A Brief History of Chiropractic

No more than a year ago, my preconception of chiropractic was probably similar to that of most Canadians; I assumed that chiropractors were doctors who specialized in back pain as it relates to the spine and musculoskeletal system. As I began to research chiropractic – dissecting both modern practice and historical origins – I found that this simplistic understanding did not account for the wide variety of diagnostic and treatment paradigms that practitioners adhere to. While many chiropractors are experts in the domains of pain and function in relation to the musculoskeletal system and spine, there are many chiropractors who purport treatment of nearly all medical ailments. These chiropractors hold on to age-old beliefs that are steeped in a spiritual mysticism and vitalism.

The invention of chiropractic is attributed to D.D. Palmer. Palmer was originally a magnetic healer who appropriated the osteopathic technique of joint manipulation. He further appropriated the medical term “subluxation” to refer to what he thought were misaligned vertebrae. Positing that these misalignments impinge on nervous tissue which control healing forces within the body, Palmer implicated subluxations as the root cause for all manner of disease. In his book The Science, Art and Philosophy of Chiropractic, he claimed:

D.D. Palmer’s practice of chiropractic may never have gained the following it has today if it weren’t for the mythologizing of a particular extraordinary deed. In 1895 – examining the back of the hearing impaired Harvey Lillard – Palmer claimed to have discovered a bony protrusion. By performing a manual adjustment of the offending vertebrae, Palmer was credited with restoring Lillard’s hearing.

Although the incident is often said to be instrumental to the proliferation of chiropractic, treatment of the deaf is not something found within the scope of modern chiropractic. In fact, no chiropractor has performed the procedure successfully under controlled conditions. The challenge of repeating this chiropractic miracle is likely attributable to the anatomy of hearing (something we now more clearly understand); the auditory nerves reside exclusively within the skull and at no point travel down the spine. To put it bluntly: chiropractic cannot heal the deaf.

As chiropractic first expanded, some practitioners incorporated radical religious and philosophical beliefs. The adoption of religious symbolism and ideology was – in part – a ploy by Palmer to protect chiropractors from prosecution for practicing medicine without a license. Although much of Palmer’s writings were contradictory and far from concise, his philosophy generally describes a Universal Intelligence (God) that manifests as an Innate healing power channeled through the nervous system and spine.

In essence, Palmer’s principles of chiropractic assert that subluxations result in interference between the Innate vitalistic force and the body by compressing the nerves, causing disease. When chiropractors perform adjustments on patients, they claim to be completing the body’s connection with Innate, allowing it to perform its healing ability. It is this practice that led chiropractors to coin the notion of, “connecting man the physical with man the spiritual,” which is often expressed as turning people’s power on.

Of course, no one would believe these things in this modern age would they? Actually, London’s own celebrity chiropractor B.J. Hardick evidently subscribes to a very similar worldview:

While many current practices today developed from mythologies of the past, chiropractic is unique for retaining much of its philosophical and religious heritage. It’s not uncommon today to hear chiropractors reference Innate or subluxations within their practice. Although the term subluxation does have an appropriate medical use, chiropractors have manipulated it to fit their own design. The lack of substantiation for vertebral subluxation did little to impede the proliferation of chiropractic.

If subluxations are a valid source of concern, we should be able to identify them, illustrate their causal link to disease, and demonstrate that their treatment has a positive effect on specific disease processes and patient symptoms. In 2009, a group of chiropractic researchers examined the evidence relating to subluxations and found “no supportive evidence . . . for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions.” Some chiropractors took issue with the findings, but none put forward a substantive critique. Indeed, when suggesting a novel scientific paradigm, the burden of proof rests on those who make extraordinary claims.

While practitioners of unproven techniques often recall the aphorism that an absence of evidence is not evidence of absence, after years of investigation, evidence of absence is precisely what plagues the chiropractic subluxation. The British General Chiropractic Council denounced the subluxation complex in 2010, followed by additional chiropractic institutions in 2015. Despite the fact that there is no evidence or plausible biological mechanism to validate subluxations as the cause of disease, and despite the fact that chiropractors can’t reliably identify subluxations, some chiropractors continue to apply this philosophy in their clinical treatment. Prominent chiropractors in support of evidence-based practice have noted the detriment to public health that is subluxation theory.

