As is the case with most growing conscious beings, the chiropractic profession clearly has been in the throes of an identity crisis during its maturation. My first direct exposure to this problem came 10 years ago at the Chiropractic Centennial Foundation Conference, in which a debate was held as to whether chiropractors should exercise diagnostic capabilities on a first-contact basis with patients, or whether they should be musculoskeletal specialists on a referral-only basis, like physical therapists.1
Two years later, I encountered this identity crisis more directly, when the World Federation of Chiropractic, at its 4th Biennial Congress in Tokyo in 1997, took up the issue as to whether the chiropractic profession should eschew any reference to itself as "alternative" rather than "mainstream," based on the strength of scientific evidence and its recognition in various government guidelines.2-6 Fortunately, at that gathering the issue was tabled, as I was able to point out at the conference that the profession harbors both mainstream and alternative elements, when you consider that the ongoing research, in 20 years' time, would be expected to expand and better define the scope of chiropractic practice.
Now, some eight years later, there is a new crisis of awareness. As the result of both a survey conducted by Manifest Communications in Toronto8 and the WFC identity conferences at Life West9 over the past two years, there appears to be a widespread perception polled from a sample of chiropractors that the public regards the profession only in terms of its ability to manage back and neck pain, as well as spinal problems. Matters such as health advice, maintenance, and wellness that form the cornerstone of patient-centered care10,11 appear to have been dismissed as not being in the public interest or concern. Indeed, the very position of the chiropractor as a wellness practitioner who would be "holistic (non-reductionist), humanistic, naturalistic (i.e. use natural remedies), therapeutically conservative, equalitarian, personable ... and caring" - the antithesis of the present medical practitioner12 - would be in danger of being scuttled if all eyes were fixated upon chiropractors being only specialists who get rid of back, neck or spinal pain.
The identity conference concluded that:9
- It is important for the profession to have an identity.
- Most agree that the chiropractic profession suffers from an unclear identity and position within today's health care plans.
- It is important to understand how chiropractors think that the profession should be viewed, and how they believe that it is actually viewed. Here, one finds significant discrepancies: whether the profession offers primary or specialist health care; whether the profession is mainstream (core to the health care delivery system) or alternative; and whether the profession offers wellness and nonsurgical/non-drug health care, or simply manages back, neck, and spinal problems.
But herein lies the problem: In its rush to achieve singular distinction and to seize the ground in which most of the training, research, and public awareness to date has taken place, the profession runs the serious risk of mortgaging its traditional and hard-won attributes. These would include the very foundations of chiropractic, such as: (1) the ability to diagnose; (2) patient-centered care;10,11 (3) primary wellness care in offering an alternative to the current medical paradigm;12 and (4) numerous research findings already published in the full range of basic research, randomized clinical trials, and case series - all of which point toward a scope of practice and model of patient care which extends well beyond the specialist role of simply managing back and neck pain.13-49 Even the most conservative musculoskeletal scope of treatment models must, at the very outset, be willing to encompass the management of headaches and conditions of the extremities (including repetitive stress disorders), for which a substantial body of research already offers promising support.13-28
What has emerged in the current concept of identity is a model that appears to have positioned medical specialists at one end and subluxation-based practitioners at the other. Neither of these poles includes making the diagnoses one would suspect that the majority of the profession performs and in which the medical profession has been shown to be deficient, as far as musculoskeletal issues are concerned.50-53 To extend this argument further, the most recent Job Analysis of Chiropractic has found that over 96 percent of the chiropractic profession in America engages in instructing their patients in health and wellness,54 two concepts I believe have been prematurely dismissed in the aforementioned identity surveys.8,9 The way chiropractors have been conducting their practices and relating to patients must not be lost here, for it is clear in virtually every survey that the satisfaction level of chiropractic patients well exceeds that observed with patients of medical provider groups.55-57
If we were to adhere strictly to the public or medical stereotype suggested by the identity communication in its present form, one could argue that we have gone back to the days of the Salem witchcraft trials or McCarthyism, in which suspicion ruled over reason, and ejection (or even death) ruled over analysis and compassion. Such things that we take for granted in 2005 (iPods, downloads, eBay, cell phones) would not have been encouraged, because 20 years ago, these, too, were not in the public consciousness. Why should the potential health benefits outlined in the aforementioned emerging chiropractic research13-49 be regarded any differently? Have we shut our eyes to the changes and upheavals in health care that are inevitable in the months and years to come?
