Critical views of chiropractic

Chiropractic, like other alternative medical professions, has received its share of criticism from the allied health sciences and, most particularly, from physicians. Some of these criticisms have also been raised within the profession. This article documents and explains critical views of chiropractic profession where they have been expressed by notable sources.

Critics have claimed:

• that Chiropractic accepts too low a standard of academic and scientific scholarship in its professional journals and schools.
• that the theoretical basis of chiropractic is not scientifically valid.
• that Chiropractic's claims for health benefits beyond certain musculoskeletal complaints are not warranted, and that chiropractors are not trained in the diagnosis of medical diseases, and so are not competent to act as comprehensive primary care health care providers.
• that rejecting universal vaccination in favor of "personal choice" puts the general population at risk for epidemics if the immunization rate falls too low, and that rejecting vaccination can expose pediatric patients to risk of preventable illnesses.
• that the care of patients with conditions that have never been shown to be efficaciously treated by chiropractors is not warranted if patients forego medically recommended vaccinations and treatments,
• that Chiropractic accepts a level of self-promotion in advertising considered unprofessional and misleading.

What is the evidence that supports or refutes them? What aspects of chiropractic practice and medical practice have combined to produce these particular complaints? Why is there controversy within the chiropractic profession about at least some of them? Chiropractors appear to respond to these allegations differently depending on their particular professional orientation. Each point is discussed in this article.

Introduction

Chiropractic has not only survived a century of controversy, but has thrived, becoming the most popular alternative medical profession in the West.

Thirty years ago, the American Medical Association (AMA) vehemently criticized the profession as "quackery" and tried to prevent it from receiving federal funds for healthcare in the USA. Chiropractic was protected by a federal judge who found those attacks to be orchestrated in an attempt to eliminate chiropractic practice altogether and to be motivated by physician self-interest.

However, there is still little evidence that mainstream medicine in the USA accepts Chiropractic as a full partner in health care, and at least some of that reluctance has been because of the critical views listed. The USA is particularly important when discussing Chiropractic, because it is the country that gave birth to the field and because it still holds the great majority of practicing chiropractors in the world. Many of the criticisms made by physicians and other health science professionals are also expressed by some chiropractors, and many of these criticisms are aimed only at subsets of chiropractors who follow particular practices and schools of philosophy, rather than the entire profession.

Chiropractors respond to some of the criticisms of the AMA and its members by saying that chiropractic research has been starved of funds, and that they have been prevented from integrating into hospital-based medicine by a medical profession that has been selective and dishonest in its use of evidence. In the 1960's, the AMA discouraged physicians from cooperating with chiropractors in patient treatment, research and educational activities such as sharing clinical research data. Chiropractors were denied access to hospital facilities, and, for instance, medical doctors were discouraged from aiding chiropractors in interpreting electrocardiograms. As a result, four chiropractors brought an antitrust case against the AMA and others, and in 1987 a Federal Judge ruled that the AMA were guilty of an illegal conspiracy to suppress competition. The judge said that the evidence at the trial showed that the AMA had taken “active steps, often covert, to undermine chiropractic educational institutions, conceal evidence of the usefulness of chiropractic care, undercut insurance programs for patients of chiropractic, subvert government inquiries into the efficacy of chiropractic, engaage in a massive disinformation campaign to discredit and destabilise the chiropractic profession and engage in numerous other responses to maintain a physician monopoly over health care.”

Although physicians today are willing to acknowlege that business interests can distort ideals of practice, and the AMA lost its legal appeals to the ruling, academic physicians feel that financial conflict of interest reveals only a minor concern. Among leaders in university based medicine, there have been decades of efforts devoted to upgrading medical practice and medical research, and in marshalling the medical profession towards more scientifically based practice. Their criticisms of the chiropractic profession are made by the same criteria that have been used over the last century to effect the transformation of American Medicine, and have become no less acute since the court ruling.

