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Chiropractic Still Controversial After Nearly 100 Years

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Chiropractic Still Controversial After Nearly 100 Years Powered By Docstoc
					Essays of an Information Scientist, Vol:3, p.529-537, 1977-78     Current Contents, #27, p.5-13, July 3, 1978




                                                      CURRENT                  COMMENT’S



                                                  Cbfropractic:     Stflf Controversial
                                                      After     Nearly   100 Years




                Whenever a journal article on                   chiropractic is making increasing
             chiropractic   appears, there is a                 inroads into American health care.
             good chance it will bear a title                      According     to Dorland’s     illus-
             similar to the one in the September                trated   Medical    Dictionary, chiro-
             13, 1974 issue of Science—’’Chiro-                 practic is a system of therapy based
             practic: Healing or Hokum?” 1Since                 on the belief that all disease is caus-
             1895, when Daniel David Palmer,                    ed by the abnormal functioning of
             a Davenport,        Iowa tradesman,                the nervous systems Chiropractic
             founded the profession that ad-                    attempts to restore the normal
             vocates healing through           spinal           functioning of the nervous system
             manipulation,      chiropractic      has           by manipulation and treatment of
             been in the center of controversy.                 the structures of the human body,
             On one side are the chkopractors                   especially the spinal column. The
             who say that millions of patients                  word chiropractic is derived from
             have found relief through chh-                     the Greek and means “done by
             practic. On the other is the medical               hand. ”d
             establishment, which advocates the                    Each year chiropractors           see
             view advanced in a 1968 report to                  about 5 million patients, who come
             Congress,     Independent        Practi-           to them with a variety of complaints
             tioners Under Medicare, submitted                  ranging from infectious diseases
             by then Health, Education and                      and physical handicaps to back
             Welfare secretary Wilbur J. Cohen,                 ailments. A high percentage of pa-
             an eminent educator. The report                    tients is seen for musculoskeletal
             concluded      that     “Chiropractic              problems.s When a patient visits a
             theory     and practice       are not              chiropractor,     he or she usually
             based upon the body of basic                       receives a spinal X ray and ex-
             knowledge      related    to health,               amination. fJ After the analysis of
             disease and health care that has                   the problem has been completed,
             been widely accepted by the sci-                   the chiropractor     makes an “ad-
             entif ic community. ”z Yet, in spite               justment” to the patient’s spine.
             of its lack of a scientific   basis.               Thk is accomplished through what



                                                         529
chiropractors    call a “dynamic                       umes tnrougn apprentlcesntp          to
thrust ,“ a quick movement that                        other      doctors.    In     addhion,
usually produces a “click” sound in                    magnetic healing, which combined
the joint      manipulated.   Spinal                   the “laying on of the hands” with a
manipulation is performed to adjust                    form      of    hypnotherapy,      and
a subluxation or misalignment of                       naturopathy,     or drugless healing,
the vertebrae. Practitioners believe                   were popular forms of health care,
that correcting the subluxation will                      Out of this unregulated environ-
cure the disease or condition being                    ment, chiropractic      emerged. By
treated.                                               most accounts, D. D. Palmer, who
   When       chiropractic     was intro-              started chiropractic, was a former
duced at the end of the 19th cen-                      grocer and fishmonger who felt he
tury, the health care professions in                   had a gift for healing.s,g He
the United States, especially in the                   operated a magnetic healing studio
midwest and west, were relatively                      in Davenport at the time of hk
unregulated.’f      There were several                 “discovery.” One of Palmer’s pa-
theones     of healing, based on dif-                  tients was Harvey Lillard, a janitor
ferent    philosophies       of disease. 5             who had been deaf for some 17
Homeopaths,          for example,        fol-          years. Discouraged that magnetic
lowed      the teaching        of Samuel               healing was not helping Lillard,
Hahnemann         of Leipzig. In 1810 he               Palmer examined his patient and
originated      a system of treatment                  found a protruding painful area on
that involved the administration            of         his back near his spine. He decided
small doses of drugs whose effects                     that attempting to reduce the bump
resembled the effects of the disease                   might bring the janitor some relief.
being treated.                                         Giving Lillard an adjustive thrust,
   Shortly before chiropractic           was           Palmer reportedly properly aligned
established,       Andrew     Taylor    Still          the patient’s vertebrae and restored
founded osteopathic         medicine.’l,v,s            his hearing.
Still believed      that the way drugs                    Scientists, however, object to the
were used and surgery performed in                     assertion that spinal manipulation
his day did more harm than good.                       cured Lillard’s hearing. According
His school of thought placed em-                       to William M. Keane, a neuro-
phasis on recognizing and correct-                     otologist at Philadelphia’s Penn-
ing structural problems and ad-                        sylvania Hospital, Department of
vocated manipulative therapy as                        Otorhlnolaryngology,      nerves con-
well as other types of treatment.                      trolling hearing are self-contained
Allopaths, or conventional medical                     in the skull and inaccessible to
doctors, made up the major group                       manipulation. Manipulation of the
of practitioners.   These doctors                      vertebrae might help some kinds of
sometimes got their training in                        dizziness, but not hearing loss.
university medical schools, some-                         Nevertheless, from his treatment




