The Philosophy of Chiropractic

Excerpted from The Future of Chiropractic Revisited: 2005 to 2015
© Institute for the Alternative Futures
January 2005.

Chiropractors vary widely in how they practice and can be generally viewed on a spectrum from conservative chiropractors who believe in continuing the traditions of chiropractic to liberal chiropractors who are more interested in mixing elements of modern and alternative therapies into the practice of chiropractic. This divide remains one of the major components of the chiropractic field yet it is a mystery to those outside the field.

This divide is embodied in chiropractic professional associations. At the most conservative end of the spectrum are chiropractors affiliated with the Federation of Straight Chiropractors and Organizations (FSCO) that believe in a narrow scope of practice based exclusively on the correction of vertebral subluxation. At the most liberal end of the spectrum are the chiropractors of the American Academy of Chiropractic Physiciana (AACP). They believe in broad scope, outcomes based, primary care chiropractic medicine, which utilizes a wide variety of treatment measures, including but not limited to, spinal manipulation.

There is greater variation among chiropractic ideas and purposes than can be captured on a simple linear diagram. Often the labels “straight” and “mixer” are used to distinguish between different types of chiropractors [49]. Historically, “straights” were followers of the Palmer’s vision of vitalism and traditional hands only adjustment of the spine while “mixers” sought to incorporate chiropractic as an independent technique into other treatment therapies. This simple dichotomy has become less useful over time. It has been suggested that there may be as many as 864 possible versions of “straight chiropractic.” [50] Self designated “straights” do seem to vary in terms of epistemologies, adherence to vitalism, rejection of the traditional disease model of illness, and methods of intervention [51]. A common denominator of “straight” chiropractic is the usage of subluxation [52].

At the risk of oversimplification, chiropractors can be viewed as falling into three groups based on their usage of evidence, diagnosis, and philosophy: evidence based chiropractors, traditional straight chiropractors, and super straight chiropractors. Evidence based chiropractors make use of the best available scientific literature and accumulated clinical knowledge to establish diagnosis, refer or co-manage when necessary, devise and revise treatment plans [53]. The evidence based chiropractor would most closely align with the AACP [54]. A traditional straight chiropractor, the largest and most varied group, views subluxation as an important component of most disease and believes the correction of subluxation restores and maintains health [55], but is sufficiently trained in diagnosis to recognize when referral or comanagement is needed. The traditional straight would most likely align with either of the more middle of the road national organizations, the American Chiropractic Association (ACA) or the International Chiropractors Association (ICA). The super straight chiropractor is focused completely on subluxation. They believe chiropractic is non-therapeutic and that it is not appropriate to refer to other health care providers since the chiropractor makes no diagnosis [56].

To gauge how the educations of different chiropractic colleges fall in this philosophical range, IAF did an informal survey asking each of the college presidents, vice-presidents, and deans that we interviewed to place both their college and the other colleges on a horizontal axis with some of the different chiropractic associations as representative of the different philosophical underpinnings of the profession [57]. The responses of the representatives, shown in Figure 1-2, include the judgment on the philosophical underpinnings of both their college and the other colleges listed. The placement of the letter represents the average position of the response for that school and the dotted line represents the range of responses. In parenthesis in Figure 1-2 are the number of graduates in 2002 from each college.

As shown in Figure 1-2, there are more chiropractic colleges that fall to the liberal end of the trend line. However, these colleges produce fewer graduates than the colleges on the more conservative end of the trend line. Colleges falling on the conservative end of the trend line had 2,056 graduates in 2002 while colleges falling on the liberal end of the trend line had 1,228 graduates. Even assuming the addition of 35 new graduates from Florida State University in 2010 and an increase of up to 100 new graduates in succeeding years, there will be more graduates from conservative chiropractic colleges.

Among practicing chiropractors, however, there may be a larger middle ground. A survey of 687 chiropractors, published in 1993, indicates that the profession is more unified on scope of practice issues than is apparent from outside observation. A survey, published by the Institute for Social Research at Ohio Northern University, show most chiropractors practice in similar ways: 98% of chiropractors recommend exercise to their patients; 94% offer wellness care; 93% make differential diagnosis; 93% offer ergonomic recommendations; 88% provide general nutritional advice; 86% give recommendations on stress-reduction; and 77% teach a relationship between spinal subluxations and internal health [59].

