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This paper, which the Journal of the American Chiropractic Association published in 1990, was adapted from a talk I gave to the association's House of Delegates on June 23, 1988.
I have been investigating quackery for more than twenty 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 is probably the most sophisticated discussion ever published about unnecessary surgery in women. And I have probably written more than any other living American on the subject of how to tell if a psychotherapist is delivering improper care. I edited a book that deals with this subject and also wrote a chapter in a college textbook which can help people spot bad advice.
This article discusses some of chiropractic's shortcomings and steps that might be taken to correct them.
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 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 has been falling, but is still too high.
Then there is the question of "preventive maintenance." A few years ago I had an interesting discussion with Arnold Cianciulli, D.C., on a radio talk show. 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 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 spines examined and "subluxations" adjusted. I don't know how many chiropractors recommend this, but it is clear that too many do so. Three investigations have been conducted by people who went to 16 or more 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 [1-3].
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, in my opinion, 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 over 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. I don't know what percentage of chiropractors are involved, but I do know that the companies marketing the supplements advertise repeatedly in chiropractic journals.
During 1988 I sent a reporter to a seminar given by a distributor of one of these companies. In the case discussed at the seminar, the patient was asked to pay $5 a day for supplements that I believe were absolutely worthless. I don't know how how many chiropractors are "prescribing" such supplements; it would be an interesting thing to study.
A recent survey by Dynamic Chiropractic4 found that 74 percent of those responding use "nutrition supplements" in their practice. Chiropractors who sell them usually charge two or three times what they pay for them. Simple vitamin/mineral preparations are much cheaper at drugstores.
Some chiropractors are prescribing homeopathic remedies. I don't believe they work either.
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.
There is also widespread confusion about spinal "adjustment." There seem to be about 25 different 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 issue of insurance claims. I've seen bills for individual modalities that cost $500, $800 or even $1000 for the first visit. Most chiropractic officials are horrified by this, but the practice-builders keep on teaching how to charge these fees. Are they part of your profession or aren't they? They claim that thousands of chiropractors their seminars and use their services. Some chiropractors pay thousands and thousands of dollars to learn their lessons. Do they throw them away--or use them?
Let me tell you how chiropractors are perceived by the insurance industry. A few 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, 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. Some of them are willing to fight, but probably most of them are not.
The way you are perceived by the medical profession is very difficult to document because nobody seems interested in taking a sophisticated survey. I know your literature talks about "acceptance." In 1975, a survey by Medical Economics magazine suggested that there had been a small 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 when chiropractic is mentioned at medical meetings, most doctors snicker.
Some doctors have established relationships with chiropractors whom they like and whom they trust to some extent. But even these doctors can have view chiropractic as a whole very negatively. The antitrust suit has discouraged medical groups from speaking out publicly against chiropractors. But don't make the mistake of thinking that because the AMA no longer attacks you, that the average physician accepts you. 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. That was true even before the antitrust suit. The chiropractic antitrust suit was able to curtail antichiropractic activity by organized medicine, but I'm not sure that that was terribly effective anyway.
Your basic enemy is yourself: your colleagues engaged in unscientific practices, economic ripoffs, cheating insurance companies, 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 may even be a 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 or other bizarre diagnostic practices? Who would be left?
When the American Chiropractic Association's Council on Nutrition issued a position paper attacking cytotoxic testing , I telephoned its vice chairman and said: "Congratulations. Can I help you? Would you like to have a professor of nutrition become a consultant to your committee free of charge? I'll find one for you." I then recruited one, but he wasn't used. If the ACA Council on Nutrition ever becomes interested in input from the scientific community, I would be delighted to arrange for it.
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.
I have also tried to help the National Association for Chiropractic Medicine, the group that rejects D.D. Palmer's basic theory. I have assembled a prominent board of advisors for them and offered help in organizing seminars on diagnosis, nutrition and pharmacology for chiropractors.
On the other hand, I want you to know that I am very antagonistic toward what your supplement companies are doing, and I'm going to try and get them stopped. I am also very antagonistic to the idea that people should come once a month to get their spine checked for subluxations. I don't know if I can curb this practice, but I will continue to criticize it through the media.
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 aren't chiropractors and chiropractic groups fighting to ban cigarette advertising, raise cigarette taxes, and ban smoking in public places?
I began collecting information about chiropractors about 20 years ago. My collection contains at least 50 books, several thousand journals, and thousands of other assorted publications, correspondence and other documents. Many of them have come unsolicited from chiropractors who happen to think that what I'm doing is valuable. I have a comprehensive understanding of the seamy side of chiropractic. I would like to take a closer look at the rest of it, something that, as far as I know, no journalist has ever attempted to do.
About three years ago I did a study of this sort when I investigated homeopathy. I went to a number of meetings. I sat in the office of a practitioner for an entire day while he saw patients. I interacted with him and with the patients. I went through homeopathic diagnosis as a patient, with no subterfuge involved, at the invitation of a homeopathic leader. My writings were then sent to homeopathic leaders throughout the United States for suggestions. I had excellent cooperation. I wound up publishing what I thought was a fairly objective picture . It contained positive points as well as criticisms, and I think that the proponents were reasonably satisfied with the outcome.
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.
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