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Chiropractic in the United States:
Training, Practice, and Research

Chapter II: Chiropractic Belief Systems
Robert D. Mootz, DC; Reed B. Phillips, DC, PhD

**Comments in red by Stephen Barrett, M.D.

A. The Origin and Evolution of Chiropractic Belief Systems

The chiropractic perspective on health and disease emphasizes two fundamental characteristics. (1) a testable principle suggesting that the structure and condition of the body influences how the body functions and heals and (2) an untestable metaphor that asserts that the mind-body relationship is instrumental in maintaining health and in healing processes. Even though early chiropractors characterized these perspectives on health as unique (Palmer, 1910), the conceptualization of the relationship between "life" and "matter" actually began with the early Greek philosophers (Hall, 1969, pp. 18-20). In fact, the origins of traditional "chiropractic philosophy" can be found within the classical philosophic disciplines (e.g., metaphysics, ontology), which attempted to explore the "nature of reality" (Phillips, 1992).

The dichotomy between the ontological principles of vitalism (which considers living things to be governed by unknown laws different from those governing inanimate objects) and materialism (which recognizes only one set of physical laws) are represented in the two fundamental characteristics of chiropractic belief systems. The concept of vitalism stems from Plato's view that life is a nonmaterial entity imposed on matter. Materialism on the other hand recognizes that all natural processes, including life, are the result of known (or knowable) physical laws.

**The American Heritage Dictionary defines "ontological" as "the branch of metaphysics that deals with the nature of being."

Chiropractic beliefs regarding the mind-body relationship and the body's ability to self-heal were characterized by early chiropractors (and even by some contemporary ones) using terminology and metaphors such as: "Universal Intelligence" controls the body's "Innate Intelligence" by directing "Life Force" through the nervous system (Stephenson, 1927; Barge, 1988). These vitalistic concepts implied an intelligent governing entity and thereby were readily perceived as spiritual constructs by many both inside and outside the profession. Early chiropractors often used these metaphorical concepts to rationalize their way of thinking about the body's self-healing capacity.

**Material things can be measured, making it possible to set up and test hypotheses about them using the scientific method. Vitalistic concepts (such as "life force or Innate Intelligence") are neither measurable or testable.

On the other hand, chiropractic's fundamental perspective relating to a significant role for body structure in the healing process is more readily defined operationally, and hence can be evaluated with the tools of science. At times, chiropractors have attempted to merge both concepts (the testable principle relating body structure to function and the untestable metaphor asserting the role the mind-body relationship plays in healing) using one concept to rationalize the other (Mootz, 1992, 1995). For example, it is common to find references in the early chiropractic literature that incorporate vitalistic beliefs about how the body self-heals intermingled with conceptually reasonable discussions on physiology and anatomy.

**It still is common, primarily among "straight" chiropractors.

Such a blending of ideas regarding an all-pervading energy being a basis for materialism is not unique to chiropractic nor is it new in philosophy and the biologic sciences (Collingwood, 1924, pp. 167; Ledermann, 1970). In the 1920s, Collingwood asserted that it made no difference to "the essence of materialism" if the "substrate behind the variety of empirical fact" was called matter, energy, or space-time. In other words, although the syntax used to characterize the two fundamental components of chiropractic belief systems was unique, the concepts have actually been of interest in classical and contemporary philosophy, as well as medicine and biology.

**This paragraph appears to be an attempt to give vitalistic concepts an aura of tradition and respectability. A more practical view would be that their espousal as a basis for health care is a sign of muddled thinking.

B. Chiropractic's Testable Principle as Materialism

In traditional chiropractic belief systems, a specific mechanistic (or testable) principle is that a spinal adjustment removes a subluxation and thereby affects physiologic function (Figure 1). Such a mechanistic principle is inherently quantifiable and can therefore be operationally defined and measured. This aspect of the chiropractic philosophy lends itself to the critical inquiry of the scientific process.

