Chiropractic – is it manipulation in more than one sense?

Chiropractic is an alternative medicine technique that uses manipulations of  spine, joints and soft tissues to treat various health issues. It is divided into two main schools, traditionalists or ‘straights’, who believe that vertebral subluxations interfere with the body’s ‘innate intelligence’ and ‘mixers’, who incorporate other practices into their treatments. Roughly one third of modern chiropractors are ‘straights’. Due to the extreme variety of beliefs and techniques used under the term ‘chiropractic’, I will concentrate on just some of them.

History of Chiropractic

 Chiropractic is the brainchild of D. D. Palmer (1845–1913), though he borrowed heavily from the ancient practice of bonesetting and the slightly older modernization of it, Andrew Taylor Still’s osteopathy, much to the anger of osteopaths. Palmer, who had previously earned a living as a ‘magnetic healer‘, founded chiropractic in 1895, claiming to have healed his janitor, Harvey Lillard, from partial deafness by manipulating his spine. Initially Palmer tried to keep chiropractic a secret, forbidding anyone else to be present while a patient was being treated, but he soon realised there was more money to be made by training others in chiropractic. So he founded Palmer School of Chiropractic in 1897. Courses originally lasted only three weeks.

Palmer taught that diseases were caused by subluxations interrupting the flow of ‘innate intelligence’, which was seen as vitalistic ‘nerve energy’ or God’s presence in humans, manifested as ‘life force’. He claimed: “A subluxated vertebra, a vertebral bone, is the cause of 95 per cent of all diseases. … The other five per cent is caused by displaced bones, other than those of the vertebral column, more especially those of the tarsus, metatarsus and phalanges, which, by their displacement, are the cause of bunions and corns.” Adjusting these subluxations back into the position would cure the disease.

Palmer published in 1910 The Chiropractor’s Adjuster: Text-Book of the Science, Art, and Philosophy of Chiropractic where he attempts to explains in about 1,000 pages what chiropractic is all about. After wading through the book – complete with bad poetry written in praise of chiropractic – the reader arrives at the explanation that the subluxations impinge nerves, which become either too tense or too slack, thus causing fluctuations of ‘tone’. ‘Tone’ in Palmer’s terms means the “normal degree of nerve tension … expressed in functions by normal elasticity, activity, strength and excitability of the various organs, as observed in a state of health.” (The Chiropractor’s Adjuster, p. 7) As the ‘innate’ was transmitted through the nerves as a vibratory wave, wrong ‘tone’ caused the diseases. How Palmer managed to detect and measure these neural vibratory waves is beyond me.

What caused the subluxations? Practically any physical activity, including sleeping, and unspecified ‘noxious substances’ – this latter was probably Palmer’s attempt of explaining contagious diseases in chiropractic terms.

 Injuries to the spine similar to those caused by railway accidents, are incident to all the avocations of life; they may occur even during sleep. ‘From baby in the high chair to grandma in the rocker,’ the axial bones are as liable to be displaced by noxious substances which enter the system in our food and drink or by inhalation as they are by accident direct.

This, of course, made sure that the chiropractors could treat patients for any disease, even if the patients had no recollection of any injury. All the chiropractor had to do was to locate the corresponding subluxation and adjust it. There will be more said about chiropractic diagnosis later.

Graduates from Palmer’s school soon opened their own schools of chiropractic. The first one was American School of Chiropractic, which opened in 1902. Palmer himself founded a school in Portland, Oregon, in 1903. Chiropractic spread like wildfire, as one chiropractor testified to the U.S. Senate: “We had at one time 200 schools in the state of Michigan. They would start up with anything, in a back parlor for instance. We had a man over on East Capitol Street a few years ago who was advertising to teach chiropractic in 30 days for $10.” Most of these institutions were very short-lived, and some were no better than diploma mills. All in all, of the known 392 chiropractic schools less than half of them were still open after their first year.

