Chiropractors yearn for greater respect and acceptance from the public, health care policy-makers and other professionals.To achieve this goal (i.e., cultural authority), DCs must first build good faith with these constituencies by developing higher standards of professional behavior, including adoption of a scientific epistemology, commitment to evidence-informed practice and accountability, frankness and balance in public relations and marketing, and a much-expanded course of rigorous scientific investigations. Indeed, this last point is an ethical mandate for any profession: to critically assess and share its clinical gifts with the rest of world.1
We believe that one of the most significant barriers to the development of "cultural authority"2 for DCs is our traditional dedication to a scientifically unsubstantiated (and largely untested) construct: the subluxation. Exemplary of this steadfast adherence to an unproved theory are the declarations concerning subluxation issued by the Association of Chiropractic Colleges (ACC) in its 1996 position paper.3 Comprised of the various presidents and deans of North American chiropractic schools, the ACC defined the profession in terms of its orientation to the traditional "chiropractic lesion." Popularly known as the ACC Paradigm, the position paper and its subluxation definition were "constructed by a process of consensus to serve as a collective political statement, not a research hypothesis."4 The intended purpose of the ACC Paradigm, as we understand it, was to foster greater unity in our historically divided profession. In this respect, we suppose, it has accomplished its purpose to some extent. In the years since, the document has been endorsed by a number of national and international organizations, including the American Chiropractic Association, the International Chiropractors' Association and the World Federation of Chiropractic.
Unfortunately, the statements concerning subluxation offered by the ACC conflict with commonly accepted scientific standards, and function to diminish the credibility of the profession. Although spinal manipulation has enjoyed some considerable success in controlled outcome studies and reviews of its usefulness for patients with low back pain (LBP),5-7 neither the cause(s) of LBP nor the mechanism(s) of its relief by adjusting are well-established.8 Evidence of the value of spinal manipulation for problems other than LBP is less extensive,9-10 and the role that subluxation (or other forms of joint dysfunction) may play in causing and/or providing relief through adjusting is uncertain. Accordingly, we believe that the ACC's assertions concerning subluxation, however well-intended, lack scientific credibility and play a significant role in preventing the profession from reaching its full potential as a credible health care art and science.
The ACC Paradigm statements concerning subluxation typify the scientifically unjustified assertions made throughout the profession.11-14 We believe that persecution and professional ostracism are the inevitable consequences of the currently indefensible clinical and physiological theories propounded by many DCs as core tenets (i.e., a priori truths or "principles"). We propose that a significant "rethink" is in order.
A Possible Alternative
Of primary concern here are the several currently unjustified claims related to subluxation appearing in the ACC Paradigm [Table 1]. The assertion that subluxation (however defined) causes compromise of "neural integrity" is fuzzy at best. The claim that subluxation-generated loss of neural integrity influences "organ system function and general health" is also unsubstantiated by currently available experimental data. Neural integrity is not defined in the ACC document, and it is not a neuroscience term with a generally accepted meaning. The ACC's subluxation assertions may be appropriate as hypotheses (tentative assertions) and proto-theories (from which testable propositions may be derived), and deserve our critical attention by means of research. However, to assert their validity in the absence of hard scientific data is to engage in dogmatism.
We believe that credible and scientifically justifiable statements concerning the beliefs and practices of doctors of chiropractic are quite possible and legitimate. Moreover, we believe that it would be just as inappropriate to discard subluxation theories - before adequate research has been conducted - as it has been for the profession to assert the clinical meaningfulness of subluxation and its correction in the absence of adequate scientific experimentation. One of the hallmarks of a science-oriented health care profession, we suggest, is that tentative assertions be offered with sufficient qualifiers to make clear the provisional character of untested and/or unproven beliefs.