In his book Chiropractic Abuse: An Insider’s Lament, chiropractor Preston Long details how the chiropractic profession is plagued by unscientific beliefs that have persisted in spite of their clash with modern scientific and medical knowledge:

“I am a chiropractor. I do not say this with pride. My profession is full of men and women who exaggerate what they can do and provide unnecessary and sometimes dangerous services to their patients. Most chiropractors are not bad people, but far too many embrace cult-like beliefs.”

Source: Chiropractic Abuse: An Insider’s Lament, pg 21

Reformation

Today, a contentious rift exists within the chiropractic community. There even exists terminology to demarcate between those clinging to the ideas of the past and those who incorporate novel techniques: straights (often self-described as principled) are those who follow the classical Palmer doctrine whereas mixers are those who incorporate other techniques including modern scientific understanding of disease processes (although mixers sometimes pursue equally suspect health practices). This leaves us with two different chiropractic philosophies. The former (the straights) generally believe that subluxations are the root cause of most disease and that a lifetime of spinal adjustments is essential for maintaining proper health. The latter (the mixers) apply spinal manipulation therapy to relieve musculoskeletal pain and generally work with patients to improve mobility and function.

So if the subluxation is a mythical concept, what benefits do chiropractors offer? A 2011 Cochrane review examined the use of combined chiropractic interventions for what chiropractors are most known for: treatment of lower back pain. While they found evidence that “chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute/subacute” lower back pain, they concluded that “there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with [lower-back pain] when compared to other interventions.” Follow up research examining spinal manipulation therapy reached a similar conclusion in 2013.

In addition to lower back pain, there is some evidence indicating that spinal manipulation may aid migraines, as well as neck pain. While the evidence is weak, this may be a result of biomechanical variability among patients, causing some patients to respond well to treatment but not others. After all, many patients swear by chiropractic; while recent Gallup polls illustrated that the American public finds physical therapy generally more effective and safer than chiropractic for neck and back pain, chiropractic care did rank higher than all other interventions. Indeed, many patients are satisfied with their chiropractic care. Despite the mixed evidence, there may be a future for spinal manipulation therapy in treating some pain and disability. If chiropractors can help curtail the opioid crisis as they purport, then their deployment in conservative musculoskeletal care is welcomed.

Unfortunately, a significant impediment to healthcare integration is the division within the chiropractic community. Chiropractic’s historical baggage has led to disparate professional identities, causing criticism from the medical community, particularly among orthopedic surgeons. It’s not hard to see why. Many chiropractors make outlandish and unsubstantiated claims regarding treatment of conditions unrelated to the musculoskeletal system. While evidence-based practitioners generally offer manipulations with the intent of mobilizing joints, those in the straight community claim to precisely adjust misaligned vertebrae and restore them to their proper positions. These claims are dismissed even by chiropractic researchers, yet many practitioners still offer these unscientific services.

A Legacy of Anti-Science

Subluxation-based chiropractic is a treatment in search of a disease. Unlike most medical research which seeks to evaluate novel treatments and diagnostic techniques, chiropractic research is still trying to vindicate an age-old approach to health. This led the American Medical Association to label chiropractic an “Unscientific Cult” as early as 1969. In response, chiropractors sued. Though the AMA lost in an antitrust suit (not by scientific merit), the war continues to this day and chiropractors have still not demonstrated the existence of the subluxation.

In contrast to health practices like physiotherapy or massage, subluxation-based chiropractors are particularly vocal in their opposition to the medical system. A likely explanation – aside from the obvious history – is that physiotherapy, massage, and even modern chiropractic are exclusively complementary to medical practices. Quite distinctly, subluxation-oriented chiropractors often find themselves in competition with the medical system; after all, subluxation-based chiropractors consider their treatment to remedy the cause of most afflictions (despite the lack of evidence). A simple Google search involving the term ‘chiropractic’ and any disease will produce unsavory results. Even chiropractic’s patriarch D.D. Palmer spent time in jail for practicing medicine without a license.

