History Volume 32, No.1 21 A History of Rehabilitation and Exercise in the Chiropractic Profession

LINDA J. YOUNG, BS*

When the chiropractic profession was born, exercise was considered that of a recreational activity such as taking a walk in the great outdoors. Neither nor chiropractic utilized exercise in the modern sense in the care or treatment of injured or ailing patients until the onset of World War I. Wartime created the need for rehabilitative services which cemented physi- cal therapy into a profession within the medical culture especially after World War II. Though chiropractic chose to remain a distinct discipline, chiropractic treatment was a popular issue during the post war era. The use of exercise as a treatment modality for chiropractic patients increased significantly throughout history. Today, exercise, either as prevention or rehabilitation is instrumental in the health and well being of the human population and is supported in allopathic medicine, chiropractic medicine, and by the United States government through its public health initiative, Healthy People 2020.

Introduction cise utilized in allopathic medicine and the Physical activity has been an integral influence of the United States government part of wellness since the beginning of in these historical events. It should be time. As we find ourselves in the age of noted that although physical activity and technology, most services come at the exercise have unique definitions, these touch of a button and there is a significant terms have been used interchangeably in increase in the number of Americans with a historical literature. sedentary lifestyle. Inactivity is having a significant, negative impact on the health Early References to Exercise in of the majority of Americans. Chiropractic Many chiropractic employ D.D. Palmer founded chiropractic in late exercise as a complementary method in 1895.1(pp 71) The profession was new and treatment and rehabilitation. The author the treatment was not well received by the speculates that improper exercise, as well allopathic community. During the early as lack of exercise, increases vulnerability years of chiropractic, exercise was recog- to acute injury and recurring episodic back nized as a necessity for health and well be- pain, and therefore warrants discussion. In ing, as in the form of taking a walk in the this article, the author will provide an great outdoors, not as a structured activity abridged account of the history of exercise for the improvement in strength or mobil- in the chiropractic profession, along with ity. Exercise was perceived as effort put parallel findings of the evolution of exer- forth by an athlete and was not used in the treatment of a patient seeking chiropractic