                                                 530
of Lillard, Palmer developed the
theory of chiropractic and began
teaching      others     his methods.
Among hk students was a son,
Bartlett Joshua Palmer, who is now
called the “Developer” of chiro-
practic medicine.
   Like many other fields, chir~
practic’s early history was marked
by dissent and factionalism from
within. Shortly after its founding, a
rift developed between father and
son, prompting         them to have
separate practices for a time and
causing      the     development     of
separate schools of chiropractic.9
Some of the early students—who
happened       to be medical doc-
tors-rejected       the notion     that
chiropractic      methods     were    a
panacea. A. L. Foster, M. D., for
example, wrote, “Other methods of
treatment have shown their effec-
continued to this day. Physicians              practicing    medicine      without   a
reject what they see as a one cause-           license.g     In      1925,    in    an
one cure profession and assert that            attempt to raise the quality of
there is no scientific evidence to             health care in their respective
support the profession’s teachings.            states, both Connecticut and Wis-
In addition,      they attack      the         consin passed “basic science” laws
chiropractor’s claim of being an en-           that required all practitioners to
try point into the health care system          take exams in anatomy, bacteri-
comparable to the general practice             ology, chemistry and other sciences
physician. Until recently, oppm                before they could apply to take
nents say, chiropractic education              their board examinations. Medical
has been in such a shambles that               authorities hoped, and many chiro-
graduates were hardly prepared to              practors thought, that chiropractic
produce an adequate diagnosis and              was doomed to extinction by the
so not enough patients were re-                stringent requirements. s In fact,
ferred to other members of the                 few chiropractors were licensed in
health care professions. Chiroprac-            those states immediately following
tic treatment also delays the patient          the implementation of the boards.
from seeking appropriate medical               But basic science boards were not
care, thus causing consequences                adopted by other states until much
that otherwise might have been                 later, and so ch~ropractic flour-
avoided, they state. Far too many X            ished. By 1931, chiropractors were
 rays are given as part of chiroprac-          legally recognized in 39 states.
tic diagnosis, critics continue, ex-           Many of the states changed their
posing patients       to unnecessa~            laws and regulations         regarding
levels of radiation. Manipulative              chiropractic     through the years,
therapy can sometimes be painful               often raising standards for licensing
and is not without its hazards, they           or wavering between the philos-
add. 10                                        ophies of the “straight” chiro-
    Despite the criticism, chiroprac-          practors and the “mixers.”
tic has made steady gains through-                By 1974, cldropractic had won
out this century. Even as the health           licensure in Louisiana and Missis-
care professions came under state              sippi, the last two states to thus
licensure (with regulations favoring           recognize the practice. At present,
medical doctors), chiropractic sur-            about 17,000 people practice chiro-
vived while alternative health care            practic in the US and another 4,000
systems like “magnetic healing”                practice    it in other countries.
 died. In 1913, Kansas became the              Switzerland, West Germany, New
 first state to legally recognize              Zealand, South Africa and Bolivia
 chiropractors.   Several states fol-          all regulate chiropractic. S In Bri-
lowed suit, but not before many                tain, the practice of chiropractic is
chiropractors    were arrested for             unlicensed, but it is not illegal.




