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Chiropractic: A Summary of Concerns

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Although obscured by controversy, there is evidence to indicate that spinal manipulation can be as effective as conventional treatment methods in relieving low-back pain.1,2,3,4 This grain of truth mixed with chiropractic vertebral subluxation theory that encompasses a broad scope of ailments makes it difficult for the average person to distinguish between appropriate and inappropriate use of manipulation by chiropractors. A person who is satisfied with chiropractic manipulative treatment for back pain might be led to believe that the same treatment can be used to treat a variety of organic ailments by correcting “vertebral subluxations.” Such treatment is usually described as a “chiropractic adjustment.”

A manual chiropractic adjustment

Although chiropractic care based on subluxation theory has been rejected by the scientific community, spinal manipulation used in the treatment of mechanical-type back pain has a plausible basis that makes it acceptable in mainstream healthcare. A good back-cracking back rub provided by a chiropractor or some other manual therapist can be a pleasurable, pain-relieving experience, and this can be a preferred method of treatment for some types of back pain. But you should be well-informed enough to know where to draw the line in separating subluxation-based chiropractic adjustments from appropriate use of generic spinal manipulation if you should consider treatment by a chiropractor. Otherwise, you might become the victim of the bait-and-switch tactics of chiropractors who offer you treatment for back pain and then attempt to indoctrinate you in subluxation theory.

Much of what follows in this article has been said before in other articles of mine posted on this site. An up-to-date summary of basic concerns about chiropractic care, however, might be useful for new readers and others, including professionals, who want a brief overview for quick reference in seeking answers to questions about the problematic aspects of chiropractic use of spinal manipulation.
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Following the Guidelines of Science: A Chiropractic Dilemma

Preamble: When my book Bonesetting, Chiropractic, and Cultism [full text] was published in 1963, renouncing chiropractic vertebral subluxation theory and recommending that chiropractic be developed as a subspecialty of medicine in the treatment of mechanical-type back pain, the chiropractic profession refused to acknowledge or review the book. I was labeled “an enemy of chiropractic.” If it had not been for the support I received from the science-based community, I might have had doubts about my mind set and my motives. Favorable reviews by members of the science-based community sustained me over the years; for that, I am deeply grateful. Today, still unheard by the chiropractic profession, the message of my Bonesetting book remains relevant in describing the problems of chiropractic. Although out of print, the entire book can be read online on Chirobase.org.

 

The Aftermath of Bonesetting, Chiropractic, and Cultism, 1963

In view of the absence of any extensive histories of chiropractic, this book has a place in medical collections and reference libraries. ─ Eric Meyerhoff, Director, The Medical Library Center of New York, N.Y.C., Library Journal, February 1, 1964

In regard to your recent application for membership in the American Chiropractic Association and insurance in the National Chiropractic Insurance Company, please be advised that the ACA membership committee has rejected your application. ─ H.W. Pruitt, D.C., Executive Secretary, American Chiropractic Association, May 17, 1965

I purchased your book some months ago on Bonesetting, Chiropractic, and Cultism. I found it to be a most intriguing and enlightening publication which has been of value to me in some of my own studies in medical anthropology. ─ James G. Roney, M.D., Ph.D., Stanford Research Institute, November 11, 1965

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Chiropractic gimmickry

[Editor's Note: Today, we have a guest post from Sam Homola, who, as you recall, practiced as a chiropractor until he ultimately realized that there is no evidence that subluxations exist. Since then, he's discussed in various places, including, we are pleased to say, SBM, his skepticism regarding chiropractic. Enjoy!]

Much has been written (and published on this site) about the implausibility of chiropractic vertebral subluxation theory which proposes that a vertebral subluxation complex or a spinal joint dysfunction “may affect organ system function and general health.” Associated chiropractic gimmickry that might be harmful as well as a waste of time and money should be also be brought to the attention of concerned consumers. As a chiropractor (retired) who has renounced subluxation theory, it might be helpful to share my concerns about some dubious chiropractic methods that are foisted upon an unsuspecting public, unchallenged in the market place.
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Low-Back Pain: Causes, Care, and Consequences

Low-back problems are one of the most common reasons for visits to doctors’ offices and the most common cause of disability among persons under the age of forty five. Most of the time, acute low-back pain is the result of simple strain and is a self-limiting condition that will resolve in four to six weeks, with or without treatment. But since back pain can be a forerunner of disability or a symptom reflecting serious pathology, every effort should be made to seek appropriate care that is based on a definitive diagnosis. Failure of physicians to ease the concerns of back-pain patients by explaining their problem and advising them in the care of back pain often results in dissatisfied patients who may be attracted by the approach of alternative medicine practitioners who tout a spurious quick-cure treatment based on a dubious diagnosis. Misinformation provided by such practitioners may contribute to disability by allowing progression of disease or by exaggerating the seriousness of the problem in the mind of the patient. Thus, while back pain is rarely serious, it should always be carefully evaluated to reach an accurate diagnosis and to determine if specialized care is needed. Care should be taken to inform the patient in a positive manner─to avoid unnecessary surgery as well as inappropriate or unnecessary treatment.