*Exercise Intern, Illinois State University & Advanced Chiropractic Clinic of care. Normal, Normal, Illinois, [email protected] Chiropractic History Volume 32, No.1 22 Dr. Palmer addresses the benefits of ex- this philosophy excluded exercise as a ercise in one of the earliest chiropractic treatment modality in the care of chiroprac- publications: tic patients in an effort to keep chiropractic The fundamental principle of nearly ‘pure.’ every branch of modern science has been Though it is evident that the Palmers the gradual metamorphosis of investigators who searched for the 'philosopher’s stone' were, and remain, a prominent name in chi- and the 'elixir of life.' The philosophers of ropractic, there were many others who in- the Middle Ages spent many long, weary fluenced the incorporation of other treat- hours of study and research chasing after ment options such as exercise into chiro- what proved to be a will-o’-the-wisp . . . practic practice. Those who were not op- Those of the twenty-first century will, no doubt, look back upon us in a similar man- posed to other methods of treatment to ner.2 complement chiropractic adjustment were Daily exercise short of fatigue, calm- classified as "mixers." Dr. Solon Langwor- ness of mind, moderate intellectual pow- thy is believed to be the first "mixer" in ers, a family life and a merry disposition 2 (emphasis added) chiropractic history. Dr. Langworthy pub- are aids to longevity. lished a chiropractic journal titled, Back- Though there is little written about exer- bone. This publication included articles of cise or rehabilitation in early chiropractic interest to the profession as well as adver- literature, there are several references to tisements for information on weight loss, activities of daily living, such as walking or how to become "strong," the use of electri- otherwise participating in physical activity. cal stimulation to increase muscle size, In fact, though D.D. Palmer supports among others. Evidence of the promotion physical activity in early chiropractic litera- of physical activity was evident in Lang- ture, he also discusses ill effects of strenu- worthy's publication, as well. For example, ous exercise. According to Dr. Palmer, The kidney is a highly vascular organ . . a man named Arba Josef submitted the fol- . the disturbance to the blood supply lowing for publication in the Backbone, caused by straining and lifting is the Laziness is a disease. No normal, well cause of disease. . . Straining and lifting adjusted human being can be lazy. The lazy displaces bones, impinges and excites man is a sick man, and like all other forms nerves, thereby causes the kidneys to per- of disease, laziness entails trouble and trials form their functions either excessively or on everyone around as well as on the “lazy 5 deficiently; these abnormal amounts of dog” himself. function result in disease.2 (author’s emphasis) Langworthy was the founder of the While D.D. Palmer developed chiroprac- school which was instrumental in compet- tic technique, it was his son, B.J. Palmer ing with D.D. Palmer and is believed to be who further developed the chiropractic pro- “one of the most influential personalities in fession. B.J. Palmer graduated from his early chiropractic.”1(pp 402) father’s school in 1902.1(pp 114) B.J. Palmer referred to himself as the "Developer" of New Prominent Figures Augment chiropractic and transformed the Palmer Change in the Profession School of Chiropractic into the largest As chiropractic evolved beyond the health practitioner college in the nation.3 Palmers, and especially with new promi- B.J.’s philosophy was to keep chiropractic nent figures in the profession, different phi- “specific, pure, and unadulterated.”1(pp 114),3 losophies emerged, and the use of treat- This philosophy came to be known as ment modalities beyond the chiropractic “straight” chiropractic, excluding all other adjustment began to take hold. The profes- forms of therapy.3,4 It is speculated that sion expanded and more schools of chiro- Chiropractic History Volume 32, No.1 23 practic were built that included curricula to chiropractors came to believe that subluxa- support the alternate "mixer" philosophy. tions were not the sole causation of disease. In 1912, the National School of Chiroprac- Factors such as diet, exercise, and rest were tic (NSC) introduced training on physio- just as important--if not more important-- logical therapeutics into its set of courses. than the correction of vertebral subluxtion.6 These courses included hydrotherapy, mas- Changes in philosophies such as this sage, "remedies both internally and exter- sparked a continued battle between two nally applied," and "muscle techniques." separate organizations of chiropractors. Physiological therapeutics was the forerun- The International Chiropractors Associa- ner of modern physical therapy.3,4 William tion (ICA) and The National Chiropractic Charles Schulze, M.D., D.C., became Association (NCA), two separate organi- president and owner of the NSC in 1916.1 zations consisting of straights and mixers, (pp 107) Arthur L. Forster, M.D. along with respectively, battled for thirty years after Schulze pioneered physiological therapeu- World War II. The NCA, later named the tics within the chiropractic profession. American Chiropractic Association (ACA) These modalities included light, heat, cold, felt that chiropractic legitimately included electricity, and water. It is significant to the use of therapeutics and clinical proce- note that nutritional interventions and exer- dures. The ICA was concerned with main- cise regimes were used at NSC long before taining the profession’s distinct identity the formation of the physical therapy pro- from medicine. By the mid 1970’s, these fession.1(pp 107) two