Chiropractic: An Alternative Healing Art
Enters The Mainstream

The movie Lorenzo's Oil offers a powerful illustration of the forces that have propelled the alternative health movement since its inception. In the movie, young Lorenzo's parents, faced with a severely ill child whose disease has no known medical cure, move heaven and earth (and a reluctant medical establishment) to save his life. Against all odds, they succeed. The intensity of their refusal to accept things as they are, and the way they demand of both themselves and others a willingness to explore unorthodox alternative healing methods, are precisely the factors that have enabled chiropractic and other natural healing arts to survive and even thrive in the face of determined opposition from organized medicine.

In 1991, after well over a decade of litigation, the United States Supreme Court affirmed a lower court ruling declaring the American Medical Association et. al. guilty of anti-trust violations that were part of an ongoing conspiracy to "contain and eliminate" (the AMA's own words) the chiropractic profession. As a result of the Wilk v. AMA suit, the medical profession reversed its longstanding ban on interprofessional cooperation between medical doctors and chiropractors, agreed to publish the full findings of the court in the Journal of the American Medical Association, and paid a large sum of money which is now being used for chiropractic research.

This has not undone the effects of a well-organized anti-chiropractic campaign by organized medicine (which at one point even included attempting to rig in advance a federally mandated study on chiropractic!), [1] but it certainly points to the dawning of a new day.

Chiropractic Research: Clinical Studies and the "Outcomes Revolution"

Spinal manual therapy, of which chiropractors are the primary providers, has now been shown by reputable researchers to be the most demonstrably effective healing method for the most common kinds of lower back pain. Each year brings the publication of more studies (published in both medical and chiropractic journals), gradually expanding the range of conditions for which chiropractic should be considered a treatment of choice.

This was not always so. For years, chiropractors were criticized for offering only anecdotal evidence (stories of people who got well under chiropractic care) in support of their methods. Despite the fact that only an estimated 15 percent of orthodox medical interventions are validated by rigorous scientific research, [2] chiropractic was repeatedly attacked as unscientific, in contrast to the presumably altogether scientific medical profession.

Two things have changed. First, as you will see in this chapter, there is now a substantial body of chiropractic research, performed under accepted scientific protocols, which even the most die-hard skeptics cannot refute. Second, there has been an increased emphasis, largely driven by governmental and economic pressures, given to what is now called "outcomes research," which in part involves asking patients to rate their degree of pain relief, return to proper function in daily activities, satisfaction with treatment, and other related factors. Outcomes research has a strong subjective component, but has risen in stature because it has the overriding virtue of including what, after all, is the whole purpose of the healing arts to bring improved health, and relief from pain and suffering, as judged by the patients themselves.

The full effects of the outcomes research revolution are yet to be felt. But one thing is clear already: patients are growing very impatient with many orthodox medical therapies, and are "voting with their feet." They are flocking in droves to alternative practitioners of all sorts, [3] some of whose approaches already have significant scientific validation (chiropractic being most prominent example), and others whose methods have yet to face the scrutiny of rigorous research.

This trend, unprecedented in its magnitude and probably nowhere near the peak of the curve as yet, portends a significant realignment in the healing arts as we know them, probably within the next generation. While it is still possible that the forces of orthodoxy may wage temporarily successful rearguard actions in some countries, blocking valid alternative methods from attaining equal status in terms of licensure and insurance reimbursement, it appears that a critical mass has already been reached, and that major changes will continue at an accelerating pace.

The chiropractic profession is in the unusual, and perhaps unique, position of having one foot inside the establishment (with licensure, insurance reimbursement, accredited training institutions, and an increasingly broad scientific research base), while the other is firmly in the alternative camp (with a philosophy of natural healing that in most cases relegates drug therapy to a position of last resort, rather than first).

As such, chiropractic provides a rare modern example of how a healing art, born in rebellion against the status quo, enters the mainstream. The history of chiropractic is for the most part an inspiring story of the triumph of the underdog, but it also contains a traveler's advisory as to the perils of the journey.

