Chiropractic Origins, Controversies, and Contributions

REVIEW ARTICLE Chiropractic Origins, Controversies, and Contributions

Ted J. Kaptchuk, OMD; David M. Eisenberg, MD

hiropractic is an important component of the US health care system and the largest alternative medical profession. In this overview of chiropractic, we examine its history, theory, and development; its scientific evidence; and its approach to the art of medicine. Chiropractic’s position in society is contradictory, and we reveal a complex dynamic of conflictC and diversity. Internally, chiropractic has a dramatic legacy of strife and factionalism. Exter- nally, it has defended itself from vigorous opposition by conventional medicine. Despite such tensions, chiropractors have maintained a unified profession with an uninterrupted commitment to clinical care. While the core chiropractic belief that the correction of spinal abnormality is a critical health care intervention is open to debate, chiropractic’s most important contribution may have to do with the patient-physician relationship. Arch Intern Med. 1998;158:2215-2224 Chiropractic, the medical profession that (whereas the number of physicians is ex- specializes in manual therapy and espe- pected to increase by only 16%).6 cially spinal manipulation, is the most im- Despite such impressive creden- portant example of alternative medicine tials, academic medicine regards chiro- in the United States and alternative medi- practic theory as speculative at best and cine’s greatest anomaly. its claims of clinical success, at least out- Even to call chiropractic “alterna- side of low back pain, as unsubstanti- tive” is problematic; in many ways, it is ated. Only a few small hospitals permit chi- distinctly mainstream. Facts such as the ropractors to treat inpatients, and to our following attest to its status and success: knowledge, university-affiliated teaching Chiropractic is licensed in all 50 states. An centers have not yet granted chiroprac- estimated 1 of 3 persons with lower back tors privileges to perform manipulation on pain is treated by chiropractors.1 In 1988 patients.7-9 Although the American Medi- (the latest year with reliable statistics), be- cal Association (AMA) no longer prohib- tween $2.42 and $4 billion3 was spent on its its members from consulting with chi- chiropractic care, and in 1990, 160 mil- ropractors, especially since it was found lion office visits were made to chiroprac- guilty of conspiracy in this regard (see be- tors.4 Since 1972, Medicare has reim- low), chiropractic’s size and power have bursed patients for chiropractic treatments, not translated into complete acceptance. and these treatments are covered as well Contradictions and tensions exist not by most major insurance companies. In only between chiropractic and main- 1994, the Agency for Health Care Policy stream medicine but within chiropractic it- and Research removed much of the onus self. Since its inception, chiropractors have of marginality from chiropractic by de- disagreed about the definition of the therapy claring that spinal manipulation can alle- and its scope of practice. Various theories viate low back pain.5 In addition, the pro- vie for dominance within the profession. A fession is growing: the number of multiplicity of competing adjustment tech- chiropractors in the United States—now niques also vie with each other under the at 50 000—is expected to double by 2010 rubric of chiropractic. The mode of chiropractic intervention—by means of the From the Center for Alternative Medicine Research, Department of Medicine, Beth hands—and its unique therapeutic niche, Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. primarily pain disorders, seem too narrow

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Downloaded From: https://jamanetwork.com/ on 09/23/2021 a foundation for its claim to encom- inconsequential or beneath their dig- clearly a folk tradition, and the lat- pass a distinct health system with au- nity.13,14 Bonesetters did much more ter could not shed its occult status. tonomous licensing, credentialing, than help mend bones. They often Chiropractic, however, could and and educational institutions. treated painful conditions caused by did describe itself as science, and in Yet, despite external conflicts “subluxations,” which meant a “joint the 19th century, such a label was and perhaps partly because of them, ‘put out’; and the one method of cure indispensable if a medical move- and despite the intraprofessional dis- [is] the wrench aid, the rough movement hoped to emerge from a host agreements and uncertainty about its ment by which it is said that the joint of contending traditions. Although scope of practice, chiropractic has is ‘put in’ again.”15(p1) self-taught, Palmer saw himself as a found an internal coherence that has Palmer frequently mentioned scientist and wasted no time in allowed it to become an enduring the bonesetter’s tradition, identified adopting prevailing scientific no- presence in the United States. This with it, and probably had some train- tions of the spinal cord to chiroprac- integrity has to do with the profes- ing in it. Palmer’s innovation profes- tic theory. An early 19th-century fas- sion’s belief in the importance of bio- sionalized the craft, guaranteeing its cination with the spinal cord led to mechanics; the centrality of manual