Something to Consider When You have Back Pain

Almost everyone will experience acute low back pain at least once during a lifetime. Much of what must be done to care for a bad back must be done by you. It would certainly help to be well informed about the causes of back pain when seeking appropriate treatment.

It goes without saying that when incapacitating back pain occurs as a result of a serious accident or injury, you should seek emergency medical care. When back pain grows progressively worse, persists unrelieved for longer than a week, or is worsened by rest, you may need the services of a specialist. Back pain that occurs for no apparent reason and does not affect movement may be a symptom referred from an internal organ. Once a diagnosis has ruled out a serious problem and it has been established that you have nonspecific or uncomplicated mechanical-type back pain, self-help measures designed to relieve your symptoms and to protect and strengthen your back may be the only treatment needed. If there is no active pathological process and your back pain lasts three months or longer, you may have a “chronic” back problem that can lead to recurring back pain, requiring ongoing vigilance and self help.

Time is the most important part of treatment for uncomplicated back pain caused by injury. It’simportant, however, to be aware of red flags indicating that back pain might be the result of something more serious that a simple strain. In the absence of red flags, imaging studies or special testing might not be indicated during the first four weeks of low back symptoms. When a red flag is present, you should not delay in reporting your symptoms to your family physician.

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Subluxation Theory: A Belief System That Continues to Define the Practice of Chiropractic

When I graduated from Lincoln Chiropractic College in 1956, I had come to the conclusion that chiropractic’s subluxation theory, that misaligned vertebrae can cause organic disease, was not true. When I began my practice in Panama City, Florida, I limited my practice to care of mechanical-type back pain and related problems. Back then, that was not too much of a stretch, since manipulative services were not readily available in medical practices and there were a number of orthopedic and physical medicine texts recommending use of manipulation in the treatment of back pain.

In 1963, I published my book Bonesetting, Chiropractic, and Cultism, renouncing subluxation theory and recommending that chiropractic be developed as physical treatment specialty in the care of back pain. The book was reviewed by the Library Journal (February 1, 1964) and recommended for inclusion in medical and reference libraries. In 1965, I received a letter from the American Chiropractic Association (ACA) informing me that my application for membership in the ACA had been rejected. In the years to follow, I published many articles in an attempt to initiate an effort to change chiropractic from a subluxation-based practice to a legitimate physical treatment method that would fit in with mainstream health care. My suggestions were ignored and I was called a “chiropractic heretic.” Today, I find myself still saying some of the things I said in my 1963 Bonesetting book, still being rejected by most of my colleagues and still voicing opposition to subluxation theory.

There are now some chiropractors who do not subscribe to the theory that some kind of segmental dysfunction in the spine can cause organic disease, but they are overshadowed by subluxation-based chiropractors who publish their own journals, using scientific-sounding jargon to defend implausible theories and dubious treatment methods. Some of these chiropractors do not use the “subluxation” word, instead substituting some other vague description of a spinal lesion, such as “joint dysfunction,” alleged to have the same affect on the nervous system and general health as a “vertebral subluxation.”
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The Image of Chiropractic: Consensus Based on Belief

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

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

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

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

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

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

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

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

A 1997 publication by the Foundation for Chiropractic Education and Research, supporting the vertebral subluxation theory, noted that “…we [chiropractors] have successfully distanced the concept of a chiropractic subluxation from that of an orthopedic subluxation.”1 When discussing “subluxations” or misaligned vertebrae, however, chiropractors often fail to point out the difference between an orthopedic subluxation and a chiropractic subluxation. Reference to subluxations in medical literature is often presented as support for the practice of chiropractic as a method of adjusting vertebral subluxations to “restore and maintain health.”

In the eyes of the public, the chiropractic vertebral subluxation theory has confused the definition of the word “subluxation,” a common medical term. Unlike the mysterious, undetectable and asymptomatic chiropractic “vertebral subluxation complex” alleged to be a cause of disease, a real vertebral subluxation, that is, an orthopedic subluxation, can be a cause of mechanical and neuromusculoskeletal symptoms but has never been associated with organic disease.

Subluxations: Real and Imaginary

An orthopedic subluxation, recognized and named as such since the days of Hippocrates, is a painful partial dislocation. Simple misalignment of a vertebra, also referred to as a “subluxation,” is commonly caused by disc degeneration, curvatures, spondylolysis, and structural abnormalities. Such a subluxation may or may not be mechanically symptomatic and can be seen on a plain x-ray image. In the absence of pathology such as disc herniation or osteophyte formation, these common vertebral subluxations or misalignments rarely affect spinal nerves and have never been associated with organic disease. Spinal nerves supply musculoskeletal structures. The body’s organs are supplied primarily by autonomic nerve ganglia and plexuses located outside the spinal column and by cranial and sacral nerves that pass through solid bony openings, providing overlapping nerve supply independent of any one spinal nerve that passes between two vertebrae.