Perhaps the most repugnant philosophical stance that remains pervasive in the chiropractic world is the fervent opposition to vaccination. While scientists and public health experts unanimously recognize vaccination as an effective approach to prevent disease with little risk, the topic remains a contentious issue within the world of chiropractic. D.D. Palmer’s son, B.J. Palmer – the great promoter of chiropractic – is largely responsible.

“The idea of poisoning healthy people with vaccine virus . . . is irrational. People make a great ado if exposed to a contagious disease, but they submit to being inoculated with rotten pus, which, if it takes, is warranted to give them a disease.”

Source: B.J. Palmer’s The Science of Chiropractic: Its Principles & Adjustments

With a long history of opposition to vaccination, chiropractors who cling to the ideas of the past put children at risk and endanger public health. If you think that chiropractic in Canada has outgrown its superstitious and unscientific views, you would be wrong. A recent investigation uncovered significant promotion of anti-vaccination propaganda among Manitoba chiropractors, leading to calls for proactive oversight and regulation. Some chiropractors are even ignorant enough to make media statements against vaccination.

“My parents chose to opt me out of the routine vaccination schedule many years before the world was paying attention to mercury toxicity, Autism, studies, or anything else … My parents wanted me to develop my immune system naturally, without interference.”

Source: Dr. B.J. Hardick [Facebook]

Anti-vaccination beliefs aren’t the only risk posed to children by chiropractors. One area in particular where chiropractic has received extensive criticism from the medical community is in the domain of pediatrics. Many chiropractors in Ontario and abroad have made outlandish claims with regards to chiropractic treatment for infants and children. While there are documented consequences from chiropractors working on infants, precise rates of complication are unknown – likely a consequence of poor adverse event documentation and reporting.

“There’s nothing that I love more than seeing a kid jumping up on the table . . . make sure they’re subluxation free and whether it ever elicits a symptomatic change in that child or not, just being able to know that we’ve turned on the power.”

Source: Dr. B.J. Hardick: A Maximized Living Co-Author explains “Why he died.”  [The Chiropractic Philanthropist]

“I check a ton of kids the day that they’re born.”

Source: Kids Chiropractic Adjustment [YouTube]

B.J. Hardick is a prominent example of a chiropractor promoting treatments for infants and children. The following images were all scraped from his professional Facebook page:

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The absurdity of chiropractors treating infants is only eclipsed by what they claim they are treating; many chiropractors advocate for treatment of children with ear infections, asthma, colic, and other non-musculoskeletal conditions. It’s important to note that the vast majority of conditions that chiropractors treat in children are self-limiting – they tend to resolve spontaneously. A prominent example is colic, for which there is no evidence supporting chiropractic treatment.

In Canada, the problem is pervasive enough that the Canadian Pediatric Society released a position paper: “Chiropractic care for children: Controversies and issues”. The original position was posted in 2002 and reaffirmed in 2016. When examining the scientific evidence, they found that there was no evidence for chiropractic to treat any pediatric disorder. Instead, they found that chiropractors put children at risk by spreading misinformation regarding immunization and by attempting to treat acute pediatric conditions that instead need serious medical treatment. These weren’t the only risks identified. The authors noted that “parents should be made aware that there is a lack of substantiated evidence for the theory of subluxated vertebrae as the causality for illness in children, and x-rays taken for this purpose expose the child to unnecessary radiation.” In fact, chiropractors often overuse x-rays. Even for lower back pain, Choosing Wisely Canada recommends against x-rays partly because it has not been shown to improve management of symptoms. Naturally, misuse of X-ray technology has a long history in chiropractic. B.J. Hardick himself claims that it’s dangerous to adjust without x-rays and has showcased x-rays of children in his YouTube videos.

In a further affront (conscious or otherwise) to public health, many chiropractors attribute risk of subluxation to how the baby is delivered (here is a prime example). Not only are they doing a disservice to public health, but they are unnecessarily shaming mothers about their personal choices regarding the birth process.

