Chiropractors are independent primary contact practitioners, licensed for both diagnosis and treatment with no requirement of referral from a medical physician. Chiropractic practice is limited not by anatomical region but according to the procedures it includes and excludes, unlike dentistry, podiatry, and optometry. The chiropractor’s legal scope of practice under state law generally excludes surgery and the prescription of pharmaceuticals; its core component is the manual adjustment or manipulation of the spine and other muscular and skeletal structures.

Chiropractic Education
The United States is home to approximately 65,000 of the world’s 90,000 chiropractors. Rigorous educational standards are supervised by government-recognized accrediting agencies, including the Council on Chiropractic Education (CCE) in the United States. After fulfilling college science prerequisites similar to those required to enter medical or osteopathic schools, chiropractic students must complete a chiropractic college program lasting four academic years, which includes a wide range of basic science courses in anatomy, physiology, pathology, taught by faculty members who hold doctorates or masters degrees in their fields of specialty. In addition, chiropractic clinical training includes extensive coursework in radiology, orthopedics, diagnosis, manual adjusting and manipulation procedures for the spine and other joints, physiotherapy, rehabilitation, public health and nutrition.

The final year of the chiropractic college curriculum is largely devoted to intensive work as clinical interns, treating patients under the supervision of experienced clinical faculty. At many chiropractic colleges, clinical training includes rotations in the chiropractic departments at Veterans Administration hospitals (where chiropractors serve on the medical staff), free clinics serving the poor, and other interdisciplinary settings where they work alongside medical physicians and other health practitioners.

Chiropractic Research

Approximately 90% of chiropractic patients present as cases with problems of the muscular, skeletal or nervous systems – principally back pain, neck pain, and headaches, the conditions for which spinal adjustment (also known as spinal manipulation) is most effective.

Since the dawn of the modern of era of chiropractic research, which began in 1975 when the U.S. federal government convened a National Institutes of Health conference on the research status of spinal manipulation, research on chiropractic has steadily expanded. There are now over 100 randomized trials on spinal manipulation. The majority address various aspects of low back pain, which reflects the fact that more than half of all chiropractic patients present with low back pain as a primary symptom.

In a substantial majority of these research studies, spinal manipulation has outperformed comparison therapies or placebo. None of the dozens of trials on low back pain found that a comparison therapy or a placebo delivered results superior to spinal manipulation. And significantly, not a single patient in any of the studies related to chiropractic – for low back pain or any other condition – experienced a major adverse side-effect.

Research on spinal manipulation for low back pain is broad and deep. This has led national medical practice guidelines in the United States and other nations to recognize spinal manipulation as a nonpharmacologic treatment method “with proven benefit” for both acute and chronic low back pain. The most influential recent set of guidelines was published by a joint panel representing the American Pain Society and American College of Physicians (Annals of Internal Medicine, 2007).

A current summary of research supporting chiropractic care for low back pain and many other conditions can be found in the peer-reviewed booklet, Chiropractic Research and Practice State of the Art. Written to be understandable by the general public and available at no charge, it can be read or downloaded here.

Daniel Redwood, DC, is a Professor at Cleveland Chiropractic College – Kansas City. He is editor-in-chief of Health Insights Today (www.healthinsightstoday.com) and serves on the editorial boards of the Journal of the American Chiropractic Association, Journal of Alternative and Complementary Medicine, and Topics in Integrative Healthcare.

Harvard’s Niteesh Choudhry, MD, PhD, lead researcher

The first sentence of this report states a blunt fact of life in the United States: “Low back pain and neck pain are extremely common conditions that consume large amounts of health care resources.” Checking in with the state of one’s own back or neck places many of us with the 26% who have low back pain and 14% neck pain in a given 3 month period. Half of us with chronic low back seek chiropractic care. $85-billion a year is spent on low back pain alone.

So, is chiropractic effective and, more specifically, cost effective, compared to other care?

Two top researchers, Niteesh Choudhry, MD, PhD and Arnold Milstein, MD filed a 15-page report on October 12, 2009 which attempts to resolve that medico-political question which has rattled around US healthcare for the last 20 years since the American Medical Association was forced, by dint of the Wilk vs the AMA anti-trust lawsuit, to allow chiropractic into the public debate as something other than quackery. Choudrey is a professor in pharmacoeconomics from Harvard Medical School and Milstein a consultant with with Mercer Health and Benefits and medical director for the influential Pacific Business Group on Health. The report is prosaically titled:

Pacific Business Group on Health’s Arnold Milstein, MD, MPH co-authored the study

The team reviewed all the effectiveness literature and cost-effectiveness literature on the question. The authors analyze leading studies which have
created confusion in the United States on the issue, showing in each
case certain “methodological limitations.” For instance, a UCLA study
that concluded chiropractic was not cost-effective did not include
surgical costs. They then turn to Europe for “high-quality” cost
effectiveness studies with a randomized group. The conclusions are mixed, interesting and a teaching lesson for those
not familiar with methods in cost analysis in the real world.

• Effectiveness Chiropractic is more effective than other modalities for treating low back and neck pain.

• Total cost of care per year  For low back pain, chiropractic care increases total annual per patient spending by $75 per year over “medical physician care.”  For neck pain, chiropractic care reduces annual spending $302 per year compared to medical physician care. The cost of care for neck pain is lowered when chiropractic is combined with exercise (and better than exercise alone).

• Cost-effectiveness  If both cost and effectiveness are considered together, chiropractic is “highly cost-effective” and “represents a good value” relative to medical physician care and “widely-accepted cost-effectiveness thresholds.” The authors then note that they were not able to incorporate data on pharmacy costs but project that, had they been able to do so, “our estimate of chiropractic’s comparative cost effectiveness is likely to be understated.”
  

Ultimately the audience for this report is healthcare purchasers – employers and government agencies – especially amidst the current healthcare reform debate. Choudhry and Milstein conclude: “

“Using data from high-quality, controlled (European Union) trials and contemporary US-based average unit prices payable by commercial insurers, we project that insurance coverage for chiropractic physician care for low back pain and neck pain for conditions other than fracture and malignancy is likely to drive improved cost-effectiveness of care.”

A health services researcher, who chose not to speak on the record, offered this blunt perspective on the study when contacted by the Integrator: 

“I didn’t seen anything glaringly
ridiculous, so the conclusions may be reasonable. I think a good health
economist would be in a better position to comment. Finding chiropractic care
(or anything else) more cost-effective than conventional medical care is in
itself, not that impressive, given how un-cost-effective conventional medical
care is.”

The study was funded by the Foundation for Chiropractic Progress, an organization established to publicize and advance positive perspectives on chiropractic. The organization recently invested $1-million in a major, Beltway-focused advertising campaign. FCER sent out an October 21, 2009 release which advertised these study outcomes.

Comment: If credibility is created by biting the hand that feeds you, this study deserves some recognition for concluding that the cost per patient for low back pain by chiropractic physicians is higher than medical physician care. This consultant’s conclusion was of course significantly softened by the over-all outcome. The study will certainly have its merits for the positioning chiropractic in healthcare reform.

This study is also instructive in other ways. First, there is the review of the limits of various methods selected in various costs studies, which leads to the dissembling and often misleading conclusion that studies of cost-effectiveness of X are conflicting. Second, the combination of higher cost but greater cost-effectiveness may be the equation that helps many therapies and practices in labor intensive (rather than drug intensive) healthcare, including complementary and alternative practices, extract the sword from the stone in the cost debate. Finally, the approach of these researchers underscores that for whole practice approaches, we are often best off to look at the whole system of cost rather than to compare modality cost versus modality cost.

One thing we know for certain after this study is that FCER will insure that policy makers and benefits purchasers know about it, and that future wanderers into the debate over chiropractic physician/medical physician costs will no0w have another report with which they’ll need to contend.

Post-script: In the context of the note in the most recent Integrator Round-up over changing terms by which the chiropractic, err, uh, chiropractic medical profession describes itself it is interesting that these researchers chose to use chiropractic physician in the comparison with medical physician services.

Prelude: Employers have an economic interest in employee health. The costs are direct, and indirect. These interests are remarkably coincident with the outcomes many CAM-IM providers claim to achieve in their work to create health with the individuals they serve.

Motivations are likely to differ. Some might call them polar opposites. The employer stakeholder in health will be interested
in the individual’s contribution to corporate profitability. The
CAM-IM practitioner stakeholder will focus on the individual’s mind-body-spirit. The practitioner may be repelled by the thought of allowing
notions of profitability to infiltrate the presumed sanctity of the
practitioner-patient relationship. Yet the outcomes each seeks are remarkable concordant.

The alignment is a classic example of the “strange bedfellows” of which politics in made. Could the employer stakeholder be CAM-IM’s best ally in moving toward a more rapid presence for CAM-IM in the health care system?

This analysis of the award-winning worksite wellness program developed by Bernie Noe, ND, for the Vermont Automobile Deals Association (VADA), is offered to bring practitioners more deeply into the cost perceptions, tools and strategies for health outcomes which are meaningful to thoughtful employers. These may appear mundane. But learning this “employer speak” may be useful to CAM-IM practitioners, to integrative clinics, to hospitals and researchers willing to think out of the box to cross the CAM-IM-employer gap.

CAM-IM clinic leaders, practitioners and researchers,
ask yourselves:

Can you show societal value of your whole practice

by reducing an employer’s global costs of health?

Determining the Employer’s Global Costs of Health

Green Mountain Wellness

When Noe received his challenge, from VADA, to develop a worksite wellness program (see prior IBN&R article), he chose to go to school on other successful programs then develop his own. His reasoning was that he wanted to be able to generate and easily evaluate program outcomes he and his client established, rather than those of an outside vendor.

Noe’s approach was based on a concept that is not familiar to many practitioners, CAM-IM or conventional: “global costs of health” to an employer. Costs to employers of an employee’s poor health go far beyond the direct costs of medical treatment or insurance. These include absenteeism, disability, low productivity and even the costs to replace and train new workers. As much of a challenge as the direct costs of paying for medical benefits can be to employers, the “indirect costs” are typically far more damaging to an employer’s bottom line.

