Contents

Introduction

NCAHF's recommendations in this paper are based upon extensive study of materials from within chiropractic itself, inquiries and investigations by government and consumer agencies, criticisms by scientists and medical practitioners, insights provided by chiropractors who share NCAHF's principles, and the Council's own investigations. NCAHF believes that the chiropractic controversy is best understood when manipulative therapy, chiropractic's unique theory, and the practices of chiropractors are considered separately.

Manipulative Therapy

There is substantial evidence that manipulative therapy has value in treating back pain. Although it may not be any more effective than other modalities in the long term, manipulation may offer short term benefits when compared to other commonly used modalities. Several studies have found that about one-third of patients will experience more rapid relief with manipulation than with other modalities.(2-4) Manipulation is probably not utilized as fully as it might be in relieving the symptoms of some chronic disorders.  It has been reported to be beneficial in controlling migraine pain.(5) Because manipulation involves the laying on of hands, a procedure employed throughout history by folk and faith healers, it enhances suggestibility and the placebo effect.(6,7) Occasionally, manipulation produces dramatic results. An example involves immediate recovery from paraplegia caused by an auto accident.(8) Manipulative therapy is not without risk. Many cases of serious complications following manipulative therapy have been reported in the medical literature. (9-15)

Chiropractic Manipulation

A major criticism of chiropractors is that they over utilize manipulation, both in excessively treating conditions known to be responsive to manipulation and in applying it to conditions for which there is no known justification. According to anecdotal reports by chiropractors, and patients who may have turned to chiropractic when conventional medical treatment failed to provide relief, manipulation has sometimes produced beneficial results. Such positive outcomes appear to be unpredictable and unexplained. These reports are selective, emphasizing positive results, but are common enough to warrant further study.

Chiropractors have demonstrated some degree of clinical success in workmen's compensation studies.(16-18) Unfortunately, the failure to apply rigorous scientific methodology has prevented the identification of any special value chiropractic manipulation might have. This absence of scientific evidence is due largely to the confidence placed in the validity of chiropractic's basic premise.

Chiropractic's Unique Therapy

The term ''chiropractic'' literally means "done by hand."  The word was adopted by chiropractic's founder, Daniel D. Palmer, a layman with an intense personal interest in the metaphysical health philosophies of his day such as magnetic healing, phrenology, and spiritualism.  In 1895, Palmer claimed to have restored the hearing of a nearly deaf janitor by manipulating his spine.

Palmer believed that he had discovered the primary cause of disease and theorized that 95 percent of all disease was caused by spinal subluxation and the others by luxated bones elsewhere in the body.  Palmer was not employing the term "subluxation" in its medical sense, but with a new metaphysical meaning.  Palmer's "subluxations" supposedly interfered with the body's expression of the Universal Intelligence (God) which Palmer dubbed the Innate Intelligence (spark of life or spirit).(19)  Thus, D.D. Palmer invented chiropractic, named it, and established a guild of practitioners to further its development.  For this reason chiropractic fits the dictionary definition of a cult (i.e. a system for the cure of disease based upon dogma set forth by its promulgator) (Webster's New Seventh Collegiate Dictionary).

The Practices of Chiropractors

Super-Straights, Straights and Spinologists

Treating "Cause" Versus "Effect"

Mixers

Naturopathy is a form of "eclecticism" (i e, a school of thought professing to select from what is best from all systems of medicine) that borrows from a wide variety of healing philosophies, applying them by subjective experience. Naturopaths usually mix common sense (e.g., advice against smoking and drug abuse and the advocacy of exercise and cleanliness) with bizarre theories about health and disease.  Naturopaths employ a wide variety of questionable methods borrowed from folk medicine, pseudoscience and discarded medical practices.  One is iridology, based upon the notion that every disease, habit, etc. is reflected directly through the nervous system to the iris of the eye.(21)

Iridology, like reflexology, scleraglyphics, graphology and a host of other suspicious diagnostic techniques, utilizes methods common to a technique known as ''cold reading''.(22) Using a chart as a guide, the clinician fishes for past and present health problems.  The subject may be quizzed, "Have you had problems with your stomach, liver, back, etc.?"  If the patient acknowledges that he/she has, or ever has had, any kind of problem in the area in question, a 'hit' is claimed, and the "finding'' is exploited. If the chart indicates a problem that the subject does not acknowledge, it can be claimed that there is "a weakness and a tendency for disease in the area" (a finding which opens the door for "preventive" treatments to keep the alleged disease from occurring). Thus, the practitioner is never judged as wrong.  Such methods are characteristic of fortune-telling, not science.