An orthopedic subluxation, a true vertebral misalignment, or a mechanical joint dysfunction that affects mobility in the spine is not the same as a “chiropractic subluxation” that is alleged to cause disease by interfering with nerve supply to organs. Such a subluxation has never been proven to exist. There is no plausible theory and no credible evidence to support the contention that “nerve interference” originating in a single spinal segment can cause an organic disease.
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Pediatric Chiropractic Care: Scientifically Indefensible?

In a paper published in 2008, two academic chiropractors offered this observation: “The health claims made by chiropractors with respect to the application of manipulation as a health care intervention for pediatric health conditions continue to be supported by only low levels of scientific evidence. Chiropractors continue to treat a wide variety of pediatric health conditions.”1

Despite lack of support by the medical and scientific community, chiropractic treatment of children is growing in popularity, and more chiropractors are specializing in “chiropractic pediatrics.”

The International Chiropractic Association offers a post-graduate “Diplomate in Clinical Chiropractic Pediatrics” (DICCP) and publishes a “peer reviewed” Journal of Clinical Chiropractic Pediatrics. The diplomate syllabus is a 30-module, 360+ hours classroom course during weekends over a three-year period. There is no hospital training and no contact with diseased or injured children — only a “mandatory observational/training weekend at a chiropractic center for special needs children under multi-disciplinary care.”2 A post-graduate certification in chiropractic pediatrics (CICCP) can be earned after 180 hours of classroom instruction.

In a June 2008 joint press release, the American Chiropractic Association’s (ACA) Council on Chiropractic Pediatrics and the Council on Chiropractic Pediatrics of the International Chiropractors Association (ICA) announced that the ICA’s Diplomate in Clinical Chiropractic Pediatrics (DICCP) is now recognized by the ACA and its council as the official credential for specialization in chiropractic pediatrics.3

Noting increasing public support for chiropractic treatment of children, a January 2009 press release from the American Chiropractic Association made this announcement: “Survey data indicates that the percentage of chiropractic patients under 17 years of age has increased at least 8.5 percent since 1991.…Studies are beginning to show that chiropractic can help children not only with typical back and neck pain complaints, but also with issues as varied as asthma, chronic ear infections, nursing difficulties, colic and bedwetting.”4

A trend toward greater utilization of chiropractic by children has not gone unnoticed by the medical profession. An article in the January 2007 issue of Pediatrics (the official journal of the American Academy of Pediatrics) described chiropractic as the most common complementary and alternative medicine practice used by children, who made an estimated 30 million visits to US chiropractors in 1997.5 In 1998, children and adolescents constituted 11% of patient visits to chiropractors.6
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Science-based Chiropractic: An Oxymoron?

I spent 43 years in private practice as a “science-based” chiropractor and a critic of the chiropractic vertebral subluxation theory. I am often asked how I justified practicing as a chiropractor while renouncing the basic tenets of chiropractic. My answer has always been: I was able to offer manipulation in combination with physical therapy modalities as a treatment for mechanical-type back pain—a service that was not readily available in physiotherapy or in any other sub-specialty of medicine.

If I had it to do over again, however, I would study physical therapy rather than chiropractic. Considering the controversy that continues to surround the practice of chiropractic, I would not recommend that anyone spend the time, effort, and money required to earn a degree in chiropractic. Physical therapy, which is now beginning to include spinal manipulation in its treatment armamentarium, may offer better opportunity for those interested in manual therapy. Properly-limited, science-based chiropractors are now essentially competing with physical therapists who use manual therapy. Unfortunately, only a few chiropractors have renounced the vertebral subluxation theory, making it difficult to find a “good chiropractor.” I consider physical therapy to be more progressive and more evidence based. For this reason, I generally recommend the manipulative services of a physical therapist rather than a chiropractor.

There are some science-based chiropractors who use manipulation appropriately, but until the chiropractic profession abandons the implausible vertebral subluxation theory and is defined according to standards dictated by anatomy, physiology, and neurology, I would not describe it as a science-based profession.
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Neck Manipulation: Risk vs. Benefit

While manipulation of any kind has the potential to cause injury, stroke caused by neck manipulation is of greatest concern. Risk must always be weighed against benefit when upper neck manipulation is considered. Risk of stroke caused by neck manipulation is statistically low, but the risk is serious enough to outweigh benefit in all but a few rare, carefully selected cases.

When the RAND (Research and Development) organization published its review of the literature on cervical spine manipulation and mobilization in 1996, it concluded that only about 11.1% of reported indications for cervical spine manipulation were appropriate and that stroke and other serious complications occurred about 1.46 times per one million neck manipulations.1 In the same year, after examining 183 cases of vertebrobasilar stroke that occurred from 1934 through 1994 following neck manipulation, the National Chiropractic Mutual Insurance Company (NCMIC) concluded that “It has to be accepted that VBS [vertebrobasilar stroke] following SMT [spinal manipulative therapy] does occur.”2
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