To gain a picture of these global costs, Noe used the following tools.

• A health risk appraisal (HRA) to provide baseline health data. (Much of this may be imbedded in a whole-person intake form.)
  
• Proven data from the Health Enhancement Research Organization (HERO) on the relationships between 10 modifiable risk factors and direct excess medical expenditures which are associated with them.
• Data from other studies on indirect costs associated with various health risks.
  

(1) Only medical expenses associated with the risks.
(2) Noe’s note states: “Examples of these indirect costs include presenteeism (low productivity), absenteeism, worker’s compensation, short and long term disability, and employee turnover.
(3) Noe’s reports to VADA, shared with IBN&R, only references “other studies.”

(4) Multiple cardiovascular disease risk includes at least 3 of hte following risks: tobaccco, blood pressure, cholesterol, exercise, bloob sugar, body weight, and stress. In Noe’s reports, he did not include those individuals in hte CVDz Risk in the other categories which counted as among the individual’s 3+ risk factors.
(4) NA indicates either that Noe could not find data or, on hte case of “Body weight” and “Obesity & Overweight,” a different category was used.

Noe then paired these estimates with outcomes of the HRA. These identified the total number of participating employees with different risks. Through simple multiplication, VADA’s members gained a powerful snapshot of their likely global costs due to modifiable risks. These data also gave Noe some ballpark, baseline numbers against which he could compare risk-associated cost estimates after a year of the program and its interventions.

Using Prochaska’s Stages of Change Model: Shifting the Employee Psyche

Noe added to this basic analysis a survey tool developed through the Stages of Change Model developed by James Prochaska, PhD on a person’s readiness to make changes in their life. Individuals self-describe which of the following stages represents their relationship to modifying their risk factors:

• pre-contemplation – no plan for change within the next 6 months
  
• contemplation – intends to make a change within the next 6 months

• preparation – intends to make a change within one month
  
• action – has made a change within the last month
  
• maintenance – has made a change between one and 6 months earlier.
  

These findings allow an employer’s wellness resources and lifestyle change intervention to target those who are most likely to benefit. Noe also gained a useful secondary measure of program outcomes. Would education about, attention to, and treatment of, these risk factors shift the employee population toward more awareness and action?

The Simple Interventions in Phase 1

The first phase of the VADA program, which received the Gold Award for Worksite Wellness from Vermont Governor James Douglas, might be characterized as intervention light. The chief tools were:

• Education and awareness to one’s own risks, through the HRA process.
• On-site screening coupled with the HRA. Referral to primary care providers of those found to have hypertension, high cholesterol, diabetes and pre-diabetes.
• Referral to an employee assistance program and a “Quitline,” provided through all hospitals in the state, which offers telephonic counseling or in-person programs. Participation was not monitored. (Noe’s firm recently added a smoking cessation program through the Quitline, with first enrollees in June 2006. This program offeres cash incentives for those who stay smoke free through their participation.)
  
• A “pedometer challenge” to get employees, and their family members, to begin exercising more, and to be aware of how much they walked in a given day.

Noe felt the pedometer challenge was particularly beneficial in achieving the outcomes. In the 12 week program, 1100 employees and their family members participated. Each received a free pedometer and an informational/motivational handout each week. The goal was for each participant to walk 10,000 steps per day. The structure was a group competition between the auto dealerships. Each weekend the winning dealership in various categories was given a sign “celebrating their success,” Noe notes. At the end, cash prizes were awarded for highest step counts, greatest employee participation, greatest family participation and the most improved individuals. Noe notes that “the goal was to get co-workers and family members to support each other and to shift the work and family environments toward encouraging physical activity.” He adds that survey-based self-reports after the challenge showed weight loss, sleep improvement, decreased fatigure and other possitive outcomes.

Under Noe’s strategy, a second phase, described
in the previous article, will involve focused medical interventions, by
licensed naturopathic physicians, on a limited population. Noe states that the selection of naturopathic physicians is because “they are experts in helping those with chronic disease to manage their conditions with low-cost, preventive therapies such as diet, lifestyle and exercise therapies, as well as natural medicine – and there is evidence that these can reduce health costs.” The services will be provided by a statewide network Noe has credentialed. Outcomes will be monitored.

Sample Shifts in Health Risks and Readiness from Phase 1

Based on second year data, provided by Noe to IBN&R – and as a basis for the Vermont award – the simple program showed a positive pattern of impact toward lowering the economic risk to VADA’s members. Positive changes were witnessed in compliance with various testing procedures. Participation in screenings jumped for colon cancer (13.1%), prostate specific antigen (36.9%), testicular self-exam (25.9%), mammogram (14.7%) and self breast exam (4.2%). More important ot VADA, a pattern of reduction of risks was found for numerous conditions.

The chart shows changes of all screened employees, 2005 to 2006, then just those screened both years, allowing an apples-to-apples comparison. The last column is those who were screened both years and participated in the pedometer challenge. With a very few exceptions – notably eating sweets and being overweight – the number of employees with a specific risk factor decreased. (Noe notes that the increase in those “overweight” can be accounted for by the decrease in “obesity,” a separate category, and thus is a positive outcome.) For many factors, the percent of participating employees found to have the risk factor fell between 15% and 25%. More significant diminutions were found in the “pedometer challenge” group. Noe is particularly pleased with the hypertension and cardiovascular risk findings.

The second year’s data on Prochaska’s readiness for change scale also produced a positive wave of movement. The percentage in the “pre-contemplation” and “contemplation” stages tended to fall. Those moving toward doing something — from “preparation” to “action” and “maintenance” tended to go up.

The principal outcomes from these measures, for Noe’s business, Green Mountain Wellness Solutions, is an expanded contract for the coming year. This will include the Phase 2 pilot interventions, using naturopathic physicians, with 43 high-cost employees, as reported earlier. Noe is clear that the outcomes will be more valuable if changes hold over two or three years.

Comment: I have reported elsewhere – and will again! – that CAM-IM leaders and stakeholders, when surveyed, have indicated that, next to the consumer, the employer has the strongest alignment of interests with integrative medicine among stakeholders in health care (i.e., as compared to “hospitals and health systems,” “government” and “insurers/HMOs”). The ability to lower the global costs of health to an employer may be the best and quickest way to show the societal legitimary of CAM-IM.

Some thoughts and lessons from Noe’s work:

• Using the Intake for Outcomes A good intake form is a “health risk appraisal” for the patient. How many practitioners doing pre-posts of their intake findings? Outcomes on a patient pool — using the estimated direct and indirect costs associated with risks, Noe uses — may be a great and simple marketing/outreach tool to back the assertion that one’s approach will save on health care costs.
• Don’t forget the basics The apparent benefits of mere consciousness (becoming aware of risks) and of the “pedometer challenge” are intriguing. How many CAM-IM practitioners are prescribing pedometers to their patients to help them increase their awareness of their daily movement/exercise?
• NCCAM – more health services/whole practice funding, please … The NIH NCCAM has identified both health services and whole practice research as priorities. Grants continue to be prioritized toward RCTs. This prioritization serves the present NIH hierarchy of values, which is an expression and outgrowth of a failing health system. The public good, harmed by escalating health care costs, suggests a re-direction is in order.
  
• Readiness for change Many CAM-IM practitioners are continuously, informally evaluating this in their patients/clients. What value may come through formally using a tool and sharing outcomes with patients? Viewing the Prochaska categories, and even knowing the science behind them, may be a lesson in tough love for patients about their role in a healthcare practice which requires changes in behavior for enduring success.
  

Readiness for Change and the Care-Givers Dilemna

Two comments on the use of the Prochaska tool. Evaluating “readiness for change,” which, when applied, focuses resources on those who are ready to make change, is anathema to many practitioners. Many, by nature, want to help everybody — which of course sets up the old paradigm verticality in practitioner-patient relationships: I can do this for you. To take

the patient into the readiness-for-change dialogue enforces the horizontal nature of patient-centered care. It also may mean that a practitioner-patient duo might conclude: No point in us working on this now, then. Not necesarily firing a patient, but at least putting them on leave. There can be immediate economic repercussions to the practitioner, as difficult to stomach for the practitioner as the feeling of rejection may be to the patient.

I am reminded of a loss of innocence I had while walking, or rather running, precincts with my brother Tom during his campaign for Seattle City Council 17 years ago. We passed by many houses in our doorbelling. I asked him: “Aren’t there voters living there? Why are we passing them?” He waved the precinct map and list of targetted addresses to me: “We don’t have the time to go to all the houses. We are targeting ‘perfect voters’ – those who have voted in each of the last three elections and who we’re pretty sure will be voting again.”

Prochaska’s model asks a similar, hard-headed economy of all who respect its findings. One targets resources on, if not “perfect patients,” then at least those who are moving toward action in making changes. Increased consciousness among CAM-IM practitioners of, and comfort with, the cold efficiencies in the evidence supporting Prochaska’s work may be a key to a employer kingdom.

(Thanks again to David Matteson for bringing Noe’s work to my attention.)

Background: The Limbo Profession

The limbo profession

Chiropractic is the limbo profession. I shared this notion early on in a slide from my presentation March 14, 2008 at the Association of Chiropractic Colleges and the Research Agenda Conference (ACC-RAC) Chiropractic is assigned, by the National Institutes of Health,
as part of complementary and alternative medicine (CAM). Yet the very
mention of that acronym in the same sentence as “chiropractic” leads
many of chiropractic’s leaders to make the sign of the cross; or
worse, to slash at the hand of some devil trying to drag chiropractic
back down into a mire out of which it feels it is just extricating
itself. CAM is seen, by these leaders, as less than chiropractic, an outsider, a reminder
of poverty and non-inclusion.