|Table 1: Assertions About Subluxation Offered by the ACC3 and a More Cautious Alternative|
|ACC Paradigm Statement||Alternative Statement|
|4.0 The Subluxation|
|Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation.||The chiropractic mission is to restore and preserve health. Chiropractors seek to do so by means of manipulation (adjusting) and other conservative interventions.|
|A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.||Many chiropractors propose that joint dysfunction (especially in the spine) may cause a range of health problems, including but not limited to various musculoskeletal disorders, and that joint correction by adjustment provides relief or resolution of these health problems. The scientific evidence necessary to substantiate or refute these clinical theories is not yet available.|
|A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence.||Doctors of chiropractic should employ an evidence-informed orientation to their patients' health concerns, drawing upon clinical experience, plausible physiological models, and the best quality clinical science literature available. Chiropractors make use of standard methods of diagnosis to assess their patients' needs. In addition, doctors of chiropractic employ various specialized methods of joint evaluation.|
To this end, we offer an alternative to the ACC's claims for subluxation (Table 1). We don't suppose that this is the only possible substitution, or that it is necessarily the best possible alternative. However, it does encompass the belief systems of many DCs, while avoiding dogmatism. The mention of an evidence orientation suggests a commitment to the critical and skeptical ways of science, while implicitly acknowledging that doctors (chiropractors and all others) must usually proceed with less-than-ideal information. The explicit recognition of our meager database speaks to our willingness to function as credible, balanced providers of information about the current state of our science and art. It is this balance, we predict, that will garner credibility among scientists, health care policy-makers, and ultimately, the public. (And if subluxation is as clinically relevant to health and health restoration as many of us have supposed, we owe it to our patients and ourselves to find out.)
Of secondary concern here is the tendency within the ACC Paradigm and elsewhere in the profession's rhetoric to define and portray the chiropractic art in terms of a focus on subluxation. Licensing statutes, political and legal activities, reimbursement plans and individual doctors' sense of identity have been predicated upon testable (but largely untested) subluxation propositions. Sooner or later, controlled studies of the clinical utility of subluxation-correction will be performed, and it is not possible to know the results before the investigations are conducted. We believe it reasonable to expect that scientific investigation may confirm some, but not all of the subluxation-related theories offered throughout our history. Chiropractors may want to re-examine the profession's role in order to maintain distinctiveness, and be more robust to criticism.15 Better, we suggest, to proceed with an image of the doctor of chiropractic based upon that which has already earned us some support in the scientific literature and in the public's eye: the chiropractor as the pre-eminent provider of manipulative/adjustive services.
Chiropractors have struggled for more than a century for professional legitimacy and social and cultural authority. Although we have gained many of the formal markers of legitimacy (licensure, third-party reimbursement for services, federal accreditation of our colleges, some public funding for research), cultural authority eludes us. Lawmakers and policy-makers still look beyond our ranks for expert opinion concerning our special area of health care. Books, Web sites and organizations have been written or established specifically to point out the foibles of DCs.
We bring much of this ridicule upon ourselves, knowingly or unwittingly, by what we say to one another and how we portray ourselves to the public we serve. The authors are not so naïve as to suggest that interprofessional turf protection, allopathic arrogance and economic competition do not also enter into the equation. However, it does seem that a great many of the bullets aimed at us are of our own manufacturing. Much of this ammunition derives from our lack of restraint in making claims for the chiropractic healing art. We believe it is quite possible, in the words of C.O. Watkins, DC, to be bold in what we hypothesize, but cautious and humble in what we claim. In so doing, we stand to expand the scientific information available to us, improve our public and interprofessional image, and build upon the benefits we already offer to patients.
Whereas the ACC Paradigm was intended to generate unity within the profession through shared (but scientifically unjustified) position statements, we recommend that an evidence-informed orientation to the chiropractic healing art is much to be preferred. Let's tell it like it is: here's what we know, here's what we don't know, but suspect. Concentrate on clinical outcomes. Deliver service as therapeutic trials with close monitoring of patients' responses. Make appropriate referrals quickly and correctly when patients do not respond. Chiropractic excellence in health care means excellent patient care - not only chiropractic care. Clinical excellence grows from clinical evidence. Let us strive for measurable results, renounce unjustified claims for outcomes, and be cautious in attributing causation to mechanisms that have not been well-studied. Let's proceed as a first-class science and art.
