Critical views of chiropractic

Chiropractic has received its share of criticism from the health sciences, most particularly from physicians in the USA, where the practice of chiropractic has its largest base. Some of these criticisms have also been echoed within the chiropractic profession. This article discusses criticisms that have been expressed by notable sources, and includes the rebuttals of chiropractors to these views. Reporting a criticism, or its rebuttal, here, does not imply that either is endorsed by Citizendium or its editors.

Introduction

Critics from the medical establishment, especially in the USA, have claimed:

• that an organized subgroup of chiropractors in the USA openly promote "drugless healing" as a business model of total health care, and even advocate expansion of market base into the care of the well child.
• that chiropractic accepts too low a standard of academic and scientific scholarship in its professional journals and schools.
• that chiropractic argues that such coursework in "medical diagnosis" qualifies its practitioners to be fully qualified to make medical evaluations, and to rule out signs of serious disease.
• that the entire basis (vertebral subluxation) of chiropractic theory is not scientifically sound.
• that some chiropractors advise parents that all vaccinations have higher risks and less benefit than any organized health science or biological science group accepts, thus exposing children to the risk of preventable illnesses and putting the general population at risk of epidemics. Worryingly, this subgroup is the same group that advocates chiropractic as comprehensive primary health care for children.
• that, in the USA, chiropractors are not trained in medicine, nursing, or health science, and so are not competent to act as comprehensive primary health care providers, yet some subgroups of chiropractors make that claim, without protest by the larger profession.
• that chiropractic accepts a general level of self-promotion in advertising that is unprofessional and misleading.
• that while chiropractic has only been shown to be effective for backpain, and some types of headache, chiropractors advertise for and treat patients for non-musculoskeletal conditions like infant colic, none the less.
• that the chiropractic profession promotes the notion that chiropractic is effective in "muscloskeletal conditions", when the evidence for relief of backpain does not in any way show that chiropractic care helps conditions such as myasthenia gravis, multiple sclerosis, or rheumatoid arthritis, or other serious and common conditions that a reasonably knowledgeable layman would assume to fall into the category of "musculoskeletal conditions"

History of antagonism between the AMA and chiropractic

In the 1960's, the American Medical Association (AMA) vehemently criticized chiropractic, and 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 was 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, engage 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.". Since then, there has been more co-operation between medical physicians and chiropractors in the USA, and many family doctors are willing to refer their patients on to chiropractors for certain conditions. However, there is still little evidence that mainstream medicine in the USA accepts chiropractic as a full partner in health care. Although physicians today acknowlege that business interests can distort their ideals of practice, academic physicians feel that any financial conflict of interest is beside the point. In university-based medicine, decades of effort have been 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, they believe, made by the same criteria that have been used to transform American Medicine.

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." Chiropractors point to evidence that they have significantly upgraded their standards of education and research independently of Medicine, and without public funding; improvements in chiropractic standards have been acknowledged by the AMA, who indeed claimed that this was a positive outcome of their campaign. Chiropractors say 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 in its use of evidence. Chiropractors claim that their training and experience in musculoskeletal conditions exceeds that of conventional physicians, and that, for several conditions, evidence-based methods have shown that chiropractic treatments are at least as effective as conventional treatments and that the risks are fewer.

Chiropractic today: many styles of practice

The varying schools and philosophies within chiropractic have led to a wide variation in practice patterns—along with debates over theory, practice, and future directions. Chiropractic was begun by an individual who did not accept the newly-emerging germ theory of disease, and who, like most healers of the time, had no formal training in science. He chose a vitalistic path for his new concept, describing an "Innate Intelligence" as the force behind the body's response to dis-ease. As chiropractic grew, an increasing emphasis on educational standards and on science in professional schools was encouraged by the creation of the CCE, chiropractic's accrediting body. Its purpose was to maintain standards of education while allowing the philosophies of the individual schools to remain intact. Some schools hold to the old tenets of Palmer, while others increasingly use science-based knowledge. At one end of the spectrum, some chiropractors adhere closely to the beliefs expressed by the founders of chiropractic and tend to reject some of the basic tenets of biological medicine, while other end practitioners reject such traditional chiropractic notions as vertebral subluxations and 'Innate Intelligence', and focus on the objective benefits of the chiropractic techniques. The vast majority practice somewhere in between these extremes.