continuation into the modern era. The mainstream speculation, and by therapy, especially for the spine; and upgrade extended to nomenclature; 1828, orthodox physicians began to a clinical dynamic that provides pa- with help from a minister conver- warn about the threat posed to the tients with explanations, meaning, sant with Greek, “bonesetting” be- organs of the body by “spinal irri- and concrete experiences that pro- came “chiropractic,” a phrase that tation.”18 Spinal irritation in the 19th mote a strong patient-physician means “hand work.” century became a catchall for a host bond, a sense of caring, and a re- of complaints. The theory was so stored sense of well-being. Magnetic Healing well accepted that Oliver Wendell Holmes (1809-1894) could com- CHIROPRACTIC’S ORIGIN Although the bonesetting tradition fortably tell the 1871 graduating gave chiropractic its method, “mag- class of Bellevue Hospital College Most sources date the birth of chiro- netic healing” provided the theory. that he kept the phrase “spinal irri- practic as September 18, 1895, when Palmer acknowledged a special debt tation” “on hand for patients that Daniel David (usually called “D. D.”) to magnetic healing when he wrote, [sic] will insist on knowing the pa- Palmer (1845-1913) shoved a single “chiropractic was not evolved from thology of their complaints.”19(p389) cervical vertebra of a deaf janitor of medicine or any other method, Gradually discarded by main- the Putnam Building in downtown except that of magnetic.”16(p111) stream medicine and replaced by the Davenport, Iowa. A mythic aura clings Derived from Anton Mesmer’s term “neurasthenia” (and later, “de- to the event, partly because of its im- (1734-1815) investigations into the pression”), spinal irritation en- portance and because there is little supposed curative effects of animal tered into chiropractic through the agreement among witnesses about magnetism, practitioners of mag- subluxation terminology of bone- when it happened, who was there, or netic healing identified the unim- setters. Palmer extended the scope what actually occurred.10 (The mythic peded flow of energy with health and of spinal irritation and subluxation aspect of the story may have been in- defined illness as obstruction. For 9 beyond the class of ailments that oth- tentionally enhanced by selecting the years before his discovery of chiro- erwise defied analysis; it was, for date of Rosh Hashanah, the Jewish practic, Palmer was one of a small him, the key to understanding New Year, which was an occasion for army of healers who routinely sickness as a whole. At the same revelation in 19th-century Ameri- “magnetized” their patients.17 Palm- time, the adoption of the widely can millennialism.11,12) Whether fact, er’s major revision of traditional accepted concept of spinal irrita- folklore, or both, the founding blow magnetism was to call it “innate tion lent credibility to chiropractic. of chiropractic was more than a intelligence” and to claim that its chance event or momentary inspira- pathway was the human nervous Popular Health Reform tion. In fact, it creatively synthesized system, especially the spinal cord. 4 previously distinct health care tra- Misaligned spinal vertebrae (the re- Palmer cured the Davenport jani- ditions: bonesetting, magnetic heal- defined bonesetters’ “subluxation”) tor of his deafness. This restoration ing, orthodox science, and popular impinge on this beneficent flow and of hearing might have been re- health reform. cause illness. By marrying magne- garded as a freak occurrence were it tism to bonesetting, Palmer created not for a medical environment in Bonesetters a new and independent medical which news of such occurrences was movement, one more capable of com- eagerly awaited. A well-publicized Bonesetters were a common fixture peting for legitimacy than either of tug-of-war between “regulars” (phy- in 19th-century health care. As with its predecessors had been. sicians) and “irregulars” (alterna- the other healing crafts—mid- tive medicine practitioners) al- wifery, tooth-pulling, and barber- Orthodox Science ready had been sweeping the surgery—bonesetting was often part- country.20 The introduction of ho- time work and served clients who Neither bonesetting nor magnetic meopathy, herbal medicine, “Mind had problems that were regarded by healing could be persuasively de- Cure,” Christian Science, health academically trained physicians as scribed as science. The former was food, and hydropathy had pre-

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Downloaded From: https://jamanetwork.com/ on 09/23/2021 pared Americans to look for cases institutions, thought a physiological cism of an anatomist35 who con- that, on the one hand, pointed to the theory of nerves was sufficient.25 John cluded after a series of experiments limitations of mainstream medi- A. Howard (1876-1953), who came that it is nearly impossible for ver- cine and, on the other, made the mi- to chiropractic from a conventional tebral displacement to impinge on raculous seem obtainable.21 The way medical background and, in 1906, a spinal nerve at the intervertebral to perfect health was on the hori- founded what became the National foramen has also weakened alle- zon, waiting to be grasped, de- College of Chiropractic, was thinking giance to the concept. scribed, and disseminated. of innate