the advancing knowledge of scientific investigation. Chiropractic philosophy has evolved over the years as a result of several factors, including continued study by the founders leading to a refinement of their earlier thoughts, as well as the need to protect the profession from legal persecution. 2. Historically, vitalism has been defined in many ways based on prevailing intellectual thought and scientific knowledge of the time, and the term has a dynamic existence. In general, vitalism suggests that a “life force” concept explains the existence of living organisms, while materialism implies that life can be explained in strictly physical terms. In chiropractic, proponents of the vitalistic approach attribute the effects of manipulation to restoring the flow of a life force (i.e., Innate Intelligence) perturbed by subluxation, whereas those in the materialistic camp attribute the effects of manipulation to physical phenomena, such as reducing nerve impingement or increasing joint range of motion.

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3. The concept of vitalism has been discussed for thousands of years, slowly evolving as new information about the world was discovered. Scientists and philosophers who participated in the discussion of vitalism include Plato, Aristotle, Galen, Harvey, Galileo, Descartes, Stahl, Newton, Barthez, Schwann, Hall, Giacomini, Bernard, Vichon, Darwin, Spencer, Pischinger, and Pert.

DEFINITIONS According to the dictionary, philosophy is: 1. The rational investigation of the truths and principles of being, knowledge, or conduct. 2. A system of philosophical doctrine: the philosophy of Spinoza. 3. The critical study of the basic principles and concepts of a particular branch of knowledge: the philosophy of science. 4. A system of principles for guidance in practical affairs: a philosophy of life. 5. A calm or philosophical attitude.16 The World Book Encyclopedia lists and defines the following branches of philosophy: 1. Metaphysics—the study of the fundamental nature of reality and existence and of the essence of things. 2. Epistemology—aims to determine the nature, basis and extent of knowledge. It explores the various ways of knowing, the nature of truth, and the relationship between knowledge and belief. 3. Logic—the study of the principles and methods of reasoning. It explores how we distinguish between good and bad reasoning. 4. Ethics—concerns human conduct, character, and values. It studies the nature of right and wrong and the distinction between good and evil. 5. Aesthetics—deals with the creation and principles of art and beauty. It also studies our thoughts, feelings, and attitudes when we see, hear, or read something beautiful.17 Note that neither chiropractic nor medicine appears as a “branch” of philosophy. Correct use of terminology would dictate that there is a “philosophy of chiropractic” but no “chiropractic philosophy.” A more colloquial use of the term “philosophy” may simply mean an individual’s beliefs. In this sense, one may label their personal beliefs as “chiropractic philosophy” but personal beliefs, no matter how systematic they may be, are not recognized as a branch or division of philosophy.

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There are subdivisions of metaphysics relevant to the discussion of vitalism, whose definitions would facilitate further discussion: 1. Materialism maintains that only matter has real existence and thoughts and feelings are the result of the activities of matter. Materialists reject spiritual values or existence outside of matter.17 2. Mechanism maintains that all happenings result from purely mechanical forces, without purpose.17 Matter is in constant motion and may be governed by natural laws, but there is no real purpose associated with the motion or its resulting effects. 3. Teleology is just the opposite of mechanism, stating that everything in the universe occurs for some purpose.17 It is as if there is some final cause to all that is happening around us. 4. Vitalism is the doctrine that phenomena are only partly controlled by mechanical forces, and are in some measure self-determining. It is also defined as the doctrine that ascribes the functions of a living organism to a vital principle distinct from chemical and physical forces. Vital principle is then defined as the force that animates and perpetuates living beings and organisms.16 Finally, the following are some terms proposed by chiropractic pioneers and the definitions commonly used in the first half of the twentieth century (with dialogue for clarification and emphasis) and often referenced (but lacking consensus within the profession) in philosophical discussions: 1. Subluxation is the condition of a vertebra that has lost its proper juxtaposition with the one above or the one below, or both to an extent less than a luxation, which impinges nerves and interferes with the transmission of mental impulses.6 2. Mental force (impulse) is that something, transmitted by nerves, which unites intelligence with matter. Mental force is called mental impulse because it impels tissue cells to intelligent action. Mental force is evidently a form of energy, or conveyed by a form of energy, for it can control forces that move matter physically or balance forces that do it. . . . Mental force is not a physical or chemical force; nor is it a stimulant.6 3. Universal Intelligence created and is maintaining everything in the universe. This is manifested by movement and is called Life. 4. Innate Intelligence is a specific, definite portion of this [Universal] intelligence, localized in a definite portion of matter and keeping it actively organized. . . . The function of an in-born, localized intelligence is to adapt some of the forces and

matter of the universe in a constructive manner. Organization points to centralization, or having a point of control. In animals, this point of control is in the brain. From this organ, Innate Intelligence sends its controlling forces via the spinal cord through the spinal column thence through the nerve trunks emitting from the spinal cord and passing through the intervertebral foramina to nerve branches ramifying to all parts of the body. Perfect adaptation of universal elements for this body depends upon perfect control by Innate Intelligence. Perfect adaptation results in health, and imperfect control results in disease. Defective control by Innate Intelligence is never from any imperfection of Innate Intelligence, which is always perfect, and assembles perfect forces in the brain, but from interference with the transmission of those Innate forces through or over the nerves. Owing to the spinal column being the only segmented structure of bone through which the nerve trunks pass, and the possibility of the displacement of its segments, changing the size and shape of the intervertebral foramina, it is possible for subluxations to occur there and offer interference with the transmission of Innate forces indirectly, if not directly. All disease is thus traceable to impingements of nerve tissue in the spinal column.6

KEY REFERENCES Pert C. Molecules of emotion. New York: Simon and Schuster, 1999. Starr P. The social transformation of American medicine. New York: Basic Books, 1982. Stephenson RW. Chiropractic textbook. Davenport, IA: Author, 1927.

REFERENCES 1. Hall T. Ideas of life and matter, vol. I. Chicago: University of Chicago Press, 1969. 2. Federspil G, Sicolo N. The nature of life in the history and philosophic thinking. Am J Nephrol 1994;14:338. 3. Wheeler L. Vitalism: Its history and validity. London: H.F. and G. Witherby, 1939. 4. Barbour I. Religion and science. San Francisco: Harper Collins, 1997. 5. Hall T. Ideas of life and matter, vol. II. Chicago: University of Chicago Press, 1969. 6. Stephenson RW. Chiropractic textbook. Davenport, IA: Author, 1927. 7. Starr P. The social transformation of American medicine. New York: Basic Books, 1982.

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8. Smith RL. At your own risk: The case against chiropractic. New York: Trident Press, 1969. 9. Keating JC. B. J. of Davenport: The early years of chiropractic. Davenport, IA: Association for the History of Chiropractic, 1997. 10. Gold R. The triune of life. Spartanburg, SC: Sherman College of Straight Chiropractic, 1997. 11. Dix D. A defense of vitalism. J Theoret Biol 1968; 20:338–340. 12. Zweifach BW. Vitalism revisited—An historical perspective of microcirculatory concepts. Int J Microcic. 1994;14:122–131. 13. Pischinger A. Matrix and matrix regulation. In:

14. 15.

16. 17.

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Heine H, ed. (Trans. N. MacLean.) Brussels: Haug International, 1991. Pert C. Molecules of emotion. New York: Simon and Schuster, 1999. Phillips RB. A contemporary philosophy of chiropractic for the Los Angeles College of Chiropractic. J Chiropr Hum 1994;4:20–25; Coulter I. Chiropractic: A philosophy for alternative health care. Oxford: Butterworth and Heinemann, 1999. Costello R, ed. Random House Webster’s College Dictionary. New York, Random House, 1991. Scott Fetzer Co. The World Book Encyclopedia, vol. 15. Chicago: World Book, 1987.

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C H A P T E R

4 PHILOSOPHY IN CHIROPRACTIC Joseph C. Keating, Jr.

O U T L I N E Epistemologies in Chiropractic MODELS AND IMPLICATIONS OF CHIROPRACTIC ORIENTATIONS CONCLUSIONS SUMMARY QUESTIONS ANSWERS KEY REFERENCES REFERENCES

INTRODUCTION THE PHILOSOPHIES OF THE PALMERS CHARACTERISTICS OF PHILOSOPHY AND SCIENCE METAPHORS, HEURISTICS, AND A PRIORI ASSUMPTIONS PRINCIPLES OF CHIROPRACTIC Holism and Conservatism Strategic Role of the Nervous System Professional Autonomy

which the art of chiropractic is practiced. Others view philosophy as a dynamic process of inquiry that might give rise to scientifically testable propositions, to exploration of ethical problems, and to novel clinical methods, but which is inevitably fluid. Some would agree that “[d]ispossessed of its philosophy, chiropractic is dispossessed of its uniqueness, and perhaps its future.”1 On the other hand, Clarence Weiant, DC, PhD (Fig. 4–1), a chiropractor-anthropologist, suggested that “chiropractic philosophy” was “the misnomer that plagues the profession,” and further opined that chiropractic theory or chiropractic principles were better terms for what has passed for philosophy in the profession.2,3 Still others,4 in rejecting the dogmatic characteristics of traditional chiropractic thought in favor of a scientific orientation, seemed to reject philosophy in its entirety. What is one to think? To make sense of philosophy in chiropractic, we will consider some of the historical roots of philosophy in the profession; its originating and most common metaphors; the similarities and differences between classical/academic philosophy and the belief systems held by chiropractors; the interactions among philosophy, science, and dogma; several of the dominant ideologies in the profession; and the ethical, clinical, and politico-legal implications of these perspectives.

OBJECTIVES 1. To review the historical roots of the principles and theories proposed by the Palmers. 2. To distinguish between philosophy as doctrine (dogma) and philosophy as a mode of critical inquiry, and to consider the relationship between philosophy and science. 3. To review several prominent principles (metaphors, heuristics, and a priori assumptions) in chiropractic. 4. To consider the variety of epistemological strategies chiropractors employ and to point out fallacies of reasoning. 5. To delineate several major orientations or “schools of thought” within the chiropractic profession and to note some of the implications of these variations.

INTRODUCTION “Philosophy” is one of the terms in chiropractic that confuses because of the multiplicity of its meanings and the diversity of its uses. Some doctors of chiropractic (DCs) view philosophy as a relatively static set of concepts from which theory is derived and upon 77

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FIGURE 4–2. Dr. D. D. Palmer, circa 1904.

FIGURE 4–1. Dr. Clarence W. Weiant, circa 1958.

THE PHILOSOPHIES OF THE PALMERS The views of the founder of chiropractic, D. D. Palmer, and his son, B. J., are the basis for much of what has been called traditional chiropractic philosophy.5 “Old Dad Chiro” (D. D.) came to the healing arts from a background in farming, grade school teaching, and spiritualism6 in the decades following the American Civil War. It was an era of intellectual expansion of the public mind, colored by such diverse ideas as animal magnetism (Mesmerism), phrenology (skull palpation to determine personality traits), natural selection (Darwinism), and the marvels of the burgeoning machine age. The harsh remedies of heroic medicine that had dominated allopathy in the earlier part of the nineteenth century were very slowly giving way to a more conservative and scientific (laboratory-based) exploration of human biology. However, the science of medicine at the end of the nineteenth century was crude by any standard and might well have produced more harm than good. Patients sought gentler alternatives to the primitive surgery and still largely empirical pharmacology of the day. Among the more popular alternatives at this time were the infinitesimal doses of the homeopath, the “revitalizing” energies of the emerging field of electro-medicine, the better

established field of magnetic healing, and the intuitively sensible mechanical methods of the osteopaths. Within this context D. D. Palmer (Fig. 4–2) sought a more rational, less esoteric explanation for the beneficial results he believed his patients derived from magnetic healing practices. He turned to the machine metaphors of his day and concluded that the positive effects of his laying on of hands resulted from the cooling qualities of his personal, excess vital magnetic energy. Palmer’s magnetic theory still involved the notion of transferring “animal magnetism” (vital energy) from doctor to patient, but now he was in synch with the machine age. His clinical targets were the inflammations that he considered central to disease, and he eventually came to believe that inflammatory processes were the consequence of anatomic disrelation, that is, of body parts being out of their proper position. As a magnetic healer Palmer used his sensitive fingers to locate the site of inflamed tissue and then, placing his fingers at these precise locations, cooled off inflammation much as one might decrease friction and heat in a gear box by pouring water or other heattransferring lubricant into it. In his palpatory methods can be seen the origins of “specificity” in later chiropractic diagnostic analyses. He prided himself on his technique of nerve tracing, which involved following a dysfunctional nerve from its spinal roots to the affected end organ, or vice versa. His advertising fliers carried testimonials that lauded this seemingly more rational approach. In later years, nerve tracing and

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joint palpation continued as the founder’s primary chiropractic assessment methods. As well, Palmer pointed out to his readers, he did not waste his healing energy by making magnetic passes over the patient’s entire body, as other magnetic healers did, but focused the outflow at the site of the biological dysfunction. D. D.’s first theory of chiropractic (1896–1903) was an extension of these concepts. Why wait for a displaced anatomical part to become inflamed, he reasoned, if the clinician’s hands could be used to replace or adjust the offending component to its proper position? First-stage chiropractic involved manipulation to adjust the tissues of the body to their presumed normal position so as to avoid or reverse friction. The theory suggested both the prophylactic and therapeutic value of what Palmer initially termed “magnetic manipulation” (chiropractic). He very unambiguously declared his ability to manually reposition any anatomic part, including the circulatory system, musculoskeletal system, and the nerves. However, Old Dad Chiro had a strong political incentive to differentiate his chiropractic from the manipulative practices of his competitors, the osteopaths. In July 1903, while teaching and practicing in Santa Barbara, California, he revised his theory to focus exclusively on the presumed effects of joint misalignment upon the nervous system.7 Henceforth, a majority of chiropractors would insist that chiropractors were only interested in neural influences upon health and that osteopaths were only interested in relieving circulatory obstructions. It was a false dichotomy, but would serve a useful purpose beginning in 1907, when the distinction produced the earliest known acquittal (i.e., the Morikubo case in La Crosse, Wisconsin) of a chiropractor on trial for unlicensed practice.8 Not content with his mechanical explanation of disease, Palmer returned to the vitalistic concepts in which his magnetic healing practice had its roots.9 Where once he had used such terms as “innate nerves” and “educated nerves” to differentiate the autonomic (involuntary) and skeletal (voluntary) divisions of the nervous system, in 1904, Palmer extrapolated these concepts into the “Innate Intelligence” and “Educated Intelligence” of the human organism.9 Educated Intelligence, he reasoned, was the product of the individual’s learning through interaction with the environment. Innate Intelligence, however, was construed as a fraction of God that inhabited the body and was responsible for maintaining health and recuperation from illness. These two “minds,” reasoned the founder, were ever active within the person, but were unaware of one another. Each exerted its influence on the body via the nerves. Palmer’s idea of an Innate Intelligence led him to reject his earlier notion that human biology could be

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adequately explained by analogy to the operations of machines. The formation of blood cells, the chemistry of digestion, the myriad functions of the internal organs, and the mental operations of the brain, he reasoned, required explanations that the simplicity of push–pull mechanics could not handle. And in positing Innate Intelligence as a fraction of Universal Intelligence (God), chiropractic theory served to unite the “material and the immaterial,” in contrast to what was seen as the atheism of medicine. Chiropractic would be a friendlier healing discipline, not only because it was gentler in its therapeutics than those of the allopathic mainstream of medicine, but because it respected and appealed to the theological values and beliefs of most patients. The vitalism of “Innate” was just a short conceptual step from the souls and spirits of Christianity and the spiritualism (seances) that had grown popular in the wake of the Civil War. D. D. Palmer’s final theory of chiropractic (1908– 1913) preserved the vitalism-through-the-nerves idea. However, by this time he had abandoned his earlier belief that nerves were pinched by joint misalignment. Instead, he proposed that skeletal misalignment caused nerves to be stretched or slackened, thereby altering vibrationally mediated nerve impulses sent to end organs. This final theory has been referred to as the tension-regulation theory of chiropractic.10 When B. J. Palmer took over control of his father’s institution (the Palmer School of Chiropractic) in 1906,11 he adopted most of the biotheological theory and clinical methods that his father had promulgated. Persecutions of chiropractors by organized medicine were growing, and one of the son’s earliest initiatives was the organization of the legal protective society known as the Universal Chiropractors’ Association (UCA; precursor of today’s American Chiropractic Association). The UCA’s first legal success occurred in La Crosse, Wisconsin, in 1907, when Palmer graduate Shegataro Morikubo was acquitted by a jury of the charge that he had practiced osteopathy without a license. The basis for this courtroom victory was defense counsel Tom Morris’ contention that chiropractors had a “philosophy and practice” that was distinct from the osteopaths: Chiropractors were only interested in the nervous system, while osteopaths were only interested in the circulation. The differences between the chiropractors’ short-lever thrusts and the osteopath’s long-lever moves helped to further distinguish the two manipulative professions. Only 24 years of age in 1906, the younger Palmer (Fig. 4–3) was captivated by the notion that the legal salvation of chiropractic could be based on the uniqueness of its philosophy. In thousands of trials in coming decades, “chiropractic philosophy” was offered as justification for the seeming violation of medical statutes, and in the great majority of cases heard by a jury,

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FIGURE 4–3. Dr. B. J. Palmer, circa 1920.

the “philosophical” uniqueness of chiropractic beliefs would prevail. Philosophy took on great significance within this young profession because of its practical value in helping chiropractors stay out of jail. In 1908, B. J. had his faculty award him the first ever “Philosopher of Chiropractic” degree (PhC). Considered a spurious degree within the mainstream of higher education, various schools continued to award the PhC into the 1960s. The courtroom helped to shape other aspects of chiropractic philosophy. Because diagnosis was considered the exclusive domain of medical practitioners, chiropractors denied that they diagnosed disease, insisting, instead, that they merely analyzed the spine for “the cause” of disease, a lesion referred to as a subluxation. Following his father’s lead, B. J. taught his students and proclaimed in court that chiropractic was not “therapeutic.” Patients were not “treated” by chiropractors; instead, the DC adjusted the spine to remove subluxations and permit the power of Innate Intelligence to reach all parts of the body (Fig. 4–4). Although some chiropractors would later acknowledge that the new jargon was merely a semantic ploy to escape the wrath of the law until separate licensure for chiropractors could be obtained,12 B. J. and his followers adopted the nondiagnostic, nontherapeutic rhetoric as a key component of their chiropractic philosophy.

Ralph W. Stephenson (Fig. 4–5), a philosophy instructor at the Palmer School in the 1920s, provided a codification of B. J.’s principles (Fig. 4–6) in his 1927 Chiropractic Textbook,13 a volume that went through many printings and was required reading at the Palmer School and several other chiropractic colleges for decades. Stephenson declared chiropractic a “deductive science” that eschewed the empirical observations and inferential reasoning of other scientific fields in favor of deduction from a true first principle. Stephenson’s first principle posited the existence of God as the explanation of all things, and the rest of the 33 catechism-like tenets were said to be derivable therefrom (Table 4–1). Armed with this “Palmer philosophy,” B. J., the self-styled “Developer” of chiropractic, preached the “gospel” of chiropractic as absolute truth wherein all of life and all of the universe were explained, and without which chiropractic was no longer “pure, straight, and unadulterated.”14 Those who disagreed or who offered alternative conceptualizations were branded “not chiropractic,” “mixers,” “medipractors,” and “medical fools.”15 Any student with the temerity to ask a question during a B. J. lecture would be told, “There’s a cow on the track; get that cow off the track,” for Palmer’s philosophy train was coming through.3 Heretics would abound, but none, it seemed, could counter the grand cosmology of B. J.’s and Stephenson’s “philosophy.” Palmer’s leadership was eventually rejected by a majority of the profession,11 but that same majority of chiropractic college graduates had trained at the Davenport, Iowa, institution and had been schooled in the inflexible ideology of the profession’s “Developer.”

CHARACTERISTICS OF PHILOSOPHY AND SCIENCE As the profession has matured, and especially in the 40-plus years since B. J. Palmer’s demise, chiropractors have grown more sophisticated in their understanding of the role that philosophical inquiry legitimately plays in the affairs of a health care discipline.16,17 Although a consensus around a philosophy of science as an appropriate basis for the art and science of chiropractic has not formed, chiropractors have shown some increasing recognition of the need to challenge their most fundamental concepts. Whereas B. J. Palmer’s philosophy involved fixed ideas whose truth was supposedly incontrovertible, scholars beyond the profession often construe philosophy as a dynamic process of inquiry rather than the inputs or conclusions drawn from such questioning (Fig. 4–7).16 In this sense, philosophy is a critical, doubting, probing endeavor wherein skepticism

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FIGURE 4–4. Advertisement for the UCA appearing in popular magazines in the 1920s.

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FIGURE 4–5. Dr. Ralph Stephenson, 1927.

TABLE 4–1.

FIGURE 4–6. Suggested relationships among Innate Intelligence, Educated Intelligence and the human body. (From Stephenson RW. Chiropractic textbook. Davenport, IA: Author, 1927.)

“A List of Thirty-Three Principles, Numbered and Named” (Stephenson, 1927)

No. 1

The Major Premise.

No. 2

A Universal Intelligence is in all matter and continually gives to it all its properties and actions, thus maintaining it in existence. The Chiropractic Meaning of Life.

No. 3 No. 4

The expression of this intelligence through matter is the Chiropractic meaning of life. The Union of Intelligence of Matter. Life is necessarily the union of intelligence and matter.

No. 6

The Triune of Life. Life is a triunity have three necessary united factors, namely, intelligence, Force and Matter. The Perfection of the Triune. In order to have 100% Life, there must be 100% intelligence, 100% Force, 100% Matter. The Principle of Time.

No. 7

There is no process that does not require time. The Amount of Intelligence In Matter.

No. 5

The amount of intelligence for any given amount of matter is 100%, and is always proportional to its requirements. No. 8

The Function of Intelligence. The function of intelligence is to create force.

No. 9

The The The The

No. 10

Amount of Force Created by Intelligence. amount of force created by intelligence is always 100%. Function of Force. function of force is to unite intelligence and matter. (continued)

PHILOSOPHY IN CHIROPRACTIC TABLE 4–1. No. 11

(Cont.)

The Character of Universal Forces. The forces of Universal intelligence are manifested by physical laws; are unswerving and unadapted, and have no

No. 13

solicitude for the structures in which they work. Interference with Transmission of Universal Forces. There can be interference with transmission of universal forces. The Function of Matter.

No. 14

The function of matter is to express force. Universal Life.

No. 12

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Force is manifested by motion in matter; all matter has motion, therefore there is universal life in all matter. No. 15 No. 16

No Motion without the Effort of Force. Matter can have no motion without the application of force by intelligence. Intelligence in both Organic and Inorganic Matter. Universal intelligence gives force to both organic and inorganic matter.

No. 17

Cause and Effect. Every effect has a cause and every cause has effects.

No. 18

Evidence of Life.

No. 19 No. 20 No. 21 No. 22 No. 23

No. 24

No. 25 No. 26

The signs of life are evidence of the intellegence of life. Organic Matter. The material of the body of a “living thing” is organized matter. Innate Intelligence. A “living thing” has an inborn intelligence within its body, called Innate Intelligence. The Mission of Innate Intelligence. The mission of Innate Intelligence is to maintain the material of the body of a “living thing” in active organization. The Amount of Innate Intelligence. There is 100% of Innate Intelligence in every “living thing,” the requisite amount, proportional to its organization. The Function of Innate Intelligence. The function of Innate Intelligence is to adapt universal forces and matter for use in the body, so that all parts of the body will have co-ordinated action for mutual benefit. The Limits of Adaptation. Innate Intelligence adapts forces and matter for the body as long as it can do so without breaking a universal law, or Innate Intelligence is limited by the limitations of matter. The Character of Innate Forces. The forces of Innate Intelligence never injure or destroy the structures in which they work. Comparison of Universal and Innate Forces. In order to carry on the universal cycle of life, Universal forces are destructive, and Innate forces constructive, as regards structural matter.

No. 27

The Normality of Innate Intelligence. Innate Intelligence is always normal and its function is always normal.

No. 28

The Conductors of Innate Forces. The forces of Innate Intelligence operate through or over the nervous system in animal bodies. Interference with Transmission of Innate Forces. There can be interference with the transmission of Innate forces. The Causes of Dis-ease.

No. 29 No. 30 No. 31

Interference with the transmission of Innate forces causes incoordination of dis-ease. Subluxations. Interference with transmission in the body is always directly or indirectly due to subluxations in the spinal column.

No. 32

The Priciple of Coordination. Coordination is the principle of harmonious action of all the parts os an organism, in fulfilling their offices and purposes. Mo. 33 The Law of Demand and Supply. The Law of Demand and Supply is existent in the body in its ideal state; wherein the “clearing house,” is the brain, innate the virtuous “banker,” brain cells “clerks,” and nerve cells “messengers.”

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First, do no harm ("Primum, non nocere")

• Is it possible to do no harm? • Should a risk/benefit analysis be used? • Is there a better principle to guide us?

At least try to do more good than harm

FIGURE 4–7. Relationship of philosophy to principles is illustrated by an imaginary (and simplified) philosophical analysis of Hippocrates’ maxim, Primum, non nocere (First, do no harm). (Reprinted by permission from the Journal of the Canadian Chiropractic Association.18 )

is prized18 rather than repudiated. The traditional divisions of classical philosophy2 have involved fields such as ethics (dealing with moral issues), aesthetics (concerned with the nature of beauty), logic (reasoning processes), ontology (dealing with metaphysics and the nature of reality), and epistemology (studying the nature of knowledge and its acquisition). Like science, philosophy often advances by formulating better questions rather than by providing answers. And though truth is the goal, philosophers recognize that truth is an ideal to aim at rather than a plateau that can be reached; in this sense, philosophy, like science, is always incomplete. As a health care profession, chiropractic legitimately includes principles related to its science as well as to its concepts, which guide its services and obligations to patients and society. Science itself was once known as “natural philosophy,” and may be seen as a child of philosophy; it is an activity in which observations of the world around us give rise to hypotheses TABLE 4–2.

and theories (tentative principles) about causal relationships among observables. The hypotheses of chiropractic science are predictions about how selected aspects of the real world will behave in the future, and are testable by experimentation (i.e., the scientific method). For example, we might predict that lowback-pain patients who receive side-posture, lumbar adjustments will experience less pain than those patients who do not. To the extent that repeated experiments (clinical trials) tend to confirm the expectation, our confidence in the hypothesis will grow. Indeed, the testability of propositions provides a demarcation between science and philosophy (Table 4–2). Philosophical and professional principles may be debated endlessly with no hope of any final resolution (e.g., Can there be any “true” scope of chiropractic practice?). Scientific investigation, in contrast, sometimes provides a sense of closure when repeated hypothesis testing produces similar or identical results. As well, scientific testing may lead us to abandon or revise previous theory, such as when hypotheses are falsified by evidence inconsistent with the theory. The ability of a hypothesis to be tested empirically (i.e., through controlled observations of the natural world), and thereby to prove its potential falsifiability, is part of what distinguishes scientific theories from philosophical speculation. Of course, scientific “truths” are never truly final statements about reality; the displacement of Newtonian physics by Einstein’s theory of

Testable and Untestable Components of a Philosophy of the Profession of Chiropractic

Untestable Principles Professional/Moral: Chiropractic is an autonomous profession Ethical imperatives (e.g., assessment/diagnosis) Ethical prohibitions (e.g., be careful not to injure the patient) Chiropractors should/should not function as adjustors only, family physicians, radiologists, industrial consultants, back specialists, minor surgeons, etc. Patient has ultimate responsibility for his/here own health Scientific: Rules of evidence (research methods) Doctors should be cautious in drawing conclusions and making claims for theory or technique Metaphors and Heuristic Concepts: The spine is a keyboard upon which the higher neural centers play Vis medicatrix naturae (the healing power of nature) Structure and function are reciprocal Life is the expression of tone

Potentially Testable (Falsifiable) Hypotheses

Basic Science Theories: Spinal subluxations produce disease Subluxation reduction improves immune function Subluxation produces relative leg length inequality Subluxation severity in adolescence predicts longevity Motion palpation of joints produces similar findings among multiple examiners Palpatory tenderness covaries with fixation in joints Clinical Science Theories and Techniques: Adjusting reduces or eliminates subluxations Adjusting improves health (and/or reduces disease) Logan Basic technique enhances immune function Adjusting produces analgesia Soft-tissue massage facilitates the effects of spinal adjusting Gonstead adjusting produces greater subluxation reduction than does Hole-in-One among low-back-pain patients Spinal manipulation relieves low back pain

Based on: Keating JC. Toward a philosophy of the science of chiropractic: A primer for clinicians. Stockton, CA: Stockton Foundation for Chiropractic Research, 1992, p 21.

