Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor Samuel Homola, DC Abstract: Use of manual therapy in the form of manipulation and massage is evident in the earliest recordings of history. Today, manual therapy is an evidence-based practice that can be used with predictable results in the treatment of a variety of neuromusculoskeletal problems. However, for some manual therapists, treatment is still based on a belief system that incorporates vitalism, energy healing, and other metaphysical concepts. Cooperation of practitioners in researching the effects of manual therapy would require uniformity based upon the guidelines of science, following rules for selection of an evidence-based therapy that produces predictable and replicable results. Such an approach would not allow contami- nation by dogma or by an agenda that is designed more to support a belief system than to find the truth. The chiropractic profession, which began with a founding father in 1895, is identified primarily by its use of manipulation. But chiropractic is based upon a vertebral subluxation theory that is generally categorized as supporting a belief system. The words “manipulation” and “subluxation” in a chiropractic context have meanings that are different from the meanings in evidence-based literature. An orthopedic subluxation, a partial disloca- tion or displacement of a joint, can sometimes benefit from manipulation or mobilization when there are joint-related symptoms. A chiropractic subluxation, however, is often an undetectable or asymptomatic “spinal lesion” that is alleged to be a cause of disease. Such a subluxation, which has never been proven to exist, is “adjusted” by chiropractors, who manipulate the spine to restore and maintain health. The reasons for use of manipulation/ mobilization by an evidence-based manual therapist are not the same as the reason for use of adjustment/manipulation by most chiropractors. Only evidence-based chiropractors, who have renounced subluxation dogma, can be part of a team that would research the effects of manipulation without bias. Key Words: Chiropractic, Evidence-Based Manual Therapy, Manipulation, Mobilization, Subluxations, Adjustments, Belief Systems n 1956, I graduated from Lincoln Chiropractic College therapeutic modalities) was not taught. I was told that Iin Indianapolis. I subsequently spent 43 years in private such treatment relieves symptoms without removing practice as a chiropractor (Figure 1). Lincoln was a the cause of disease. After my first year at Lincoln, I “straight” school, which taught that most ailments were began to have doubts about what I was being taught. A caused by vertebral subluxations, requiring only one treat- leading 1947 chiropractic textbook1 proclaimed “…Of ment: spinal adjustments to remove nerve interference. all the causes of disease, there is one which is more Physiotherapy (in this context, defined solely as physical universally present that any other, and that is sublux- ation of vertebrae. Probably in all abnormal states there Address all correspondence and request for reprints to: is a demonstrable spinal lesion…” Many chiropractors Samuel Homola believed that adjusting the spine would release a vital 1307 East Second Court force that would allow the body to heal itself. I read Panama City, FL 32401 Fisher’s 1948 book Treatment by Manipulation2. Fisher, [email protected] an English orthopedic surgeon who specialized in the use of manipulation, warned of the dangers of vertebral The Journal of Manual & Manipulative Therapy E14 / The Journal of Manual & Manipulative Therapy, 2006 Vol. 14 No. 2 (2006), E14 - E18 Reforming a Profession With the goal of promoting use of spinal manipu- lation in the treatment of back pain, while working to reform chiropractic by placing proper limitations on use of spinal manipulation by chiropractors, I began practice in Panama City, FL. When it became apparent that chiropractic was hopelessly mired in subluxation chicanery, I began work on my book Bonesetting, Chi- ropractic and Cultism4, which was published in 1963. In the final sentence of its last chapter, I wrote: “…Unless the chiropractic profession as a whole specializes in the physical treatment of back disorders... and earns reciprocity with other healing professions, under the guidance of medical science, there will be no justification for the existence of chiropractic when an adequate number of medical specialists and medical technicians make scientific manipulation available in a department of medical practice…” Today, most chiropractic colleges include instruction in use of physical therapy modalities and other adjunctive procedures. A few colleges are still “straight,” teaching that spinal adjustment is the only treatment needed for Fig. 1: Author demonstrating lumbar spine manipulation most ailments, emphasizing “spinal analysis” rather than diagnosis. All of the colleges, however, still cling to the belief that adjusting the vertebrae will improve health subluxation theory2: “…The dangers of building up a by removing nerve interference, despite rejection of this revolutionary system of medicine based upon such a belief by medical scientists5,6. slender hypothesis, unsupported by scientific evidence, is so incalculable that it is our duty as guardians of the public health to fight against this menace...” I was also How Chiropractic Is Defined greatly impressed by the work of Mennell, a specialist In 1895, D.D. Palmer7, a magnetic healer, announced, in physical medicine, who wrote extensively about use “…ninety-five percent of all diseases are caused by displaced of joint manipulation. In his 1952 book The Science vertebrae, the remainder by luxations of other joints…” and Art of Joint Manipulation: The Spinal Column3, This “bone-on-nerve” theory was simple: Adjusting the he lamented inappropriate use of a greatly neglected vertebrae to remove interference with the flow of nerve treatment method: energy would allow the body to heal most diseases. “…One point requires emphasis, namely that the In July of 1996, the Association of Chiropractic Col- faith of those who rely on manipulative treatment as a leges (ACC), representing 16 North American chiropractic sole remedy is unjustifiable. At its best, treatment by colleges, issued a position paper defining subluxation manipulation is only one of sixty-odd remedies --many and scope of practice in a less simplistic manner8. The with sub-divisions-- that are employed in Physical Medicine paper said, in part: “…Chiropractic is concerned with alone, while other remedies outside this field of medical the preservation and restoration of health, and focuses science are countless. Choice of the one remedy that will particular attention on the subluxation. A subluxation be of service is the great difficulty that besets medical is a complex of functional and/or pathological articular practitioners, and treatment by manipulation should changes that compromise neural integrity and may influ- occupy a more prominent place in the armamentarium ence organ system function and general health...” than it has hitherto done… “ In November 2000, the International Chiropractic What I read in books written by orthopedic and Association and the American Chiropractic Association physical medicine specialists made more sense to me endorsed the ACC paradigm and its views on subluxation. than what I was being taught in chiropractic college. I In May of 2001, the World Federation of Chiropractic rejected the vertebral subluxation theory as a basis for also endorsed this definition. The document was included use of spinal manipulation. I felt that spinal manipula- in Appendix A of the 2005 edition of Job Analysis of tion could be of value in the treatment of back pain Chiropractic9, published by the National Board of Chi- and related problems but was not adequately available ropractic Examiners. in medical practice. Perhaps, with time and change, the Offering support for this vague, non-falsifiable premise, chiropractic profession could fill this need. the Foundation for Chiropractic Education and Research Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor / E15 (FCER) published The Role of Subluxations in Chiro- and maintain health. The current Master Plan of the practic10. Moving away from the original “bone-on-nerve” American Chiropractic Association (ACA)15 holds that theory, a more sophisticated, all-inclusive definition for “…The relationship between structure and function a chiropractic subluxation was formulated10: in the human body is a significant health factor and […] “…The concept of the Vertebral Subluxation Complex such relationships between the spinal column and the (VSC), having been developed over the past 20 years, nervous system are highly significant because the normal attempts to allow a broader field of chiropractic clinical transmission and expression of nerve energy are essential management to be incorporated into a single conceptual to the restoration and maintenance of health…” model. It embraces the holistic nature of the human While there is a paucity of credible evidence support- body, including health, well-being, and the doctor/patient ing the use of spinal manipulation in the treatment of relationship as well as the changes in nerve, muscle, health problems and no evidence to support the theory connective, and vascular tissues which are understood that vertebral subluxations can cause visceral disease,