organizations called a truce and de- cided to work together in an effort to gain World War II Changes the Profession federally recognized accreditation of chiro- A paradigm shift unfolded in the early practic education.1(pp 181) 1940’s, nearly fifty years after the birth of chiropractic. Changes occurred in chiro- Chiropractic Methods Broaden practic in response to World War II. Many The changes in chiropractic approaches chiropractors were called to active duty continued at a rapid rate as exercise, and forcing the closure of several chiropractic other methods of treatment became incor- schools.1(pp 178) In 1944, Congress author- porated into formal chiropractic training as ized legislation that rejuvenated chiroprac- evidenced by references in textbooks used tic education and the enrollment in the re- in the curriculum at the Palmer School. As maining chiropractic schools. Though fed- an example, in 1946, the Palmer School of eral funding for chiropractic was minimal Chiropractic published a textbook titled compared to that of the millions of govern- Correlative Chiropractic Hygiene, written ment dollars for the construction of medi- by Dr. Donald Pharaoh. In his book, Dr. cal teaching hospitals, veterans of the war Pharaoh discusses exercise as it relates to were able to use their GI benefits to pay for posture, though he does not describe spe- tuition for a .1(pp 178) cific exercises that are appropriate for cor- This brought about promise for expansion rect posture. Pharaoh claimed that if a of chiropractic. “In the decade immedi- child was taught correct posture through ately following the war’s end, chiropractic explanation and demonstration, the muscles care for veterans and the rehabilitation of and ligaments would respond provided the polio victims were popular issues.”1(pp 182) proper posture was maintained while walk- Though the battle of the straight and the ing, sitting, or standing.7 Pharaoh contin- mixers continued, an increasing number of ued to explain that strengthening weak Chiropractic History Volume 32, No.1 24 muscles was another option for teaching or a Medical Division, staffed by medical correcting posture; however, he cautioned doctors, and a Chiropractic Division.1(pp 170) exercise should not be too strenuous as to It is speculated that the Rehabilitation lab cause fatigue in an effort to avoid risk of was located in the medical division where aggravating the condition.7 research equipment and diagnostic equip- That same year, the Palmer school pub- ment were utilized. This would be consis- lished another textbook written by Dr. tent with B.J. Palmer's desires to keep chi- Ralph W. Stephenson simply titled, Chiro- ropractic pure, separate and distinct from practic Textbook. The author states: the practice of medicine or . Exercise is the natural and normal amount of movement of the body and its Exercise Becomes Mainstream in parts to obtain the normal amount of adaptation that is due to every part of it. Chiropractic Natural demand in order to obtain the Evidence throughout chiropractic litera- normal supply of adaptation.8 (author’s empha- ture suggests that the combination of ma- sis) nipulation, passive movement, and exercise Thus, according to Stephenson, chiroprac- has been demonstrated to be beneficial for tic care would only be supportive of exer- treatment and rehabilitation of chiropractic cise if it conformed to that definition. Ste- patients. The author speculates that this phenson believed that natural exercise pro- combination of treatment modalities most vided a biological and beneficial likely offers the optimal opportunity for the "tiredness" and any exercises that were un- body to heal itself. natural or caused exhaustion or fatigue In 1979, evidence of corrective exercise would not be advantageous. Dr. Stephen- for promotion of the formation and preser- son claimed that because the athlete is de- vation of good lordotic curves in the spine veloped abnormally, he is at risk of becom- exist in Dr. Fred Barge’s second volume of 8 ing pathological as a result. his textbook for chiropractors titled Torti- During this same time period, several collis. Dr. Barge makes an analogy of na- photographs appeared in chiropractic litera- ture and man. Just as an animal stretches ture depicting a "Rehabilitation Labora- in the morning, by arching its neck, back tory" at the Palmer school. Photos illus- and lower back, Barge reasons that humans trate the existence of a treadmill, a spe- should perform these movements/exercises cially constructed tricycle for children, a as well. “Only man bends over forward punching bag, rowing machine, neck mus- upon rising, puts on his shoes or slippers cle developer, forearm developer, spirome- and thus strains the lower back and ter, upper-arm developer, push and pull leg discs.”10 In this book, Dr. Barge diagrams developer, mechanical horse, shoulder de- some stretches/exercises that promote good veloper, bicycle, climbing bars, and kiddy lordotic curves. (Figure 3) cars used to train the paralyzed how to One of the biggest proponents of exer- 9 walk. (Figures 1,2) The equipment in the cise as a part of chiropractic treatment is Rehabilitation Laboratory was used as an Craig Liebenson, D.C.11 His 1996 text, incentive for patients to use paralyzed Rehabilitation of the Spine extensively cov- parts, and “at no time, in no way, do we use ers all aspects of spinal rehabilitation with 9 any therapeutic apparatus on any case.” emphasis on spinal stabilization exercises, The chiropractic literature also supports the active rehabilitation protocols and the role establishment of a Palmer School Research of activity and exercise in disability pre- 1(pp 170) Clinic circa 1935. The clinic housed vention. Chiropractic History Volume 32, No.1 25

