The chiropractic professions,like Rodney Dangerfield and Aretha
Franklin, Longs for respect.While the popularity of chiropractic
continues to grow ( of the estimated 80% of people with back problems,
two-thirds opt for chiropractic treatment), the road to official recognition has been long and arduous. Mainstream medical doctors have criticized chiropractic education, and have until recently branded the entire profession " quackery."
The word "chiropractic" is derived from the Greek words, cheir, meaning hand, and Praktikos, meaning practics, which is suitable since a large part of chiropractic therapy involves spinal manipulations. Although the founding of the profession is credited to a former Iowa grocer named Daniel David Palmer in 1895, ancient writings and paintings show that techniques of body manipulation date back to early civilizations, including Babylon, Assyria, China, Greece, Rome and Egypt.
Palmer, a self-described "magnetic healer," restored the hearing of a deaf janitor by adjusting the janitor's spine. Based on this, Palmer hypothesized that the basic cause of most afflictions involved interference with nerve flow, or "innate intelligence," caused by misaligned spinal bones, or vertebrae. Specifically, this out-of-place vertebrae was termed a "subluxation". This theory is also what raises the ire of the orthodox medical establishment, who contend that such mystical subluxations simply don't exist. In 1973, a noted anatomist from Yale University tested Palmer's subluxation theory by collecting the spines of three adults and three infants within 3-6 hours after they died. Though he applied tons of twisting force to these spines by using special instruments, he was unable to cause the nerve compression attributed to subluxations.
Opponents of chiropractic have used studies such as this to brand chiropractic a "pseudoscience," despite subjective reports of patients who've been helped by chiropractic treatment. Such criticism lead to the filing of a 1976 antitrust lawsuit by five chiropractors. On September 25, 1987, federal district judge Susan Getzendanner found the American Medical Association and other medical organizations named in the suit were guilty of conspiracy in restraint of trade against the chiropractic profession, and had unlawfully deprived chiropractors of associating with medical doctors. The judge further decreed that calling chiropractors "unscientific cultists" eroded the credibility of chiropractors to the public.
Besides having to deal with what they call "allopaths," or orthodox medical doctors, chiropractors engage in internecine warfare. Three main chiropractic organizations currently exist. By far the largest of the three is the American Chiropractic Association, who espouses what's called "mixers" in chiropractic parlance. Mixers use a variety of therapies besides traditional manipulations. These include heat, acupuncture, ultrasound, message, hydrotherapy, and advice on nutrition and exercise.
The International Chiropractic Association, comprises "straights," or those chiropractors that follow the dictum of D.D.Palmer, and use only spinal adjustments to treat patients.
By far the smallest and newest chiropractic organization is the National Association of Chiropractic Medicine, founded in 1984. This group espouses ideas considered heretical by the other two organizations. For one, the NACH completely disavows the existence of subluxations, the actual basis of the entire profession. Instead, these maverick chiropractors prefer a mere scientific approach based on provable therapy.
Typical of the views of these iconoclasts was that expressed by one of the organization's founders, chiropracter Daniel Futch. Futch, who practices in Madison, Wisconsin, was originally trained as an X-ray technician. He told a writer from American Health magazine last year (3) that the full body x-rays routinely taken by most chiropractors has "limited diagnostic value," and also exposes the bone marrow to large doses of radiation.
Concerning subluxations, Futch said like the legendary Unicorn, "it sounds great, but nobody's ever really found one." He says that what chiropractors refer to as subluxations are nothing more than commonly misaligned vertebrae that show up on anyone's X-ray. He says such common misalignments only cause pain when diseases such as arthritis are present, and there's no evidence that they cause nerve impingement. Futch also says that if chiropractic adjustments will help pain, they'll work quickly. He finds the idea of regular chiropractic treatments for "maintenance" ludicrous. The main benefit of chiropractic, asserts Futch, is a rapid relief of both acute and chronic back pain.
One item beyond argument, however, is the extent of back pain. Recorded cases of back pain have increased 169 percent since 1970, or 14-times faster than the population growth. More than 30 million Americans suffer from back pain. The cost of treating back pain is estimated to range between $14 billion to $18 billion annually, with $6 billion for occupational back pain.
But recent studies over the past few years have shown that chiropractic can be an effective modality for conditions such as acute lower back pain. For example, a 1990 British study compared chiropractic with hospital-based treatment that included physical therapy and traction. The study, which involved 741 patients between the ages of 18 and 65, concluded that "For patients with low back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison to hospital outpatient management in those with chronic or severe pain."4
Another study, published in the Journal of Manipulative and Physiological Therapeutics in March/April, 1992, analyzed 23 clinical trails to conclude that spinal manipulation is consistently better than an array of comparative low back pain treatments. According to the chief author of the study, Robert Anderson, the average patient receiving spinal manipulation is better off than 54% to 85% of patients receiving comparison treatment. Anderson, of the San Francisco Spine Institute in Daly City, not only holds a doctor of chiropractic degree, but also an MD and PhD.
