Chiropractic’s Contentious History as Alternative Care
For over a century, chiropractic has been a focal point of intense debate and skepticism in both the medical and non-medical communities. Based on the practice of correcting misalignments in the spine via manual manipulation, chiropractic is claimed, by those who practice it, to restore or maintain the health of the nervous system.
A significant number of people in the medical community, however, consider chiropractic medicine to be unscientific, unreliable, and unhelpful. Dr. William Jarvis, for example, in an online article titled “Chiropractic: A Skeptical View” from chirobase.org, attests to what is perceived as a lack of fundamental scientific evidence for the treatment: “In the final analysis, the validity of chiropractic is not a medical controversy as much as one of the basic sciences….Basic biological sciences have a public duty to objectively test a theory as radical as chiropractic’s to determine whether it is valid.”
Even today, a substantial amount of research is being devoted to determining the extent to which scientific evidence of the chiropractic’s benefit can be verified, if any such benefit exists. Chiropractic is not recognized as a legitimate form of allopathic medical treatment by the American Medical Association (AMA), but nevertheless, it is one of the most popular forms of Complementary and Alternative Medicine (CAM). The National Center for Complementary and Alternative Medicine (NCCAM), a federal organization under the auspices of the National Institutes of Health, offers data collected by the 2007 National Health Interview Survey concerning the popularity of CAM in the United States. According to one statistic offered on NCCAM’s website, 8.6% of 23,393 adults surveyed reported that they had received chiropractic or osteopathic manipulation in the past year, and 38.3% percent of these adults reported using any form of CAM. Despite its popularity as an alternative treatment, however, significant skepticism persists due to the lack of scientific evidence indicating the effectiveness of chiropractic care. Regardless of the tension that has existed and continues to exist between those on both sides of the issue, the history of chiropractic care in the Unites States is, at the very least, an interesting one.
Chiropractic, as it exists in the United States today, was established by Daniel David Palmer in 1895. According to the NCCAM, Palmer, a self-taught healer, believed that spinal manipulations could correct misalignments, which he called “subluxations,” that interfere with what he referred to as the body’s “natural healing ability.” As a practice not justified by substantial medical evidence, chiropractic naturally came into conflict with conventional medicine. The claim that spinal manipulation could help treat a wide variety of maladies, from acne to epilepsy to cancer, was (and is still very much today) indeed a controversial one in the eyes of many medical scientists, who immediately dismissed the practice as witchcraft and quackery. The backlash to chiropractic matched the controversy surrounding it, so much so that in 1906, Daniel’s son B.J. founded the Universal Chiropractors Association (UCA) for the purpose of legal defense. Though not the first attempt at formal organization, the UCA was “the most enduring and most successful at the time,” according to a history offered by the American Chiropractic Association (ACA). The ACA also cites a 2004 article by Dr. Joseph Keating Jr. in Dynamic Chiropractic in describing the legal conflicts between early chiropractic practitioners and conventional allopathic doctors: through 1931 there were around 15,000 lawsuits against 12,000 practicing chiropractors in the United States. The UCA’s staunch stance against the AMA and mainstream medicine under B.J. Palmer estranged several, more moderate practitioners and led to the formation of a rival interest group, the American Chiropractic Association, in 1922. After the departure of B.J. Palmer from the UCA in 1926, however, the two groups reconciled their differences and joined, in 1930, to form the National Chiropractic Association, the political predecessor of today’s ACA.
The sharp disagreements between allopathic physicians and chiropractic practitioners escalated well into the mid-twentieth century, so much so that the AMA began to formally adopt positions against the practice. In Section 3 of their Code of Ethics, written in 1957 and based upon previous ethical decrees, the AMA took a formal yet subtle stance against chiropractic and other forms of osteopathic treatment as scientifically unfounded: “A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily associate professionally with anyone who violates his principle.” In 1966, a policy passed by the AMA House of Delegates stated, “It is the opinion of the medical profession that chiropractic is an unscientific cult whose practitioners lack the necessary training and background to diagnose and treat human disease. Chiropractic constitutes a hazard to rational health care in the United States because of its substandard and unscientific education of its practitioners and their rigid adherence to an irrational, unscientific approach to disease causation.”
Meanwhile, advocates for chiropractic were working on obtaining what they felt was fair representation in the public sphere. These efforts were at first unfruitful for the advocates but were later met with success in the 1970’s and 1980’s. In 1971, the Council on Chiropractic Education (CCE), which had been working throughout the previous decades to improve the standards of education at chiropractic institutions across the country and close substandard institutions, was incorporated by the U.S. Office of Education as an autonomous national organization, according to the CCE’s own history. In 1974, the CCE was awarded a position on the list of the Nationally Recognized Accrediting Agencies, an honor which has been renewed continuously ever since. Although this success did not legitimize chiropractic within the realm of mainstream medicine, it did represent a willingness, on the part of the Federal Government, to ensure that standards were established and enforced for chiropractic education for the purpose of safe practice.
