For over a hundred years chiropractors fought to protect their unique identity. The enemy is no longer a zealous American Medical Association or critics like the skeptics The enemy are those among our own ranks who want to force all chiropractors to take the path they are on. They pontificate about “unity” when the mean forcing non believers to follow their dogma, rather than respect the diversity that is chiropractic, linked by the recognition that there is a relationship between the structure of the spine the function of the nervous system and wellbeing. To fully understand what is happening in the UK you need to look at the history. One hundred years ago chiropractors were being jailed for practising medicine without a licence. Most resisted some saw their futures being subservient to medicine.
Chiropractic had its first major victory over medicine in the Wilk case in 1990 and even in victory, there were chiropractors who saw this as an opportunity to take their skills into the temple of medicine. Led by Charles Duvall DC in the US they formed the National Association for Chiropractic Medicine NACM. They described themselves as a “consumer advocacy association of chiropractors who confine their scope of practice to scientific parameters and seek to make legitimate the utilization of professional manipulative procedures in mainstream health care delivery.The used weasel words like protecting the public” not forgetting the “foremost requirement for membership in the NACM, that a Doctor of Chiropractic Medicine renounce the chiropractic hypothesis (subluxation) as a basis for their scope of practice. They were promoted by chiropractic skeptics in the US like Stephen Barrett and his website Chirobase. Having started with a fan fare I will tell readers what became of them in my next posting.
Elements in the BCA were also choosing the same direction at this time as they did not have a popular mandate they just got themselves into leading positions in the BCA, ECU, AECC and later WIC, (successful chiropractors did not have the time). The BCA pushed for statutory self regulation selling the profession a pup that would also bite the hand that was feeding it.
The GCCs first case was against BCA member Roger White, the patient wore a wire and expert witness for the defence Richard Brown told the PCC it was not acceptable to use the term Subluxation as a diagnosis. Richard Brown was a young inexperienced expert for the defence looking for an opportunity to work for the GCC. If this was his audition for the GCC he passed even though BCA member Roger White was not happy with his testimony. Now he is the president an representative of all BCA members and they don’t even question his appointment allthough he earned a nice crust from the GCC.
The second hearing was GCC v BCA member Jesper Jensen, GCC chief executive Margret Coats first effort at defining the scope of chiropractic practice with the help of her expert David Byfields report who despite failing miserably to define chiropractic scope of practice and did not not get much more expert work after thisperformance. Nevertheless Byfield rose to become head of the Welsh Institute of chiropractic and a member of the GCC despite all the questions I raised about his integrity.
David is a good committee man who knows which side his bread is buttered on, however you have to wonder about anyone who puts a medal he won when he was 14 on his CV for the GCC. The arguments Byfield made as to why he believed “Subluxation” was a clinical myth were so weak he altered the evidence against the chiropractor (37 times) so he could have the debate he wanted to have, about subluxation causing “disease” and all that rubbish. The GCC/BCA are now producing the same shit again, nine years on but who is going to defend the profession now.
It is worth reading how Byfield performed under cross examination and although a senior BCA member, he testified he did not like BCA promotional material?? Presumably because it was wriiten to keep core members on board rather than to reflect the BCA councils own personal views on chiropractic scope of practice. I gave the transcript of the hearing to Simon Singhs legal team to illustrate that the BCA did not always believe the the claims they put on their website even thought the vast majority of chiropractors did.
So when BCA president Richard Brown states this week “The BCA have not supported the concept of the Vertebral Subluxation complex for years”. What he means is the political circumstances were not right to give the GCC/BCA alliance the oppertunity to speak against it.
Below are some of the arguments I made nine years ago against Byfields work: “The Report”, they are just as relevant today, unfortunately few chiropractors listened to my warnings about Coats and the GCC in 2001. The GCC/BCA alliance have bided their time and used the fear created by the skeptic complaints to push for prescribing and to medicalise chiropractic. There is little UK chiropractors can do now short of resigning from the register. Claims on Jesper Jensens website were the issues that Margaret Coats was complaining about, the same type of claims Zeno has complained about nine years on. They were not settled then because people are more interested in having power than acting in the professions or the publics best interests. The following is section of the report dealing with the scope of practice issue. The entire report is about 20,000 words and was written in 2002.
4.1 In my opinion the Website does not contradict any of the aims of the GCC to protect the public and raise standards, ensuring chiropractors practice in a safe competent manner. Dr Jensen fully endorses the search for evidence of the efficacy of chiropractic, to be used as a guide in the care of chiropractic clients.
4.2 The information contained in the Website, though not acceptable for publication in a peer reviewed journal, is such as would normally be contained in information leaflets and promotional material used by the chiropractic profession worldwide, including the BCA. The text was derived from a number of different sources and presented in a similar way as information in BCA leaflets.