"Straight" chiropractors limit their practices to analyzing the spine and correcting subluxations; those who retain a literal belief that they are affecting "Innate Intelligence" are often called "superstraights"; chiropractors who mix spinal manipulation with other treatments are called "mixers". These factions have been in disagreement with each other for most of chiropractic's history, disagreements that have been fought out in courts and state legislatures and remain unresolved. Both classes are criticised by Health Sciences, but for partly different reasons: straights for allegedly overusing spinal manipulation and applying it to conditions for which it offers no benefit, mixers for a claimed propensity to promote dubious ‘remedies’, including homeopathic remedies and dietary supplements of no demonstrated benefit. Both classes have, particularly in the past, opposed many scientifically-based public health measures including immunization, fluoridation, pasteurization of milk, prescription drugs and surgery.

The chiropractic perspective

Some critics claim that an organized subgoup of chiropractors in the USA openly promote "drugless healing" as a business model of total health care, and even advocate expansion of market base into the care of the well child.

Chiropractors indeed believe that it is important to minimise the use of drugs, and see their role in particular as being to pursue alternatives to drugs. They believe that preventative care is also an important part of health care, one that is particularly important for children.

Drugless stance on healing

Some critics are concerned that while chiropractic has been shown to be effective for backpain, headache and certain musculoskeletal conditions, chiropractors treat patients for a much wider range of conditions where there is no strong objective evidence that their interventions are effective.

Most chiropractors take a drugless approach to healing, considering that the side effects of drugs can complicate the patient's health status. Physicians are 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 misled into not taking 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.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 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. They claim to work to relieve pain using manual methods and expect that this will minimize the need for medications and thus reduce the potential for side effects which carry greater risk than of any of their treatments.

The spinal cord carries a vast amount of information from peripheral organs and tissues to the brain, including sensations of pain, touch, and 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 might influence virtually any 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.

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.

Some critics have warned about the over-willingness of chiropractors to accept anecdotal evidence of efficacy, while conversely, 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.

Anecdotal evidence is subject to recall bias, which is the human psychological tendency to preferentially recall unusual cases and forget routine cases. Recall bias is the reason why anecdotal evidence of efficacy or safety of a treatment has been discounted by the mainstream medical community. The scientific method has been embraced by the mainstream medical community as the ideal technique for determining the truth; the scientific method is simply the testing of hypotheses with experiments. Anecdotal evidence is therefore not scientific evidence of efficacy, and too encumbered by recall bias to garner acceptance as a way of rationally determining the truth. The mainstream medical community views anecdotal evidence as a way of generating new hypotheses for later scientific testing, not as proof of any hypothesis in and of itself.

Joseph Keating, professor at the Los Angeles College of Chiropractic and a prominent historian of chiropractic said in 1997 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 chiropractic techniques. However, in 1998, Keating published a review about the Journal of Manipulative and Physical Therapy from 1989-1996. He concluded that scholarly activity within chiropractic had improved significantly, and 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."

Scientific foundations of chiropractic

Some critics have claimed that the theoretical basis of subluxation is not scientifically sound.

The founder of chiropractic, D.D. Palmer, thought that most 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 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..

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 for example, Ronald Carter, a former President of the Canadian Chiropractic Association, proposed that the "subluxation story" should be abandoned, suggesting 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 D.D. Palmer's theories remain speculative. Chiropractors believe that their own experience of the efficacy of chiropractic for their patients is sufficient justification for retaining Palmer's explanations. Some chiropractors also believe that retaining these concepts are important for the future of Chiropractic as a viable, independent profession, believing that this will ensure that Medicine will not absorb chiropractic.

Chiropractors also feel that criticism of the scientific basis of their treatments smacks of 'double standards', and feel that scientific evaluation of treatment interventions are similarly lacking in many areas of care that are fully accepted by Medicine. They believe that family doctors do not routinely investigate the causal basis of their patients' symptoms, but usually prescribe treatments based on their clinical experience of what has been effective in similar cases in the past - just as chiropractors do.

Vaccination

Some critics claim that some chiropractors advise parents that all vaccinations have higher risks and less benefit than any organized health science or biological science group accepts, thus exposing children to the risk of preventable illnesses and putting the general population at risk of epidemics.