                                         532
Belgian     chiropractors        practice       at         macle cmropractlc           colleges      that
the pleasure          of the crown           and           were accredited      eligible for federal
French      practitioners      are unregu-                 funding.    The American            Medical
lated. In Italy, achlropractor             must            Association      contested       chwoprac-
work under          a licensed       allopath.             tic’s recognition     but was told that
Nine Canadian          provinces     and one               the Commissioner        does not have to
Australian       province       license       the          express    an opinion        on the use-
practicers      well. From informal in-                    fulness or legitimacy of the field of
quiries I have learned that chiro-                         training.    Accredited         institutions
practic     is not unknown              in the             simply    meet     educational         stand-
USSR. It enjoyed a vogue in the                            ards. 1I
past. The Soviet government                 does              The CCE set up standards for
not license chiropractors.           It would              chiropractic schools. 5 For example,
seem that chiropractic          is tolerated,              students admitted to an accredited
however.                                                   school must have completed two
    Once the states accepted the pro-                      years of a science curriculum in a
fession, chiropractic         turned its at-               college. A course of study that in-
tention to the problems            of federal              cludes at least 1840 hours of basic
recognition.      In response to a seven-                  science     (anatomy,      physiology,
year effort by chiropractors                 and           chemistry, pathology and hygiene)
supporters,      who lodged a vigorous                     and 2080 hours of clinical science,
mail campaign, 10Congress, in 1972,                        including    diagnosis,    gynecology
passed a law (PL 92-603) that said in                      and obstetrics, principles of chiro-
part that Medicare payments could                          practic and other such subjects,
go to chiropractors             for manual                 must be followed. Eighty hours in
manipulation       of the spine to correct                 requirements selected by the col-
a subluxation        that appeared        on an            lege and 200 more hours in optional
X ray. The coverage under Medi-                            electives must also be taken, bring-
care was gained despite opposition                         ing the total number of hours re-
by medical         physicians      and some                quired to 4,200 for the four-year
senior citizens’ groups.                                   course. The chiropractic profession
    Another      victory     came in 1974                  feels that the upgrading of educa-
when      the US Commissioner                   of         tional standards and formal ac-
Education       granted the Council of                     creditation of its colleges have done
 Chiropractic       Education      (CCE) the               much to invalidate some criticisms
 right to accredit        chiropractic       col-          by its opponents. However, it is still
 leges as institutions of higher learn-                    possible to question the value of an
 ing. The CCE is an autonomous                             education based on an unproven
 corporation      sponsored by the ACA                     theory.
 and the Federation         of Chiropractic                   At present there are four chiro
 Licensing     Boards       of the various                 practic colleges in the US that are
 states. 5 The commissioner’s             action           accredited. 5 They are the Los




                                                     533
Angeles College of Chiropractic        in            The      chiropractic    community
Glendale,    California;   the National           publishes its findings in a body of
College    of Chiropractic     in Lom-            journal literature that is largely
bard, Illinois; Northwestern     College          unknown to health care profes-
of Chiropractic      in St. Paul, Min-            sionals in other disciplines. There
nesota; and Texas Chiropractic       Col-         are at least two major             US
lege in Pasadena, Texas. Four more                chiropractic journals representing
colleges in the US have achieved                  the two chiropractic factions: the
status as recognized candidates for               ACA Journal of Chiropractic       and
accreditation.  Three foreign col-                the     International      Review   of
leges are also affiliated with CCE.               Chiropractic.     In addition, almost
  Besides   qualifying for Medicare               every state and five Canadian prov-
payments    and federal funding for               incial associations sponsor their
their accredited     colleges, chiro-             own journals. Foreign journals of
practors have been eligible since                 chiropractic are published in Aus-
1974 for the National Institutes of               tralia, Britain, New Zealand, and
Health grants for research into                   Africa.
spinal manipulation.                                 Chiropractic     journals are not
   Lack of research has indeed been               covered in the major indexing ser-
a resounding criticism against the                vices, including Index Medicus and
profession.    Chiropractors      have            ISI” ‘s Science Citation Index@ .
responded that prejudice kept them                Neither are they covered in Current
out of the running for government                 Contents” . At 1S1, we have not
grants, which support much of the                 purposely excluded these journals.
medical     community’s      research.            They have never been covered for
Now chiropractors have at least a                 several reasons. Lack of demand
potential source of funding. Yet                  for their inclusion is but one. The
neither of the two grants awarded                 primary reason is their lack of
by NIH for research into spinal                   scholarly content. For example, the
manipulative therapy has gone to a                International   Review of Chiroprac-
chiropractor.                                     tic is little more than a newsletter.
   The profession’s stated concern                The ACA Journal of Chiropractic
with research is indicated by its                 contains one or two “professional
establishment of the Foundation for               papers” in each issue, but none
Chiropractic   Education and Re-                  that I saw documented original re-
search. This nonprofit institution                search.
makes grants for research and has                    Despite the strides made by their
supported projects at the University              profession, chiropractors feel they
of Colorado at Boulder and the                    still have several stumbling blocks
Rensselaer Polytechnic Institute in               to overcome.      The majority of
Troy, N.Y. s In addition, chiroprac-              chiropractors    who are “mixers”
tic colleges are conducting their                 note that all “usual and customary”
own research projects.                            chiropractic services are covered