Naturopathic treatments may include shining colored lights on the patient (i.e., chromotherapy) on the theory that red "...might be used in ailments of the blood . . orange is helpful in fevers...yellow rays aid stomach troubles", and so forth.  Patients might be sold "glandular" products on the theory that pills made from eyes will help the eyes, pancreatic substances the pancreas, liver extracts the liver, and so forth.  Naturopaths prescribe megavitamins and herbs, either of which may function as drugs, belying the claim that their therapies are "drugless" or benign. Naturopaths tend to emphasize colonics based upon the discredited nineteenth century "intestinal toxicity" theory. The different kinds of treatments employed by naturopaths and mixer chiropractors are not necessarily any more "natural'' than those used by medical practitioners, but are simply non-scientific in nature or application.

Antiscience Attitudes

In addition, chiropractors generally oppose public health programs such as fluoridation, immunization, and sometimes pasteurization of milk.  Those who engage in nutrition counseling commonly attack modern food technology and promote unscientific ideas.  It seems curious that although chiropractic students use many standard medical textbooks, what they learn deviates significantly from others schooled in the health sciences.  The source of these problems appears to be faulty schooling where chiropractic philosophy and pseudoscience are mixed with training in manipulative therapy.

Hazardous Practices

The practice of greatest concern is the rotary neck movement (sometimes called "Vaster cervical'' or "rotary break"). This type of manipulation has led to trauma (25-27), paralysis (28,29), strokes (30,31), and death (32-33) among patents.  Even chiropractic's legal advisors have warned against its use.(34)

The overuse of x-ray by chiropractors poses potential patient harm.  Of primary concern is the 24' x 36' full spine x-ray. This technique exposes patients to a substantial amount of radiation. (35,38)  Exposing the body trunk to x-rays can have serious long-range consequences (36-37) and should be avoided.   Further, according to NCAHF's chiropractic advisors, such radiographs have little or no diagnostic value.

Hucksterism

First, is the practice of leading people to believe that vague symptoms common to everyday life are warning signs of serious disease in need of chiropractic care.   Second, is the tactic of selling patients on a belief that weekly or monthly "preventive" chiropractic care is needed to insure health.  Third, is the rehearsal of explanations to recite to patients who have become discouraged in order to keep them returning despite the apparent absence of benefit.

The message, which is clear to NCAHF from its review of such abuses, is the critical importance of patient trust and practitioner trustworthiness in health care.   Chiropractors pay strong lip service to freedom of choice in the health marketplace. However, after reviewing many of the techniques taught by the success promoters in chiropractic, such "freedom" could easily be construed to mean a license for unethical practitioners to use their superior position in the doctor/patient relationship for exploitation.  Patients who are deceived or desperate because of sickness, fear or pain are not choosing freely.

State Licensure, Regulation, and Recognition

Representatives on chiropractic examining boards enjoy state authority to endorse nonscientific practices among chiropractors. NCAHF agrees with the 1967 Report of The Health Manpower Commission which called for a reexamination of the basic assumption that the censure of chiropractors facilitates regulation (40), and the assessment by Consumer's Union that "current licensing laws, in our opinion, lend a aura of legitimacy to unscientific practices and serve to protect the chiropractor rather than the public." (41)

Legislators who review chiropractic practice acts are sometimes confused by the warring factions within chiropractic.  Straights wish to have chiropractic practice limited to the manipulation of the spine for the purpose of removing "subluxations."  Mixers favor expanding practice acts to permit them to engage in a broad scope of practice. Mixers outnumber straights by about four-to-one enabling them to exert more pressure on legislators.  Consumers will benefit if scope-of-practice laws are designed in terms of proven safety and effectiveness and not the views of special interest groups.