intelligence when he warned Many chiropractors no longer The unique union of boneset- students not to “dwindle or dwarf chi- refer to simple subluxation but to a ting, magnetism, and orthodoxy was ropractic by making a religion out of “vertebral subluxation complex,” warmly received. The conflict for a technic.”26(p17) The first chair of what with an expanded meaning of me- medical hegemony both helped and became the Council for Chiropractic chanical impediments beyond bone was helped by chiropractic. Palm- Accreditation, Claude O. Watkins displacement that can include mo- er’s invectives against the establish- (1909-1977), called for scientific re- bility, posture, blood flow, muscle ment of “germo-anti-toxis-vaxi- search and the abandonment of all tone, and the condition of the nerves radi-electro-microbio-slush death cultist and vitalist principles, starting themselves.36 Some want to aban- producers”22 resonated with the with that of the innate.27 don the term altogether because it movement, as did his grandiose Today, a substantial number of “threatens to strangle the disci- promises of a medicine “destined to chiropractors are anxious to sever all pline.”37 Others speak of manipu- be the grandest and greatest of this remaining ties to the vitalism of in- lable spinal lesions,38 chiropractic le- or any age”16(p224) because it was suc- nate intelligence. For these practi- sions,39 or vertebral blockage.40 For cessful in all forms of disease. Chi- tioners, the notion of the innate serves D. D. Palmer, the meaning of sub- ropractic was the glamorous new re- only to maintain chiropractic as a luxation was clear and unambigu- cruit in the old war with mainstream fringe profession28 and to delay its ous; today, it refers to an assort- medicine. Conventional medicine “transition into legitimate profes- ment of disturbances. Subluxation recognized the threat (see below) sional education, with serious schol- is defined less in theory than in prac- and had its own rhetoric ready. For arship, research, and service.”29(p41) tice: subluxation is what a chiro- example, in 1925, Morris Fishbein practor corrects. What Palmer ini- (1889-1976), editor of The Journal Against the Notion of tiated with a single thrust has of the American Medical Associa- Subluxation evolved into an array of meanings. tion, wrote that chiropractors ar- rived on the health care scene Palmer’s followers were also quick The “Straight-Mixer” Schism “through the cellar...besmirched to amend the notion of subluxa- with dust and grime.”23(p98) tion. For Palmer, the term referred Serious as disagreement over the in- to the static misalignment of a single nate and subluxation was for chiro- DISSENSION WITHIN vertebra. In the earliest chiroprac- practic, it is overshadowed by the THE MOVEMENT tic text ever published (Modernized struggle for self-definition. For the Chiropractic, 1906), the meaning of Palmers, mastery over the spine Palmer may have articulated a medi- subluxation was expanded to in- meant mastery over nearly all dis- cal system with a single bold stroke, clude issues of joint mobility.30 In the ease. They believed that chiroprac- but neither he nor his son and suc- late 1930s, these ideas were ex- tic was not the best response; it was cessor, Bartlett Joshua Palmer (usu- tended further, making spinal fixa- the only response. When other prac- ally called “B. J.,” 1882-1961), de- tion, or restricted movement, the fo- titioners suggested that they might spite their best efforts, could keep it cus of chiropractic manipulation.31 be guilty of narrow-mindedness, from beginning to unravel shortly Some early chiropractors consid- B. J. Palmer denounced them as “chi- thereafter. ered curvature of the spine and pos- ropractoids” who had adulterated ture defects caused by muscular im- the “specific, pure, and unadulter- Against the Notion of balance to be crucial and bone ated” chiropractic tradition, open- “Innate Intelligence” involvement secondary,23 while oth- ing the way to “mixers.”41(p49) B. J. ers thought that subluxation arose Palmer’s labeling of “straight” prac- Palmer’s notion of innate intelligence from fatigue or tension in the back titioners at war with “mixers” is still (seethesubsectionon“MagneticHeal- muscle.32 Another group33 main- used today to describe an unre- ing” under “Chiropractic’s Origin”) tained that subluxations were dis- solved schism. was in dispute from the beginning. turbances in the nerves themselves “Straights” tend to rely exclu- Many of his first disciples, destined or in the muscles surrounding them, sively on spinal adjustments, to em- themselves to be influential teachers rather than defects in the bones. phasize innate intelligence, and to of chiropractic, never adopted it. The Support for the original no- subscribe to the notion that sub- list of those who reject the innate as tion of subluxation was also re- luxation “is the leading cause of dis- “religiousbaggage”readslikeanhonor duced by continuous biomedical ease in the world today.”42(p25) Since roll of chiropractic’s history.24 Willard criticism that points away from, and the 1930s, straights have been a very Carver (1866-1940), who founded a finally discounts, bone alignment as distinct minority in the profes- core group of chiropractic teaching the cause of back pain.34 The criti- sion.43 Nonetheless, they have been