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relativity provides an obvious example of the tentative character of scientific knowledge. Philosophy and science are also characterized by the reasoning process(es). Workers in both disciplines make use of deductive reasoning. In deduction, conclusions are derived by reasoning from initial, unchallenged premises: To the extent that the premises are true, and assuming that one’s reasoning is logically sound, conclusions will also be true. A classic example of deductive reasoning is: Premise: All Greeks are mortal. Premise: Socrates is a Greek. Conclusion: Socrates is mortal. Scientific reasoning, on the other hand, makes use of both deductive and inferential reasoning. Clinicians, for example, may base their manipulative technique on a knowledge of spinal architecture deduced from the “truths” of anatomical science. When inferential reasoning is employed, on the other hand, one or more premises are admittedly tentative, inasmuch as they are based on necessarily limited observations. Because observation may be faulty, owing to imperfection in the observation process or the limitations (unrepresentativeness) of the observations, the conclusions drawn may be incorrect. The hypotheses that comprise Newton’s theory of physics were accurate only up to a point, but could not accurately predict natural phenomena at very high speeds (i.e., speeds approaching that of light). A series of clinical experiments demonstrating pain relief for migraine patients who receive rotary cervical manipulations may not accurately predict the clinical outcomes of patients with muscle contraction headache who receive similar adjustments. And the proverbial turkey who expected to be fed each morning at 7 am based on prior experience (empirical observations) may lose its head on Thanksgiving morning. Scientific testing can produce quite unexpected and counterintuitive results. METAPHORS, HEURISTICS, AND A PRIORI ASSUMPTIONS As a clinical discipline, the chiropractic profession quite legitimately makes use of a variety of principles (see Table 4–1) to guide its service to patients, its quest for better understanding of the problems patients present and the methods that may be helpful in overcoming these problems, and to direct its interactions with the rest of society. Unlike the pure or basic sciences, which pursue knowledge for its own sake, chiropractors (and other types of doctors) have a social mission: the betterment of their patients. As members of an applied discipline, chiropractors adopt (and should critically evaluate) moral precepts, such

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as Hippocrates’ admonition to first do no harm. Chiropractors may adopt or reject the scientific method as a means of furthering knowledge of health and illness. The manual practitioner may accept the notion that intervention in the neural activity of patients is a strategic and beneficial path to assisting patients, or may turn to alternative (e.g., mechanical) explanations for the apparent benefits of the care they provide. The DC may construe her or his role narrowly, for instance, as a spinal-subluxation-only doctor or as a specialist in musculoskeletal problems. Alternatively, the chiropractor may see herself or himself as a primary care physician who deals with a wide range of musculoskeletal, visceral, and behavioral disorders. Some chiropractors limit their interventions to the root meaning of “chiropractic,” that is, done by hand, while others employ a variety of complementary, supplementary, and alternative treatment methods, such as nutritional advice, herbal remedies, exercise recommendations, electrotherapeutic devices, and adjusting instruments. For many of these issues, there may be no inherently right or wrong choice, while for others the process of critical thinking and/or scientific testing may provide at least partial answers. In many instances, society and its constituents (e.g., state legislatures, other health professions, insurance companies) may superimpose boundaries or offer political or financial incentives that also influence chiropractors’ choices of principles. It is incumbent upon the DC, therefore, to be familiar with traditional and contemporary forces that shape and mold the beliefs and values of the profession. Many principles of healing are expressed as metaphors. These are statements that are not necessarily true, but nonetheless provide a sort of mental shorthand that conveys potentially valuable ideas. For example, physiologist Irvin Korr’s notion that “the spine is a keyboard upon which the higher centers play” is not to be taken literally. No one will mistake the spine for a musical instrument, yet Dr. Korr’s poetry directs our attention to interactions within the central nervous system (CNS), and may suggest novel or improved methods of helping patients. Similarly, Innate Intelligence (or vis medicatrix naturae [the healing power of nature]) may be seen as a metaphor for homeostasis. Whether the recuperative activities of the organism are best construed as a fraction of God is perhaps better left to theologians than to doctors, but if the idea of Innate Intelligence reminds the clinician to consider gentler, more conservative means of healing first (i.e., before more drastic remedies are applied), it has served a valuable heuristic purpose. Heuristics also provide important concepts for the healing art. A heuristic construct or model is one that aids in organizing information, and therefore has

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error of offering descriptive terms (e.g., homeostasis) as causal explanations; Innate can no more explain human biological function than deities serve as scientific explanation for the world around us. The materialism of science is one of its defining characteristics. Science is atheistic (which is not to say it is antitheistic). PRINCIPLES OF CHIROPRACTIC

FIGURE 4–8. The “safety-pin cycle.” BC = brain cell; TC = tissue cell. (From Stephenson RW. Chiropractic textbook. Davenport, IA: Author, 1927.)

educational value. Like metaphors, heuristics are not offered as truth, or as hypotheses to be subjected to testing for validity, but as a sort of mental shorthand. Concepts such as the “supremacy of the nerves” or vis medicatrix naturae have heuristic value. The “safety-pin cycle” offered by Stephenson (Fig. 4–8),13 which conveys the notion of reciprocal communication within reflex arcs, may be said to serve a heuristic purpose. All philosophy and science are based on a priori assumptions, that is, upon ideas that are accepted as true if only for the sake of proceeding further. For example, scientists accept (without “proof”) that there is a real world, that there are causes and effects in this physical reality, and that these causes and effects are potentially discoverable by means of the scientific method. If scientists did not posit these admittedly dogmatic (i.e., accepted without evidence) beliefs, their work would be over before it began. The “dogma of science,” if you will, has utility in that it allows scientific research to proceed. One of the reasons why vitalism (e.g., the vitalism of Innate Intelligence) is generally rejected in biological science is its lack of utility. It is difficult if not impossible to imagine testable propositions (hypotheses) that could only be spawned by belief in spirits (immaterial intellect). For instance, theories of subluxations and the clinical syndromes they supposedly produce can be derived and tested without recourse to vitalism. Innate Intelligence fails as an essential, a priori assumption for a science of chiropractic. Nevertheless, as noted earlier, Innate may have clinical value as a heuristic concept. If the notion reminds practitioners of the great complexity of human physiology and of how much we have yet to learn (our innate ignorance?), then it may encourage a cautious and humble approach to treating patients. If Innate serves as a synonym for homeostasis, that is, as a descriptive label for an ontological (inherent, irreducible) property of biological organisms, then it is acceptable. Problems arise, however, when we make the

The healing power of nature is but one of many concepts that have guided chiropractors in the profession’s first century. Among other principles favored by chiropractors are notions such as therapeutic conservatism, holism, the strategic role of the nervous system, the autonomy of chiropractic as a profession, and a variety of epistemologies. A closer look at these ideas is in order. Holism and Conservatism Chiropractors emerged from the nineteenth century as one of a few surviving alternatives to the harsh remedies of heroic medical practice. Heroic medicine was characterized by such severe methods as blood-letting, purgatives and emetics, counterirritation, and proprietary pharmaceuticals (patent medicines) whose constituents included heavy doses of alcohol, opiates, mercury, and other toxins.19 Theorists of this orientation to health care held that the harshness of the remedy should be in proportion to the severity of the patient’s disease, which meant that the sickest individuals received the heaviest doses of dangerous drugs and procedures. Patients, on the other hand, sought gentler forms of help when sick and turned to the less invasive, nonpoisonous methods of the homeopaths, osteopaths, naturopaths, and chiropractors. Although these alternative practitioners, viewed as quacks by the politically dominant allopathic branch of the healing arts, might not cure their patients, neither were their methods likely to exacerbate the patients’ conditions. The conservatism of chiropractors’ orientation to health care is fostered in part by chiropractors’ rejection of drugs and surgery as a part of the chiropractic art. (To be sure, there have always been chiropractors who have wished to include at least some types of more invasive procedures, but this has been, and seemingly remains, a minority perspective.) This rejection of pharmaceuticals and surgery has been written into many statutes governing the practice of chiropractic; in some states it is illegal for a DC to recommend even nonprescription medications. With medicine and surgery generally outside their realm of legitimate practice, chiropractors have sought to maximize patient benefit through more conservative, relatively less invasive means of intervention. As well, many chiropractors have been vocal

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opponents of various treatments encouraged by allopathic medicine.20 At the turn of the century, the father of chiropractic railed against vaccination and vivisection (cutting into the living tissues of humans and animals).21,22 Palmer’s conservative orientation to health care, as well as the views of those who have followed in his footsteps, is generally consistent with the beliefs associated with the construct of Innate Intelligence: Chiropractors have sought by gentle methods to assist nature’s own ability to repair injury, recover from disease, and maintain health. This does not imply that chiropractic care is riskfree, of course. It seems a truism that any procedure with the potential to help also carries the risk of harm.23 An adjustment inevitably produces at least microtrauma in the tissue of the recipient, and more serious injury, although rare, should be of concern for the chiropractor. The ionizing properties of x-ray also have the potential to harm. Criticisms of the profession have often focused on acts of omission rather than commission, such as neglecting to perform an adequate diagnosis and/or to refer when the nature of the patient’s problem lies beyond the scope of competence of the DC. Conservative health care also implies conscientious attention to the details of the patient’s condition and circumstance. Chiropractic conservatism may also be seen as consistent with the principle of holism, which posits the interconnectedness of all aspects of the individual patient’s functioning. Chiropractors often express their holistic beliefs by asserting a reciprocal relationship between the structure and function of the body. Another way in which holistic views are expressed by chiropractors is the notion that the CNS provides an integrative and regulatory mechanism for all physiological functions. Sometimes referred to as the “supremacy of the nervous system,” this idea runs parallel to chiropractors’ attention to dysfunctions of the spine and to their concern to treat the patient “as a whole.” As well, chiropractors have traditionally adhered to the belief that the patient, rather than disease per se, should be the focus of the doctor’s concern. Holism also involves the belief that the patient is a potent and indispensable factor in recovery from disease and the maintenance of health. A corollary is the notion that the patient is ultimately responsible for her or his own health and illness. Holism has its limitations and hazards as well as its benefits. One risk is that health professionals may ignore the details of patients’ problems in favor of what Oliver Wendell Holmes referred to as the “naturetrusting heresy.”24 When holism is coupled to vitalistic beliefs, there may be a tendency to believe that the complexities of health problems can be ignored by directing treatment to a supposedly centralized healing power.25 When belief in a patient-centered vital force

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supplants the quest to understand and deal with the nuances of disease and illness, holism has gone awry and clinical conservatism may be abandoned. Strategic Role of the Nervous System Since 1903, when D. D. Palmer decided that “the body is heated by nerves and not by blood,”7 a majority of chiropractors have contended that the benefits derived from adjusting joints are attributable, predominantly or exclusively, to the effects of improved joint mechanics upon the nerves exiting the spine. Although the founder’s tension-regulating concepts10 did not gain wide acceptance, B. J. Palmer’s ideology made much of neural reflexes, and emphasized afferent and efferent communication between neural centers and end organs. “Mental impulses” were said to communicate information from Innate Intelligence and the brain to all tissues in the body. Quoting from the classic text by Gray, many chiropractors asserted that the nervous system controls all parts of the body, and therefore the effects of manipulative interventions may influence a wide range of disorders and organ systems. The focus of clinical attention has been on subluxation of joints (Fig. 4–9), especially spinal joints, and the positive effects upon neural behavior thought to derive from the reduction or elimination of subluxation. For some members of the profession, the remediation of spinal dysfunction has been linked to a belief in Innate Intelligence (whose “messages” are thought to be disrupted or blocked by malfunctioning joints). For others, the benefits of subluxation–reduction upon neural function are considered independent of any vitalistic construct. First appearing in the medical literature, the term subluxation predates chiropractic by more than a century26 and classically referred to a misalignment of joint surfaces. Chiropractors have subsequently drawn a distinction between the “allopathic subluxation” (joint misalignment only) and the “chiropractic subluxation,” which, by definition, involves some impact upon the function of nerves passing through or otherwise influenced by associated joint structures (e.g., the intervertebral foramina). Contemporary usage by chiropractors has greatly expanded the meaning of subluxation to include joint fixation (altered motion), changes in the tension of associated muscles, and histopathological alterations; the term “subluxation complex” is often employed to refer to this panoply of joint-centered dysfunctions.27 An additional distinction may be drawn between subluxation complex and subluxation syndrome. The latter includes the signs and symptoms of disease thought to be caused by or associated with subluxation complex. The Association of Chiropractic Colleges, organized by the presidents and senior administrators of

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syndrome are deficient.31 Although some work on animal models is available,32 the basic science model is incomplete33 and clinical trials of the adjustive arts have not concurrently monitored the putative lesions whose eradication is thought to produce beneficial clinical outcomes. Relatedly, clinical trials of the purported benefit of adjustive interventions are generally limited to musculoskeletal problems (e.g., low back pain and headaches) and have ignored subluxation constructs. Clinical research on the effects of manipulation in visceral disorders is also scarce.34 Craig Nelson has suggested that the most fundamental research questions related to subluxation and its supposed effects have neither been addressed nor even properly conceptualized.35 Despite the absence of adequate scientific information about subluxation and its hypothesized consequences, the notion of the strategic role of the nervous system is valuable and legitimate in several respects. Part of the value of this principle is demonstrated by the impetus it has given the profession to develop the manipulative arts. As a prescientific notion (i.e., offered as metaphor rather than asserted as truth), the idea of the CNS and the spine as regulators and targets for therapeutic intervention has given rise not only to subluxation theories, but to various non-subluxation-centered (and even non-CNSfocused) forms of conservative care.36–38 For instance, early college cofounder Alva Gregory proposed that spinal segmental levels be stimulated by manipulation based on spinal nerve distribution to diseased end organs, as well as for the purpose of correcting subluxation.39 FIGURE 4–9. “Subluxated vertebra.” (Courtesy of Cleveland Chiropractic College Archives, Kansas City.)

chiropractic schools in North America, offered the following thoughts about the quintessential chiropractic lesion: 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 structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence.28 Many theories have been devised to account for the supposed effects of subluxation and its elimination by manual therapies.29,30 However, the critical laboratory and clinical research that would be necessary to substantiate the meaningfulness of subluxation

Professional Autonomy Chiropractors have struggled throughout their first century to establish themselves as an independently licensed and self-regulating profession of healers; the final American state to grant licensure, Louisiana, did so in 1974. Drawing upon nineteenth century populist calls for “medical freedom” and “the right of the sick to get well” by means of a doctor of their own choosing, chiropractors successfully lobbied legislatures and mounted initiative campaigns to secure legal protection from the onslaught of political medicine (which does not agree with the principle of professional autonomy for chiropractors). And beyond licensure, turf battles over scope of practice, access to hospitals, and inclusion in various private and governmental health care plans have kept the profession in a continuous state of political activism. The hurlyburly of this struggle has reinforced chiropractors’ need and claim to be a “separate and distinct” profession. And, as we have seen, the struggle has colored both theory and practice.

PHILOSOPHY IN CHIROPRACTIC

The century-long war with medicine and other political forces has also fostered a degree of professional xenophobia. Chiropractors have repeatedly warned one another that organized medicine was planning to “steal chiropractic.”40,41 In the wake of the assimilation of a majority of the state’s osteopathic profession by the California Medical Association in the early 1960s,42 chiropractors’ fear of absorption were ignited and would smolder for decades.43,44 Meanwhile, the American Medical Association’s Committee on Quackery45 sought to “contain and eliminate” the chiropractic profession, prompting a 14-year-long lawsuit by several chiropractors, brought under the provisions of the Sherman Anti-Trust Act46,47 ; chiropractors had good reasons for their paranoia. To be sure, calmer voices have also been heard within the profession. The late Joseph Mazzarelli, former president and chairman of the board of the International Chiropractors’ Association (ICA) and chair of Palmer College’s board of trustees, insisted that the development of manipulative skills by allopathic physicians was not only not a threat, but something to be encouraged.48 He believed that instruction in “manual medicine” for medical doctors would foster greater interdisciplinary cooperation and respect. As recently as 1995, the Council on Chiropractic Education (CCE), under the guidance of then CCE president Carl S. Cleveland III (Fig. 4–10), convened a meeting to formally consider the relative merits of continuing isolation versus integration with the wider health care community.44,49–58 Unfortunately, the profession’s ostracism from the allopathic profession until the late 1980s also meant alienation from most other health care providers and funders. Hospital-based chiropractic care, where

FIGURE 4–10. Dr. Carl Cleveland III, president of the CCE, 1995.

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greater professional interaction might occur, is still rare. The autonomy implicit in state laws regulating chiropractors is complicated by differences in the scopes of practice permitted by the various jurisdictions, differences that foster uncertainty about what chiropractors can and cannot do as healers. Chiropractors continue to be the stepchildren of the health professions, and must struggle for rights and privileges that seem to come more easily to other professionals. Even today, there are no state-university-based chiropractic colleges and no formal teaching-hospital residencies in the United States, although the situation has been changing rapidly on the international front (e.g., University of Glamorgan in Wales, Macquarie University and the Royal Melbourne Institute of Technology in Australia, Universit´e de Quebec a` Trois Rivi`eres in Canada, and the University of Southern Denmark). In the 1990s, chiropractors were finally successful in acquiring a few million dollars for clinical research from the National Institutes of Health, but there may be a hint of tokenism in this accomplishment. The granting of research funding to chiropractors has been increased recently with the establishment of the National Center for Complementary and Alternative Medicine. Epistemologies in Chiropractic Epistemology is that branch of classical philosophy that concerns itself with the nature of knowledge and the ways by which understanding may be increased. Throughout most of its early history the chiropractic profession differed from other health care provider groups in that it did not widely accept the principles of the scientific method as a basis for advancing knowledge. To the contrary, chiropractors offered a wide range of “ways of knowing” what works and why in its clinical art,59,60 including a great many rationales that classically trained logicians refer to as fallacies of reasoning (Table 4–3). This is perhaps to be expected in a profession that has, through ostracism and in some cases by its own preference, remained isolated from the wider health science and scholarly communities. Among the epistemologies offered in the profession are empiricism (knowing by doing or observing), rationalism (based on deduction from established knowledge), spiritual inspiration (insight derived from ethereal sources), and the epistemology of science. The empirical and rational approaches to knowledge derivation may be subdivided into those involving critical thinking and systematic method and those lacking such qualities (e.g., critical empiricism vs. uncritical empiricism). The same could be said of allopathic medicine in the nineteenth century, which was only slowly adopting experimentation as a basis for the clinical art. “Trial-and-error” empiricism on the part of individual

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Several Fallacies of Reasoning Offered in Defense of the Chiropractic Profession and Its Healing Art

TABLE 4–3.

Fallacy

Definition

Example

Appeal to authority

The opinion of experts or presumed experts is accepted as truth

We know that subluxation is meaningful because Palmer (or other guru) said

Appeal to ignorance

The absence of evidence is offered as evidence

so We know chiropractic works because it has never been disproved

Argument ad hominem

An argument is dismissed based not on its content but upon characteristics of the individual making it An argument in which an irrelevancy is

We know Keating’s view of chiropractic philosophy is flawed because he is not a chiropractor We know that subluxation is meaningful

Non sequitur

offered as evidence

because if it were not, there’d be no need for chiropractors

Overgeneralization

Evidence in support of some component of a theory is extrapolated beyond the limits of the study that generated it

Post hoc, ergo propter hoc*

When two events occur close in time,

Selective evidence

the first is assumed to be the cause of the second Refusal to consider evidence that refutes a favored theory

We know that subluxations are meaningful because clinical trials have demonstrated that low-back-pain patients improve when they are adjusted We know that XYZ technique is effective because patients improved after its use Listing only studies that support the value of spinal adjusting, but not those that are equivocal or that challenge its effectiveness

* Latin for “After this, therefore because of this.”

allopathic practitioners was widespread in that era, and the descriptive epistemology embodied in museum displays gave way only grudgingly to laboratory studies of cause and effect in medicine. When chiropractic appeared at the turn of the century, it found its scientific justification in the older, observational mode of “validating” its methods.61,62 The proof that chiropractic “works” was considered obvious to anyone who would take the time to watch chiropractors impart benefit to patients; remnants of this casual, unsystematic, uncontrolled, and uncritical empiricism are still found among chiropractic practitioners and theorists today. D. D. Palmer decried the trial-and-error reasoning of his allopathic competitors, and contended that chiropractic was a superior science and art because it was theory-based. The subsequent writings of B. J. Palmer63 and Ralph W. Stephenson13 expanded upon this notion. Chiropractic as a “deductive science” posited 33 a priori principles (see Table 4–1) as absolute truths from which all other clinical hypotheses and methods were derivative and subordinate. This uncritical rationalism finds contemporary expression in the teachings of some straight chiropractors.64

There have been other ways of knowing in the profession. Old Dad Chiro suggested that he had acquired his understanding of chiropractic concepts from a physician who had practiced in Davenport, Iowa, some 50 years earlier65 ; it has been suggested that this Jim Atkinson was deceased, and had perhaps imparted his knowledge to D. D. Palmer through seances. Spiritual inspiration was also a theme of the “Developer,” who credited many of his insights to listening to the Innate Intelligence within him. Dr. Fred H. Barge continued this tradition when he suggested that his literary offerings derived from “listening to my Innate teacher”; he characterized himself as “only the scribe,”66 and stated the positions that “belief in chiropractic philosophy gives one a life without fear”66 and there are no alternatives to “true chiropractic philosophy.”67 Such confidence, derived from a priori truths and/or inspiration from beyond the physical universe, may have its place, for example, in religion, but is the antithesis of the skepticism and critical thinking that characterize philosophy and science. Nevertheless, many chiropractors have found justification for the chiropractic art through a combination of

PHILOSOPHY IN CHIROPRACTIC

FIGURE 4–11. Dr. C. O. Watkins, circa 1935.

uncritical rationalism (deduction from theory) and uncritical empiricism (casual observation). “We know chiropractic works,” it is suggested, because it is based on true principles (e.g., anatomy, physiology, or the 33 tenets of Palmer) and proven every day in doctors’ offices. An orientation to a more critical empiricism and critical rationalism, such as is found in science, has a briefer but increasingly prominent role within the profession. One of the earliest philosophers of a science of chiropractic was C. O. Watkins (Fig. 4–11), a 1925 Palmer graduate who practiced quietly in rural Montana and encouraged more critical thinking through his writings and activism within the broad-scope National Chiropractic Association.68,69 Passionate in his commitment to conservative health care, he was also distressed by the casual reasoning of his colleagues, and offered numerous papers suggesting a more scientific orientation for the profession. His 1944 manifesto, The Basic Principles of Chiropractic Government,70 called for what has since been labeled a “scientistpractitioner model” for chiropractors.71 Watkins and those chiropractors since who have established the burgeoning scientific enterprise within the profession72 look to the hypothetical– deductive model of research for their epistemology. Deduction from almost any source is considered a legitimate source of testable propositions (hypotheses), but no theory or subset thereof (i.e., hypothesis) is considered valid until it has survived repeated experimental attempts at falsification. This scientific

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orientation is certainly not capable of addressing all the issues of concern to the profession (see Table 4–2), but is suitable for those propositions that deal with the effectiveness of clinical methods and the mechanisms of clinical benefit. The delightful emergence and preliminary success of the chiropractic scientific enterprise during the past two decades is evidence of this commitment, and has also served the profession well in the political arena. As members of the profession have become more fluent in the language and methods of clinical research and science, doors have opened for DCs. The chiropractic healing art has become more credible to government and to third-party payors of chiropractic services in part because of the fruits of this more critical epistemology. A segment of the profession increasingly shares the language and epistemology of the wider health care community, and as communication between disciplines expands, old doubts and grudges are likely to diminish. To be sure, the metamorphosis toward a more critical chiropractic will be gradual, perhaps painful, but also increasingly inevitable. Nevertheless, there are many in the profession who have perceive this evolution toward skepticism and critical evaluation of a priori beliefs as a threat to traditional chiropractic.73 A. Earl Homewood (Fig. 4–12) opined that in his nearly 50 years as a chiropractor he had never seen any benefit derived from research in the profession.74 Others observe the shroud of science in which allopathy has wrapped itself, and in rejecting the persecution by medicine, tend to reject the scientific method as well. Still others are unaware of the epistemology inherent in the scientific method. Some fear that the success enjoyed in controlled trials of spinal manipulative therapy for lowback-pain patients will serve to limit the chiropractor

FIGURE 4–12. Drs. Earl Homewood (left ) and Lee Arnold in Florida, 1987.

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to a musculoskeletal scope of practice. And in the still combative intra- and interprofessional environment in which chiropractors practice, the move toward a more scientific chiropractic is genuinely fraught with unknowns. Organized medicine may indeed use chiropractors’ self-criticism against chiropractors, as it has in the past.75 MODELS AND IMPLICATIONS OF CHIROPRACTIC ORIENTATIONS The diversity of thought (principles, philosophy) among chiropractors defies comprehensive evaluation. Even among the “purists” of traditional chiropractic thinking, the range of beliefs is difficult to enumerate.76 Historically, chiropractors divided themselves into two camps, straights and mixers, but this simple dichotomy no more captures the multiplicity of ideas in the profession than does Democrat

TABLE 4–4.

versus Republican adequately describe the political diversity in the United States. Nevertheless, a thumbnail sketch of prevailing philosophical orientations within the profession may serve a heuristic purpose (Table 4–4). The notion of an evidence-based chiropractic has grown during the past decade. Widely misunderstood to mean that only validated methods should be employed by chiropractors, evidence-based chiropractic is more properly understood to be a commitment to make use of the best available information in formulating plans for patient care. Practitioners of evidencebased chiropractic recognize that there will never be adequate clinical experimentation to make treatment choices solely based upon experimentally validated procedures, and that each patient presents an idiosyncratic pattern of needs, problems, and biological characteristics. Commitment to the scientific method of knowledge acquisition is strong; interest

Several Characteristics of Three Orientations to (“Philosophies” of) Chiropractic

Orientations

Evidence-Based

Traditional Straight

Purpose-Straight

Purpose

“Get sick people well” and

“Get sick people well” and

Help patient (client?)

promote health “Mission statement”*

promote health

achieve maximum potential “Correction of vertebral subluxations”*

“Alleviation of pain and disease conditions”* and health promotion Critical rationalism; scientific empiricism

“Correction of the cause of disease”* and health promotion Various†

Subluxation research

Important, but not necessarily essential

Important

Public health responsibilities

Triage and referral;

Triage and referral;

“Deductive science” (i.e., uncritical rationalism) Unnecessary to prove existence of subluxation; may study detection methods Spinal analysis only

analysis (or spinal analysis only) and prevention Innate Intelligence as

Innate Intelligence as

Epistemology

diagnosis and analysis; prevention Vitalism and holism

Holism; homeostasis as ontological characteristic

causal explanation; predictable influence; “life is Intelligent”

Scope of practice

Broad

Traditional advocate of straight chiropractic, but teaches broad-scope methods

causal explanation; unpredictable influence; “life is Intelligent” Narrow scope; exclusively spinal subluxation focused

(e.g., physiotherapeutics) Professional autonomy

Strongly committed

Strongly committed

Source: Based on reference 81. * From Gelardi TA. The science of identifying professions as applied to chiropractic. J Chiropr Hum 1996;6:11–17. †

Including critical and uncritical rationalism, critical and uncritical empiricism, spiritual inspiration, etc.

Strongly committed

PHILOSOPHY IN CHIROPRACTIC

in the investigation of subluxation syndrome may or may not be present. The evidence-based chiropractic doctor tends to be broad-scope in her or his methods, but this is not an essential characteristic of this school of thought. The range of conditions to which the evidence-based chiropractic clinician will apply her or his skills is also not a defining trait. Alleviation of pain and other symptoms is considered an appropriate goal for the DC, perhaps even a moral imperative. Evidence-based chiropractors commit themselves to strenuous continuing education in order to maintain awareness of the “state of the literature” in the science of chiropractic. As well, these doctors are perhaps more likely than others to support, and even participate in, research activities. Traditional straight chiropractic concerns itself primarily with the detection and correction of subluxations, in the belief that such interventions help to relieve disease and promote health. With the passage of time and vicissitudes of chiropractic history, traditional straight chiropractic practitioners have grown more relaxed in the range of therapeutic methods they encompass. The Palmer College of Chiropractic, for example, today offers instruction in clinical procedures that its former president, B. J. Palmer, dismissed as medical (e.g., diagnosis, physiotherapeutics). This orientation promotes no single epistemology, and although the Palmer College of Chiropractic has been a leader in developing the research infrastructure in the profession, a wide variety of “ways of knowing” are encountered among its faculty. Vitalism is a prominent feature of traditional straight chiropractic. Purpose-straight chiropractic (PSC), also known as the “objective-straight” or “super-straight” school of thought,42 has developed through the teachings of Reggie Gold, Thom Gelardi, and Joseph Strauss.73,77–79 Diseases are acknowledged to be multifactorial in origin, and any particular patient’s distress may or may not be caused by spinal subluxation. Subluxations outside the spine and pelvis are not considered appropriate clinical targets for the purpose-straight chiropractic practitioner. The signs and symptoms of disease are considered irrelevant for the purpose-straight chiropractic doctor, whose sole professional concern is the detection and correction of subluxation. The significance of the traditional chiropractic lesion is accepted as an a priori truth, and scientific investigation of subluxation syndrome is considered inappropriate, because the purpose-straight chiropractic clinician has no interest in and assumes no responsibility for the patient’s state of health. Everyone, it is suggested, would be better off without the “nerve interference” implicit in spinal subluxation, but no one can predict when a subluxation may manifest in signs and symptoms. Research to improve methods of subluxation detection and correction

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(in contradistinction to investigations of subluxation syndrome) is considered acceptable but not imperative, because the primary reasoning strategy of the purpose-straight chiropractic doctor is deduction (i.e., uncritical rationalism). Stephenson’s 33 principles (Table 4–1) have been considered a valued basis for the art and science of chiropractic. The PSC approach to chiropractic came into conflict with several constituencies. The nondiagnostic orientation of this perspective stands in contrast to most statutes governing the practice of chiropractic. Some degree of compromise by the chief institutional proponent of PSC, Sherman College of Straight Chiropractic (SCSC), was apparently reached with the CCE circa 1995, when the SCSC was first recognized by the accreditation agency. The CCE’s educational standards require training in diagnosis and referral when appropriate to other health care provides. Accordingly, there would seem to be some disconnect between this institution’s ideology and its actual instructional practices. It should be noted that several of SCSC’s presidents (e.g., Thomas Gelardi, DC, David Koch, DC) have been articulate contributors to philosophical dialogue within the profession (e.g., reference 64). CONCLUSIONS “Chiropractic philosophy” began its life as a series of hypotheses and a priori assumptions with roots in the popular and academic culture of the nineteenth century. The professional autonomy of chiropractors gained impetus from courtroom and legislative successes wherein the argument that chiropractors had a separate and distinct “philosophy” and practice aided in acquittals of chiropractors charged with unlicensed practice and helped to secure licensing laws. “Philosophy” became a powerful rallying theme, and was offered as a set of incontrovertible truths. In contrast to the inflexible beliefs of Palmerson philosophy, classical philosophy is seen as a process of inquiry with no definite end-point. Much of what has traditionally been identified as philosophy in chiropractic are principles and hypotheses that merit either the critical consideration of the philosophical process or the rigorous investigations of the scientific method. Shorn of their dogmatic rigidity, many of the ideas comprising traditional chiropractic philosophy are quite appropriate as metaphors, heuristics, and sources of testable propositions (hypotheses). As a health care profession, chiropractors quite legitimately make use of professional, ethical, and scientific principles. A distinctiveness of the profession may be found in the unique constellations of ideas and methods that constitute the subject matter for philosophy and science in chiropractic. Also in contrast

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to most other health professions, chiropractors offer a variety of conflicting epistemological principles, and have not reached consensus on the value of the scientific method. Evolving from and even today operating within a hostile interprofessional environment, the critical self-examination of principles and hypotheses that constitute classical philosophy and science is often seen as risky. Chiropractors have been loath to lower their guard long enough for self-examination of the profession, for fear of further onslaught from political medicine.80 The diversity of ideas in the profession defies comprehensive description, but several more or less distinct groupings of principles may be identified. Among the more prominent of these are evidencebased chiropractic, traditional straight chiropractic, and purpose-straight chiropractic. Differences among these schools of thought often form the basis for intraprofessional disputes, and failure to coalesce around a shared set of principles has hampered formation of a united front for interprofessional activity. Greater attention to both shared and disputed principles (i.e., greater philosophical inquiry) might aid in promoting unity within the profession. The rich diversity of chiropractic, with its fundamental concern for patient welfare and benefit, could become a boon rather than a hindrance to the profession.

ACKNOWLEDGMENTS

My thanks to Carl S. Cleveland III, DC, for his critical review, to Allan Gotlib, DC, and the Journal of the Canadian Chiropractic Association for permission to reprint, and to the National Institute of Chiropractic Research for its financial support of work related to the completion of this chapter.

SUMMARY 1. The principles of chiropractic evolved partly from the seminal teachings of D. D. Palmer. Their distinctiveness from many ideas in allopathic medicine took on new significance when they provided what was termed a “separate and distinct philosophy” that met the legal and political needs of the besieged new profession. B. J. Palmer developed the idea of philosophy as irrefutable doctrine by which not only health care, but life itself, seemed to be explained. B. J. rejected the inferential reasoning of the scientific method in favor of deduction from “true principles.” A codification of Palmer’s principles was offered by Ralph W. Stephenson, and became required reading for generations of chiropractors.

2. Classical philosophy is a process of probing, doubting, and skeptical inquiry. Philosophers apply their critical skills to issues such as beauty (aesthetics), morality (ethics), reasoning (logic), reality (ontology), and knowledge (epistemology). Several of these fields of inquiry are quite relevant to the chiropractic profession and merit indepth investigation (e.g., the ethics of clinical practice, the development of reasoned arguments, and the avoidance of logical fallacies when considering chiropractic issues). The relatively recent emergence of robust research by chiropractors has encouraged commitment to the epistemology of science. Like classical philosophy, science in chiropractic requires attention to logic and systematized methods of gaining knowledge and understanding. Stripped of their doctrinal (dogmatic) quality, many of the ideas offered by the Palmers and their successors are useful and legitimate concepts for guiding the science and practice of chiropractic. 3. Among the most prominent principles of chiropractic philosophy are homeostasis, holism, conservatism, the strategic role of the nervous system, and the desire for professional autonomy. These principles (including metaphors, heuristics, and a priori assumptions) may give rise to testable propositions (hypotheses) and/or may serve as constituents of that constellation of methods and values that uniquely characterize the chiropractic profession. 4. Chiropractors have employed a wide range of epistemologies (ways of knowing) to defend their art and professional autonomy. This diversity has included critical and uncritical empiricism (e.g., private research), critical and uncritical rationalism (e.g., so-called deductive science), spiritual inspiration, and the scientific method. As well, various chiropractic authors and speakers have offered a number of logical fallacies in justification of the clinical art. In order to further the profession’s research enterprise and to encourage greater integration with the wider health science and scholarly communities, chiropractors will need to separate the chaff from the wheat. A stronger and more widespread commitment to the epistemology of science may facilitate both of these goals. 5. The diversity of beliefs among chiropractors defies comprehensive description. However, several clusterings of these ideas may provide a useful mental shorthand, and seem to parallel some of the major political divisions within the profession. The practical (clinical) and ethical implications of these groupings (e.g., evidence-based chiropractic, traditional straight chiropractic, purpose-straight chiropractic) deserve thoughtful study by the profession.

PHILOSOPHY IN CHIROPRACTIC

QUESTIONS 1. The major premise of the Stephenson/Palmer set of 33 principles is A. That subluxation is the cause of all disease. B. That life is the expression of tone. C. The existence of God who maintains the existence of the universe. D. An Innate Intelligence that directs all the function of the body from above down and inside out. E. Both constructive and destructive survival values. 2. Which of the following is an important difference between classical philosophy and traditional chiropractic philosophy? A. Classical philosophy deals with ontology/metaphysics, logic, and epistemology. B. Classical philosophy encourages a process of inquiry rather than a set of fixed beliefs. C. Classical philosophy does not make use of deductive reasoning. D. Classical philosophy makes no contribution to “natural philosophy.” E. Classical philosophy is “godless.” 3. True or false: Deductive reasoning cannot be employed in the situation where the premises of an argument are based on observations of nature. 4. Which of the following is a metaphor? A. Chiropractic first, medicine second, surgery last. B. First, do no harm. C. Adjusting reduces subluxation, which, in turn, promotes health and relieves disease. D. We know chiropractic works because it is just naturally right. E. The brain is the master switchboard of the body. 5. Science differs from philosophy in that: A. Empirical activity is not essential to philosophical inquiry. B. Science does not involve deductive reasoning. C. Science provides truth, whereas philosophy is only speculation. D. Science does not make use of a priori assumptions. E. All of the above.

ANSWERS 1. 2. 3. 4. 5.

