Critical views of chiropractic

As the most popular of the alternative medical professions in the West, chiropractic stands alone as a major profession in the healing arts that is outside the Health Sciences. Accordingly, in its 100-year history, Chiropractic has been under frequent attack from Osteopathy, from Medicine, and from scientists critical of its scientific foundations. None the less, its appeal to patients is such that Chiropractic has not only survived, but thrived. At this time, the most profound criticisms of Chiropractic probably come from the chiropractic profession itself. As the varying schools and philosophies within Chiropractic are even less cohesive than those found within other health professions, such as Nursing or Physical Therapy, a range of practice patterns with the profession are to be expected - along with controversies over theory and practice, and debate about the future direction of the field.

Why should Chiropractic be less cohesive in underlying views than, for example, Physical Therapy or Nursing? Unlike the founding philosophies of these other relatively recent health professions, Chiropractic was originated by an individual who disdained the newly emerging germ theory of disease , and had no formal training in science. However, like these other professions, as Chiropractic developed, there has been an increasing emphasis on educational excellence in professional schools, with a strong focus on science in the classroom. Overall, this has resulted in a very wide range of individual practice styles in current chiropractors. At one end of the range, some chiropractors who reject basic tenets of biological medicine, while at the other end, some chiropractors who reject such traditional chiropractic notions as vertebral subluxations and "innate intelligence" altogether.

The purpose of this article is to document and explain critical views of chiropractic where they have been expressed by notable sources, whether from within the chiropractic profession or from scientific or medical sources. Criticism from the public, when organized by consumer groups, is also briefly noted. Reporting a criticism here does not imply that that criticism is endorsed by Citizendium or its editors.

Health Sciences

Current criticism from the health sciences has been mainly directed at concerns over the extent of chiropractic practice (the wide range of conditions that some chiropractors are willing to offer treatment), and at the advice that chiropractors give to their patients against vaccines and standard medical treatments. There is also deep concern about what is seen as a weakness in the scientific quality of the professional literature of chiropractic. For these reasons, a segment of health science professionals have remained very sceptical of or even hostile to chiropractic practice. Such hostility is most common in the USA, where regulation of chiropractic (and the health sciences) is less vigorous than in European and Canadian health care systems, and where the chiropractic profession is much larger than in any other country.

Interestingly, the editorial view of chiropractic from Medicine and the health sciences, even in the USA has also been complimentary, at least in comparison to other forms of alternative medicine. One authoritative medical textbook, in reference to chiropractic as one field of alternative medicine states: "unfortunately, most of the other fields have no agreed upon practice standards, credentialing processes, requirements for continuing education, or accountability."

Evidence standards in chiropractic

There is concern about what is seen as weakness in the scientific quality of the professional literature of chiropractic. Some critics, and indeed some of the leaders of the chiropractic profession, have warned about the over-willingness of chiropractors to accept anecdotal evidence of the efficacy of chiropractic. , while on the other hand, when adverse events are associated with chiropractic manipulations (for instance when a patient has a stroke soon after a spinal adjustment) chiropractors are too ready to dismiss the adverse event as “unrelated". In short, the criticism is that many chiropractors are too ready to embrace evidence that is supportive of chiropractic, however weak it may be, and too quick to denounce evidence of its risks unless the evidence is overwhelming. In both cases, the scientific view would advise caution in interpretation and careful further investigation under controlled conditions.

In 1997, the historian of chiropractic Joseph Keating described chiropractic as a 'science, antiscience and pseudoscience', and said "Although available scientific data support chiropractic's principle intervention method (the manipulation of patients with lower back pain), the doubting, skeptical attitudes of science do not predominate in chiropractic education or among practitioners". He argued that chiropractic's culture has nurtured antiscientific attitudes and activities, and that "a combination of uncritical rationalism and uncritical empiricism has been bolstered by the proliferation of pseudoscience journals of chiropractic wherein poor quality research and exuberant over-interpretation of results masquerade as science and provide false confidence about the value of various chiropractic techniques".

This does not apply to all research on chiropractic; in 1998, after reviewing the articles published in the Journal of Manipulative and Physical Therapy (JMPT) from 1989-1996, Keating concluded that "substantial increases in scholarly activities within the chiropractic profession are suggested by the growth in scholarly products published in the discipline's most distinguished periodical (JMPT). Increases in controlled outcome studies, collaboration among chiropractic institutions, contributions from nonchiropractors, contributions from nonchiropractic institutions and funding for research suggest a degree of professional maturation and growing interest in the content of the discipline." However the JMPT remains the only chiropractic research journal that is recognized by the NIH Library of Medicine, and the only one indexed in Index Medicus.