Figure 1. Photograph of exercise equipment in the Palmer Rehabilitation Laboratory circa 1945. Courtesy of Palmer College of Chiropractic Archives.

Figure 2. Rowing machine, parallel bars and stationary bicycle from the Palmer Rehabilitation Laboratory circa 1945. Courtesy of Palmer College of Chiropractic Archives. Chiropractic History Volume 32, No.1 26

Figure 3. Dog stretching in hyperextension (left) after Barge9 with human exercise of full-spine hyperextension stretch after Troyanovich.11

Burl Pettibon, D.C. describes how sub- Donald Harrison, M.S., D.C. dedicates luxation complexes include soft tissue in an entire chapter in his book titled Chiro- his textbook titled Pettibon Spinal Bio- practic: The Physics of Spinal Correction Mechanics Theory and Implications. Petti- CBP Technique, to “mirror image” exer- bon explains that the paravertebral muscles cises. These exercises are prescribed spe- pull on their bone of attachment altering cifically to address abnormal posture in an the angle of attachment to the spine, caus- effort to relieve stress and return nerve ing an unequal angle of pull. Paired mus- function to the paraspinal tissues. 14 cles on opposite sides of the spine in the Additionally, Stephan Troyanovich, area of subluxation will actually weaken, D.C. promotes the performance of reha- though one will be stronger than the other. bilitative exercise as an adjunct to spinal According to Pettibon, “Exercise is the .15 Nearly twenty percent of only way to strengthen a muscle, and that a his entire text, Structural Rehabilitation of weak muscle with proper nerve supply be- the Spine & Posture: A Practical Ap- ing suddenly returned cannot be expected 12 proach, is devoted to the proper implemen- to hold in its normal position.” Exercise tation of range of motion, isometric and as an important adjunct to the chiropractic isotonic exercise in the treatment of the adjustment would become an essential spine, while only six percent of the book is component of Dr. Pettibon's technique. dedicated to procedures. Dr. Ronald Aragona developed a chiro- In 2004, Cooperstein and Gleberzon au- practic technique he called Applied Spinal thored a text evaluating twenty-three Biomechanical Engineering (ASBE). He "brand name" technique systems in use in would develop exercise maneuvers de- the chiropractic profession.4 Seven of the signed to restore normal coupled motions twenty-three methods incorporate the use to the spine. In a study of rehabilitative of exercise as part of their basic regime maneuvers used to restore intrinsic muscle with several promoting exercise as an inte- function to the weak side of spinous proc- gral part of their overall methodology. ess rotation, Speiser, Aragona and Heffer- These specific citations4,10,11-15 are in- nan conclude that specific therapeutic exer- cluded as evidence of the increasing role cises can be prescribed to address the exercise has played in specific chiropractic myopathic component of the vertebral sub- 13 techniques and approaches in the manage- luxation complex. ment of chiropractic patients. Chiropractic History Volume 32, No.1 27 developed from without, as much a result Physical Therapy: A Chiropractic of its ostracism by medicine as its own de- Analog? sire to remain separate and distinct.”16, On Physiotherapy modalities have been 23 February 1918, Mary McMillan, be- used as a healing art since the beginning of came the first physical therapist in the man. Exercise became most prominent in country and would become known as the the allopathic community through the evo- "Mother of Physical Therapy."16 lution of physical therapy. There is evi- The events leading to World War II dence that exercise was used for treatment prompted change for allopathic medicine as in allopathic medicine in the late 1800’s to well, reinforcing the relationship between treat orthopedic disorders.16 During this physical therapy and the medical commu- time, orthopedists became a specialty in nity. Three years prior to World War II, a medicine and treated patients who had reconstruction aide corps was fully devel- problems with muscles, joints, and bones. oped and ready to serve. The American These physicians used heat to relieve pain, Physical Therapy Association became pre- massage to treat muscle spasms, and exer- pared for the onset of war by contacting the cise to strengthen weak muscles and they medical department regarding the forma- realized the benefits of these treatments. tion of a reserve unit of physical therapists. Because these treatment modalities were Physical therapists found themselves well time consuming, the orthopedists utilized prepared to report to the Surgeon General women who had physical education back- that they were ready as an organization to grounds and some knowledge of anatomy, cooperate fully as a rehabilitative team for physiology, and kinesiology to perform the wounded soldiers. It was at this point that therapy.16 physical therapists solidified their place in The onset of World War I had an instru- the system.16 After a twenty- mental role in the development of the five year battle, in 1944, full military rank physical therapy profession and recognition was granted to physical therapy aides.16 from the United States Government. The Ninety years later, chiropractic is just now need for WWI casualties to rehabilitate and beginning to obtain an equal footing. 