C. B. False E. A.

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KEY REFERENCES Donahue JH. Philosophy of chiropractic: Lessons from the past—Guidance for the future. J Can Chiropr Assoc 1990;34(4):194–205. Gaucher-Peslherbe PL. Chiropractic: Early concepts in their historical setting. Lombard, IL: National College of Chiropractic, 1994. Keating JC. The embryology of chiropractic thought. Eur J Chiropr 1991;39(3):75–89. Keating JC. Toward a philosophy of the science of chiropractic: A primer for clinicians. Stockton, CA: Stockton Foundation for Chiropractic Research, 1992. Keating JC, Mootz RD. The influence of political medicine on chiropractic dogma: Implications for scientific development. J Manipulative Physiol Ther 1989;12(5):393–398. Martin SC. “The only truly scientific method of healing”: Chiropractic and American science, 1895–1990. Isis 1994;85(2):207–227. Nelson C. The subluxation question. J Chiropr Hum 1997;7:46–55. Stephenson RW. Chiropractic textbook. Davenport, IA: Author, 1927. Strauss JB. Refined by fire: The evolution of straight chiropractic. Levittown, PA: Foundation for the Advancement of Chiropractic Education, 1994. Weiant CW. Chiropractic philosophy: The misnomer that plagues the profession. Arch Calif Chiropr Assoc 1981;5(1):15–22.

REFERENCES 1. Morinis EA, quoted in Barge FH. Life without fear. Eldridge, IA: Bawden Brothers, 1987, p x. 2. Weiant CW. Chiropractic philosophy: The misnomer that plagues the profession. Dig Chiropr Econ 1979;22(3):40–41, 44–45. 3. Weiant CW. Chiropractic philosophy: The misnomer that plagues the profession. Arch Calif Chiropr Assoc 1981;5(1):15–22. 4. Watkins CO. Is chiropractic unity possible? Natl Chiropr J 1946;16(12):29–30. 5. Keating JC. The embryology of chiropractic thought. Eur J Chiropr 1991;39(3):75–89. 6. Donahue J. D. D. Palmer and the metaphysical movement in the nineteenth century. Chiropr Hist 1987; 7(2):22–27. 7. Keating JC. “Heat by nerves and not by blood”: The first major reduction in chiropractic theory, 1903. Chiropr Hist 1995;15(2):70–77. 8. Rehm WS. Legally defensible: Chiropractic in the courtroom and after, 1907. Chiropr Hist 1986;6:50–55. 9. Donahue J. D. D. Palmer and Innate Intelligence: Development, division and derision. Chiropr Hist 1986;6: 30–36. 10. Gaucher-Peslherbe PL. Chiropractic: Early concepts in their historical setting. Lombard, IL: National College of Chiropractic, 1994.

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11. Keating JC. B. J. of Davenport: The early years of chiropractic. Davenport, IA: Association for the History of Chiropractic, 1997. 12. Beideman RP. Seeking the rational alternative: The National College of Chiropractic from 1906 to 1982. Chiropr Hist 1983;3:16–22. 13. Stephenson RW. Chiropractic textbook. Davenport, IA: Author, 1927. 14. Palmer BJ. The hour has struck [pamphlet]. Davenport, IA: Palmer School of Chiropractic, 1924, p 29. 15. Donahue JH. Disease in our principles: The case against Innate Intelligence. Am J Chiropr Med 1988;1(2):86–88. 16. Donahue JH. Philosophy of chiropractic: Lessons from the past—Guidance for the future. J Can Chiropr Assoc 1990;34(4):194–205. 17. Donahue JH. Philosophy for chiropractic: An activity or a doctrine? Activator Update 1991;6(3):1, 3–4. 18. Keating JC. Philosophy: The art of skepticism. J Can Chiropr Assoc 2000;44(2):79–84. 19. Joachims L. Allopathic medicine in Kansas, 1850–1900. Arch Calif Chiropr Assoc 1982;6(1):67–79. 20. Campbell JB, Busse JW, Injeyan HS. Chiropractors and vaccination: A historical perspective. Pediatrics 2000;105(4). Available at: www.pediatrics.org/cgi/ content/full/105/4/e43. 21. Gielow V. Old Dad Chiro: A biography of D. D. Palmer, founder of chiropractic. Davenport IA: Bawden Brothers, 1981:61–62. 22. Palmer DD. The Chiropractic 1897(Jan);17 (Palmer College Archives). 23. Nykoliation J, Mierau D. Adverse effects potentially associated with the use of mechanical adjusting devices: A report of three cases. J Can Chiropr Assoc 1999;43(3):161–167. 24. Starr P. The social transformation of American medicine. New York: Basic Books, 1982, p 56. 25. American Chiropractic Association. Statement to Associated Press, 1 April 1994. 26. Terrett AGJ. The search for the subluxation: An investigation of medical literature to 1895. Chiropr Hist 1987;7(1):28–33. 27. Gatterman MI, Hansen DT. Development of chiropractic nomenclature through consensus. J Manipulative Physiol Ther 1994;17(5):302–309. 28. Association of Chiropractic Colleges. The ACC chiropractic paradigm. J Manipulative Physiol Ther 1996;19(9):634–637. 29. Gatterman MI, ed. Foundations of chiropractic: Subluxation. St. Louis: Mosby, 1995. 30. Leach RA. The chiropractic theories, 3rd ed. Baltimore: Williams & Wilkins, 1994. 31. Keating JC. To hunt the subluxation: Clinical research considerations. J Manipulative Physiol Ther 1996;19(9):613–619. 32. DeBoer KF, McKnight ME. A surgical model of a chronic subluxation in rabbits. J Manipulative Physiol Ther 1988;11(5):366–372. 33. Haldeman S. Neurological effects of the adjustment. J Manipulative Physiol Ther 2000;23(2):112–114. 34. Budgell BS. Spinal manipulative therapy and visceral disorders. Chiropr J Aust 1999;29(4):123–128.

35. Nelson C. The subluxation question. J Chiropr Hum 1997;7:46–55. 36. Martin RJ. The practice of correction of abnormal function. “Neurovascular dynamics” (NVD). Sierra Madre, CA: Author, 1977. 37. Mueller RO. Autonomics in chiropractic: The control of autonomic imbalance. Toronto: Chiro Publishing, 1954. 38. Terrett AGJ: Cerebral dysfunction: A theory to explain some of the effects of chiropractic manipulation. Chiropr Tech 1993;5(4):168–173. 39. Gregory AA. Spinal treatment, 2nd ed. Oklahoma City: Palmer-Gregory College of Chiropractic, 1912. 40. Kuxhaus RL. Why are medical doctors trying to steal chiropractic? Los Angeles: Public Education Publications, 1969. 41. Weiant CW. B. J. Palmer and the “German issue”: The crisis in postwar European chiropractic. Chiropr Hist 1982;2:40–44. 42. Fielder AL. The importance of chiropractic philosophy in our schools. Arch Calif Chiropr Assoc 1981;5(1):23–26. 43. Gevitz N. The DO’s: Osteopathic medicine in America. Baltimore: Johns Hopkins University Press, 1982. 44. Williams SE. Isolation or integration: Chiropractic— The road less traveled. J Am Chiropr Assoc 1995;32(8): 49–52. 45. Trever W. In the public interest. Los Angeles: Scriptures Unlimited, 1972. 46. Chapman-Smith D. The Wilk case. J Manipulative Physiol Ther 1989;12(2):142–146. 47. Wilk CA. Medicine, monopolies and malice: How the medical establishment tried to destroy chiropractic in the US. Chicago: Author, 1996. 48. Mazzarelli JP. Manual medicine a threat to chiropractic? Arch Calif Chiropr Assoc 1981;5(1):59–61. 49. Allenburg JF. Some implications of health reform for college programs in education and research. J Am Chiropr Assoc 1995;32(3):41–44. 50. Chapman-Smith D. Ignore the marketplace and kiss yourself goodbye. J Am Chiropr Assoc 1995;32(4): 44–45. 51. Cianciulli AE. Chiropractic in the information age. J Am Chiropr Assoc 1995;32(4):34–36. 52. Cleveland CS. Isolation or integration: Observation and comments. J Am Chiropr Assoc 1995;32(2):23–24. 53. Goodin M. Isolation or integration—Is there really a choice? J Am Chiropr Assoc 1995;32(5):60–62, 98. 54. Grassam I. Isolation or integration? J Am Chiropr Assoc 1995;32(6):57–58. 55. Haldeman S. The role of chiropractic in an integrated health care system. J Am Chiropr Assoc 1995;32(6): 58–59. 56. Sawyer RE. Isolation or integration: Back pain or primary care? J Am Chiropr Assoc 1995;32(7):44–46. 57. Sportelli L. Isolation or integration: Is there really a choice? J Am Chiropr Assoc 1995;32(7):46, 61–64. 58. Winterstein JF. Isolation or integration: Suggested principles of integration. J Am Chiropr Assoc 1995;32(8):52– 55. 59. Keating JC. A survey of philosophical barriers to technique research in chiropractic. J Can Chiropr Assoc 1989;33(4):184–186.

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60. Keating JC. Chiropractic: Science and antiscience and pseudoscience, side by side. Skeptical Inquirer 1997;21(4):37–43. 61. Martin SC. Chiropractic and the social context of medical technology, 1895–1925. Tech Culture 1993;34(4):808– 834. 62. Martin SC. “The only truly scientific method of healing”: Chiropractic and American science, 1895–1990. Isis 1994;85(2):207–227. 63. Palmer BJ. Induction vs. deduction [pamphlet]. Davenport, IA: Palmer School of Chiropractic, 1915. 64. Keating JC. Purpose-straight chiropractic: Not science, not health care. J Manipulative Physiol Ther 1995;18(6):416–418. 65. Palmer DD. The chiropractor’s adjuster: The science, art and philosophy of chiropractic. Portland, OR: Portland Printing House, 1910, pp 11–12. 66. Barge FH. Life without fear. Eldridge, IA: Bawden Brothers, 1987:i. 67. Barge FH. Is there a true chiropractic philosophy? Yes, and there are no alternatives. In: Proceedings of the 1991 International Conference on Spinal Manipulation. Arlington, VA: Foundation for Chiropractic Education and Research, 1991. 68. Keating JC. C. O. Watkins: Pioneer advocate for clinical scientific chiropractic. Chiropr Hist 1987;7(2): 10–15. 69. Keating JC. C. O. Watkins, DC, grandfather of the Council on Chiropractic Education. J Chiropr Educ 1988;2(3):1–9. 70. Watkins CO. The basic principles of chiropractic government. In: Keating JC. Toward a philosophy of the science of chiropractic: A primer for clinicians. Stockton,

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CA: Stockton Foundation for Chiropractic Research, 1992. Keating JC. Toward a philosophy of the science of chiropractic: A primer for clinicians. Stockton, CA: Stockton Foundation for Chiropractic Research, 1992, p 21. Keating JC, Caldwell S, Nguyen H, Saljooghi S, Smith B. A descriptive analysis of the Journal of Manipulative and Physiological Therapeutics, 1989–1996. J Manipulative Physiol Ther 1998;21(8):539–552. Strauss JB. Refined by fire: The evolution of straight chiropractic. Levittown, PA: Foundation for the Advancement of Chiropractic Education, 1994. Homewood AE. What price research? Dyn Chiropr 1988;6(6):32–33. Gibbons RW. Chiropractic’s Abraham Flexner: The lonely journey of John J. Nugent, 1935–1963. Chiropr Hist 1985;5:44–51. Keating JC. Shades of straight: Diversity among the purists. J Manipulative Physiol Ther 1992;15(3):203–209. Gold RR. The triune of life. Spartanburg, SC: Sherman College of Straight Chiropractic,1998. Strauss JB. Reggie: Making the message simple. Levittown, PA: Foundation for the Advancement of Chiropractic Education, 1997. Gelardi TA. The science of identifying professions as applied to chiropractic. J Chiropr Hum 1996;6:11–17. Keating JC, Mootz RD. The influence of political medicine on chiropractic dogma: Implications for scientific development. J Manipulative Physiol Ther 1989;12(5):393–8. Proceedings of a conference on philosophy in chiropractic education. Fort Lauderdale, FL: World Federation of Chiropractic, 2000, p 73.

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C H A P T E R

5 COMMUNICATION IN THE CHIROPRACTIC HEALTH ENCOUNTER: SOCIOLOGICAL AND ANTHROPOLOGICAL APPROACHES Ian D. Coulter

O U T L I N E Summary of the Preencounter Experience THE HEALTH ENCOUNTER Communication Explanation of the Health Problem Explanation of the Treatment Explanation of Chiropractic Quality of the Communication CONCLUSION SUMMARY QUESTIONS ANSWERS KEY REFERENCES REFERENCES

INTRODUCTION QUALITATIVE RESEARCH—AN ALTERNATIVE RESEARCH MODEL FOR CHIROPRACTIC QUALITATIVE RESEARCH IN CHIROPRACTIC A MODEL FOR EXAMINING THE CHIROPRACTIC HEALTH ENCOUNTER PREENCOUNTER EXPERIENCE Route to the Chiropractor Push Factor Pull Factor The Social Context Social Legitimacy Prior Health Problems

limited specialty focusing on the treatment of neuromusculoskeletal conditions3 through spinal manipulative therapy.4 This has led some to argue that chiropractic is akin to a subspecialty within medicine and not a broad-based alternative to traditional medicine,5 while others have been willing to ascribe a broader, primary care role to chiropractic.6–8 The narrow view of chiropractic as a subspecialty stands in stark contrast to the sociological/anthropological literature on chiropractic, so much so that it almost seems as if two different professions are being described. There are two major reasons for this: First, the focus of the studies is quite different. For epidemiology and health services research, the focus is on such things as the presenting condition, the diagnosis, the distribution of conditions among the patients, utilization patterns, cost of care, objectively measured outcomes,

OBJECTIVES 1. To define what is meant by the health encounter. 2. To discuss methodological issues in studying the health encounter. 3. To discuss some of the main findings of qualitative research into the chiropractic health encounter. 4. To describe what is known from sociology and anthropology about communication within the chiropractic health encounter.

INTRODUCTION The increasing body of data on the epidemiology and utilization of chiropractic,1 as well as a growing body of health services research,2 presents chiropractic as a 99

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satisfaction with care, and efficacy of care, which usually means efficacy of manipulation.2 For the sociologist/anthropologist, the focus is more likely to be the total health encounter and the overall effectiveness of the care. The second reason is to be found in the research methods used and the type of data collected. For epidemiologists and health services researchers, the data are overwhelmingly quantitative in nature and derived from patient files,9 surveys,10 billing records,11 clinical assessment instruments,12 validated health status instruments,13 and validated satisfaction instruments.14 Anthropologists and sociologists, however, are much more likely to use observation techniques and collect qualitative data.15 To understand this, it is necessary to understand something about qualitative methods. QUALITATIVE RESEARCH—AN ALTERNATIVE RESEARCH MODEL FOR CHIROPRACTIC The social sciences have developed a range of qualitative research techniques to overcome what are seen as methodological weaknesses in traditional positivist, empirical, quantitative studies. Although an extensive critique of these approaches is beyond the purpose of this chapter, a brief outline is necessary. A major critique is that quantitative methods are not grounded in the perspective of the research subjects but in that of the researcher. To this extent, they focus on objectively defined variables that can be correlated with behavior (e.g., age, gender, income, and occupation), identifying those variables that have predictive explanatory power. Secondly, quantitative methods tend to measure stable characteristics that can be replicated and measured reliably by other researchers using valid and reliable instruments. This approach does not give much attention to the context in which events occur and the more ephemeral aspects of social interactions. The image of society involved in the positivist/quantitative research paradigm reflects a deterministic social environment and structure (i.e., all events have sufficient causes). Under this paradigm, the social world is as amenable to the methods of science as the natural world.16 Within the social sciences, a contrary view of both social reality and the methods needed to investigate it has developed. Here the view is of society as a negotiated order. Instead of society settling around the individual in some monolithic/deterministic fashion, the individual is in a constant interaction with society in a process that constructs the meanings of things and events in any given situation. If you wish to know why individuals behave the way they do, you need to find out what meanings the objects or events have

for them in that particular situation. The purpose in this approach therefore is to ground research in the perspective of the subjects, not the researcher. The focus is more on discovery and understanding than on explanation. The methods that have developed to conduct this type of research have been variously termed qualitative, interpretative, sensitizing analyses, and grounded theory. The underlying philosophical/theoretical paradigms include phenomenology (the study of phenomena), hermeneutics (the science of interpretation), and symbolic interactionism. In anthropology, it is the basis of ethnographic research.17 A major feature of qualitative research is a preference for “grounded” concepts and theories. In practical terms, this implies approaching the field with minimum predetermined concepts and theories. Furthermore, even those that are used must be amenable to constant revision as the research proceeds. The objective is to generate concepts that do not distort or do violence to the phenomena under study and that are sensitive to change in the study population. One of the strengths of this approach is a more dynamic picture of the social processes involved than possible from a static view captured by quantitative methods. When the focus is on operationalizing quantitative measures, particularly when this is done prematurely, there is the danger of either overlooking the relevant variables or oversimplifying them. A further advantage is that grounded theory is immediately available to the social participant by being comprehensible and self-obvious, because the results are based on the world view of the participants. The methodologies of grounded theory have been extensively documented. Among the methods used are observation, focus groups, the use of key informants, unstructured questionnaires, participant observation, ethnography, analysis of documents, and narrative analysis. Several methodological issues present themselves in the use of qualitative methodologies. There is some consensus that genuine qualitative analysis requires intimate knowledge by the researcher of the social setting and thus is timeconsuming. In anthropology, this may involve long periods of living in the field with the subjects. There are also a set of issues around the selection of informants and the choice of both what to observe and what elements to observe. There are issues of reliability and validity of observations by either a single informant or a limited number of observers, and in the selection of documents. However, questions raised about the reliability and validity of qualitative methods have been shown not to be insurmountable. Use of multiple methods of data collection has been recommended by numerous authors. Jick18 has termed this approach triangulation. Methodologically, the best approach is to integrate both qualitative and quantitative methods.19

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Qualitative research is uniquely useful in areas where the phenomenon under study has not been extensively researched or clearly understood. Crabtree and Miller17 distinguish several aims of scientific research that lead to distinct types of analysis: identification, description, explanation, generation and association, explanation testing, and prescription/control. In qualitative research, analysis is primarily focused on the first three. QUALITATIVE RESEARCH IN CHIROPRACTIC Several authors have discussed the application of these methods to chiropractic research.16,20–25 Among these commentators there is a strongly expressed belief that positivist/quantitative approaches to chiropractic care have failed to capture the nature of the health encounter and therefore failed to understand the meaning of chiropractic care for the patient, ultimately failing to understand the effectiveness of this form of care. While in chiropractic these two approaches have tended to be used independently of each other, they could be used as complementary methods and a theoretical framework for doing this has been developed.26 A MODEL FOR EXAMINING THE CHIROPRACTIC HEALTH ENCOUNTER In a sociological sense, the health encounter embraces all those events that occur between the patient and the clinic staff from the moment patients enter the chiropractic office until they exit. While the doctor–patient interaction is generally considered to be the most important part of the encounter, others may play just as important a role, from the staff at the front desk to the chiropractic assistant. Consequently, when studying this encounter, it is important to observe the total encounter. The most extensive observational study done to date on the chiropractic health encounter is by Kelner, Hall, and Coulter, who from 1975 until 1980 randomly sampled 1 in 5 Canadian chiropractors, for a total of 349 chiropractors.27 Each chiropractor was interviewed in his or her practice and where possible, the researchers observed care being given. Additionally, 70 clinics were randomly selected for a rapid ethnographic assessment where two trained qualitative researchers spent 1–2 days observing all aspects of the clinic.28 In addition, 658 randomly chosen patients in these clinics completed an interview through a structured questionnaire and were observed receiving care. A smaller number of patients were interviewed in depth to create vignettes of care that focused on the total care for a given episode and not simply a single day. Last, but not least, one of the researchers became

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a patient for a 6-month period to conduct a participant observation. In addition to being drawn from random samples, the participation rate was 80% for chiropractors and 89% for patients. The end result was that the research team had available an extensive body of quantitative data from structured questionnaires and documents, and a wealth of qualitative observational data. The description, therefore, is grounded in a very comprehensive analysis. The following discussion enriches the data by drawing on other qualitative research studies that have also focused on the health encounter provided a wealth of confirmatory data. PREENCOUNTER EXPERIENCE Strictly speaking, the health encounter begins with the first visit to the chiropractor. However, encounters do have a history prior to this point and this history influences the encounter in many ways. In analyzing how a patient gets to a chiropractor, we must distinguish between “push” factors and “pull” factors. Route to the Chiropractor In the Kelner et al. study, 56% of the patients had used some other form of care prior to chiropractic. In more recent studies1 this number had fallen to 30%, indicating that a sizable proportion of the patients had tried some other form of care first. It might also indicate that over the last 30 years a change has occurred in that in the earlier study the majority had not gone directly to a chiropractor (i.e., seeing another health provider first), but currently the majority do. This might reflect a change in the legitimacy of chiropractic as seen by the patient. In the earlier period, even controlling for past experience with chiropractic, the patients still used an indirect route to the chiropractor. However, the higher the educational attainment of the patient, the more likely they were to go directly to the chiropractor, bypassing other health providers. For the most part, this prior care is medical care followed by physical therapy. The most common reason given for seeking chiropractic care is dissatisfaction with the results from other forms of care. This therefore might be termed the push factor, that is, the reason the patient moves from one form of care to considering another form of care. It, however, does not ensure they end up in a chiropractic office. Receiving prior care has several implications for the chiropractic encounter. First, it ensures that the patient comes to the encounter with a basis for comparison by which to judge the performance of the chiropractor. Second, it means the chiropractor is dealing with an already dissatisfied patient. Third, it implies that a patient’s major focus is going to be on results. Although chiropractors often interpret the dissatisfaction as a general dissatisfaction with medicine, only

Push Factor

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5% patients listed that as a reason: 88% of the patients had a family medical doctor and 85% were generally satisfied with the care they received from that doctor. Thus, the dissatisfaction is highly focused for a specific problem or health complaint. The overwhelming reason given for actually ending up in chiropractic is that the patient has heard that chiropractors are good for this particular complaint. The route to a particular chiropractor is most frequently via patient referrals, which accounts for 45% of the patients; for 30% this patient is a family member. The patient therefore meets the chiropractor with a preexisting recommendation. Given the very high levels of patient satisfaction with chiropractic care,14 this is likely to be a positive recommendation. The fact that the recommendation is followed implies that the source is credible to the patient. Because the chiropractor has an established point of contact with the patient prior to meeting him or her, giving them a preexisting relationship that they can build on and into, the chiropractor may further reassure this person by using the previous patient as an example of success.29

Pull Factor

The Social Context The health encounter does not occur in a social vacuum. It occurs in a social context in which certain definitions and meanings are socially constructed and applied to groups, individuals, and processes. Within the health field these meanings determine what illnesses are considered legitimate, which patients are considered legitimate (as opposed to malingerers), which forms of treatment are legitimate, and last, but not least, which therapists are legitimate. This process of legitimacy occurs at numerous levels, from legislation that controls licensure and/or registration of the therapist, to what therapies are covered by insurance payment, to what therapies are approved for use, to a broader social/political process in which the health professions compete with each other for legitimacy. For the most part, those groups that are licensed by the state, that are considered to meet the standards of the professions (that is, are autonomous, self-disciplining, have a code of ethics, act in the patient’s interest, and are therefore considered altruistic), are bestowed legitimacy by the state and by society. Chiropractic is one of the unique groups in that for much of its history it has achieved legislative recognition, is frequently covered by insurance plans, and has all the characteristics of a profession, but has nevertheless been denied legitimacy by such powerful groups as traditional medicine and other health professions.30 Even within the social sciences, chiropractic was once labeled as a marginal profession, a deviant theory of disease, a definition of a deviant situation, heterodox Social Legitimacy

(as opposed to orthodox), a caste, and an outcast.31 It would be reassuring to conclude that these challenges to chiropractic legitimacy were a thing of the past, but recent events, such as fierce debate over the possible inclusion of a chiropractic program in a Canadian university, has shown clearly that influential groups still question the legitimacy of this practice.32 Much of chiropractic history can be interpreted as a struggle for legitimacy, culminating, perhaps, in the legal antitrust suit successfully taken against the American Medical Association. The process of legitimacy also applies to the patient. In his seminal work on the sick role, Parsons33 saw the doctor’s role as one that controlled what might be a form of deviance, the sick role. Under this theory, for society to function it must control the circumstances under which members of the society are legitimately sick and can therefore be excused from social responsibilities. “Within this framework the sick role is supposed to be temporary, undesirable and socially disruptive. The professional is a technical expert who legitimizes the claim to illness and is responsible for returning the sick person to his normal role in society.”34 Chiropractors, as primary contact health professionals, are also in the business of legitimating the individual in the patient role. Given this social background, we can add a further important element that has implications for the health encounter. For the chiropractors’ part, it has meant a need to establish the legitimacy not only of the actual treatment plan but of the profession itself. This is seen in the encounter as a need to explain the nature of the chiropractic paradigm and its difference from other paradigms, such as medicine. Historically, it has also meant a degree of defensiveness on the part of the chiropractor.35 The chiropractor faces the prospect of a patient who may have been warned against chiropractic from some powerful individuals such as his or her medical physician. For the patient, taking the step to consult a chiropractor may represent an unorthodox step, a step into the unknown. In the past, chiropractic was virtually never portrayed in the media or in popular entertainment in a positive light, a fact in stark contrast to medicine. For the latter, most people will have been to a medical doctor and a medical clinic since birth, and even if they have not, they will have seen it portrayed so many times on TV and in movies, they will have a reasonable idea of what to expect from the white coat and stethoscope, the treatment room, and the waiting room. They may even have a good idea of what kind of magazines they will find in the waiting room. All of this means that the medical doctor–patient encounter occurs within a set of largely shared meanings about what should happen. The patient is able to accept within this structure a state of undress and

COMMUNICATION IN THE CHIROPRACTIC HEALTH ENCOUNTER

behavior, such as an intrusive examination, that would not be tolerated elsewhere. The key element here is that much of this behavior will be expected by the patient prior to the visit, and so the encounter can proceed with a minimal amount of justification for what is to occur. For the chiropractic patient on the first visit, there may be no prior meanings or expectations either about the setting or the behavior that is to occur: Is the patient to disrobe? Is the patient to be given a medical examination (blood pressure, temperature, weight, etc.)? In this sense, the first visit is much more problematic for chiropractic care because nothing prior to it may have prepared the patient for the encounter. In addition, for many patients seeking care, previous care has failed, which often results in a questioning of their health status. This is exacerbated in the case of chronic nonspecific neuromusculoskeletal problems because they are expected to be self-limiting, do not lend themselves to a definitive diagnosis, frequently have a psychosocial component, and do not have highly effective therapies. Sociologists have distinguished between the disease or trauma a person has (the disordered biology), the way the individual acts and interprets this as the illness, and the social construction by which the individual acts out the illness as the sick role or sickness. When the patient comes to the chiropractor, all three may be in play and impacted by the encounter. Abnormal illness behavior, such as hypochondria, may undermine the purpose of the sick role, which is to seek care and a cure. Vernon36 has suggested that chiropractors may be effective because much of their care is focused on illness behavior. Under this model, abnormal illness behavior, such as prolonged rest, avoidance of activity, increased stress, increased use of medications, and retreat into the sick role on a permanent basis may be transformed by chiropractic care by getting the patient focused on taking control of his or her life and resuming normal activities. Prior Health Problems The last element that must be considered as part of the preencounter is the actual health problem that the patient brings to the chiropractor. This represents the material the chiropractor has to work with. The conditions presented are overwhelmingly neuromusculoskeletal in nature. Hurwitz et al.1 found that 68% of the patients sought care for low back pain, nonneuromusculoskeletal conditions accounted for less than 1%, and headaches for only 7%. In the earlier study by Kelner et al.,27 three conditions (general back/spine, neck/shoulder, and lower back) accounted for 57% of the conditions being presented to the chiropractor, while headaches accounted for 6%. Although the full range of disease and illness may be experienced in the chiropractic office, the number of conditions

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the patients report as their presenting complaint and which are recorded as diagnoses in the patient records is quite narrow.1 When asked to identify the particular conditions they thought chiropractic was suitable for, 57% of the patients listed four or fewer complaints, with general back and spine being listed by 60% of the patients.27 From one point of view this narrow range of presenting problems might seem to restrict chiropractic in its scope of practice and also in what it might achieve. However, as we explore later, chiropractic has been able to build a broader-based “wellness” paradigm37,38 that can focus not only on manipulation/adjustment, but also on such things as exercise, nutrition, stress management, and weight control. Summary of the Preencounter Experience This discussion of the preencounter lays out what might be termed the preconditions for the health encounter proper. It establishes both the type of condition presented to the chiropractor as the health problem and the type of patient who seeks the care. It also determines the social context within which both the patient and the chiropractor interact. As we have noted, this social context cannot always be considered benign to chiropractic, and has both debits and credits. On the credit side, the patient comes with a condition that appears to often respond to conservative care. Because patients are most likely to come because some other patient has recommended this particular chiropractor, they come with a testimonial for the chiropractor and a previous relationship the practitioner can build upon. Patients also often come from therapy that has failed to get results for them. On the debit side is the fact that patients have a comparison therapy to evaluate chiropractic against. At the very least, the chiropractor must obtain better results than their prior care. But new patients may also come with some serious concerns about chiropractic fueled in part by questions about chiropractic legitimacy, but also fueled by ignorance of what constitutes chiropractic care and further, what constitutes appropriate chiropractic care. THE HEALTH ENCOUNTER Although the nature of chiropractic care is clearly an important part of the encounter, the focus here is on the sociological aspects of the health encounter. We can note that 98% of chiropractors report adjustments as their primary mode of therapy,27 and adjustment was recorded in 84% of the patient records for low back pain.1 In one sense the chiropractic health encounter poses a challenge. The conditions treated by chiropractors are not unique and are also treated by a wide

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range of other health professionals. The modalities of treatment are also not unique. Spinal manipulation is performed by osteopaths, physical therapists, and medical physicians, and perhaps by many others. The adjunctive therapies such as heat, electrical therapy, mechanotherapy, acupuncture, ultrasound, exercise, massage, soft tissue therapy, vitamins, and nutritional supplements are all to be found in other practices. Even aspects of “chiropractic philosophy,” with its emphasis on vitalism, holism, naturalism, humanism, therapeutic conservatism, and critical rationalism,39 are not unique to chiropractic and are shared by many other complementary and alternative therapies. Yet chiropractic patients often describe their experience as unique. The uniqueness therefore must be located not in any single element of the encounter, but in all the elements taken together—the totality of the chiropractic health encounter. We will attempt to give a sociological answer as to why this encounter is perceived as unique. Communication What sociologists/anthropologists have isolated most clearly is the nature of the communication that occurs within the chiropractic health encounter. Given the preencounter factors described above, communicating with patients poses a significant challenge to chiropractors. Nevertheless, evidence from sociology and anthropology supports that chiropractors are very effective at communicating. In chiropractic, explanations to the patient tend to be of three different types: (a) an explanation of the health problem, (b) an explanation of the treatment, and (c) an explanation of chiropractic. Chiropractors report concentrating most of their explanations on the nature of the patient’s health problem. The patients also confirm that this is the most extensive of the explanations given. Chiropractors use a range of methods in giving these explanations, including visual aids such as charts, skeletal models, and printed materials. More than 90% of the chiropractors report using such visual aids; 73% report using analogies or models; and 63% use the theories of chiropractic in their explanation.27 The patients, for their part, report that x-rays (52%), charts of the body (50%), and skeletal models (34%) are the most frequently used methods. In his observation study of the chiropractic health encounter, Coulehan40,41 notes that chiropractors provide concrete, understandable explanations of the health problem. The explanations tend to be physical and lend themselves to the use of analogies and models, such as mechanical devices (e.g., a skeletal model) to depict the problem. While the explanation will include elements of the philosophy of chiropractic,

