Chiropractic: More Than Spinal Manipulation This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Chiropractic Humanities 1998; 8: 71–76 ~ FULL TEXT
Cheryl Hawk, D.C., Ph.D.
Palmer Center for Chiropractic Research
741 Brady Street
Davenport, IA 52803
Chiropractic has made great advances in its acceptance by the general public and the biomedical establishment in recent years. However, the medical establishment still views chiropractic as a procedure – spinal manipulation – rather than as a profession which operates based on a unique approach to health care. This article provides a rationale and support for chiropractic as a profession that offers a unique approach to health care, based on the chiropractic belief system and the interpretation of the chiropractic clinical encounter developed by medical anthropologists. Requirements and implications for the future development of the profession in this direction are discussed.
Key Indexing Terms: Chiropractic, Medical Anthropology
From the Full-Text Article:
Introduction
Chiropractic has made great advances in its acceptance by the general public and by the biomedical establishment in recent years. This rise in status accompanies, but is not wholly attributable to, the blossoming of complementary and alternative therapies on the health care scene. Eisenberg’s seminal report on the use of “unconventional” (complementary and alternative) health care practices in the U.S. indicated that approximately one-third of Americans had used some type of complementary practice in 1993, and that chiropractic, used by 10% of Americans, was the most common of those practices. [1]
The 1994 Robert Wood Johnson Access to Care Survey also showed chiropractic to be the most commonly used complementary therapy, used by 6% of Americans, compared to 0.4% using acupuncture. [2] Furthermore, in the only survey to date of U.S. medical practitioners (in the Chesapeake Bay area of the U S), 49% considered chiropractic to be “a legitimate medical practice,” while 46% considered it to be “alternative medicine;” 56% had referred patients for chiropractic treatment. [3]
Procedure or Profession?
However, even though the medical establishment apparently accepts chiropractic at an unprecedented level, it still views chiropractic as a procedure – spinal manipulation – rather than as a profession which operates based on a unique approach to health care, and may entail a number of procedures within its model of health care and scope of practice. [4, 5] In its taxonomy of complementary practices, the Office of Alternative Medicine (OM) of the National Institutes of Health places chiropractic under “manual healing” rather than “alternative systems,” in which naturopathy is placed, although it also employs manual therapy among other procedures. [6] This is at odds with chiropractors’ own opinions of the profession; chiropractors consider themselves to be primary providers of health services. [7]
Which is it? Is chiropractic synonymous with spinal manipulation? Or is chiropractic a complete system of health care? If it is the former, then it can be done by other health professionals such as family physicians, physiatrists, or physical therapists. Spinal manipulation could then be added to the armamentarium of medical therapies and accepted as mainstream rather than complementary or alternative.
If chiropractic is a complete system of health care, then it must have more to offer than the procedure of spinal manipulation. Spinal manipulation, or to use the correct term used by the profession, chiropractic adjustment, may be considered the centerpiece of chiropractic’s therapeutic options. However, its application must be informed by a unique approach to healing and health that is distinct from, although not necessarily at odds with, the medical model. For it is the philosophy, the intuitive knowledge – the belief system that differentiates a complete system from a procedure.
Chiropractic Philosophy and Belief system
For its first hundred years, chiropractic evolved along its frequently rocky path and grew strong because of its philosophy and belief system, which provided a unique perspective of healing and health.
Essential components of the traditional chiropractic belief system are:1) ability of the body to heal itself
2) the central role of the nervous system in regulating health, and
3) the importance of the relationship between structure, as expressed through the
musculoskeletal system, to function, as expressed through the nervous system. [4]Chiropractors believe that restoring normal structural relationships in the spine through specific application of force contributes to optimal functioning of the nervous system, which in turn has a central regulating effect on other body systems. Furthermore, other elements – physiological, psychological, and environmental that have bearing on the body’s ability to heal itself and the smooth functioning of the nervous system are also considered essential in chiropractic.
