He conjures up a few horror stories of patients under what are undoubtedly bizarre but thankfully unusual circumstances of chiropractic care. In his treatise, Dr. Chotkowski appears to hide behind the skirts of previous attacks against chiropractic, which are presented as having the force of gospel. These include:
• At Your Own Risk: The Case Against Chiropractic, by Ralph Lee Smith;2
• "Ten Things Your Chiropractor Won't Tell You," an article in the trade magazine Smart Money;3.
• "Chiropractic," an essay published over 70 years ago by H.L. Mencken,4 that lovable curmudgeon;
• A cover story in the June 1994 issue of Consumer Reports which reviewed what it considered to be exaggerated claims of success by the profession, in addition to an excessive number of cerebrovascular accidents following manipulation.5
For good measure, Chotkowski throws in a trip to the movies in which he witnesses a spoof on chiropractic in a screening of "Out to Sea" with Walter Matthau and Jack Lemmon. Because a feigned chiropractic sequence "drew a hilarious response of glee from the audience," Chotkowski seems to feel that he has obtained proof positive that "the audience recognized the hoax" which he ascribes to the entire profession. Needless to say, this is but one of many surreal examples of the depths to which Chotkowski descends in his book. Siskel and Ebert, Dr. Chotkowski is not.
The problem with all the above references, with the exception of the film comedy, is that they are vulnerable to criticism to the point of self-immolation. For example, the 30-year-old missive by Ralph Lee Smith,2 among other issues, praises the jurisdiction of Louisiana for being the last state in the union in 1969 to refuse to grant licensure to chiropractic. We all know, of course, that this resistance was overcome five years later and that chiropractic is now the only form of health care with alternative characteristics licensed to practice in all 50 states. We also note with wonder how Dr. Chotkowski manages to emulate a code of morality and ethical principles from Louisiana, a state not traditionally associated in the past for its political integrity.6
John Protos' article3 likewise falls victim to inaccuracies and prejudices which I have previously shown at length to have seriously undermined both its credibility and sincerity.7 In short, Protos:
- Erroneously assumes that the National Association of Chiropractic Medicine (with a membership less than 300) represents widespread dissatisfaction with chiropractic, in opposition to virtually all published reports.8-10
- Makes fallacious cost comparisons drawn from flawed studies10,11 which I have refuted at length elsewhere.12
- Incorrectly assumes that practitioners other than chiropractors display better competence and safety records in adjusting while the evidence is to the contrary.13
- Vastly overstates the accident rate of cervical and lumbar manipulations while ignoring the fact that NSAIDs produce mortality rates 400 times greater.14
- Misleads his readership into believing that chiropractors customarily prescribe up to 90 visits for a particular episode when, in fact, chiropractors participated in the development of the AHCPR guidelines which recommend a maximum of two chiropractic treatment regimens for a defined condition, each lasting no longer than two weeks.15
- Incorrectly brushes aside a considerable body of evidence supporting the efficacy of chiropractic management of several childhood and adolescent conditions, including scoliosis,16,17 otitis media,18,19 colic20 and enuresis.21
- Rubber stamps the erroneous "urban legend" that back pain is a self-resolving phenomenon, whereas Dr. Croft's recent prospective study of acute back pain cases which became chronic argues precisely the opposite.22
The Mencken essay is amusing but shows its age by not only attacking chiropractic in its infancy, but condemning "medical men who have been bitten by the public hygiene madness," "the so-called science of public hygiene," and chiropractors as "ex-boilermaker(s)" who "play on ... vertebrae as on a concertina." This kind of presentation may have been effective for performing in the orpheum vaudeville circuit 70 years ago, but has no place in a medical or scientific forum.
Finally, there is the issue of the reference to Consumer Reports.5 While Chotkowski seems barely able to conceal his joy in reporting from the article that "one insurance company paid out 140 claims to patients who had suffered a stroke after spinal manipulation ... and that CR mentions that even this number may represent only the tip of the iceberg," what he fails to disclose is that, after five months of being challenged on the accuracy of this information by William Lauretti, DC, the editorial director was forced to reduce his number by seven-fold, writing both a personal letter of apology and a correction published in a subsequent issue of Consumer Reports.23
Stripped of the validity of his supporting references, where does Chotkowski go from here? For starters, he stumbles through an inordinately large number of inaccurate and misleading statements in the book as well as some outrageous gaffes. They are too numerous to account for completely in this space, but here is a sampler:
- Chotkowski argues that the AHCPR guidelines pointed out that spinal manipulation was "a great deal more expensive" than the use of NSAIDs; however, no such analysis was ever made in this publication.15
- Chotkowski insists that chiropractic "does not alter the course" of such childhood illnesses as ear infections, bed wetting or colic, yet fails to cite or refute the literature specifically addressed to these conditions, as discussed above.18-21
- Chotkowski curiously refers to the AHCPR as the Agency for Health Care and Physical Rehabilitation instead of Agency for Health Care and Policy Research; elsewhere, he misspells Paul Shekelle's name and refers to the antineoplaston guru in Texas as Brudzinski instead of Burzynski; and in one other location, he refers to "reflexology, homeopathy, Christian Science, and other forms of Chinese medicine." Archie Bunker could not have fared any worse.