Look at us, they say: We’re licensed in 50 states, covered (partly at least) by Medicare and by most employer health plans, credentialed and practicing in the Veterans’ Administration facilities and making headway in other Department of Defense initiatives. We’re at the table, in DC, working hard, continuously lobbying, taking on on HMO exclusions, making headway year by year, busting back the AMA when they encroach on our rights to make a living, advancing continuously even against continuous attacks from the mainstream.

There’s the rub, and the limbo for chiropractic. Despite chiropractic’s
advances, the field remains the licensed natural healthcare discipline
that conventional medicine most loves to hate. In my own examination of hospital-based integrative clinics,
only a fraction – 5 of 27 (19%) – had a chiropractor on staff. By
comparison, massage therapists were in nearly 100%. Licensed
acupuncturists, newer players in the field, were in 65%. Naturopathic
physicians, despite only having licensure in a minority of the states
in which the integrative clinics were located, were in just one fewer
(4) of the clinics. And this paltry inclusion comes despite the fact
that chiropractors are better integrated into the payment system and
have relatively high utilization by the very consumers to whom such
clinics are seeking to appeal. Why the short shrift? Typically an
orthopedic surgeon who effectively has veto power in the system threatens to hold
up the whole integrative undertaking if a chiropractor is involved.

In short, chiropractic has, frequently, successfully, fought its way
in. However, chiropractic has much less often been invited to the table. So the
question was front and center at the 2008 ACC-RAC: How can “cultural
authority” be established by chiropractic?

1. A starting place for gaining authority: invite more outsiders to the conference

I have worked closely with many chiropractic leaders over the past decade. Lou Sportelli, DC, and Tino Villani, DC have supported many aspects of my work, including this newsletter. ACC’s executive director David O’Bryon, past ACC chair Reed Phillips, DC, PhD, and the immediate past chair of the profession’s accrediting agency, Joe Brimhall, DC, have been among my close colleagues since 2004. We’ve helped organize the National Education Dialogue to Advance Integrated Health Care: Creating Common Ground and the Academic Consortium for Complementary and Alternative Health Care.

It was through those connections that I was invited to speak, a talk
on our work with other disciplines, conventional and “CAM,” to enhance interdisciplinary collaboration. In short, some of my best
friends are chiropractors. Yet for all this connectivity, I must
report, sheepishly, that the experience of being at ACC-RAC with these
professionals, educators and scientists opened my eyes significantly to
the strength and, well, authority of the profession. I met many fine, earnest
professionals (and a happy number of very enjoyable souls, not necessarily a separate category), all working
hard to better their profession. In a context shaped by prejudice (I
received bias against chiropractic from my Bostonian Mom),
connection is useful. Chiropractic would serve itself to invite more
outsiders to their ACC-RAC meeting.

NYCC campus

2. Portrait of a Community Network: The New York Chiropractic College

In this culture, one gains authority by having a golf course on campus. New York Chiropractic College
has one. Well, 9 holes. More important, authority may be gained through connectivity.The upstate New York institution, located on
3200 acres, also boasts a Department of Acupuncture and Oriental
Medicine (AOM). Jason Wright, LAc, is president of NYCC’s
faculty senate. A medical doctor is on staff in the principal NYCC
teaching clinic. In addition NYCC has: relationships with 5 separate
Veterans’ Administration hospitals; participation in a Blue Cross hospice care program; partnerships with 2 community clinics; and a further relationship with the Monroe Community Hospital. I learned all this as a quick download from Frank Nicchi, DC, NYCC president. Nicchi is among chiropractic leaders who are not CAM-adverse. A decade ago he began attending the Harvard conferences when the
“integrative medicine” discussion began. Nicchi sees
value, and a potential for enhanced cultural presence, in chiropractic
affirmatively linking with the other, philosophically-aligned,
health-oriented natural healthcare disciplines.

Claire Johnson, MSEd, DC

3. The Journal of Chiropractic Education: A Retrospective Look at Journal Articles

One tool of authority available to the chiropractors for the past 20 years is The Journal of Chiropractic Education,
published by the ACC. No other “CAM” field – naturopathic medicine,
AOM, or massage – has a publication dedicated to fostering and
publishing the scholarly and research writings of its educators. In Volume 22, Number 1, researcher Claire Johnson, MSEd, DC and editor Bart Green, DC, MSEd published a data-based evaluation of the articles in JCE

since it was founded. The greater part of the authority in the piece
was its honesty. Of the total of articles, 66% were found to be
non-data in nature. A minority of schools were responsible for a vast
majority of the publications. Interestingly, there appeared to be a
strong correlation between the schools which had a high level of publications and those which have extended their institutions in the last decade to become multidisciplinary by adding AOM and/or naturopathic medicine programs. In
short, interest in research may be correlated with interest in
multidisciplinary activity. The authors recommend that in the future
“more efforts and resources [should be] dedicated to data-driven
studies.”

Authority through integrative clinics

4. Authority via Model Integrative Clinics: NWHSU & Woodwinds & University of Minnesota

One non-data article in the current JCE, by James Lehman, DC, MBA and Paul Suozzi, PhD,
suggests that a great way for chiropractic “to build higher cultural
authority” is to “found integrative centers of excellence.” Lehman, a member of the faculty at the University of Bridgeport, figure that chiropractic might be able to integrate practitioners
without the biases in practitioner choices and therapies seen in many
conventional integrative clinics. Clinical educators with Northwestern Health Sciences University
(NWHSU) – a former chiropractic school which now has programs in AOM and
massage offers a model to back the theory. NHSU developed and runs an
integrative clinic on the highly regarded Natural Care Center at Woodwinds Health Campus. NWHSU is also in discussions about developing and managing a clinic with the Center for Spirituality and Health at the University of Minnesota.
Notably, interest in the UM partnership was stimulated by the
authority NWHSU gained through its modeling of a successful integrative
clinic at Woodwinds. Another indication of authority gained: NWHSU’s work will be featured at the May 2008 Integrative Medicine for Health Care Organizations conference sponsored by Health Forum/American Hospital Association.

Reed Phillips, DC, PhD, founding chair of the multidisciplinary educators’ consortium

5. Authority via Mentoring: A Special Role with Emerging Natural Health Disciplines?



The guild warriors among the chiropractic profession are a powerful,
accomplished group. The internal line on their skill development is
that they learned from the best at guild politics: “the medics”
(AMA/MDs). Guild action is typically a dual visioned game: carve out
more territory for yourself from those above you while not forgetting
to slap down those at your heels and encroaching on your space. While
the independent practice of physical therapists
is particularly worrisome, the emerging licensed disciplines
representing massage therapists, AOM, naturopathic physicians and even
Yoga therapists can also be viewed as competitors. Chiropractors were
once virtually the one and only alternative; now there are increasing
numbers of others. Many chiropractors see the rise of these competitors
are led by an instinct to not align. Why help them? Yet other leaders, like O’Bryon, Phillips, Brimhall, Nicchi, Chuck Sawyer, DC at
NWHSU, and others see that there is a place here for chiropractic to
support and mentor some of these disciplines, while also learning from
them. Notably, the 2 retreats of the multidisciplinary Academic Consortium for Complementary and Alternative Health Care (ACCAHC), which I presently direct, were held in donated space at Southern California University of Health Sciences, formerly only a chiropractic college, and then Western States Chiropractic College. The
third, in May 2009, will be hosted by Sawyer’s NHSU. Chiropractic
educators in ACCAHC have been profoundly positive and empowering
players.

6. Guild Resistance to CAM Alliances: Are They Above or Below Us?

Sometimes, determining who it is okay to associate with, deciding who
is where in the pecking order of “cultural authority” can be
challenging. I had a conversation with a group of chiropractors at the
ACC-RAC who were more profession-aligned than educational
institution-aligned. They were strongly opposed to any chiropractic
affiliation with the “CAM” universe. One reason: To their
understanding, none of the other CAM fields had gained the authority of
chiropractic’s status as a direct access practice. Therefore, to be
identified with CAM would, by association, only invite limits. In fact,
however, the assumption is not true, as I shared. First, the AOM
profession in New Mexico (“Oriental Medical Doctors”) and Florida
(“Acupuncture Physicians”) has very broad practice rights. Inside the
AOM profession is a move to establish the field with more primary care
authority. More significantly, the naturopathic physicians have a
broader scope than chiropractors in all, or almost all, of the 14
jurisdictions in which NDs are licensed. Naturopathic practice
typically also has prescribing rights – an enviable scope inclusion for
any guild-oriented battler. This information, however, didn’t seem to
change them. Don’t bother me with the facts. My mind is made up. The animus behind the decision to not collaborate, right or wrong, resonates with that in integrative medical doctors who don’t have the authority to put chirorpactors in their clinics: It’ll be harder for me to do what I want with you connected.