In the same survey 88.6% opposed giving chiropractors broad based prescription rights for all medicines. Only a minority felt that minor surgery (23.5%) was “appropriate for the chiropractic profession’s scope of practice”. Interestingly, only a slight majority (51.2%) opposed writing prescriptions for musculoskeletal medicines [60].

This is just a brief overview of the variety of philosophies and of historical differences within the chiropractic profession. To truly capture the diversity of the profession would require a much deeper analysis. Suffice to say, the diversity of chiropractic has made pursuing a common vision for the profession and integrating into the healthcare system difficult. Evidence based chiropractors have many of the skills and philosophical grounding that makes integration into the medical system easier. More liberal traditional straight chiropractors can integrate into the medical system if they are inclined to do so. However, the terminology of subluxation and the subluxation complex is often off-putting to medical practitioners and policymakers, partly due to a lack of scientific evidence and partly due to its philosophical foundations. The unwillingness of super straight chiropractors, a minority of the profession, to perform a diagnosis and co-manage patients is a significant stumbling block to those within the profession who desire closer integration with the medical community.

Footnotes

  1. The straight/mixer disunity within the profession, for all of it significance, is not something that most consumers either perceive or understand. In this context, one of the experts we interviewed told us a story about a fellow chiropractor. At a dinner party a woman who was a chiropractic patient asked the only chiropractor at the party whether he was a straight or a mixer. The other guests were not sure whether the woman was asking about the doctor’s sexual preference or the way he preferred his whiskey.
  2. Keating JC (1992, Mar/Apr) Shades of straight: diversity among the purists. Journal of Manipulative and Physiological Therapeutics, 15(3): 203-9.
  3. Keating JC (1993, Dec.) Scientific epistemology and the status of chiropractic: we are what we do. European Journal of Chiropractic, 41(3): 81-8.
  4. “A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.” Association of Chiropractic Colleges (ACC), Chiropractic Paradigm. Retrieved online 1/22/2004 at http://www.chirocolleges.org/paradigm_scopet.html
  5. Depending on their training and the scope of practice in the state they practice in.
  6. Another subgroup represented by the National Association for Chiropractic Medicine (NACM) takes more narrow view. Whereas the AACP believes in a wide variety of treatment measures, the NACM restricts members to NMS conditions and manipulation by hand only.
  7. A traditional straight chiropractor may or may not use ancillary methods depending on their philosophy, training, and scope of practice.
  8. Keating, Joseph C. (2004) Scopes of Purpose, Scopes of Practice: Distinguishing Among Evidence-Based Practice, Traditional Straight Chiropractic, and “Super-Straight” Ideologies. A Presentation to the Canadian Memorial Chiropractic College February 2004.
  9. IAF would like to acknowledge the source for this survey, Dr. Carl Cleveland III’s presentation, “Chiropractic Identity, From the Profession’s Perspective”, a presentation to The World Federation of Chiropractic Identity Conference, February 2004. In IAF’s interview with Dr. Cleveland we asked him place the schools on the spectrum. He had hoped to survey his colleagues at the Identity Conference, but time did not allow it. He suggested that IAF do the survey as part of this report, hence its use here.
  10. National Center for Education Statistics, op. cit.Some interviewees felt the McDonald survey was biased toward the “conservative” or “straight” side of the spectrum due to the wording of the questions. It should be noted that the survey was not published in a peer reviewed journal. (2003, June 2) New Study Finds Unity in Chiropractic. Dynamic Chiropractic. Volume 21, Issue 12. Retrieved online 8/24/2004: http://www.chiroweb.com/archives/21/12/19.html. 60 (2003, June 2) New Study Finds Unity in Chiropractic. Dynamic Chiropractic. Volume 21, Issue 12. Retrieved online 8/24/2004: http://www.chiroweb.com/archives/21/12/19.html.

This article was posted on Match 21, 2005.