The backlash from the medical profession was inevitable. Chiropractors exhibited an unquestionable air of superiority, starting with Palmer, who considered himself a genius. This is a typical quote from him:

 These discoveries and their development into a well-defined science are worth more to the student, practitioner and those desiring health, than all the therapeutical methods combined.

I am the originator, the Fountain Head of the essential principle that disease is the result of too much or not enough functionating. … It was I who combined the science and art and developed the principles thereof. I have answered the time-worn question —what is life?

Other chiropractors were no less boastful. An advertisement by the Universal Chiropractors’ Association claimed:

 No method of combating disease has ever deserved to be called scientific until Chiropractic was developed. The Chiropractor knows — not guesses — but knows — what organs in the body are weak or diseased after he has analyzed the spine. The only reason why a Chiropractor cannot promise a complete cure to every patient in the world — is the possibility that the case has gone so far that Nature herself will not cure it.

Heinrich Matthey, a medical doctor in Davenport, Iowa, accused Palmer of teaching an unproven medical concept and practising medicine without a licence. In 1906 Palmer was convicted of violating medical practice laws and jailed when he refused to pay the $350 fine. He was only one of first of many other chiropractors who were charged for practising medicine or osteopathy without a license. Osteopaths had never forgiven Palmer and the chiropractors for practising what they considered “bastardized osteopathy” and pursued chiropractors with undiminished zeal. Finally, starting in 1913 in Kansas, states started to licensing chiropractors ending with the last state, Louisiana, in 1974.

Chiropractic was also beset with internal trouble. Starting already in 1906, Oakley Smith, a graduate of Palmer’s school, founded a splinter group called naprapathy. He was soon followed by the second ever student of Palmer, Andrew P. Davies, who founded neuropathy, an amalgam of osteopathy and chiropractic. Neuropathy appears to have disappeared without a trace, but naprapathy is still practiced and is popular in some European countries. Palmer was openly disdainful of these splinter groups, but his scorn for them was nothing compared to what was to follow.

Early on, John Howard, who was one of Palmer’s earliest graduates, realized that spinal manipulation could not cure every disease, no matter what Palmer claimed. He started the National School of Chiropractic in 1906 and moved it to Chicago in 1908. His system used light, heat, water, electricity and other forces with chiropractic.

Palmer exploded. He called these ‘mixers’ “unprincipled shysters”, “kleptomanic scavengers” and “grafters and vampires” who chased after “foul, unclean, filthy, unwholesome” methods. Chiropractic now in essence divided into two groups, ‘straights’, who followed the Palmer system and ‘mixers’, who added other methods to their treatments. This splintering has continued to this day and new systems of treatments are constantly being invented. It can be said that today chiropractic is a diverse collection of beliefs and practices under one term.

Palmer’s son, B. J. Palmer, had studied chiropractic under his father, graduating in 1902. When his father suddenly moved to Portland, Oregon, to open a new school, B.J. took over the Davenport school. Upon his return in 1904, D. D. tried to regain the control of the school from his son, only to fail. The best he could do was to go into partnership with his son, and he lost even that when he was jailed in 1906. After being released from the jail, D. D. found that his son had been busy with legal manoeuvres and had obtained the complete control of the school. B.J. would not even let his father enter the campus grounds.

Palmer, after being refused entry to the Davenport school, had travelled from state to state opening new, unsuccessful schools of chiropractic. He returned to Davenport in 1913, intending to lead the homecoming parade. What happened next is somewhat in dispute, since two versions exist. According to one version, B. J. had his father removed from the procession when he refused to ride in a car, according to another, B. J. struck D. D. with his car when D. D. refused to leave. D. D. died three months later in California, officially of typhoid, after having left instructions to sue B. J. and to bar him from D. D.’s funeral. The charge was dropped.

B. J. made chiropractic into a full commercial venture. The students of his schools were now taught business. The courses included Salesmanship, Personal Magnetism, Business Relations, Advertising, Selling the Patient and Keeping Yourself Sold. Even other “alternative medicine” practitioners were offended by the aggressive sales techniques now employed by chiropractors. This legacy is still visible in the modern business practices of chiropractors.

