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Chiropractors claim their profession was founded in 1895 when Daniel David Palmer restored the hearing of a deaf janitor by "adjusting" a bump on his spine. Soon afterward, he concluded that misaligned bones ("subluxations") interfered with the body's expression of "Innate Intelligence" -- the "Soul, Spirit, or Spark of Life" that controlled the healing process.
Although philosophy and treatment vary greatly from one practitioner to another, most of today's 60,000-or-so chiropractors can be classified as "straights" or "mixers." Straights tend to cling to Palmer's doctrine that most diseases are caused by misaligned spinal bones ("subluxations") correctable by spinal adjustment. Some straights, however, maintain that they neither diagnose nor treat diseases, but confine themselves to detecting and correcting vertebral subluxations. Mixers acknowledge that factors such as germs and hormones play a role in disease, but they tend to regard mechanical disturbances of the nervous system as the underlying cause of lowered resistance to disease. Louis Sportelli, D.C., who later became chairman of the American Chiropractic Association's board of governors, expressed this concept in a pamphlet called "What Kinds of Conditions Do Chiropractors Treat?" which he distributed in the 1980s. The pamphlet stated:
The doctor of chiropractic directs his attention to the spine, searching for an area which is deviant from normal. The deviation or malpositioning of a spinal vertebra may cause a neurological imbalance within the body, setting the stage for lowered resistance, and subsequently a disease process. . . .
Chiropractic is based on the premise that every gland, organ and cell of the body needs a nerve supply to function properly. Therefore it would seem logical that malfunctions in these areas would also respond to chiropractic adjustments.
It is with this basic thought in mind that the answer to, "What can you treat, doctor?" could be as varied and vast as the nervous system itself.
In addition to spinal manipulation, mixers may prescribe nutrient concoctions, homeopathic products, and various types of physiotherapy (heat, cold, traction, exercise, massage, and ultrasound). Straights tend to disparage medical diagnosis, claiming that examination of the spine is the proper way for chiropractors to analyze their patients. Mixers are more likely to diagnose medical conditions in addition to spinal abnormalities, and to refer patients to medical practitioners for treatment. Some practitioners claim that chiropractic treatment is effective against nearly the entire range of human ailments. A small percentage of chiropractors reject Palmer's dogma and treat only musculoskeletal problems. I do not believe that spinal manipulation is effective against other problems.
During the past few years, two reports about the treatment of low-back pain have placed chiropractic in a favorable light. One, issued by the RAND Corporation, concluded that spinal manipulation was appropriate for some cases of low-back pain. The other, produced by the Agency for Health Care Policy and Research (AHCPR), judged manipulation useful for controlling symptoms while awaiting the spontaneous recovery that occurs within a month in most patients with low-back problems.
Although chiropractors have promoted these reports as endorsements of chiropractic, they are not. They merely support the use of manipulation in carefully selected patients. Only a few of the research studies on which their conclusions were based involved manipulation by chiropractors; most were done by medical doctors and physical therapists whose practices are not identical to those of chiropractors. Most chiropractors manipulate the vast majority of patients who walk through their door, some use techniques that have not been studied scientifically, and many urge all of their patients to undergo monthly or even weekly "preventive maintenance" visits throughout their life. In addition, many chiropractors emphasize a technique that is more vigorous (and therefore less safe) than the controlled manipulation used by other practitioners. The only places where "chiropractic" and "chiropractors" are mentioned in the body of the AHCPR report are in the passages about the make-up of the AHCPR expert panel.
X-rays and Medicare
Most chiropractors claim that x-rays help them locate the "subluxations" that D.D. Palmer envisioned. But they do not agree among themselves about what subluxations are. Some chiropractors believe they are displaced bones that can be seen on x-rays and can be put back in place by spinal adjustments. Others define subluxations vaguely or say they do not necessarily show on x-rays. But what chiropractors contend about x-rays also depends upon who asks and how the question is posed.
Chiropractic coverage under Medicare, which began in 1973, was limited to manual manipulation of the spine for the treatment of "subluxations demonstrated by x-rays to exist." To enable payment, federal officials accepted an elaborate chiropractic "definition" of subluxations for which payment could be made. During the mid-1980s, the U.S. Department of Health and Human Services' Office of the Inspector General (OIG) surveyed 145 chiropractors by telephone about their billing practices. Eighty-four percent said that some subluxations do not show on x-rays. Nearly half responded that when billing Medicare, they "could always find something" (by x-ray or physical examination) to justify the diagnosis, or they actually tailored the diagnosis to obtain reimbursement. The OIG's report noted that chiropractic manipulation was the ninth most frequently billed procedure under Medicare during 1983.