Chiropractic today: many styles of practice

As the varying schools and philosophies within Chiropractic are less cohesive than those within other health professions, such as Nursing or Physical Therapy, a range of practice patterns is to be expected - along with debates over theory, practice, and future directions. Why are chiropractors less cohesive in their views than, for example, physical therapists or nurses? Unlike these other relatively young professions, Chiropractic was begun by an individual who did not accept the newly emerging germ theory as the cause of disease, and who had no formal training in science. He chose a vitalistic path for his new concept, describing an "Innate Intelligence" as the driving force for the body's response to dis-ease. However, as Chiropractic developed, there has been increasing emphasis on educational excellence and on science in professional schools. As some hold to the old tenets of Palmer and others cite their newfound knowledge from science, there becomes a wide range of practice styles. At one end of the range, some chiropractors reject some of the basic tenets of biological medicine and adhere closely to the beliefs expressed by the founders of chiropractic, while at the other end, some practitioners reject such traditional chiropractic notions as vertebral subluxations and "Innate Intelligence" altogether, and focus on the objective benefits of the chiropractic techniques of care.

Criticism from the Health Sciences has been mainly about the extent of chiropractic practice (the range of conditions for which chiropractors offer treatment), and about advice that chiropractors give against vaccines and standard medical treatments. There is concern 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 believe there is a link between autism and additives in vaccines, and advise their patients on this basis, whereas large well-controlled studies have concluded that there is no such link.[5] For these reasons, a segment of health science professionals have remained very sceptical of, or even hostile to, Chiropractic. Such hostility is most common in the USA, where regulation of Chiropractic (and the health sciences) is less vigorous than in Europe or Canada, and where there are more chiropractors than anywhere else.

Interestingly, the editorial view of Chiropractic from the Health Sciences, even in the USA, has also been complimentary, at least compared to other forms of alternative medicine. One authoritative medical textbook praises chiropractic (by comparison with other fields of alternative medicine) stating: "unfortunately, most of the other fields have no agreed upon practice standards, credentialing processes, requirements for continuing education, or accountability."

Evidence standards in chiropractic

• Some critics claim that Chiropractic accepts too low a standard of academic and scientific scholarship in its professional journals and schools.

In particular, some critics (and some leaders of the Chiropractic profession) have warned about the over-willingness of chiropractors to accept anecdotal evidence of efficacy , while conversely, 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 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.

Joseph Keating, professor at the Los Angeles College of Chiropractic and a prominent historian of chiropractic has written extensively to criticise weaknesses in the arguments of chiropractors, and disreputable practices within the profession. In 1997, he said that "the doubting, skeptical attitudes of science do not predominate in chiropractic education or among practitioners". He stated that there is scientific support for chiropractic's main intervention method (spinal manipulation of patients with lower back pain), but chiropractic's culture has nurtured antiscientific attitudes, and poor science published in poor journals by chiropractors who are not well trained in science has given chiropractors false confidence about the value of various other chiropractic techniques.

However, in 1998, Keating published a review about the Journal of Manipulative and Physical Therapy (JMPT, the discipline's "most distinguished periodical") from 1989-1996. He concluded that scholarly activity within Chiropractic had improved significantly over this period, saying that "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 recognized by the NIH Library of Medicine, and the only one indexed in Index Medicus.

Chiropractors submit that though these criticisms hold some validity, they feel they unfairly hold chiropractic to a higher standard than medicine when considering that scientific evaluation of treatment interventions in all disciplines is lacking.

Scientific foundations of chiropractic

• Some critics have claimed that the theoretical basis of chiropractic is not scientifically valid.

The founder of Chiropractic, DD Palmer, thought that most all health problems were caused by spinal misalignments ("vertebral subluxations") that blocked the flow of "innate intelligence" along spinal nerves. Accordingly, he proposed that chiropractic adjustments might be effective in treating many diseases (indeed, almost any disease). Since then, chiropractors have been alert for evidence that their manipulations might be beneficial in conditions not directly related to the spine. There is some evidence (from case studies) that in some cases they do have benefits, but this evidence is generally regarded as weak because it may be influenced by the beliefs and expectations of the patient and the practitioner, and improvements after treatment may be coincidental instead of causally related. A common criticism of chiropractors has been the willingness of some to treat conditions where there is no validated basis for believing chiropractic to be effective, especially conditions that might be life-altering without concurrent medical care .

