Confessions of a Quackbuster

This blog deals with healthcare consumer protection, and is therefore about quackery, healthfraud, chiropractic, and other forms of so-Called "Alternative" Medicine (sCAM).

Sunday, March 13, 2005

Chiropractic - a study by Mahlon Wagner, PhD

Chiropractic - a study by Mahlon Wagner, PhD

A 100 year struggle from pseudoscience to legitimacy
By Mahlon Wagner, Ph. D.

It is estimated that 75% of all Americans will suffer from lower back pain (LBP) at some time. Treatment of this common ailment has been estimated to cost $24 billion every year. (Compare this to the annual cost for treating lung cancer of $4 billion.) Clearly, if inexpensive spinal manipulation (without drugs or surgery) could alleviate some of this suffering it would be most beneficial to the public and health care organizations.

In the United States there are more than 50,000 chiropractors, making them the third largest group of health practitioners after physicians and dentists. The chiropractic of today was popularized in the United States in 1896 by Daniel David Palmer living in Iowa.

Anti-Medical Ideologies

Many chiropractors today continue to follow some of the more controversial ideas of D. D. Palmer and his heirs such as opposition to the use of drugs, to vaccinations and immunizations1, 2 without which the current state of health in our society could not have been achieved.

A recent survey of attitudes by chiropractors 2 shows that 80% do not want children to be required to prove that they have been immunized before entering public schools, between 41% and 68% are ignorant of public health victories over many crippling diseases through immunization programs, and most chiropractors simply reject the scientific evidence.

These attitudes suggest a strong emotional commitment to an anti-medical ideology that has pervaded chiropractic philosophy and history. Subsequent letters responding to the survey give additional ample evidence of this anti-medical paranoia. 3,4,5,6 Student attitudes become increasingly anti-vaccination during their four years of training, and they report informal sources are most important (ignoring scientific evidence).7


In general, most “conventional” chiropractors begin by examining the spine for subluxations and “adjusting” them to relieve LBP and a host of other ailments. Critics argue that subluxations exist only in the minds of the chiropractor. For example, when one potential patient visited several chiropractors, each one found quite different subluxations on spinal x-rays.8

Some chiropractors are quick to claim that patients who have been adjusted often report improvements in such conditions as asthma, bed wetting (enuresis), mental illness, depression, premenstrual syndrome, diabetes, angina and heart disease, colds and flu, constipation, tension and anxiety as well as lower back pain. This last condition, LBP, is the primary reason most patients first consult a chiropractor. There is some research to support the efficacy of spinal manipulation for alleviating LBP.

A 1991 public opinion poll by the Gallup Organization found that “90% of chiropractic patients felt their treatment was effective and more than 80% were satisfied with that treatment.” While patient satisfaction is undoubtedly an important outcome, there are many reasons for differences in patient satisfaction which are not related to the efficacy of the proposed treatment.

Nutritional Advice

Up to 80% of chiropractors give nutritional advice and actually sell nutritional/vitamin supplements directly to their patients.9 Many of these supplements (including homeopathic remedies, Chinese products and glandular substances) appear to be therapeutically worthless, but provide a significant financial income (often more than $50,000 per year).

A survey of California chiropractors found they had received a median of 80 class hours of formal nutrition education and many reported being able to readily diagnose osteoporosis, arthritis and allergies.10 About 65% of all chiropractors are dispensing nutritional products every day.11 These chiropractors encourage patients to come back for monthly adjustments long after the original LBP is gone. Many even suggest regular maintenance adjustments for infants and children to “prevent future health problems” such as colon cancer.12

Applied Kinesiology

Applied Kinesiology is used by 40% of chiropractors.13 It involves testing muscle strength to diagnose “weakness” of bodily organs as well as to determine which remedies (often homeopathic or nutritional supplements) would be effective.

For example, the chiropractor may place a potential remedy upon the chest or the tongue of the patient and test the resistance of one arm to movement before and after placing the remedy. Or the chiropractor might place a potato, egg or other substance upon the chest and discover allergies that need treatment.

Considerable research (some of it found in the chiropractors’ own Journal of Manipulative and Physiological Therapeutics) has demonstrated that there is no scientific basis to such muscle testing.14

Questionable Methodologies

More than 43% report giving homeopathic remedies. And significant numbers of chiropractors use pendulums (dowsing), and magnet therapy.15, 16 Clearly, the fact that so many chiropractors use these suspect and unproven methods casts serious doubt upon the whole profession.