In 1997, after many years of intense lobbying, chiropractors persuaded Congress to remove the mandatory x-ray provision. The Balanced Budget Act of 1997 eliminates the requirement as of January 1, 2000, and requires the Secretary of Health and Human Services to develop and implement utilization guidelines for chiropractic coverage when a subluxation has not been demonstrated by X-ray. The new policy is expected to increase the number of claims Medicare pays for chiropractic services.
Managed-care plans provide unlimited access to one's primary physician, but specialized care must be authorized by that physician -- usually a family practitioner. Chiropractors are worried that if they cannot be accessed directly, their income will suffer. Moreover, in communities where managed care predominates, nonparticipating chiropractors could lose their ability to earn a living. Chiropractic leaders are attempting to deal with this threat by claiming that chiropractors are primary-care providers to whom patients should be given access without referral.
In line with this viewpoint, most chiropractors claim they can diagnose conditions within their scope and refer the rest to appropriate providers. However, clinical training in chiropractic schools is vastly inferior to that in medical schools. Whereas medical school faculties are large and contain experts in virtually every aspect of medical practice, chiropractic schools have little or no input from medical experts. Whereas medical students see patients encompassing the full range of disease, most patients seen by chiropractic students have musculoskeletal problems. Although some of their courses are based on standard medical textbooks, chiropractic students lack the clinical experience necessary to make the information meaningful. Chiropractic schooling in such subjects as pediatrics, obstetrics, and gynecology is usually limited to classroom instruction with little or no actual patient contact and no experience with hospitalized patients. One school, for example, has used only rubber models to teach students how to perform pelvic and rectal examinations! The thousand-member Federation of Straight Chiropractors and Organizations (FSCO) asserts that chiropractic practice should be limited to the analysis and correction of "subluxations." FSCO asserts that chiropractors are neither licensed nor trained to diagnose medical problems or make medical referrals. Large percentages of chiropractors do not believe that immunizations are effective and do not recommend them to their patients [1,2].
For these reasons and more, the claim that chiropractors are generally qualified to be "primary-care providers" is absurd.
In 1992, researchers at the Stanford Stroke Center asked 486 California members of the American Academy of Neurology how many patients they had seen during the previous two years who had suffered a stroke within 24 hours of neck manipulation by a chiropractor. The survey was sponsored by the American Heart Association. One hundred seventy-seven neurologists reported treating 55 such patients, all of whom were between the ages of 21 and 60. One patient had died, and 48 were left with permanent neurologic deficits such as slurred speech, inability to arrange words properly, and vertigo. The usual cause of the strokes was thought to be tearing of the vertebral artery walls . A recent review of 116 articles published between 1925 and 1997 found 177 cases of neck injury associated with neck manipulation, at least 60% of which was done by chiropractors .
One patient proven to have been killed by neck manipulation was Kristi A. Bedenbaugh, a medical office administrator and former beauty queen from Little Mountain, South Carolina. In 1993, Kristi consulted a chiropractor seeking relief from the pain of sinus headaches. During her second visit, she suffered a stroke immediately after the chiropractor manipulated her neck. She died three days later, one day before her 25th birthday. The autopsy revealed that the manipulation had split the inside walls of both of her vertebral arteries, causing the walls to balloon and block the blood supply to the lower part of her brain. Additional studies concluded that blood clots had formed on the days the manipulation took place. In 1997, the State Board of Chiropractic Examiners of South Carolina issued a consent order in which the chiropractor agreed to pay a $1,000 fine and to acquire 12 hours of continuing education credits in the areas of neurological disorders and emergency response.
How common are strokes following neck manipulation? Nobody knows. No clinical research has addressed this problem, and chiropractic malpractice insurance companies have refused to make their data public . Most speculations run from 1 in 400,000 to 1 in 3,000,000. But when manipulations are done without valid reason -- as they often are -- no complication is excusable.
For Additional Information
To what extent can chiropractors help people? Does it ever make sense to seek chiropractic care? If so, how can a reliable chiropractor be found? These questions -- which are not simple to answer -- are thoroughly discussed in Chiropractic: The Victim's Perspective (1995), written by George J. Magner, III, and Inside Chiropractic: A Patient's Guide (1999), by Samuel Homola, D.C. Both were edited by me and published by Prometheus Books. Together they provide the most detailed analysis of the chiropractic marketplace ever published. Comprehensive information is also available on Chirobase, our skeptical guide to chiropractic history, theories, and current practices.