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Downloaded From: https://jamanetwork.com/ on 09/23/2021 able to transform their status as pur- ing, bending—require a normal Diversity in Manipulation ists and heirs of the lineage into in- range of motion. Greater mobility, fluence dramatically out of propor- or “mobilization,” can be coaxed Chiropractors besides the Palmers tion to their numbers.44 from the joints with the assistance were quick to make their own con- “Mixers” tend to be more open of a physical therapist, for example, tributions, and the profession soon to conventional medicine and to who can stretch the lower spine by encompassed diverse styles, which mainstream scientific tenets. For to- gently moving the thigh of a per- often occasioned fresh disputes.51 day’s majority mixers, subluxation son lying on his or her side. Even- Whereas the Palmers emphasized is one of many causes of disease.45 tually, mobilization reaches an elas- one vertebra at a time, Carver de- This translates into a greater use of tic barrier of resistance, known to veloped methods to adjust the lum- therapies other than spinal manipu- chiropractors as “end feel.” bar spine as a unit. Practitioners such lation. The National Board of Chi- Chiropractic manipulation is as Oakley Smith and Solon Lang- ropractic Examiners46 indicates that a method of moving vertebrae worthy borrowed long-lever osteo- most chiropractors use conven- beyond end feel, but not so far as pathic techniques and folk meth- tional physical therapy techniques, to destroy the integrity of joint ods such as Bohemian (Czech) such as corrective exercise, ice packs, structure. The adjustment tempo- manipulation. “Diversified tech- bracing, bed rest, moist heat, and rarily creates an increased range of nique” is the label for the largest and massage. Nutritional supplements motion. The patient feels the most eclectic collection of different are the next leading nonmanipula- change and often hears a popping methods many chiropractors use.52 tive therapy in mixer practice, and or cracking noise, which some Besides the forceful techniques, depending on state laws, some chi- attribute to a sudden liberation of gentler methods of manipulation are ropractors provide acupuncture, ho- synovial gases.50 common in chiropractic. The sacro- meopathy, herbal remedies, and even The vertebrae can be moved by occipital technique, developed by biofeedback.47 direct contact—the “short-lever” DeJarnette in the 1930s,53 relies on Paradoxically, mixers, despite technique—or through a distant the passive weight of a patient press- their wide range of therapeutics, tend linkage, or the “long-lever” method. ing down on strategically placed to have a narrower and more mod- The latter method is used, for ex- padded wedges to reposition the est claim for chiropractic’s scope of ample, when a dynamic thrust of the pelvis and spine. The Logan basic practice. Also, some mixers see thigh moves a vertebra in the lower technique54 applies light thumb themselves less as traditional chiro- spine. “Amplitude” refers to the pressure close to the sacrotuberous practors and more as practitioners depth or distance traveled by a prac- ligament to move the sacrum. The of a generic complementary medi- titioner’s thrust. When joints are less activator technique55 makes use of cine.48 A second, larger group of mix- accessible or when a long lever is in- a small spring-loaded instrument ers seeks to situate themselves in the volved, the amplitude increases. The that looks like a small plunger with broader mainstream health care sys- degree of force applied is yet an- a hard sponge on the tip to deliver tem as specialists in musculoskel- other variable. pressure to the vertebrae. Some prac- etal disorders.49 titioners use tables with segmental Emblematic Chiropractic drop pieces to allow low-force, high- SPINAL MANIPULATION: Adjustment velocity adjustment.56 In total, ob- THE CORE servers of the profession have CHIROPRACTIC ACT Palmer claimed to have discovered counted between 9657 and more than the use of spinous and transverse 20058 specifically chiropractic-type Adjusting with the hands—the sig- processes of the spine as levers and maneuvers. Most chiropractors draw nature chiropractic gesture—is the to be the first to use direct contact on a variety of maneuvers on the unifying activity that allows chiro- with a vertebra that was “out.”16(p19) basis of education and personal af- practic to transcend its internal dis- B. J. Palmer developed the “recoil ad- finity, and most develop their own cord and create a coherent profes- justment,” in which a practitioner distinctive style.59 sion. Overriding disputes within the quickly pushes the vertebra into mo- profession, the core question for all tion and then, instead of maintain- CHIROPRACTIC BATTLE chiropractors remains unchanged and ing pressure, relies on a fast release FOR ACCEPTANCE agreed on: how should the hands to generate a type of rebound. B. J. move the vertebrae? Beneath doctri- Palmer thought this maneuver al- Chiropractic’s cohesiveness has been nal disparity and clinical diversity, chi- lowed the body’s innate intelli- forged in its battle for licensing. Chi- ropractic has an internal cohesion that gence to set a vertebra in its exact ropractors fought zealously for their is more than a defensive reaction to place. With or without recoil adjust- current legal and professional sta- a critical world. Chiropractors be- ment, the short-lever technique— tus, suspending doctrinal wars when lieve that the correction of spinal ab- touching the vertebra directly at high questions of state licensing were at normality—the adjustment of verte- velocity and low amplitude, that is, stake.60 The opposition was usually brae—is a critical healing act. by moving a small distance—with organized medicine. Obviously, vertebrae move all the spinal or transverse process as From the beginning, chiroprac- the time. The physical activities of a fulcrum is considered the typical tors understood that the decisive fac- daily life—exercise, turning, twist- chiropractic maneuver. tor for success was professional self-