- He consistently attempts to smear the image of chiropractors as individuals whose occupation consists of "twisting the neck"; indeed, in several instances, he cites a Finnish study which reported that patients who twisted their spines laterally to each side and backwards and forwards 10 times every hour throughout the day took longer to recover than those who simply walked about and did nothing, "which tended to negate the AHCPR findings." The only problem with this bizarre rendition of "twist and shout" is that it has absolutely nothing to do with chiropractic; rather, it is the truth which appears to have become twisted. Chotkowski's ignorance as to precisely what chiropractors do in therapy is appalling, if not libelous.
- He attempts to discredit the meta-analysis of Paul Shekelle24 (which did not even mention chiropractic) by indicating that it received funding from chiropractic sources, ignoring how many medical trials have been funded and published using far more generous and prevalent pharmaceutical sources.
- He equates chiropractic as "unscientific" and allopathic medicine as "scientific," failing to appreciate the fact that only 15% of any medical interventions are currently supported by valid evidence,25 while only one percent of the articles in medical journals are scientifically sound.26
- He fails utterly to grasp the implications of the terminology of subluxation, despite the fact that I sent him a copy of my monograph on this very topic27 in response to his invitation for "scientific input" prior to the writing of his book. Despite the fact that he managed to reprint my entire letter in his treatise, he chose not to refute any part of it, but instead took issue with a point raised by the author of the foreword. Rather than displaying any attempt to arrive at any working concept of the subluxation terminology, he instead condemns it outright. For him to renounce the term outright is as futile and ill-advised as if one were to condemn quantum mechanics simply because it attempts to advance our understanding of matter by describing its wavelike properties in addition to its more commonly accepted particulate nature.
- Chotkowski goes to great length to demonstrate how Getzendanner's opinion on the Wilk case was anything but an endorsement of chiropractic, but simply a cease and desist order to the AMA vis-a-vis restraint of trade. He fails to demonstrate any further widely known excesses of the AMA, such as the judicial order to curb their intimidations of collaborating physicians in the DuPage opinion,28 or how they more recently transgressed ethical boundaries by attempting to endorse Sunbeam products.
- A note in proof gleefully adds the negative evidence recently published in a pair of studies addressing asthma29 and low back pain30 in the New England Journal of Medicine. However, design flaws and egregious misstatements in these articles seriously undermine the integrity of these studies, as I and others have described in detail elsewhere.31-33
- Attempting to represent the profession as entrepreneurial and enterprising, Chotkowski recreates his impressions of: 1. a visit to a chiropractic college, which he depicts as overprivileged; 2. a lecture on headaches, including an unsubstantiated chart of evidence concerning all the conditions treated by a chiropractor; and 3. the wisdom of a chiropractor in Alaskan bush country.
Other than reprinting my letter (with no apparent comprehension of its contents), Dr. Chotkowski displays no inclination in his book to balance these viewpoints with those of the mainstream organizations which are truly representative of the profession. Until he does, he is guilty of selectively fishing for stories of atrocities which he attempts to convey in his book. As far as the college which he visited is concerned, less of Chotkowski's attack has to do with the college than with his preconceived prejudices -- including his pervasive belief that the world would be a better place if all chiropractic colleges were simply converted into medical schools.
Filled with ignorance, buffoonery, gaffes, inaccurate statements and downright sloppiness, this missive may or may not represent a threat to chiropractic. A very recent issue of Dynamic Chiropractic has aptly likened Dr. Chotkowski to Second Lieutenant Hiroo Onoda, who was continuously engaged in guerilla warfare in the island of Lubang in the South Pacific 30 years after World War II had ended. Like Onoda, Chotkowski seems to be viewing the world (in this case chiropractic) the way it appeared 30 years ago with little regard for the present.35
If I were to reciprocate with the ignorant rantings which Dr. Chotkowski has unequivocally expressed in his writing, I would be guilty of portraying the entire allopathic profession as being as careless, misguided and unprincipled as Chotkowski has attempted to do with chiropractic. Fortunately, most individuals in the health care professions would not stoop to such a level. The first sentence of Chotkowski's book insists that "it is written without malice," which struck this reader as a hoax far greater than any which the author attempted to depict.