What makes this argument even more absurd is that the survey on which the identity document8 rests is not even what the public thinks, but what an arbitrary sample (whose validity may be unsubstantiated) believes that the public is thinking. This is no less mind-boggling than a recent report that I have cited several times, which indicates that pediatricians who are supposedly treating childhood otitis media are both prescribing antibiotics and rendering a bacterial diagnosis based solely upon what they suspect the affected child's parents are seeking for treatment.58 If this isn't voodoo medicine in its worst form, I can't imagine what is. It is merely a daisy chain of mind games, the antithesis of what we call evidence-based medicine. It would truly be a comedy of errors - to say nothing of a tragic mistake - to cast the future image of chiropractic's potential exclusively on what one believes the public wants to hear.
Indeed, if one were to single-mindedly pursue the "chiropractic fixes pain" model, this would be running counter to the entire history that gave rise to this form of health care: Individuals became aware of the limitations of the medical care they received and began to look into alternatives for health care. This not only served as the very basis for what is now the National Center for Complementary and Alternative Medicine (NCCAM) at the NIH, but also extended well beyond America's borders. As long ago as the 1960s, people were seeking less toxic, more humane, and more sustained healing experiences in this pursuit, which continues to this day.59 Indeed, the need to pursue the concept of patient-centered health care, instead of the traditional medical model, has been explicitly spelled out in the NCCAM's most recent Strategic Plan.60 To go marching off in the opposite direction to this movement would ultimately be self-defeating and out of step with what society is truly demanding.
This sentiment is not only shared by what we might refer to as the card-carrying proponents of alternative medicine, but by senior health officials as well. No less a party than the Institute of Medicine had this to say about the nation's current health care system:
"The challenge is to bring the full potential benefit of effective health care to all Americans while avoiding unneeded and harmful interventions and eliminating harmful complications of care. Meeting this challenge demands a readiness to think in radically new ways about how to deliver health care services and how to improve their quality. Our present efforts resemble a team of engineers trying to break the sound barrier by tinkering with a Model T Ford. We need a new vehicle or perhaps, many new vehicles. The only unacceptable alternative is not to change."61
And no less a personage than the director of the National Institutes of Health, Elias Zerhouni, had this to offer recently in an address to the Harvard School of Public Health:62
"I think we are going to start to focus more on early intervention in the 21st century as compared with the 20th century. The paradigm of medicine is changing. In the past, we just didn't know about biological systems enough to intervene before a disease struck someone. You are going to see an increase, and we are seeing that now, in the approaches that are not just medication, but lifestyle changes. I think that you are going to see a lot of behavioral and social science impact on how we organize society to decrease disease burden."
And finally, the coup de grace from the NIH director:
"If we practice medicine the way we do today in 25 years, we will have lost the game."
Indeed. Chiropractic must not be misled into slavishly adopting a model that simply reinforces a public stereotype ... and only a perceived one at that. If that occurs, the entire identity of the profession becomes merely a cliché, about which the Czechoslovakian playwright and political leader Vaclav Havel had considerable insight:63
"The cliché organizes life, it expropriates people's identity, it becomes ruler, defense lawyer, judge, and the law."
And the identity of chiropractic becomes possibly an irreversible downward spiral which only perpetuates the problems in health care that the entire science, art and philosophy of chiropractic were conceived to overcome. Chiropractic identity not only becomes a cliché, but also one that shackles future innovation, research and dialogue, which could perhaps not have been better expressed than by the following passage from the concrete experiences of motherhood:
"So long as the source of our identity is external - vested in how others judge our performance at work, or how others judge our children's performance, or how much money we make - we find ourselves hopelessly flawed, forever short of the ideal."64
Let us hope that chiropractic never thwarts its growth by going down this path. Rather, it needs to take a more objective and grounded assessment of its capabilities and future from its research.
- Conference of the Chiropractic Centennial Foundation, Washington, D.C., July 6-8, 1995.
- Bigos S, Bowyer O, Braen G, et al. Acute Low Back Pain in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, 1994, Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.
- Rosen M. Back Pain: Report of a Clinical Standards Advisory Group Committee on Back Pain. London, 1994, HMSO.
- Commission on Alternative Medicine, Social Departementete. Legitimization for Vissa Kiropraktorer. Stockholm, 1987;12:13-16.
- Thompson CJ. Second Report, Medicare Benefits Review Committee. Canberra, 1986: Commonwealth Government Printer, Chapter 10 [Chiropractic].
- Hasselberg PD. Chiropractic in New Zealand: Report of a Commission of Inquiry. Wellington, 1979, Government Printer.
- Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and alternative medicine. Annual Review of Internal Medicine 2002;136:216-227.
- Sarner M. Presentation at the Public Relations Kickoff for Foot Levelers, Parker Seminars, Las Vegas, Nevada, Jan. 15, 2005.
- Consultation on Identity: Quantitative Research Findings. World Federation of Chiropractic, Dec. 7, 2004. www.wfc.org/doc_uploads/
- Gatterman MI. A patient centered paradigm: a model for chiropractic education and research. Journal of Alternative and Complementary Medicine 1995;1:371-386.