Several concepts used by chiropractors are not used in the Health Sciences; in particular, the concepts of 'vertebral subluxation' and 'innate intelligence'. Some chiropractors recognise that these concepts are impediments to better integration with the Health Sciences, and have urged the Chiropractic community to abandon them. For example, Ronald Carter, a former President of the Canadian Chiropractic Association, proposed that the "subluxation story" should be abandoned rather than simply re-packaged. He suggested that 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.

Other chiropractors have gone further, Samuel Homola, an outspoken dissident within the profession, has argued that evidence-based chiropractic is the only way forward for chiropractors to gain greater acceptance by conventional medicine. Homola's views however represent those of only very few chiropractors.

For scientifically minded physicians, the lack of proof that nerve conduction is actually affected by chiropractic manipulation means that DD Palmer's theoriesremain speculative.

Vaccination

• Some critics claim that rejecting universal vaccination in favor of "personal choice" puts the general population at risk for epidemics if the immunization rate falls too low. Especially, some critics are concerned that rejecting vaccination can expose pediatric patients to risk of preventable illnesses like whooping cough (pertussis) and lockjaw (tetanus).

Despite overwhelming evidence that vaccination is a highly effective way of controlling infectious diseases, many chiropractors are opposed to vaccination. For example, a survey in the Canadian Province of Alberta found that 27% of chiropractors advised their patients against having themselves or their children immunized (about the same proportion as advised in favour of immunization). 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), supports 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) [6] and the World Chiropractic Alliance (WCA)[7] have adopted very similar positions.

While 'freedom of choice' seems innocuous to those who are unfamiliar with the biology of vaccination, to scientists and physicians there are public health consequences if more than a very few people opt out of universal vaccination. For vaccination to be effective in controlling infectious diseases that spread from person to person, there must be a very high immunity rate in the population (typically 85% or higher). If too many people 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 people who are unvaccinated, but also people who have already accepted the risk of vaccination for the greater good. 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 supported policies of compulsory vaccination and consider it irresponsible for organisations like the ICA and ACA not to do likewise.

Those chiropractors who advise against certain vaccinations are not convinced that evidence for its benefits always outweighs the risks to an individual. While the percentage of those willing to immunize for life threatening diseases such as polio or diptheria may be higher, when new vaccines are introduced to protect against relatively rare conditions or conditions such as chicken pox, the balance of benefits and risks is much harder to establish. Because the risks associated with chicken pox are not considered to have a high incidence of death or disability, the possible risks in the vaccine itself may outweigh the benefits. They feel that the individual should be allowed to make the choice for themselves. Such skepticism is not restricted to Chiropractic, but as a healthcare profession, this position has greater implications in the fields of public health. In Canada, chiropractors have been formally prevented from advising against vaccination.

The general efforts of the chiropractic profession to dissuade the public from accepting the polio vaccine in the 1950's and 1960's in the USA may have sparked some of the bitter resentment towards chiropractic that spawned the AMA lawsuit and hinders chiropractic from being accepted as a member of the health sciences. However, some chiropractors now hold views more in line with physicians and public health officials and have spoken out against chiropractic policies that they feel don't do enough to prevent anti-vaccination efforts by members of the profession. Writing in Dynamic Chiropractor, Stephen Perle and Randy Ferrance : say they are not aware "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 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

• Some critics argue that Chiropractic's claims for health benefits beyond certain musculoskeletal complaints are not warranted, and that chiropractors are not trained to diagnose medical diseases and so are not competent to act as comprehensive primary care health care providers. Some are also concerned that chiropractors are not trained in the diagnosis of medical diseases and are therefore not competent to act as comprehensive primary care health care providers.

