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).

Thursday, December 23, 2004

A chiropractic school at FSU: Unanswered questions

A chiropractic school at FSU: Unanswered questions

by Sam Homola, DC

I recently received this question: "Why would you suggest that it might be better to train physical therapists in the use of manipulation than to open a chiropractic school at FSU?"

My answer:

Chiropractic at Florida State University:

Unanswered Questions

The proposed plan to establish a school of chiropractic at Florida State University sounds promising in view of intentions to start from scratch and use a science-based approach, combining a chiropractic degree with a master's degree in an established health science such as nutrition or exercise. It's important to remember, however, that chiropractic is based upon an unsubstantiated, implausible theory which proposes that correction of "vertebral subluxations" will improve health. Although such subluxations have never been proven to exist, with no compelling evidence that a subluxation or any other joint dysfunction affects general health, a position paper issued by the Association of Chiropractic Colleges (ACC) in 1996 concluded that "Chiropractic is concerned with preservation and restoration of health and focuses particular attention on the subluxation." This ACC Paradigm was endorsed by the International Chiropractic Association and the American Chiropractic Association in November of 2000 and by the World Federation of Chiropractic in May of 2001.

If there is to be a university-based college of chiropractic, it would be essential to first examine the theory of chiropractic according to the rules of evidence and science. If the chiropractic subluxation theory is rejected by scientific consensus, training of chiropractors in the use of manipulation and physical treatment modalities at FSU would be similar to that of physical therapists. If chiropractors are to be trained as "neuromusculoskeletal specialists," it might be necessary to include training in use of prescription medication and certain invasive diagnostic procedures if the chiropractor is to function as an independent practitioner in a capacity beyond that of a physical therapist. Such chiropractors would work much like a physiatrist, with emphasis on use of manipulation and physical treatment methods. Either way, there would be duplication of existing medical services. Unchanged, chiropractic would continue to be a form of "alternative medicine," allowing chiropractors to use this approach in competing with medical practice as primary care physicians, using their university degree as a badge of approval in the use of unproven and implausible treatment methods. Obviously, treatment methods and scope of practice should be established before opening an FSU school of chiropractic, which would require a new and clear definition of chiropractic.

If chiropractic is not redefined, establishment of a chiropractic college as part of an accredited, science-based university may not be feasible. On the plus side, a science-based chiropractic college with a new approach and a new definition of chiropractic, associated with a major university, may force changes that will reduce the number of subluxation-based chiropractors, which would be a change for the better. But if this means duplication of services that could be provided by physical therapists and other health-care providers, is a new chiropractic college really necessary? Would an FSU chiropractic college duplicate the subluxation-based Palmer College of Chiropractic Florida in Port Orange, Florida, which teaches "The Big Idea of Chiropractic"? Or would it move diametrically away from the principles of Palmer, inviting confrontation in a divided camp?

There are some good chiropractors who do a good job treating some types of back pain, offering manipulative services not readily available in medical practice, but they work more like physical therapists than subluxation-based chiropractors who adjust or manipulate the spine to restore and maintain health. At the present time, state laws and chiropractic organizations define chiropractic as a method of correcting subluxations, not as a method of treating back pain. Although physical therapists manipulate or mobilize the spine as a treatment for back pain and not for correction of subluxations to remove nerve interference, chiropractic associations support efforts to prevent the use of spinal manipulation by a physical therapist. This has the effect of restricting appropriate use of spinal manipulation. Will FSU become mired in this squabble?