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Downloaded From: https://jamanetwork.com/ on 09/23/2021 regulation, which would mean for federal civil service employees; of the American population suffers protection from uninformed and allowing federal income deduc- from some sort of chronic pain. possibly adverse supervision and the tions for chiropractic care; and fi- It is no secret that low back pain bolstering of public confidence in the nally, allocating federal research and chronic pain are the Achilles’ modality. State recognition was first money through the National Insti- heel of biomedicine and present a achieved in Kansas in 1913; Louisi- tutes of Health for chiropractic re- need and opportunity for alterna- ana granted recognition in 1974. The search.45 tive responses. By far the largest 60 years in between testify to the ve- The final victory came with percentage of patients—at least hemence with which conventional what chiropractors refer to as the 80%—go to chiropractors for neu- medicine resisted. “trial of the century,” which again roskeletal and musculoskeletal Hostility on the part of conven- pitted them against the medical es- problems.70 Of these patients, at least tional medicine usually backfired. tablishment. From its inception in 65% have back pain; most other The struggle in California serves as 1847, the AMA had a clause that symptoms involve the neck, extremi- a case in point. Tullius Ratledge prohibited members from consult- ties, and head.71 (1881-1967) led a fledgling move- ing with practitioners “whose prac- ment to license chiropractic in the tice is based on an exclusive PATIENT PERCEPTIONS state.61 In 1916, he was sentenced to dogma.”63(p171) In 1957, in reaction 90 days in jail for practicing medi- to gains made by chiropractic, the Many large and methodologically cine without a license. As with most AMA explicitly interpreted this sound surveys from diverse sam- chiropractic arrests, the charge arose clause to forbid consultations with pling populations leave little doubt not from patient complaints but from chiropractors, and in 1963, the that patients believe chiropractic medically instigated entrapment. Chi- AMA’s Committee on Quackery was works for them. The results show that ropractors were charged with violat- formed primarily “to contain and most chiropractic patients and former ing the medical practice act and the eliminate chiropractic.”64(p292) patients are likely to be satisfied with controversy generated publicity on a In1976,5chiropractorsbrought the treatment they received.72-75 Stud- scale the licensing attempt had never a suit against the AMA and allied ies that compare patients’ satisfac- enjoyed before. California chiroprac- conventional medical organization with chiropractic with that of tors adopted the slogan, “Go to jail tions. In 1987, after long and costly conventional medicine in treating low for chiropractic.” At the height of the litigation, the US District Court in back pain demonstrate marked pref- controversy, 450 chiropractors were Illinois found the AMA and many of erence for chiropractic. A 1986 sur- jailed in a single year.62 Undeterred, its associates, including the Ameri- vey of members of a Washington State many set up portable tables to treat can College of Radiology and the health maintenance organization that fellow prisoners and visiting pa- American College of Surgeons, guilty offers both conventional and chiro- tients. Chiropractors forgot whether of conspiracy against chiropractors practic care compared the responses a colleague believed in the innate or and in violation of the federal anti- of 359 patients treated by conven- subluxations or was a mixer or trust laws. The permanent injunc- tional physicians with those of 348 pa- straight. By the time a woman chiro- tion issued against the AMA re- tients treated by chiropractors. Pa- practor collapsed after a 10-day hun- quired The Journal of the American tients treated by chiropractors for low ger strike in jail, public sympathy had Medical Association to publish the back pain were 3 times as likely— swung to the side of chiropractic’s court’s judgment.65 In 1990, the US 66% to 22%—to report that they were courageous practitioners, and the Supreme Court let this decision “very satisfied” with the care they had medical lobby had been routed. In stand without comment. The AMA, received.76 A Utah study (1973) re- 1922, in a state referendum, Califor- chiropractic’s historic enemy, had ported comparable results.77 Pa- nians voted by an overwhelming ma- been forced to cease and desist. tients perceive chiropractic as a