Despite continuing heavy opposition by medical profession, chiropractic became the largest “alternative” health business in America during the 1930’s and it has stayed in that position. In addition to medical opposition, chiropractic also has trouble with advances in scientific medicine and the new efficient drugs. In response, chiropractic schools have improved their curricula, which had been of very low quality, in some cases even any physiological training was absent.

 Claims of chiropractic

Starting with D. D. Palmer, as has been seen before, chiropractic has made sweeping claims about its therapeutic value. Modern claims of conditions that chiropractic can treat include ADHD, agitation, allergies, anxiety, arm pain, asthma, bloating, burping, chest pains, cluster headaches, colic and bed-wetting in babies and children, depression, dizziness/giddiness, ear infections, fatigue, fibromyalgia, foot and ankle issues, hand/finger pains, headaches, heartburn, hip and groin pain, indigestion, insomnia, Irritable Bowel Syndrome, knee conditions affecting ligaments or cartilage, leg cramps, lower back pain with or without leg pain, menstrual and period pains and spasms, mid-back pain, migraines, nausea, neck pain, osteoarthritis, osteoporosis, palpitations, restless legs, restlessness, rotator cuff issues, sciatica, scoliosis, shoulder pain, Tennis or Golfer’s Elbows, vertigo, visual disturbances and wind. Every single one of these modern claims has been taken from currently active chiropractors’ websites.

 Claims like these – only some of the claims have any scientific backing for them, of which more later – are the reason not only medical profession, but also some chiropractors are critical of unsubstantiated claims. The fragmentation that has been inherent in chiropractic since early days is surfacing in the issue of efficacy of chiropractic. Some chiropractors adhere to evidence-based guidelines in their claims, while others apply antiscientific ideas and make claims based on mistaken beliefs stemming from Palmer’s original claims.

Probably the sharpest chiropractor critic of the use of unsubstantiated claims by chiropractors has been Samuel Homola. He writes:

 A good chiropractor can do a lot to help you when you have mechanical-type back pain and other musculoskeletal problems. But until the chiropractic profession cleans up its act, and its colleges uniformly graduate properly limited chiropractors who specialize in neuromusculoskeletal problems, you’ll have to exercise caution and informed judgment when seeking chiropractic care.

 A recent review of chiropractors’ claims found that 95% of the 200 investigated chiropractor websites made unsubstantiated claims about at least one condition that has no scientific evidence that chiropractic is efficient for its treatment. This points to a huge problem with the trustworthiness of claims made by chiropractors and is a serious cause for concern for anyone considering having chiropractic treatment.

Chiropractic diagnostic methods

 As chiropractic deals in most part with treating the subluxations that are causing the patient’s condition, the chiropractic diagnostic methods deal with locating the subluxations. This is far from easy, as will become apparent, so there are hosts of different diagnostic methods. I will deal with only some of them, since dealing with every single one would demand a separate post.

 The easiest method – I have to admit, this is not practised much today – is just to take the symptoms and medical history of the patient, consult any of the chiropractic symptomalogy or treatment manuals and apply the prescribed treatment. This method, however, has a hidden pitfall: chiropractic texts disagree which area of the spine should be manipulated for a condition. For example, Chiropractic Principles and Technique states: “When a subluxation is produced in the lower dorsal or upper lumbar region of the vertebral column, no untoward effects may follow at once. But years later, perhaps, the individual develops typhoid fever.” But Chiropractic Diagnosis states that adjustment should be made in the “middle dorsal, lower dorsal, and upper lumbar area of the spine for typhoid fever.” Yes, I’m aware that these are old textbooks, but the situation has not changed since their publication.

 Most common method is to take the medical history, then examine the posture and inspect and palpate the spine, using motion palpation and nerve tracing, which are chiropractic techniques, together with tests for musculoskeletal function to identify vertebral subluxations. X-rays are often taken to exclude organic disease or injury. Some chiropractors are known to X-ray every single patient that passes their doors, whether X-raying is indicated or not.