Partap S. Khalsa, DC, PhD, NCCAM program officer

7. Authority via NIH Research? Don’t Take It Personally, But, Well, No Time Soon …

One member of the closing panel of the meeting was the lone, licensed CAM professional on staff at the NIH National Center for Complementary and Alternative Medicine (NCCAM): Partap Singh Kahlsa, DC, PhD. Khalsa revealed that the new NCCAM director Josephine Briggs, MD,
had shared with staff, more than once, that she viewed manipulative
therapy as “low hanging fruit” for showing the value of CAM. Khalsa
then took a useful, unusual turn in his presentation on the
relationship of research to cultural authority. He described how
positive outcomes from a NIH consensus is the authoritative blessing at the NIH. Then he led
the assembled chiropractic leaders through the outcomes of a recent
such consensus conference on Vitamin D and bone health. For vitamin D,
there are hundreds or even thousands of clinical trials (my notes arE
not clear); for chiropractic there are 60-70 total on back pain,
chiropractic’s leading area of research. Yet, other than for a few
conditions like rickets (“fair evidence” said Khalsa, adding: “I mean,
this is Herman Melville stuff …’), most of the conclusions were
light, “inconsistent.” The message: Put all your eggs in the NIH basket if

you wish to have a long-shot potential of gaining cultural authority at
some point after Florida is submerged by global warming,

Mathew Kowalski, DC

8. Harvard-Osher Based Chiropractor: “Behave Your Way In”

The final panel also included the wizened integrative chiropractic commentary from Mathew Kowalski, DC, the lead chiropractor at the integrative clinic sponsored by the Osher Clinical
Center for Complementary and Integrative Medical Therapies.
Before Osher, Kowalski worked in a half-dozen health system-based
integrative settings, going back to 1991. He asked, rhetorically: “The
biggest common denominator in all the experiences on how I got it?” He
pauses: “I asked.” There are 30 chiropractors credentialed into VA
facilities, 49 in US Department of Defense establishments, and 180 in
“civilian hospital based chiropractic practice.” This totals some 260
out of 70,000 chiropractors. Why so few? Says Kowalski:
“(Chiropractors) just don’t ask.” Most MDs, he said, have never met a
chiropractor, “don’t know how to use one and hospitals don’t know what
to do with them.” His conclusion, at this time, is that most of the
advances he has made are more from individual achievement than cultural
authority. I don’t embrace chiropractic but I like this one chiropractor.
Chiropractors, says Kowalski, “need to educate [our] way in.” More than
that, chiropractors need to keep the patient at the center of their
motivation for connecting with hospitals or medical doctors: “We need
to behave our way in.” That stated, Kowalski noted that the Osher
position was the first in which the invitation did not come from his
own initiative. Said Kowalski: “There was some cultural authority
there.”

Comments: This article begins and ends on the same
note: relationships. A year ago at this time I was just completing some
exciting work with a chiropractic organization. A colleague who is a
chiropractic educator and I recommended that the group take a series of
steps to support their members in developing networks of relationships
with other CAM and conventional providers. The visual was a simple
wheel with the chiropractor in the center, and spokes radiating out to
one each: massage therapist, primary care MD/DO, AOM professional,
naturopathic doctor, physical therapist, mental health/psychologist and
an orthopedic surgeon. The recommendation was that the organization
have an internal goal of supporting their members to each have at least
one of each of these practitioners with whom he or she felt comfortable
cross-referring. We said: Just explain to each that your patients want you to be connected. Do this and you will be playing against type. Others won’t expect this of chiropractors. The organization has not, to my knowledge, moved on the suggestion, or anything like it.

At the end of my presentation on enhancing collaboration, which began with a description of chiropractic’s limbo, I used a slide with a photo of a Roy Lichtenstein painting.
The blond has a telephone clutched to her right ear, her eyes are shut
from fear and a tear is falling from the left eye. She is saying: “Oh
no!! I can’t believe I forgot to have a relationship.”

Coda: Barack Obama’s powerful speech on race March 18, 2008, is fresh in mind as
I write this. In the healthcare integration process,
it is the chiropractors who have had the harshness of the psychic stamp that, in race
relations, is paralleled by the experience of slavery on the soul of
the black man. The chiropractors were the chief targets of
the AMA’s vicious anti-quackery campaigns in the 1960s-1970s. It is the
chiropractors who successfully fought the financially bloodying 12 year, David-versus-Goliath anti-trust
suit against the AMA which, with the chiropractic victory, ended the
worst of sanctioned, institutional medical bigotry in the United
States. It was the chiropractors who asserted a place on the bus of US healthcare, and refused to move.

In truth, for most of the last century of chiropractic’s
existence, chiropractors were not allowed, by our culture’s established
medical authorities, to have a relationship with them. Chiropractic learned to go it alone, come hell or high water, developing a learned ferocity through the pattern of received abuse. Yet now that profession’s destiny, it’s ability to gain authority, to fully serve clients, is inextricably linked to its ability to throw off that isolation through a patterned network of ongoing, essential relationships with other healthcare stakeholders. Secure inside that web, the gold ring of cultural authority will be in hand.

Since around 2800BC, the needle like branches of a plant found in China called Ma-Huang have been used successfully there against asthma of light to medium severity. In the 16th century AD the physician pharmacologist Li Shih-chen listed it as an asthma treatment in his massive reference work, which is still seen as the authoritative reference for oriental herbal medicine.Ma-Huang, a member of the Gnetales family, resembles a horsetail. It is closely related to the Welwitschia mirabilis of South Africa. Ephedra helvetica, another relation, is used by herbalists in Switzerland, Spain, Italy and France. Another botanical relative is Ephedra distachya, the joint pine of Persia and India which quickly relieves bronchial spasm (RF Weiss, Herbal Medicine, AB Arcanum, Gothenburg, 1988).

In 1926, the drug company Merck produced a synthetic version of Ephedra, the alkaloid ephedrine. This, like the herbal remedy, has been widely used and both have been critically investigated over the years (Br J Clin Pharmacol, 1976, 3). However, the natural version has proved to have several advantages over the man made product: it is better tolerated by the patient, causing fewer heart problems like palpitations and hypertension.

Interestingly, if the Ma-Huang root is included in the preparation made from this plant’s branches, heart problems are reduced. Proprietary asthma drugs made from synthetic ephedrine, Benylin and Sudafed, are well known for their strong stimulant effect on the heart.

Khellah a member of the carrot family which grows wild in Egypt and countries of the eastern Mediterranean can either prevent asthma attacks or significantly reduce their frequency and severity (GV Anrep and others, J Pharm Pharmacol, 149, 3; and W Martindale, The Extra Pharmacopoeia, vol 1, Pharmaceutical Press, London 1958). Khellah is rapidly absorbed if taken by mouth, so injections are not needed. Although it is usually regarded as a preventative rather than therapeutic measure, its antispasmodic action lasts for around 6.5 hours, longer than that of modern asthma drugs. Toxicity is extremely low and there are practically no side effects, even when taken over a long period (RF Weiss, reference as above).

The latest orthodox drug derivative of Khellah is disodium chromoglycate (DSCG), marketed by Fisons as Intal. It is intended to stave off an asthma attack. In some patients it may cause a cough, throat irritation and bronchospasm (MIMS, July 1992).

Myrrh on the other hand, is a useful treatment, taken along with other asthma relieving drugs where the asthma is caused by catarrhal infection of the respiratory tract and bronchioles (R W Davey and others, Comp Med Res, Jan 1990). It has been shown to be effective against 20 strains of microbial organisms, including those that are regarded by orthodox medicine as multi drug resistant.

Harald Gaier is a registered naturopath, osteopath and homoeopath.

The history of chiropractic, like all healing arts, is largely one in which empirical process has preceded theoretical formulation. In other words, from the earliest days practitioners have applied new manual treatment methods on an intuitive, empirical basis, noted that some are more effective than others, and theorized on the basis of these findings as to the underlying mechanisms.

When certain methods have demonstrated their effectiveness over a period of time, they, along with the theories used to explain them, become part of what we might call the “chiropractic corpus,” the body of tradition, evidence, and practice which is the contribution of the chiropractic school of knowledge to the healing arts as a whole.

Not until the late Twentieth Century was this accumulated body of chiropractic knowledge sufficiently grounded in scientific research to allow wide recognition across professional boundaries. Fortunately, that point has now been reached. It therefore seems timely to review the nature of the chiropractic diagnostic and therapeutic model, so that it can be well understood by the public and other health professionals.

Part of this review is an examination of chiropractic theory past and present. It is important to sift out ideas which may have been state of the art in 1910 or 1950, but which are no longer fully tenable. Chief among these is the idea that the chiropractic adjustment works primarily by physically moving a vertebra that is out of place back into place.

The Bone-Out-of-Place Theory

The early chiropractors assumed that their adjustments worked by moving misaligned vertebrae back into line, thereby relieving pressure caused when those bones impinged directly on spinal nerves. The standard explanation given to patients was the analogy of stepping on a garden hose if you step on the hose the water canât get through, and then if you lift your foot off the hose, the free flow of water is restored. Similarly, the explanation went, the chiropractic adjustment removes the pressure of bone on nerve, thus allowing free flow of nerve impulses.

Based on the information available in the early years, such a theory was plausible. Chiropractors were able to feel interruptions in the symmetry of the spinal column with their well-trained hands, and in many cases could verify this on x-ray (discovered in 1895, the same year as chiropractic). They would then adjust the vertebra with manual pressure, attempting to move it back into line. More often than not, patients reported significant functional improvements and healing effects.

But there are problems with the theory. This can most simply and directly be illustrated by noting the fact that, after an adjustment resulting in dramatic relief from headaches or sciatica, an x-ray will rarely show any discernible change in alignment. (Such comparative x-rays are now considered inappropriate, because of the unnecessary radiation exposure). Long-term positive health changes have not been definitively shown to correlate with symmetrical alignment of spinal bones on any consistent basis.

Though much excellent work has been done by chiropractors whose understanding of their healing art was based on the bone-out-of-place theory, the theory has not stood the test of time. This does not mean that chiropractic is invalid, only that this late nineteenth century explanation has been overtaken by later developments.

While misalignments may play a role in the interpretation of spinal subluxations, they are no longer believed to play the central role. But if the old explanation of misaligned bones pressing on nerves is inadequate, what new theory has replaced it? To answer this question, we need to move beyond the essentially two-dimensional viewpoint of the misalignment theory, and include motion as an added dimension.

The Intervertebral Motion Theory

In the 1930s, Belgian chiropractor Henri Gillet developed a theory of intervertebral motion and fixation, in which he asserted that it was loss of normal spinal joint movement, rather than misalignment, that was the underlying explanation for the vertebral subluxation. He agreed with the bone-out-of-place adherents that the interplay between the skeletal system and the nervous system was crucial, but parted ways with them regarding the causal process underlying the abnormal nerve signaling. Rather than attributing the subluxationâs effects to direct pressure of misaligned bone on nerve, Gillet theorized that loss of proper joint dynamics was the underlying issue.

