Critical views of chiropractic

In its 100-year history, chiropractic has been under frequent attack from osteopathy, from conventional medicine, from scientists critical of its scientific foundations, and recently from web-based critics of its advertising tactics and of the extravagent claims and dubious practices of some chiropractors. Although the profession has survived, and indeed thrived, the profession itself has voiced many of these critical views of chiropractic in a move to reform chiropractic from within.

The purpose of these article is to document and explain these critical views where they have been expressed by notable sources, whether from within the chiropractic profession or from scientific or medical sources. Reporting a criticism here does not imply that that criticism is endorsed by Citizendium or its editors. It is not the intent to comment on the merits of the various criticisms; counter arguments can be raised against any criticism, and these are generally not reported except insofar as the explanation may contain an implicit defence.

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.

• 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. [7]

• 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 criticising both 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". 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 (The 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."

Chiropractic treatment of non-spinal disorders

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 [8]

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.

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. They are particularly skeptical about the benefits of chiropractic for illnesses not directly related to the spine.

Criticism from the 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 stated 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."

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 might only be effective because of the reassuring and calming effect on the mother and/or child. Otitis media in infants is another condition that some DCs claim to manage efficiently[9][10]. 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.[11] Chiropractors, who also have training in physical examination, believe that they have an important 'watchful waiting' role in monitoring otitis media. Many physicians however feel that even if chiropractic treatment osf such conditions has some benefits by exploiting the placebo effect, there is a risk that false reassurance delays more appropriate medical treatment and that chiropracters, 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.

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 DCs could correct such a disorder.

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, from their clinical experience but without firm scientific evidence, that several conditions can indeed be resolved by chiropractic interventions. In particular, 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. .

Chiropractic and vaccination

Despite overwhelming evidence that vaccination is a highly effective method of controlling infectious diseases, some chiropractors maintain a strongly antivaccination bias. 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. 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) has adopted a very similar position.

This attitude continues to have a negative influence on both public acceptance of vaccination and acceptance of the chiropractic profession by orthodox medicine, and is contrary to the general belief of the medical profession that mass vaccination has enormous health benefits and is an essential part of a responsible public health policy. For vaccination to be effective as a way of controlling disease, there must be at a very high vaccination rate in the population (typically 85% or higher), at which point, for an individual, the risks become greater for vaccination than for avoiding vaccination, because every vaccination generally carries some low level of direct risk. However, 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. 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 do do likewise.

Some chiropractors are speaking out against anti-vaccination doctrine. 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."

External criticism

• 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