This is a holistic and patient-centered viewpoint. Within the context of a close doctor-patient relationship, where the doctor views the patient as a whole person, not simply a spine, chiropractic adjustments are applied, frequently in conjunction with other noninvasive therapies. These include “mainstream” therapies such as nutrition and lifestyle counseling and corrective exercise, as well as complementary therapies such as massage, acupressure, homeopathy, and herbal medicine. [7, 8]
Chiropractic Is More Than Spinal Manipulation
Clearly, this view of chiropractic belief and practice includes more than spinal manipulation. Chiropractors know they do more than spinal manipulation. Their patients know they do more than spinal manipulation. In fact, many medical practitioners and the general public know it as well. Interviews with medical practitioners and laypeople who had never used chiropractic indicated that some of their negative attitudes about chiropractic were associated with chiropractors’ use of nutrition, nutritional supplements, and physical therapy modalities since these interviewees felt that the sphere of chiropractic should encompass only spinal manipulation. [9, 10] Why, then, does chiropractic continue to be “officially” recognized as synonymous with spinal manipulation? Why do most of the clinical trials involving chiropractic equate chiropractic and spinal manipulation?
Reductionism is the short answer to this question. Reductionism, in which the whole is never more than the sum of its parts, and in which often a part becomes all that is recognized of the whole, reduces chiropractic to spinal manipulation. Reductionism allows chiropractic to fit securely into the medical model, by removing the “big picture.” Reductionism is operating whenever chiropractors, researchers, other health professionals, or the public focus on only one aspect of the entire gestalt that makes chiropractic unique. [11] Reductionism is easy; it is much easier to say that chiropractors are “back doctors,” that what they do is “fix a bone out of place,” than to describe the principles stated above. However, reductionism is often useful, and even necessary, in research settings because it narrows reality to a manageable scope that allows single factors to be studied at a given time. As long as research is conducted with an understanding of this limitation, that reality is always greater than the sum of its parts, reductionism serves a useful function and new knowledge can be gained through a thoughtful analysis of the results.
It is much harder and sometimes impossible to study reality without isolating individual aspects. Thus it is much harder to describe what chiropractors actually do, as is illustrated in the ensuing discussion, rather than simply to say they manipulate the spine. However, it is essential that the complexity of reality not be discounted. Thus this discussion illustrates that chiropractic, far from being synonymous with spinal manipulation, represents a complex and characteristic dynamic between doctor and patient, one which has been analyzed by medical anthropologists without a heavy reliance on references to spinal manipulation at all. [11, 12]
Elements of the Chiropractic Encounter
The specific components of the chiropractic encounter, as described by Coulehan [12], are:acceptance and validation of the patient and his or her problem
acceptable expectations and explanations for the course of treatment
concrete and convincing clinical actions, and
a plan for the positive engagement of the patient in treatment.These components are discussed below.