Explanation of the Health Problem

it tends to be mechanistic in nature. “The net effect is a logical set of explanations which appeal to common sense, use scientific terminology, yet promote a natural, noninvasive, holistic approach to healing.”40 Oths,42 in analyzing communication in a chiropractic clinic, also stresses that chiropractic explanations are simple and understandable and harmonize very well with the way individuals conceptualize things in an industrialized society. She further notes that there is a high degree of congruence between the explanations the patients give of their illness with those of the chiropractor. Her conclusion is that the patients internalize the chiropractic model of disease to a high degree. In her study of a chiropractic office, the communication was reinforced by pamphlets, charts, and diagrams throughout the clinic, as well as by videos. As with Coulehan’s study, she found that chiropractors made extensive use of analogies and constantly translated medical jargon into lay terms the patient could understand. For her, this demystified both medicine and the patient’s health problem. Jamison23 observed that chiropractors use different explanatory paradigms with their patients. On the one hand, much of the explanation for the problem is mechanistic, but on the other hand they invoke various versions of a holistic paradigm. In the mechanistic model, the body is likened to a machine that will be repaired through chiropractic. In the holistic paradigm, the perspective is broadened to see the body as a selfhealing entity but with interference in its ability to do so. While the explanation will focus on the presenting problems, it will also be broadened to include aspects of the patient’s life, such as nutrition, stress, weight, posture, and exercises.39,40 It is in the explanation of the problem that the chiropractor is presented with the opportunity to expand the intervention beyond the presenting symptoms and into lifestyle counseling, or what some have termed wellness care.37,38 In explaining the nature of treatment, the chiropractor again uses a range of techniques. Sixty-four percent of chiropractors report using the theories of chiropractic to explain the treatment, although only 12% of the patients report this is what happened.43 This explanation will often begin with the initial spinal examination41 and will usually occur concurrent with hands-on touching by the chiropractor; it may also be accompanied with extensive use of visual aids. The hands-on examination plays a powerful role in chiropractic, both recreating the pain the patient is suffering through palpation, but also eliciting additional stress points that may not be detected by the patient.41 This provides powerful and instant confirmation that the chiropractor knows and understands the patient’s body.39 Jamison sees this

Explanation of the Treatment

COMMUNICATION IN THE CHIROPRACTIC HEALTH ENCOUNTER

as an important element in establishing a shared understanding of the patient’s problem. She notes, “The pain, the soreness, tenderness, and tightness elicited by palpation forms the basis of this mutual understanding. In addition to responding to specific questions, the patient’s unsolicited grimaces, grunts, yelps, and jocular complaints provide a useful feedback to the practitioner.”44 It also validates the patient’s problem as legitimate and detectable by others. Oths,42 by analyzing the narratives occurring at this point of the encounter, found that most of the dialogue can be considered instrumentally oriented (information exchange) as opposed to affective (characterized by feeling or emotion). Again she found that the amount of touch in these encounters was extensive (the chiropractor maintained physical contact with the patient up to 90% of the treatment time). As Coulehan notes, “Chiropractors attend to bodily discomfort with more handling, more touching, that opens up a channel of communication now neglected by physicians.”41 Explanation of the treatment goes beyond the immediate therapy to the discussion of a treatment plan which lays out the way in which the treatment will proceed but also the patient’s responsibilities.27 A standard theme of the observation studies that have been done on chiropractic is that the care is cooperative. Oths42 found that the chiropractor constantly stressed negotiation and collaboration with the patient, a model of mutual participation. Under this approach, Jamison44,45 found that chiropractors expected the patients to participate in their own care. Coulehan41 calls this an “engaging plan” in which the patient and the chiropractor come together. Coulter39 points out that, at a fundamental level, this form of cooperation is almost a prerequisite for some forms of treatment (such as cervical manipulation), which is difficult to perform without the cooperation of the patient. He notes that manipulation should more correctly be viewed not as something done by the chiropractor to the patient, but as something the chiropractor and the patient’s body cooperate to deliver. Given the lack of knowledge that any new patient is likely to have about chiropractic and given the questions raised about the legitimacy of chiropractic, this area poses a particular challenge for chiropractic. In the explanation the chiropractor will attempt to define the profession and its practice. Coulter43 found that chiropractors will use a variety of methods to do this. Fifty-one percent used the philosophy of chiropractic; 52% used the theories of chiropractic; 59% used the art of chiropractic; 53% stressed the science; 47% used the modalities; and 64% stressed the scope of practice. Interestingly, Coulter43 found

Explanation of Chiropractic

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that only 9% of the patients gave a definition that contained any chiropractic philosophy. Cowie and Roebuck29 in the first ethnographic study of chiropractic noted that the chiropractor was well aware that the first visit posed difficulties for the patient. Much of the effort of the chiropractor therefore was oriented towards explaining the “nature, purpose, philosophy, and promise of chiropractic.”29 They found that the chiropractor has, as a central concern, the general impression the patient forms about chiropractic. The chiropractor encouraged open discussion of this with the patient so that any negative conceptions could be dealt with. This also allowed the chiropractor to identify difficult patients. This included the extent to which the patient was willing to share the practitioner’s views, the depth of the philosophical conversion, and whether they were likely to accept a chiropractic model of care and comply with it. Anderson,46 using narrative analysis of chiropractic encounters, also notes that this conversion experience into the chiropractic ethos was expressed in the narratives in 64% of the patients. A conversion was also present in all the narratives of the chiropractors themselves. Oths42 also notes this need to convert the patient to a chiropractic way of thinking during which the patient comes to share the chiropractor’s explanatory model. It was cemented in her study by the “warm, caring, affable, and continuously informative manner during encounters.”42 She found that the chiropractor went to “great lengths to educate new patients to a new way of thinking about their often long-standing problems.”42 Coulehan41 sees this process as one in which the chiropractor attempts to establish a link or fit with the patient and to determine if the patient is someone they can help. To do this, the chiropractor needs to know not only the physical problem but the patient’s attitude toward the problem and toward chiropractic. Quality of the Communication Almost without exception, observational studies point to the quality of the communication between chiropractors and their patients. Jamison44 found that patients ranked the explanation given to them as understandable, helpful, complete, believable, and satisfactory; 86% expected to understand their condition better. Coulehan40,41 notes that chiropractors have what he terms “faith that heals”; that is, they not only believe strongly in their profession, but also believe strongly that they can help a given patient. Cherkin, MacCormack, and Berg47 found in comparing the views of family physicians and chiropractors that the former were less likely to believe they were adequately trained to manage low back problems and to more often be frustrated by these kinds of patients and to think they have no physical problem. The

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chiropractors expressed more confidence and were more comfortable about managing back pain. Chiropractors therefore bring to their communications a confidence and assuredness that is convincing to their patients. Coulehan41 also concludes that chiropractors demonstrated both empathy for the patient (“the fact that the patient’s symptoms are real, cause suffering, and require serious professional attention is never at issue”41 ) and genuineness. The latter refers to the ability to be themselves in the relationship. This is coupled with a belief that all patients will do well and that a promise of improvement is continuously made to the patient.46 Oths42 notes that the chiropractor was open and frank in his attitude to the patient, showing respect in how the patient was addressed, giving praise and encouragement, and using sustained eye contact. She notes, “Throughout all interactions, Dr. A’s dialogue is characterized by acute openness, honesty, and frankness.”42 Another element is that the care does not “subtract the patient”41 ; that is, the chiropractor does not depersonalize the problem by referring to the body part. Oths42 found that the chiropractor would always use the possessive pronoun (“your knee”) when referring to a patient’s body and would use the pronoun “we” when talking about what was to be done, as in “all we can do is try to get it as strong as possible.”42 In their study, Kelner et al.27 found that the care was always highly personalized for the individual patient. It was also highly personal in that it always involved the chiropractor. For example, the patient does not get referred out to fill a prescription; most visits will involve hands-on care by the chiropractor. As Coulehan notes, chiropractors “do something; they do not just sit and talk or write prescriptions.”40 As noted earlier, chiropractic care involves extended periods where the chiropractor is in physical contact with the patient. CONCLUSION What conclusions have been drawn from the qualitative observation studies of the chiropractic encounter? For Kelner et al. it is the following: It offers intelligible care; the chiropractors try to provide their patients with an understanding of their injury or illness, using a language which patients can comprehend. They explain the plan of treatment, the progress of the case, and the relation of their illness to environmental conditions. Finally, they try to make patients aware of their personal role and responsibility in the maintenance of their health. Chiropractic is cooperative care—patients participate as

partners in the treatment and enhancing of their own health.27 Coulehan concludes: Physicians can learn from the success of the clinical art in chiropractic. This art begins with “the faith that heals,” and it involves an interaction that may well function as a positive feedback system to promote healing. By healing, I mean a satisfactory outcome for the patient: relief of pain, diminished anxiety, acceptance of one’s lot in life, less disability, a positive mental attitude.40 Finally, Oths draws the following conclusion: Given chiropractic’s unified theory of disease etiology, which provides a rational interpretation of a patient’s problem and an unambiguous method for treating it, the practitioner and the patient can reach a common level of understanding. The end result is most often a patient highly satisfied with the care received. From the observations made in this study, one might be inclined to agree with Kleinman et al. that the chiropractor is “more interested and skilled in handling illness problems” than the M.D.42 What all the studies share is the belief that to understand chiropractic the focus must be on the total health encounter. It is here that we will locate all the elements that structure and contribute to chiropractic as experienced by the patient and by the chiropractor. Chiropractic cannot be simply reduced to a single therapy (i.e., manipulation), to a single philosophy (i.e., vitalism), or to a single condition (i.e., low back pain). Like all healing professions, chiropractic combines some science and a lot of art, the latter expressed in the very unique relationship that chiropractors build with their patients. At the core of this relationship is communication, building trust, commitment, and, ultimately, the conversion of the patient into a chiropractic patient. SUMMARY 1. The health encounter includes the total interaction between the chiropractor, the office staff, and the patient. All health encounters are preceded by a preencounter history that impacts on the encounter, and frequently involves treatment by another health care provider for the specific problem. In the case of chiropractic patients, this prehistory will also often involve hearing negative messages

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from powerful groups about the legitimacy of chiropractic. 2. To capture the nature and components of this health encounter requires the use of qualitative research methods, because qualitative research methods are grounded in the perspectives of the social actors rather than the perspective of the researcher. Through the use of accepted qualitative observation methods we are able to capture the total health encounter in a way not possible by the standard quantitative methods of questionnaires, interviews, or review of patient files. Although qualitative methods have been used to study chiropractic, the number of studies is still modest. 3. The picture of chiropractic derived from qualitative studies stands in stark contrast to that derived from epidemiology and health services research, which show chiropractic to consist mainly of manipulation for a limited number of health problems. The route to the chiropractor is influenced by a major push factor, dissatisfaction with the results of other care; the route is also influenced by one major pull factor, recommendation by another patient. The qualitative studies of the chiropractic encounter have identified the doctor–patient communication as the key component. 4. Focusing on the communication aspect of the health encounter allows us to focus on an aspect other than the efficacy of treatment procedures per se. The communication addresses the nature of the patient’s health problem, the plan of treatment, and chiropractic itself; the end result of effective communication is a patient converted to the chiropractic paradigm, who is highly satisfied with the care given, who is more likely to adhere to the treatment program, and who is more likely to use chiropractic in the future.

QUESTIONS 1. What is the major difference between quantitative and qualitative research methods as they apply to chiropractic care? 2. What are some components of the chiropractic health encounter? 3. Chiropractic communications to patients tend to be of what three different types? 4. How do questions related to social legitimacy affect communication during the chiropractic health encounter? 5. What common conclusions have many sociological/anthropological studies come to regarding the chiropractic health encounter?

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ANSWERS 1. Quantitative methods tend to come from the perspective of the researcher, while qualitative methods attempt to understand the perspective and context of the individuals being studied. 2. The health encounter encompasses all the events, interactions, and behaviors that occur during a patient’s visit to a chiropractor’s office. This includes interaction with office staff, as well as with doctors. 3. Explanation of the patient’s health problem, an explanation of chiropractic treatment, and an explanation of the profession of chiropractic. 4. Most chiropractors allay a patient’s fears and unknowns regarding chiropractic by spending time explaining to the patient the profession and its philosophy, theories, and methods. 5. Chiropractors tend to be excellent communicators, providing understandable explanations to their patients and engaging them in a cooperative effort to heal. KEY REFERENCES Coulehan JL. Adjustment: The hands and healing. Culture Med Psychiatry 1985a;9:353–382. Coulter ID. Alternative philosophical and investigatory paradigms for chiropractic. J Manipulative Physiol Ther 1993;16:419–425. Coulter ID. Chiropractic: A philosophy for alternative health care. Oxford: Butterworth-Heinemann, 1999. Crabtree BF, Miller WL, eds. Doing qualitative research. Research methods for primary care. London: Sage, 1992. Hurwitz E, Coulter I, Adams A, Genovese B, Shekelle P. Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 1998;88(5):771–776. Jamison JR. An interactive model of chiropractic practice: Reconstructing clinical reality. J Manipulative Physiol Ther 1997;20(6):382–388. Kelner M, Hall O, Coulter I. Chiropractors, do they help? Toronto: Fitzhenry & Whiteside, 1980. Oths K. Communication in a chiropractic clinic: How a DC treats his patients. Culture Med Psychiatry 1994:18(1):83– 113. Vernon H. Chiropractic: A model of incorporating the illness behavior model in the management of low back pain patients. J Manipulative Physiol Ther 1991;14(6): 379–389.

REFERENCES 1. Hurwitz E, Coulter I, Adams A, Genovese B, Shekelle P. Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 1998;88(5):771–776.

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2. Mootz RD, Coulter ID, Hansen DT. Health services research related to chiropractic: Review and recommendations for research prioritization by the chiropractic profession. J Manipulative Physiol Ther 1997;20(3):201– 217. 3. Shekelle PG. What role for chiropractic in health care? N Engl J Med 1998;339(15):1075–1075. 4. Christensen M, Morgan D, eds. Job analysis of chiropractic. A project report of the practice of chiropractic within the United States. Greely, CO: National Board of Chiropractic Examiners, 1993. 5. Nelson CF. Chiropractic scope of practice. J Manipulative Physiol Ther 1993;16:488–497. 6. Coulter ID. Is chiropractic care primary health care? J Can Chiropr Assoc 1992;36:96–101. 7. Bowers LJ, Mootz RD. The nature of primary care: The chiropractor’s role. Top Clin Chiropr 1995;2(1):66–84. 8. Gaumer GL, Walker A, Su S. Chiropractic and a new taxonomy of primary care activities. J Manipulative Physiol Ther 2001;24(4):239–259. 9. Shekelle PG, Coulter ID, Hurwitz EL, et al. Congruence between decisions to initiate chiropractic spinal manipulation for low back pain and appropriateness criteria in North America. Ann Intern Med 1998;124:9–17. 10. Hawk C, Long CR, Boulanger K. Development of a practice-based research program. J Manipulative Physiol Ther 1998;21(3):149–156. 11. Stano M, Smith M. Chiropractic and medical costs of low back pain care. Med Care 1996;34:191–204. 12. Christensen HW, Nilsson N. The reliability of measuring active and passive cervical range of motion: An observer-blinded and randomized repeat-measures design. J Manipulative Physiol Ther 1998;21:341–347. 13. Vernon H, Mior S. The neck disability index: A study of reliability and validity. J Manipulative Physiol Ther 1991;14:409–415. 14. Coulter ID, Hays RD, Danielson CD. The chiropractic satisfaction questionnaire. Top Clin Chiropr 1994;1: 40–43. 15. Anderson R. Strong and weak measures of efficacy: A comparison of chiropractic with biomedicine in the management of back pain. J Manipulative Physiol Ther 1998;21(6):402–409. 16. Coulter ID. Alternative philosophical and investigatory paradigms for chiropractic. J Manipulative Physiol Ther 1993;16:419–425. 17. Crabtree BF, Miller WL, eds: Doing qualitative research. Research methods for primary care. London: Sage, 1992. 18. Jick TD. Mixing qualitative and quantitative methods: Triangulation in action. In: Van Maanen J, ed. Qualitative methodology. Beverly Hills, CA: Sage, 1979. 19. Buchanan DR. An uneasy alliance: Combining qualitative and quantitative research methods. Health Educ Res 1992;19:117–135. 20. Kleynhans AM. Where chiropractic and philosophy meet. J Aust Chiropr Assoc 1990;20(4):129–134. 21. Kleynhans AM, Cahill D. Paradigm for chiropractic research. J Aust Chiropr Assoc 1991;21(3):102–107. 22. Kleynhans AM. Developing philosophy in chiropractic. J Aust Chiropr Assoc 1991;21(4):161–167.

23. Jamison JR. Chiropractic holism: Interactively becoming in a reductionist health care system. Chiropr J Aust 1993;23(3):98–105. 24. O’Malley JN. Toward a reconstruction of the philosophy of chiropractic. J Manipulative Physiol Ther 1995;18(5):285–292. 25. Mealing D. Quantitative, qualitative and emergent approaches to chiropractic research: A philosophical background. J Manipulative Physiol Ther 1998;21(3):205– 211. 26. Beckman J, Fernandez C, Coulter ID. A systems model of health care: A proposal. J Manipulative Physiol Ther 1995;19(3):208–215. 27. Kelner M, Hall O, Coulter I. Chiropractors, do they help? Toronto: Fitzhenry & Whiteside, 1980. 28. Scrimshaw SCM, Hurtado E. Rapid assessment procedures for nutrition and primary health care. Los Angeles: UCLA Latin American Center Publication, 1987. 29. Cowie JB, Roebuck J. An ethnography of a chiropractic clinic: Definitions of a deviant situation. New York: The Free Press, 1975, p 82. 30. Coulter ID. Conflict between the health professions. ACA J Chiropr 1994:4:21–26. 31. Coulter ID. The sociology of chiropractic. Future options and directions. In: Haldeman S, ed. Modern developments in principles and practice of chiropractic. New York: Appleton-Century-Croft, 1992. 32. De Robertis MM. Chiropractic goes to university. Sci Rev Altern Med 1998;2(2):49–55. 33. Parsons T. The social system. Glencoe, IL: Free Press, 1951. 34. Bloom S, Summey P. Models of the doctor–patient relationship: A history of the social system concept. In: Gallagher EB, ed. The doctor–patient relationship in the changing health scene. Washington, DC: DHE, 1976 (Publication No. (NIH) 78–183). 35. Wardwell W. The reduction of strain in a marginal role. Am J Soc 1955;30:339–348. 36. Vernon H. Chiropractic: A model of incorporating the illness behavior model in the management of low back pain patients. J Manipulative Physiol Ther 1991;14(6):379–389. 37. Coulter ID. The patient, the practitioner, and wellness. Paradigm lost, paradigm gained. J Manipulative Physiol Ther 1990;13:107–111. 38. Hawk C. Should chiropractic be a “wellness” profession. Top Clin Chiropr 2000;7(1):23–26. 39. Coulter ID. Chiropractic: A philosophy for alternative health care. Oxford: Butterworth-Heinemann, 1999. 40. Coulehan JL. Adjustment: The hands and healing. Culture Med Psychiatry 1985;9:353–382. 41. Coulehan JL. Chiropractic and the clinical art. Soc Sci Med 1985:21(4):383–390. 42. Oths K. Communication in a chiropractic clinic: How a DC treats his patients. Culture Med Psychiatry 1994:18(1):83–113. 43. Coulter ID. Uses and abuses of philosophy. Philosophical Constructs for the Chiropractic Profession 1992;2(1):3–7.

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44. Jamison JR. Compliance or empowerment: An Australian case study. Chiropr J Aust 1997;27(2):111– 116. 45. Jamison JR. An interactive model of chiropractic practice: Reconstructing clinical reality. J Manipulative Physiol Ther 1997;20(6):382–388.

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46. Anderson ST. Narrative and the chiropractic encounter. J Chiropr Hum 1995;5(1):41–49. 47. Cherkin DC, MacCormack FA, Berg AO. Managing low back pain: A comparison of the beliefs and behaviors of family physicians and chiropractors. West J Med 1988;149:475–480.

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C H A P T E R

6 INTERNATIONAL STATUS, STANDARDS, AND EDUCATION OF THE CHIROPRACTIC PROFESSION David A. Chapman-Smith and Carl S. Cleveland III

O U T L I N E INTRODUCTION PROFESSIONAL ORGANIZATION International Organizations World Federation of Chiropractic (WFC) F´ed´eration Internationale de Chiropratique Sportive (FICS) Council on Chiropractic Education International (CCEI) World Regional Organizations US National Organizations Canadian National Organizations LAWS GOVERNING THE RIGHT TO PRACTICE CHIROPRACTIC Right to Practice Professional Titles EDUCATION LITERATURE, RESEARCH, AND CLINICAL GUIDELINES Textbooks Scientific Journals Searching Chiropractic Literature Searching Biomedical Literature Research—Organization and Funding The Consortial Center for Chiropractic

Research–United States Consortium for Chiropractic Research–Canada Clinical Guidelines and Task Forces CHIROPRACTIC AND COMPLEMENTARY AND ALTERNATIVE MEDICINE Definitions Is Chiropractic Part of CAM? The Benefits and Disadvantages of Classification as CAM CAM Utilization Significance for Chiropractic ACCEPTANCE AND UTILIZATION OF CHIROPRACTIC SERVICES Public Acceptance Utilization of Chiropractic Services Satisfaction Rates and Cost Sensitivity Medical Attitudes FUTURE DIRECTIONS SUMMARY QUESTIONS ANSWERS KEY REFERENCES REFERENCES

4. To describe the educational standards for chiropractors in different nations. 5. To review the importance of scientific research, the peer-reviewed literature, and official guidelines in the development and acceptance of chiropractic. 6. To discuss the advantages and disadvantages of labeling chiropractic as a complementary or alternative treatment approach (CAM).

OBJECTIVES 1. To review expansion of chiropractic around the world. 2. To describe the goals of the major international professional organizations. 3. To review laws governing the right to practice chiropractic in different parts of the world.

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7. To discuss the future options available to chiropractic as a profession and the manner in which it is likely to be identified internationally. INTRODUCTION The art of joint and soft-tissue manipulation, a central aspect of chiropractic practice, has been practiced and recorded since ancient Chinese, Egyptian, and Greek civilizations. Hippocrates, known as the father of medicine, wrote a complete text on the subject. This art, however, fell into disuse by the medical profession in modern times. In Europe and North America in the eighteenth and nineteenth centuries, spinal manipulative therapy was practiced mainly by bonesetters, lay persons who frequently inherited the skills and tradition from their parents and were dismissed as uneducated and dangerous by the medical profession. Medical education, then as now, provided no training in this approach to physical examination and treatment. The history of the profession established by D. D. Palmer, and developed in its early years by his son B. J. Palmer, is described more fully in Chapter 2. Table 6–1 gives key dates relevant to the expansion and growth of the profession to its current impressive international status. After the founding of the Palmer School of Chiropractic in 1897, chiropractic education and practice spread throughout the United States and Canada. The State of Kansas (1913) and the Province of Alberta (1923) became the first jurisdictions in each of these countries to pass legislation recognizing and regulating the practice of chiropractic. In the early twentieth century, students came to the United States from Australia, New Zealand, Europe, Japan, and South Africa, and then returned home to commence the development of the profession in their countries. Today there are approximately 100,000 chiropractors in more than 80 countries, many new schools of chiropractic, and greatly increased public awareness and acceptance of chiropractic health care, and the profession is growing more quickly than ever. In the words of a 1997 US government report, “[s]pinal manipulation and the profession most closely associated with its use, chiropractic, have gained a legitimacy within the United States health care system that until very recently seemed unimaginable.”1 In the past several decades, chiropractic has undergone a remarkable transformation. Labeled an “unscientific cult” by organized medicine as little as 20 years ago, chiropractic is now recognized as the principal source of spinal manipulation, one of the few treatments recommended by national evidence-based guidelines for the treatment of low back pain. In the areas of training, practice, and research, chiropractic has emerged from the periphery of the health care system and is playing an increasingly important role

in discussions of health care policy.1 This chapter addresses the status of the chiropractic profession today, both in the United States, where it was founded five brief generations ago, and throughout the increasingly small and interconnected world we now inhabit. PROFESSIONAL ORGANIZATION International Organizations Until the 1970s relatively few countries outside North America had laws formally recognizing chiropractic practice, none had schools of chiropractic, and the future status of the profession remained heavily dependent upon the United States. That has now changed. Since 1999 there are more chiropractic schools outside the United States than within, there is chiropractic legislation in all world regions, and it is predicted that by 2010 there will be 150,000 chiropractors, with 50,000 of them practicing outside the United States. As a consequence of these developments, the last 20 years have seen the formation and growth of world organizations to coordinate the international development of chiropractic education, practice, and growth. Founded in 1988 and having its offices in Toronto, Canada, the WFC’s voting members consist of 81 national associations of chiropractors, which range from the largest, such as the American Chiropractic Association (ACA), the Canadian Chiropractic Association (CCA), and the International Chiropractors’ Association (ICA), to the smallest, such as those associations representing the few pioneering chiropractors in countries such as Bolivia, Ghana, Iceland, Mauritius, and Saudi Arabia. The WFC has become the profession’s primary forum for developing a consistent basis for chiropractic principles, laws, scope of practice, and education in all world regions. This consistency is important for patients (e.g., those who travel internationally for work, education, and family reasons) and the unity and future prosperity of the profession. Three examples of the important role served by the WFC are:

World Federation of Chiropractic (WFC)

1. Maintains an international paradigm for chiropractic. In July 1996, the Association of Chiropractic Colleges (ACC), representing all 17 accredited colleges in Canada and the United States, unanimously agreed upon a “Paradigm of Chiropractic,” a fundamental position statement on the chiropractic profession’s role in health care. That paradigm was subsequently adopted for the profession in the United States by its two national associations, the ACA and the ICA. These organizations, in turn, jointly submitted it to the WFC for adoption internationally. The ACC Paradigm, now also the WFC Paradigm, was adopted at the WFC

INTERNATIONAL STATUS, STANDARDS, AND EDUCATION OF THE CHIROPRACTIC PROFESSION TABLE 6–1.

Chiropractic History: Key Dates

Date

Historical Event

1895 1897

D. D. Palmer commences practice as a “chiropractor.” The Palmer School of Chiropractic, the first chiropractic educational institution, opens.

1913

Kansas becomes the first US state to recognize and license the practice of chiropractic.

1923

Louisiana became the last state in 1974. Alberta becomes the first province to license chiropractic practice in Canada. Ontario follows in

1933

1925. Newfoundland is the last province, in 1992. The US Council of State Chiropractic Examining Boards is established with a mandate to provide unified standards for licensure. Renamed the Federation of Chiropractic Licensing Boards (FCLB) in 1974.

1939

The Canton of Zurich, Switzerland, becomes the first jurisdiction outside North America to license

1944

The Foundation for Chiropractic Education and Research (FCER) is established and, to the present time, is the profession’s foremost agency for funding of postgraduate scholarship and research. The US National Board of Chiropractic Examiners (NBCE) is established to promote consistency and reciprocity between state examining boards. The US Council on Chiropractic Education (CCE) is recognized by the federal government as the accrediting agency for schools of chiropractic. This leads to the development of affiliated

the practice of chiropractic.

1963 1974

1979

1987

accrediting agencies in Canada, Europe, and Australia/New Zealand. Chiropractic in New Zealand, the report of the NZ Commission of Inquiry into Chiropractic,is published. This was the first government commission to adopt a full judicial procedure, hearing evidence on oath and subject to cross-examination when examining patients, chiropractors, medical doctors, and others on the role of the chiropractic profession. The Commission’s recommendations strongly endorse chiropractic services and call for medical cooperation. The report has a major impact internationally.

1988

Final judgment in Wilk vs. American Medical Association entered, opening the way for much greater cooperation between medical and chiropractic doctors in education, research, and practice in the United States and internationally. World Federation of Chiropractic (WFC) is formed. The WFC, whose members are national associations of chiropractors in more than 78 countries, is admitted into official relations with the World Health Organization (WHO) as a nongovernmental organization (NGO) in January 1997.

1993

The Manga Report in Canada, the first government-commissioned report by health economists

1994

looking at the cost-effectiveness of chiropractic services, recommends a primary role for chiropractors with back pain patients on grounds of safety, cost-effectiveness, and patient preference, and concludes that this will save hundreds of millions annually in direct health care costs and work disability payments. Government-sponsored expert panels developing evidence-based guidelines for the management of patients with back pain in the United States (Agency for Health Care Policy and Research1 ) and the United Kingdom (Clinical Standards Advisory Group) provide the first authoritative reports that manipulation is a proven and preferred treatment approach for most acute lowback-pain patients.

1996

US government begins official funding support for an ongoing agenda for chiropractic research. To continue this agenda, the Consortial Center for Chiropractic Research is formed in 1997, comprising chiropractic schools, university research departments, and federal government

1998

agencies, and is based at Palmer College of Chiropractic. The first year in which there were more chiropractic schools outside the United States (17) than within (16): Australia (2), Brazil, Canada (2), Denmark, France, Japan, Korea, New Zealand, South Africa (2), Sweden, and the United Kingdom (4). In 2002, there were three schools in Australia, two in Brazil, and one in Mexico. Several unofficial schools in Japan are upgrading programs in partnership with accredited schools from Australia and North America.

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FIGURE 6–1. The Association of Chiropractic Colleges’ Chiropractic Paradigm (July 1996), which was adopted internationally by the World Federation of Chiropractic in May 2001. For the full text of the paradigm, visit www.chirocolleges.org.

Assembly in Paris in May 2001. Figure 6–1 summarizes the paradigm. 2. Maintains uniform policies. Working in partnership with many specialized organizations in chiropractic, and consulting with its member national associations, the WFC has held conferences that have produced important consensus, direction, and policy on matters such as: • The role of philosophy in chiropractic education. • Acceptable interim standards of education in countries establishing their first school of chiropractic. • Nonuse of prescription drugs in chiropractic practice. • An acceptable definition of chiropractic for use internationally in general dictionaries for the public. This definition reads as follows: “Chiropractic is a health profession concerned with the diagnosis, treatment, and prevention of disorders of the musculoskeletal system, and the effects of these disorders on the nervous system and general health. There is an emphasis on manual treatments, including spinal manipulation.” 3. Avoids the loss of international professional identity. The international chiropractic community has

looked at the difficulties encountered by the osteopathic profession in its development. The profession of osteopathy was founded in the United States in the same era as chiropractic, and had a number of similarities. Because of a lack of unity and coordination it no longer has a consistent international identity. In the United States, Doctors of Osteopathy (DOs) have similar training and specialties to medical doctors, including use of prescription drugs and surgery. In the United Kingdom, osteopaths retain their traditional focus on osteopathic manipulation without use of drugs and surgery and require a 4-year, full-time education for licensure and practice. In many other countries, other health professionals or lay persons commence practice as an osteopath after several weekends of technique classes. This loss of common educational standards and professional identity has been a major impediment to the growth of a uniform identity for the osteopathic profession. The international chiropractic community, through the WFC, has made the development of a uniform education and identity a primary goal. The WFC enables the chiropractic profession to play an effective and respected role in the international health community. The most successful agency

INTERNATIONAL STATUS, STANDARDS, AND EDUCATION OF THE CHIROPRACTIC PROFESSION

of the United Nations, and the one responsible for health, is the World Health Organization (WHO). The WFC was accepted into official relations with WHO in 1997, and is active in supporting WHO’s public health initiatives, including its antismoking campaign, or Tobacco-Free Initiative (TFI). For more information on the structure and activities of the WFC visit www.wfc.org. F´ed´eration Internationale de Chiropratique Sportive (FICS)

FICS, which has its offices in Lausanne, Switzerland, was established in 1986, and serves a similar role to the WFC in the specialized and increasingly important arena of sports chiropractic. It has coordinated postgraduate education and encouraged the greatly increased participation of chiropractors in sports medicine teams at the summer and winter Olympics and at many other national and international sporting competitions. Council on Chiropractic Education International (CCEI)

Governments generally require that educational programs for professionals meet minimum standards established by an independent expert body approved by them, called an accreditation agency. In the United States, the accreditation agency for chiropractic education, recognized by the federal government since 1974, is the Council on Chiropractic Education (CCE). CCE’s structure and standards have been followed by similar CCEs in Australia, Canada, and Europe, and have now led to the formation of the Council on Chiropractic Education International (CCEI), which is developing standards for newer chiropractic schools in countries and regions that do not yet have their own accreditation agency. CCEI presently functions from the offices of US CCE in Scottsdale, Arizona. World Regional Organizations These exist in several regions, with the strongest and most developed being the European Chiropractors’ Union (ECU). In Europe, health care policy and laws in individual countries are increasingly influenced by the European Union and its Parliament, based in Brussels. US National Organizations As the profession becomes established in each country, state/provincial and national organizations are formed to represent the interests of the profession and its patients in areas such as public relations, legal rights, reimbursement for care, regulation of chiropractic practice, education, and research. Contact addresses for national associations worldwide may be found at www.wfc.org. The American Chiropractic Association (ACA) (www.amerchiro.org) and the International Chiropractors’ Association (ICA) (www.chiropractic.org) represent the profession at the federal level. They have

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been responsible for lobbying for inclusion of chiropractic services in federal programs such as Medicare, Medicaid, and the Military and Veterans’ Administration Healthcare Systems, and for initiating and building national support for major lawsuits to fight illegal discrimination against chiropractic services. They are most effective when working together, and frequently do so. The ACA is considerably larger than the ICA, but together their members represent fewer than 20% of American chiropractors, a much lower membership level than national associations in other countries. Their work is made more difficult by small organizations with extreme viewpoints that claim democratic authority and seek a profile at the national level, groups such as the National Association of Chiropractic Medicine (limiting chiropractic to the management of musculoskeletal pain syndromes) and the World Chiropractic Alliance (limiting chiropractic to location and correction of vertebral subluxations). Because health care laws, rights, and funding arrangements are matters of state law, a chiropractor’s first priority in professional membership is often his or her state association. US state associations are separate in structure and law from the two national associations. They are represented at the national level by the Congress of Chiropractic State Associations (COCSA) (www.cocsa.org). The Association of Chiropractic Colleges (ACC) (www.chirocolleges.org), as its name implies, represents chiropractic colleges, both in the United States and in other countries. The Council on Chiropractic Education (CCE) (www.cceusa.com) is the organization that provides minimum standards, inspections, and accredited/approved status for chiropractic colleges. The Federation of Chiropractic Licensing Boards (FCLB) (www.fclb.org) is the national body that coordinates and represents state licensing boards. It annually reviews and publishes a summary of state requirements for a license to practice chiropractic. The FCLB is affiliated with the National Board of Chiropractic Examiners (NBCE) (www.nbce.org), which sets and administers the federal licensing examinations in the United States. The Foundation for Chiropractic Education and Research (FCER) (www.fcer.org) was founded in 1944. The FCER is the premier and best-funded research foundation established by the chiropractic profession. It holds a biennial International Conference on Spinal Manipulation (ICSM) for the presentation of new research. The Consortial Center for Chiropractic Research (CCCR) (www.c3r.org) is a national research organization, founded in 1997, that holds an annual meeting funded by the federal government, the Research Agenda Conference (RAC), which brings together researchers from chiropractic colleges, other university science faculties, and the National

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Institutes of Health (NIH) to plan research and develop research skills. Chiropractors may obtain their professional liability/malpractice insurance from many companies. One, originally established by the profession as a mutual society and by far the largest malpractice insurer for chiropractors in the United States, is the National Chiropractic Mutual Insurance Company (NCMIC), which also provides substantial funding for chiropractic research. Canadian National Organizations The Canadian Chiropractic Association (CCA) (www.ccachiro.org), with approximately 5000 members, is the second biggest national association after the American Chiropractic Association. In Canada, as in Australia, there is only one association in each province/state, and it is a division and legal part of the national association. There is, therefore, no need for an organization such as a council of state organizations as exists in the United States, and information on the provincial/state associations is available from the national association. Licensing and disciplinary responsibilities for chiropractors are carried out by the Canadian Federation

TABLE 6–2.