Relatively early on, chiropractors came up with the idea of using diagnostic machines to help them to locate the subluxations. One of the first chiropractors to do so was B. J. Palmer. He introduced a diagnostic device called neurocalometer, invented by Dossa D. Evans, in 1924. It had two heat-detecting probes that were moved slowly down the spine. It was supposed to register whether points on either side of the spine had different temperatures. According to chiropractic theory, a subluxation-impinged nerve would be inflamed, thus generating heat, and the subluxation would register hotter than the rest of the spine. There is no scientific evidence for this claim.

‘Straight’ chiropractors were outraged. Palmer had long been regarded as their leader, and now he was introducing machinery to chiropractic, the very hallmark of ‘mixers’. Not only that, but he was not going to sell his neurocalometers, they were to be leased on very high fees: $1,000 advance payment and monthly instalments of $10 for a minimum of 10 years. The contract also stated that the leaser had to charge the patients a minimum of $10 per use. As a result, ¾ of Palmer’s students left the school and enrolment dropped to under 500. Many members of the faculty also left, opening a new school in Indianapolis, to which most of the former students of Palmer’s school moved. Those who actually had leased the gadget soon became dissatisfied and a number of lawsuits followed. The modern versions of this device are still marketed and are being used by many chiropractors.

 Applied kinesiology is used to identify internal problems, like weak organs, by testing muscle vitality. Muscles are tested manually for resistance. The theory behind this diagnostic practice is that every organ dysfunction is accompanied by a weakness in a specific corresponding muscle, called the viscerosomatic relationship. Double-blinded tests have shown that the test cannot distinguish between the test substance and a placebo and that applied kinesiology tests are not reproducible.

 Depending on the quality of the chiropractic school the practitioners have graduated from, their diagnostic skills may be far below of what would be required. This is a problem especially where chiropractic and chiropractic schools are not effectively regulated by mandatory registration, and has historically been an ongoing issue in chiropractic.

Hunting the wily subluxation

 The greatest problem chiropractic has is its basic premise, that diseases are caused by subluxations. Even the use of subluxation has been controversial from its very beginning, and today some chiropractors reject both the concept and the term. However, it is supported by other chiropractors.

So what is the subluxation in the chiropractic sense? The WHO defines it as:

 A lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. It is essentially a functional entity, which may influence biomechanical and neural integrity.

The ACC (The Association of Chiropractic Colleges) definition is:

A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence.

Chiropractors have been trying to prove the existence of vertebral subluxations ever since D. D. Palmer first came up with the concept without any success. Some – usually ‘straight’ – chiropractors claim that subluxations show readily on an X-ray, others deny this. When chiropractors have been challenged to provide the X-ray images with the visible subluxations, they have refused. I wonder why.

Some chiropractors resort to trying to waffle the issue completely. A representative quote comes from Tedd Koren, DC:

The vertebral subluxation cannot be precisely defined because it is an abstraction, an intellectual construct used by chiropractors, chiropractic researchers, educators and others to explain the success of the chiropractic adjustment.

This is not a unique state of affairs, abstract entities populate many branches of science…

Subluxations, genes, gravity, the ego and life are all heuristic devices, “useful fictions” that are used to explain phenomenon that are far larger than our understanding. We use them as long as they work for us and discard or limit their application when they become unwieldy or unable to account for new observations…

Critics of chiropractic have incorrectly assumed that chiropractic is based on the theory or principle that vertebral subluxations cause “pinched” nerves that cause disease. They have it backwards. Chiropractic is based on the success of the spinal adjustment. The theory attempting to explain the success of the adjustment (nerve impingement, disease, subluxations) followed its clinical discovery.

This rather disingenuous attempt at explanation ignores completely what D. D. Palmer claimed:

About 95 per cent of diseases are due to vertebrae being racked out of alignment; the remainder is caused by sub-luxations of other joints. An example of the latter cause is the case of a sprained knee which a student has just relieved by one adjustment. Replacing the projecting portion of the knee which was impinging upon a nerve gave immediate relief.