Efforts by the chiropractic profession to dissuade people from accepting the polio vaccine in the 1950's and 1960's in the USA sparked much of the resentment towards chiropractic that spawned the AMA lawsuit, and which still hinders chiropractic from being accepted as a member of the health sciences. Even today, some chiropractors believe that there is a link between autism and additives in vaccines on the basis of early studies that have been extensively criticised, and despite evidence from large well-controlled studies showing no such link.[5] 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 to avoid medicines and drugs, 'traditional straight' chiropractors are opposed to compulsory 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. Many chiropractors support immunization for life-threatening diseases such as polio or diphtheria, but some think that, when new vaccines are introduced to protect against relatively benign conditions such as chicken pox, the balance of benefits and risks is less clear. Because chicken pox carries a relatively small risk of death or disability, the possible risks of vaccination might outweigh the benefits, and they believe that the principle of informed consent should apply, giving the individual the right 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.

Other chiropractors hold views in line with those of physicians and public health officials, and have spoken out against chiropractic policies that they feel don't do enough to oppose anti-vaccination efforts. 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." In Canada, chiropractors have been formally prevented from advising against vaccination.

Limited versus unlimited provision of healthcare

Some critics argue that chiropractic's claims for health benefits beyond certain musculoskeletal complaints are not warranted.

The sharpest 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 standard medical treatments. These are mainly aimed at those chiropractors who follow the traditional ideas of chiropractic as an unlimited healing art, and who most aggressively market the profession as a general alternative to the health sciences. Currently, that traditional "straight chiropractic" philosophy is best represented in the USA. There is concern that many chiropractors promote popular beliefs that critics claim are outside their scope of practice and professional knowledge, and which are rejected by mainstream science and medicine. Chiropractic is effective in some musculoskeletal conditions, but critics claim that this is unreasonably generalized to "musculoskeletal conditions", a phrase without specific meaning that does not include the conditions, such as myasthenia gravis, multiple sclerosis, or rheumatoid arthritis, that any reasonably knowledgeable layman might assume to be such a condition.

Many physicians are concerned about all treatments that have no accepted scientific basis or validated evidence of efficacy, because ineffective treatments might delay more appropriate treatment. In 1998, the 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. 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. 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 children, not only because of the unknown risks of treatment, but also because they fear that parents may be risking their children's health 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 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 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. Chiropractors argue that their education in physical examination is equivalent to that in the health sciences, and so consider this concern unwarranted.

Competence

Some critics claim that chiropractors are not trained to diagnose medical diseases and so are not competent to act as comprehensive primary care health care providers

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. Today's chiropractor has completed courses in medical diagnosis and patient management designed to allow them to assess patients at the entry level and make appropriate decisions for treatment or referral. Some chiropractors have hospital privileges, while others are involved in integrated healthcare environments that employ the skills of all branches of healthcare, but most are sole practitioners in the primary care role. With the advent of Health Maintenance Organizations (HMOs), most third 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. Most chiropractors consider themselves well prepared as primary care providers.

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 plaintiffs 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 unethical and unprofessional. Chiropractors, on the other hand, enthusiastically embraced advertising and, being 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 advertisements for such services as Cosmetic surgery and drugs are now common in the USA.

Safety and consent

Critics of chiropractic have expressed doubt about the safety of chiropractic. This includes doubt over the repeated exposure of chiropractic patients to X-rays based on the scientifically dubious theory of subluxations, the risk of fracture and dislocation, and the risk of vertebral artery dissection. Manipulation of the neck can lead to strain on the vertebral artery, and critics point to people who have had serious injuries and death resulting from chiropractic neck manipulation.

In Trick or Treatment, a book by Simon Singh and Edzard Ernst, the case of Laurie Mathiason, a Canadian woman who died following chiropractic neck manipulation, is presented along with legal findings regarding the culpability of the chiropractor involved. A number of other cases are listed from Canada, and Canadian research is presented which the authors claim implies that chiropractic treatment can increase the risk of arterial damage by a factor of five. Based on this, Singh and Ernst raise questions about whether or not chiropractors are adequately abiding by the requirements of informed consent that are present in most nation's health regulatory frameworks. They point to a study of British chiropractors published in 2005 on their approach to consent policy which found that only 23% of chiropractors in Britain discuss potential serious side effects of chiropractic treatment - Singh and Ernst conclude that this is not sufficient either to meet the rules regarding consent set by the British government's Department of Health or the rules set out by the General Chiropractic Council in the UK.

Contextually, the possible safety problems and shortcomings in informed consent procedure are particularly damaging as many chiropractors, as with many alternative medicine practitioners, are frequently critical of the side-effects of "established" or "mainstream" medicine.

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