16 return to the front lines was a major event that generated the founding of the Recon- Government, Physical Therapy structive Program by the Surgeon General & Chiropractic of the United States Army. The Surgeon The United States Government played General defined the term physiotherapy as, an instrumental role in the development “…physical measures such as are em- and acceptance of physical therapy into the ployed under physiotherapy, including hy- allopathic community, especially during dro, electro, mechano therapy, active exer- WWI, while little support was offered to cises, indoor and outdoor games, and pas- the chiropractic community. Again, after sive exercises in the form of massage.”16 WWII, chiropractic received limited assis- Because the Surgeon General initiated the tance and recognition from the government use of these services, the United States compared to that of the allopathic commu- Government supported it, and the medical nity. The United States Government is a community respected these reconstructive prominent fixture in healthcare today. aides, “physical therapy cemented its posi- Still, chiropractors battle for recognition. tion within the framework of the evolving In 1994, the U.S. Department of Health and health care paradigm while chiropractic Human Services published a Clinical Prac- Chiropractic History Volume 32, No.1 28 tice Guideline titled, Acute Low Back Prob- These guidelines interestingly correlate lems in Adults. In regards to exercise, the with Dr. D.D Palmer’s words from 1910, summary of the report suggests that a pro- “Daily exercise short of fatigue, calmness gram of gradually increased aerobic and of mind, moderate intellectual powers, a back-strengthening exercises for the treat- family life and a merry disposition are aids ment of low back problems was superior to to longevity.”2(emphasis added) A common doing no exercise at all.17 The panel of sense approach to healthy living seems to twenty-three experts responsible for the span three different centuries. reviewing the scientific literature and creat- ing the clinical practice guideline predomi- Conclusion nantly consisted of medical physicians, os- From a broad perspective, it is evident teopathic physicians, physical therapists that there are commonalities related to ex- and nurses. Despite the level of expertise ercise or physical activity from the late the chiropractic profession has on back 1800s through the present among the allo- pain, Scott Haldeman, M.D., D.C, a dual pathic medical community, the chiropractic degree holder in both medicine and chiro- community, and as advocated by the practic and John Triano, D.C. were the United States Government for the overall only individuals to participate with chiro- health and well being of the human popula- practic credentials.18 tion. The chiropractic profession initially The government’s involvement in considered exercise as a general activity healthcare today supports a disease preven- that could help maintain health as a part of tion initiative. The United States Govern- a healthy lifestyle. World War I and World ment recognizes lack of physical activity as War II changed how medicine would use a major health concern and continues to exercise as a specific method to assist in advocate exercise, among other areas of the healing of wounded military personnel; health and wellness, via the public health physical therapy came into existence initiative, "Healthy People." The govern- largely as a result of these wars. Chiro- ment has been crusading in the public practic was present to add its unique ap- health domain for over thirty years.18 In proach to relief of pain and disability sec- December 2010, the United States Depart- ondary to war, and the profession expanded ment of Health and Human Services re- its use of therapeutic modalities and exer- leased the newest agenda for disease pre- cise to supplement the chiropractic adjust- vention and health promotion titled ment. Today, exercise as a primary inter- "Healthy People 2020." This continued vention for the treatment of patients is at initiative has expanded on Healthy People the forefront of chiropractic practice. 2010 due to the (limited) success of the program. Among the thirteen topics of in- terest ranging from Adolescent Health to Global Health, physical activity guidelines of Healthy People 2020 are contained in the Health-Related Quality of Life and Well-Being category. The physical activ- ity guidelines for Healthy People 2020 en- courage regular physical activity including participation in moderate and vigorous physical activities and muscular strength.19 Chiropractic History Volume 32, No.1 29 Notes Wilkins.

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