Malpractice insurers have some power to encourage and enforce rational practices by chiropractors.  These companies may deny insurance coverage to or withhold payment from non-scientific practitioners.  In doing so they will simultaneously protect the public health and their purse.

The Reformers

One small faction of reformist chiropractors is conducting and publishing meaningful research in the field of manipulative therapy.  This group is not openly critical of chiropractic's shortcomings and has not agitated for outright repudiation of the "subluxation" theory.  They apparently seek to change chiropractic by evolution, bypassing the theory by ignoring it or applying the term "subluxation" to a number of spinal aberrations in a general manner.  It is NCAHF's view that these chiropractors are too greatly outnumbered and overshadowed by practitioners profiting from pseudoscience to effectively change chiropractic in this manner.

A more progressive-minded group has formed the National Association for Chiropractic Medicine (NACM), a professional association with views which are in harmony with science and consumer protection.  Using guidelines set forth by the NCAHF Task Force on Chiropractic, NACM has openly renounced the "subluxation" theory and unscientific practices.  Members limit their scope of practice to neuro musculo-skeletal conditions, and its modes of treatment to those which have scientific validity. NACM does not present itself as an alternative health care system to medical science.

NCAHF'S Description of a Scientific Chiropractor

A scientific chiropractor will:

1. Advance only methods of diagnosis and treatment which have a scientific basis.
2. Openly disclaim the nonscientific 'subluxation theory'.
3. Restrict the scope of practice to neuromusculoskeletal problems loosely defined as Type M conditions (i.e. muscle spasms, strains, sprains, fatigue, imbalance of strength and flexibility, stretched or irritated nerve tissue, and so forth) recognizing that some Type M problems will fall outside the scope of even a scientific chiropractor.
4. Work closely with medical practitioners, consulting with them on cases involving possible pathology and readily referring when reasonable and prudent.
5. Use conservative methods of manipulative therapy.
6. Avoid exposing patients to unnecessary radiation.
7. Work to increase public awareness about abuses by non-scientific chiropractors.
8. Help other chiropractors become more scientific in their approaches to health care delivery.
9. Work to prohibit unqualified practitioners of all kinds from performing manipulation.
10. Aid in the prosecution of alleged malpractice.

Scientific chiropractors will not:

1. Use the title "doctor" in such a way as to mislead someone to believe the practitioner is other than a chiropractor.
2. Induce anyone to behave that a chiropractor should be consulted first in preference to a medical practitioner in respect to any disease or disorder.
3. Induce anyone to believe that chiropractic adjustment will cure or alleviate infectious diseases, arthritis, cancer, diabetes, nutritional deficiencies or excesses, appendicitis, blood disorders, kidney diseases, gall bladder problems, hypertension, ulcers, heart disease or other non-Type M conditions.
4. Fail to take reasonable steps to advise a patient to consult or continue consulting a medical practitioner when engaged by someone requiring medical care.
5. Publish or publicly exhibit any circular extolling non-scientific chiropractic treatment or preventive care.
6. Condemn without scientific justification public health measures such as fluoridation, immunization, pasteurization of milk, etc.
7. Use their status as a health professional to sell or profit from the sale of products to patients.
8. Excessively treat patients.
9. Present themselves as specialists in pediatrics or claim the ability to treat children's diseases.
10. Claim that chiropractic adjustments will help raise resistance to disease or prolong life without valid evidence.
11. Claim to be a "(w)holistic" practitioner.
12. Claim to be qualified as a "family practitioner."
13. Practice obstetrics.
14. Claim to be qualified to administer mental health care.
15. Utilize unproven*, disproven, or questionable methods, devices, and products such as adjusting machines, applied kinesiology, chelation therapy, colonic irrigation, computerized nutrition deficiency tests, cranial osteopathy, cytotoxic food allergy testing, DMSO, gerovital, glandular therapy, hair analysis, herbal crystalization analyses, homeopathy, internal managements, iridology, laser beam acupuncture, laetrile, magnetic therapy, Moire contourographic analysis, Neurothermograph, orthomolecular therapy, pendulum divination, pyramid power, "Reams" test, reflexology, scleraglyphics, Spinal column stressology, Thermography Thermoscribe, Toffness device, and so forth.