valu- jority to license the profession, and able component of their health care. all chiropractors still in jail were par- CHIROPRACTIC doned on grounds that they had been HEALTH CARE SCIENTIFIC EVIDENCE unjustly accused.10 Each state had its FOR SPINAL MANIPULATION version of this battle; chiropractic Chiropractic health care is based on emerged the winner every time. the endemic presence of pain, espe- Obviously, unimpeachable testimo- Federal acceptance was later in cially low back pain, in the United nials are not sufficient evidence of coming, beginning in the 1970s States. Between 70% and 80% of all effectiveness or efficacy. Science de- when state licensing was already uni- adults experience low back pain at mands controlled studies to estab- versal. Federal recognition consoli- some time in their lives,66 and in any lish legitimacy, and although the dated state acceptance by provid- one year, more than 50% of Ameri- methodological problems for study- ing coverage for chiropractic under cans suffer from the telltale nagging- ing low back pain are notorious,78 es- Medicaid, Medicare, and Worker’s tugging sensation.67 So pervasive is pecially for nonpharmacological in- Compensation; accepting the Coun- back pain in this society that, as one terventions,79 such studies are the cil of Chiropractic Education as the authority has mused,68 it might be only basis for evaluating spinal ma- official accrediting agency of chiro- abnormal not to suffer from it. nipulation. Fortunately, about 40 practic colleges; granting sick leave Chronic pain is no less a problem, randomized controlled trials (RCTs), based on chiropractic certification and data69 suggest that nearly a third predominantly for low back pain, ex-

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Downloaded From: https://jamanetwork.com/ on 09/23/2021 ist for spinal manipulation. Unfor- ment. These trials make a better case of manipulation for low back pain tunately, a substantial number of for spinal manipulation. Nine tri- concluded that these RCTs actually concern forms als90-98 show significant benefits, 4 99-102 [S]pinal manipulation is of short- of spinal manipulation that may not trials indicate no difference, 1 term benefit in some patients, particu- 103 correspond to chiropractic treat- trial is difficult to interpret, and larly those with uncomplicated, acute low- ment (eg, osteopathic manipula- 1104 shows improvement in only a back pain. Data are insufficient concerning tion, British Cyriax treatment, Aus- subgroup in the post hoc analysis. the efficacy of spinal manipulation for tralian Maitland methods, and Dutch Again, problems abound. For ex- chronic low-back pain.106(p590) manual therapy). Despite this addi- ample, which outcome and what ex- Another meta-analysis107 reported tional weakness, these RCTs are the act time were prospectively viewed similar findings. Still another sys- basis with which to evaluate the ef- as the decisive measure are some- tematic review that studied only the ficacy of spinal manipulation and, it times unclear. Also, a large 4-arm 5 trials that were clearly chiroprac- is hoped, of chiropractic. The sci- trial (manipulation vs physical tic manipulation (as opposed to entific investigation of clinical ma- therapy vs general practitioner vs other or imprecise forms of manual nipulation has taken 4 forms: sham- placebo ultrasound or diathermy) is therapy) and did not mathemati- controlled RCTs, equivalency RCTs difficult to characterize because it cally aggregate the outcomes re- comparing manipulation with con- combined patients with low back ported that108(p487): ventional treatments, systematic pain with those with neck pain and evaluations in the form of meta- had both equivalency and sham [A]lthough the small numbers of chi- analysis, and large-scale pragmatic comparisons. The results are none- ropractic RCTs and the poor general RCTs. theless interesting: manipulation and methodological quality precludes physical therapy were significantly [sic]the drawing of strong conclusions, Sham-Controlled RCTs more beneficial than the general chiropractic seems to be an effective for Low Back Pain practitioner but did not reach treatment of back pain. However, more statistical significance when com- studies with a better research method- Since 1974, at least 11 single-blind pared with the sham trial. General ology are clearly still needed. RCTs with at least 1 arm being a practitioners’ results were signifi- Pragmatic RCTs sham control have been performed cantly worse than those in the sham for Low Back Pain for spinal manipulation for low back comparisons.105 pain. Four trials80-83 show no differ- Equivalency trials can have Pragmatic RCTs compare 2 treat- ence with manipulation and sham; problems. They often do not con- ments under conditions in which 3 trials84-86 clearly show a benefit; and trol for unequal belief and credibil- they would be applied normally or 3 trials87-89 allow for the possibility ity and the comparability of physi- optimally. Practitioners and pa- of some value for manipulation, de- cian-patient contact time, and it is tients are not blinded, and these tri- pending on what is considered the sometimes questionable whether als generally do not control for a outcome, the duration of the out- the conventional therapies in the wide range of “nonspecific” effects. come, and how outcome