“The more natural the delivery, the less interference, the fewer interventions medically that are necessary, the less trauma to the skull . . . I had a baby last week where unfortunately based on the way the baby was presented, they had to turn the baby manually inside the mom and then pull the baby out. So the baby’s neck was definitely subluxated.”

Source: Kids Chiropractic Adjustment [YouTube]

“One fact we do know, however, is that the first subluxation usually happens in the birth canal because of the normal trauma associated with vaginal deliveries. Even babies delivered by C-section are subject to birth trauma and vertebral subluxation. This is why it is absolutely critical for parents to bring their babies to their chiropractor as soon after birth as possible. This will ensure that their child’s nervous system is functioning at full capacity, which will provide the framework for a long life of health and vitality.”

Source: http://drhardick.com/kids-chiropractic

Where are the regulators?

In 1991, chiropractors became authorized to use the title ‘doctor’ under the Chiropractic Act. This privilege has been used irresponsibly by chiropractors nation-wide when making public statements on medical concerns unrelated to musculoskeletal issues. When the public is likely to conflate the use of the title ‘doctor’ with ‘medical doctor’, it is irresponsible to apply the title in the context of non-musculoskeletal medical advice; this is especially true when practitioners are disseminating misleading information.

The College of Chiropractors of Ontario is the self-regulating body for chiropractic in Ontario. As authorized in the Chiropractic Act, the chiropractic scope of practice is as follows:

• The practice of chiropractic is the assessment of conditions related to the spine, nervous system and joints and the diagnosis, prevention and treatment, primarily by adjustment, of,
  • (a) dysfunctions or disorders arising from the structures or functions of the spine and the effects of those dysfunctions or disorders on the nervous system; and
  •  (b) dysfunctions or disorders arising from the structures or functions of the joints.

The problem is that the application and enforcement of this scope is open to broad interpretation. If you subscribe to the classical subluxation philosophy and believe that spinal adjustments channel the healing power of Innate through the body, what could possibly be considered outside of a chiropractor’s scope of practice?

How pervasive is the belief among practitioners that chiropractic can effectively treat a wide range of medical conditions unrelated to the spine? Unfortunately, it is not known. No regulatory body surveys and disseminates this information and existing literature on the topic is unreliable at best. A recent survey of Canadian chiropractors indicated that large proportions of chiropractors in clinical practice use entirely unsubstantiated diagnostic and treatment techniques (for example, 22% claimed to prescribe homeopathy – a treatment that isn’t only unproven but implausible).

Ultimately, the regulatory body has not enforced evidence-based practices, resulting in a vast number of chiropractors who sell useless, even dangerous treatments. My article regarding the Byron-based chiropractor who uses a cheap ear thermometer to diagnose subluxations is a prime example of a chiropractor running a successful business in spite of either having no idea what he is doing, or consciously conning his patients. It’s worth repeating: where are the regulators?

Unfortunately, patients seeking responsible chiropractic care must be extra diligent in screening their care provider. My advice would be to take time to examine the chiropractor’s website. Do they make absurd claims regarding non-MSK conditions? Do they treat infants? Do they treat subluxations? Do they offer long-term treatment/payment plans? Do they advertise testimonials regarding conditions outside of the scope of chiropractic? Do they perform x-rays on every patient? If the answer is yes to any of these, you’re very likely dealing with a quack.

“Good chiropractors are essentially physical therapists who specialize in the spine. Spinal manipulation is an effective option for mechanical low back pain, but physical therapists and some doctors also use that treatment. Some chiropractors want to be primary care providers and treat a variety of non-MSK diseases, but they are not trained to do that. Many chiropractors subscribe to outright quackery like applied kinesiology; and only half of them support vaccination. A medical subluxation is a partial dislocation of a joint that is readily visible on x-ray; the “chiropractic subluxation” is a myth and does not show on x-ray. And chiropractic can be dangerous: stroke is a rare but devastating complication of neck manipulations.”

Source: Interview with Dr. Harriet Hall