A Message to Chiropractors:
Your Real Enemy Is Youself!
Stephen Barrett, M.D.
I have been investigating quackery for more than 40 years. My concept of quackery is broad yet simple: anything involving overclaim in the field of health. My attention is not confined to chiropractic but includes just about every kind of overclaim. For example, one book I edited was probably the most sophisticated discussion ever published about unnecessary surgery in women. And I have written extensively about how to tell if a psychotherapist is delivering improper care.
My chiropractic source materials include hundreds of books, thousands of journals, and tens of thousands of assorted publications, audiotapes, videotapes, advertisements, correspondence, and other documents. Many have come unsolicited from chiropractors who happen to think that what I'm doing is valuable. This article discusses some of chiropractic's shortcomings and steps that could be taken to correct them. It updates my 1988 presentation on this topic to the American Chiropractic Association's House of Delegates.
Your "philosophy" is a confused mess. I understand that many of you have abandoned D.D. Palmer's notion that misaligned spinal bones are the main cause of disease. But many chiropractic offices have charts, models of bones, and lighted displays that purport to illustrate how misalignments cause disease.
Do chiropractors treat "pinched nerves?" Do they release "nerve energy?" Is "choked off" nerve energy the source of disease? There isn't the slightest scientific basis for such beliefs. If you don't abandon them completely, along with the term "subluxation," you will be considered quacks and cultists by the scientific community whether they say so openly or not.
On the other hand, it is clear that chiropractors help people. I'm not quite sure how, and I'm not sure that you know either. But some of you are obviously doing something right. I am not sure who or what you should be treating. I'm not sure this is clear to you either—and it won't be clear to me until it's clear to you. I would suggest that you make an attempt to define your scope. That won't be simple to do, but as long as your scope is undefined, you are going to be criticized for exceeding it.
Then there is the issue of x-rays. I doubt that 14" x 36" full-spine films yield much useful information. The percentage of chiropractors utilizing such films for screening purposes is no longer high, but it is still too high.
Then there "preventative maintenance." Years ago, on a radio talk show, I had an interesting discussion with Arnold Cianciulli, D.C., a prominent New Jersey chiropractor who later became a board member of the Chiropractic Foundation for Education and Research. He and I seemed to agree on what would be improper for chiropractors to do, but we disagreed on what percentage were acting improperly. He thought there were just a few, while I thought there were many. During the program, five chiropractic patients called in to criticize me. Upon questioning, all five said they had been seeing their chiropractor once a week for ten years. I don't think people who feel well should come weekly or monthly for life to have their spine examined and "subluxations" adjusted. I don't know how many chiropractors recommend this, but it is clear that too many do so. Investigations have been conducted by people who went to several chiropractors and said they felt well but wanted a checkup. Almost all of the chiropractors recommended treatment, but there was little or no agreement about what needed treatment.
There are also abuses in the area of nutrition. The number of people who can benefit from high doses of vitamins is very limited. Moreover, I don't believe that any disease for which megavitamin therapy is actually appropriate falls within within the scope of chiropractic. Diseases of this type are seldom appropriate for general medical practitioners either, but are usually treated by medical specialists. Yet many chiropractors prescribe megavitamins to their patients.
I know that some chiropractors understand scientific nutrition principles and use them to advise patients properly. However, I also know there are chiropractors who are doing unscientific nutrition. At least a dozen companies market "dietary supplements" that contain little bits of animal glands, enzymes, vitamins and/or minerals. Some of these companies market hundreds of concoctions that don't have the slightest use for anybody. These concoctions are marketed through seminars and books that indicate how to "prescribe" them. I have several such books. One lists more than a hundred diseases and five or six supplements for each. It is illegal to market supplements for the treatment of disease without FDA approval. It is also unscientific and unethical. Companies marketing such supplements advertise repeatedly in chiropractic journals.
Surveys by the National Board of Chiropractic Examiners (NBCE) have repeatedly asked chiropractors whether "nutritional counseling, therapy, or supplements" was part of their practice. Large majorities have said it was. I don't know how many of these were prescribing supplements inappropriately, but I suspect it was nearly all of them.