Scientific foundations of chiropractic

Several concepts that are widely used by chiropractors are not used in the conventional health sciences; in particular, the chiropractic concepts of vertebral subluxation and innate intelligence. Some leaders of the chiropractic profession have recognised thqt these concepts are impediments to greater integration of chiropractic and healthsciences, and have urged the community to abandon them.

Vaccination

There is also concern among health science professionals that many chiropractors promote popular beliefs that lie outside their scope of practice and professional knowledge and which are rejected by mainstream science and medicine. For example, some chiropractors promote their belief in a link between autism and additives in vaccines, and promote their opinions as almost certainly true, rather than entirely speculative.

Despite overwhelming evidence that vaccination is a highly effective method of controlling infectious diseases, many chiropractors are strongly opposed to vaccination. For example, a survey in the Canadian Province of Alberta found that 27% of the chiropractors who completed the survey advised their patients against having themselves or their children immunized (about the same proportion as advised in favour of immunization). At this time, in Canada,

In line with a general philosophy of chiropractic to avoid medicines and drugs, 'traditional straight' chiropractors are opposed to childhood vaccination. Their main association, the International Chiropractors Association (ICA), is "supportive of a conscience clause or waiver in compulsory vaccination laws, providing an elective course of action for all regarding immunization, thereby allowing patients freedom of choice in matters affecting their bodies and health." The American Chiropractic Association (ACA) [4] and the World Chiropractic Alliance (WCA)[5] have adopted very similar positions. Although personal choicce seems innocuous to those who are not intimately familiar with the biology of vaccination, unless very few people elect out of universal vaccination there are Public Health consequences.

For vaccination to be effective as a way of controlling infectious disease spread between people, there must be at a very high immunity rate in the population (typically 85% or higher). If too many individuals are unvaccinated, then there is a real risk of an outbreak of disease, and because vaccination is never 100% effective, this puts at risk not only those who are unvaccinated, but also those who have already accepted the risk of vaccination for the greater good.

What are the risks of vaccination? What are the risks of being unvaccinated? Bradley, P. Should childhood immunisation be compulsory? [Journal Article] Journal of Medical Ethics. 25(4): 330-334, 1999 Aug.

Because of this, the policy has to be compulsory to be fair, otherwise a few who avoid vaccination gain benefits at the expense of the majority. Accordingly, many scientific and medical organisations have strongly and publicly supported policies of compulsory vaccination and consider it irresponsible for organisations like the ICA and ACA not to do do likewise.

Those chiropractors who do advise against vaccination are not convinced that the evidence for its effectiveness outweighs the possible risks to an individual. However, in Chiropractic, there has been a long history of resistance to acceptance to the benefits of vaccination and of the acceptance of ancedotal reports of illnesses and conditions that occur in children during the the same early childhood years when vaccinations are given as likely to represent a harmful side effect of the vaccinations. The resistance to the endorsement of vaccination by Chiropractic even occurred during the 1950's and 1960's when the polio vaccines stopped the epidemic of childhood paralysis in the United States and elsewhere. The willingness to accept conditions as due or probably due to vaccines because of evidence and logic considered grossly inadequate and faulty by scientists is evident by a review of the chiropractic literature.

When new vaccines are introduced to protect against relatively rare conditions, the balance of benefits and risks is much harder to establish, particularly because the risks are uncertain without extensive experience over a prolonged period. Such skepticism is not restricted to chiropractic; what is particular to chiropractic is a belief by some that chiropractic offers a feasible alternative to vaccination. It is not clear how common such beliefs are amongst chiropractors, but they have been expressed for example by the WCA.

Some chiropractors are speaking out against anti-vaccination views. For example, writing in Dynamic Chiropractor, Stephen Perle and Randy Ferrance harshly criticise anti-vaccination chiropractors: "We are not aware," they write, "of a single well-controlled study which found that chiropractic care prevented any infectious disease or reduced the severity of such a disease." They declare that it is dishonest of chiropractors to warn their patients about the danger of vaccinations without advising them of their benefits, and endorse the guidance of the College of Chiropractors of Ontario, which states, in its "Standard of Practice", that "Chiropractors may not, in their professional capacity express views about immunization/vaccination as it is outside their scope of practice."

Limited v Unlimited Provision of healthcare

It wasn't so long ago that a college president suggested, "Rigor mortis is the only thing we can't help!" Joseph Keating, chiropractic historian.