                                            534
by most private health insurance                   one such dewce, called the spectiic
plans, but that Medicare         and Blue          adjustment machine, could, “with-
Cross plans only pay for spinal                    out exceeding pressures recom-
manipulative     therapy     and not for           mended for use on humans.. put a
the other types of treatment         they          nail through a half-inch board.” He
prescribe. They are also continually               states that “if the compressor gauge
fighting    against    legislation    that         or part of the control mechanism
 would limit their practice to spinal              becomes      defective,   the device
manipulation only.                                 could maim or kill the ‘patient.’ “12
    Chkopractors also regularly face                  Beyond all of this, chiropractors
opposition    from journalists     and             say that people who visit them do
consumer advocates. For example,                   get well and point to case histories
in 1976, the practitioners were dealt              to support their assertions.s The
a blow by a Consumer Reports                       claim is supported by social science
study. The study concluded that                    research as well. The chiropractor
chiropractic is a “significant hazard              “often succeeds in treatment when
 to many patients.” It decried the                 other practitioners have failed,” ac-
“aura of legitimacy” licensing laws                cording to a study by psychiatrist
have lent to the practice. The                     Gregory Firman and sociologist
report also urged government to                    Michael S. Goldstein. 13 “Whether
restrict the chiropractors’ scope of               this success is due in fact to greater
practice to musculoskeletal com-                   professional skill and knowledge
plaints. In addition,       it recom-              (particularly in the musculoskeletal
mended that chiropractors be pro-                  area), to more positive feeling
hibited from treating children. 11                 engendered in the patient by the
    After urging readers to recon-                 ‘patient’ orientation of the practi-
sider before going to a chwoprac-                  tioner, as opposed to the ‘illness’
tor, the report then listed some                   orientation of the physician, or to
pointers, offered by chiropractors,                the placebo effect of the ‘laying on
to those who would go anyway.                      of the hands’ is unclear. ” 13 Accord-
Readers were told to avoid practi-                 ing to chiropractors,      the practi-
tioners who make claims about                      tioners succeed because they treat
cures, ask the patient to sign a con-              the whole patient, not just part of
tract for services, advertise free X               one.
rays, want advance payments or                        Palmer’s theory      of vertebral
charge for extra units of treatment,               subluxation     causing pressure on
or who talk of irreversible damage                 spinal nerves has been found er-
if treatment isn’t started right away.             roneous in a scientflc test. 14 And
   Moreover,     Professor    Edmund               you would think that any school-
Crelin of the Yale-New Haven                       child who has had a course in
Medical Center warns of potentially                hygiene would be suspicious of
lethal devices which many chiro-                   anyone claiming to cure tuber-
practors use. He has reported that                 culosis by spinal manipulation. Yet



                                             535
chiropractic    rolls on, attracting        been published        on changes m
more patients each year.                    neural proteins after nerve dam-
   Perhaps    spinal    manipulation        age. 21 While I cannot comment on
therapy is efficacious  for a certain       the merits of this research, it is still
small group of physical conditions.         far from the clinical testing that
If so, the onus is on the chiroprac-        chiropractors themselves could do.
tors to prove it. But, according to         I suppose, if any clinical research
Dr. H. Thomas Ballantine, Jr., of           based on chiropractic theory were
Massachusetts      General Hospital,        to satisfy the standards of leading
“the chiropractors and their pro-           medical journals,        it would be
ponents      have    challenged    the      published in one of them. I have not
medical profession and the biologic         seen such an article yet.
scientists to disprove the theory and           What we don’t know about
efficacy of chiropractic. ” IS It is        chiropractors     is the number of
time that chiropractors      produced       backs they have literally broken or
their own body of documented                the nerve damage they have caus-
research    as scientific evidence.         ed. But then we really don’t know
Their inability or unwillingness to         how often physicians make bad
do so does much to invalidate their         diagnoses, or perform poor or un-
claims.                                     necessary      operations.       Medical
   Of course,       the chiropractic        science still has a long way to go
associations have begun to fund             before it will be able to cure the
research     which is relevant      to      myriads of diseases and physical
chiropractic. So far, work at the           conditions, One might argue that
University of Colorado, which was           the state of medical science and the
supported in part by these funds,           inadequacy of some of its practi-
has led to the publication of papers         tioners have enabled chhopractic
in such mainstream journals as               to thrive. Human beings have the
Brain     Research,     Mathematical         eternally    optimistic    belief that
Biosciences,     and     Expen”mental        somewhere, somehow, something
Neurology.    Several of these papers        will provide a cure.
have concerned      models of neuron            Lest there be any doubt about my
networks,    neuron    configurations,       opinion on this subject, let me
and nerve compression.      16-19 Other      reiterate.     Much       chiropractic,
work reported     a method of preci-         especially that which claims a cure
sion analysis of spinal X rays, which        for cancer or heart disease, is a
would enable researchers to record           palpable and dangerous fraud. The
more accurate data on the exact              only controversy        concerns     the
positions of tissues of the spinal col-      other possibly legitimate applica-
umn.zo Research findings have also           tions of spinal manipulation.




                                          536
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