- Gatterman MI. The philosophy of patient centered practice. Proceedings of A Conference on Philosophy in Chiropractic Education. World Federation of Chiropractic, Nov. 5-7, Fort Lauderdale, FL, pp. 11220.
- Coulter I. The patient, the practitioner, and wellness: paradigm lost, paradigm gained. Journal of Manipulative and Physiological Therapeutics 1990;13(2):107-111.
- Vernon H. Basic scientific evidence for chiropractic subluxation. In: Gatterman M [Ed.]: Foundations of Chiropractic Subluxation. St. Louis, MO: Mosby, 1995, p. 37.
- Cramer GD, Fournier JT, Henderson CNR, Wolcott CC. Degenerative changes following spinal fixation in a small animal model. Journal of Manipulative and Physiological Therapeutics 2004;27(3):141-154.
- Boline P, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amiltriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1995;18(3):148-154.
- Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache. Journal of the American Medical Association 1998;280(18):1576-1579.
- Nilsson N, Christensen HW, Hartvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 1997;29(5):326-330.
- Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies in the prophylaxis of migraine headache. Journal of Manipulative and Physiological Therapeutics 1998;21(8):511-519.
- Tuchin PJ, Pollard H, Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. Journal of Manipulative and Physiological Therapeutics 2000; 23(2): 91-95.
- Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: a systematic review of the literature. Spine 1996;21(15):1746-1760.
- Kjellman GV, Skagren EI, Oberg BE. A critical analysis of randomised clinical trials on neck pain and treatment efficacy: a review of the literature. Scandinavian Journal of Rehabilitative Medicine 1999;31:139-152.
- Bronfort G, Assendelft WJJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headaches: a systematic review. Journal of Manipulative and Physiological Therapeutics 2001;24(7):457-466.
- Vernon H, McDermaid CS, Hagino C. Systematic review of randomized clinical trials of complementary/alternative therapies in the treatment of tension-type and cervicogenic headache. Complementary Therapies in Medicine 1999;7:142-155.
- McCrory DC, Penzien DB, Hasselblad V, Gray RN. Evidence Report: Behavioral and Physical Treatments for Tension-Type and Cervicogenic Headache. Des Moines, IA: Foundation for Chiropractic Education and Research, 2001.
- Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1998;21(5):317-326.
- Winters JC, Sobel JS, Groenier KH, Arendzen HJ, Meyboom-de Jong B. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised, single blind study. British Medical Journal 1997;314:1320-1325.
- Strait BW, Kuchera ML. Osteopathic manipulation for patients with confirmed mild, modest, and moderate carpal tunnel syndrome. Journal of the American Osteopathic Association 1994;94(8):673.
- Bergman GJD, Winters JC, Gronier KH, Pol JJM, Meyboom-de-Jong B, Postema K, van der Heijden GJMG. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain. Annals of Internal Medicine 2004;141(6):432-439.
- Fallon JM. The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media. Journal of Clinical Chiropractic Pediatrics 1997;2(2):167-183.
- Fallon J, Edelman MJ. Chiropractic care of 401 children with otitis media: a pilot study. Alternative Therapies in Health and Medicine 1998;4(2):93.
- Froehle RM. Ear infection: a retrospective study examining improvement from chiropractic care and analyzing for influencing factors. Journal of Manipulative and Physiological Therapeutics 1996;19(3):169-177.
- Wiberg JMM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled trial with a blinded observer. Journal of Manipulative and Physiological Therapeutics 1999;22(8):517-522.
- Mercer C, Nook BC. The efficacy of chiropractic spinal adjustments as a treatment protocol in the management of infantile colic. Proceedings of the 5th Biennial Congress, Auckland, New Zealand, May 17-22, 1999, pp. 170-171.
- Klougart N, Nilsson N, Jacobsen J. Infantile colic treated by chiropractors: a prospective study of 316 cases. Journal of Manipulative and Physiological Therapeutics 1989;12(4):281-288.
- Leach RA. Differential compliance instrument in the treatment of infantile colic: a report of two cases. Journal of Manipulative and Physiological Therapeutics 2002;25(1):58-62.
- Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. Journal of Manipulative and Physiological Therapeutics 1994;17(9):596-600.
- Gemmell HA, Jacobson BH. Chiropractic management of enuresis: time-series descriptive design. Journal of Manipulative and Physiological Therapeutics 1989;12(5):386-389.
- Bronfort G, Evans RL, Kubic P, Filkin P. Chronic pediatric asthma and chiropractic spinal manipulation: a prospective clinical series and randomized clinical pilot study. Journal of Manipulative and PhysiologicalTherapeutics 2002;24(6):369-377.