Historical Roots

Spinal manipulation has existed in one form or another for millennia. Accounts of manipulative therapies go as far back as 2700 B.C. in China, and a similar legacy has been bequeathed to us by ancient civilizations from Babylonia to Central America to Tibet.

Hippocrates (460 B.C.) was an early practitioner of spinal manipulation and according to some scholars, the Father of Medicine used manipulation "not only to reposition vertebrae, but also thereby to cure a wide variety of dysfunctions. [4] The Hippocratic Corpus, recorded by physician-scholars in Alexandria, Egypt, when that city was the cultural center of Western civilization, includes detailed descriptions of manipulative methods.

Galen, Greek-born Roman physician who lived in the Second Century A.D., and whose approach to healing set the officially recognized standard in Western medicine for 1,500 years after his death, also utilized spinal manipulation, and reported successfully resolving a patient's hand weakness and numbness by manipulating the seventh cervical vertebra. [5]

As Europe endured what later would be known as the Dark Ages, these healing traditions were preserved in the learning centers of the Middle East by the ascendant Arabic civilization. Later, this body of knowledge returned to Europe, and the works of Hippocrates and Galen formed the foundation of Renaissance medicine. Ambroise Par�, sometimes called the Father of Surgery, used manipulation to treat French vineyard workers in the Sixteenth Century. [6]

During the centuries that followed, up to the beginning of the modern era, manipulative techniques were passed down from generation to generation within families. These "bonesetting" methods, which were transmitted not only from father to son but often from mother to daughter, played an important role in the history of non-medical healing in Great Britain and similar methods are common in the folk medicine of many nations.

Birth of the Modern Professions

In the second half of the Nineteenth Century, the United States was a crucible of natural healing theory and practice. Two manipulation-based healing arts, osteopathy and chiropractic, trace their origins to that era. Both began in the American Midwest.

Neither emerged in a vacuum. A medical physician, Dr. J. Evans Riadore, wrote in 1843 in Irritation of the Spinal Nerves that "if any organ is deficiently supplied with nervous energy or of blood, its functions immediately, and sooner or later its structure, become deranged." Robert Leach, D.C., in The Chiropractic Theories: A Synopsis of Scientific Research, says of this, "Apparently Riadore concluded that irritation of the spinal nerve roots resulted in diseases; he even advised manipulation to treat this disorder. [7]

Dr. Riadore's work predated by decades the development of osteopathy by Andrew Taylor Still, in the 1870s, and the introduction of chiropractic by Daniel David Palmer in the 1890s. Whether or not Still and Palmer were personally aware of Riadore's work, and it seems likely that they were, their pioneering efforts certainly occurred in a context where work such as Riadore's was in the public domain.

Interestingly, Riadore's statement about deficiency "of nervous energy or of blood" summarizes in one phrase the respective founding principles of chiropractic and osteopathy. Since its beginnings, chiropractic has attributed the central role in health to the nervous system. Osteopathy is founded on the Law of the Artery, with which Dr. Still asserted the primacy of the circulatory system.

Both Still and Palmer formulated their hypotheses and built their new professions against a backdrop of medical orthodoxy which they found to be frequently ineffective, and sometimes barbaric. Dr. Still, a Missouri country doctor, had lost three of his children to spinal meningitis. The standard treatment of the era was cauterization (burning through the skin with a hot iron), followed by the application of bloodsucking leeches to the raw exposed tissues of the spinal area. After the death of his children, like the Biblical Job, Still cried out in his pain for understanding. He spent the remainder of his life developing the natural healing art he called osteopathy.

Chiropractic: Then and Now

D.D. Palmer founded chiropractic on the premise that the vertebral subluxation was the cause of virtually all disease, and the chiropractic adjustment its cure. This "one cause-one cure" philosophy has played a central role in chiropractic history first as a guiding principle, and later as an historical remnant, a bulls-eye at which the slings and arrows of organized medicine have repeatedly been hurled.

