Chiropractic; Identity; Subluxation
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Journal of Contemporary JCC Chiropractic Chiropractic Identity Ebrall THE CONVENTIONAL IDENTITY OF CHIROPRACTIC AND ITS NEGATIVE SKEW Phillip Ebrall BAppSc(Chiro), DC (Hon), PhD, PhD(Cand).1 ABSTRACT anesthetic, to create a blister over the spinal segment or creating painful irritation with surgical incision. (6-8) Objective: To discuss the professional identify of His new method to correct a subluxed vertebra became chiropractic as evident in the profession’s literature. known as the chiropractic adjustment and these behaviors indisputably constitute conventional chiropractic (9) Methods: Structured literature review followed by a notwith-standing a vocal minority who think otherwise. pragmatic historical narrative of found artefacts. (10) That which Palmer founded as ‘adjusting by hand’ Results: The literature appears vague regarding (11) is now colloquially known as ‘cracking backs.’ (12) chiropractic’s identity. One would think the practice of manually adjusting Discussion: The literature does allow a broad subluxation would form a consistent identity for the determination that the identity of chiropractic is uni- profession Palmer founded but this was not to be. In his modal gathered around the founding premise of DD mid-1990s thesis (13) examining chiropractic in Australia, Palmer with an informed prediction of a left-skewed, sociologist O’Neill noted ‘the deceptively simple question negative distribution of concessional chiropractors “what is a chiropractor” still lacks a definitive answer.’ representing no more than 30% of all. It appears this (14) The same question had been posed 20 years earlier minority becomes more dogmatic as it concedes elements by Haldeman, who came to be an eminent member of of conventional identity and adopts extreme evidence- the profession. He asked ‘what is a chiropractor, and based musculoskeletal medicine to become a sect of what does he do?’ (15) Not one of a recent series of 13 about 0.2% of all. About 70% of chiropractors identify papers addressing the question ‘what is chiropractic’ and with subluxation in an evidence-informed context and reporting ‘papers describing the chiropractic profession I call this representation the conventional chiropractic and chiropractic practice’ addressed identity. (16, Table 1) identity. This question would be answerable with a common Conclusion: The identity of chiropractic may now be professional identity that did not distinguish between described as conventional when its practitioners adhere to the discipline as a body of knowledge forming the science the profession’s founding precepts, or concessional when of chiropractic, and the profession as the group of people it modifies or ignores these. The majority of the profession engaged or qualified in expressing that knowledge, can be considered conventional. (J Contemporary Chiropr based on standards of practice, codes of ethics and 2020;3:111-126) of professional conduct. It is the lack of a professional identity gathering these that the evidence shows to allow Key Indexing Terms: Chiropractic; Identity; Subluxation. contemporary counterfactual argument within and about chiropractic. INTRODUCTION This paper applies the methods of a pragmatist to The premise of chiropractic is straight forward; subluxed examine chiropractic’s professional identity by con- vertebrae compromise the nervous system, modulating sidering a historical context for adjectives descriptive of tone and the resultant state of Wellbeing. (1, pp 404, 632, chiropractors, such as ‘straight’ or ‘mixer’, and ‘dogmatic’ 656, 659) Variants of this idea are found throughout the or ‘evidence-based.’ Australasia allows a case study medical literature of the 16th through 19th Centuries of identity as it developed outside North America, the (2,3) and the chiropractic literature of the 20th Century. founding home of the profession. In Australasia the (4) delineating terms are ‘main-stream’ and ‘second-stream.’ Palmer’s original contribution was the use of the (17) spinous and transverse processes as levers to manually This paper addresses the research question ‘what is the replace subluxed vertebra (5), thus avoiding the painful professional identity of chiropractic’ and will identify medical approach of cauterizing with a hot iron, without the terms ‘conventional’, ’concessional’, and ‘negative left skew’ as appropriate descriptors in the 21st Century, 1 Chiropractic writer, Asia. J Contemp Chiropr 2020, Volume 3 111 Chiropractic Identity Ebrall formalizing the split identity that emerged during the this critique on the basis of my systematic analysis of the first decade of the profession. chiropractic literature undertaken in March 2019 using the search string ‘papers given as first-level related from METHODS chiropractic [mesh] AND (subluxation [ti] OR subluxation [ab])’ in the form ‘“chiropractic”[MeSH Terms] AND The literature of professions was searched to establish a (subluxation[ti] OR (“joint dislocations”[MeSH Terms] contemporary interpretation of ‘identity’ in the context OR (“joint”[All Fields] AND “dislocations”[All Fields]) of a health profession. The discipline’s literature as OR “joint dislocations”[All Fields] OR “subluxation”[All indexed by the Chiropractic Library Collaboration (18) Fields]))’. 