**In other words, if the chiropractic "subluxation" is defined as something that can be seen and objectively measured, it would be possible to test whether chiropractic methods can modify it. Figure 1 (not reproduced here) is a table from a chiropractic textbook which indicates that it would be possible to test the ability of spinal manipulation to improve body function, but it would not be possible to test relationships between "Universal Intelligence," "Innate Intelligence," and body physiology.

However, materialism and its mechanistic procedures do not explain what the purpose behind the life-matter or mind-body relationship is. Although of lasting philosophic intrigue, the answers to questions regarding the essence and purpose of life are not readily found with the tools needed for basic and clinical research.

**In fact, they have nothing whatsoever to do with either research or science, and they have no practical relevance to health care.

Therefore, chiropractic's mechanistic principle is merely a way in which the clinician and scientist can describe and investigate that which is observed in his or her patients (Keating, 1987).

**The first step in investigating it would be to define it. However, chiropractors cannot agree on what they are seeing or doing or what they should be doing. (As a knowledgeable observer once noted, "For every chiropractor, there is an equal but opposite chiropractor.")

Some attempts by early chiropractors to rationalize away the need to measure and quantify the effects of chiropractic care by incorporating vitalistic beliefs about life itself had the unintended consequence of confounding otherwise rational model building.

**This is a convoluted way to characterized the delusional thinking of early chiropractors, which still influences chiropractic beliefs and practices today.

In actuality, the recognition that living things undergo processes beyond what is measurable and understandable at a given point in time is not an "outlier" concept at all. The early physiologic concepts of homeostasis and contemporary models regarding complex behaviors of simple systems form the basis of "holistic" approaches to health care (Mootz, 1995; Schwartz, 1997).

**Dr. Mootz and Phillips would like us to believe that chiropractic's philosophical muddle is just another way to look at homeostasis (the tendency of organisms to maintain internal equilibrium by adjusting their physiological processes). I inspected Dr. Schwartz's article, but could not understand it. Here's a representative paragraph:

A dynamical energy systems approach encourages us to be open to entertaining and evaluating such novel ideas as the notion that biological cells can rectify and signal average weak energy fields or that nonlinear stochastic resonance may allow very tiny electromagnetic signals to be registered selectively and interactively. Moreover, new ideas bridging classical and quantum physics, currently evolving in quantum brain dynamics and consciousness, can be extended to quantum cardiac dynamics and consciousness. . . . The "stairway to the mind" itself is an emergent, interactive stairway that extends from the quantum to the cultural, involving nonlinear dynamics . . and emergent properties at all levels.

Some of the above buzzwords apply to real scientific effects, but the paragraph itself is nonsense. A Quackwatch physics advisor, after noting the alleged link between quantum mechanics and culture, wondered whether the author believes that atoms and molecules can prefer Wagner to Bach. If anyone reading this understands what Schwartz's article has to do with chiropractic, please let me know.

C. Chiropractic's Untestable Metaphor as Holism

Holism represents a philosophic perspective on the integration of body, mind, and spirit that posits that health depends on obedience to natural laws and that deviation can result in illness. Holism is based on the doctrine of teleology, which implies that there is a design or purpose in nature. An idealistic or vitalistic component can be seen in teleology. Based on the vitalism and metaphysics of his time, D.D. Palmer provided chiropractic a teleological metaphor when he expounded the concept that there is a "universal intelligence" that is manifest in living things as an "innate intelligence," which provides purpose, balance, and direction to all biologic function (Palmer, 1910). The classic medical concept of homeostasis also has its roots in the teleology of holism.

**Chiropractors like to describe Palmer's theory as a metaphor. I think it is more meaningful to describe it as a delusion.

Although many great advances in 20th-century medicine have resulted from the mechanistic application of the scientific method (e.g., antibiotics for bacterial infections), science has also seen advances from theories based on global, contextual overviews of the environment (e.g., Darwinian concepts on evolution) (Mootz, 1995). Mechanistic philosophy in medical practice has made significant contributions in many clinical situations, particularly for emergent conditions. However, mechanistic or reductionistic approaches have not been as successful with chronic degenerative disease.