While few contemporary chiropractors would endorse such a simplistic formulation, it nonetheless remains true that the raison d'�tre of the chiropractic profession is the detection and correction of spinal subluxations. Chiropractors may, in fact, do much more, but it is our ability to do this one thing well that has allowed us to survive for a century under a constant barrage of medical opposition, some of it justified, most of it not.

The "one cause-one cure" adherents among the early chiropractors had two major political effects on the development of the profession. First, their deep faith in the truth of their message, combined with the sometimes stunningly positive results of chiropractic adjustments, created a strong and steadily growing activist constituency of chiropractic supporters. In their zeal, they forged a grassroots movement which assured the survival of the profession through some very stormy years in the first half of the Twentieth Century. But at the same time, by sometimes making inflated claims, and failing to back those up with hard evidence, some early chiropractors also managed to convince most medical physicians and, through them, a substantial portion of the general public that chiropractors were not to be trusted.

In this conflict, the medical profession was by no means a disinterested party solely seeking to protect the public well-being. It faced in chiropractic an intrepid economic competitor with a competing philosophy that raised the possibility of healing without drugs, which were, and still are, the medical profession's primary healing tool.

The Wilk v. AMA suit brought to light a decades-long pattern of conspiracy, lies and political intrigue which exposed the AMA for what it was: a trade association whose principal loyalty was to the self-interest of its membership. The American judicial system may sometimes seem to move interminably slowly, but in this case justice finally prevailed.

A Complex Legacy

Contemporary chiropractors have inherited both the positive and negative aspects of this complex legacy. We look back at our professional forebears, and honor the level of sacrifice their commitment called forth, while at the same time seeking to adapt to the needs of a new era.

Our task is in many ways easier than theirs. Starting with D.D. Palmer, thousands of chiropractors were charged with practicing medicine without a license. Hundreds, including Palmer himself, went to jail. [8] Civil disobedience was an integral part of the early development of the chiropractic profession, as it would later become in the civil rights movement. When Dr. Palmer was jailed in 1906, he said, "I have never considered it beneath my dignity to do anything to relieve human suffering." Like Thoreau before him and Martin Luther King later, Palmer understood that the defense of basic rights sometimes requires time behind bars.

Because of the sacrifices made by Palmer and so many others through the years, chiropractors today are able to practice freely, and the profession is truly coming of age in our time. Over the past several decades, the chiropractic profession has undergone profound changes, as standards in education, research, and practice methodology have steadily risen to meet the demands of a fast-changing society. An excellent historical review, for those seeking greater detail, is contained in the book Dynamic Chiropractic Today, written by a former president of the British Chiropractors Association, Michael Copland-Griffiths, D.C.

Chiropractors are now licensed throughout the English-speaking world, and in many other nations as well. Educational standards and testing procedures are rigorous. Numerous college science courses are required prior to entering chiropractic school, and the chiropractic college curriculum extends four or more years. Highly-trained faculty fill both the basic science and clinical science departments at all chiropractic colleges, which are accredited by government-supervised agencies in the various countries.

In Australia, the first wholly government-funded chiropractic training program in the world was incorporated into a university curriculum in 1980. In Quebec, a similar program began in 1993 at the state (provincial) university. These programs are a sign of things to come, and foreshadow a far greater integration of chiropractic into the health care system of the future. The greatest strides in the late-twentieth century have been in the area of research. No longer can chiropractors be criticized for lacking a firm base of scientific research. The tide has truly turned, as chiropractic has entered the modern era.

Chiropractic Research

The early leaders of the chiropractic profession recognized the value of research. Dr. B.J. Palmer, the founder's son, conducted numerous studies between the 1910s and the 1950s, documenting the effects of chiropractic adjustments on such physical functions as blood pressure, heart rate, respiration, and brain-wave patterns.