LAWS GOVERNING THE RIGHT TO PRACTICE CHIROPRACTIC Right to Practice The chiropractic profession is recognized by law in many countries, in all world regions, as summarized in Table 6–2. Official recognition can be given by governments and health authorities in three different ways. The

Countries Where Chiropractors Are Recognized by National Health Authorities

African Region

Asian Region

Eastern Mediterranean Region

Botswana∗ Ethiopia† Kenya† Lesotho∗ Mauritius† Namibia∗

China–Hong Kong∗ Japan† Malaysia† Philippines† Singapore† Taiwan†

Cyprus∗ Egypt† Greece† Iran∗ Israel† Jordan†

Nigeria∗ South Africa∗ Swaziland∗ Zimbabwe∗

Thailand‡

Lebanon†

Latin American Region Argentina† Brazil† Chile† Colombia† Costa Rica∗ Ecuador†

of Chiropractic Regulatory Boards (CFCRB), whereas the Canadian Chiropractic Examining Board (CCEB) (www.cceb.ca) is responsible for establishing a national licensing examination. The Canadian Chiropractic Research Foundation (CCRF) (www.ccachiro.org) is an established funding agency and is active in establishing training grants and small research grants for young investigators. Professional liability insurance is provided by the Canadian Chiropractic Protective Association (CCPA). Similar to the United States, chiropractors may obtain malpractice protection from private companies, but the great majority receive it from the CCPA, an affiliate of the CCA, which uses some of its revenue to fund chiropractic education and research.

Guatemala† Honduras† Mexico∗ Panama∗ Peru† Venezuela†

Libya† Morocco† Qatar† Saudi Arabia∗ Turkey† United Arab Emirates∗

North American Region Bahamas∗ Barbados∗ Belize† Bermuda† British Virgin Islands† Canada∗

Leeward Islands∗ Puerto Rico∗ Trinidad & Tobago† United States∗ US Virgin Islands†

European Region Belgium∗ Croatia† Denmark∗ England∗ Finland∗ France∗

Italy‡ Liechtenstein∗ Netherlands† Norway∗ Portugal∗ Russian Federation†

Germany† Hungary† Iceland∗ Ireland†

Slovakia† Sweden∗ Switzerland∗

Pacific Region Australia∗ Fiji† Guam∗ New Caledonia† New Zealand∗ Papua New Guinea†

Cayman Islands† Jamaica† Listed according to the seven world regions adopted by the World Federation of Chiropractic. In most other countries, there are no chiropractors in practice, and national health authorities have not considered recognition or lack of recognition. ∗

Recognized pursuant to legislation.

†

Recognized pursuant to general law.

INTERNATIONAL STATUS, STANDARDS, AND EDUCATION OF THE CHIROPRACTIC PROFESSION

first is by legislation, and there is now legislation to recognize and regulate the profession in Africa (Namibia, Nigeria, South Africa, and Zimbabwe), the Asia-Pacific region (Australia, Hong Kong–Peoples Republic of China, and New Zealand), the eastern Mediterranean (Cyprus, Iran, and Saudi Arabia), Europe (Belgium, Denmark, Finland, France, Norway, Sweden, Switzerland, and the United Kingdom), Latin America (Mexico and Panama), and North America (Canada and the United States). In all instances, legislation authorizes primary practice with the right and duty to diagnose, including the right to provide or order diagnostic imaging. Examples of chiropractic international legislation can be found in Figure 6–2. Chiropractic practice may be recognized under general law without the existence of specific chiropractic legislation. Sometimes legality under general law has been confirmed by ministerial ruling, as, for example, in Fiji, Mauritius, and Venezuela. On other occasions, it has been confirmed by decisions of the courts, as in Brazil, Chile, and Greece. Elsewhere there may be general legislation, as in Germany, where chiropractors practice under umbrella legislation authorizing many types of health providers to practice natural health care methods under the general title of heilpraktischer. The third method of recognition applies to countries where the practice of chiropractic is legally unrecognized or technically in breach of the law, but is not obstructed by national health authorities. This is possible because chiropractic practice is noninvasive, makes no use of drugs or surgery, and is recognized to be of public benefit. The six countries that have taken legal action against duly qualified chiropractors in recent years are France and Iran (both of which have now changed their positions and passed laws to recognize the profession), Italy, South Korea, Spain, and Thailand. In some European countries, including Austria, the Czech Republic, and Hungary, spinal manipulation is expressly designated as being part of the practice of medicine. However, chiropractic services in Europe are in the middle of a general and rapid move to full legal acceptance. This is a result of the European Parliament’s May 1997 adoption of the Lannoye Report, which noted the high level of public acceptance of chiropractic and other complementary health care services in Europe, the unsatisfactory situation for European citizens of having these services legally recognized in some countries but not in others, contrary to the principles of the European Union, and recommended that practice be approved by law throughout Europe. This has already led to new laws in Belgium and France, and similar legislative approval is presently under discussion in Italy, Portugal, and Spain.

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Professional Titles Various titles are authorized by law in different countries. The title chiropractor or its equivalent (e.g., chiropraktor [German], chiropraticien[ne] [French], kiropraktor [Scandinavian languages], quiropraxia [Spanish]) is universal. Use of the title Doctor of Chiropractic is common throughout North America, reflecting the fact that North American chiropractic colleges grant a Doctor of Chiropractic degree. In North America, the title doctor is used by all primary contact health professionals with the right and duty to diagnose, including dentists, optometrists, osteopaths, podiatrists, and psychologists. Many states in the United States also authorize use of the title chiropractic physician. These states, which include California, Florida, Illinois, New York, and Ohio, recognize three categories of physicians: (a) chiropractic, (b) medical, and (c) osteopathic. One reason for legislation to regulate a health profession is to prevent unqualified practitioners or lay persons from passing themselves off as members of that profession, exposing the public to ineffective or harmful treatments. For this reason chiropractic laws typically prohibit persons without a license from using the above protected titles or otherwise holding themselves out expressly or by implication as being engaged in the practice of chiropractic.

EDUCATION There is much misunderstanding of the extent and quality of chiropractic education. Focus groups held in Canada and the United States typically find that many members of the public think that chiropractic education is of approximately 2 years duration, is significantly inferior to medical education, and consists of chiropractors teaching other chiropractors in unregulated private schools. In fact, in North America there is a minimum requirement of 7 years of university-level training, all aspects of education must meet official accreditation standards, and a graduate must also complete state/provincial and national licensing board examinations before gaining the right to practice. Independent government and medical studies in the United States,2 Sweden,3 and New Zealand4 have concluded that chiropractic education is the equivalent of medical education in all of the basic sciences. At the University of Southern Denmark, for example, chiropractic and medical students take a basic sciences program in the same department for 3 years, with many shared subjects, lecturers, and classes, dividing into separate streams for clinical education. Until the 1990s, virtually all accredited chiropractic education was given on the North American model and was therefore easy to summarize and describe, that is, entrance requirements of 2–3 years in

A

B

FIGURE 6–2. Chiropractic laws exist not only in all US states, but also in many other countries. Here are extracts from chiropractic legislation from the (A) United Kingdom and (B) Hong Kong. (Reproduced with permission from Chapman-Smith D. The chiropractic profession. Des Moines, IA: NCMIC Group, 2000:31.)

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INTERNATIONAL STATUS, STANDARDS, AND EDUCATION OF THE CHIROPRACTIC PROFESSION

qualifying subjects and then 4 years of undergraduate chiropractic college education, leading to a Doctor of Chiropractic degree. Now, despite a broadly consistent international standard of education, the position is more complex for several reasons: 1. Entrance requirements vary by country, reflecting differing educational systems. In many countries, including Australia, Brazil, Mexico, South Africa, and the United Kingdom, students enter chiropractic education—as in medical and other health care education—directly from secondary school (high school). 2. In all of the above countries chiropractic education is within the public university system and leads to different degrees. Graduates of the Technikon Natal in Durban, South Africa, receive a master’s degree (M Tech Chiro), and graduates of Macquarie University in Sydney, Australia, receive the M Chiro master’s degree. Graduates of the University of Surrey in the United Kingdom receive the MSc (Chiro) degree. Chiropractors are no longer “DCs” throughout the world. 3. The international chiropractic community, through its adoption of the WFC’s Tokyo Charter in 1997, has recognized that when chiropractic education is first introduced into a country, it may initially have to be on a limited basis for an interim period. For example, in the 1990s in Japan, the Japanese Chiropractic Association formed a partnership with the School of Chiropractic at RMIT University to commence a 3-year program for high school graduates that has now matured to a 5-year program at the international standard. In Brazil, the Brazilian Chiropractors’ Association, Palmer University, and Feevale University of Novo Hamburgo, Brazil, formed a partnership that commenced a 2-year program for health professionals (e.g., medical doctors, physical therapists, nurses) that has now matured into a 5-year program for high school graduates. 4. Finally, in some countries without laws governing chiropractic education and practice, such as Germany, Honduras, Japan, and Taiwan, there are large numbers of lay persons with limited, parttime technique instruction only who are practicing as chiropractors. They are similar to the bonesetters of yesteryear in Europe and North America. Starting with Japan, which has an estimated 10,000 such practitioners, accredited colleges from Australia and North America are working with the national association (representing chiropractors from accredited chiropractic schools) and the local technique schools to present conversion degree courses that would convert these “chiropractors” to a level suitable for safe and effective practice

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in their own countries, but not qualify them at the international level so as to allow them to sit for licensing exams to practice in other countries. They are going to commence upgrading local schools to the international level of accredited chiropractic education. Table 6–3 lists the 35 chiropractic programs worldwide in 2002 that are accredited or recognized by the government or national association in the country in which the school is located. A noteworthy current development in the United States, which follows the newer model of chiropractic education founded in Australia and Europe and results from the vision and work of the Florida Chiropractic Association, is the decision to open a school of chiropractic at Florida State University, with the first entering class due to commence in September 2004. This will be the first US chiropractic program at a state university. It will likely lead to others, and represents another significant step in the integration of chiropractic into the mainstream American health care system. LITERATURE, RESEARCH, AND CLINICAL GUIDELINES When the first edition of this text was published in 1980, chiropractic literature and science were in their infancy. There were no indexed, peer-reviewed chiropractic journals, and there were very few specialty texts in such important areas as skeletal radiology, the cervical spine, or overviews of chiropractic technique. At approximately the same time, the National College of Chiropractic launched the Journal of Manipulative and Physiological Therapeutics (1978), now the profession’s flagship journal, and the ICA sponsored a conference (1979), producing the papers on which the first edition of this text was based. The years since have seen a dramatic growth in the number of chiropractic scientists worldwide with doctoral degrees in the clinical and basic sciences and, from them and others, the development of a mature chiropractic scientific literature base. This is found both in the profession’s own periodicals and textbooks and in other medical and health science publications. This literature base and the research upon which it is founded have been vital to the continued growth and status of the profession. They have become the basis for the profession’s future health in an era that will be increasingly governed by evidence-based care. Public and private reimbursement plans for employees, injured workers, automobile accident victims, and seniors will generally pay for services supported by sound research data on safety, effectiveness, and patient satisfaction, and exclude services without any

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TABLE 6–3.

Accredited or Recognized Chiropractic Colleges (2002)

Australia Maquarie University Centre for Chiropractic

Durban, South Africa www.ntech.ac.za

Sydney, Australia www.chiro.mq.edu.au

School of Chiropractic, Technikon Witwatersrand Johannesburg, South Africa

Faculty of Chiropractic, Murdoch University

www.twr.ac.za

Perth, Australia www.vet.murdoch.edu.au/vbs/chiro/ Department of Complementary Medicine, Faculty of Chiropractic, RMIT University Melbourne, Victoria, Australia www.rimit.ed.au/cocm Brazil Faculty of Chiropractic, Feevale Central University Novo Hamburgo, Brazil www.feevale.tche.br Faculty of Chiropractic, University Anhembi Morumbi S˜ ao Paulo, Brazil www.anhembi.br Canada Canadian Memorial Chiropractic College Ontario Canada www.cmcc.ca Universite´ du Quebec ´ a` Trois-Rivieres, ` Sciences de la sante´ Quebec, ´ Canada www.uqtr.uquebec.ca Denmark University of Southern Denmark, Faculty of Health Sciences Odense, Denmark www.ou.dk France Institut Franco-Europeen ´ de Chiropratique Paris, France www.ifc.net Japan RMIT University Chiropractic Unit—Japan Tokyo, Japan Korea Hanseo University, RMIT Chiropractic Division Seoul, Korea www.hanseo.ac.kr Mexico Faculty of Chiropractic, Universidad Estatal del Valle de Ecatepec Ecatepec, Mexico

Sweden Scandinavian School of Chiropractic Stockholm, Sweden United Kingdom Anglo-European College of Chiropractic Bournemouth, UK www.aecc chiropractic.ac.uk McTimoney School of Chiropractic Oxford, Oxfordshire, UK www.mctimoney.org.uk The Welsh Institute of Chiropractic School of Applied Sciences, University of Glamorgan Pontypridd, Wales, UK www.glam.ac.uk United States Cleveland Chiropractic College Kansas City, MO www.clevelandchiropractic.edu Cleveland Chiropractic College Los Angeles, CA www.Clevelandchiropractic.Edu Life Chiropractic College—West Hayward, CA www.lifewest.edu Life University Marietta, GA www.life.edu Logan College of Chiropractic Chesterfield, MO www.logan.edu National University of Health Sciences Lombard, IL www.nuhs.edu New York College of Chiropractic Seneca Falls, NY www.nycc.edu Northwestern Health Sciences University Bloomington, MN www.nwhealth.edu

New Zealand New Zealand College of Chiropractic Auckland, New Zealand www.chiropractic.ac.nz

Palmer College of Chiropractic Davenport, IA www.palmer.edu

South Africa School of Chiropractic, Technikon Natal

San Jose, CA www.palmer.edu

Palmer College of Chiropractic—West

(continued)

INTERNATIONAL STATUS, STANDARDS, AND EDUCATION OF THE CHIROPRACTIC PROFESSION TABLE 6–3.

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(Cont.)

Parker College of Chiropractic Dallas, TX www.parker.edu Sherman College of Straight Chiropractic Spartanburg, NC www.sherman.edu Southern California University of Health Sciences Whittier, CA www.scuhs.edu

such data or evidence base. What follows is a brief review of the literature and how it may be accessed. Textbooks More major texts on chiropractic have been published in the last 10 years than in the previous history of the profession, and many are of the highest quality by any standards. For example, the first edition of Foreman and Croft’s Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome,5 when published in 1988, was described by Ruth Jackson, MD, a leading medical author in that field, as “the most remarkable compilation of scientific and factual data thus far published concerning the many facets of the cervical spine.” The second edition of Essentials of Skeletal Radiology (1996),6 by chiropractic radiologists Yochum and Rowe, was glowingly reviewed in the New England Journal of Medicine as a “textbook that should be required reading for any student of radiology.”7 Another major chiropractic radiology text, Clinical Imaging: With Skeletal Chest and Abdomen Pattern Differentials (1999),8 edited by Marchiori, has contributions from many chiropractic and medical radiologists. It is praised as “an outstanding text” from “an outstanding group of radiologists” in the foreword by Francis Burgener, MD, Professor of Radiology, University of Rochester Medical Center, Rochester, New York. Professor Vert Mooney, past chair, Department of Orthopedic Surgery, University of California at San Diego, in a foreword in Spinal Rehabilitation, edited by Stude9 of the College of Chiropractic, Northwestern Health Sciences University, states that the text “clearly demonstrates the ongoing integration of chiropractic into comprehensive medical care,” is “a unique blend of the two major physical approaches to spinal care—manual therapy and active exercise,” and “is the way of the future” and “forward thinking at its very best.” Chiropractic Technique (1993) by Bergmann, Petersen, and Lawrence,10 Chiropractic Manipulative Skills (1996) by Byfield,11 and Mechanically Assisted Manual Techniques: Distraction Procedures by Bergmann and Davis (1998)12 are examples of

Texas Chiropractic College Pasadena, TX www.txchiro.edu University of Bridgeport College of Chiropractic Bridgeport, CT www.bridgeport.edu/chiro Western States Chiropractic College Portland, OR www.wschiro.edu

sophisticated texts on chiropractic technique. A major chiropractic text on soft-tissue examination and treatment is Functional Soft-Tissue Examination and Treatment of Manual Methods,13 edited by Hammer. Texts such Rehabilitation of the Spine: A Practitioner’s Manual (1996), edited by Liebenson,14 Conservative Management of Cervical Spine Syndromes (1999), edited by Murphy,15 The Cranio-Cervical Syndrome: Mechanisms, Assessment and Treatment, edited by Howard Vernon,16 and the present text draw together contributions from leading experts from many disciplines worldwide in a way that was not possible in the past. Fundamentals of Chiropractic Diagnosis and Management (1991), edited by Lawrence,17 and Differential Diagnosis for the Chiropractor: Protocols and Algorithms (1997) by Souza18 are major general clinical texts of 600 and 750 pages, respectively. There are texts of similar quality in many specialty areas such as anatomy,19 low back pain,20 cervical spine disorders,21 head pain,22 pediatrics,23,24 somatovisceral aspects of chiropractic,25 and sports injuries.26,27 Managing Low-Back Pain (1992, 3rd ed.) edited by Kirkaldy-Willis, a Canadian orthopedic surgeon, and Burton, an American neurosurgeon, is an example of a leading medical text on back pain in which the principal authors of the chapter on manipulation, Cassidy and Thiel, are chiropractors.28 Scientific Journals The profession’s leading peer-reviewed journal, indexed in Index Medicus and therefore easily accessible to everyone reading health sciences literature, is the Journal of Manipulative and Physiological Therapeutics (JMPT), which has been published in the United States since 1978. Table 6–4 lists other peer-reviewed chiropractic journals. Most of the papers published in the chiropractic literature, not surprisingly, come from chiropractors and chiropractic research institutions. However, the journals, and particularly JMPT, routinely receive and publish research from other health disciplines. Similarly, chiropractic research is now regularly published

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Peer-Reviewed Chiropractic Periodicals

TABLE 6–4.

General Journals Australia

Chiropractic Journal of Australia

Canada

Journal of the Canadian Chiropractic Association European Journal of

Europe Japan United States

Chiropractic Japanese Journal of Chiropractic Sciences Chiropractic Research Journal Journal of Manipulative and Physiological Therapeutics

Special Interest Journals United States

Chiropractic History Journal of Chiropractic Education Journal of the Chiropractic Humanities Journal of Vertebral Subluxation Research Topics in Diagnostic Radiology and Advanced Imaging

in leading medical journals such as the Annals of Internal Medicine, British Medical Journal, Clinical Biomechanics, Journal of the American Medical Association, New England Journal of Medicine, Pain, and Spine. Today, research relevant to the chiropractic profession can be published in hundreds of journals. The electronic database MANTIS, important for chiropractors because it indexes research in the specialized field of manual and alternative therapies, references more than 1000 journals. And this is only one database of relatively narrow scope targeted at disciplines not well represented in the major biomedical databases such as Index Medicus/MEDLINE. Searching Chiropractic Literature MANTIS (Manual, Alternative, and Natural Therapy Index System) (www.healthindex.com) is a database that provides coverage for health care disciplines not significantly represented in the major biomedical databases, including the chiropractic profession. The Index to Chiropractic Literature (ICL) (www. chiroindex.org) is published by the Chiropractic Library Consortium (CLIBCON) for the chiropractic

profession and the public at large. It indexes all chiropractic peer-reviewed journals since 1985. The Cumulative Index to Nursing and Allied Health Literature (CINAHL) (www.cinahl.com) indexes more than 1200 nursing, allied health, and health sciences journals, including chiropractic journals, since 1982. The Alt Health Watch (www.search.epnet.com) database focuses on complementary and alternative approaches to health care and wellness. It indexes journals as well as various other publications, including association and consumer newsletters, since 1980. AMED (www.bl.uk/services/information/amlist .html), the Allied and Complementary Medicine Database compiled by the British Library Health Care Information Service, is another database for students, clinicians, and researchers looking for information on complementary and alternative medicine. Searching Biomedical Literature The Cochrane Library (www.cochranelibrary.com) database is compiled by the Cochrane Collaboration, an international organization named after a famous British epidemiologist. This group also reviews and summarizes all the research evidence in all fields of health care to formulate recommendations. The reviews currently found in the Cochrane Database of Systematic Reviews, many of which are of importance to chiropractic practice, are indexed in MEDLINE under the abbreviation Cochrane Database Syst Rev. MEDLINE (www.pubmed.gov) is the major and well-known database established by the US National Library of Medicine. MEDLINE is the electronic equivalent of Index Medicus, the print version, which is now little used. This is the database that developed the Medical Subject Headings (MeSH) that now form the basis of searches in most databases. It covers more than 4600 biomedical journals. Many of these databases may be accessed through EBSCO Information Services (www.epnet.com). Research—Organization and Funding Historically, as remains the case today, much chiropractic research has been performed in chiropractic colleges supported by organizations such as the Foundation for the Advancement of Chiropractic Education (FACE), the National Institute of Chiropractic Research (NICR), and the Consortium for Chiropractic Research (CCR), the latter established by 16 US chiropractic colleges in the late 1980s. However, the chiropractic profession’s principal research organization, established in 1944, has been the Foundation for Chiropractic Education and Research (FCER), now based in West Des Moines, Iowa. By 1990, the annual research budget of FCER was approximately $2 million,

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drawn from within the profession from contributions by individual chiropractors and from chiropractic organizations and vendors. Major additional funding in recent years has come from the National Chiropractic Mutual Insurance Company, the largest malpractice insurer for the chiropractic profession. A significant new development during the past decade has been the formation of chiropractic research networks based on a national research plan, with the participation of multidisciplinary experts and institutions and significant government funding. The Consortial Center for Chiropractic Research–United States The Consortial Center for Chiropractic Research (CCCR) was formed as a result of an opportunity to establish a chiropractic research center with historic funding from the US National Institutes of Health in 1997. Headquartered at the Palmer Center for Chiropractic Research in Davenport, Iowa, the consortium has involved investigators from 13 chiropractic and other universities and colleges. The mission of the center is to develop an infrastructure to evaluate the safety and effectiveness of chiropractic care. One of its main functions has been to increase the experience and sophistication of chiropractic researchers by sponsoring training courses and conferences, and by developing, reviewing, and funding developmental and pilot studies in the clinical and basic sciences. Projects initially supported by the CCCR have been leveraged into larger, more definitive studies, enhancing the scientific basis for chiropractic. The CCCR cosponsors, with the US Health Resources and Services Administration (HRSA), the annual Research Agenda Conference (RAC), an interdisciplinary meeting designed to advance the scientific capabilities of the chiropractic profession. The director of the CCCR is William Meeker, DC, MPH, Vice President for Research, Palmer Chiropractic University System. The CCCR received the first major funding for a chiropractic research center from the US government, indicating a major shift in attitude toward chiropractic at this important policy and funding level. Consortium for Chiropractic Research–Canada The Consortium for Chiropractic Research (CCR) is similar to the US consortium but was first established by the Canadian Chiropractic Association without government funding or assistance. Participating institutions include Canada’s two chiropractic colleges, several major universities, and the Institute of Work and Health. The CCR has now attracted several major government grants, including a recent grant of $1 million for a randomized controlled trial comparing chiropractic, medical, and joint chiropractic/

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medical management of patients with chronic tensiontype headache. Clinical Guidelines and Task Forces An excellent illustration of the current status and maturity of chiropractic practice and research is found in the work of national and international clinical guideline panels and other task forces since the early 1990s. Firstly, chiropractic developed the unity, expertise, and professional maturity to produce its own national consensus guidelines for chiropractic practice in the United States (Mercy Conference Guidelines, 199129 ) and Canada (Glen Erin Conference Guidelines, 199330 ). Representative panels met to forge guidelines from the scientific literature and clinical expertise in all major areas of practice—from examination, diagnosis, and record keeping to modes of care, frequency, and duration of care and contraindications. Next, chiropractors were included on government-sponsored interdisciplinary expert panels for development of national guidelines for the management of back pain in various countries, including the United Kingdom,31 the United States,32 Denmark,33 and New Zealand.34 All of these panels produced national guidelines endorsing chiropractic management by recommending spinal manipulation and return to activities of daily living as a first line of management for most patients with low back pain. Furthermore, many recommended against many standard medical treatments including bed rest, traction, joint injections, and various other physical therapy and pharmaceutical modalities. As Redwood says, “The release of the AHCPR Guidelines (the 1994 guidelines in the US from the Agency for Health Care Policy and Research, US Department of Health and Human Resources) was a truly seismic event (Fig. 6–3). The medical press expressed amazement that the federal guidelines for the management of LBP (low-back pain)—the nation’s most prevalent musculoskeletal ailment and the most frequent cause of disability for persons under age 45—now assign a pivotal role to spinal manipulation of which 94% is provided by chiropractors.”35 At the same time, an interdisciplinary Task Force on Whiplash-Related Disorders with foremost experts from Europe and North America was meeting in Quebec, Canada, to provide clinical guidelines for the management of trauma to the cervical spine. Again there was chiropractic representation, and in 1995, the Quebec Task Force delivered guidelines indicating that management of soft-tissue injuries to the neck should be similar to management of back pain, that is, early return to function and activities rather than rest or immobilization in a collar, with joint manipulation and mobilization recommended to

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B

A

FIGURE 6–3. Clinical practice guidelines from (A) the US (Agency for Health Care Policy and Research, DHHS 1994) and (B) the UK (Royal College of General Practitioners, 1998). (Reproduced with permission from Chapman-Smith D. The chiropractic profession. Des Moines, IA: NCMIC Group, 2000:110.)

improve range of motion and reduce pain.36 Similar advice came from two other expert panels where chiropractic and medical scientists sat together, panels selected by the RAND Corporation37 and the Cochrane Collaboration.38 A final example of the chiropractic profession’s present status as a full partner in the clinical health sciences research community is the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its

Associated Disorders. The United Nations, in conjunction with the orthopedic community worldwide, has proclaimed the years 2000 to 2010 the “Bone and Joint Decade” to promote research into better understanding of the musculoskeletal system and its clinical management. The Task Force is currently part way through a 6-year program of original research, literature review, and guideline development to strengthen understanding of the safety and effectiveness of the

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various common methods of treating cervical spine disorders, a field in which all treatments lack strong scientific evidence of effectiveness. A number of scientists with chiropractic training play a significant role in this Task Force along with scientists with qualifications in epidemiology, economics, research methodology, and a number of medical specialties. CHIROPRACTIC AND COMPLEMENTARY AND ALTERNATIVE MEDICINE Chiropractors prefer to see themselves as a separate and distinct profession, and traditionally they have practiced in isolation from other health professionals. Until the 1980s, they were forced to do so because their central art of spinal adjustment was criticized by the medical profession as potentially dangerous, ineffective, and inappropriate. However, several major developments of the past 20 years have changed all of that. One has been new research and clinical guidelines supporting the effectiveness and appropriateness of chiropractic care for patients with highly prevalent conditions such as chronic headache, neck pain, and back pain. Of equal importance is increased public dissatisfaction with traditional medical care, its overdependence on technology and drugs, and its failure to address the wider aspects of health for many ailments, especially chronic conditions. Since the 1980s patients throughout the western world have gone shopping for health, and a majority have tried one or more alternatives, such as acupuncture, chiropractic, homeopathy, and naturopathy, for various health care needs. Others in the world of health care have labeled chiropractic and these professions complementary and alternative medicine (CAM), and identified chiropractic as the leading example of a CAM discipline. This is currently proving to have at least as many advantages as disadvantages for the profession. Whatever an individual chiropractor’s response to this development may be, the chiropractor should understand the CAM classification and its ramifications for chiropractic practice now and in the future. Definitions As yet there is no agreed upon definition for CAM, a term coined in 1987 by David Reilly, MD, a Scottish physician and homeopath. Until the late 1990s, the essence of definitions in Europe and North America was “forms of treatment not commonly taught in medical schools.” This meant that CAM was a catchall term covering everything from chiropractic to crystal therapy and folk remedies. This explains why established and legally regulated disciplines, such as chiropractic and osteopathy, did not want to be labeled as CAM.