The concept of holism is difficult to approach with scientific methodology; it cannot be measured, tested, or operationally defined.

**In other words, holistic notions cannot be disproved.

Holism defines current methods of mechanistic determinism and reductionism because it is not finite (Mootz, 1995). Yet in practice, physicians implicitly rely on a patient's innate ability to heal. Ledermann (1970) articulated physicians' relationship with a patient's "holistic power" (innate ability to self-heal) this way: Physicians "cannot measure this power in units, but they attempt to gauge its strength. A surgeon for instance who envisages a major operation on a patient must assess this person's capacity to stand up to the strain of the operation, and he must therefore estimate his vitality, his holistic power. Any doctor is concerned with the holistic recuperative power of his patients" (Ledermann, 1970, pp. 34-35).

**In making such judgments, surgeons would consider the patient's general health, cardiac status, and a large number of other measurable factors that enable reasonable prediction. Of course, some people do much better or much worse than expected. The above paragraph attributes this to "holistic power," which cannot be measured.

Holism can be taken to a dogmatic extreme and if trusted implicitly, the holistic application of any method of natural healing may fail to prevent illness or restore health. When viable nonholistic alternatives to healing exist, contemporary Western society typically dictates their use if natural methods are insufficient or seem unreasonable. For example, although a bone or joint infection may eventually be able to fully heal with natural means, albeit with deformity and risk of systemic infection, a more reasonable (and socially acceptable) course is to treat the patient with a timely application of antibiotic therapy. As Ledermann (1970,pp. 32-33) states, "the unspecific approach is thus limited, and it is the duty of the therapist to assess each patient's condition and to apply specific measures, based on the mechanistic-materialistic approach, if necessary."

**In other words, treatment is a good idea if it will help a sick person to get better. I wonder how many of our tax dollars were spent to support this brilliantly written report.

A complete reliance on a holistic universal intelligence entails dogma and is not acceptable in current chiropractic philosophy or practice (Phillips, 1992). Although untestable scientifically, the concepts proposed by chiropractic's metaphor (and holistic models in general) can still be subject to critical review and refinement (Milus, 1995).

**Attempting to do this would be about as useful as attempting to measure the number of angels that would fit on the head of a pin. If you don't believe me, read Dr. Milus's article. His address at the time it was published was Thomas B. Milus, DC, 90 E. Tasman Drive, San Jose, CA 95134.

Popper (1960) suggested that the formulation of proper lines of questioning about new knowledge and ideas can be useful. For example, rather than defending assertions (or questioning the source of knowledge) about the body's self-healing capacity, one might try to identify and revise conceptions regarding self-healing that are inconsistent with available evidence.

D. Chiropractic's Unique Perspective

Although chiropractic shares much with other health professions, its emphasis and application of philosophy distinguishes it from modern medicine. Chiropractic philosophy gravitates toward a contextual, naturopathic approach to health care (Black, 1990). Aspects of the chiropractic perspective that reflect its holistic orientation are listed in Table 1.

 Table 1. Chiropractic Perspectives That Reflect a Holistic Approach to Patient Care

  • noninvasive, emphasizes patient's inherent recuperative abilities
  • recognizes dynamics between lifestyle, environment, and health
  • emphasizes understanding cause of illness in an effort to eradicate, rather than palliate, associated symptoms
  • recognizes the centrality of the nervous system and its intimate relationship with both the structural and regulatory capacities of the body
  • appreciates multifactorial nature of influences (structural, chemical, and psychological) on the nervous system balances benefit versus risk of clinical interventions
  • recognizes as imperative the need to monitor progress and effectiveness through appropriate diagnostic procedures prevents unnecessary barriers in the doctor-patient encounter
  • emphasizes a patient-centered, hands-on approach intent on influencing function through structure
  • strives toward early intervention emphasizing timely diagnosis and treatment of functional, reversible conditions

By comparison, the traditional, allopathic model suggests that disease is the result of an environmental agent's virulence overwhelming the host organism (Mootz, 1995).