Chiropractors seem to gravitate in a higher percentage than other professions into some very strange things. I happen not to believe in "applied kinesiology." I don't believe that each disease is accompanied by a weak muscle or that putting a potato on your chest or sugar under your tongue and then pulling on a patient's arm can yield any useful information. Yet it's being done. The NBCE surveys have also found that more than 30% of chiropractors said they practiced homeopathy. Homeopathic products are worthless.
There is also widespread confusion about spinal "adjustment." There seem to be about 100 systems of manipulative treatment. It's hard to imagine that they are all equally valid. If some are not, why haven't chiropractors abandoned them?
There is also the problem of inappropriate charges. I've seen bills totaling thousands of dollars per month for services. Some practice-builders and equipment sellers teach how to charge these fees. Practice-builders state that thousands of chiropractors attend their seminars and use their services. Manufacturers of worthless devices advertise through chiropractic publications and exhibit their wares at chiropractic conventions. Some chiropractors pay thousands of dollars to learn deceptive practice-building techniques.
Let me tell you how chiropractors are perceived by the insurance industry. Several years ago, I gave a talk to senior claims examiners representing more than a hundred companies. When I asked how many service chiropractic claims, 160 hands went up. But when I asked how many were not having trouble with chiropractic claims, not one hand was raised. As far as I can tell, nearly every insurance company that is handling chiropractic claims has a very low opinion of your profession. I would not suggest that you attribute that to outside enemies. The insurance companies simply represent themselves. They're not organized in any way. They look at the claims and they are horrified.
The way you are perceived by the medical profession is very difficult to document because nobody seems interested in taking a sophisticated survey. During the past twenty years there has been a modest increase in the number of referrals between medical doctors and chiropractors. Chiropractors regard this as "acceptance" by medical doctors. However, I can assure you that the average physician still views chiropractic very harshly.
As far as the general public is concerned, that's also a difficult thing to measure. There's a very strong body of negative feeling that you're not exposed to because the people who hold it simply don't go to you. On the other hand, you have some very staunch believers.
For the most part, you have no "natural enemies." Medical doctors might be considered potential natural enemies because they think your subluxation theory is absurd. And to the extent that this represents chiropractic to them, they don't like you. On the other hand, most medical doctors don't know what you're doing and probably don't care what you're doing. Although they are potential enemies, they have their hands full with their own political problems and are not interested in working against you politically.
Your Real Enemy
Your basic enemy is yourself: your colleagues engaged in unscientific practices, economic ripoffs, cheating insurance companies, opposing vaccination, selling unnecessary supplements, and generally overselling themselves. Most chiropractors would like to believe that the number of such colleagues is small. I think it is large and is probably a large majority.
Can "mainstream" chiropractic somehow cast off chiropractors who recommend weekly or monthly visits for life, who prescribe worthless and illegal nutrition supplements, who charge $500 or more for an initial visit, or who utilize applied kinesiology, contact reflex analysis, or other bizarre diagnostic practices? Who would be left?
Over the years, a number of chiropractors have approached me for help. Some, for example, said: "I want to practice scientifically. What can I do? How can I get on a hospital staff?" Some were having difficulty in gaining permission to attend lectures at hospitals in their community. In every case, I offered to use my influence to help them get permission to do so and advised that doing this might eventually provide an opportunity to demonstrate that what they did was useful enough to warrant staff privileges.
To establish credibility with the scientific community (which extends beyond the medical profession), you have to do meaningful research. There are also some other things that you ought to do that won't cost a penny. To begin with, endorse water fluoridation. Chiropractors have been in the forefront of political battles against fluoridation as well as against immunization. If you want scientific credibility, you had better reverse those processes and come out on the side of science. And do something about cigarettes, the nation's leading cause of premature deaths. Why haven't chiropractors and chiropractic groups been fighting to ban cigarette promotion, raise cigarette taxes, and ban smoking in public places?
I sincerely hope you can build on what is good about chiropractic and get rid of what isn't. I may not be chiropractic's best friend, but I am not its worst enemy. Your real enemy is yourself.
Comments about this article are welcome. The most interesting ones will be posted.This article was revised on January 22, 2009.