Later work by medical researchers Schmorl and Junghans, and many more who followed, verified the complex role of the “vertebral motor unit,” consisting of bones, muscles, ligaments, blood vessels, and nerves. This model is now widely accepted.

All of these structural components are involved in the subluxation complex. Bypassing the old argument of whether the causative factor in the vertebral subluxation is the bone or the muscle, the work of Gillet, Schmorl, Junghans, and others allowed the problem to be seen from a broader, multi-faceted perspective, in which all components of the intervertebral joint are involved in an elaborate interplay. This model first achieved profession-wide attention among chiropractors in the 1980s, and now enjoys broad acceptance in chiropractic college curricula throughout the world.[1]

Jerome McAndrews, D.C., an early advocate of motion theory and practice who later served as president of Palmer College of Chiropractic, translated this model into visual terms when I spoke with him during preparation of this book.

“View it as a mobile hanging from the ceiling,” Dr. McAndrews said. “As it hangs there, it is in a state of dynamic equilibrium. Then, if you cut one of the strings, the whole mobile starts moving, because its balance has been upset. Eventually, it slows down and reaches a new state of dynamic equilibrium.”

The bodyâs musculoskeletal system works in much the same way, Dr. McAndrews explained. If its normal balance is disrupted, it has no choice but to compensate. Structural patterns will be altered to a greater or lesser degree, depending on the nature and intensity of the forces that threw off the old pattern of balance.

If chiropractic care is sought early, relatively little treatment may be required, because these compensations will not have had time to deeply imbed themselves structurally. Thus, a child injured playing football at age ten might need just one or two adjustments, but if that child waits until age forty before seeking chiropractic care (not an uncommon occurrence), the situation may prove far more complex. Patterns of long-term muscular rigidity, calcium deposits in ligaments, and significant structural shifts of the vertebral column or ribcage, for example, may set in with relative permanence.

In some such circumstances, when much time has passed, the achievable therapeutic goal may be limited to partial restoration of mobility and function. Returning to the once-upon-a-time perfection of the ten-year oldâs pre-injury body becomes impossible somewhere along the way.
The theory of dynamic equilibrium, with its emphasis on intervertebral motion and fixation, has the great advantage of allowing, for the first time, a coherent explanation of chiropractic and the subluxation complex that can be communicated in familiar terms to medical practitioners and researchers. This has resulted in clearer lines of communication between chiropractors and medical professionals. While some hold onto the old model and terminology, the stage has been set for completion of this significant shift in perspective, as the new generation of chiropractic and medical practitioners trained after it took hold comes of age.

Wide-Ranging Effects of Spinal Manipulation

Restoring mobility to a joint by manipulation eases the stress at that joint and in the surrounding tissues. Unless complicating factors are present, muscular tension eases in the area that has been adjusted. As joint dysfunction decreases, other secondary symptoms such as pain, tingling, or numbness along the path of the nerves originating at the involved spinal level also improve.

Though the vast majority of chiropractic patients arrive seeking help for musculoskeletal problems like back pain, neck pain, and headaches, spinal adjustments can also have positive effects on other organs and systems. While chiropractic adjustments are directed to restoring motion at specific vertebral joints, the effects of these adjustments extend beyond the local area where the adjustive force is applied. Effects can extend to all structures served by the nerves originating in the spine.

Thus, neck adjustments can affect not only the neck and arms, but also the function of various organs in the head (via sympathetic pathways), and in the chest and upper abdomen (via the parasympathetic vagus nerve). Upper back adjustments can affect not only the upper back, but also the lungs, heart, and parts of the digestive tract. Adjustments of the lower back may influence not only the lower back and legs, but also the kidneys, pelvic organs and lower digestive tract.

The First Chiropractic Adjustment: A Case of Hearing Restored

The first chiropractic adjustment in 1895 was one in which the patient sought help for back pain, and got results far beyond his expectations. Harvey Lillard, a deaf janitor in the building where D.D. Palmer had an office, came to Palmer bent over with back pain. Palmer gave him a spinal adjustment, after which Mr. Lillard stood up straight, was free of back pain, and able to hear for the first time in many years.

At first, it appeared that Palmer might have discovered a cure for deafness, but similar results were not forthcoming when other deaf people heard about Harvey Lillard and sought Palmerâs help. And while there have been other instances through the years of hearing restored through spinal manipulation (including one by Canadian orthopedist J.F. Bourdillion, M.D.)[2] these have been rare, and no predictable pattern has emerged. The story of Lillardâs recovery has been used for many years to disparage chiropractic, with repeated charges by the naysayers (primarily anti-chiropractic MDs) that such an event is impossible, because no spinal nerves supply the ear. Once, when I was testifying as an expert witness in a patientâs automobile accident case, the opposing attorney, his voice dripping with sarcasm, attacked me with this very story.
It is important to refute the charge specifically. The underlying physiological mechanism is called the somato-autonomic reflex, fully recognized in all modern medical and chiropractic textbooks. Its name describes the interaction between the muscular and skeletal system (soma, or body), and the autonomic (involuntary) portion of the nervous system. Signals initiated by spinal manipulation are transmitted via autonomic pathways to internal organs.

In the case of Palmerâs first adjustment, the relevant nerve pathway starts in the upper back, coursing up the neck and into the skull along the sympathetic nerves which eventually lead to the blood vessels in the ear. Proper functioning of the hearing apparatus depends on a normal blood supply, which in turn depends on an adequate nerve supply.

While it is true that there are no spinal nerves as such directly supplying the ear, it is absolutely untrue that no nerve pathway links the two areas. The pathway exists, and any claims to the contrary betray ignorance of fully accepted modern physiology research.

Further Examples of Manipulationâs Effects on Internal Organs

Just as there are autonomic pathways supplying the ear, similar pathways lead from the spine to all parts of the body. A broad array of research has verified that these pathways exist, and that in some instances spinal manipulation can positively affect problems caused by them. The work of Czech neurologist Karel Lewit, M.D., American orthopedic surgeon John McMillan Mennell, M.D., and others has been particularly helpful in spreading these concepts beyond the chiropractic community. Dr. Lewit has for many years successfully used spinal manipulation to treat tonsillitis, breathing problems, migraine, vertigo, and much more.[3]

An example of a potential future direction for joint medical-chiropractic research is found in the book Chiropractic: Interprofessional Research, a summary of research presented at the World Chiropractic Conference, held in Venice, Italy in 1982. A series of studies by chiropractors, working in concert with Italian medical doctors, demonstrated promising effects of chiropractic treatment in cases of vertigo, tinnitus (ringing of the ears), headaches, and visual disorders.[4]
There is far less research available concerning chiropracticâs effects on visceral (internal organ) disorders than exists in relation to lower back pain and other musculoskeletal problems. This is because the chiropractic profession has had to prioritize the research it could afford to pursue in the absence of significant government funding. Proving the validity of chiropractic manipulation for those conditions most commonly treated by chiropractors (low back pain, neck pain, and headaches) has been the highest priority.

There is, nevertheless, a growing body of literature, some of it published in peer-reviewed scientific journals, on the effects of manipulation for problems related to internal organ dysfunction. Some of these are controlled clinical trials, while others are thought-provoking case studies which point to the need for more extensive future research:

A randomized, controlled clinical study demonstrated that diastolic and systolic blood pressure decreased significantly in response to chiropractic adjustments of the thoracic spine (T1-T5), while placebo and control groups showed no such change. This study demonstrated short-term effects of manipulation on blood pressure, and indicates a need for studies on long-term effects.[5]

As noted earlier in this book, there have been two controlled clinical trials which studied the effects of spinal manipulation on dysmenorrhea. The results were quite promising, and further research is in progress.[6,7]

A study at the National College of Chiropractic showed a marked increase in the activity levels of certain immune-system cells (PMNs and monocytes) after thoracic spine manipulation. These increases were significantly higher than in control groups, who were given either sham manipulation or soft-tissue manipulation.[8]

A study involving 73 Danish chiropractors in 50 clinics showed satisfactory results in 94 percent of cases of chiropractic research:infant colicinfant colic. The results occurred within two weeks, and involved an average of three treatments.[9]

Several case studies have indicated that bladder dysfunction can be responsive to lower back manipulation.[10,11]

Lung volume and forced vital capacity (a measure of lung strength), were shown in a series of cases to increase after chiropractic adjustments.[12,13]

A 7-month-old infant suffering from chronic constipation since birth (with a history of hard, pellet-like stools following hours of painful straining) was restored to normal bowel function by full-spine and cranial adjustments.[14]

A two-year-old child medically diagnosed with asthma and enuresis (bedwetting) improved dramatically as a result of spinal adjustments, after medication had proved inadequate.[15]

Pelvic pain and pelvic organ dysfunction, in which there was no accompanying lower back pain, was shown in a case study to resolve fully with chiropractic manipulation of the lumbar spine, after numerous failed attempts at treating the symptoms medically.[16]

A 5-year-old girl, who was experiencing up to 70 seizures a day, was treated with upper neck adjustments and became virtually seizure-free.[17]

Further exploration of chiropracticâs effects on internal organ problems holds great promise. Studies are underway as this book goes to press, and many more are expected. This may turn out to be the most fertile area for chiropractic research in the Twenty-First Century.

The Chiropractic Perspective

Looking back over the material weâve covered, how would we best summarize the differences between the chiropractic approach and the standard medical model?

First and foremost, the chiropractic model views symptoms in a broad context of health and body balance, not as isolated aberrations to be suppressed and then forgotten. Chiropractors recognize the need for thorough evaluation of symptoms, but do not assume that the elimination of symptoms is the ultimate goal of treatment. Just as peace is not the absence of war, health is not the absence of disease symptoms. The true goal is sustainable balance. This is recognized by chiropractors and by holistic medical physicians as well.