Physical therapists trained in the use of spinal manipulation, sans the subluxation theory, could fill the need for manipulative therapy without encroaching upon chiropractic dogma. At the present time, the use of manipulation/mobilization by physical therapists to relieve and prevent disability is more evidence based than the belief-driven adjustment/manipulation used by chiropractors to "restore and maintain health." Properly-limited chiropractors, who use manipulation appropriately, would welcome examination of the chiropractic theory by academia and by medical scientists. And I suspect that few science-based chiropractors would object to inclusion of spinal manipulation in the treatment methods of physical therapists, physiatrists, and other practitioners who use manual medicine. But chiropractors who cling to the subluxation theory to justify their existence as independent practitioners may resist any change in the definition of chiropractic, opposing use of spinal manipulation by anyone other than a chiropractor, even if it means perpetuating inappropriate use of such treatment. Such chiropractors point to studies indicating that spinal manipulation is effective in the treatment of some types of back pain in a misguided attempt to support adjustment of subluxations in the treatment of general health problems -mixing science and pseudoscience to sell false hope. University-trained, science-based chiropractors who practice a properly defined, limited form of chiropractic would have to split away from the majority of chiropractors who practice a traditional form of chiropractic, which often embraces such dubious practices as homeopathy and applied kinesiology.

The State of Florida defines practice of "chiropractic medicine" as "...a noncombative principle and practice consisting of the science of the adjustment, manipulation, and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that are interfering with the normal generation, transmission, and expression of nerve impulses between the brain, organs and tissue cells of the body, thereby causing disease, are adjusted, manipulated, or treated, thus restoring the normal flow of nerve impulse which produces normal function and consequent health by chiropractic physicians using specific chiropractic adjustment or manipulation techniques taught in chiropractic colleges accredited by the Council on Chiropractic Education. No person other than a licensed chiropractic physician may render chiropractic services, chiropractic adjustments, or chiropractic manipulations." (FL Statute ยง460.403)

This unscientific, implausible definition of "chiropractic medicine" defines chiropractic as practiced by chiropractors who manipulate the spine for reasons rejected by physical therapists and other science-based practitioners. In 1998, there were more than 4,000 chiropractors licensed under this definition in the State of Florida, fourth in the nation in the number of chiropractors per state. Can the FSU chiropractic college teach a different kind of chiropractic -a science-based chiropractic- without a change in state law? If chiropractic is redefined at FSU, would an unchanged state law permit science-based graduates of FSU to practice a different kind of chiropractic in Florida? How would a new state law affect the thousands of chiropractors now practicing in the State of Florida? Would FSU chiropractors work more like physical therapists? Or would their training include use of prescription medication to allow them to function as independent neuromusculoskeletal specialists? Any reasonable change in the definition of chiropractic, requiring departure from the vertebral subluxation theory, would encroach upon the established practice of physical therapy or physical medicine. It seems likely that many chiropractors will oppose any change in the definition of chiropractic, since the subluxation theory is the basis for licensing chiropractors in most states. But I do not see how the fundamental definition of chiropractic could be tolerated in a science-based university.

I fear that a chiropractic school at a major university like FSU will attract well-meaning, highly qualified students who know little or nothing about chiropractic, unaware of the stigma associated with chiropractic and unprepared to compete with fundamental chiropractors or to endure the criticisms of those who oppose them. Some may realize too late that they have made a bad career choice.

I struggled through 43 years of practice as a "good chiropractor," but I cannot, in good conscience, recommend that anyone follow in my footsteps. A Ph.D. program in physical therapy which includes training in spinal manipulation might make more sense for qualified individuals.

All parties concerned must determine if a chiropractic school at Florida State University is feasible or necessary, if graduates of such a school are needed to provide services based primarily upon use of spinal manipulation. How chiropractic is defined and taught at FSU, and the behavior of its chiropractic school graduates, may have a profound effect on public health, reflecting upon FSU's credibility as a science-based institution. A new and different kind of chiropractor trained at FSU, supported by science and by law, might need a new degree that will differentiate him or her from graduates of subluxation-based chiropractic colleges. For example, a Doctor of Chiropractic Therapy (D.C.T.) degree for a group-dependent therapist, or a Doctor of Chiropractic Medicine (D.C.M.) degree for an independent neuromusculoskeletal specialist, would indicate training different from that required for a standard Doctor of Chiropractic (D.C.) degree.

An opinion from

Samuel Homola, D.C.

Panama City, Florida