**No they don't. The scientific health-care model gives appropriate weight to both types of factors.

Since the perceived cause is environmental in nature, the solution is to counter the perceived environmental factor (e.g., using an antibiotic for a bacterial infection). The naturopathic approach provides a different perception as to the nature of disease causation. As Palmer originally queried, why would one individual working in the identical environment become sick when the other remained healthy (Palmer, 1910)? The traditional naturopathic answer is that one exhibited a decreased host resistance, hence, the appropriate solution would be to direct treatment at the host in order to strengthen it, regardless of the nature of any environmental agents.

**They claim to do this, but there is little evidence to substantiate that they actually do it.

In contemporary clinical practice, one can find elements of both naturopathic and allopathic philosophy among all types of providers.·

The difference between chiropractic and traditional naturopathy and osteopathy may be less obvious. Osteopathy originally emphasized the relationship body structure was thought to have with the circulation of "vital body fluids." However, the osteopathic profession in the United States essentially evolved parallel with traditional medicine. The result has been that many, if not most, contemporary osteopathic physicians practice nearly identically to medical providers. Osteopathy has long incorporated surgical and pharmaceutical approaches in training and practice, in great measure to the exclusion of manual procedures.

**Yes, the belief that osteopathic manipulation can boost general health is gradually fading away.

Much like chiropractic, contemporary osteopathic approaches to manual treatment methods have also emphasized neurological aspects of the body's structure/function relationships over their original circulatory models. Today, the similarities between some contemporary chiropractic and osteopathic approaches are substantial; however, the chiropractic profession as a whole centers itself exclusively on manual (e.g., spinal adjusting, manipulation, muscle work, exercise) and physiologic (e.g., nutrition, lifestyle modification) approaches to healing.

**In other words, some osteopaths and chiropractors still cling to their cultist roots.

As with traditional naturopaths, there is vigilance among chiropractors to the adage do no harm, which continues to position mainstream chiropractic as a drugless (as well as nonsurgical) healing art. Naturopaths tend to emphasize physiologic approaches to healing more than many chiropractic traditionalists. Interestingly, the early evolution of chiropractic and naturopathy had much in common. Many of the early naturopathic and chiropractic schools offered dual degree tracts and there was much incorporation of each other's clinical approaches in practice.

Another characteristic of chiropractors' training is an emphasis on the importance of clear communication with patients. Chiropractors have traditionally allowed time to provide detailed reports of clinical findings and discussion of treatment plans to patients in clear, understandable terms.

**Yes, but not necessarily accurate terms. Chiropractors are notorious for their "reports of findings," during which they relate the patient's symptoms to "subluxations" and recommend multiple spinal adjustments to correct them.

However, like all health care providers, contemporary chiropractic physicians are confronting the challenges of increased demands for clinical efficiency and cost-containment.

E. Distinctions Between Traditional and Contemporary Chiropractic Belief Systems

Traditional and contemporary chiropractic philosophies both display the dualism of testable principle (materialism) and untestable metaphor (holism). However, contemporary chiropractic incorporates a new perspective that escaped the early traditionalists (Milus, 1995; Phillips, 1992). There is recognition that the untestable constructs of holism cannot be used to rationalize explanations for clinically observed phenomenon. There is also appreciation for and understanding of the nature of scientific inquiry. Contemporary chiropractic philosophers have communicated a greater understanding of scientific methods and critical inquiry (Mootz, 1995; Milus, 1995). Theory development, even in qualitative domains and with scientifically untestable models, can be subject to critical review and refinement.

**Chiropractic philosophy—old and new—may give comfort to its adherents, but it has no practical value for treating patients. The better chiropractic schools, including the one headed by Dr. Phillips, no longer emphasize Palmer's metaphysical notions. However, they are still taught at most of the others.