measures comparison group have been ad- The goal is clinical decision. By far are aggregated. The methodologi- equately tested. Nonetheless, this the largest and most sophisticated cal quality of these trials, with evidence can be considered impres- such pragmatic experiment took few exceptions, is weak (eg, high sive. Most comparison trials show place in the United Kingdom. A to- dropout rates, insufficient num- manipulation to be better, and no tal of 741 men and women with bers, generalizability of treatment trial finds it to be significantly worse, chronic low back pain at 11 matched procedures, and outcome mea- than conventional treatments. As pairs of chiropractic clinics and hos- sures with uncertain relationships to 1 researcher-scholar44(p368) put it, pital outpatient departments were expected changes), thus making “more orthodox therapy, such as randomly assigned to either chiro- conclusions problematic. Advo- standard physical medicine or an- practic or conventional care. The re- cates argue that the practitioners algesics, despite being more ‘scien- sults demonstrated that were not properly trained and too tific,’ is not better.” little treatment was given, and de- chiropractic almost certainly confers tractors argue that there was insuf- Meta-analytic Reviews worthwhile, long term benefit in compari- ficient blinding and that at least 1 of for Low Back Pain sonwithhospitaloutpatientmanagement. the interventions used more than The benefit is seen mainly in those with manipulation.85 Meta-analytic attempts to objec- chronic or severe pain.”109(p1431) tively summarize most of the above- Equivalency or Comparative mentioned spinal manipulation tri- The 3-year follow-up confirmed these RCTs for Low Back Pain als for low back pain and create a findings.110 Curiously, this study con- larger, more statistically valid pool tradicts the preponderance of other At least 15 equivalency trials90-104 for of subjects on which to draw con- RCTs in which the advantages of ma- low back pain have been done in clusions have been important in the nipulation were more pronounced for which 1 group of patients received scientific discussion of spinal ma- acute pain. (Extrapolating these re- manipulation and at least 1 other nipulation. The most widely results to the United States is difficult group received conventional treat- ported meta-analytic study of RCTs because the biomedical manage-

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Downloaded From: https://jamanetwork.com/ on 09/23/2021 ment of low back pain in these 2 is scarce. A few such RCTs exist and use beyond treating low back pain. countries is radically different.) include menstrual pain,123,124 hyper- Regardless of what future research will As mentioned earlier, on the ba- tension,125,126 and chronic obstruc- demonstrate, chiropractic will un- sis of these RCTs and meta-analyses, tive lung disease.127 Drawing any con- doubtedly be an important and the Agency for Health Care Policy clusions, besides that there is a need prominent feature of US health care. and Research in December 1994 for research, is premature. This un- Part of its strength may lie in the do- stated5(p34) with guarded optimism that even balance of broad claims and main of the art of healing and how the scarce science is undoubtedly a source chiropractic profession negotiates the [M]anipulation can be helpful for pa- of friction between the profession and patient-physician relationship. tients with acute low back problems For people with chronic pain or when used within the first month of the biomedical community. symptoms. A trial of manipulation for with other refractory conditions, the patients with symptoms longer than a Adverse Effects of Chiropractic chiropractic visit itself can be a source month is probably safe, but efficacy is of comfort even without the addi- unproven. The scientific value of manipulation of a demonstrable scientific com- tion needs to be viewed in the con- ponent. Treatment by a chiropractor Scientific Evidence for the text of possible adverse effects. Of can generate a sense of understand- Benefits of Chiropractic for 138 cases of serious complications ing and meaning, an experience of Neck Pain and Headache due to chiropractic, a recent re- comfort, an expectation of change, view128 found more than 8 of 10 were and a feeling of empowerment.136 Chi- After low back pain, neck pain from cervical manipulation. Seri- ropractic’s combination of vitalist “in- and headache constitute the largest ous adverse incidences from neck nate intelligence” and simple me- such research category, compris- rotation have included vertebrobasi- chanical explanation can give rich ing at least 10 trials. Of 6 trials of lar accidents with consequences vocabulary for just those illnesses con- neck pain,111-116 2 sham trials111,112 such as brainstem or cerebellar ventional medicine remains poorly show benefits with manipulation; 2 infarction (or both), Wallenberg equipped to address. Research indi- equivalency trials113,114 show manipu- syndrome, locked-in syndrome, cates that for many of the illnesses chi- lation to be superior to conventional and such problems as spinal cord ropractic treats, precise diagnosis, as- therapy; and in the 2 comparison tri- compression, vertebral fracture, tra- surance of recovery, and physician- als in which manipulation is additive