I must unfortunately conclude that, outside of a casual reading or two of the National Enquirer at the supermarket, this book to me represents perhaps the lowest standard of journalism that I have ever seen.
References
- Chotkowski LA. Chiropractic: The Greatest Hoax of the Century? Kensington, CT: New England Novelty Books, 1998.
- Smith RL. At Your Own Risk: The Case Against Chiropractic. New York, NY: Pocket Books, 1969.
- Protos J. Ten things your chiropractor won't tell you. Smart Money January 1997.
- Mencken HL. Essay on chiropractic.
- Chiropractors: can they help? Do they harm? Consumer Reports June 1994, pp. 383-390.
- Warren RP. All the King's Men. New York, NY: Harcourt, Brace & Jovanovich, 1920.
- Rosner A. Response to "Ten Things Your Chiropractor Won't Tell You." Des Moines, IA: Foundation for Chiropractic Education and Research, January 1997.
- Cherkin DC, MacCornack FA. Patient evaluations of low back pain care from family physicians and chiropractors. Western Journal of Medicine 1989;150:151-155.
- Sawyer CE, Kassak K. Patient satisfaction with chiropractic care. Journal of Manipulative and Physiological Therapeutics 1993;16(1):25-32.
- Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. North Carolina Back Pain Project. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors and orthopedic surgeons. New England Journal of Medicine 1995;333(14):913-917.
- Shekelle PG, Markovich M, Louie R. Comparing the costs between provider types of episodes of back pain care. Spine 1995;20(2):221-227.
- Rosner A. Letters to the editor. Spine 1995;20(23):2595-2598.
- Terrett AGH. Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. Journal of Manipulative and Physiological Therapeutics 1995;18(4):203-210.
- Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. Journal of Manipulative and Physiological Therapeutics 1995;18(8):530-536.
- Bigos S, Bowyer O, Braen G, et al. Acute Low Back Pain 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.
- Plaugher G, Cremata EE, Phillips RB. A retrospective consecutive case analysis of pretreatment and comparative static radiological parameters following chiropractic adjustments. Journal of Manipulative and Physiological Therapeutics 1990;13(9):498-506.
- Lantz CA, Chen J. The effect of chiropractic full spine adjustments on adolescent idiopathic scoliosis with curves less than 20 degrees. Proceedings of the International Conference on Spinal Manipulation, Bournemouth, United Kingdom, October 18-19, 1996.
- Froehle RM. Ear infection: a retrospective study examining improvement from chiropractic care and analyzing for influencing factors. Journal of Manipulative and Physiological Therapeutics 1996;19(3):169-177.
- Fallon JM. The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media. Journal of Clinical Chiropractic Pediatrics 1997;2(2):167-183.
- Klougart N, Nilsson N, Jacobesen J. Infantile colic treated by chiropractors: a prospective study of 316 cases. Journal of Manipulative and Physiological Therapeutics 1989;12(4):281-288.
- Reed WR, Beavers S, Reddy SK, Kern G. Chiropractic management of primary nocturnal enuresis. Journal of Manipulative and Physiological Therapeutics 1994;17(9):596-600.
- Croft PR, Macfarlane GJ, Papadopoulos AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. British Medical Journal 1998;316:1356-1359.
- Correction. Consumer Reports March 1995, p. 132.
- Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low back pain. Annals of Internal Medicine 1992;117(9):590-598.
- Smith R. Where is the wisdom: the poverty of medical evidence. British Medical Journal 1991;303:798-799.
- Lock S. Introduction. In: Lock S [ed.] The future of medical journals. British Medical Journal 1991, pp. 1-8; London, United Kingdom.
- Rosner AL. The role of subluxation in chiropractic. Des Moines, IA: Foundation for Chiropractic Education and Research, 1997.
- Leonard J. Chinnici vs. Central DuPage Hospital Association. Case No. 89C07752, July 2, 1990.
- Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. New England Journal of Medicine 1998;339(15):1021-1029.
- Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O'Shaughnessy D, Walker C, Goldsmith CH, Duku E, Sears MR. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. New England Journal of Medicine 1998;339(15):1013-1020.
- Rosner AL. Response to Cherkin article in the New England Journal of Medicine. Dynamic Chiropractic November 2, 1998;16(23).
- Rosner AL. Rebuttal to Cherkin comments in Dynamic Chiropractic. Dynamic Chiropractic January 1, 1999;17(1).
- Rosner AL. Scratching where it itches. Core issues in chiropractic research. Dynamic Chiropractic January 1, 1999;17(1).
- Chapman-Smith D. Back pain, science, politics and money. The Chiropractic Report November 1998;12(6).
- Dyanamic Chiropractic April 19, 1999;17(9).
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