101 papers were returned and all were one or was searched for primary data, and secondary data were more of opinion, cohort studies with ill-defined terms, found by citation harvesting of returned papers from literature reviews, or other. the initial search. The standard assessment processes used by historians to validate found papers and related As a pragmatic historian and educator I argue that resources were applied. Primary sources were evaluated vagueness envelops the professional identity of by understanding who wrote it, what questions were chiropractic. My use of the term ‘vagueness’ is after addressed, and why? (19) The 6 evaluative questions Swinburne’s examination (43) and includes inexactness identified by Garraghan (20) to validate historical and imprecision, qualities that are appropriate to describe artifacts were consistently applied to all papers. ongoing argument over basic clinical procedures within chiropractic. To demonstrate polar divergence I present The initial search term was ‘identity’ and I report that the 2 examples: a conflict regarding the role of radiography, literature does not return a common, shared professional and actions by a minority to become part of medicine identity for the chiropractic profession; also, that various complete with prescribing rights for listed medications. professional bodies including the Word Federation of Chiropractic (WFC) lack commonality in their The Radiography Cleft understanding of the profession they represent. With regard to the clinical use of radiography in RESULTS chiropractic practice there are 2 strongly held oppos- The Matter of Professional Identity ing views. I accept this as evidence of a heterogeneity of clinical ideas within the profession. (44-52) My critical In general a profession is an occupation based on skill or interpretation of this heterogeneity is the dissent by 1 education (21) where the holder has autonomy. (22) The group from the opinion of another regarding clinical themes of professional identity are given as ‘selflabeling radiography. as a professional, integration of skills and attitudes as a professional, and a perception of context in a professional The evidence in this case reveals 2 quite different community.’ (23) Chiropractic appears as a profession to standards (53-56), each claiming to be best practice for the the public (24-26) and to health-care peers. (27) Given that use of diagnostic imaging in clinical chiropractic. Both chiropractors exist under legislation in over 40 countries groups claim to be evidence-based, with 1 aligned with (28,29) they are considered as health practitioners and evidence seen through a biomedical lens and the other the occupational regulators and education accreditors with evidence seen through a lens of chiropractic clinical are overt regarding the need to demonstrate professional practice. In turn, this leaves educational institutions skills and attitudes. (30) Indeed, ‘Universal Competency presented with a choice between 2 conflicting versions 1’ of the Council on Chiropractic Education Australasia of evidence, (57) if indeed a choice is needed to teach (CCEA) is ‘Practicing Professionally’. (30 p. 10) clinically-based practice standards regarding chiropractic radiography or the medical view where the diagnostic The Matter of Chiropractic Identity intent of imaging is different. The debate is acrimonious (46) and ad hominem. (58) Different positions within chiropractic are shown to have different ideas of what chiropractic is or should be (31-34) The pragmatist’s perspective is that the clinical Individual opinions (35,36) range from it being a drug- chiropractic view predates the biomedical view by free (37) wellness profession (38) treating beyond the decades and that pre-treatment radiographs provide spine (39) to only a spine-care profession with manual important clinical information. Some consider they methods, (40,41) or, in a basic form, centering on the are required for safety (59-61) while others consider analysis and adjustment of vertebral subluxation. (42) otherwise. (62) A critical analysis of the biomedical approach promoted by the WFC suggests flaws in its The literature offers few published intellectual constructs of basic understanding of clinical chiropractic practice chiropractic