cheal rupture, diaphragm paraly- patient agreement about the nature of to conventional treatment in 1 arm, sis, and internal carotid hema- a problem hasten recovery.137,138 1 trial115 shows benefits of manipu- toma.118,129-131 Although the rate of Chiropractic finds its voice ex- lation, and 1116 shows no difference serious complications is still debat- actly where biomedicine becomes in- in treatment results. Whereas in a re- able (because the exact denomina- articulate. Too often, biomedicine centmeta-analysis,itwasbelievedthat tor and numerator are unknown), fails to affirm a patient’s chronic conclusions“mustbemadecautiously estimates vary from 1 in 400 000132 pain. Patients think their experi- because of the small number of tri- to between 3 and 6 per 10 mil- ence is brushed aside by a physi- als,” it could still report that “there lion.118 Some researchers133 have ad- cian who treats it as unjustified, un- is early evidence to support the use vocated an informed consent pro- founded, or annoying, attitudes that of manual treatments in combination cedure before patients receive heighten a patient’s anguish and in- with other treatments for short term cervical manipulation with thrust tensify suffering.139 Chiropractors [neck] pain relief.”117(p1296) Another techniques, and others118,134 have never have to put a patient’s pain in recent meta-analysis118 of cervical ma- noted that appropriate examina- the category of the “mind.” They nipulation had a similar outcome. Of tion procedures and specific styles never fail to find a problem. By root- the headache trials, the single sham of manipulation may reduce the in- ing pain in a clear physical cause, control trial119 for migraine shows a cidence of complications. The po- chiropractic validates the patient’s benefit with manipulation, 2 equiva- tential for complications with lum- experience. Even for patients with lency trials120,121 (1 for post-traumatic bar spine manipulation seems less acute pain, chiropractic’s assertive- headache and 1 for tension headache) serious. The chief concern is cauda ness, clarity, and precision provide show a benefit with manipulation, equina syndrome, and the esti- reassurances. As an anthropolo- and a third122 (muscle-contraction mated rate of occurrence has been gist140(p83) has noted: headache) is difficult to interpret. between “one in many millions of Again, the systematic review hesi- treatments”135 to less than 1 per 100 [T]he chiropractor provides the patient tantly concluded that the manipu- million manipulations.106 with a structured, supportive environ- lation “may be beneficial for muscle ment and theoretical explanations 118(p1755) designed to take the mystery out of tension headaches.” THE ART OF MEDICINE process and problems. In essence, the AND CHIROPRACTIC’S chiropractor first manipulates a pa- Scientific Evidence for the EFFECTIVENESS tient’s belief structure before manipu- Benefits of Manipulation for lating his or her physical structure. Other Conditions It could be argued that additional evidence for chiropractic’s effective- Chiropractic is in no sense pas- The evidence for chiropractic’s com- ness is still required for it to estab- sive; it is, from the start, engaged. Ex- petence for conditions beyond pain lish its scientific merits, especially for cept when contraindicated (as in pa-

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Downloaded From: https://jamanetwork.com/ on 09/23/2021 tients with neoplastic disease and Accepted for publication August 6, 12. Arasola K. The End of Historicism: Millerite Her- meneutic of Time Prophecies in the Old Testa- those with extreme osteoporosis), 1998. ment. Uppsala, Sweden: Faculty of Theology, Uni- some form of therapy is almost al- This study was supported in part versity of Uppsala; 1989. by grant U24 AR43441 from the Na- 13. Cooter R. Bones of contention? orthodox medi- ways indicated. For most symp- cine and the mystery of the bone-setter’s craft. toms, there is a suitable manipula- tional Institutes of Health, Bethesda, In: Bynum WF, Porter R, eds. Medical Fringe and tion or a designated mode of redress. Md; the John E. Fetzer Institute, Medical Orthodoxy, 1750-1850. London, Eng- land: Croom Helm; 1987:158-173. Chiropractic adjustment evokes Kalamazoo, Mich; the Waletzky 14. LeVay D. British bone-setters. Hist Med Q. 1971; an experience of change so palpable Charitable Trust, Washington, DC; the 3:13-15. that the patient can often hear it in the Friends of the Beth Israel Hospital, 15. Paget J. Cases that bonesetters cure. BMJ. 1867; 1:1-4. characteristic “pop” or “crack,” indi- Boston, Mass; the J. E. and Z. B. But- 16. Palmer DD. Textbook of the Science, Art and Phi- cating that normal range of motion ler Foundation, New York, NY; and the losophy of Chiropractic. Portland, Ore: Port- Kenneth J. Germeshausen Founda- land Printing; 1910. has been exceeded and a state of 17. Fuller RC. Mesmerism and the American Cure greater mobility and ease, however tion, Boston, Mass. of Souls. Philadelphia: University of Pennsylva- temporary, has been achieved. A per- We thank Harvey Blume, Janet nia Press; 1982. 18. Shorter E. From Paralysis to Fatigue: A History ception of transformation has been Walzer, MEd, Debora Lane, and Mar- of Psychosomatic Illness in the Modern Era. New audibly triggered. 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