When an interdisciplinary panel from the Rand think tank in Santa Monica, California reviewed 67 articles and 9 books published between 1955 and 1989, they concluded that data from 22 controlled studies supported using manipulation to treat acute lower back pain in patients showing no signs of nerve root involvement.5 The lead researcher in the Rand Study, Dr.Paul Shekelle, a physician, later commented that he didn't "for a second believe in subluxations," but was convinced that spinal manipulation does work--although he couldn't explain exactly why.
According to Scott Haldman, MD, PhD, DC, an associate clinical professor at the University of California, Irvine, and adjunct professor at Los Angeles Chiropractic College, manipulation may offer pain relief through relaxing muscles. Or it may stimulate nerve receptors around joints, increasing pain tolerance. He notes that a recent study found that manipulation stimulates the release of pain-killing beta-endorphin into the blood. Another theory holds that manipulation increases spinal motion, which unlocks fixed joints that can cause pain. Thus, restoring mobility will offset pain.
Still more evidence comes from a study done at an HMO in Washington State and reported in the March, 1989 issue of the Western Journal of Medicine. Researchers in the study found that chiropractic patients were three-times as likely as patients of family physicians to report that they were satisfied with the care they received for lower back pain (66% versus 22% ). The patients said that medical doctors who treated them for acute lower back pain didn't adequately discuss their diagnosis, and displayed less compassion and understanding compared with chiropractors.
An earlier study by the same researchers found that MDs were generally more frustrated than chiropractors about treating back pain, and less confident in their ability to forestall recurrences. One author of the study, Daniel C. Chefkin, PhD, said that chiropractors appeared more confident and reassuring about back pain
"There is a physical contact, snapping and popping, "said Chefkin. "In many cases, there is almost miraculous relief from pain. Patients generally come away satisfied. I'd say that 80 percent of people who see chiropractors have positive things to say about it, whereas it's probably the reverse with medical doctors."
But what about economic considerations, which is certainly important in today's climate of rising health care costs. Statistics show that national spending for chiropractic therapy rose from $1.19 billion in 1980 to $4.2 billion in 1988. The percentage of Americans going to chiropractors increased from 4% in 1980 to 7% in 1990.
A study by Myron Stano, PhD, professor of economics and management at Oakland University in Rochester, Michigan, looked at the comparative costs of treating back pain. He reported his results in the June, 1993 issue of the Journal of Medical and Physiological Therapeutics. Stano's retrospective study of 395, 641 patients over two years found that patients using medical services other than chiropractic paid more than chiropractic patients, mainly due to increased hospitalizations.
Another study in Texas found that medical claims for sacroiliac joint sprain cost 30% more than chiropractic claims for the same diagnosis during the same time period. The average cost for claims was $914 for medical claims, $643 for chiropractic.
Most recently, a team of Canadian health economists strongly recommended chiropractic as being the most cost-effective treatment for back pain. The study was based on an international review of medical literature, plus interviews with researchers, practitioners, and patients. The principal researcher in the study, Pran Manga, said that many conventional medical therapies are of questionable validity or are clearly inadequate. Some are even unsafe, and could cause complications, he added.
Chiropractors are hopeful that studies such as those cited here will gain them newfound respect and recognition. Limitations of chiropractic do exist, however. Several studies report that chiropractic manipulation isn't suitable for children. Others warn against cervical manipulation, or "neck cracking," which has resulted in a few cases of paralysis and stroke onset. And one of the main complaints that medical doctors raise against chiropractors is excessive taking of X rays.
While the animosity between medical doctors and chiropractors has simmered over the last few years, the public faith in chiropractic remains undaunted. Chiropractic ranks just behind medicine and dentistry as the largest health care profession in America. Americans spend nearly $2 1/2 billion each year for chiropractic care. Over 30 U.S. hospitals now employ staff chiropractors, and the country now has over 45,000 practicing chiropractors, The 14 accredited American chiropractic colleges produce 3,000 new chiropractors each year, who are licensed to practice in all 50 states.
Many medical plans now accept the legitimacy of chiropractic therapy, and the average DC earns $179,500 a year, with a net of $74,000. even a few medical doctors are grudgingly admitting that chiropractic may not be so bad after all. At a symposium on back manipulation conducted by the American Academy of Orthopedic Surgeons recently, almost a third of the attending surgeons revealed that they referred patients to chiropractors for spinal manipulation.
It seems clear that for many cases of uncomplicated back and musculoskeletal pain, the hands on approach of chiropractic may be just what the doctor should have ordered.
REFERENCES
1. Crelin E. A scientific test of the chiropractic theory.
American Scientist 61:574-580, 1973
2. Getzandanner S. Memorandum opinion and order in Wilk et al v. AMA et al. 671 F Supp 1465, U.S. District Court for the Northern District of Illinois, Eastern Division, September 25, 1987.
3. Fultz O. Chiropractic: What can it do for you? American Health, April, 1992, pp.41-43.
4. Meade TW, et al. Low back pain of mechanical origin:randomized comparison of chiropractic and hospital outpatient treatment. British Medical Journal 300:1431-1437, 1990.
5. Shekelle PG, et al. The appropriateness of spinal manipulation for low-back pain. Part 1: project overview and literature review. Santa Monica, Calif., Rand Corp, 1991
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