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 al- ternative 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 ten- sions, chiropractors have maintained a unified profession with an uninterrupted commitment to clini- cal 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 chiro- practic 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 ARCH INTERN MED/ VOL 158, NOV 9, 1998 2215 ©1998 American Medical Association. All rights reserved. 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 move- ment 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-