Acceptance and Validation. Acceptance of the patient, in the sense of demonstrating positive regard and appreciation for his or her feelings and beliefs, is considered to be a core quality for successful doctor-patient interactions. [12–14] Chiropractors are sensitive to the need to form a bond of mutual acceptance with their patients, in which both accept and accommodate the other’s belief system. [12, 15, 16] Chiropractors tend to relate to patients in a more personal and egalitarian manner than do medical doctors, using common language and genuineness, i.e., being oneself without resorting to the “physician role”. [12, 14, 17, 18] Furthermore, the patient’s sense of acceptance is enhanced by the traditional chiropractic approach of treating the patient rather than the disease, which stems from the theoretical basis of chiropractic, in which the body is viewed as a whole and illness as a lack of harmony of body systems. [19, 20] In general, patients’ satisfaction with health care has been linked to the doctor’s ability to be considerate, treat them as persons, and to treat them with respect without “talking down” to them. [21]
In conjunction with acceptance, the chiropractor validates the patient’s health problem, often serving to legitimize the sick role of patients whose complaints were not considered “real” by medical doctors. [12, 22] Traditional and popular healing systems, of which chiropractic is an example, have been noted to deal more willingly and successfully with illness, or the patient’s perception of his or her experience than does biomedicine, which focuses on disease and discounts illness. [23]
Expectations and Explanations. As discussed above, an essential, perhaps the essential feature of chiropractic is its characteristic belief system. Chiropractors tend to have strong belief in their approach to care, another characteristic they share with other indigenous healers. [12, 24] Thus they are able to convincingly communicate their expectations of efficacy to the patient, and instill similar positive expectations in patients both through their own belief and through the type of explanations they present. In studies of patient satisfaction, provision of understandable explanations for conditions and treatments is an important factor contributing to the high level of patient satisfaction with chiropractic care. [12, 25–28] In Cherkin and MacCornacks study of satisfaction with low back pain care by family practice physicians and chiropractors, 53% of chiropractic patients were very satisfied with the amount of information they received about their pain, as opposed to 17% of family practice patients. [27] Chiropractic patients also were more likely to report receiving information on recovery time and instructions for self care. Chiropractors tend to explain the patient’s condition in nontechnical terms, using analogies that are acceptable to patients and easy to understand, attributing physical symptoms to physical causes. [12] Most chiropractors (80–90%) use a visual aid such as an X-ray, illustration, diagram, or model of the spine to explain the patient’s problem, which not only clarifies the explanation but further validates the reality of the complaint. [12, 18, 27]
Clinical Actions. Clinical chiropractic action revolves around physical touch. The physical exam as well as the treatment involve manipulation and mobilization of the patient’s body, and make it clear that the chiropractor is “doing something”. [29] Chiropractic has even been characterized as a method of treating illness by physical touch. [18] The therapeutic value of touch has been well established and is not unique to chiropractic; it is generally viewed as a “placebo” effect. [12, 25, 30] The effects of spinal manipulation are often attributed to this “placebo” effect. [12]
However, chiropractors believe that the chiropractic adjustment has a specific corrective effect on an area of spinal dysfunction (the subluxation). Although this lesion and the effects of its correction have yet to be well documented through rigorous investigations [31], there is some evidence from clinical trials, using control groups given treatments employing physical touch like light massage, that indicates an effect of spinal manipulation beyond that of the general effect of touch alone. [32] However, the undoubted ability of “hands-on” treatments to create an atmosphere of caring, intimacy, reassurance, and comfort has a definite, if nonspecific, positive impact not only on patient psychology but on physiology as well. For example, in a study of diet-induced atherosclerosis in rabbits, the animals that had been handled and petted by one researcher had significantly less plaque formation. [33–35]
Plan for Engagement of Patient in Treatment. The active involvement of the patient in a health partnership is an important part of chiropractic care. [12] Although chiropractic manipulation is termed “passive” care, in that the manipulation is done by the doctor to the patient, the partnership between doctor and patient that extends beyond spinal manipulation requires conscious participation and cooperation, primarily through patient “buy-in” of the chiropractic belief system. [36] Furthermore, chiropractors frequently give patients instructions for lifestyle modifications and stress the importance of providing the body with optimal conditions for healing. [9, 12, 17, 36, 37]
Interaction Analysis of the Chiropractic Clinical Encounter. An indepth interaction analysis, using a standard method for content analysis (Bale’s method), of one chiropractor’s relationship with his patients supports the idea that chiropractic practice is a distinct approach to patient care, rather than simply the delivery of spinal manipulation. [36] Although this study investigated only one chiropractor’s patient interactions (with 57 patients, 8 of whom were new), the patients were demographically representative of the chiropractor’s patient population, and his practice characteristics appear similar to those of many chiropractors. [12, 16] Oths targeted information exchange and affect (both verbal and nonverbal) as the primary elements of clinical communication, based on studies of patient satisfaction with medical care. [36, 38] Patients, especially those with chronic conditions such as low back pain, have been shown to be particularly dissatisfied with their medical physicians’ affective behavior, as well as the quality of information on their condition.