As Dr. Bill Meeker16 and others have suggested, challenging discoveries will arise in committing to the path of evidence,17,18 but greater rewards will follow. Our never-ending concern with patient recruitment and education, the appeal of enchanting theories, and the impact of personalities over substance will eventually fade. From a more substantive foundation, a stronger profession can emerge; one that is prepared to participate and compete successfully in the health care marketplace. By transforming traditional "tenets" into testable propositions (hypotheses), doctors of chiropractic will acquire the authority we deserve to make even greater contributions to the health and welfare of our patients, and the subluxation's role in health and disease may be determined.
- Jonas W, Levin JS. Essentials of Complementary and Alternative Medicine. Philadelphia: Lippincott Williams & Wilkins, 1999.
- Starr, P. The Social Transformation of American Medicine. New York: Basic Books, Inc., 1982, pp. 12-3.
- Association of Chiropractic Colleges. Position paper #1. JMPT Nov/Dec 1996;19(9):634-7.
- Phillips RB. Campus Connection Aug/Sept 2003:2.
- Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. Rockville, MD: AHCPR Publication No. 95-0642, 1994.
- Bronfort G. Spinal manipulation: current state of research and its indications. Neurological Clinics of North America Feb. 1999;17(1):91-111.
- Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brook RH. The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review. Santa Monica, California: RAND Corporation, 1991 (Document #R-4025/1-CCR/FCER).
- Haldeman S. Neurologic effects of the adjustment. JMPT Feb. 2000;23(2):112-4.
- Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low-back pain and neck pain: a systematic review and best-evidence synthesis. Spine Journal 2004;4(3):335-6.
- Coulter ID, Hurwitz EL, Adams AH, Meeker WC, Hansen DT, Mootz RD, Aker PD, Genovese BJ, Shekelle PG. The Appropriateness of Manipulation and Mobilization of the Cervical Spine. Santa Monica CA: RAND Corporation, 1996 [RAND MR-781-CCR].
- Grod J, Sikorski D, Keating JC. The unsubstantiated claims of the largest state, provincial and national chiropractic associations and research agencies. JMPT Oct. 2001;24(8):514-9.
- Hurwitz EL, Phillips RB. Chiropractic advertising in the Yellow Pages: a content analysis. JMPT 1987;11:281-9.
- Keating JC, Hansen DT. Quackery vs. accountability in the marketing of chiropractic. JMPT Sept. 1992;15(7):459-70.
- Sikorski DM, Grod JP. The unsubstantiated web site claims of chiropractic colleges in Canada and the United States. Journal of Chiropractic Education 2003;17(2):113-9.
- Menke JM. Principles in integrative chiropractic. JMPT May 2003;26(4):254-272.
- Meeker WC. Believe it or not, chiropractic science is evolving! Dynamic Chiropractic, May 25, 2004;22(13):48-9.
- Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA Neck Pain Study. American Journal of Public Health 2002;92(10):1634-41.
- Hurwitz EL, Morgenstern H, Vassilaki M, Chang LM. Adverse reactions to chiropractic treatment and their effects. J Manipulative Physiol Ther 2004;27(1):16-25.
Joseph C. Keating Jr., PhD
Thomas E. Hyde, DC, DACBSP
J. Michael Menke, MA, DC
David Seaman, DC
Port Orange, Florida
Richard E. Vincent, DC
Larry H. Wyatt, DC, DACBI
Click here for previous articles by Joseph Keating Jr., PhD.
Dr. Thomas E. Hyde is a graduate of Florida State University and Logan College of Chiropractic.
Click here for previous articles by J. Michael Menke, MA, DC, PhD.
Click here for more information about David Seaman, DC, MS, DABCN.
Richard Vincent, DC, a graduate of the Chiropractic Institute of New York (1950), is a seasoned veteran in the ongoing social, political and economic evolution of the chiropractic profession. He has served as president of the Massachusetts Chiropractic Society, chairman of the Massachusetts Board of Chiropractic Examination and Registration, president of the Federation of Chiropractic Licensing Boards and president of the National Board of Chiropractic Examiners.