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However, the matter of definition has now advanced, and has been most thoroughly addressed so far in a British government report titled Complementary and Alternative Medicine released in December 2000.39 The Select Committee on Science and Technology of the UK House of Lords acknowledges in this report that any exact definition of CAM, a broad and heterogenous field of health care, is impossible. However, it rejects the British Medical Association’s approach of defining CAM as “forms of treatment not taught in medical and paramedical schools.” Apart from other considerations, this approach “is now unsatisfactory” because medical schools are offering familiarization courses in CAM, and use of various forms of CAM by medical doctors is growing. Support is given to the philosophical position in the “more encompassing” definition of CAM given by the Cochrane Collaboration: A broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. This definition, however, requires practical refinement. The Select Committee acknowledges that it is inappropriate to group “well-established and generally accepted CAM therapies such as osteopathy and chiropractic,” which have a substantial research base, with those that are undeveloped and have no evidence base. For this reason, the committee divides CAM into “three broad groups”: 1. Complementary and alternative. These are the “principal disciplines” of acupuncture, chiropractic, herbal medicine, homeopathy, and osteopathy, “seen as the ‘Big 5’ by most of the CAM world.” They are the most organized and regulated professions, have “an individual diagnostic approach,” and have a research base. 2. Complementary. These are therapies that “do not purport to embrace diagnostic skills” and “are most often used to complement conventional medicine.” Examples given are aromatherapy, Alexander Technique, bodywork therapies including massage, counseling, stress therapy, hypnotherapy, reflexology and shiatsu, meditation, and mind/body healing. 3. Alternative. These disciplines, like those in the first group, have an individual diagnostic and treatment approach but are “indifferent to the scientific principles of conventional medicine” and propose “various and disparate frameworks of disease

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causation.” The alternative group has two subgroups: • “Traditional systems of health care” which have been long-established, such as Ayurvedic medicine (India) and traditional Chinese medicine. • “Alternative disciplines which lack any credible evidence base,” such as crystal therapy, iridology, and radionics. Accordingly, under this British government classification, chiropractic is a group 1 form of CAM. By definition that means that it • Is based on scientific principles compatible with western medicine (unlike group 3 disciplines). • Has established a research base (unlike group 2 and group 3 disciplines). • Has its own distinct diagnostic and treatment approach (unlike group 2 therapies). • Has well-developed professional organizations (more than group 2 and group 3 disciplines). • May be complementary or alternative to medical services. For chiropractic this is a significant advance from simply being described as CAM, and represents a classification that most chiropractors will find useful if not totally acceptable. Is Chiropractic Part of CAM? The answer to this question depends upon one’s perspective. Chiropractic opinion is divided. Most others in the health care system, as evidenced by current policies of the US National Institutes of Health, the European Parliament in its adoption of the 1997 Lannoye Report,40 and the World Health Organization in its current strategies on traditional medicine and CAM,41 clearly see chiropractic as part of CAM. Arguments that chiropractic services are not CAM, but rather part of mainstream and core health care services, are that they are based upon the same anatomical, physiological, and scientific principles of western medicine, employ treatment methods with proven efficacy, and with respect to patients with back pain—who comprise the majority of chiropractic practice—are services that represent a first line of treatment recommended by evidence-based national clinical guidelines in many countries including the United Kingdom31 and the United States.32 Arguments that chiropractic is CAM flow from the traditional paradigm of chiropractic care, which is different from medical practice in that the underlying focus is upon vitalism, healing from within and influencing general health through the correction of subluxation/spinal dysfunction to restore the normal

regulatory functions of the nervous system. Spinal adjustment or manipulation to relieve back pain and restore joint and muscle function is now mainstream, but the same treatment methods to empower the body to regulate visceral functions such as respiration and digestion, and to improve overall health and wellness, are CAM. The Benefits and Disadvantages of Classification as CAM Overall, and against all expectations within the chiropractic profession a decade ago, the classification of chiropractic as CAM is proving helpful to the profession at this stage in its history. Seen as the leading force in CAM, chiropractic is getting much greater government, legislative, media, and research attention than it could have achieved on its own. Examples of this include the following: 1. In the United States, it has been the formation of the National Center for Complementary and Alternative Medicine at the National Institutes of Health (NIH) that led to significant research funding for the profession, to federal funding for the Consortial Center for Chiropractic Research based at Palmer College in Davenport, Iowa, and to the first federal employment of a chiropractor at the NIH. 2. In Europe, it is the European Parliament’s 1997 adoption of the Lannoye Report on CAM that has led to legislation recognizing the chiropractic profession in Belgium (1999) and France (2001), and that will finally bring the same legal recognition in Italy, Portugal, Spain, and throughout Europe. 3. There have been recent national surveys on the use of CAM in Australia and New Zealand, Canada, the United States, most European countries, and Israel. All identify high use of and satisfaction with chiropractic services—little or none of this data and resulting media comment on chiropractic would have existed without CAM. 4. The rise of CAM has now brought endorsement of chiropractic by the World Health Organization, the United Nations’ influential agency governing health and health care policy in all countries and world regions. Because of the extensive use of traditional medicine (e.g., Chinese, Indian Ayurvedic, Arabic Unani, African herbal/animal/spiritual medicine) in the developing world, and now CAM in the developed world, in May 2002, WHO launched its first-ever global strategy for traditional medicine/CAM.41 This strategy calls for national policies in all countries to support education and research and integration into health care of the major relevant disciplines within traditional medicine/CAM. Within

INTERNATIONAL STATUS, STANDARDS, AND EDUCATION OF THE CHIROPRACTIC PROFESSION

this strategy, WHO is identifying chiropractic as a primary example of a now developed and established CAM discipline. 5. Importantly, CAM provides a secure environment in which to discuss somatovisceral responses to chiropractic treatment, and to promote research in that area. In a world where there is new acknowledgment that traditional Chinese medicine, Ayurvedic medicine, healing touch, spiritual healing, and relaxation therapy are methods of promoting the natural healing powers of the body and influencing many disease processes, chiropractors can discuss all spine-related disorders more freely. However, these benefits must be weighed against disadvantages. At the same time as CAM brings more overall awareness, recognition, and research opportunities for the chiropractic profession, it positions chiropractic as outside mainstream health care services. This means that those responsible for third-party funding for health services, whether in government programs, managed care organizations, or employer health plans, tend to view chiropractic care as an optional extra rather than a core service. Chiropractic education and practice have become most fully funded and integrated into the health care system where the profession has united to promote a mainstream identity rather than a CAM identity, as for example in Canada, Denmark, Norway, and the United Kingdom. CAM Utilization The use of CAM grew significantly throughout the Western world in the 1990s. In the United States, total annual visits for CAM increased by 47%, to 629 million visits, between 1990 and 1997. This exceeded total visits to all US primary care medical physicians by 243 million.42 Chiropractic was the single most used form of CAM, being used by 11–16% of the adult population.42 There is similar data from Canada, Europe, Australia, and New Zealand. Health care experts accept that this is a permanent change in the health care system, and not a passing fad. Extensive research in Europe and North America shows that CAM patients are a normal cross-section of the population shopping for health. In North America, a small number of patients distrust and reject the conventional medical system and therefore place their primary reliance on CAM including chiropractic—about 4.4% of CAM users or 2% of the total population—but the great majority want integrated care.43 They tend to use the medical profession for acute infections, cancer, and broken bones, chiropractic and acupuncture for back pain and headache, and homeopathy for allergies.

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By 1997, 60% of US medical schools had courses introducing students to CAM, including chiropractic, and the figure will now be much higher. There is a similar trend in Europe. For example, at the School of Medicine, University of Southampton, England, all students have a 1-day clinical attachment to a chiropractor or visit a chiropractic college as part of their CAM study module. Significance for Chiropractic The significance for chiropractic is that the profession and its practice are no longer isolated in the health care system. Chiropractors must understand how they are viewed by others. Only then will they understand how best to integrate their practices with those of other providers. If the chiropractic profession is to evolve to its full potential, generally and in the practices of individual chiropractors, it must respond to the now clear public expectation of integrated care. ACCEPTANCE AND UTILIZATION OF CHIROPRACTIC SERVICES Public Acceptance Wherever the chiropractic profession has become established, general public surveys have reported high levels of acceptance of chiropractic. A 1969 Gallup Poll in Denmark showed that 81% of the adult population wanted chiropractors to be recognized by law and funded through the national health plan on a similar basis to medical doctors and dentists,44 which is now the case. A number of surveys in Australia, the United States, and Canada since the 1980s report that approximately 3 of 4 individuals responding to independent random telephone surveys agree that chiropractors have an important place in the total health system and that chiropractic services should be covered by health insurance; this support comes from a substantial majority of those who have never visited a chiropractor.45 Utilization of Chiropractic Services In the United States, the percentage of the adult population using chiropractic services each year doubled from 5% to 10% between 1970 and 1990. In addition, even though access has become more difficult for many Americans because of restrictive policies in HMOs and other managed care organizations, national surveys in 1997 by Eisenberg from Harvard42 and Astin from Stanford43 report that 11–16% of adult Americans now consult a chiropractor annually. The exact rate varies by state, and significant factors include the number of chiropractors in practice, as well as levels of third-party reimbursement coverage.

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Continued growth in utilization rates can be anticipated for reasons that include the following: 1. The growth in number of chiropractors. 2. The dramatic increase in public demand for and use of complementary and alternative therapies. 3. The increased integration of chiropractic and medical services now that medical physicians have accepted that chiropractors have a valuable role in the management of back pain and other spinerelated disorders. In Canada, the picture is the same. In 1994– 1995, a national population health survey by Statistics Canada46 reported that 11% of Canadians aged 15 years and older consulted a chiropractor during the previous 12 months, varying from 17% in the western and prairie provinces to approximately 3% in Atlantic Canada, where there are fewer chiropractors and provincial government health plans do not include coverage for the cost of chiropractic services. Studies from Australia, Canada, Europe, and the United States show that chiropractic patients are generally representative of the whole adult population and come from all socioeconomic groups. Children are the one group that is underrepresented. There is a trend to overrepresent patients from higher education and income groups. Satisfaction Rates and Cost Sensitivity All health care professions, and those who manage or pay for health care services, are now aware that patient satisfaction is an important measure or “outcome” in health care. Satisfaction surveys have consistently shown high satisfaction rates amongst chiropractic patients. Cherkin and McCornack studied 457 back pain patients at a Washington HMO who had visited either family physicians or chiropractors. They found that the percentage of chiropractic patients who were “very satisfied” with the care they received for low-back pain was three times that of patients of family physicians (66% vs. 22%), and that common reasons for higher satisfaction included more information received about the back problems, the amount of time chiropractors spent listening to patients’ description of pain, the chiropractor’s acceptance that the pain was real, and confidence in both diagnosis and effectiveness of treatment.47 Despite this high level of satisfaction, utilization rates for chiropractic services are very sensitive to cost, much more so than general medical and dental care. In the United States, Shekelle et al. have shown that where the patient copayment is 25% of the fee or greater, utilization of chiropractic services falls by approximately 50%. When patients have similar

copayments for chiropractic and medical care, and are then given free medical care, utilization of fee-forservice chiropractic care falls by 80%.48 The same point is demonstrated by a UK study of 11 general medical practices in the Southwestern region of Wiltshire.49 Following the 1994 UK back pain guidelines recommending skilled manipulation as a primary approach to treatment, the Wiltshire Health Authority provided funding for “manipulation services” in a pilot project to see if general medical practitioners (GPs) would then follow the guidelines. With this funding, there was a major shift in medical referral patterns. From July to October 1995, without funding, GPs referred only 2% of their back pain patients for manipulation (2% to chiropractors, 0% to osteopaths), while from November 1995 to March 1996, with funding available, 53% of back pain patients were referred (28% to chiropractors, 25% to osteopaths). Referrals for physical therapy services, funded during both periods, went down from 72% to 21%. Recorded benefits included fewer referrals to secondary care, less drug use, and fewer certified sickness days. The key to all of this was the availability of funding. Medical Attitudes In the twentieth century, there was a history of competition and dispute between the chiropractic and medical professions, first broken in America by the watershed judgment in the case of Wilk vs. The American Medical Association in 1987. Today, there are rapidly growing integration of chiropractic and medical services and mutual respect. This is illustrated in the following 1998 comments from Marc Micozzi, MD, PhD, of the College of Physicians of Philadelphia50 : The Agency for Health Care Policy and Research (AHCPR) recently made history when it concluded that spinal manipulative therapy is the most effective and cost-effective treatment for acute low-back pain. . . . One might conclude that for acute low-back pain not caused by fracture, tumor, infection, or the cauda equina syndrome, spinal manipulation is the treatment of choice. Because acute low-back pain is the most prevalent ailment and most frequent cause of disability for persons younger than 45 years of age in the United States, adherence to these practice guidelines could substantially increase the numbers of patients referred for spinal manipulation. Chiropractors provide 94% of spinal manipulation. As physicians are becoming increasingly willing and able to justify referral for complementary care . . . we must foster the

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FIGURE 6–4. At the Texas Back Institute in Dallas, which offers a full range of conservative and surgical treatments in one of the most sophisticated back-care facilities in the United States, Dr. John Triano, one of the staff chiropractors, presents a case to staff physicians, surgeons, and physical therapists during the regular interdisciplinary review of interesting cases on weekend rounds. (Reproduced with permission from Chapman-Smith D. The chiropractic profession. Des Moines, IA: NCMIC Group, 2000:139.)

development of training, research and clinical protocols to support integration . . . in a way that promotes favorable clinical outcomes. Alternative medicine can benefit from the kind of support from which mainstream medicine has benefited over the years. When all is said and done, what works will no longer be called mainstream or complementary—it will just be called good medicine. These words, from an eminent US physician published in the official journal of the American College of Physicians, the Annals of Internal Medicine, illustrate the major change that has occurred. The comments appear in an editorial regarding a study on the appropriateness of chiropractic care appearing in the same issue of the Annals. Today there are chiropractors on staff at the Asaf Harofeh Hospital in Tel Aviv, Israel, the Kimberly Hospital in South Africa, the university hospitals in Bergen and Oslo, Norway, the Copenhagen University Hospital in Denmark, and in hospitals and multidisciplinary clinics throughout North America. Many chiropractic offices are located in health centers with other primary care providers (Fig. 6–4). Significant barriers to the full integration of chiropractic and medical services remain, but these are no longer the attitudes of individual medical doctors in practice, education, and research. Instead, they are barriers erected by medical associations, which, like chiropractic associations, are trade organizations whose fundamental mission is to protect their profession and the economic interests of their members. These associations typically work with

government and private third-party payors and managed care organizations to restrict funding for, and therefore access to, chiropractic services. For example, medical groups, working with members and allies in the US Department of Health and Human Services and Blue Cross/Blue Shield, have brought about a situation in which chiropractic services under the federal government’s Medicare program have primarily been delivered in recent years by physical therapists, medical doctors, and doctors of osteopathy. This situation gave rise to the pending lawsuit between the American Chiropractic Association and the Department of Health and Human Services. A refreshing example of cooperation is found in the United Kingdom where the British Medical Association has been openly supportive of the development and regulation of chiropractic services since the 1993 publication of its study of complementary medicine on the grounds that chiropractic is an established discipline and many British Medical Association members wish to refer patients for chiropractic care.51 There is also cooperation at the international level, where principle seems to triumph over practical politics more easily. The World Federation of Neurology, the World Federation of Public Health Associations, and the International Council of Nurses all actively supported the World Federation of Chiropractic during its 1997 admission into official relations with the World Health Organization and its affiliate, the Council of International Organisations of Medical Services (CIOMS). The World Federation of Neurology observed in its letter of support that “the relationship between the medical and

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chiropractic professions worldwide has become increasingly one of mutual respect and collaboration.”52 FUTURE DIRECTIONS The path to full integration of chiropractic services into mainstream health care remains a controversial issue both within and outside the chiropractic profession. Outside expert commentators have offered consistent advice. In 1979, a New Zealand Commission of Inquiry into Chiropractic, which looked at the profession more thoroughly than any independent investigation before or since, found that “chiropractic is a branch of the healing arts specializing in the correction by spinal manual therapy of what chiropractors identify as biomechanical disorders of the spinal column. They carry out spinal diagnosis and therapy at a sophisticated and refined level.”4 The Commission concluded that “chiropractors do not provide an alternative comprehensive system of health care, and should not hold themselves out as doing so,” that “the responsibility for spinal manual therapy training . . . should lie with the chiropractic profession,” and that “in the public interest and in the interests of patients there must be no impediment to full professional cooperation between chiropractors and medical practitioners.” Chiropractic, said the Commission, should be seen as an important specialized branch of mainstream health care services. In the following year, writing about the future role of chiropractors in the first edition of this text, the eminent sociologist Walter Wardwell, PhD, saw three possible futures for the profession: (a) practice on medical referral, which he thought unlikely, (b) continuation of the alternative parallel status to medicine that chiropractic had at that time, or (c) a more defined, limited primary contact status similar to dentists, optometrists, podiatrists, and psychologists. As a long-time patient and observer of the profession he considered the latter, based upon the conservative management of neuromusculoskeletal disorders without the use of drugs or surgery, the best. Patients have delivered the same message. Surveys consistently show that the great majority of chiropractic patients have neuromusculoskeletal disorders, principally back pain, neck pain, and chronic headaches. “These conditions are the kinds that the public believes that chiropractors can treat best,” says Wardwell, and if the profession emphasized this identity, “medical opposition should cease, the public’s image of chiropractors should improve, payments for services rendered should be more readily made, the number of referrals to chiropractors by other types of practitioners should increase, and chiropractors should gain an even more secure place in the American health care system.” However, Wardwell

acknowledged that the future really depended upon what chiropractors themselves wanted. Almost 20 years later, in 1998, the Institute of Alternative Futures (IAF) agreed. The IAF was commissioned by the NCMIC Group, which provides professional liability, managed care, and other services to the chiropractic profession, to provide expert reports first, on the future of chiropractic, and second, on the future of complementary and alternative approaches to health in the United States. The IAF identified three major priorities for the chiropractic profession: 1. To define its role in the rapidly changing health care system. Are chiropractors spinal specialists, primary care providers, partners with medicine in mainstream health care, or holistic practitioners’ alternative to and separate from the medical profession? The profession lacked a clear role in health care said the IAF, and a serious coordinated effort from the grassroots up was necessary to correct the problem. Without a clear and agreed upon role, and a shared vision, the profession would decline and suffer greatly in the near future because of new competitive pressures. 2. To collect convincing data and practice statistics from clinical practice. Currently such data only existed for the management of patients with back pain, and to a lesser degree those with neck pain and headache. There now needed to be a similar effort in all significant areas of chiropractic practice, including preventive care and health promotion. 3. To develop the skills and capacities to work in many different health care environments. Major changes lay ahead for everyone and the ability to be creative and integrate in various delivery systems would be key to the survival and growth of the profession. The IAF described four possible scenarios for the US chiropractic profession in 2010, which are summarized in Table 6–5. In scenario 1, excellent new outcomes data proves that chiropractic care is cost-effective and these services become available in back centers, with greatly increased demand matching an increased supply. In scenario 2, the profession has no shared vision or good data beyond low-back pain and has little room for growth. This results in a number of chiropractic colleges closing, and the proportion of spinal manipulation in the United States delivered by chiropractors dropping from 90% to 50%. In summary, the IAF’s reports are optimistic if the chiropractic profession can adapt to the challenges of the era, but sobering if it cannot. The future of chiropractic as a healing profession “will be shaped

INTERNATIONAL STATUS, STANDARDS, AND EDUCATION OF THE CHIROPRACTIC PROFESSION TABLE 6–5.

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Overview of Four Scenarios for Chiropractic in 2010

Scenario 1: More and Better Health Care Managed care, outcomes, and consumers drive health care. Chiropractic care is proven cost-effective for low-back pain, headaches, neck pain, arthritis, scoliosis, asthma, and repetitive stress injuries, and as suplementary therapy for cancer and other conditions where the disease or treatment involves significant pain. Wal-Mart creates ”The Back Center” in its stores and expands access to low-cost chiropractic care. There are 103,000 chiropractors, with average visits per week holding at about 120, with back conditions representing 50% of visits and wellness another 20%. Underemployment among chiropractors holds at about 15%, Scenario 2: Hard Times, Frugal Health Care Chiropractic is drastically affected by frugal universal coverage through managed care; outcomes limit manipulation to back problems. Meanwhile, 50% of spinal manipulation is delivered by physicians, nurses, and other health professionals. Chiropractic colleges close as only 68,000 chiropractors are needed in 2010. Many of those still practicing are forced to sell “the $10 treatment.” Wellness visits decline and underemployment grows to 35%. Scenario 3: Self-Care Rules Very effective self-care, including advanced home health systems and universal catastrophic coverage, make health care a buyer’s market. Individuals and families can do most of their care very effectively at home, lowering the need for all types of providers. Surplus providers exceed the 450,000 number forecast in the 1990s by the Pew Commission. Health care professionals who provide ”touch” are in high demand but competition is fierce. Chiropractors are able to increase demand significantly by ensuring they provide care to 60% of those Americans with back problems (rather than 40% as in the 1990s). Chiropractors also expand the indications they can treat with proven efficacy as well as provide evidence that for many people wellness visits are appropriate. The success of chiropractors leads to 85,000 chiropractors in 2010 (about 20,000 fewer than anticipated in 1997), but they are doing well. Scenario 4: The Transformation Chiropractors’ clarified and expanded vision for the profession leads them to expand their contribution to health outcomes for their patients and their communities. Wellness and self-healing through enabling the body to function effectively (the innate healing force) becomes a much-sought-after contribution of chiropractors through manipulation—so sought-after that 50% of manipulation in 2010 is performed by nonchiropractors. Chiropractors broaden what they do with and for their patients and their communities. For their patients, they combine intelligent information systems with high touch and assertive coaching. From Institute for Alternative Futures. Future of complementary and alternative approaches (CAAs) in US health care [unpublished monograph]. Alexandria, VA: Author, 1998.

by a host of forces” but the greatest of these is “the identity and creativity of chiropractors. . . . [T]he future of chiropractic is in the hands of chiropractors themselves.”53 SUMMARY 1. In the early twentieth century, students came to the United States from Australia, New Zealand, Europe, Japan, and South Africa, and then returned to commence the development of the profession in their countries. Today there are approximately 100,000 chiropractors in more than 80 countries, and many new schools of chiropractic. Since 1999 there have been more chiropractic schools established outside the United States than within. Chiropractic legislation exists in all world regions, and it is predicted that by 2010 there will be 150,000 chiropractors, with 50,000 of them practicing outside the United States. 2. The World Federation of Chiropractic (WFC) is the largest and most widely recognized of the

international chiropractic organizations. Founded in 1988 and having its offices in Toronto, Canada, the WFC’s voting membership consists of 78 national associations of chiropractors. The WFC has become the profession’s primary forum for developing a consistent basis for chiropractic principles, laws, scope of practice, and education in all world regions. Other prominent organizations include the F´ed´eration Internationale de Chiropratique Sportive (FICS), the Foundation for Chiropractic Education and Research (FCER), and the Council on Chiropractic Education International (CCEI). 3. There is now legislation to recognize and regulate the profession in Africa (Namibia, Nigeria, South Africa, and Zimbabwe), the Asia-Pacific region (Australia, Hong Kong–Peoples Republic of China, and New Zealand), the eastern Mediterranean (Cyprus, Iran, and Saudi Arabia), Europe (Belgium, Denmark, Finland, France, Norway, Sweden, Switzerland, and the United Kingdom), Latin America (Mexico and Panama),

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5.

6.

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and North America (Canada and the United States). In all instances, legislation authorizes primary practice with the right and duty to diagnose, including the right to provide or order diagnostic imaging. In North America, there is a minimum requirement of 7 years of university-level training. All aspects of education must meet official accreditation standards, and a graduate must also complete state/provincial and national licensing board examinations before gaining the right to practice. Independent government and medical studies in the United States,2 Sweden,3 and New Zealand4 have concluded that chiropractic education is the equivalent of medical education in all of the basic sciences. The scientific literature base, and the research upon which it is founded, has been vital to the continued growth and status of the chiropractic profession. There has been a dramatic growth in the number of chiropractic scientists worldwide with doctoral degrees in the clinical and basic sciences and, from them and others, the development of a mature chiropractic scientific literature base. The primary scientific databases relevant to chiropractic research include MANTIS (Manual, Alternative, and Natural Therapy Index System); the Index to Chiropractic Literature (ICL) published by the Chiropractic Library Consortium (CLIBCON); the Cumulative Index to Nursing and Allied Health Literature (CINAHL), which indexes over 1200 nursing, allied health, and health sciences journals, including chiropractic journals, from 1982; Alt Health Watch; and the Allied and Complementary Medicine Database (AMED) compiled by the British Library Health Care Information Service. Arguments that chiropractic services are not complementary or alternative, but rather part of mainstream and core health care services, are that they are based upon the same anatomical, physiological, and scientific principles of Western medicine, and employ treatment methods with proven efficacy, at least with respect to patients with back pain. Arguments that chiropractic is a CAM treatment flow from the traditional paradigm of chiropractic care, which is different from medical practice in that the underlying focus is upon vitalism, healing from within and influencing general health through the correction of subluxation/ spinal dysfunction to restore the normal regulatory functions of the nervous system. The future role of chiropractic is uncertain and its identity internationally as yet not well defined. Chiropractic has been described as a profession that stands “at the crossroads of mainstream and alternative medicine.” Chiropractors must agree

upon and establish a much clearer identity in the health care system if their profession is to thrive and realize its exciting potential. QUESTIONS 1. What is the Association of Chiropractic Colleges’ Paradigm of Chiropractic? Why was it adopted by the World Federation of Chiropractic? What is its current significance? 2. Describe and illustrate the roles of chiropractic professional associations at the state/provincial level, the national level, and the international level. 3. A 1997 US government report concluded that “in the past several decades chiropractic has undergone a remarkable transformation. . . . [I]n the areas of training, practice, and research, chiropractic has emerged from the periphery of the healthcare system and is playing an increasingly important role in discussion of healthcare policy.” Discuss. 4. During the past 20 years others in the health care system have labeled chiropractic as a major discipline within complementary and alternative medicine (CAM). Discuss the advantages and disadvantages of this, and give your opinion on whether it has been beneficial for the profession. 5. Why is a clear professional identity important for the future of the chiropractic profession? What choices of identity are open to the profession? What do you think the profession’s identity should be? Give reasons for your opinions.

ANSWERS 1. The ACC Paradigm of Chiropractic is a series of statements describing the nature of chiropractic and its professional attributes. It was adopted by the ACA, the ICA, and the World Federation of Chiropractic, making it one of the foundation documents by which the professional organizations can agree to pursue common goals and objectives. Its significance for the WFC is that it provides a consistent basis upon which to develop the profession in countries that have not yet established chiropractic. 2. Each professional association deals with health industry issues, regulations, and legislation at its own level. In the United States, each state maintains its own chiropractic law, and there are many inconsistencies from state to state, necessitating a variety of approaches across states to support the profession. At the national level, the associations take on larger roles related to national legislation, legal issues that have broad impact, and issues

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related to public relations and image building. The same is true with international organizations, but they tend to provide assistance and information across international borders. 3. Until the latter part of the twentieth century, the presence of chiropractic in scientific and policy circles was relatively unseen. However, chiropractic educational institutions have significantly upgraded their programs and the profession has initiated a number of scientific efforts that culminated, in the 1990s, with the advent of the first significant federal funding for research in the profession’s history. Today, many textbooks and scientific journals are being produced by the profession, and these have had significant impact on old medical attitudes. The profession has tackled the challenge of practice guideline development, leading to the inclusion of chiropractic in many arenas in the health industry. Collaboration and cooperation between chiropractors and other health professionals have grown steadily. 4. In the 1990s, the CAM label was developed and applied to a wide variety of health care practices that did not seem to fit within the standard, Westernized biomedical paradigm. As the largest and most successful of these professions, chiropractic has been touted as a model of CAM professional development. Generally, CAM professions and procedures have been seen as “unscientific,” even when there is solid factual evidence of utility for some procedures (as is the case with spinal manipulation). The advantage of being included in CAM is that chiropractic has been able to capitalize on scientific funding opportunities and increase its share of influence in CAM communities. The disadvantage is that the CAM label still positions chiropractic outside the mainstream of health care, even though chiropractic has arguably become a mainstream practice in many countries. 5. A clear professional identity is important to be able to define and market chiropractic services and benefits to the public. It is also important to help focus the resources and energies of the profession to sustain its development in an efficient way. It is also important to be able to communicate effectively and work with other health professions. There are many identity choices, but the two major directions are to integrate more fully with the rest of the health care industry or to remain as more independent (and perhaps more isolated) health care practitioners. Arguments will continue about whether chiropractors should and can be spinal specialists, primary care providers focusing on the neuromusculoskeletal system, or alternative providers. Regardless of choice, the profession will need to come to a consensus on direction, collect convincing data

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to support the position, and develop the skills and capacities to work in a variety of health care environments. KEY REFERENCES Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical practice guideline no. 14. AHCPR Publication No. 95–0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, 1994. Chapman-Smith DA. Legislative approaches to the regulation of the chiropractic profession. J Can Chiropr Assoc 1996;40:108–114. Chapman-Smith DA. The Chiropractic Profession, Chap. 9. West Des Moines, IA: NCMIC Group, 2000.

REFERENCES 1. Bigos SJ, Bowyer OR, Braen GR, Brown K, et al. Acute low back problems in adults. Rockville, MD: AHCPR, 1997 Feb. AHCPR Publication No. 97-N012. 2. Cherkin DC, Mootz RD, eds. Chiropractic in the United States: Training, practice and research. AHCPR Publication No. 98-N002. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, 1997. 3. Commission on Alternative Medicine, Social Departementete. Legitimization for Vissa Kiropraktorer [English summary]. Stockholm, Sweden: 1987: 12–13–16. 4. Hasselberg PD. Chiropractic in New Zealand, report of the commission of inquiry. Wellington, New Zealand: Government Printer, 1979;130–131, 198. 5. Jackson R. Foreword. In: Foreman SM, Croft CA. Whiplash injuries: The cervical acceleration/deceleration syndrome. Baltimore, MD: Williams and Wilkins, 1988. 6. Yochum TR, Rowe LJ. Essentials of skeletal radiology. Baltimore, MD: Williams and Wilkins, 1996. 7. Book review. N Engl J Med 1996;334:1675. 8. Marchiori DM. Clinical imaging with skeletal, chest and abdomen pattern differentials. St. Louis, MO: Mosby, 1999. 9. Stude DE. Spinal rehabilitation. Stamford, CT: Appleton and Lange, 1999. 10. Bergmann T, Peterson D, Lawrence D. Chiropractic technique: Principles and procedures. New York: Churchill Livingstone, 1993. 11. Byfield D. Chiropractic manipulative skills. Oxford: Butterworth-Heinemann, 1996. 12. Bergmann TF, Davis PT. Mechanically assisted manual techniques: Distraction procedures. St. Louis, MO: Mosby Yearbook, 1998. 13. Hammer WI. Functional soft-tissue examination and treatment by manual methods: New perspectives, 2nd ed. Gaithersburg, MD: Aspen, 1999. 14. Liebenson C, ed. Rehabilitation of the spine: A practitioner’s manual. Baltimore, MD: Williams and Wilkins, 1996. 15. Murphy DR. Conservative management of cervical spine syndromes. New York: McGraw-Hill, 1999.

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16. Vernon H. The cranio-cervical syndrome: Mechanisms, assessment and treatment. Oxford: ButterworthHeinemann, 2001. 17. Lawrence DH, ed. Fundamentals of chiropractic diagnosis and management. Baltimore, MD: Williams and Wilkins, 1991. 18. Souza TA. Differential diagnosis for the chiropractor: Protocols and algorithms. Gaithersburg, MD: Aspen, 1997. 19. Cramer GD, Darby SA. Basic and clinical anatomy of the spine, spinal cord and CNS. St. Louis, MO: Mosby Yearbook, 1995. 20. Giles LGF, Singer KP, eds. Clinical anatomy and management of low-back pain. Oxford: Butterworth-Heinemann, 1997. 21. Vernon H. Upper cervical syndrome: Chiropractic diagnosis and treatment. Baltimore, MD: Williams and Wilkins, 1998. 22. Curl DD, ed. Chiropractic approach to head pain. Baltimore, MD: Williams and Wilkins, 1994. 23. Anrig C, Plaugher G. Pediatric chiropractic. Baltimore, MD: Williams and Wilkins, 1997. 24. Davies NJ. Chiropractic pediatrics: A clinical handbook. New York: Churchill Livingstone, 2000. 25. Masarsky CS. Somatovisceral aspects of chiropractic: An evidence-based approach. Philadelphia: Churchill Livingstone, 2001. 26. Souza TA, ed. Sports injuries of the shoulder: Conservative management. New York: Churchill Livingstone, 1994. 27. Hyde TE, Gengenbach M, eds. Conservative management of sports injuries. Baltimore, MD: Williams and Wilkins, 1997. 28. Kirkaldy-Willis WH, ed. Managing low-back pain, 3rd ed. New York: Churchill Livingstone, 1992. 29. Haldeman S, Chapman-Smith D, Petersen DM, eds. Guidelines for chiropractic quality assurance and practice parameters: Proceedings of the Mercy Center Consensus Conference. Gaithersburg, MD: Aspen Publishers, 1993. 30. Henderson DJ, Chapman-Smith DA, Mior S, Vernon H, eds. Clinical guidelines for chiropractic practice in Canada. J Can Chiropr Assoc 1994;38(1 suppl). 31. Waddell G, Feder G, et al. Low-back pain evidence review. London: Royal College of General Practitioners, 1996. 32. Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical practice guideline no. 14. AHCPR Publication No. 95–0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, 1994. 33. Manniche C, et al. Low-back pain: Frequency management and prevention from an HDA perspective. Danish Health Technology Assessment 1999;1(1). 34. Accident Rehabilitation and Compensation Insurance Corporation of New Zealand and the National Health Committee. New Zealand acute low-back pain guide, and guide to assessing psychosocial yellow flags in acute low-back pain. Wellington, New Zealand: Authors, 1997.