A chiropractor is a cultist -- in the medical sense, a person who assumes all disease stems from one cause or can be cured by a single method. According to the chiropractor, there is one common denominator in all disease-nerve interference; and one panacea for every ailment -- the spinal "adjustment" that removes such interference. Kathleen Cassidy Doyle, cited by Samuel Homola

Many physicians are concerned about all treatments that have no established scientific basis or clearly validated evidence of efficacy, feeling there is a risk that ineffective treatments might delay more appropriate medical treatment. Chiropractors divide themselves into those who practice "subluxation based" care and those that restrict their practices to musculoskeletal type problems. Subluxation based practices claim to improve health by removing interference to the nervous system. Physicians and scientists are particularly skeptical about the benefits of chiropractic for illnesses not directly related to the spine. Pediatricians are especially concerned about the use of chiropractic care for infants and children, not only because of the unknown risks associated with the treatments, but they fear parents unknowingly risk their children's lives by not having them evaluated by a physician properly trained in childhood diseases in a timely manner. Chiropractic treatment of infantile colic, otitis media, and issues relating to vaccination are common points of contention.

Infantile colic

For example, infantile colic is a condition characterised by uncontrollable crying in infants with no clear cause: some reports suggest that chiropractic is efficacious, others do not. Chiropractic is also used to treat asthma; and can be efficacious, but probably no more so than placebo treatment. Placebo effects can be very powerful, indicating the important ability of the mind to contribute to healing, and in some cases chiropractic might be efficacious because it exploits the placebo effect in an efficient way. Chiropractors believe that any treatment that results in less dependence on medication has value, even if it might only be effective because of the reassuring and calming effect on the mother and/or child.

Otitis media

Otitis media in infants is another condition that some chiropractors claim to manage efficiently. In the past, antibiotics were the treatment of choice, but recent studies suggest that waiting as long as three days before beginning a regimen could save as many as 30% from unnecessary exposure to antibiotics. Chiropractors, who also have training in physical examination, believe that they have an important 'watchful waiting' role in monitoring otitis media. However, many physicians feel that, even if chiropractic treatment of such conditions has some benefits by exploiting the placebo effect, there is a risk that false reassurance delays more appropriate medical treatment and that chiropractors, unlike pediatricians and primary care physicians, do not have the examining skills required to know when referral to a specialist in Ear, Nose and Throat (Otolaryngology) is required to prevent permanent hearing loss or complications such as brain abscess.

Use of CAMs

Mixer chiropractors may use a wide variety of alternative type treatments in their practices, sometimes for conditions where there is no good scientific evidence that these treatments are efficacious. These may include nutritional supplements, acupuncture, applied kinesiology, and prayer.

Drugless stance on healing

Although the practice of chirpractic has changed considerably since its inception, most types of chiropractors continue to take a drugless approach to healing within their own practices. Physicians remain concerned that this position can mislead some patients into thinking that all drugs are unnecessary or even harmful, and to overestimate the body's intrinsic ability to remain healthy. They fear that some patients with specific serious conditions that can be treated effectively with medications may even be led to not take these potentially life-saving treatments, such as insulin, blood pressure regulators, and cholesterol lowering drugs. They are also concerned that patients may even forego life-saving testing laboratory tests such as colonoscopies and physicals that can "catch" some cancers while they are still treatable.

American Medical Association (AMA)

In 1998, the AMA published a report on Alternative Medicine. Referring to chiropractic, this stated that manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints, and that some chiropractors limit their practices to these conditions. The report also acknowledged that, in a national survey of referral patterns by board-certified family physicians and internists, 47% said they would refer patients for chiropractic treatment. However, the AMA Report also suggests that most chiropractors continue to claim that chiropractic manipulation cures disease rather than simply relieving symptoms. "They promote manipulation as useful in a host of conditions, ranging from infectious diseases to immune therapy, even claiming to prevent future conditions from occurring (even if years away) including menstrual irregularity, difficulty giving birth, and cancer. Chiropractors commonly provide advice in nutrition and other preventive practices, and maintain that a regular series of "adjustments" is needed by most persons to maintain optimal health." In 1997, the AMA adopted as a statement of Policy that "Patients who choose alternative therapies should be educated as to the hazards that might result from postponing or stopping conventional medical treatment."

The chiropractic perspective

Because they feel that healing comes from within the body, chiropractors don't talk of 'cure', but of 'helping the body cure itself'. As a result, the traditional chiropractor sees all who suffer as in need of his or her help. The degree to which they claim to be able to help varies, not only from condition to condition but also from case to case, and also because different chiropractors use different techniques. The spinal cord does carry a vast amount of information from peripheral organs and tissues to the brain, including sensations of pain, touch, temperature. In addition, virtually every organ and its blood supply is regulated both directly by efferent nerves, many of which travel down the spinal cord, and indirectly by neuroendocrine regulation of hormone secretion. Accordingly, disruption of spinal information flow can influence virtually every organ system. However it is not clear that any particular organ dysfunction is caused by a disorder of spinally-mediated information transfer, or whether manipulation by chiropractors could correct such a disorder, and scientists and physicians generally are skeptical about these possibilities.