Unfortunately, B.J. Palmer's studies, like other chiropractic (and medical) research from the first half of the twentieth century, do not meet the criteria demanded by the modern scientific community. In the context of their time, however, an era when medical clinical trials were just beginning, Palmer's work marked the first serious attempt at objective measurement of the physiological effects of the chiropractic adjustment.

Through the years of Palmer's preeminence in the chiropractic world, many other independent chiropractors and chiropractic colleges also carried the torch of research, exploring new adjusting methods and measuring their effects. Like Palmer's studies, these too are of significant historical interest, but did not follow the rigorous scientific protocols demanded of today's research.

By the early 1970s, the scientific gap between chiropractic and medicine had widened, and the more far-sighted chiropractic leaders realized that it had to be closed as quickly as possible. Looking back now from the vantage point of the 1990s, it is remarkable that so much has been accomplished in such a short time.

Dr. Suh and the University of Colorado Project

Beginning in the 1970s, first with grants from the International Chiropractors Association, and later with added financial support from the American Chiropractic Association and the federal government of the United States, Chung Ha Suh, Ph.D., and his colleagues at the Biomechanics Department of the University of Colorado began a series of studies which have provided an extensive body of chiropractic-related scientific research.

It is worth noting that Dr. Suh, the first American college professor willing to stick his neck out for chiropractic research, grew up in Korea, where he had not been subjected to the same life-long anti-chiropractic bias as his American colleagues. In undertaking this research, he had to withstand intense pressure from powerful forces within the American medical and academic establishments. The AMA and cohorts condemned chiropractic for lack of scientific underpinning, while at the same time doing everything in their considerable power to prevent chiropractors from ever obtaining the funding and university connections necessary for the development of such a research base.

Time and again in American history, it has been immigrants who have brought to our land the fresh perspectives needed to move our society forward. In addition, progress has often required the courage to stand up against politically powerful forces of stagnation. Dr. C.H. Suh stands as a modern exemplar of both these traditions.

The research at the University of Colorado involved two major projects. In one, Dr. Suh developed a complex computer model of the cervical spine, which allowed a deeper understanding of spinal joint mechanics and their relationship to the chiropractic adjustment.

The second project involved studying the effects of compression on spinal nerve roots. Seth Sharpless, Ph.D., Marvin Luttges, Ph.D., and their colleagues demonstrated that minuscule amounts of pressure on a nerve root (10mm Hg, equal to a feather falling on your hand), resulted in up to a 50 percent decrease in electrical transmission down the course of the nerve supplied by that root. [9] Chiropractors have long claimed that minimal pressure on nerves could have a significant physiological impact. This study gave credence to such claims and offered a promising path for future research.

Most of the recent interdisciplinary clinical research jointly conducted by chiropractors and medical physicians has been done outside the United States, which still remains the last, strongest bastion of the medical ancien regime. The most influential research studies of the past decade were done in Canada, Great Britain and the Netherlands.

The Canadian Study

In 1985, a landmark study was published in the Canadian Family PhysicianCanadian Family Physician [10] which researched the effects of chiropractic adjustments for people with severe and chronic lower back pain. The approximately 300 subjects in this study had been "totally disabled" by back pain for an average of seven years, and had gone through the full gamut of standard medical interventions.

The study found that after two to three weeks of daily chiropractic adjustments, between 79 and 93 percent of those patients without spinal stenosis (narrowed spinal cord) had good to excellent results, reporting substantially decreased pain and increased mobility. Even among those with a congenitally or developmentally narrowed spinal cord, a significant number showed substantial improvement. Remember that every single one of these people had gone through extensive, unsuccessful medical treatment prior to being allowed to participate as a research subject. After chiropractic treatment, over 70 percent of those studied were improved to the point of having no work restrictions. Moreover, follow-up a year later demonstrated that the changes were long-lasting.