Many physicians are concerned about all treatments that have no accepted scientific basis or validated evidence of efficacy, because ineffective 'alternative' treatments might delay more appropriate treatment. In 1998, the American Medical Association (AMA) published a report on "Alternative Medicine". About Chiropractic, it stated that manipulation has reasonably good efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints, that some chiropractors limit their practices to these conditions, and that, in a national survey of family physicians and internists, 47% said they would refer patients for chiropractic treatment. However, the Report also said that most chiropractors "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 as a statement of Policy, said that "Patients who choose alternative therapies should be educated as to the hazards that might result from postponing or stopping conventional medical treatment."

Pediatricians are especially concerned about chiropractic treatment of infants and children, not only because of the unknown risks of treatment, but also because they fear that parents unknowingly risk their children's lives by not having them seen by a physician who is properly trained in childhood diseases in a timely manner. Chiropractic treatment of infantile colic, otitis media, "excessive crying", or Attention Deficit Hyperactivity Disorder are common points of contention.

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. Chiropractors believe that any treatment that results in using less medication has value, even if it might be effective only because of its 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 three days before beginning a regimen could save as many as 30% from unnecessary exposure to antibiotics. Chiropractors, who are trained 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 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.

While chiropractors have shown to be as or more competent than their medical counterparts in the musculoskeletal arena, physicians are concerned when claims are made that chiropractors are primary care providers, a term used to describe entry level physicians or general practitioners. This designation may also be a remnant of the AMA boycotting efforts that resulted in elevating chiropractic education standards in order to diagnose and accomodate patients without requiring a referral from a physician. However, with the advent of Health Maintenance Organizations (HMOs), most 3rd party payors consider chiropractic as a specialty field that may be considered a portal of entry (not requiring a referral from a physician) for musculoskeletal conditions. This is a designation that bodes well for science minded chiropractors, who acknowledge that Medicine is better equipped to manage the variety of patients that enter primary care. Subluxation based chiropractors continue to consider themselves primary care, though these numbers may be getting smaller.

Drugless stance on healing

• Some critics are concerned that the care of patients with conditions that have never been shown to be efficaciously treated by chiropractors is not warranted if the patient forego medically recommended vaccinations and medically prescribed treatment, because such care exposes patients to proven risk without offering proven benefit.

Although the practice of Chiropractic has changed considerably since its inception, most chiropractors continue to take a drugless approach to healing. Physicians remain concerned that this 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 serious conditions that can be treated effectively with medications may be led to not take potentially life-saving treatments, such as insulin, blood pressure regulators, and cholesterol lowering drugs. They are also concerned that patients may even forego laboratory tests such as colonoscopies and physicals that can "catch" some cancers while they are still treatable.

Advertising

• Some critics claim that Chiropractic accepts a level of self-promotion in advertising that is unprofessional and misleading.

In 1992, attorney George McAndrews, who represented the plainiffs in the Wilk ''et al.'' vs AMA court case, wrote an open letter to the chiropractic profession warning that 'scare tactic' advertising damages the newly won respect within the AMA.

For most of the 20th century, physicians in the USA disdained advertising as both unethical and unprofessional. Chiropractors, on the other hand, enthusiastically embraced advertising and, because they were outside the organisational components of referral mechanisms found in medicine, considered this an acceptable option. More recently, the formal sanction against physician advertisements has been lifted, and currently media advertisements for such services as Cosmetic surgery and drugs are common in the USA.

The chiropractic perspective

Chiropractors suggest that they continue to be misunderstood by the health sciences. 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. They claim to work to relieve pain using manual methods and expect that this will minimize the need for pain medications and thus reduce the potential for side effects which carry greater risk than of any of their treatments.

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. Scientists and physicians generally are skeptical about these possibilities, while believing that, in some cases, chiropractic treatment might be efficacious because it exploits the placebo effect in an efficient way.

Some chiropractors nevertheless believe that several conditions can be resolved by chiropractic interventions. Such beliefs are based on their clinical experience, not on 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 what seems to be a symptom of an organ disease is actually the result of a 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 original cause of the problem. Regardless, chiropractors feel that their high patient satisfaction rates and low malpractice rates show that their patients are well informed about the limitations, the risks, and the benefits.

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