Table 1 This dissatisfaction often results in a change in provider to an alternative therapy, particularly chiropractic. [36, 38] Oths analyzed the clinical encounter in five phases: intake, orthopedic examination, consultation, spinal manipulation treatment, and reexamination. Table 1 summarizes the communication patterns by clinical phase. Clearly, a positive affect was a large component of the doctor’s verbal exchange with patients, particularly during the treatment phase, which one may infer must contribute to a positive treatment effect.
From patient satisfaction surveys she administered in conjunction with her observations, Oths concluded that the following factors contribute to the high levels of satisfaction and treatment compliance shown by chiropractic patients: [36]l) the initial provision of a large amount of understandable and acceptable information
on the patient’s condition,
2) the treatment approach, and
3) continued personal affective dialogue between doctor and patient.
She further comments that the pattern of supplying the patient with readily understandable explanations
of both their condition and of how chiropractic works has the effect of “manipulating a patient’s belief
structure before manipulating his or her physical structure, providing an analogous structural realignment
in both the mind and body”. [36 p. 83]
Conclusion
Chiropractic is at a crossroads. Its success with the public, based on 100 years of helping people, often without the support, protection, or approval of established health care, has resulted in its current position as the most commonly used form of complementary therapy in the U.S. Research investigations documenting its efficacy for musculoskeletal conditions have made it one of the complementary practices most acceptable to the medical community. Chiropractic is on the verge of complete acceptance into the health care mainstream. The crossroad is this: Which path will the profession take to reach full acceptance? One path is chiropractic is the procedure of spinal manipulation; the other is chiropractic is a unique approach to health and health care.
The path of least resistance is to accept the role of spinal manipulators, specialists in low back pain. The OAM and the medical establishment in general already accept the profession in this capacity. Chiropractors’ acceptance of it as well could accelerate the mainstreaming of the profession’s educational institutions, increase its research funding, and hasten integration on interdisciplinary teams of medical personnel. Many chiropractors advocate, and have already taken this path. The danger here is that once chiropractors go down this path, they may become virtually indistinguishable from the other medical practitioners already existing within the medical establishment.
The mission statements of most chiropractic colleges and the attitudes expressed in surveys of chiropractors indicate the profession is leaning toward the second path, acceptance of the role of primary providers with a distinct approach to health and health care. [7, 8, 19] Although the foregoing discussion provides some support and rationale for this position, it is a far more difficult path. It is more difficult in terms of education, because few chiropractic colleges now provide adequate clinical training in a comprehensive approach to care or training in the scientific method to encourage analytical thought or research productivity. [39, 40]
It is far more difficult in terms of research, because although there is an impressive body of evidence supporting manipulation as a palliative treatment of musculoskeletal conditions, researchers have barely begun to scratch the surface of the mystery of the subluxation and its possible effect on general health, which is at the heart of chiropractic philosophy. [31] However, if the profession can ground its clinicians and researchers in both philosophy and science, this path may lead to the exploration of new knowledge of how the body and mind work as well as to the possible discovery of previously unknown mechanisms of healing. It may lead to a better understanding of the complex interactions that contribute to that dynamic known as the healing encounter.
However, it is critical that chiropractic institutions, faculty, and practitioners do not just pay lip service to this path. It requires a serious commitment to the exploration of new knowledge through good science and a comprehensive approach to clinical care. It requires a realistic, unbiased assessment of the profession’s needs in pursuing it. And it requires combining science with intuition and abandoning rhetoric in favor of dialogue. These actions are prerequisites to travel on this path into the second century of chiropractic. There, it may hopefully join the mainstream of healthcare with its identity and integrity intact, recognized as an important contributor to and equal partner in the continual growth of the art and science of healing.
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