Recently, one chiropractor noted this disturbing trend and pointed out that many current practices are devoid of rational thinking and, in fact, are dogmatically shamanistic.15

Claims To Legitimacy

The patients and the public are frequently told that “chiropractic works.” “Twenty-five million patients can’t be wrong.” Two thousand four hundred years of spinal manipulations testify to its validity. Since there are no drugs or surgery, it is much safer, milder and more effective than conventional medicine. And we need only look at who supports chiropractic to know that it is worthwhile.

Many famous people have sought out chiropractic treatment, such as: Presidents Harry S. Truman, Ronald Reagan and George Bush, as well as John Wayne and even several sports teams.17 But this is an example of faulty reasoning. Appeals to authority or a roll call or a majority vote of intellectuals or prominent people is not the appropriate way of deciding scientific truth. There is an old Chinese proverb that even if thousands of people say a foolish thing, it still remains foolish.

The “test of time” argument is also not valid or else we would also have to consider astrology and dowsing to have been proved by their longevity. Longevity also is a poor substitute for good scientific research.

The second claim is that “chiropractic works.” It has been commonly accepted that when left untreated 48% of LBP patients are better within one week, 75 to 85% of sufferers report recovery from LBP within one month and are able to return to work. And 92% recover within two months.

Chiropractic treatment often does provide immediate relief, but this could be temporary or illusory (not due to the treatment itself) and there is conflicting evidence of long-lasting relief.

So when we are told that chiropractic “works” we might often be dealing with a lack of understanding of the placebo effect (that suggestion or even no treatment at all are equally effective) and as Oliver Wendel Holmes (1842) argued:

“90% of those patients seen by a physician in daily practice would recover, sooner or later, with more or less difficulty, providing nothing is done to interfere seriously with the efforts of nature.”18

Whatever one thinks about chiropractic, we must agree that it has achieved great success as an industry. It is licensed in every state and is covered by many health insurance plans.

To what does chiropractic owe its success? First, chiropractic has been described as the “greatest tribute to applied public relations that the world has ever known.” Many chiropractors advertise widely in newspapers and other media and also make extensive use of “practice building seminars” where they learn how to attract patients and how to keep them coming back long after the original pain is gone.

In fact, many of the brochures distributed to patients make claims for chiropractic that are not currently justified by available scientific evidence.19

Second, the chiropractic profession has been claiming persecution by the scientists, physicians and an intellectual elite throughout its 100-year existence. The American public is well known for its sympathies for an underdog or the persecuted, regardless of the reasons for the rejection.

In addition, it has been suggested that precisely because of the AMA opposition, the chiropractic profession temporarily put aside its internal divisiveness to unite against an external hostile force.20

Third, chiropractic shares with other alternative approaches a dissatisfaction with and/or distrust of physicians who may prescribe expensive drugs or painful surgery. Often physicians either find nothing wrong with the patient or else tell them that time alone will cure the ailment.

The first (psychosomatic) suggestion may offend the patient and the second may frustrate the patient who wants a fast, easy “fix.” In contrast, the chiropractor may take more time to talk to the patient and readily agrees that the patient indeed has a problem--a serious problem.

It has even been suggested that it is quite appropriate to ensure patient satisfaction by providing simplistic (and often erroneous) explanations for the patient’s suffering.21 The positive and confident demeanor (of the chiropractor) has been found to result in greater patient satisfaction than the cautious, non-positive demeanor (of the physician).21

The chiropractor impresses upon the patient that he will help by direct, drugless, and essentially pain-free intervention to quickly alleviate the pain. This is followed by a physical ritual of a “laying on of hands.” The healing/therapeutic power of touch is well documented in both scientific research and in the Christian tradition.22

And finally, many chiropractors offer a simplistic explanation about health similar to other “holistic” approaches and reinforce a distrust of conventional medicine and science. Actually it is ironic that chiropractors claim to be holistic when, in reality, many are narrowly fixated upon the spine.

In summary, chiropractors have become excellent salesmen, psychologists and therapists. They have learned to appeal to the fears of the patients and how to offer comfort and relieve anxieties.

This success has been achieved although there is no solid scientific evidence for subluxations. In spite of, or unfortunately, perhaps because of, the use of pseudoscientific techniques such as applied kinesiology, homeopathy and others, and in spite of a vitalistic, occult philosophical tradition, chiropractic is now celebrating 100 years of success.