Modern-day chiropractic also recognizes that confidence in chiropractic methods is not a substitute for substantive description, observation, evaluation, and communication of chiropractic concepts to society at large. A clear elucidation of its philosophy and avoidance of the dogma and rhetoric that has characterized uncritical doctrines in both medicine and chiropractic in the past will enhance the future success of chiropractic. Some self-proclaimed "chiropractic philosophers" of today continue to confuse medical bashing, rhetoric, and enthusiasm for chiropractic with philosophy. Even chiropractic's most prominent early "philosopher," B.J. Palmer, made the distinction between having pride and enthusiasm about what chiropractors do, and philosophy (Mootz, 1992).

**In other words, if chiropractors want to make claims, they should use scientific methodology and test their claims with well-designed studies. The percentage of chiropractors who would agree with this is unknown. Genuine embrace of this idea would require abandoning quack methods of diagnosis and treatment that are still widely used. It would be interesting to know what the authors mean by "modern-day chiropractors" and what percentage of the profession would meet their criteria. My guess is that the majority would not. The "uncritical doctrines" of medicine's past occurred before the development of scientific methodology an, as far as I can tell, no longer exist today. Chiropractic's "uncritical doctrines," though less prominent, are still very much in evidence.

F. Variation in Chiropractic Perspectives

The terms "straight" and "mixer" were used by early chiropractors to distinguish between chiropractors whose therapeutic armamentaria included only manual adjusting and those who also used other therapies such as nutritional and lifestyle counseling or physiotherapeutic modalities. Historically, chiropractic schools would affiliate with a particular national professional association that gravitated toward a "straight" or "mixer" perspective. Although there are still remnants of this dichotomy, the situation has changed with the advent of federally recognized accreditation, research consortia, and more collaborative political agendas. Distinctions among current chiropractic perspectives are complex and can no longer be viewed as a simple dichotomy.

**That's true, but the terms "straight" and "mixer are still widely used. In fact, one school (Sherman College of Straight Chiropractic) even uses the term "straight" in its name.

Table 2 lists some of the attributes of chiropractic belief systems and indicates the range of perspectives along each philosophical dimension.

Table 2. Range of Belief in Chiropractic
 Perspective Attribute

Potential Belief Endpoints
 Scope of practice:

 narrow ("straight")—    —broad ("mixer")
 Diagnostic approach:

intuitive—   —analytical 
 Philosophic orientation:

 vitalistic—   —materialistic
 Scientific orientation:

 descriptive—   —experimental
 Process orientation:

 implicit—   —explicit
 Practice attitude:

 doctor/model-centered—    —patient-situation-centered
 Professional integration :

 separate and distinct—    —integrated into mainstream

A comprehensive survey of chiropractic practitioners' philosophic beliefs could not be found, although a recent study offers some insight into treatment scope preferences (Christensen, 1993). In a nationwide survey of more than 6,000 practicing chiropractors, over two-thirds reported using nonadjustive techniques such as exercise, nutritional counseling, and various physiotherapeutic modalities. More than 93 percent of chiropractors report using a full-spine adjustive approach (i.e., general adjustive procedures that may involve any region of the spine) as their primary chiropractic treatment procedure. The remainder characterized themselves as emphasizing upper cervical methods (2 percent) or other techniques (5 percent).

**The survey, done in 1991, garnered responses from 4,835 full-time practitioners. The nonadjustive techniques included: exercises (used by 95.8% of respondents); ice packs/cryotherapy (92.6%); bracing (90.8%); nutritional counseling, therapy or supplements (83.5%); bed rest (82%); foot orthotics or heel lifts (79.2%); hot pack/moist heat (78.5%); traction (73.2%); electrical stimulation (73.2%); massage therapy (73%); ultrasound (68.8%); acupressure/meridian therapy (65.5%); casting/taping, strapping (48.2%); homeopathic remedies (36.9%); inferential current (36.9%); direct current, electrodiagnosis or iontophoresis (26.9%); infrared or other heat-producing devices (19%); whirlpool/hydrotherapy (12.7%); acupuncture (11.8%); and biofeedback (9.6%). "Chiropractic nutrition" typically entails quack diagnostic tests and the sale of irrationally prescribed supplements. Meridian therapy and homeopathy are not valid approaches. In addition to standard methods, the adjustive techniques included activator methods (51.2% of respondents); applied kinesiology (37.2%), cranial therapy (27.2%), and several others that are extremely dubious. Taken together, these data suggest to me that more than 80% of chiropractors are involved in unscientific and/or quack practices. Even if this estimate is a bit high, what do you think it means that Drs. Mootz and Phillips failed to reveal these findings?