A significant turning point in the relationship between chiropractic and conventional medicine occurred when Charles Wilk and four other chiropractors filed a lawsuit against the AMA in 1976, on the basis that the AMA, as well as several other organizations including the American Hospital Association, the American College of Surgeons, and the American College of Physicians, had engaged in trust-like activities to contain and hinder the growth of chiropractic. During the proceedings over the next eleven years, the AMA made several settlements. According to a June 2011 article by Steve Agocs in Virtual Mentor, the AMA’s Journal of Ethics, these settlements resulted in several significant changes to the AMA’s previous policies. Such changes on the part of the AMA included relaxing its policies on doctors’ referrals of patients to chiropractors, as well as a modification of its Principles of Medical Ethics to reflect this new position. When a decision for the case Wilk et al. vs. the AMA, et al. was finally reached in 1987, U.S. District Court Judge Susan Getzendanner held that the AMA, through its Department of Investigation and, specifically, its Committee on Quackery (1963-1974), had made its goal “to contain and eliminate chiropractic.” Based on a similar ruling in Goldfarb v. Virginia State Board (1975), which held that lawyers were not exempt from anti-trust laws and therefore could not engage in such activities as price-fixing, the court ultimately issued an injunction against the AMA for engaging in activities with similar motives, including “conduct[ing] nationwide conferences on chiropractic,” “prepar[ing] and distribut[ing] numerous publications critical of chiropractic,” and “assist[ing] others in the preparation and distribution of anti-chiropractic literature.” The settlements and subsequent decision in Wilk ultimately allowed for association between physicians and chiropractic practitioners without reprimand from the AMA.
Today, the official policy of the AMA towards chiropractic reflects the decision made in Wilk. According to the Opinion 3.041 of the AMA, which was first issued in 1992, “It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient. A physician may refer a patient for diagnostic or therapeutic services to a chiropractor permitted by law to furnish such services whenever the physician believes that this may benefit his or her patient. Physicians may also ethically teach in recognized schools of chiropractic.” This has led to some degree of dissipation in the burning tensions between conventional allopathic medicine and chiropractic treatment. Steve Agocs, in his aforementioned article in Virtual Mentor “Chiropractic’s Struggle for Survival,” attests to how some doctors and chiropractors have come to reach such a détente: “…in the current era medical doctors and chiropractors openly refer to each other for diagnostic services, treatment, and co-management of cases, and chiropractors serve alongside medical practitioners in clinics and hospitals all over the country.”
Nevertheless, the tensions still do exist, particularly over the legitimacy of chiropractic as a form of treatment. The main issue for a lot of allopathic physicians is that there is still a lack of conclusive evidence showing that spinal manipulations can result in health improvements, independent of other variables. Some even claim that the effects of chiropractic are deleterious, such as Dr. Steven Barrett. In an online article, “Chiropractic’s Dirty Secret: Neck Manipulations and Strokes,” Dr. Barrett cites several studies that potentially implicate neck manipulation as a cause of vertebral artery dissection, where the inner lining of the vertebral artery tears, causing blood to clot and impede blood flow to the brain. One such study, consisting of an interview and blinded chart review, performed in 2003 by Dr. W.S. Smith at the University of California, San Francisco, concluded that patients that had suffered from cervical arterial dissection were more likely to have undergone spinal manipulation in the past 30 days (14%) than control patients not suffering from the dissections (3%). The questions ultimately involved with such studies are whether these pathologies are due to chiropractic itself or chiropractic malpractice, whether such complications are predictable, and what should be done to inform patients of any potential risks associated with chiropractic.
On the other side of the issue, there are also studies that potentially indicate the efficacy of chiropractic care. For example, according to the data from the 2002 NHIS, cited by the National Center for Complementary and Alternative Medicine, 66 percent of patients who had reported using chiropractic for back pain also reported receiving “great benefit” from the treatment. A review of scientific evidence cited on the NCCAM’s website, conducted in 2010, ultimately found chiropractic treatment to be helpful in dealing with certain disorders, including back pain, migraines, upper- and lower-extremity joint conditions, and whiplash-related injuries. The review also found chiropractic medicine to be unhelpful in treating certain conditions, including asthma and hypertension. including asthma and hypertension. A randomized, double-blind study comparing active and simulated spinal manipulations as treatments for acute back pain and sciatica, carried out by Valter Santilli, MD, and published in The Spine Journal, found that 28% of the patients who had received active spinal manipulation reported having no local back pain after 180 days of treatment, compared to only 6% of the simulated manipulation group that reported the same outcome. Also, 55% of the active manipulation patients reported having no radiating pain after 180 days, compared to only 20% in the simulated manipulation group. Many, however, remain skeptical of the extent of chiropractic’s benefit, especially in regards to its claimed ability to treat conditions such as hypertension and asthma.
Regardless of the debate that still exists, chiropractic has grown significantly as an alternative form of treatment in the past century, and, as chiropractic has become more popular and widespread, it has also fallen more under the guidelines of federal regulation for the purpose of insuring adequate training and safety. While there is a lack of evidence indicating chiropractic’s appropriateness in the treatment of many medical conditions, a growing body of research attempts to build a case for its effectiveness in improving certain musculoskeletal ailments. In this context, chiropractic may prove in the future to be an effective complement or alternative to conventional palliative care.
This article was updated on 9/1/2011.