While chiropractors are trained in state-of-the-art diagnostic techniques, and while chiropractic examination procedures overlap significantly with those used by conventional medical physicians, chiropractors evaluate the information gleaned from these methods from a perspective that recognizes the intricate structural and functional interplay between different parts of the body.
The contrasting medical and chiropractic diagnostic approaches to pain provide a case in point. In my experience, conventional medical physicians far more frequently than chiropractors make the assumption that the location of a pain is the location of its cause. Thus, knee pain is generally assumed to be a knee problem, shoulder pain is assumed to be a shoulder problem, etc. This pain-centered diagnostic logic frequently leads to increasingly sophisticated and invasive diagnostic and therapeutic procedures. (If physical examination of the knee fails to clearly define the problem, then the knee is x-rayed. If the x-ray fails to offer adequate clarification, then an MRI of the knee is performed, etc.)

Chiropractors also utilize these diagnostic tools. I refer some patients for x-rays and MRI studies. My point is not to criticize these machines, but to present an alternative diagnostic model. I have seen more than a few cases of knee trouble where this entire high-tech diagnostic scenario was played out, and the cause of the problem turned out to be in the lower back.

If the lower back is mechanically dysfunctional, and in need of spinal manipulation, this can often place unusual stress on the knees. In cases of this sort, one can spend months or years medicating the knee symptoms with painkiller pills and/or steroid injections, or performing knee surgery, without ever addressing the real problem. This is not an isolated hypothetical instance. It happens far too often.

Whole-Body Context

The chiropractic approach to musculoskeletal pain involves evaluating the site of pain in a whole-body context. Shoulder, elbow and wrist problems can of course be caused by problems in the shoulder, elbow and wrist but pain in all of these joints frequently has its source in the neck. Similarly, pain in the hip, knee, and ankle can also have its source at the site of the pain but in many cases the source lies in the lower back. The need to consider this chain of causation is built into the core of chiropractic training.

Chiropractors from D.D. Palmer onward have purposely refrained from assuming that the site of a symptom is the site of its cause. They have assumed instead that the source of the pain should be sought somewhere along the path of the nerves leading to and from the site of the symptoms.
Thus, a pain in the knee might come from the knee itself, but if we trace the nerve pathways between the knee and the spine, we find along the way possible areas of causation in or around the hip, in the deep muscles of the buttocks or pelvis, in the sacroiliac joints, or in the lower spine.

Furthermore, if an imbalance does exist in the lower spine (at the fourth lumbar level, for example), it might have its source right there at L4, or might in turn be a compensation for another joint dysfunction elsewhere in the spine, perhaps in the middle or upper back. Thus, an integrated, whole-body approach to structure and function is of great value.

For a patient with an internal organ problem, chiropractic diagnostic logic would include evaluation of those spinal levels which are the source of the nerve supply to the involved area, as well as consideration of possible nutritional, environmental and psychological causes. Chiropractic practice standards also mandate timely referral to a medical physician for diagnosis and/or treatment, for any condition that is acute and dangerous, or when a reasonable trial of chiropractic treatment (current standards in most cases limit this to about one month) fails to bring satisfactory results.

Wellness and the Chiropractic Model

The chiropractic model pays heed to patientsâ nutritional needs, exercise habits, work conditions, and psychological health. In many cases, particularly with regard to nutrition and exercise, the chiropractor will act as a teacher, directly counseling patients on proper diet or exercise methods. In other instances, chiropractors will make referrals to other health practitioners, or to appropriate classes in the community.

The traditional chiropractic philosophy I learned during my training anticipated in many respects the concepts that comprise the modern wellness paradigm. Aside from being taught the importance of good diet, exercise, and emotional health, we also learned that it is far better to practice prevention than to engage in crisis-care, and that health is far more than the absence of symptoms. These ideas together form a respectable foundation for a profession that seeks to practice holism.

Notes

1. Copland-Griffiths, Dynamic Chiropractic Today, p. 159

2. Bourdillion, J.F. Spinal Manipulation. pp. 205-206

3. Copland-Griffiths, op. cit. p. 162

4. Mazzarelli, Joseph, D.C. (editor). Chiropractic: Interprofessional Research. pp. 69-76.

5. Yates RG, Lamping DL, Abram NL, Wright C. “Effects of Chiropractic Treatment on Blood Pressure and Anxiety: A Randomized, Controlled Trial.” Journal of Manipulative and Physiological Therapeutics, 1988; 11: 484-488.

6. Kokjohn K, Schmid DM, Triano JJ, Brennan PC. “The Effect of Spinal Manpulation on Pain and Prostaglandin Levels in Women with Primary Dysmenorrhea.” Journal of Manipulative and Physiological Therapeutics, 1992; 15: 279-285.

7. Thomason, PR, Fisher BL, Carpenter PA, Fike GL. “Effectiveness of Spinal Manipulative Therapy in Treatment of Primary Dysmenorrhea: A Pilot Study.” Journal of Manipulative and Physiological Therapeutics. 1979; 2: 140-145.

8. Brennan PC, Kokjohn K, Katlinger CJ, Lohr GE, Glendening C, Hondras MA, McGregor M, Triano JJ. “Enhanced Phagocytic Cell Respiratory Burst Induced by Spinal Manipulation: Potential Role of Substance P.” Journal of Manipulative and Physiological Therapeutics, 1991; 14: 399-408.

9. Klougart N, Nillson N, Jacobsen J. “Infantile Colic Treated by Chiropractors: A Prospective Study of 316 Cases.” Journal of Manipulative and Physiological Therapeutics, 1989; 12: 281-288.

10. Falk, JW. “Bowel and Bladder Dysfunction Secondary to Lumbar Dysfunctional Syndrome.” Chiropractic Technique, 1990; 2: 45-48.

11. Borregard, PE. “Neurogenic Bladder and Spina Bifida Occulta: A Case Report.” Journal of Manipulative and Physiological Therapeutics, 1987; 10: 122-123.

12. Masarsky, CS and Weber M. “Screening Spirometry in the Chiropractic Examination.” ACA Journal of Chiropractic, February 1989; 23: 67-68.

13. Masarsky, CS and Weber M. Chiropractic and Lung Volumes A Retrospective Study. ACA Journal of Chiropractic, September 1986; 20: 65-68.

14. Hewitt, EG. “Chiropractic Treatment of a 7-Month-Old With Chronic Constipation: A Case Report. Proceedings of the National Conference on Chiropractic and Pediatrics (International Chiropractors Association), 1992; 16-23.

15. Bachman TR, Lantz, CA. “Management of Pediatric Asthma and Enuresis With Probable Traumatic Etiology.” Proceedings of the National Conference on Chiropractic and Pediatrics (International Chiropractors Association), 1991: 14-22.

16. Browning, JE. ” Mechanically Induced Pelvic Pain and Organic Dysfunction in a Patient Without Low Back Pain.” Journal of Manipulative and Physiological Therapeutics, 1990; 13: 406-411.

17. Goodman R. “Cessation of Seizure Disorder: Correction of the Atlas Subluxation Complex.” Proceedings of the National Conference on Chiropractic and Pediatrics (International Chiropractors Association), 1991: 46-56.©1993, Daniel Redwood, D.C.

The intensity of their refusal to accept things as they are, and the way they demand of both themselves and others a willingness to explore unorthodox alternative healing methods, are precisely the factors that have enabled chiropractic and other natural healing arts to survive and even thrive in the face of determined opposition from organized medicine.

In 1991, after well over a decade of litigation, the United States Supreme Court affirmed a lower court ruling declaring the American Medical Association et. al. guilty of anti-trust violations that were part of an ongoing conspiracy to “contain and eliminate” (the AMA’s own words) the chiropractic profession. As a result of the Wilk v. AMA suit, the medical profession reversed its longstanding ban on inter-professional cooperation between medical doctors and chiropractors, agreed to publish the full findings of the court in the Journal of the American Medical Association, and paid a large sum of money which is now being used for chiropractic research.

This has not undone the effects of a well-organized anti-chiropractic campaign by organized medicine (which at one point even included attempting to rig in advance a federally mandated study on chiropractic!),[1] but it certainly points to the dawning of a new day.

Chiropractic Research: Clinical Studies and the “Outcomes Revolution”

Spinal manual therapy, of which chiropractors are the primary providers, has now been shown by reputable researchers to be the most demonstrably effective healing method for the most common kinds of lower back pain. Each year brings the publication of more studies (published in both medical and chiropractic journals), gradually expanding the range of conditions for which chiropractic should be considered a treatment of choice.

This was not always so. For years, chiropractors were criticized for offering only anecdotal evidence (stories of people who got well under chiropractic care) in support of their methods. Despite the fact that only an estimated 15 percent of orthodox medical interventions are validated by rigorous scientific research,[2] chiropractic was repeatedly attacked as unscientific, in contrast to the presumably altogether scientific medical profession.

Two things have changed. First, as you will see in this chapter, there is now a substantial body of chiropractic research, performed under accepted scientific protocols, which even the most die-hard skeptics cannot refute. Second, there has been an increased emphasis, largely driven by governmental and economic pressures, given to what is now called “outcomes research,” which in part involves asking patients to rate their degree of pain relief, return to proper function in daily activities, satisfaction with treatment, and other related factors. Outcomes research has a strong subjective component, but has risen in stature because it has the overriding virtue of including what, after all, is the whole purpose of the healing arts to bring improved health, and relief from pain and suffering, as judged by the patients themselves.

The full effects of the outcomes research revolution are yet to be felt. But one thing is clear already: patients are growing very impatient with many orthodox medical therapies, and are “voting with their feet.” They are flocking in droves to alternative practitioners of all sorts,[3] some of whose approaches already have significant scientific validation (chiropractic being most prominent example), and others whose methods have yet to face the scrutiny of rigorous research.
This trend, unprecedented in its magnitude and probably nowhere near the peak of the curve as yet, portends a significant realignment in the healing arts as we know them, probably within the next generation. While it is still possible that the forces of orthodoxy may wage temporarily successful rearguard actions in some countries, blocking valid alternative methods from attaining equal status in terms of licensure and insurance reimbursement, it appears that a critical mass has already been reached, and that major changes will continue at an accelerating pace.
The chiropractic profession is in the unusual, and perhaps unique, position of having one foot inside the establishment (with licensure, insurance reimbursement, accredited training institutions, and an increasingly broad scientific research base), while the other is firmly in the alternative camp (with a philosophy of natural healing that in most cases relegates drug therapy to a position of last resort, rather than first).