There are two significant, well-established national chiropractic trade associations. The largest is the American Chiropractic Association (ACA), which is believed to include about 25 percent of chiropractors in the United States as members. The ACA (and its precursor organization the National Chiropractic Association) has historically been associated with a broad-scope approach to chiropractic practice and appears to be most representative of the mainstream of the profession. The International Chiropractors Association (ICA) is primarily a U.S.-based alternative to the ACA and has a much smaller membership (believed to count between 5-10 percent of chiropractors among its dues-paying members). The ICA tends to position itself as representative of members with more traditional chiropractic perspectives.

**Yes, and it is opposed to immunization and fluoridation.

A few other national groups identify with more extreme perspectives. The National Association of Chiropractic Medicine (NACM) supports limiting chiropractors to only the treatment of certain musculoskeletal conditions, while the World Chiropractic Alliance (WCA) promotes addressing only a single chiropractic spinal lesion, the vertebral subluxation. However, both organizations are proprietary (as opposed to being representative of their memberships) and have a very small number of members (believed to be in the low hundreds).

**The National Association for Chiropractic Medicine was a reformist group that renounced Palmer's theories as delusions and was the only chiropractic organization to speak out against the gamut of quack chiropractic practices. What do you think it means that Drs. Mootz and Phillips would describe it as "extreme"?

G. Summary

Traditional chiropractic belief systems focused on the body's ability to self-heal, the nervous system's role in overall health, and the role body structure was thought to play in function of the nervous system. Early articulation of these concepts by chiropractors was often cloaked in terminology that conveyed spiritual connotations. In addition, vitalistic explanations of self-healing confounded many outside the profession when used by early chiropractors to deny the value of quantitative evidence on clinical effectiveness.

Contemporary chiropractic belief systems embrace a blend of experience, conviction, critical thinking, open-mindedness, and appreciation of the natural order of things. Emphasis is on the tangible, testable principle that structure affects function, and, the untestable, metaphorical recognition that life is self-sustaining and the doctor's aim is to foster the establishment and maintenance of an organism-environment dynamic that is the most conducive to functional well-being.

**Chiropractors hope to substantiate their usefulness without having to abandon Palmer's notions. Whether this is possible remains to be seen.

Contemporary chiropractic philosophy recognizes its partnership with the greater body of philosophy and science in general. Most contemporary chiropractors and their organizations distinguish between what is known and what is believed.

**I am not sure whether this can be measured. I don't think it has been.

Chiropractic belief systems embrace the holistic paradigm of wellness while incorporating deterministic materialism for the establishment of valid chiropractic principles. Chiropractic's philosophic foundation serves as the basis for theoretical development, not a substitution for it (Phillips, 1992).

**A better view would be that Palmer's theories are a millstone around chiropractic's neck.

References

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Christensen M, Morgan D (eds). Job Analysis of Chiropractic: A Project Report, Survey Analysis and Summary of the Practice of Chiropractic within the United States. Greeley, CO: National Board of Chiropractic Examiners, 1993.

Collingwood RC. Speculum Mentis on the Map of Knowledge. Oxford at the Clarendon Press, 1924.

Hall TS. Ideas of Life and Matter, Vol 1. Chicago & London: The University of Chicago Press, 1969:18-20.

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Palmer, DD. The Science, Art, and Philosophy of Chiropractic. Portland, OR: Portland Printing House 1910.

Phillips RB, Mootz RD. Contemporary chiropractic philosophy. In Haldeman S (ed). Principles and Practice of Chiropractic, 2nd Ed. Norwalk, CT: Appleton & Lange, 1992.

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Stephenson RW. Chiropractic Textbook. Davenport, IA: Palmer School of Chiropractic, 1927.

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