Let’s face it, subluxations have never been detected, even chiropractors disagree whether they exist or not, and there has been not a single scientific shred of evidence for their existence. Once these are removed, what reason there is any longer for ‘straight’ chiropractic and the exaggerated claims I presented earlier?

It’s only fair that I will let chiropractors themselves have the last word on subluxations:

…there were no studies that demonstrated a satisfactory link of evidence to the chiropractic subluxation construct as per strength, consistency, specificity, temporal sequence, dose response, experimental evidence, biological plausibility, coherence, and analogy. Specifically, there were no studies that found subluxation to have a relative risk or odds ratio. No studies were found that demonstrated the subluxation to be consistently found in different people of gender or race, location or even circumstance. Subluxation was not found to be specifically linked to any one disease complex. Temporal sequence studies were not noted. The subluxation was not noted in any studies related to dose response. Animal based studies that were used to satisfy the experimental evidence were limited. There were no studies that offered a biological plausibility that would isolate subluxation as a causal factor in disease. There were no studies linking the subluxation as a coherent construct and supported by generally known facts about the natural history and biology of any disease. There were no studies found that suggested the subluxation as a causal agent similar to other factually demonstrated causal agents.

Dangers of chiropractic

 Chiropractic is relatively safe – with one major exception, and that is the cervical manipulation. This is done by the chiropractor rotating the head of the patient to rotate the spine. The extreme motion associated with this technique can cause the vertebral artery to stretch and tear its lining. A blood clot that forms over the injured area can dislodge and block a smaller artery that supplies the brain. This can cause stroke, which in some cases has resulted in death.  This is what happened to Pierrette Parisien:

 Parisien, a 36-year-old mother of two who lived in the Montérégie region southwest of Montreal, had receiving regular chiropractic care from the same practitioner for nine years before her death. She went for treatment in February 2006 after she developed headaches and dizziness from acute neck pain. Parisien visited a chiropractor three times that winter, with the third visit proving to be her last. She fell unconscious after treatment and slipped into a coma, dying two days later.

 Whatstheharm.net has more cases where chiropractic treatment has caused death or severe injury.

 The greater danger is reliance on questionable chiropractic claims and dubious diagnostic tests they perform.

In 2011, Beverly Yardley had attended the Functional Endocrinology Center in Denver, Colorado, for a lump on her neck. This center was run by Dr Credeur, a chiropractor. When she asked Dr Credeur about the lump, he told her, “Well it’s some kind of thyroid disorder probably,” and “We’ll get you on a healthy diet and healthy lifestyle”. Turns out it was Stage 2, B-cell lymphoma. This doctor performed diagnosis by glance, and that is definitely not proper practice. Reliance on such would have patients dying of misdiagnosed illnesses.

 The scientific evidence for chiropractic

There is high-quality evidence that chiropractic is effective for acute and chronic low-back pain, knee osteoarthritis (only as a part of other treatment regimes, not alone), and Tennis Elbow. The evidence is inconclusive or contraindicatory for all the other conditions chiropractors claim to treat.

 If you decide to visit a chiropractor for any of these conditions, there are still a few things to keep in mind.

 Make sure that the chiropractor you visit is a ‘mixer’ and not a ‘straight’. Better still, if they have a website, check that they claim to treat musculoskeletal conditions only.

 Avoid any chiropractor who relies on dubious diagnostic devices and techniques, such as the neurocalometer or applied kinesiology described earlier.

 Don’t let the chiropractor talk you into long series of treatments, and check how long similar physiotherapy treatment would last. On no account buy into the marketing hype that you need chiropractic treatments “for as long as you want to stay healthy”. This is an attempt to tempt you into having so-called maintenance treatments, which are of no known efficacy.

 And, finally, make sure whether there are treatments by physiotherapists that would have a similar result. Physiotherapists are registered, regulated and have gone through thorough medical training. Very often you will also find that their treatments come at a much lower price, and in the case of UK, where I reside, are free on your GP’s referral.