These results are remarkable, but what was extraordinary about the Canadian study was the fact that it was jointly administered by Dr. J.R. Cassidy, a chiropractor, and Dr. W.H. Kirkaldy-Willis, a world-renowned orthopedic surgeon. In 1993 Dr. Cassidy became the first chiropractor to be named research director of a university orthopedics department, at the University of Saskatchewan where this research was done.

The landmark Canadian study clearly demonstrated the effectiveness of chiropractic adjustments for treating chronic lower back pain, even when standard medical interventions have been exhausted. Yet, sadly, many physicians seem unaware of this study and too few take the logical next step of referring patients with these symptoms to a chiropractor.

The British Study

In 1990, the British Medical Journal published a study called "Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Outpatient Treatment," by an orthopedic surgeon, Dr. Thomas Meade.[11] Meade's research compared chiropractic manipulation with standard hospital outpatient treatment for lower back pain. The medical treatment consisted of wearing a corset and attending physical therapy sessions. Over 700 patients were involved in the study.

Dr. Meade concluded:

"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 a later interview with the Canadian Broadcasting Corporation, Dr. Meade said,

"Our trial showed that chiropractic is a very effective treatment, more effective than conventional hospital out-patient treatment for low-back pain [emphasis added], particularly in patients who had back pain in the past and who [developed] severe problems. So, in other words, it is most effective in precisely the group of patients that you would like to be able to treat . . . One of the unexpected findings was that the treatment difference the benefit of chiropractic over hospital treatment actually persists for the whole of that three-year period [of the study] . . . it looks as though the treatment that the chiropractors give does something that results in a very long-term benefit. [12]

The great significance of the Meade study is that it is the first randomized study to demonstrate long-term benefits from chiropractic care. One baseless, but persistent, criticism of chiropractic has been that while it may offer short-term relief, it is of no lasting value. The Canadian and British studies, taken together, should by any reasonable standard be sufficient to lay this old falsehood to rest. Nonetheless, the criticism continues to appear in print, and needs to be answered forthrightly whenever it rears its head.

The RAND Study

In 1992, the widely respected RAND Corporation, a health care think tank, released a study on the appropriateness of spinal manipulation for lower back pain. Authored by a multidisciplinary panel headed by Paul Shekelle, M.D., the study marked the first time that representatives of this prestigious group had officially recognized spinal manipulation as an appropriate treatment for some patients with lower back pain. RAND's procedures involved an extensive review of the scientific literature on the treatment of back pain, and a consensus process among the participants to determine areas of agreement.

The rather limited nature of RAND's endorsement of spinal manipulation must be seen in context to be properly understood. RAND is known for its thoroughgoing critical evaluations and the great caution of its assessments, which is part of the reason that its conclusions are often taken by federal officials as something close to the final word on health matters. While its conclusions on spinal manipulation failed to go as far as many chiropractors would have liked, they nonetheless were far more favorable than RAND's recent pronouncements on other controversial medical issues such as heart surgery.

The national media were quick to grasp the significance of the RAND report. In the weeks and months immediately following its release, high-profile news reports appeared in American newspapers, magazines and electronic media, declaring that chiropractic was finally being "accepted." Of course, millions of chiropractic patients had already accepted it happily for years, but the RAND report marked the scaling of an inner wall of the health establishment.

The Dutch Study

A Dutch study published in the British Medical Journal in 1992 compared the results of back and neck pain patients treated with physical therapy against those given chiropractic manipulation, and also compared these two methods to placebo treatment and standard medical treatment by a general practitioner.