35. Redwood D. Chiropractic. In: McClosky MS, ed. Fundamentals of complementary and alternative medicine, Chap. 7. New York: Churchill Livingstone, 1996. 36. Spitzer WO, Skovron ML, et al. Scientific monograph of the Quebec task force on whiplash-associated disorders: Redefining whiplash and its management. Spine 1995;20:8S. 37. Coulter ID, Hurwitz EL, et al. The appropriateness of manipulation and mobilization of the cervical spine. Document No. MR-781-CR. Santa Monica, CA: RAND, 1996. 38. Aker PD, Gross AR, et al. Conservative management of mechanical neck pain: Systematic overview and metaanalysis. BMJ 1996;313:1291–1296. 39. House of Lords Select Committee on Science and Technology. Complementary and alternative medicine. 6th Report. London: 2000. 40. Lannoye Paul, Report on the status of nonconventional medicine. Committee on the Environment, Public Health and Consumer Protection Complementary, European Parliament, 1997; #A4–0075/97. 41. WHO. Traditional Medicine Strategy 2002–2005, WHO, Geneva, Document WHO/EDM/TRM/2002.1. 42. Eisenberg DM, David RB, et al. Trends in alternative medicine use in the United States. JAMA 1998;280:1569–1575. 43. Astin JA. Why patients use alternative medicine: Results of a national study. JAMA 98;279:1548–53. 44. Gautvig M, Hvird A. Chiropractic in Denmark. Copenhagen: Danish Pro-Chiropractic Association, 1975. 45. Chapman-Smith DA. The chiropractic profession, Chap. 9. West Des Moines, IA: NCMIC Group, 2000. 46. Millar WJ. Use of alternative health care practitioners by Canadians. Can J Public Health 1997;155–158. 47. Cherkin DC, McCornack FA. Patient evaluations of low-back pain care from family physicians and chiropractors. West J Med 1989;150:351–355. 48. Shekelle PG, Rogers WH, Newhouse JP. The effect of cost sharing on the use of chiropractic services. Med Care 1996;34:863–872. 49. Scheurmier N, Breen AC. A pilot study of the purchase of manipulation services for acute low-back pain in the United Kingdom. J Manipulative Physiol Ther 1998;21:14–18. 50. Micozzi MS. Complementary care: When is it appropriate? Who will provide it? Ann Intern Med 1998;129:65– 66. 51. British Medical Association. Complementary medicine, new approaches to good practice. Oxford: Oxford University Press, 1993. 52. Letter dated 17 September 1996 from the World Federation of Neurology to the CIOMS. 53. Institute for Alternative Futures. Future of complementary and alternative approaches (CAAs) in US health care [unpublished monograph]. Alexandria, VA: Author, 1998.

C H A P T E R

7 INTEGRATION OF CHIROPRACTIC IN HEALTH CARE William C. Meeker and Robert D. Mootz

O U T L I N E Multidisciplinary Practice Interdisciplinary Practice Chiropractic Perspective Medical Perspective Public and Private Payor and Policy Level Basic Payor Concepts and Integration The Position of Chiropractic CHALLENGES TO INTEGRATION SUMMARY QUESTIONS ANSWERS KEY REFERENCES REFERENCES

INTRODUCTION EVOLUTION OF CHIROPRACTIC INTEGRATION: CAM AND INTEGRATIVE MEDICINE MODELS FOR INTEGRATION IN THE HEALTH SYSTEM Chiropractic Roles Patient Level Practitioner and Clinical Level A Model for Clinical Integration Parallel Practice Collaborative Practice Consultative Practice Coordinated Practice

sum of its parts. When discussing the integration of chiropractic into the health care system, one must consider what this integration means to the profession and practice of chiropractic, why it must be discussed, and what the implications could be. As will be seen, the full integration of chiropractic into the health care system is complex and answers to these questions are not clear. Chiropractic is constantly striving to attain higher levels of cultural authority, respect, and influence, not just as a matter of survival, but as a matter of professional flourishing consistent with its ideals and goals. At the same time, chiropractors have struggled mightily with fears of coaptation and loss, fearful that a stronger alliance with other health professions and structures would lead to the dilution and eventual elimination of the profession’s unique approach to health. The ambiguity of this situation and the many reasons for and against integration have led to bitter battles within the profession. An open discussion

OBJECTIVES 1. To briefly discuss complementary and alternative medicine (CAM) and integrative medicine and how chiropractic may relate to each model. 2. To describe the current position of chiropractic, discuss the three main factors of integration, and offer three potential roles for chiropractors in the health care system. 3. To define various types of integrated clinical behavior between practitioners. 4. To discuss some barriers to full health system integration for chiropractic.

INTRODUCTION Integration is defined as the act of combining something into an integral whole, with the implication that the whole functions smoothly and is greater than the 135

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of this topic will hopefully contribute to the genesis of creative solutions, both short- and long-term. This chapter illustrates a scheme of integration at three levels, each with its own attributes and interrelations. An additional model for clinical integration is also described. Throughout the following paragraphs, the position of chiropractic is defined and trends suggested by data and observation are offered. Future chiropractors will be able to use the understanding gleaned from this data to help define their own goals and roles regarding integration, and to inform the dialogue that surely must continue. EVOLUTION OF CHIROPRACTIC Other chapters in this book discuss the history of chiropractic and its struggle for survival and acceptance in a relatively hostile environment. The road to acceptance has not been smooth, yet today chiropractic is the largest, most regulated, and best recognized of the alternative health professions. Although in existence for more than a century, it is only in the past decade or two that chiropractic has been placed by many observers under the umbrella of complementary and alternative medicine (CAM).1 The definition of CAM has been very problematic and no one definition is universally accepted. The US National Center for Complementary and Alternative Medicine has defined CAM as, “health care practices outside the realm of conventional medicine, which are yet to be validated using scientific methods.”2 CAM is represented by a very diverse collection of professions with unique philosophies, traditions, procedures, professional attributes, histories, and patients.3,4 Not all chiropractors like the CAM label because of the implicit lack of research validation, which is no longer true for conditions such as low back and neck pain. Many chiropractic leaders worry about their profession being lumped together with a very heterogeneous group of diverse and highly controversial practices.5 Nevertheless, the ongoing public debate about whether and how to integrate CAM into mainstream medicine also applies to chiropractic. Chiropractic does appear to be in a different position than many CAM professions such as acupuncture, homeopathy, massage, and naturopathy by virtue of being the most widely disseminated and licensed indigenous healing system in the United States and with growing international recognition (see Chapter 6). In the past 30 years, the profession has enjoyed steadily increasing acceptance and use by the public and third-party payors.6 Walter Wardwell, a sociologist who researched chiropractic, once described it as “marginal” and “deviant.”7 In the not too distant past, chiropractors were jailed for practicing medicine

without a license, whereas today, chiropractic education is accredited by the US Department of Education and students can receive federally guaranteed loans to attend chiropractic training institutions. A paper on chiropractic written by chiropractors was recently published in the Annals of Internal Medicine, one of the most influential scientific biomedical journals in the world, making the case that chiropractic is now at the crossroads between mainstream and alternative medicine.8 The amount and quality of chiropractic research have also been growing steadily for the past 15–20 years. From the vantage point of many CAM professionals, these accomplishments place chiropractic within the mainstream health care. Yet, despite this apparent progress, some still perceive chiropractic as a controversial profession with controversial ideas and practices. Simply being identified as a CAM practice is an indication of the uncertainty that the dominant biomedical system still entertains about the validity and effectiveness of chiropractic. Critics are quick to pounce on the profession’s slow pace of scientific development regarding chiropractic theory and spinal manipulation, and some observers question the role, value, and even safety of chiropractic care.9 Chiropractors are only rarely represented in formulating health policy and have only recently been included in positions of scientific and clinical authority. For example, only one employee of the $25 billion US National Institutes of Health is a chiropractor. From the vantage point of many within the conventional medical system, chiropractic remains largely outside of the mainstream. Total integration in the health care system is a multifaceted enterprise. One way to understand the current position of chiropractic is to examine potential roles for its practitioners, and gauge the perspective of different stakeholders, such as the patient, the chiropractor, the medical profession, public and private payors, and policy makers. INTEGRATION: CAM AND INTEGRATIVE MEDICINE To understand integration better, a distinction must be made between procedures, professions, and philosophies. Adoption of new procedures and substances (e.g., drugs) into medicine is a well-known path. Although not as logical and straightforward as assumed, the ideal process follows a given sequence. That is, scientific evidence is accumulated on both the mechanism and clinical effect of a novel procedure or substance, information is disseminated in scientific journals and discussed by experts at professional meetings, and gradually (and sometimes very quickly) the new procedure or substance is adopted

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by practitioners. Rarely is this process called integration. Instead, it is called innovation. This distinction is puzzling because it seems to exclude CAM from the process. For example, when a medical physician prescribes St. John’s wort instead of Prozac for mild depression, this is referred to as integration rather than innovation. Is this because of the origin of the innovation, or is it something else? This distinction may occur when the innovation is pulled out of context from a wholly separate method of healing. For example, although a homeopathic remedy may be prescribed by a medical physician, is it fair to administer this remedy outside of the practice of homeopathy? Or more to this chapter’s point, can spinal manipulation simply be adopted by conventional medicine and declared an innovation? Perhaps, because the use of spinal manipulation is growing in other professions. However, the viewpoint of this chapter is that the concept of integration should be reserved for the appropriate union of different health practitioners and different health philosophies, and not simply the use of CAM procedures by the medical profession. The most interesting discussions regarding health system integration are now going on in the context of CAM.10,11 The term integrative medicine was coined by Ralph Snyderman and Andrew Weil to denote more than the simple use of CAM procedures by medical practitioners.12 Integrative medicine aims to restore the focus of medical practice on health and healing and to emphasize the central role of the patient–practitioner relationship and activating the body’s innate healing power. Integrative medicine promotes using both conventional medical care and adopting some CAM concepts, such as prevention, which includes all aspects of lifestyle, diet, exercise, and emotional and spiritual health. It purports to realign medical care with the patient as the focal point and encourages the use of scientifically proven CAM methods. A reason offered for the phenomenal growth of CAM is a perception that mainstream medicine has lost some of its caring and humanitarian roots. With integrative medicine, it is thought that adoption and assimilation of CAM will heal the shortcomings of modern conventional medicine by essentially giving it a new paradigm.13 Unfortunately for the CAM professions, it is clear that those who propose to take charge of integrative medicine are medical physicians.12 An alternative to this scenario is to hire CAM practitioners to work in conventional medical settings (and vice versa) under various forms of multidisciplinary and interdisciplinary practice, thus ensuring that patients receive the best of both worlds and that each system of healing is preserved and practiced by those with appropriate training.

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MODELS FOR INTEGRATION IN THE HEALTH SYSTEM To provide a context for understanding the various perspectives involved in the discussion of the integration of chiropractic into the health care system, three levels of integration are offered, each demonstrating challenges as well as opportunities. These potential levels of integration in the health system are (a) the patient level, (b) the practitioner or clinical level, and (c) the public and private payor and policy level. Each level is described below. The practitioner or clinical level is further explored using a model of interdisciplinary behavior to describe the different ways in which practitioners can interact with one another. Chiropractic Roles At least three distinct, but not mutually exclusive, roles for chiropractors have received discussion in the chiropractic literature7,14,15 : 1. As generalist primary care providers focusing on neuromusculoskeletal conditions and prevention 2. As musculoskeletal and spine specialists working in a multidisciplinary fashion 3. As generalist providers of an alternative to medical care focusing on subluxation, and/or using a variety of CAM and conventional methods Chiropractors have many of the attributes of primary care providers and often describe themselves as such.16 Others point out that chiropractic has more of the attributes of a limited medical profession, akin to dentistry or podiatry.7 This issue is a great source of debate within the profession. It has implications for educational direction and professional policy making. Furthermore, the way in which each role is viewed outside the profession influences the extent and nature of integration. Finally, what role chiropractors should or could play in the health delivery system is subject to several different perspectives within the system. Patient Level The first level to consider is the patient or health consumer. At this level, integration decisions are made by patients, and not by practitioners or third-party payors. Patients are clearly the most potent integrators in the health delivery system today. Patients decide what combination of care they need regardless of the constraints, incentives, and controls placed on health care consumption by health plans, insurance companies, and government programs. While the policies and procedures of the reimbursement system may enhance or constrain use of certain health services, some patients are still willing to find what they want and

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pay for it themselves if deemed necessary. From this point of view, market dynamics prevail and demand leads to supply. Long-time observers have noticed that modern attitudes regarding health practitioners do not include the overwhelming respect and deference once accorded them. In these times, some patients exercise their own judgment and take personal responsibility for their health. They peruse the Internet for medical information and ask for second opinions. Patients are not likely to tell their medical doctors about their consultations with CAM practitioners because they view their medical doctor as just one more member of a larger health care team, and no longer the sole provider. Users of both CAM and conventional medicine are equally confident with their practitioners.17 Chiropractic is very well integrated in the everyday health care decisions of a large number of people. Approximately 65,000 chiropractors in the United States see approximately 20 million patients per year.8 Chiropractors are used more often than any other so-called CAM provider group, at approximately 192 million patient visits per year, representing 30% of all visits to all CAM practitioners and equal to almost 50% of all visits to primary care medical physicians in the United States.18 Utilization by the public has tripled in the past two decades from approximately 3.6% in a 1980 survey19 to an estimated 11%, according to a national telephone survey in 1997.18 Musculoskeletal pain is a common and important public health problem that has not generally received much attention from traditional medical practitioners,20 and chiropractors are apparently filling this void when treating these conditions. Patients go to chiropractors overwhelmingly for musculoskeletal complaints, primarily back pain (approximately 60%) and head, neck, and extremity problems.21,22 At least one-third of all patients seeking care for low back pain first consult with a chiropractor.23–25 Patients also seek chiropractic care for general health concerns and prevention.26 Multiple studies have documented that patients are more satisfied with chiropractic care than medical care for spinal conditions.16,27–29 In summary, patients have direct access to licensed chiropractors in the United States and are willing to pay a great deal out of their own pocket to receive chiropractic care.30 Acceptance at this grassroots level is one of chiropractic’s major strengths. Practitioner and Clinical Level Integration at the practitioner level has complexities of its own, and has much to do with the way in which delivery systems are organized and financed. At this level, integration decisions are made primarily

by practitioners. Integration happens when clinical decisions include more than one practitioner in the best interest of the patient. This level is highly influenced by the attitudes of both chiropractors and medical physicians, and when these attitudes are not in alignment, integration is not likely to occur. This has been the state of affairs for much of the past century, but both medical and chiropractic practitioners seem to be willing to shift to a more cooperative mode. The ideal integration scenario at the clinical level involves mutual respect and understanding of the role of each profession in case management. A high premium is placed on strong communication and teamwork in this model of integration. A Model for Clinical Integration Ivey31 has presented a useful model to describe the variety of collaborative relationships and behaviors that can exist among health care practitioners in clinical settings. It ranges on a continuum from individual “parallel practice” to the formalized “interdisciplinary health care team” (Fig. 7–1). Generally speaking, as the complexity of a patient’s problem increases, so does the need for collaboration with other health practitioners. Additional knowledge, skills, and experience brought by other practitioners, both conventional and CAM, are often necessary to provide the best possible care for a patient. However, as collaboration and the need for team-like behavior increases, professional autonomy decreases. While developed to help train allied health professionals in multiprofessional settings, Ivey’s model can also apply to various forms of chiropractic clinical integration. Parallel practice is the traditional and most common form of health care practice, and characterizes most of chiropractic practice today. In this model, each practitioner is an autonomous decision maker, managing the majority of patients without a great deal of input or communication from a professional colleague or organization. Each practice operates in parallel with similar practices, with little collaboration most of the time. Each practitioner has a

Parallel Practice

Professional autonomy decreases Shared expertise increases Parallel Practice

Consultation

Collaboration

Multidisciplinary Practice

Coordination

Interdisciplinary Health Care Team

FIGURE 7–1. A model demonstrating a continuum of relationships among practitioners that helps define integration at the clinical decision-making level.

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clearly defined role, at least as perceived by the public, and patients choose their own providers. In this model, practitioners rarely share their expertise with one another and in fact compete with each other for patients in the marketplace. When parallel practice prevails, patients integrate their own health care, and may not even tell their doctors about other professionals they may be seeing, even when receiving care by multiple practitioners for the same condition.17

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that all practitioner-to-practitioner and practitionerto-patient decisions and communications take place in a prescribed, timely, and documented fashion (although informal discussions are common, too). This type of practice is generally expensive and complicated, and is generally only seen in large tertiary care settings dealing with the most difficult and chronic cases. The term multidisciplinary is often used loosely to refer to any kind of collaboration between members of two or more health professions. It is also often used interchangeably with interdisciplinary, but these two concepts are different. Formal multidisciplinary practice involves all levels of collaboration, consultation, and coordination, and is usually managed by a leader, most often a medical physician. Members of multidisciplinary teams do not necessarily meet together. Instead, patients are referred serially from one specialist to another all of whom report to the leader who makes most case-management decisions and has ultimate authority for the care. In multidisciplinary settings, clinical integration requires that clinical care pathways and triage protocols be developed. Assigned roles are affected by business realities, competition, personalities, and staff availability. Which practitioner a patient sees is usually based on scientific evidence, patient preference, provider expertise, and provider desire. As a result, there are many forms of multidisciplinary practices in existence today.

Multidisciplinary Practice

Collaborative practice is initiated when a health practitioner recognizes the need to seek additional expertise. This behavior is mainly characterized by making a patient referral to a colleague, often a specialist. Patient referrals can be made on a formal or informal basis, and may or may not require some kind of reciprocal documentation. However, proper referral protocol generally requires the sharing of patient information and case management plans.32 The decision to collaborate is generally taken case-by-case and leaves a great deal of professional autonomy intact. Additionally, practitioners may call on their colleagues to give advice, but retain primary decision-making authority. For example, a chiropractor may refer a patient to a medical radiologist for magnetic resonance imaging (MRI), but the chiropractor will retain the patient’s case management. Integration at this level begins to be driven by health care practitioners rather than patients, although patients often have a say in the referral decision. Although at times there is concern about the potential for selfinterest in this process, especially when there is a financial association between practitioners, when done for appropriate clinical reasons, the patient is better served by this integrative behavior.

Collaborative Practice

Consultative practice is a higher order of collaboration in which two or more health professionals work together in a more extensive and ongoing fashion relative to the care of a patient. Consultation involves the giving and taking of expert advice in a collegial and professional manner. The relationship can also be formal or informal. In this model, practitioners respect an agreed-upon division of expertise and work as a team. Practically speaking, this kind of clinical behavior is most often found in multiprofessional settings where complex and chronic cases are routine. The integration of health care professionals and procedures is primarily driven by practitioners at this level and rarely by patients.

Consultative Practice

Coordinated practice consists of a more formalized system of consultation and decision making and often includes a management function (e.g., a case manager). The case manager (or case coordinator) is responsible for ensuring

Coordinated Practice

True interdisciplinary practice is rare. It involves a very high level of all forms of collaboration, consultation, and coordination, and is especially characterized by the development of a consensus about what to do, usually via group meetings. Care pathways and treatment algorithms are explicit and formal. A very high value is placed on mutual goals, teamwork, and mutual respect. Shared expertise is maximized while individual professional autonomy is minimized. Activities around case management are organized, logical, and efficient.

Interdisciplinary Practice

As a group, chiropractors are torn between wanting to be a more integral part of the health delivery team and being afraid of the implications of such integration. A history of unfair medical ostracism and persecution has made chiropractors extremely protective of their independence and autonomy. Until 1980, the American Medical Association maintained that it was unethical for a medical physician to associate or refer to a chiropractor. As a result, chiropractors successfully developed loyal patient bases outside of conventional health care circles, and played a primary care role for some of

Chiropractic Perspective

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their patients. Referral and other forms of collaboration were, until recently, relatively rare. In relationship to medical practitioners and even fellow chiropractors, parallel practice prevailed. On the other hand, largely as a result of changing medical attitudes, a significant number of chiropractors now enjoy practices that are increasingly based on medical referrals; an additional number of chiropractors are working in multidisciplinary settings.33,34 Astin,35 in a recent summary of other surveys, indicated that chiropractic was one of the most accepted forms of complementary and alternative medicine. Gordon,36 in a survey of medical physicians in a large HMO, found that a majority wanted chiropractic to be available to their patients. Patient referrals between chiropractors and medical physicians may be larger than many realize. A survey of family physicians and chiropractors in North Carolina found that two-thirds of the physicians felt at least moderately informed about chiropractic, and that 65% had referred patients to chiropractors.37 In the same survey, 98% of chiropractors had referred patients to medical physicians. Berman38 found that 49% of East Coast family practice physicians considered chiropractic a “legitimate medical practice.” There is little doubt that research on spinal manipulation has contributed significantly to a better opinion of chiropractic by medical physicians, especially among those who deal with back and neck pain. Chiropractic research has evolved significantly over the past quarter century, and has demonstrated that collaboration with the mainstream scientific community is effective.39 Spinal manipulation, the treatment procedure most identified with chiropractic, has been subjected to more than 70 randomized clinical trials and many more additional studies with generally positive results.8 Many nations have created clinical guidelines for back pain, and most have included spinal manipulation as an evidence-based treatment option.40 Multidisciplinary organizations, such as the North American Spine Society and the American Back Society, have included chiropractors since the early 1980s. The Chiropractic Healthcare Section is now part of the American Public Health Association, and chiropractors have been elected to its governing council for at least a decade.41 The ultimate example of the power of research culminated in 1994 with the publication of clinical care guidelines for acute low back pain by the US Agency for Health Care Policy and Research (now AHQR).42 While chiropractic was not specifically mentioned in these guidelines, spinal manipulation received the highest rating for evidence (a “B”) and was endorsed by the federal government as a treatment for low back pain. Chiropractors were appointed to the Medical Perspective

commission developing these guidelines and made significant contributions to the discussion. When chiropractors simultaneously began publishing their own practice parameters,43 this was a tremendous boost to the credibility of chiropractic in wider health care circles. Today, while it is encouraging for patients to realize that their medical and chiropractic practitioners are developing better relations, some surveys37,44 indicate that significant barriers still exist between the two professions. Another recent survey of US chiropractors reported that less than 5% practice in multidisciplinary settings.21 Perhaps of greater interest is that a survey of leading CAM clinics, especially those in medical environments, shows that less than half include chiropractors as CAM providers.45 Other health professionals also tend to see chiropractors mostly in the limited role of a back specialist and are uncomfortable with suggested primary care roles.37 Public and Private Payor and Policy Level Regardless of how patients, chiropractors, and medical physicians view the role of chiropractic within the health care system, the group with the greatest leverage is comprised of public and private organizations and institutions that deal with the business of delivering and financing health care. The cost of health care in the United States is borne by one, or a combination of, three sources: individuals, the government (such as Medicare), and private companies (e.g., health insurance companies, employee health plans). Delivery structures that combine both financing and health care services run the gamut from HMOs to various forms of preferred provider organizations (PPOs), independent practice associations (IPAs), and others. The delivery and financing systems are in a constant state of flux for a variety of complex social and economic reasons. While the “insurer” or “health plan” is sometimes perceived as a special interest concerned only with minimizing cost of care, other issues (not to mention bureaucratic inertia) are involved. Major integration decisions can occur at the public and private payor and policy level because of its political and economic power. This level is highly interactive with both previous levels because payment and delivery systems have a large influence on practitioner and patient behavior. Basic Payor Concepts and Integration Essentially, the decision to integrate a service, such as chiropractic, into a health plan involves many questions, such as: Is the service effective? Does it have a solid evidence base? Can it be administered? Are there clear thresholds for what is or is not covered under the plan? Is there consumer demand for the benefit? Will having it sell more policies or bring more members

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into the plan? Does inclusion make business sense? Is inclusion economically viable? Indemnity-based insurance only makes economic sense when the chance of needing a service is very low, and the cost of the service is beyond most people’s means.46 For example, for an infrequent event such as a car accident or a heart attack, experienced by only a small number of people at any single point in time, it makes sense to have large number of people contribute to a pool of money to cover these costs for the few who receive them. This is the basic principle behind insurance. However, it does not make economic sense to cover a service that many people routinely use, even if it is beneficial. For example, health insurance companies would go broke paying for private chefs cooking healthy, low-fat, low-sodium meals for their policyholders, even if this proposition has health benefits. Thus, health benefit inclusion decisions are based on the incidence of conditions, and not on the basis of health maintenance or prevention. For similar reasons, administrative oversight of health plans for appropriateness and quality requires that clear, predictable, and accountable methods exist to determine when services should be covered. Care pathways and treatment guidelines are the usual methods used to convey appropriateness. The logistics of integrating chiropractic into conventional medical settings requires a definition of the role that chiropractic will play in specific patient scenarios. In the current era of accountability and competition for health care dollars, clear articulation of where and when chiropractic fits is critical. The idea that a full cadre of providers is going to evaluate and treat every patient is unrealistic. Instead, triage and referral protocols will need to be developed.47 This may be difficult for some chiropractors to accept given their tradition of autonomy and independent decision making. Furthermore, appropriateness refers not only to what is clinically appropriate for the patient, but also with regard to the business contract between the health plan and the purchasers. For example, arguments for preventive care, however rational they may be, may not justify the use of a premium payor’s dollars under a specific insurance contract. Another issue that impacts integration relates to professional liability. Providers who practice together and develop explicit patient flow protocols may share each other’s legal liability for malpractice and negligence. Hence, chiropractors seeking to work in a multidisciplinary spine center may be subject to higher malpractice premiums, and medical physicians working with CAM practitioners may worry about their shared liability.48 The issue of integration is further complicated by how insurance and health plan “products” evolve according to different state regulations, community

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preferences, product innovation by carriers, and consumer demand. Jensen49 suggested that most employer-sponsored health plans routinely include a chiropractic benefit, even in the absence of “insurance equality” mandates. However, conventional medical and chiropractic cultures do not default to inclusion, or even coreferral.50 As regulatory mandates have forced conventional insurers to address various specified benefits such as chiropractic and CAM coverage, the industry has responded with a variety of less-thanoptimal solutions. For example, “dollar cap” benefits usually allow a defined amount of coverage to be applied to chiropractic services. Condition-based coverage tries to make allowances for specific patient diagnoses. Gatekeeper methods assign a primary care provider to oversee, coordinate, and allocate specialist or nonroutine care. Open access models, where patients self-refer within their plan, are the polar opposite of gatekeeper approaches and rely on strong care coordination and quality oversight in order to work well. In any of these approaches, a plan may contract with a network of providers to control quality and costs. Many “innovations” have evolved whereby delivery of benefits can be provided in parallel to the basic or core benefits package. When providers of service do not have a common culture, the path of least resistance for the plan to meet consumer demand (or a regulation) is to cover the service by making it selffunding. This can be done by setting aside the difference between the basic premium and that collected from the extra fee (“a rider”) for the service. This is not infrequent for optometric or chiropractic benefits. Entirely separate plans may also be written, as is common for dental coverage. One must understand these intricacies to understand that just because a service (e.g., chiropractic) may be paid for (covered) under the purview of a conventional health reimbursement plan or delivery system, it may not be subject to any form of clinical integration in the actual delivery of care to a patient. In other words, while the health plan may cover both chiropractic and conventional medicine, thus making the plan nominally integrated, clinical integration at the practitioner level is completely sidestepped. The Position of Chiropractic Historically, chiropractors have not been included in health insurance systems because of professional isolation and other factors, which have already been described, thus limiting their leverage when changes in the systems occur. Nevertheless, encouraging trends have emerged. It is quite clear now that CAM expenditures in the United States represent a large economic market, estimated at $35–$50 billion per year.11 Chiropractic probably accounts for close to $10 billion in

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third-party reimbursements, plus an additional $10– $15 billion in out-of-pocket expenses paid directly by patients to chiropractors. The size of this market has not gone unnoticed by those interested in such matters, and it is easy to make an economic case for integrating chiropractic services.51 A study completed in 1996 indicated that chiropractic care was routinely reimbursed for Medicare patients, as well as for injured workers, in the United States. At least 75% of insurance plans and 50% of health maintenance organizations covered chiropractic services at least to some extent.49 The proportion of HMOs offering chiropractic may now have reached 65%.11 Another recent survey also indicated that significant gains have been made by CAM in the managed care and insurance industries, and concluded that it is largely a result of huge public demand and the desire to be competitive with other organizations. Additional factors include potential cost-effectiveness and savings, client satisfaction, and whether or not research exists indicating clinical effectiveness of the CAM.52 The federal government is also beginning to recognize the impact of chiropractic and CAM. Following the 1994 release of its guidelines for acute low back pain, the Agency for Health Care Policy and Research (AHCPR) commissioned a monograph on the chiropractic profession. Compiled and edited by a multidisciplinary team of authors, this work is a landmark, representing the recognition and presence of chiropractic in the US health-delivery system.53 Recently, Congress caused the White House Commission on Complementary and Alternative Medicine Policy to be formed, which has now made recommendations regarding the coordination of CAM research, CAM education and training, provision of information regarding CAM to health professionals, and appropriate access to and delivery of CAM for the public.54 After years of hard negotiating and direct intervention by the US Congress, chiropractic care is finally being offered to military personnel and veterans.55 In summary, although most chiropractors currently benefit from being included in a greater range of insurance and other types of health care reimbursement plans than ever before, the advent of managed care has not been a boon to this phenomenon. One could argue that attitudes have changed and that the overall market for chiropractic appears to be expanding. It is also true that additional restrictions on reimbursable services have hampered the economic viability of many individual chiropractors. There are still significant barriers to what most would call a level playing field. Many chiropractors wonder how they will benefit by being more fully integrated in the health care system when integration generally

means more administrative hassle, less autonomy, and reduced fees than with private-pay patients. Nevertheless, a final encouraging observation can be made. Attitudes, policies, and procedures regarding chiropractic are no longer monolithic across healthdelivery organizations. There is a plurality of diverse approaches, each with potential opportunities and pitfalls for chiropractors that must be examined on a caseby-case basis. CHALLENGES TO INTEGRATION Additional research is needed to ascertain how different forms of practice, such as collaborative and consultative practices, can lend themselves to enhanced communication between providers. Chiropractic seems well-integrated from the patient perspective, and increasingly so at the payor and delivery system levels. However, as a consequence of the way in which these systems are organized, chiropractic may continue to operate only in the parallel and collaborative practice models. True consultative and coordinated multidisciplinary and interdisciplinary practices may not be easily obtained, and patients that could benefit from chiropractic care may not receive it. There are significant challenges to interdisciplinary practice within the current health-delivery system for medical practitioners and chiropractors that represent special challenges inherent in different philosophical discipline, “turf” battles, nonstandard practices, administrative and other resistances to change, history of conflict, habit, lack of experience, and knowledge. Although it is tempting to simply add a few procedures from another discipline (either chiropractic or medical) and call that integration, this should be resisted. True integration will only come when there is a sense of common goals, agreed-upon roles, and a common process to arrive at these goals. In addition to policy and procedural barriers, individual barriers to integration exist. Integrative clinical behavior requires that professionals be both willing and able to work together in caring for patients. Both attributes are not easy to acquire, and having one does not necessarily lead to the other. All health professions tend to attract intelligent and strong-willed individuals whose natural proclivities for autonomy, authority, and individual success are enhanced by their training. Interdependency and team decision making have not generally been stressed in their education. Chiropractic institutions have not traditionally taught students how to interact with other health professionals; the converse is also true. Differences in terminology, philosophy, knowledge, experience, and credentials all serve as barriers to effective communication. When elements of market competition, professional

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chauvinism, and fear of the unknown are considered, the challenge of integration seems forbidding indeed. In fact, finding a way to overcome these personal barriers to integrative care is one of the most challenging aspects of improving the quality of health care worldwide. Finally, from an overarching sociologic view of political and economic professional clout, chiropractic should consider its cultural authority to improve its integration into the health care system. As described by Enzmann, cultural authority is the hallmark of a successful profession.56 Cultural authority is derived from competence and social legitimacy. Culturally endowed competence is composed of behaviors that are validated by peers, have a rational base (i.e., science in health care professions) achieved by standardized training and practice, are measured by culturally relevant outcomes, and are subject to group consensus and compliance. Social legitimacy requires the demonstration of collegial critical thinking and moral attributes that serve a higher social purpose (i.e., the public’s health). The attainment of a high level of cultural authority has allowed medicine to dominate the health care industry for many years. Now, with the older paternalistic practitioner-centered health care paradigm under siege, and the new patient-centered approach gaining ground, chiropractic is in an excellent position to align itself with emerging social values and norms. Goals and resources for attaining cultural authority, however, have to be explicitly defined and addressed. SUMMARY 1. Observers have placed chiropractic as a part of the field of complementary and alternative medicine (CAM), which generally designates those methods of healing not commonly practiced by medical physicians. Some chiropractors may not appreciate this label because they see it as a barrier to fully integrating chiropractic into mainstream health care. Integrative medicine is a movement largely led by medical physicians who seek to transform medical care to a more humanitarian mode, focusing more on the patient and less on disease and technology. In this sense, integrative medicine shares much of the philosophical alignment of CAM and chiropractic. 2. The profession of chiropractic has evolved and successfully reached a point where it provides health care for many patients. It is both mainstream in terms of its use and acceptance, and alternative in terms of using a treatment approach that is very different from that of traditional medicine. Integration in the health care sense is a multifaceted

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enterprise that involves the combining of separate practices and health disciplines at three levels of consideration: the patient, the practitioner, and the payor and delivery systems. Three potential roles that have been described for chiropractors are (a) as generalist primary care providers focusing on neuromusculoskeletal conditions and prevention; (b) as musculoskeletal and spine specialists in a multidisciplinary mode; and (c) as generalist providers of an alternative to medical care with the focus on subluxation and/or the use of a wide variety of CAM methods. 3. When diverse disciplines work together in the interest of the patient, clinical integration is taking place. The nature and extent of these collaborative relationships can be named and placed on a continuum ranging from independent parallel practice to the extremely interactive “interdisciplinary health care team.” As collaboration increases, expertise is shared but autonomy decreases. At this level, integration has been increasing as a result of the changing attitudes of both chiropractors and medical practitioners. 4. Barriers to the integration of chiropractic into the health care system include factors within the chiropractic profession, factors within the medical profession, and factors within third-party payors. Factors within the chiropractic profession include a lack of cohesiveness between practitioners and a lack of perceived social legitimacy. Factors within the medical profession include a history of conflict with chiropractic, competition for patients and areas of expertise, lack of understanding of chiropractic, lack of experience in communicating with chiropractors, and lack of research. Factors within third-party payors include vastly different policies regarding coverage and reimbursement levels, resistance to change, and fear that liberalized reimbursement policies will lead to increasing health care costs.