*Except on an approved experimental basis in which patients are fully-informed about risk-benefits, protocols are monitored by an Independent Committee, and patients are not charged a fee for services or products.

Recommendations

To consumers:

1. As consumers you are largely at your own risk when choosing a practitioner of any kind because the law offers more protection to providers than consumers.  Therefore choose health-care practitioners carefully - particularly a chiropractor.
2. Distinguish between manipulative therapy per se and treatment based upon the specious chiropractic theory.  Be alert to the fact that, although manipulatlve therapy has distinct value in the treatment of back pain and may provide subjective relief on other chronic conditions, and chiropractors are educated and trained in manipulation, they represent but one source of this service.  If you do choose a chiropractor, ask him/her to work closely with your medical doctor.
3. Chiropractic theory is nonscientific, and most chiropractors have not been taught to practice on the basis of the same body of knowledge about health and disease recognized by health scientists around the world.
4. Understand that some chiropractic treatments involve considerable risk.   Manipulation involving the rapid rotation of the head and neck or sudden movements have greater potential for injury than more conservative types of therapy.  Do not submit to a "full spine" x-ray.  This practice has doubtful diagnostic value, and the radiation exposure may have long range dangers.
5. Be aware that many chiropractors engage in nonscientific practices which can result in unnecessary expense.  Also, nonscientific practitioners may delay the proper treatment of serious disorders causing excessive debility or needless death.
6. Beware of chiropractors who advertise about "danger signals that indicate the need for chiropractic care," make claims about cures, try to get patients to sign contracts for lengthy treatment, promote regular preventive "adjustments," use scare tactics, or disparage conventional health care.
7. Demand that your legislative representative introduce and/or support laws that provide greater consumer protection in health care.
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To Insurance Carriers and Third-party Payers:

1. Limit reimbursement to medically necessary services and to those practitioners who provide appropriate medical documentation that establishes the diagnosis and justifies treatment.
2. Establish an independent commission financed by an insurance industry levy to investigate and curtail fraud and abuse in health care.

To Legislators:

1. Recognize that legislatures have the greatest power to control chiropractic practices.   Regulatory agencies and the courts can only enforce the laws passed by legislative bodies.  Education alone cannot protect consumers or help people who do not realize that they are being deceived.
2. Restrict the scope of practice of chiropractors to neuromusculoskeletal problems.   Prohibit their treatment of other conditions unless under medical referral.   Specify the procedures that chiropractors may NOT perform, such as: Colonies. herbology, hair analysis, cancer therapies, or any unproven methods unless working on a bonafide experimental project in cooperation with qualified medical researchers.
3. Restrict the use of x-ray by chiropractors--particularly prohibit techniques that involve unnecessary radiation exposure to patients such as the "full spine" x-ray.
4. Prohibit chiropractors from using the title 'doctor' in any manner that doesn't clearly reveal that they are chiropractors.
5. Incorporate chiropractic training into the same university systems which teach medical, dental, and other allied health professionals so that instruction in basic sciences and training in diagnosis and patient screening will be brought up to the same standards as other primary entry health care providers.  Designate the chiropractic degrees issued by these institutions "Doctor of Chiropractic Medicine" to distinguish them from previous diplomas.  Establish standards for people holding "Doctor of Chiropractic" diplomas to upgrade themselves to the standards of the new degree.   Set a time limit (e.g. ten years) in which this upgrading must occur to maintain licensure.
6. Permit Doctors of Chiropractic Medicine to utilize prescription drugs suitable to the limitations of their practices.
7. Regulate all health care providers through a single board of quality assurance constituted by a wide variety of members adept in the methods of scientific methodology and the bases for consumer protection legislation.  Include on the board representatives from the basic sciences, public health, education and legitimate consumer groups.  Restrict practitioners from the various health care delivery providers to service in a consultant status.
8. Make violation of the medical practice act a felony.