Distinguishing Good Chiropractic From The Bad

What is very sad is that there are many good, honest, dedicated and scientific chiropractors. These people reject all of the pseudoscience and they shun the unethical and deceptive practices of many chiropractors.

What is needed then, is some way to distinguish these scientifically-oriented practitioners from the poor chiropractors. In fact, suggestions have recently been offered to physicians who may be considering referring patients for chiropractic care.23

But perhaps the best guidelines are negative ones. That is, one should avoid chiropractors who engage in suspicious practices. Warning Signs

As one critic said, much of chiropractic is “the only legally recognized and licensed superstition in the United States today.”24

1. International Chiropractic Association. Policy Handbook & Code of Ethics. “Immunization and vaccination.” 1993; p. 28. Arlington, VA.

2.Colley F & Haas M. Attitudes on immunization: a survey of American chiropractors. J Manip Physiol Ther. 1994; 17 (9): 584-590.

3. Cashley MAP. Attitudes on immunization: a survey of American chiropractors (letter). J Manip Physiol Ther. 1995; 18 (6):420-421.

4. Colley F & Haas M. Reply to Cashley. J Manip Physiol Ther. 1995; 18 (6): 421.

5. Demetrious J. Attitudes on immunization: a survey of American chiropractors (letter). J Manip Physiol Ther. 1996; 19 (4): 280-281.

6. Colley F & Haas M. Reply to Demetrious. J Manip Physiol Ther. 1996; 19 (4): 281-282.

7. Busse JA, Kulkarni AV, Campbell JB & Injeyan HS. Attitudes toward vaccination: a survey ofCanadian chiropractic students. Canadian Medical Journal, 2002; (June) 166 (2): 1531-1534.

8. Jarvis W. Chiropractic: a skeptical view. Skep Inquirer. 1987; 12: 47-55.

9.Christensen MG & Morgan D. Job analysis of chiropractic, summary of the practice of chiropractic within the United States. 1993. Greeley, CO: National Board of Chiropractic Examiners.

10.Newman CF, Downes NJ, Tseng RY, McProud LM & Newman LK. Nutrition-related backgrounds and counseling practices of doctors of chiropractic. J Amer Dietetic Assoc. 1989; 89: 939-943.

11.Barrett S. Chiropractors and nutrition: the supplement underground. Nutr Forum. 1992; 9 (July/August): 25-28.

12. Peet P & Peet J. Chiropractic Pediatric & Prenatal Reference Manual. 1992; South Burlington, VT: Baby Adjustors, Inc.

13.Gemmell HA & Jacobson BH. Practice methods and procedures of chiropractic doctors in Oklahoma. Oklahoma Chiropr J. 1989; (Spring): 6-7.

14.Klinoski B & LeBoeuf C. A review of the research papers published by the International College of Applied Kinesiology from 1981-1987. J Manip Physiol Ther. 1990; 13: 190-194.

15.Hultgren GM & Jeffers JS. Shamanism, a religious paradigm: its intrusion into the practice of chiropractic. J Manip Physiol Ther. 1994; 17 (6): 404-410.

16.Hawk E, Byrd L, Jansen RD & Long CR. Use of complementary healthcare practices among chiropractors in the United States: a survey. Altern Ther. 1999; 5 (1): 56-62.

17.Wilk CA. Chiropractic Speaks Out. 1976; Park Ridge, IL: Wilk Publ Co.

18.Holmes OW. (1842) Homoeopathy and its kindred delusions. In Stalker D & Glymour C. (Eds.) Examining Holistic Medicine. 1985; Buffalo NY: Prometheus Press.

19. Grod, JP, Sikorski, D & Keating JC. Unsubstantiated claims in patient brochures from large state, provincial and national chiropractic associations and research agencies. JMPT, 2001; 24 (5): 4-9.

20.Kaptchuk TJ & Eisenberg DM Chiropractic: origins, controversies and contributions. Arch Intern Med. 1998;159 (Nov 9): 2215-2224.

21.Thomas KB. General practice consultations: is there any point in being positive? BMJ. 1987; 294: 1200-1202.

22.Firman GL & Goldstein MS. The future of chiropractic: a psychosocial view. NEJM. 1975; 293: 639-642.

23.Homola S. Finding a good chiropractor. Arch Fam Med. 1998; 7 (Jan/Feb): 20-23.

24.Weil A. Chapter 11. Some medical heresies: osteopathy, chiropractic, naturopathy. In: Healing and Health. 1983; Boston: Houghton Mifflin. 123-142.

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