Since the original observations of DD Palmer, chiropractors have been alert for evidence that their manipulations might have such beneficial effects. There is evidence (from case studies) that they can, but this evidence is generally regarded as weak because it may be influenced by the prior beliefs and expectations of the patient and the practitioner. Only if it leads to an objective protocol for intervention with objectively verifiable efficacy can it be regarded as validated. A common criticism of chiropractors has been the apparent willingness of some to offer treatment for conditions where there is no validated basis, especially those that might be life-altering without concurrent medical care.

Some chiropractors nevertheless believe that several conditions can indeed be resolved by chiropractic interventions. Such beliefs are based on their clinical experience, not on firm scientific evidence from large controlled trials, and not on any scientific demonstration of a causal mechanism linking the intervention to its claimed effect. It is possible that cases that have not responded to conventional treatment might include some where the underlying cause is indeed a disorder of neural regulation of an organ system, as the failure of conventional treatment might be taken as excluding more common causes of dysfunction, such as infectious disease. It is also possible that a symptom apparently of an organ disease is actually the result of a somatic reflex pain generated from the spine. Thus, if an organ-related complaint responds to chiropractic adjustments, it is possible that a spinal condition was the cause of the problem in the first place.

External links

Controversies within the chiropractic profession

Examples of the debates within chiropractic include:

• Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor

Samuel Homola DC, a second generation chiropractor and an outspoken dissident within the profession, expresses his opinion that evidence-based chiropractic is the only way forward for chiropractic to gain greater acceptance by conventional medicine.

• Chiropractic, Bonesetting, and Cultism - Samuel Homola (entire book on-line).

This book, published in 1964, contains trenchant criticism of the profession, and the following year Homola's application to renew his membership of the American Chiropractic Association (ACA) was rejected. In 1991, David Redding, chairman of the ACA board of governors, welcomed Homola back to the ACA. In 1994, 30 years after its publication, the book was reviewed for the first time in a chiropractic journal. [6]

• Chiropractic Ethics: An Oxymoron?

JC Smith DC writes in 1999 that ethical issues are "in dire need of debate" because of "years of intense medical misinformation/slander" and because of well-publicised examples of tacky advertising, outlandish claims, sensationalism and insurance fraud.

• Critical thinking

Christopher Kent, president of the Council on Chiropractic Practice, advises his colleagues of the importance of high standards of evidence, noting that in the past DCs were too ready to accept anecdotal evidence

• Open Letter to the Profession (See Chiroweb for commentary.)

A 1992 letter from attorney George McAndrews, who represented the plainiffs in the Wilk ''et al.'' vs AMA court case, warns the chiropractic profession that 'scare tactic' advertising damages the newly won respect within the AMA.

• Subluxation - The Silent Killer

A 2000 commentary by Ronald Carter, Past President of the Canadian Chiropractic Association discussing his opinion that the "subluxation story", regardless of how it is packaged, is not the answer. He suggests it is time for the 'silent majority' to present a rational model of chiropractic so that it can become an essential member of the health care team.

• Joseph Keating, professor at the Los Angeles College of Chiropractic and a prominent historian of chiropractic has written extensively both to criticise weaknesses in the arguments used by chiropractors, and to denounce disreputable practices within the profession. In 1997, he described chiropractic as a 'science, antiscience and pseudoscience', and said "Although available scientific data support chiropractic's principle intervention method (the manipulation of patients with lower back pain), the doubting, skeptical attitudes of science do not predominate in chiropractic education or among practitioners"[7]. He argued that chiropractic's culture has nurtured antiscientific attitudes and activities, and that "a combination of uncritical rationalism and uncritical empiricism has been bolstered by the proliferation of pseudoscience journals of chiropractic wherein poor quality research and exuberant over-interpretation of results masquerade as science and provide false confidence about the value of various chiropractic techniques". However, in 1998, after reviewing the articles published in the Journal of Manipulative and Physical Therapy (JMPT) from 1989-1996, he concluded,

"substantial increases in scholarly activities within the chiropractic profession are suggested by the growth in scholarly products published in the discipline's most distinguished periodical (JMPT). Increases in controlled outcome studies, collaboration among chiropractic institutions, contributions from nonchiropractors, contributions from nonchiropractic institutions and funding for research suggest a degree of professional maturation and growing interest in the content of the discipline."

Criticism from other professions, and public groups

• Keeping Your Spine In Line, Adjusting the Joints, and Video - Alan Alda, PBS, Scientific American Frontiers Web Feature (combines internal and external criticism)
• Chirobase: Skeptical guide to chiropractic history, theories, and current practices - Stephen Barrett MD and Samuel Homola DC (combines internal and external criticism)
• Novella S (1997) Chiropractic: Flagship of the Alternative Medicine Fleet Part One and Part Two