QUESTIONS 1. What does CAM stand for and why is chiropractic considered a part of it? 2. When integration is discussed in relation to health care, which items could be integrated? 3. What are three roles that chiropractors could play in the health system? 4. What are the three interacting levels of the health system that provide the background for discussing integration in this chapter? 5. What are some of the barriers to the full integration of chiropractic?

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ANSWERS 1. CAM stands for complementary and alternative medicine. This term became more widely used in the 1990s as a replacement for the more divisive alternative medicine moniker previously used. This term also better reflects the reality that many patients choose both traditional and nontraditional care; one is not necessarily an alternative to the other. Chiropractic is considered part of CAM because it is not taught in traditional medical education. 2. Integration could apply to specific procedures or substances, to philosophies or approaches to health, or to health professions. Each has different implications. For example, procedures might be integrated but not professions or philosophies. 3. Three potential roles that have been described for chiropractors are (a) as generalist primary care providers focusing on neuromusculoskeletal conditions and prevention; (b) as musculoskeletal and spine specialists in a multidisciplinary mode; and (c) as generalist providers of an alternative to medical care with the focus on subluxation and/or the use of a wide variety of CAM methods. 4. The interacting levels are the patient level, the practitioner or clinical level, and the public and private payor and policy level. 5. There are many barriers to full integration of chiropractic into the health care system, including competition, lack of understanding, and attitudes between medical and chiropractic practitioners; the structures, policies, and procedures inherent in the way health delivery and reimbursement systems are organized; and the lack of cultural authority invested in the chiropractic profession KEY REFERENCES Astin JA, Marie A, Pelletier KR, Hansen E, Haskell WL. A review of the incorporation of complementary and alternative medicine by mainstream physicians. Arch Intern Med 1998;158(21):2303–2310. Cherkin DC, Mootz RD, eds. Chiropractic in the United States: Training, practice, and research. AHCPR Publication No. 98-N002. Rockville, MD: Agency for Health Care Policy and Research, 1997. Eisenberg DM, Kessler RC, Van Rompay MI, et al. Perceptions about complementary therapies relative to conventional therapies among adults who use both: Results from a national survey. Ann Intern Med 2001;135:344– 351. Enzmann D. Surviving in health care. St.Louis: Mosby-Year Book, 1997. Faass N, ed. Integrating complementary medicine into health systems. Gaithersburg, MD: Aspen, 2001.

Jonas WB, Levin JS, eds. Essentials of complementary and alternative medicine. Baltimore, MD: Lippincott Williams and Wilkins, 1999. Kaptchuk TJ, Eisenberg DM. Varieties of healing. 1: Medical pluralism in the United States. Ann Intern Med 2001;135:189–195. Kaptchuk TJ, Eisenberg DM. Varieties of healing. 2: A taxonomy of unconventional healing practices. Ann Intern Med 2001;135:196–204. Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002;136:216–227.

REFERENCES 1. Jonas WB, Levin JS, eds. Essentials of complementary and alternative medicine. Baltimore, MD: Lippincott Williams and Wilkins, 1999. 2. National Center for Complementary and Alternative Medicine. http://nccam.nih.gov. 3. Kaptchuk TJ, Eisenberg DM. Varieties of healing. 1: Medical pluralism in the United States. Ann Intern Med 2001;135:189–195. 4. Kaptchuk TJ, Eisenberg DM. Varieties of healing. 2: A taxonomy of unconventional healing practices. Ann Intern Med 2001;135:196–204. 5. Hawk C, Byrd L, Jansen Rd, Long CR. Use of complementary healthcare practices among chiropractors in the United States: A survey. Altern Ther Health Med 1999;5(1):56–62. 6. Stano M, Ehrhart J, Allenburg T. The growing role of chiropractic in the health care industry. J Am Health Policy 1992;2:39–45. 7. Wardwell WI. Chiropractic. History and evolution of a new profession. St. Louis: Mosby Year-Book, 1992. 8. Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002;136:216–227. 9. Ernst E. Chiropractic care: Attempting a risk-benefit analysis. Am J Pub Health 2002;92:1603–1604. 10. Mootz RD, Meeker WC, Hawk C. Chiropractic in the health care system. In: Cherkin DC, Mootz RD, eds. Chiropractic in the United States: Training, practice, and research. AHCPR Publication No. 98-N002. Rockville, MD: Agency for Health Care Policy and Research, 1997. 11. Faass N, ed. Integrating complementary medicine into health systems. Gaithersburg, MD: Aspen, 2001. 12. Snyderman R, Weil AT. Integrative medicine. Bringing medicine back to its roots. Arch Intern Med 2002;162:395–397. 13. Bell IR, Caspi O, Schwartz GER, et al. Integrative medicine and systemic outcomes research. Issues in the emergence of a new model for primary health care. Arch Intern Med 2002;162:133–140. 14. Teitelbaum M. The role of chiropractic in primary care. Findings of four community studies. J Manipulative Physiol Ther 2000;23:601–609. 15. Hawk CK. Chiropractic and primary care. In: Lawrence D, et al., eds. Advances in Chiropractic, Vol. 3. Chicago: Mosby Year Book, 1996.

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16. Hawk C, Long C, Boulanger K. Patient satisfaction with the chiropractic clinical encounter: Report from a practice-based research program. J Neuromusculoskeletal Syst 2001;9:109–117. 17. Eisenberg DM, Kessler RC, Van Rompay MI, et al. Perceptions about complementary therapies relative to conventional therapies among adults who use both: Results from a national survey. Ann Intern Med 2001;135:344–351. 18. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990– 1997. Results of a follow-up national survey. JAMA 1998;280:1569–1575. 19. Von Kuster T. Chiropractic health care. A national study of cost of education, service, utilization, number of practicing doctors of chiropractic and key policy issues. Washington, DC: Foundation for the Advancement of Chiropractic Tenets and Science, 1980. 20. Deyo RA, Cherkin DC, Conrad D, Volinn E. Cost, controversy, crisis: Low back pain and the health of the public. Ann Rev Public Health 1991;12:141–156. 21. Christensen MG, Kerkhoff D, Kollasch MW, eds. Job analysis of chiropractic: A project report, survey analysis and summary of the practice of chiropractic in the United States. Greeley, CO: National Board of Chiropractic Examiners, 2000. 22. Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG. Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 1998;88(5):771–776. 23. Carey TS, Evans AT, Hadler NM, Kalsbeek W, McLaughlin C, Fryer J. Care-seeking among individuals with chronic low back pain. Spine 1995;20:312– 317. 24. Carey TS, Evans AT, Hadler NM, et al. Acute severe low back pain. A population-based study of prevalence and care-seeking. Spine 1996;21(3):339–344. 25. Shekelle PG. Factors associated with choosing a chiropractor for episodes of back pain care. Med Care 1995;33:842–850. 26. Rupert R. A survey of practice patterns and the health promotion and prevention attitudes of US chiropractors. Maintenance care: Part I. J Manipulative Physiol Ther 2000;23(1):1–9. 27. Cherkin DC, MacCornack FA. Patient evaluations of low back pain care from family physicians and chiropractors. West J Med 1989;150:351–355. 28. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. N Engl J Med 1995;333:913–917. 29. Hertzman-Miller RP, Morgenstern H, Hurwitz EL, Yu F, Adams AH, Harber P. Comparing the satisfaction of low back pain patients randomized to receive medical or chiropractic care: Results from the UCLA low-back study. Am J Public Health 2002;92:1628– 1633. 30. Jackson P. Summary of the ACA professional survey on chiropractic practice. J Am Chiropr Assoc 2001;38(2):27– 30.

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31. Ivey S, Brown KS, Teske Y, Silverman D. A model for teaching about interdisciplinary practice in health care settings. J Allied Health 1988;17:189–195. 32. Mootz RD. Interprofessional referral protocols. In: Fass N, ed. Integrating complementary medicine into health systems. Gaithersburg, MD: Aspen, 2001. 33. Triano JJ, Raley B. Chiropractic in the interdisciplinary team practice. Top Clin Chiropr 1994;1:58–66. 34. Wolinsky H, Brune T. The serpent and the staff: The unhealthy politics of the American Medical Association. New York: Jeremy P. Tarcher/Putnam, 1994. 35. Astin JA, Marie A, Pelletier KR, Hansen E, Haskell WL. A review of the incorporation of complementary and alternative medicine by mainstream physicians. Arch Intern Med 1998;158(21):2303–2310. 36. Gordon NP, Sobel DS, Tarazona EZ. Use of and interest in alternative therapies among adult primary care clinicians and adult members in a large health maintenance organization. West J Med 1998;169(3):153–161. 37. Mainous AG, Gill JM, Soller JS, Wolman MG. Fragmentation of patient care between chiropractors and family physicians. Arch Fam Med 2000;9:446–450. 38. Berman BM, Singh BK, Lao L, et al. Physician’s attitudes toward complementary or alternative medicine: A regional survey. J Am Board Fam Pract 1995;8: 1–6. 39. Meeker WC, Mootz RD, Haldeman S. The state of chiropractic research. Top Clin Chiropr 2002;9:1–13. 40. Koes BW, van Tulder MW, Ostelo R, Burton AK, Waddell G. Clinical guidelines for the management of low back pain in primary care. An international comparison. Spine 2001;26:2504–2514. 41. Baird R, Pammer JC. 1995 APHA annual meeting: Chiropractic’s struggle for full section status comes to a close. J Am Chiropr Assoc 1996;33(1):36–41. 42. Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical practice guideline no. 14. AHCPR Publication No. 95–0642. Rockville, MD: Agency for Health Care Policy and Research, 1994. 43. Haldeman S, Chapman-Smith D, Petersen D, eds. Guidelines for chiropractic quality assurance and practice parameters. Gaithersburg, MD: Aspen, 1992. 44. LeBoeuf-Yde C, Andren JA, Gernandt M, Malmqvist S. Interprofessional contacts between chiropractors and other health-care professionals in Sweden as seen from a chiropractic perspective. J Manipulative Physiol Ther 1997;20:241–245. 45. Hanks JW. Chiropractic inclusion in complementary and alternative medicine clinics: Analysis of current trends. Top Clin Chiropr 2001;8(2):20–25. 46. Mootz RD. Health insurance benefits constructs. Top Clin Chiropr 2000;7(2):57–63. 47. Mootz RD, Bielinski LL. Issues, barriers, and solutions regarding integration of CAM and conventional health care. Top Clin Chiropr 2001;8(2):26–32. 48. Cohen MH. Legal issues in complementary and integrative medicine. A guide for the clinician. Med Clin North Am 2002;86:185–196. 49. Jensen GA, Roychoudhury C, Cherkin DC. Employersponsored health insurance for chiropractic services. Med Care 1998;36(4):544–553.

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50. Bielinski LL, Mootz RD, eds. Issues in coverage for complementary and alternative medicine services: Report of the Clinician Workgroup on the Integration of Complementary and Alternative Medicine. Olympia, WA: Washington State Office of the Insurance Commissioner, 2000. 51. Manga P. Economic case for the integration of chiropractic services into the health care system. J Manipulative Physiol Ther 2000;23:118–122. 52. Pelletier KR, Astin JA. Integration and reimbursement of complementary and alternative medicine by managed care and insurance providers: 2000 Update and cohort analysis. Altern Ther Health Med 2002;8:38–44.

53. Cherkin DC, Mootz RD, eds. Chiropractic in the United States: Training, practice, and research. AHCPR Publication No. 98-N002. Rockville, MD: Agency for Health Care Policy and Research, 1997. 54. White House Commission on Complementary and Alternative Medicine Policy. www.whccamp.hhs. gov. 55. Lott CM. Integration of chiropractic in the Armed Forces health care system. Mil Med 1996;161:755– 759. 56. Enzmann D. Surviving in health care. St. Louis: MosbyYear Book, 1997.

C H A P T E R

8 THE CLINICAL EFFECTIVENESS OF SPINAL MANIPULATION FOR MUSCULOSKELETAL CONDITIONS Gert Bronfort, Mitchel Haas, and Roni Evans

O U T L I N E Neck Pain Mid-Back Pain, Coccydynia, and Extremity Conditions Cost-effectiveness of Spinal Manipulation AREAS FOR FUTURE RESEARCH Special Populations Practice Optimization Manipulative Therapies Regimens and Technique Systems SUMMARY QUESTIONS ANSWERS KEY REFERENCES REFERENCES

INTRODUCTION EVALUATING EVIDENCE OF TREATMENT EFFECTIVENESS Evidence-Based Summaries Systematic Reviews Clinical Guidelines Randomized Controlled Trials Nonrandomized Comparative Intervention Studies Uncontrolled Intervention Studies Expert Opinion EFFECTIVENESS OF SPINAL MANIPULATION FOR COMMON MUSCULOSKELETAL PROBLEMS Low Back Pain Sciatica and Lumbar Radiculopathy

4. To summarize recently published clinical trials regarding the effectiveness of spinal manipulation for extremity conditions. 5. To identify gaps in existing knowledge and to suggest areas for future research.

OBJECTIVES 1. To review the most appropriate study designs for evaluating treatment effectiveness and to discuss methods of summarizing research reporting on treatment effectiveness, including randomized clinical trials, systematic reviews, and evidencebased clinical practice guidelines. 2. To summarize, based on systematic reviews, evidence-based clinical guidelines, and recently published clinical trials, what is known regarding the effectiveness of spinal manipulation for acute and chronic low back pain. 3. To summarize, based on systematic reviews, evidence-based clinical guidelines, and recently published clinical trials, what is known regarding the effectiveness of spinal manipulation for acute and chronic neck pain.

INTRODUCTION Chiropractors, like other health care providers, have been urged to adopt evidence-based health care as a basis for ensuring optimal case management by integrating individual clinical expertise with the best available scientific evidence. Evidence-based health care deemphasizes intuition, unsystematic clinical experience, and pathophysiological rationales as the basis for clinical decisions; instead, it emphasizes acquisition, understanding, and application of the available and accumulating scientific evidence from 147

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high-quality clinical research.1 This chapter describes the best current scientific evidence regarding the effectiveness of spinal manipulation for several commonly encountered problems in chiropractic practice. Although spinal manipulation is only one of the procedures in the chiropractic treatment armamentarium, it is often recognized as chiropractic’s signature procedure. As such, manipulation has been the most studied procedure used by chiropractors. For the purpose of this chapter, manipulation refers to segment-specific spinal manual therapy, including high-velocity, low-amplitude thrust techniques, segmental mobilization, and low-force and mechanicalassisted adjustments.2 The chapter begins with a description of the key attributes of “evidence” and the appropriate types of studies to evaluate treatment effectiveness. This is followed by a summary of the best current evidence available on the clinical effectiveness of spinal manipulation for low back pain, neck pain, and other musculoskeletal conditions. Cost-effectiveness of spinal manipulation is addressed briefly. Finally, areas for future research are identified and discussed. EVALUATING EVIDENCE OF TREATMENT EFFECTIVENESS Several attributes of scientific evidence may affect its usefulness and perceived value. The most important attributes include study type and methodological quality, as well as quantity and consistency of evidence.3 Study type refers to the design of a study, such as a randomized controlled trial and case study, which are often prioritized into a hierarchy reflecting the strength of evidence, the ability to minimize bias, and the ability to make causal inferences regarding treatment effectiveness. It is well recognized that greater weight must be given to a large randomized controlled trial than to a single case study in clinical decision making. Although certain study types may sit at the top of the evidence hierarchy, they shouldn’t automatically be considered a good source of evidence. The value placed on research, and consequently how much faith is put in the results, is largely determined by the methodological quality of a study, or how well a study has been performed. Methodological quality is determined from specific criteria according to study type. Studies with higher methodological quality within each study type are considered to be less likely to yield spurious results, and thus their results are given more importance. Also, the level of confidence in the evidence for effectiveness depends on the quantity of evidence. It is preferable to have numerous highquality trials with consistent results before accepting

TABLE 8–1.

Study Types

Evidence Hierarchy (Highest to Lowest) Evidence-based summaries Systematic review Clinical guidelines Randomized controlled trials Nonrandomized comparative intervention studies Uncontrolled intervention studies Expert opinion

or rejecting the effectiveness of a treatment for a particular condition. As always, evidence must be interpreted in the context of the patient population, practitioner population, clinical setting, and therapy under study. Judgment must always be exercised when attempting to apply evidence from a study to one’s individual practice. For example, the results of a study on high-velocity, low-amplitude manipulation may not be generalized to a light or nonforce technique. There are a number of proposed schema for classifying study designs.4 The evidence hierarchy presented in Table 8–1 is a simplified taxonomy based on two of the most important characteristics of study design: randomization and control/comparison group. Evidence-Based Summaries A systematic review is a comprehensive review of the scientific (peer-reviewed) literature that includes an exhaustive literature search, a specific research question, inclusion/exclusion criteria to identify the relevant studies, an evaluation of study quality, a summary of the literature, and a qualitative or quantitative synthesis of study findings to make inferences about the strength of supporting or refuting evidence.5 A meta-analysis is a quantitative systematic review that pools the findings of multiple studies to give an overall numerical estimate of a treatment effect.6 If studies are too dissimilar, statistical pooling of data may not be sensible. An alternative is then a type of systematic review called a best-evidence synthesis.7 This approach uses a predetermined set of rules to evaluate the strength of evidence, weighing the magnitude of treatment benefit as well as study quality and quantity. A systematic review is considered the highest form of evidence because it combines the findings of multiple studies to give a better perspective than any single trial.5 Of particular advantage to the clinician is that the literature has already been summarized. A limitation of systematic reviews is that individual study findings may be included even when the authors of the Systematic Reviews

THE CLINICAL EFFECTIVENESS OF SPINAL MANIPULATION FOR MUSCULOSKELETAL CONDITIONS

original studies have made false conclusions from their own data. Additionally, as with any type of study, the trustworthiness of a systematic review is dependent on how well it was performed. Clinicians must also be careful to assess the relevance of the review to their own patients and method of practice.8,9 A growing international organization, The Cochrane Collaboration, is likely to play an increasing role in the generation of the systematic reviews that will carry the most weight when it comes to informing national policy decisions. This international, multidisciplinary group of volunteer researchers has set a goal to produce high-quality reviews with commitments to regular updates.10 Cochrane reviews on the role of spinal manipulation for neck pain, low back pain, and headache are underway. Since the beginning of the 1990s, clinical guidelines have increasingly become a familiar part of clinical practice. Clinical guidelines have been defined as systematically developed statements to assist practitioners and patients in decisions about appropriate health care for specific clinical circumstances.11,12 Guidelines based on critical appraisal of the scientific evidence (also called evidencebased guidelines) are designed to provide specific information about which interventions are of proven benefit by documenting the strength of the evidence of the supporting data. The limitations that exist for systematic reviews also apply to clinical guidelines.

Clinical Guidelines

Randomized Controlled Trials The randomized controlled trial (RCT) is considered the sine qua non of research methodology because it provides the most reliable estimate of treatment effect with the least biased method of causal inference.13 The inclusion of a comparison group permits the evaluation of fundamental clinical questions such as the following: Does manipulation make an important contribution to patient progress? Is manipulation better than other therapies? Is manipulation an active ingredient in patient care? By randomly assigning patients to experimental and comparison treatment groups, known and unknown factors that could affect treatment outcome are controlled for, leaving any differences between groups attributable to the specific treatments. Randomization also aids in concealment of allocation to treatment or control groups, a critical factor to prevent biased study results.14 Although they are considered the gold standard for determining treatment effectiveness and form the underlying basis for evidence-based summaries, randomized controlled trials do have limitations, including limited generalizability. By conducting these studies in ideal settings with clinical protocols

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that do not always reflect clinical practice and controlling patient selection and treatment delivery, results often cannot be applied to everyday practice. Furthermore, standardization of therapies in these studies does not permit individualization of treatment, which may be an important component of care. All in all, the precision in information that an RCT can provide comes at the expense of not always being able to generalize research findings to practice.15 Nonrandomized Comparative Intervention Studies Nonrandomized comparative studies differ from randomized controlled trials in that patients are not randomized to treatment groups. This may happen when patients are improperly randomized (e.g., the everyother-patient method) or in comparison studies where patients select their therapy. Quality in these studies varies tremendously, from poorly designed pragmatic studies to rigorously controlled treatment protocols. These studies may be either prospective (i.e., patients are recruited into the study when it begins) or retrospective (i.e., patients have already received treatment and researchers are going through the results after the fact to see how they fared). This study type has several important advantages.15 First, the nonrandomized comparative study designs are amenable to large studies conducted in clinical practice to evaluate treatment effects in natural settings and can be used to investigate a wide variety of patients, therapies, and practices. Nonrandomized comparative studies can be also be used to generate hypotheses for RCTs, confirm findings of RCTs, and determine the generalizability of RCTs under less controlled conditions. The downside to nonrandomized comparative studies is the absence of randomization, which weakens causal inference and group comparibility. Consequently, treatment effects may be confounded by patient characteristics; that is, if randomization is not used to ensure that groups of patients are as similar as possible to begin with, it is possible that differences in results are actually a result of some difference between the two groups. The generalizability to practice that a nonrandomized comparative study can provide comes at the expense of potential bias in ascertaining the cause of a treatment effect.15 Uncontrolled Intervention Studies Uncontrolled intervention studies may be thought of as nonrandomized comparative trials, as described above, but without comparison groups. These studies consist of case series and case studies and may be prospective or retrospective. The most important such study is the large, prospective, practice-based case series, which can give precise estimates of therapeutic

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progress over time. However, these studies cannot be used to make causal inferences. Without a proper concurrent comparison group, we cannot rule out natural history and external factors as the causes of the observed patient improvement. Expert Opinion This category refers to anecdotes and accounts of personal experience of leaders in a health care field in the absence of documented evidence. Practitioners must often make clinical decisions regarding treatments for patients where there is little or poor scientific evidence. Consequently, clinical experience plays a critical role in evidence-based practice.1 However, personal clinical experience can be misleading for many reasons. For example, some patients get better in spite of care, doctors can make errors in diagnosis and prognosis, and in the absence of careful documentation, there is a greater tendency to remember successes than to remember failures. There are also issues of interpretation such as, “I know the patient got better because he never returned to the office.” Therefore, while many such anecdotes and personal experiences delivered by often charismatic leaders are interesting or even impressive, they do not represent scientific evidence to prove or disprove a therapy. EFFECTIVENESS OF SPINAL MANIPULATION FOR COMMON MUSCULOSKELETAL PROBLEMS Low Back Pain Since the mid-1970s, more than 50 reviews have been published assessing the effectiveness of spinal manipulation, mainly for low back pain (LBP).16 Most of these reviews have been of a qualitative nature. However, since 1985, several systematic reviews have emerged, as well as evidence-based clinical guidelines based on these reviews. Overall, the methodological quality of systematic reviews has continued to improve over time, but there are still a number of individual differences in how spinal manipulation reviews have been performed. For instance, two reviews by Assendelft et al.17,18 focused entirely on trials addressing the efficacy of chiropractic spinal manipulation for patients with LBP, while other reviews did not distinguish practitioner type and included manipulation performed by medical doctors and physical therapists. The result of the second review (which was an update of the first), involving a total of eight RCTs, was that no convincing evidence of the efficacy of chiropractic spinal manipulation for either chronic or acute LBP could be demonstrated.18 Van Tulder et al.19 used a protocol similar to that used by Koes et al.20 for quality scoring and abstracting, but with

the addition of specific rules to determine the presence and strength of evidence of efficacy. They, too, did not distinguish manipulation performed by chiropractors from that performed by other practitioners. The review by Bronfort et al.21 differed from the other systematic reviews by primarily basing the evidence on studies from which the unique effect of spinal manipulation could be isolated. Also, the review did not rely on authors’ conclusions (as others had) but formed conclusions based on evidence rules and synthesis of abstracted quantitative data from each randomized clinical trial. The number of randomized clinical trials addressing spinal manipulation for LBP increased substantially from 1985 to the end of the twentieth century. In the Ottenbacher et al. 1985 review,22 only 9 studies were available, compared with the most recent review by van Tulder19 (1997), which identified 25 studies evaluating spinal manipulation for LBP. Tables 8–2 through 8–7 summarize all of the currently published randomized clinical trials assessing spinal manipulation for LBP. All of these differences among systematic reviews have the potential for generating varying conclusions regarding the efficacy of spinal manipulation. Surprisingly, the conclusions regarding spinal manipulation for acute LBP have been relatively consistent, with the exception of the Koes et al. review.20 While the majority of the reviews indicated that there is some evidence supporting the short-term efficacy of spinal manipulation for acute LBP, Koes et al. found the evidence inconclusive. For chronic LBP, the results of the systematic reviews have been more mixed, with the earlier reviews finding inconclusive evidence and later reviews finding moderate to strong evidence for the benefit of spinal manipulation. Table 8–8 summarizes the systematic reviews and evidence-based guidelines that have addressed spinal manipulation therapy (SMT) for low back pain, both acute and chronic. Additional randomized clinical trials of SMT for LBP have been published.23–29 A study by Andersson et al.26 compared osteopathic spinal manipulation to standard medical care for patients with LBP of 3 weeks’ to 6 months’ duration. Both groups showed similar clinical results, but patients who received spinal manipulation required significantly less medication. A trial by Skargren et al.24,25 compared physical therapy and chiropractic for acute and chronic neck and back pain patients and found both treatments to be equally effective both short and long term for LBP patients. A randomized trial by Cherkin et al.23 compared chiropractic spinal manipulation, McKenzie therapy, and an educational booklet that served as a minimal intervention control. No differences between spinal manipulation and McKenzie groups were

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RCTs on Acute Low Back Pain in Which It Was Possible to Isolate the Unique Contribution of Spinal Manipulation/Mobilization to the Overall Treatment Effect

TABLE 8–2.

First Author, Reference Number, and Year

Study Groups (n)

Results

Glover38 (1974)

G1: 1 SMT-MD + 4 daily sessions of

G1 more pain reduction after the first treatment in subgroup with duration 16/min Acute dyspnea History of high blood pressure and heart disease with orthopnea and paroxysmal nocturnal dyspnea

Congestive heart failure

Chronic dyspnea

Congestive heart failure; anemia (blood loss, pallor,

Edema Generalized edema: distended jugular veins, bilateral rales in basilar portion of lungs, dependent edema in lower extremities (pitting edema in ankles and feet) Hypertension Systolic: systolic is elevated but diastolic is not Diastolic: both are elevated

Congestive heart failure; other causes include liver disease and nephrotic syndrome

Cyanosis Central cyanosis: history of cardiac symptoms from birth or childhood, dyspnea, heart murmur, and possibly congenital heart failure Peripheral cyanosis

Congenital heart disease Congestive heart failure, mitral stenosis, arterial (diabetes, intermittent claudication) or venous obstruction (varicose veins, thrombophlebitis)

weakness); hyperthyroidism (evidence of thyrotoxicosis)

Physical Examination As a screening procedure, chiropractors should consider

Cardiovascular Screening Procedure

1. Looking for signs of cardiovascular disease (edema, cyanosis, dyspnea). 2. Assessing the pulses (upper and lower extremities). 3. Taking the blood pressure. 4. Auscultating the heart. Patients should be investigated further or referred to an internist or cardiologist if they exhibit risk factors and possible red flags for cardiovascular disease, or abnormal results on the cardiovascular screening examination. If there are any abnormal or suspicious findings, the following examination should be considered. Examination Observe for signs of (a) edema, particularly around ankles and feet in congestive heart failure; localized to one extremity in peripheral vascular obstruction; (b) cyanosis; peripheral cyanosis (bluish discoloration of distal extremities or nail beds) in congestive heart failure and mitral stenosis, or central cyanosis of skin and

Cardiovascular

Atherosclerosis; primary (essential) hypertension, or secondary to endocrine, renal disease

mucous membranes of the mouth in cyanotic congenital heart disease (uncommon); and (c) dyspnea, increased and shallow respiratory rate at rest, and difficulty breathing during recumbency, somewhat relieved by sitting up (orthopnea); common in cardiogenic pulmonary edema. Palpate peripheral arterial pulses for heart rate, rhythm, pulse wave characteristics, and sometimes obstructions. These can be detected by an examination of radial, brachial, and carotid arterial pulses. The radial pulses are useful to detect rate and rhythm. Larger-diameter arteries such as the brachial and carotid arteries are better for detecting pulse characteristics. For rate and rhythm, palpate the radial pulses bilaterally. Compress the radial pulse at the wrist, just lateral to the tendon of the flexor carpi radialis muscle, with the pads of the index and middle fingers until a maximal pulsation is felt. Feel for rhythm. If regular, count beats over 15 seconds and multiply by 4. If irregular, count the beats over 60 seconds. Some causes of irregular rhythm may be sinus arrhythmia, extrasystole of either atrial or ventricular origin, and atrial tachycardia or fibrillation. Some causes of irregular pulse characteristics are aortic reflux or vasodilation for large-volume pulses, peripheral arterial vasoconstriction, or low cardiac output

THE PHYSICAL EXAMINATION

for small-volume pulses. Pulsus bisferiens (pulse with two “humps”) felt at the brachial pulse may be caused by aortic stenosis with incompetence.17,19,20 All arterial pulses should be assessed if the patient presents with signs and symptoms of peripheral vascular disease. The proper protocol for taking blood pressure requires a patient to be comfortably seated for 5 minutes before the assessment, no caffeine at least 30 minutes prior to the reading, and the arm relaxed and supported. Hypertension is determined only after abnormal readings on three consecutive evaluations unless the blood pressure is severely elevated. Blood pressure readings can be taken in both arms. It is normal to have up to a 5–10 mmHg difference in readings between arms. A difference of 10–15 mmHg or greater suggests obstruction in the arm with lower pressure or arterial compression. Blood pressure varies depending on what people are doing (e.g., sleeping versus exercising), and is almost always higher later in the day than in the morning. Regardless, the higher numbers are always used to determine normal from abnormal blood pressure. Hypertension is determined by elevated systolic, diastolic, or both pressures. Table 27–11 classifies blood pressure readings. To reinforce the importance of detecting and monitoring blood pressure, Table 27– 12 identifies some of the risks for end-organ complications associated with hypertension. For more information on the classification of blood pressure, see references 21 and 22.

Take the arterial blood pressure

Auscultation of the heart assesses the timing of the heart contraction–relaxation cycle, the patency of the heart valves, and the quality of blood flow through the heart. Other sounds associated with the normal heart sounds (murmurs) usually indicate abnormal blood flow in the heart (Fig. 27–3).

Auscultate the heart

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TABLE 27–12. Risk for Organ Damage Associated with Hypertension Target Organ

Associated Risk

Heart Brain

Heart failure, myocardial infarction Transient ischemic attack (TIA) and stroke

Eye Kidney Large blood

Hypertensive retinopathy Hypertensive nephropathy Aortic dilatation, aortic valve reflux,

vessels

abdominal aortic aneurysm, dissecting aortic aneurysm

It is recommended that one use a good-quality stethoscope. Earpieces should fit snugly and the tubing should be thick enough to minimize external sounds. Use the diaphragm (flat side) to pick up highpitched sounds (i.e., second heart sounds) and the bell (curved surface) to pick up low-pitched sounds (i.e., murmurs). Make sure you are familiar with the physiology of the cardiac cycle before proceeding. The following has been recommended as the sequence to follow when examining the heart.23 While auscultating, listen for the normal first and second heart sounds (S1 and S2), as well as any abnormal heart sounds. Table 27–13 has further information on auscultation of the heart. 1. The patient lies supine with head elevated to 30 degrees. Inspect and palpate the precordium, second intercostal spaces bilaterally, and left sternal border and apex (fifth left intercostal space). Assess apical impulse in terms of location, amplitude, and duration. If not found on palpation, try again with patient lying in the left lateral decubitus position and auscultate using the bell.

Classification of Blood Pressure Readings

TABLE 27–11.

Blood Pressure Reading (mmHg)

Classification