Chiropractic's future is immensely rich with clinical promise. In the past 113 years, the chiropractic profession has grown from a single practitioner to tens of thousands of chiropractors throughout the world. Despite unrelenting pressure and against immense odds, chiropractic has not only survived, but also flourished.
In my 35 years as a doctor of chiropractic, I have seen radical changes in the chiropractic profession. Licensure was obtained in the last holdout states, Louisiana and Mississippi. Federal accreditation resulted in a revolution in chiropractic education. Peer-reviewed scientific journals have been created to disseminate the growing body of knowledge specific to our profession. Exciting new technologies allowing for the objective evaluation of neurospinal function, including surface EMG, infrared thermal scanning, heart rate variability and MRI have been developed and made available to the chiropractor. Interdisciplinary cooperation is better than ever: Medical facilities that once shunned doctors of chiropractic and their patients now actively solicit referrals. And chiropractic has been rated one of the top career choices in the United States by independent authors.
The profession and those we serve can justly be proud. Yet, in our quest for recognition, certain factions within the chiropractic profession seem to have lost sight of why we sought such recognition in the first place - to get chiropractic's unique contribution to human health disseminated as widely as possible. In losing sight of purpose, these factions have initiated policies and processes that are actually antithetical to it. We remain a profession divided. What will be our role as the 21st century unfolds? Will it occur as a result of careful deliberation or from the caprice of political processes? Let's consider our options.
The late sociologist Dr. Walter Wardwell proposed that chiropractic become a limited branch of medicine, such as dentistry or podiatry, addressing only the treatment of musculoskeletal disorders.1,2 Chiropractors who accept this model are encouraging their colleagues to abandon chiropractic terminology such as vertebral subluxation, analysis and adjustment. They perceive the chiropractor as one of many practitioners who employ "manipulative therapy" in the treatment of facet-joint dysfunction.3 Questionable premises have been proffered to support the limited medical specialty model.
Myth #1: Chiropractic Care Is a Scientifically Proven Approach to Low Back Pain
Some chiropractic leaders have suggested that low back pain should be our point of entry into the health care system. They frequently base this opinion on the premise that there is sound, incontrovertible scientific evidence that chiropractic care represents a superior approach to low back pain. In actuality, the evidence is equivocal at best.
First, manipulative therapy is not synonymous with chiropractic care. A growing number of practitioners, particularly physical therapists and osteopathic physicians, offer this service. While adjustment of vertebral subluxation is a unique service provided by chiropractors, spinal manipulative therapy is a common-domain procedure.
In addition, the scientific evidence supporting manipulation as a treatment for low back pain is equivocal. A review in the Cochrane Database sought "to resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high‑quality randomized controlled trials."4
What did these investigators conclude? "Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. ... There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low‑back pain." And what of the claim that chiropractors offer more effective manipulative treatment for back pain than other providers? The authors note: "[P]rofession of manipulator ... did not affect these results."
Myth #2: Eighty Percent of the Population Suffers Low Back Pain
Another reason for promoting a "back pain treatment" identity is the claim that 80 percent of the American population suffers from low back pain. The reasoning is that since few of these patients actually need surgery, even by medical standards, if we sell ourselves as "back pain doctors," our market share will soar.
According to data from a recent study at Duke University, roughly 13 percent of the adult population reported suffering from pain in either the low back or upper back.5 Previous authors have suggested much higher numbers, but these were generally best estimates. While some dispute the number in the Duke study, it appears that the oft‑cited 80 percent figure has been exaggerated.
Myth #3: Back Pain Is the Second- Leading Reason for Physician Visits
The third myth also sounds compelling from a marketing perspective: "Only the common cold causes more people to seek the services of a doctor than back pain." Waddell notes: "This has been repeated ad nauseum in the introduction of papers about back pain until it has become a kind of creed. ... It comes from an old paper by Cypress [1983], using data from 1977‑1978 and questionable diagnostic coding. It gives a very false impression."6
A 1995 study paints a very different picture. Data from the National Ambulatory Medical Care Survey ranked mechanical low back pain as the fifth-leading reason for a physician visit.7 It trailed hypertension, pregnancy care, general medical exams and wellness care, and acute respiratory infections. Low back pain accounted for a mere 2.8 percent of office visits.
Put another way, more patients in that cohort saw a doctor for exams and wellness care than mechanical low back pain!
Finally, an article in The New York Times listed back pain as the eighth-leading reason for a medical visit.8 It should be clear that any strategy based upon promoting chiropractic care as a treatment for back pain is not only flawed philosophically, but also makes no sense based on the evidence.
The sad thing about this is that the public is desperately seeking leadership in the wellness area. They are seeking strategies that will improve their quality of life, regardless of whether or not they have identifiable ailments. Our target market should be 100 percent of health care consumers, not just the subset of those with musculoskeletal pain syndromes.
Chiropractic adjustment is not a subset of manipulative therapy. It cannot be viewed like a drug or electrical modality that can be consistently applied without regard for the unique skills of the doctor, or the uniqueness of each interaction between a specific doctor and a specific patient. It is not just another treatment technique in a long and growing litany of treatment techniques. Nor can its value be determined solely by a patient's subjective symptomatic response.
Our unique contribution to health care goes beyond a method - adjustment of the spine. It embraces a philosophical paradigm radically different from that of allopathy. To forsake our philosophy, limit our field of inquiry to randomized controlled trials, and deny that the spiritual component of human existence is an inherent aspect of the healing process is to deny the very basis for our existence as a separate and distinct profession.
Strengthened by increased recognition, we must now direct our efforts toward an increased awareness of why we sought that recognition. The culture wants what we have to offer - improved quality of life. Do we as a profession have the vision and the commitment to deliver the goods?
References
- Wardwell WI. Social factors in the survival of chiropractic. Sociological Symposium No. 22, Spring 1978.
- Wardwell WI. Present and future role of the chiropractor. In: Haldeman S, Ed. Modern Developments in the Principles and Practice of Chiropractic. Norwalk, Conn.: Appleton-Century-Crofts, 1980.
- Murphy DR, Schneider MJ, Seaman DR, et al. How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropractic & Osteopathy 2008;16:10.
- Assendelft WJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain. Cochrane Database Sys Rev 2004;(1):CD000447.
- What are the costs of treating low back pain? The Back Letter 2004;19(5):56. Based upon data from Luo X, Pietrobon R, Sun SX, et al. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine 2004;29(1):79‑86.
- Waddell G. The Back Pain Revolution, 2nd ed. Edinburgh: Churchill Livingstone, 2004.
- Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine 1995;20(1):11.
- Kolata G. Healing a bad back is often an effort in painful futility. The New York Times, Feb. 9, 2004.
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