- 39. Ali S, Hayek R, Holland R, McKelvy S-E, Boyce K, Curson P. Effect of chiropractic treatment on the endocrine and immune system in asthmatic patients. Proceedings of the 2002 International Conference on Spinal Manipulation, Des Moines, IA: Foundation for Chiropractic Education and Research, pp. 57-58.
- Gleeson M, Clancy RL, Hensley MJ, Cripps AW, Henry RL, Wlodarczyk JH, Gibson PG. Development of bronchial hyperreactivity following transient absence of IgA. American Journal of Respiratory and Critical Care Medicine 1996;153[6 Pt 1]:1785-1789.
- Liebl NA, Butler LM. A chiropractic approach to the treatment of dysmenorrhea. Journal of Manipulative and Physiological Therapeutics 1990;13(3):101-106.
- Boesler D, Warner M, Alpers A, Finnerty EP, Kilmore MA. Efficacy of high-velocity low-amplitude manipulative technique in subjects with low back pain during menstrual cramping. Journal of the American Osteopathic Association 1993;93(2):203-214.
- Kokjohn K, Schmid DM, Triano JJ, Brennan PC. The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea. Journal of Manipulative and Physiological Therapeutics 1992;15(5):279-285.
- Stude DE. The management of symptoms associated with premenstrual syndrome. Journal of Manipulative and Physiogical Therapeutics 1991;14(3):209-216.
- Walsh MJ, Chandraraj S, Polus BI. The efficacy of chiropractic therapy on premenstrual syndrome: a case series study. Chiropractic Journal of Australia 1994;24(4):122-126.
- Walsh MJ, Polus BI. A randomized, placebo-controlled clinical trial on the efficacy of chiropractic therapy on premenstrual syndrome. Journal of Manipulative and Physiological Therapeutics 1999;22(9):582-585.
- Falk JW. Bowel and bladder dysfunction secondary to lumbar dysfunctional syndrome. Chiropractic Technique 1990;2(2):45-48.
- Wagner T, Owen J, Malone E, Mann K. Irritable bowel syndrome and spinal manipulation: a case report. Chiropractic Technique 1995;7(4):139-140.
- Pikalov A, Kharin VV. Use of spinal manipulative therapy in the treatment of duodenal ulcer: a pilot study. Journal of Manipulative and Physiological Therapeutics 1994;17(5):310-313.
- Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. Journal of Bone and Joint Surgery 2002;84-A(4):604-608.
- Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. Journal of Bone and Joint Surgery 1998;80-A(10):1421-1427.
- Matzkin E, Smith EL, Frccero D, Richardson AB. Adequacy of education in musculoskeletal medicine. Journal of Bone and Joint Surgery 2005;87-A(2):310-314.
- Vlahos K, Broadhurst NA, Bond MJ. Knowledge of musculoskeletal medicine at undergraduate and post-graduate levels. Australasian Musculoskeletal Medicine May 2002;28-32.
- Job Analysis of Chiropractic. Greeley, CO: National Board of Chiropractic Examiners, 2005, p. 138.
- Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR, North Carolina Back Pain Project. The outcomes and costs for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. New England Journal of Medicine 1995;333(14):913-917.
- Cherkin DC, MacCornack FA. Patient evaluations of low back pain care from family physicians and chiropractors. Western Journal of Medicine 1989;150:351-355.
- Hertzman-Miller RP, Morgenstern H, Hurwitz EL, Yu F, Adams AH, Harber P, Kominski G. Comparing the satisfaction of low back pain patients randomized to receive medical or chiropractic care: results from the UCLA Low-Back Pain Study. American Journal of Public Health 2002;92(10):1628-1633.
- Mangione-Smith R, McGlynn EA, Elliott MN, Krogstad P, Brook RH. The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics 1999;103(4 Pt1):711-718.
- Gordon J. The White House Commission on Compelementary and Alternative Medicine Policy and the Future of Healthcare. Alternative Therapies in Health and Medicine 2004;10(5):20-23.
- National Center for Complementary and Alternative Medicine. The Strategic Plan 2001-2005: Expanding Horizons of Health Care. http://nccam.nih.gov/about/plans/fiveyear/index.htm.
- Chassin MR, Galvin RW, National Roundtable on Health Care Quality: The urgent need to improve healthcare. Journal of the American Medical Association 1998;280(11):1000-1005.
- Zerhouni E. April 14, 2005, quoted in the Boston Globe, April 19, 2005, pp. D1, D4.
- Havel V. Disturbing the Peace: A Conversation with Karel Huizdala, London, United Kingdom: Faber & Faber, Chapter 5, 1990.
- Melinda Marshall, Good Enough Mothers: Changing Expectations about Ourselves. Princeton, NJ: Princeton University Press, 1993, ch.4.
Anthony Rosner, PhD
Click here for more information about Anthony Rosner, PhD, LLD [Hon.], LLC.