As such, chiropractic provides a rare modern example of how a healing art, born in rebellion against the status quo, enters the mainstream. The history of chiropractic is for the most part an inspiring story of the triumph of the underdog, but it also contains a travelerâs advisory as to the perils of the journey.

Historical Roots

Spinal manipulation has existed in one form or another for millennia. Accounts of manipulative therapies go as far back as 2700 B.C. in China, and a similar legacy has been bequeathed to us by ancient civilizations from Babylonia to Central America to Tibet.

Hippocrates (460 B.C.) was an early practitioner of spinal manipulation and according to some scholars, the Father of Medicine used manipulation “not only to reposition vertebrae, but also thereby to cure a wide variety of dysfunctions.[4] The Hippocratic Corpus, recorded by physician-scholars in Alexandria, Egypt, when that city was the cultural center of Western civilization, includes detailed descriptions of manipulative methods.

Galen, Greek-born Roman physician who lived in the Second Century A.D., and whose approach to healing set the officially recognized standard in Western medicine for 1,500 years after his death, also utilized spinal manipulation, and reported successfully resolving a patientâs hand weakness and numbness by manipulating the seventh cervical vertebra.[5]

As Europe endured what later would be known as the Dark Ages, these healing traditions were preserved in the learning centers of the Middle East by the ascendant Arabic civilization. Later, this body of knowledge returned to Europe, and the works of Hippocrates and Galen formed the foundation of Renaissance medicine. Ambroise ParŽ, sometimes called the Father of Surgery, used manipulation to treat French vineyard workers in the Sixteenth Century.[6]

During the centuries that followed, up to the beginning of the modern era, manipulative techniques were passed down from generation to generation within families. These “bonesetting” methods, which were transmitted not only from father to son but often from mother to daughter, played an important role in the history of non-medical healing in Great Britain and similar methods are common in the folk medicine of many nations.

Birth of the Modern Professions

In the second half of the Nineteenth Century, the United States was a crucible of natural healing theory and practice. Two manipulation-based healing arts, osteopathy and chiropractic, trace their origins to that era. Both began in the American Midwest.

Neither emerged in a vacuum. A medical physician, Dr. J. Evans Riadore, wrote in 1843 in Irritation of the Spinal Nerves that “if any organ is deficiently supplied with nervous energy or of blood, its functions immediately, and sooner or later its structure, become deranged.” Robert Leach, D.C., in The Chiropractic Theories: A Synopsis of Scientific Research, says of this, “Apparently Riadore concluded that irritation of the spinal nerve roots resulted in diseases; he even advised manipulation to treat this disorder.[7]

Dr. Riadore’s work predated by decades the development of osteopathy by Andrew Taylor Still, in the 1870s, and the introduction of chiropractic by Daniel David Palmer in the 1890s. Whether or not Still and Palmer were personally aware of Riadoreâs work, and it seems likely that they were, their pioneering efforts certainly occurred in a context where work such as Riadoreâs was in the public domain.

Interestingly, Riadoreâs statement about deficiency “of nervous energy or of blood” summarizes in one phrase the respective founding principles of chiropractic and osteopathy. Since its beginnings, chiropractic has attributed the central role in health to the nervous system. Osteopathy is founded on the Law of the Artery, with which Dr. Still asserted the primacy of the circulatory system.

Both Still and Palmer formulated their hypotheses and built their new professions against a backdrop of medical orthodoxy which they found to be frequently ineffective, and sometimes barbaric. Dr. Still, a Missouri country doctor, had lost three of his children to spinal meningitis. The standard treatment of the era was cauterization (burning through the skin with a hot iron), followed by the application of bloodsucking leeches to the raw exposed tissues of the spinal area. After the death of his children, like the Biblical Job, Still cried out in his pain for understanding. He spent the remainder of his life developing the natural healing art he called osteopathy.

Chiropractic: Then and Now

D.D. Palmer founded chiropractic on the premise that the vertebral subluxation was the cause of virtually all disease, and the chiropractic adjustment its cure. This “one cause-one cure” philosophy has played a central role in chiropractic history first as a guiding principle, and later as an historical remnant, a bulls-eye at which the slings and arrows of organized medicine have repeatedly been hurled.

While few contemporary chiropractors would endorse such a simplistic formulation, it nonetheless remains true that the raison dâ�tre of the chiropractic profession is the detection and correction of spinal subluxations. Chiropractors may, in fact, do much more, but it is our ability to do this one thing well that has allowed us to survive for a century under a constant barrage of medical opposition, some of it justified, most of it not.

The “one cause-one cure” adherents among the early chiropractors had two major political effects on the development of the profession. First, their deep faith in the truth of their message, combined with the sometimes stunningly positive results of chiropractic adjustments, created a strong and steadily growing activist constituency of chiropractic supporters. In their zeal, they forged a grassroots movement which assured the survival of the profession through some very stormy years in the first half of the Twentieth Century. But at the same time, by sometimes making inflated claims, and failing to back those up with hard evidence, some early chiropractors also managed to convince most medical physicians and, through them, a substantial portion of the general public that chiropractors were not to be trusted.

In this conflict, the medical profession was by no means a disinterested party solely seeking to protect the public well-being. It faced in chiropractic an intrepid economic competitor with a competing philosophy that raised the possibility of healing without drugs, which were, and still are, the medical professionâs primary healing tool.

The Wilk v. AMA suit brought to light a decades-long pattern of conspiracy, lies and political intrigue which exposed the AMA for what it was: a trade association whose principal loyalty was to the self-interest of its membership. The American judicial system may sometimes seem to move interminably slowly, but in this case justice finally prevailed.

A Complex Legacy

Contemporary chiropractors have inherited both the positive and negative aspects of this complex legacy. We look back at our professional forebears, and honor the level of sacrifice their commitment called forth, while at the same time seeking to adapt to the needs of a new era.
Our task is in many ways easier than theirs. Starting with D.D. Palmer, thousands of chiropractors were charged with practicing medicine without a license. Hundreds, including Palmer himself, went to jail.[8] Civil disobedience was an integral part of the early development of the chiropractic profession, as it would later become in the civil rights movement. When Dr. Palmer was jailed in 1906, he said, “I have never considered it beneath my dignity to do anything to relieve human suffering.” Like Thoreau before him and Martin Luther King later, Palmer understood that the defense of basic rights sometimes requires time behind bars.

Because of the sacrifices made by Palmer and so many others through the years, chiropractors today are able to practice freely, and the profession is truly coming of age in our time. Over the past several decades, the chiropractic profession has undergone profound changes, as standards in education, research, and practice methodology have steadily risen to meet the demands of a fast-changing society. An excellent historical review, for those seeking greater detail, is contained in the book Dynamic Chiropractic Today, written by a former president of the British Chiropractors Association, Michael Copland-Griffiths, D.C.

Chiropractors are now licensed throughout the English-speaking world, and in many other nations as well. Educational standards and testing procedures are rigorous. Numerous college science courses are required prior to entering chiropractic school, and the chiropractic college curriculum extends four or more years. Highly-trained faculty fill both the basic science and clinical science departments at all chiropractic colleges, which are accredited by government-supervised agencies in the various countries.

In Australia, the first wholly government-funded chiropractic training program in the world was incorporated into a university curriculum in 1980. In Quebec, a similar program began in 1993 at the state (provincial) university. These programs are a sign of things to come, and foreshadow a far greater integration of chiropractic into the health care system of the future.
The greatest strides in the late-twentieth century have been in the area of research. No longer can chiropractors be criticized for lacking a firm base of scientific research. The tide has truly turned, as chiropractic has entered the modern era.

Chiropractic Research

The early leaders of the chiropractic profession recognized the value of research. Dr. B.J. Palmer, the founderâs son, conducted numerous studies between the 1910s and the 1950s, documenting the effects of chiropractic adjustments on such physical functions as blood pressure, heart rate, respiration, and brain-wave patterns.

Unfortunately, B.J. Palmerâs studies, like other chiropractic (and medical) research from the first half of the twentieth century, do not meet the criteria demanded by the modern scientific community. In the context of their time, however, an era when medical clinical trials were just beginning, Palmerâs work marked the first serious attempt at objective measurement of the physiological effects of the chiropractic adjustment.

Through the years of Palmerâs preeminence in the chiropractic world, many other independent chiropractors and chiropractic colleges also carried the torch of research, exploring new adjusting methods and measuring their effects. Like Palmerâs studies, these too are of significant historical interest, but did not follow the rigorous scientific protocols demanded of todayâs research.

By the early 1970s, the scientific gap between chiropractic and medicine had widened, and the more far-sighted chiropractic leaders realized that it had to be closed as quickly as possible. Looking back now from the vantage point of the 1990s, it is remarkable that so much has been accomplished in such a short time.

Dr. Suh and the University of Colorado Project

Beginning in the 1970s, first with grants from the International Chiropractors Association, and later with added financial support from the American Chiropractic Association and the federal government of the United States, Chung Ha Suh, Ph.D., and his colleagues at the Biomechanics Department of the University of Colorado began a series of studies which have provided an extensive body of chiropractic-related scientific research.

It is worth noting that Dr. Suh, the first American college professor willing to stick his neck out for chiropractic research, grew up in Korea, where he had not been subjected to the same life-long anti-chiropractic bias as his American colleagues. In undertaking this research, he had to withstand intense pressure from powerful forces within the American medical and academic establishments. The AMA and cohorts condemned chiropractic for lack of scientific underpinning, while at the same time doing everything in their considerable power to prevent chiropractors from ever obtaining the funding and university connections necessary for the development of such a research base.

