The difficulty begins with the definition. The term "alternative" has been used interchangeably with "complementary" and "unconventional"; at times, people have applied such appellations as "nonorthodox," "natural," "holistic," and at times "non-Western." The German definition (nicht Schulmedizin, lit. "not school medicine") is deceptively simple in that it denotes health care practices not taught at university medical facilities or medical schools. However, the German definition opens the door to a virtual avalanche of interventions, which can rain down upon the unsuspecting inquirer with the relentlessness of the pots and pans tumbling out of Fibber McGee's overstuffed closet.
With the beckoning facade of the Statue of Liberty, the term "alternative" gives the impression of welcoming a multitude of immigrant health care interventions into public acceptance. This would include those health care practices which have become widely regarded as the "more established" adjuncts to conventional medicine, such as chiropractic, osteopathy, acupuncture, massage and physical therapy, homeopathy, Chinese medicine, herbal medicine, and various forms of biofeedback and mind-body medicine. However, the term also admits such interventions as shamanism, hydropathy, grahamism, mesmerism, therapeutic touch, Christian Science, dianetics, and pentecostal healing. By becoming such a melting pot of health care interventions, large and small, outside of mainstream medicine, the term "alternative" has become stretched to the point of near meaninglessness.1
With its long and painstaking establishment of its accredited professional degree program and licensure in every state, its legal recognition and victories, and its development of evidence-based expertise in back care to becoming a first choice for health care intervention supported by over 40 clinical trials, three meta-analyses2-4 and two governmentally sanctioned sets of clinical guidelines,5,6 chiropractic has much to be proud of. Back care specialists with a formal background in chiropractic education have every reason to become testy when their efforts appear to be placed under the same umbrella as those of, for example, the Rosicrucians. Indeed, chiropractic would give every indication of having achieved mainstream status, so that its being referred to as "alternative" would appear to be a step backward. Also, there are those who would argue that chiropractic as an "alternative" therapy is keeping bad company.
Yet there is more to this issue than meets the eye. It would be best to consider three lines of reasoning and then reflect upon a few more general observations.
1. "Alternative" is the only accurate descriptor for at least some indications for chiropractic intervention: It is only with the publications of the British and American (AHCPR) guidelines for low back pain within the past year that official government recognition has been extended to chiropractic, and only for a very limited set of clinical conditions (acute low-back pain). For even this specialized set of circumstances to achieve recognition as "mainstream," publication of over 20 years of research (including over 40 clinical trials) in the peer-reviewed literature was necessary.
At present, it is impossible for this writer to conclude that chiropractic interventions for conditions in the somatovisceral category (otitis media, dysmenorrhea, colic, enuresis, vertigo, hypertension) have achieved this level of documentation or recognition. Accordingly, chiropractic could not possibly be considered "mainstream" in treating these particular conditions at this time; the term "alternative" for this set of patient complaints must therefore apply since conditions (repetitive stress syndrome, headache, cervical or chronic back pain) are more completely documented for chiropractic intervention but still fail to approach the rigor discussed earlier for the treatment of low-back pain. I expect it's only a matter of time before chiropractic interventions for conditions other than low-back pain achieve mainstream recognition and status. Nothing less would be expected of new medical procedures as they are reported and researched. It has been argued that it was only after the publication of the Flexner Report 85 years ago7 that the hospital-centered allopathic medical model became established as mainstream, while homeopathy, chiropractic, and naturopathy were relegated to the sidelines.8
What I am suggesting is there is a duality in how chiropractic intervention is described: for low-back conditions, it has finally and only very recently been recognized as mainstream; for all other conditions, it can only be referred to as an alternative intervention at this time.
2. As an "alternative" therapy, chiropractic has kept anything BUT bad company. Significant recognition and perhaps increased utilization has been extended to chiropractic following its description as one of the most widely used modalities of treatment by Eisenberg in the New England Journal of Medicine.9 Alternative therapies have gained the section of medical faculty at Harvard Medical School and has been offered as a comprehensive course there, and in no fewer than 26 other leading medical schools across the United States.10 Finally, they have gained the imprimatur of the National Institutes of Health by capturing the attention of both the public and Congress and achieving status in 1991 within the NIH as the Office of Alternative Medicine.
Rather than disparagement, a result of the association of alternative medicine and chiropractic has been its much greater recognition (and positive perception) by both the public and other health professions -- including allopathic medicine. In securing government funding for research, the consequences have been enormous. For the first time last year, chiropractic research has garnered over $3,000,000 in federal sponsorship of research.
3. The term "alternative" is a useful means to distinguish the chiropractic paradigm. In establishing chiropractic as conservative, drugless, and patient centered (rather than disease-centered), it is useful to apply a terminology which assures that chiropractic does not become absorbed by the current medical paradigm. Whether that term is "alternative" or some other more precise wording which more appropriately accords chiropractic its attributes as a systematic body of knowledge with at least as much of a clinical underpinning as standard medical interventions remains to be seen. The term "complementary" might be more appropriate in laying the groundwork for more fruitful collaborations between the chiropractic and medical professions, both in research and in clinical practice.
Thus, I would have to conclude that it is more appropriate for chiropractic to at least grasp, if not embrace, the term "alternative." For a profession that already encompasses a huge range of manual and adjuvant techniques, to say nothing of precise definitions of the vertebral subluxation, to do otherwise would seem hypocritical. It also provides the means for a productive dialogue with the public. If its long legal, social, and scientific history are kept in perspective, chiropractic's relationship with the alternative medical movement will not compromise its integrity.
References
- Wardwell WI. Alternative medicine in the United States. Soc. Sci. Med. 38(8):1061-1068 [1994].
- Anderson R, Meeker WC, Wirick BE, Mootz RD, Kirk DH, Adams A. A meta-analysis of clinical trials of spinal manipulation. J. Manipul. Physiol. Ther. 15(3): 181-194 [1992].
- Shekelle P, Adams AH, Chassin MR, Hurwitz E, Brook R. Spinal manipulation for low back pain. Ann. Int. Med. 117(7): 590-598 [1992].
- Koes BW, Bouter LM, van der Jeijden GJMG. Methodological quality of randomized clinical trials on treatment efficacy in low back pain. Spine 20(2): 228-235 [1995].
- Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. December 1994.
- Rosen M. Report of a Clinical Standards Advisory Group committee on back pain. London, HMSO, 1994.
- Flexner A. Medical education in the United States. New York: Carnegie Foundation for the Advancement of Teaching, 1910.
- Borkan J, Neher JO, Anson O, Smoker B. Referrals for alternative therapies. J. Fam. Pract. 39(6): 545-550 [1994].
- Eisenberg DM, Kessler RC, Foster C, Norlack FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. New Engl. J. Med. 328(4): 246-252 [1993].
- Monson N. Alternative medicine education at medical schools. Are they catching on? Altern. and Compl. Ther. 1(3): 168-171 [1995].
Anthony Rosner, PhD
FCER Research Director
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