The results were impressive, and showed that both chiropractic manipulation and physical therapy were significantly more effective than a placebo treatment or treatment by a general practitioner. In addition, those receiving manipulation showed more improvement than the physical therapy patients, in fewer visits. [13]

Additional developments include:

An Australian study showed that patients who were treated by chiropractors lost four times fewer work days from low-back pain than those treated by medical doctors. [14]

A cost-comparison study in the Journal of Occupational Medicine demonstrated that the compensation costs for lost work time were ten times as high for those receiving standard, non-surgical medical care than for those who were treated by chiropractors. [15]

A study of Florida worker's compensation cases indicated that patients receiving chiropractic care were temporarily disabled for half the length of time, were hospitalized at less than half the rate, and accrued bills less than half as high as patients receiving medical care for similar conditions. [16]

Preliminary results of a study on headaches showed spinal manipulation to be more effective than prescription medication for long-term pain relief. The chiropractic patients maintained their levels of improvement, while those treated with medication returned to their pre-treatment status in an average of four weeks after completion of treatment. [17]

The North American Spine Society (an interdisciplinary body consisting of expert practitioners and academics from the medical, osteopathic and chiropractic professions) rated spinal manipulative therapy in Category I, the highest rating, for treatment of lower back pain. Chiropractic adjustments were described as generally accepted, well-established, and widely used. [18]

AV MED, the largest health maintenance organization (HMO) in the Southeastern United States sent 100 medically unresponsive patients to a chiropractor. Eighty-six percent of this group were helped. As a result of two to three weeks of chiropractic care, all 12 patients medically diagnosed as needing disc surgery were able to avoid surgery, saving AV MED $250,000, and sparing the patients the risks and consequences of unnecessary surgery. [19]

A study published in the Western Journal of Medicine in 1989 found that chiropractic patients were more satisfied with their care than back pain patients of family practice physicians by a ratio of three to one. Interestingly, initial discussion of this study in medical journals generally assumed that the greater satisfaction rates among chiropractic patients were due entirely to allegedly superior doctor-patient relationships on the part of chiropractors. Left out of the analysis for the most part was the possibility that the difference may have been due in large measure to the greater effectiveness of chiropractic treatment methods.

In fact, chiropractic manipulation has been shown to be far more effective than the bed rest and prescription medications routinely prescribed by family practice physicians and general practitioners for back and neck pain, as shown in the study that follows. [20]

A clinical trial found that bed rest plus nonsteroidal anti-inflammatory medication (which together form the standard method with which family practice physicians and general practitioners treat low back pain) brought results worse than a placebo treatment. [21] This is particularly problematic in light of the fact that more people initially go to these primary care doctors for low back pain than to any other type of practitioner. Chiropractic treatment for lower back pain has been shown in many studies to be significantly superior to a placebo, and no reputable study has ever shown it to be worse than a placebo.

The November 1992 issue of Journal of Family Practice, the major journal for family practice physicians in the United States, included three strongly pro-chiropractic articles, which urged readers to "re-evaluate chiropractic" and "reconsider referrals to chiropractors for musculoskeletal problems." The first paper was co-authored by Peter Curtis, M.D., of the Department of Family Medicine at the University of North Carolina, Chapel Hill, and Geoffrey Bove, D.C., a Ph.D. candidate in the Department of Cell Biology and Anatomy at the same school. The other two articles were editorials supporting the Curtis-Bove article, one by noted researcher Daniel Cherkin, Ph.D., and the other by three Israeli medical doctors who supported the conclusions of Drs. Curtis and Bove. [22]

A study by the Gallup Organization determined that 90 percent of chiropractic patients rated their treatment as effective, and 80 percent were satisfied with the treatment they received and felt that most of their expectations were met. [23]

Chiropractors and the millions who have benefited from chiropractic care over the years believed all of this to be true from the beginning. That's why they fought so hard for its full acceptance as a legitimate, recognized healing art. Finally, enough objective scientific data now exists to show that their faith in chiropractic was not misplaced.

As scientific research continues to validate the chiropractic approach, the case for full recognition and integration grows stronger year by year. This is the path required of all alternative healing methods seeking to cross the bridge from alternative to mainstream. As each alternative enters the mainstream, the stream itself is forever changed.

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