Time and again in American history, it has been immigrants who have brought to our land the fresh perspectives needed to move our society forward. In addition, progress has often required the courage to stand up against politically powerful forces of stagnation. Dr. C.H. Suh stands as a modern exemplar of both these traditions.

The research at the University of Colorado involved two major projects. In one, Dr. Suh developed a complex computer model of the cervical spine, which allowed a deeper understanding of spinal joint mechanics and their relationship to the chiropractic adjustment.

The second project involved studying the effects of compression on spinal nerve roots. Seth Sharpless, Ph.D., Marvin Luttges, Ph.D., and their colleagues demonstrated that minuscule amounts of pressure on a nerve root (10mm Hg, equal to a feather falling on your hand), resulted in up to a 50 percent decrease in electrical transmission down the course of the nerve supplied by that root.[9] Chiropractors have long claimed that minimal pressure on nerves could have a significant physiological impact. This study gave credence to such claims and offered a promising path for future research.

Most of the recent interdisciplinary clinical research jointly conducted by chiropractors and medical physicians has been done outside the United States, which still remains the last, strongest bastion of the medical ancien regime. The most influential research studies of the past decade were done in Canada, Great Britain and the Netherlands.

The Canadian Study

In 1985, a landmark study was published in the Canadian Family PhysicianCanadian Family Physician [10] which researched the effects of chiropractic adjustments for people with severe and chronic lower back pain. The approximately 300 subjects in this study had been “totally disabled” by back pain for an average of seven years, and had gone through the full gamut of standard medical interventions.

The study found that after two to three weeks of daily chiropractic adjustments, between 79 and 93 percent of those patients without spinal stenosis (narrowed spinal cord) had good to excellent results, reporting substantially decreased pain and increased mobility. Even among those with a congenitally or developmentally narrowed spinal cord, a significant number showed substantial improvement. Remember that every single one of these people had gone through extensive, unsuccessful medical treatment prior to being allowed to participate as a research subject. After chiropractic treatment, over 70 percent of those studied were improved to the point of having no work restrictions. Moreover, follow-up a year later demonstrated that the changes were long-lasting.

These results are remarkable, but what was extraordinary about the Canadian study was the fact that it was jointly administered by Dr. J.R. Cassidy, a chiropractor, and Dr. W.H. Kirkaldy-Willis, a world-renowned orthopedic surgeon. In 1993 Dr. Cassidy became the first chiropractor to be named research director of a university orthopedics department, at the University of Saskatchewan where this research was done.

The landmark Canadian study clearly demonstrated the effectiveness of chiropractic adjustments for treating chronic lower back pain, even when standard medical interventions have been exhausted. Yet, sadly, many physicians seem unaware of this study and too few take the logical next step of referring patients with these symptoms to a chiropractor.

The British Study

In 1990, the British Medical Journal published a study called “Low Back Pain of Mechanical Origin: Randomized Comparison of Chiropractic and Hospital Outpatient Treatment,” by an orthopedic surgeon, Dr. Thomas Meade.[11] Meadeâs research compared chiropractic manipulation with standard hospital outpatient treatment for lower back pain. The medical treatment consisted of wearing a corset and attending physical therapy sessions. Over 700 patients were involved in the study.

Dr. Meade concluded:
“For patients with low-back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison to hospital outpatient management.”
In a later interview with the Canadian Broadcasting Corporation, Dr. Meade said,
“Our trial showed that chiropractic is a very effective treatment, more effective than conventional hospital out-patient treatment for low-back pain [emphasis added], particularly in patients who had back pain in the past and who [developed] severe problems. So, in other words, it is most effective in precisely the group of patients that you would like to be able to treat . . . One of the unexpected findings was that the treatment difference the benefit of chiropractic over hospital treatment actually persists for the whole of that three-year period [of the study] . . . it looks as though the treatment that the chiropractors give does something that results in a very long-term benefit.[12]

The great significance of the Meade study is that it is the first randomized study to demonstrate long-term benefits from chiropractic care. One baseless, but persistent, criticism of chiropractic has been that while it may offer short-term relief, it is of no lasting value. The Canadian and British studies, taken together, should by any reasonable standard be sufficient to lay this old falsehood to rest. Nonetheless, the criticism continues to appear in print, and needs to be answered forthrightly whenever it rears its head.

The RAND Study

In 1992, the widely respected RAND Corporation, a health care think tank, released a study on the appropriateness of spinal manipulation for lower back pain. Authored by a multidisciplinary panel headed by Paul Shekelle, M.D., the study marked the first time that representatives of this prestigious group had officially recognized spinal manipulation as an appropriate treatment for some patients with lower back pain. RANDâs procedures involved an extensive review of the scientific literature on the treatment of back pain, and a consensus process among the participants to determine areas of agreement.

The rather limited nature of RANDâs endorsement of spinal manipulation must be seen in context to be properly understood. RAND is known for its thoroughgoing critical evaluations and the great caution of its assessments, which is part of the reason that its conclusions are often taken by federal officials as something close to the final word on health matters. While its conclusions on spinal manipulation failed to go as far as many chiropractors would have liked, they nonetheless were far more favorable than RANDâs recent pronouncements on other controversial medical issues such as heart surgery.

The national media were quick to grasp the significance of the RAND report. In the weeks and months immediately following its release, high-profile news reports appeared in American newspapers, magazines and electronic media, declaring that chiropractic was finally being “accepted.” Of course, millions of chiropractic patients had already accepted it happily for years, but the RAND report marked the scaling of an inner wall of the health establishment.

The Dutch Study

A Dutch study published in the British Medical Journal in 1992 compared the results of back and neck pain patients treated with physical therapy against those given chiropractic manipulation, and also compared these two methods to placebo treatment and standard medical treatment by a general practitioner.

The results were impressive, and showed that both chiropractic manipulation and physical therapy were significantly more effective than a placebo treatment or treatment by a general practitioner. In addition, those receiving manipulation showed more improvement than the physical therapy patients, in fewer visits.[13]

Additional developments include:
An Australian study showed that patients who were treated by chiropractors lost four times fewer work days from low-back pain than those treated by medical doctors.[14]

A cost-comparison study in the Journal of Occupational Medicine demonstrated that the compensation costs for lost work time were ten times as high for those receiving standard, non-surgical medical care than for those who were treated by chiropractors.[15]

A study of Florida workerâs compensation cases indicated that patients receiving chiropractic care were temporarily disabled for half the length of time, were hospitalized at less than half the rate, and accrued bills less than half as high as patients receiving medical care for similar conditions.[16]

Preliminary results of a study on headaches showed spinal manipulation to be more effective than prescription medication for long-term pain relief. The chiropractic patients maintained their levels of improvement, while those treated with medication returned to their pre-treatment status in an average of four weeks after completion of treatment.[17]

The North American Spine Society (an interdisciplinary body consisting of expert practitioners and academics from the medical, osteopathic and chiropractic professions) rated spinal manipulative therapy in Category I, the highest rating, for treatment of lower back pain. Chiropractic adjustments were described as generally accepted, well-established, and widely used.[18]

AV MED, the largest health maintenance organization (HMO) in the Southeastern United States sent 100 medically unresponsive patients to a chiropractor. Eighty-six percent of this group were helped. As a result of two to three weeks of chiropractic care, all 12 patients medically diagnosed as needing disc surgery were able to avoid surgery, saving AV MED $250,000, and sparing the patients the risks and consequences of unnecessary surgery.[19]

A study published in the Western Journal of Medicine in 1989 found that chiropractic patients were more satisfied with their care than back pain patients of family practice physicians by a ratio of three to one. Interestingly, initial discussion of this study in medical journals generally assumed that the greater satisfaction rates among chiropractic patients were due entirely to allegedly superior doctor-patient relationships on the part of chiropractors. Left out of the analysis for the most part was the possibility that the difference may have been due in large measure to the greater effectiveness of chiropractic treatment methods.
In fact, chiropractic manipulation has been shown to be far more effective than the bed rest and prescription medications routinely prescribed by family practice physicians and general practitioners for back and neck pain, as shown in the study that follows.[20]

A clinical trial found that bed rest plus nonsteroidal anti-inflammatory medication (which together form the standard method with which family practice physicians and general practitioners treat low back pain) brought results worse than a placebo treatment.[21] This is particularly problematic in light of the fact that more people initially go to these primary care doctors for low back pain than to any other type of practitioner. Chiropractic treatment for lower back pain has been shown in many studies to be significantly superior to a placebo, and no reputable study has ever shown it to be worse than a placebo.

The November 1992 issue of Journal of Family Practice, the major journal for family practice physicians in the United States, included three strongly pro-chiropractic articles, which urged readers to “re-evaluate chiropractic” and “reconsider referrals to chiropractors for musculoskeletal problems.” The first paper was co-authored by Peter Curtis, M.D., of the Department of Family Medicine at the University of North Carolina, Chapel Hill, and Geoffrey Bove, D.C., a Ph.D. candidate in the Department of Cell Biology and Anatomy at the same school. The other two articles were editorials supporting the Curtis-Bove article, one by noted researcher Daniel Cherkin, Ph.D., and the other by three Israeli medical doctors who supported the conclusions of Drs. Curtis and Bove.[22]

A study by the Gallup Organization determined that 90 percent of chiropractic patients rated their treatment as effective, and 80 percent were satisfied with the treatment they received and felt that most of their expectations were met.[23]

Chiropractors and the millions who have benefited from chiropractic care over the years believed all of this to be true from the beginning. Thatâs why they fought so hard for its full acceptance as a legitimate, recognized healing art. Finally, enough objective scientific data now exists to show that their faith in chiropractic was not misplaced.

As scientific research continues to validate the chiropractic approach, the case for full recognition and integration grows stronger year by year. This is the path required of all alternative healing methods seeking to cross the bridge from alternative to mainstream. As each alternative enters the mainstream, the stream itself is forever changed.