Basic Scientists

1. Recognize that the chiropractic controversy involves the basic sciences more than medicine per se.  These sciences are chiropractic's intellectual competitors in a manner similar to flat-earth believers versus astrological societies; however, chiropractic must be taken more seriously because it involves health care.
2. Take chiropractic seriously enough to become knowledgeable about its basis and conduct basic research to test the validity of its claims.
3. Use your influence to bring about reform in the health marketplace.

Academicians and Educators

1. Recognize that the academic community has an obligation to the communities at large to help resolve controversial issues which bear upon public health and well being.
2. Recognize that chiropractic promotes itself as an alternative to conventional scientifically-based health care, and that it is the largest and best organized nonscientific health care system in Western society.  Its impact upon public health is too great to ignore.
3. Become familiar with chiropractic's tenets and practices.  Teach about these to your students.
4. Be aware that chiropractic recruiters are working through career guidance counselors to attract students to the profession.  Inform students about the true nature of chiropractic so they can make wise choices.
5. Urge educators to work with reformist chiropractic organizations to incorporate chiropractic education into accredited universities.

To Attorneys and Law Enforcement Agencies:

1. Recognize that litigation offers an effective means to bring reform to chiropractic.   A number of scientifically oriented chiropractors now stand ready to offer assistance in malpractice lawsuits.  This helps to take away the usual defense of justifying a chiropractor's clinical inadequacies of diagnosis and treatment as standard practice.
2. Become familiar with the fallacies and common abuses of chiropractic.  Attorneys with insights in these areas can serve as specialists in the prosecution of chiropractic malpractice
3. Vigorously enforce current scope of practice laws.  Many of the current abuses by chiropractors are illegal.

To Medical Doctors, Dentists, and Other Scientific Health Care Providers:

1. Limit your professional association to chiropractors who reject the cultism and pseudoscience of chiropractic and meet the criteria for scientific practitioners as suggested by NCAHF.
2. Encourage professional associations to undertake studies of chiropractic within their regions and issue appropriate statements of their findings.
3. Actively lobby legislators to enact laws to curtail abuses by chiropractors and other health care deliverers.
4. Report chiropractors who exceed their legal scope of practice to law enforcement agencies.
5. Provide educational materials to patients about the nature of chiropractic.
6. Cooperate with efforts to control the quality of health care delivery such as the establishment of a single regulatory board with broad representation from basic science and legitimate consumer groups for all providers.

To Reformist Chiropractors:

1. Organize yourselves into a clearly identifiable group with a code of ethics, standards of practice, and scientific guidelines.
2. Publicly proclaim the shortcomings of cultist and pseudoscientific chiropractors.
3. Lobby for laws to reform chiropractic practice.
4. Be available to attorneys to enable injured patients to receive just recompense for abuses by irresponsible and nonscientific chiropractors, and to bring pressure by the courts to more clearly define malpractice.
5. Press for reform within established chiropractic organizations.
6. Encourage chiropractors who have remained silent about the abuses of public relations oriented chiropractic leadership while they practiced in a reasonable conservative manner to take a stand for reform.
7. Establish a liaison between your reformist groups and other professional health organizations to gain their support and cooperation.

References

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36. Smith, P and Doll, R., "Mortality among patients with ankylosing spondylitis after a single treatment course with x-rays", Brit Med J, 284:449-460, 1982
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43. Whorton, J., Crusaders for Fitness, NJ: Princeton University Press, 1982

Please retain the following notice on any copies made of this position paper:

For more information, write: NCAHF, P.O. Box 1276, Loma Linda, CA 92354-1276; Fax: 909-824-4838. Donations to NCAHF are tax deductible under IRS tax code 501 (c)(3).