4.3 As some of the claims which are considered untruthful and misleading by the report are also on GCC and BCA public information materials. In my opinion Dr Jensen had no reason to think statements derived from these sources and Palmer College, the highly regarded chiropractic college where he studied, would be considered to be dishonest, untruthful, or misleading.
4.4 In my view it is possible to rebut the comments made by Dr Byfield on each section of the Website (pages 28-84). There are also 35 instances where the Report has been misquoted or misinterpreted in sections: [1v,vi,vii,viii. 2i. 3ii,iv. 5i,ii,ii,v,viii,ix. 6i. 6biii. 7i,iii,iv,v. 8i. 10vi. 11i. 12i,iv. 13ii,iii,iv,v. 15v. 16ii,iv. 17viii.]
4.5 In my opinion, the Website reflects the broad scope of practice of the profession, and asks questions of the bio-medical health paradigm that one would expect informed consumers to be aware of. The Website presents a point of view that is exemplified by the Association of Chiropractic Colleges (“ACC”) chiropractic paradigm, which is generally considered mainstream chiropractic.
4.6 Nobody would dispute the Report’s assertion that most of the evidence for the efficacy of chiropractic is in the treatment of back and neck pain, and that most people visit chiropractors for the treatment of pain syndromes. However, the point of websites like Dr Jensen’s is to explain how chiropractic could help people with a variety of other conditions, because of a relationship between the spine, the nervous system and the symptoms people experience daily yet get very little relief from allopathic therapy. However, the Website does not claim to treat or cure any condition mentioned therein.
4.7 Health is a natural phenomenon; the body is in a constant dynamic flux between health and disease. The body’s ability to adapt to chemical, emotional and physical stress enable it to maintain a state of health. The goal of the traditional chiropractor is to facilitate the body’s natural healing and regulatory systems so the individual has the potential to achieve optimal well-being. The Website attempts to help the public understand the difference between health care and disease care. In my opinion, chiropractic care is preferable to invasive treatments at port of entry in a progressive health service, something that is repeated throughout the Website.
4.8 Regarding treatment, the GCC Standard of Proficiency Required for the Competent and Safe Practice of Chiropractic Care states at section 5.1 [appendix 10] :-
“A chiropractor must be competent to select the appropriate treatment for the individual patient and be proficient in its delivery. A chiropractor should be competent to recognise the risk or contra-indications associated with any treatments. A chiropractor should also know and understand the theories underlying such treatments.”
Dr Jensen has explained the theory behind correcting the vertebral subluxation complex “VSC” throughout the Website in simple language that members of the public can understand. It was not intended for peer review.
4.9 The Report at the end of the paragraph on page 12 suggests that it is wrong for Dr Jensen to promote his practice as anything but a “typical chiropractic practice”. There is no requirement on Dr Jensen to market his practice as a “typical chiropractic practice”. The GCC Code of Practice at Section 8.9 states that [appendix 10]:-
“A chiropractor may indicate that a practice is wholly or mainly devoted to particular types of treatment.”
4.10 As mentioned above, many of the criticisms in the Report directed at the Website are because of an apparent lack of evidence to support the claims and the omission of referencing. These criticisms apply right across the health spectrum for reasons that will become obvious, they apply to most of the BCA promotional leaflets [appendix 3]. The assumption that all orthodox medicine is evidence based and the gold standard for chiropractic is incorrect according to David Eddy only a small percent of medical practice is evidence based (BMJ 1994) [appendix 5]. A recent joint statement from the International Committee of Medical Journal Editors [appendix 5b] questioned the integrity of the “evidence” being produced from clinical trials. “The use of clinical trials primarily for marketing, in our view makes a mockery of clinical investigation….” They are now reviewing the inclusion criteria for their journals. Promotional material in GP’s surgeries is often inaccurate, out of date and biased, according to a Kings Fund report in 1999 [appendix 6].
4.11 Dr Jensen is also criticised for not referring to the complications of manipulation. I am not aware of an independent study that has demonstrated a significant risk from a chiropractic adjustment. To complicate this kind of research further, there are many variables which need to be considered, particularly different techniques, some gentle, others more forceful. “Is chiropractic treatment safe”? asks BCA leaflet “A Helping Hand”, “Chiropractic is remarkably safe” even after surgery, is the answer. [appendix 3], again the BCA leaflet on Sports Injuries states, “As chiropractic does not involve drugs or surgery, there is none of the risks of side-effects associated with these treatments”. It is only this year the BCA has produced a leaflet acknowledging slight “risk” from chiropractic treatment.
4.12 There is no obligation on chiropractors to reference all their publicity material, and it is not normal practice. Section 8.10 of the GCC Code of Practice states that “The publicity materials of chiropractors may refer to clinical research material published by them or others”. The Report states that it should be required. In response to this request, Dr Jensen has now added references to the Website for clarity, these are accurate and clearly identified at the end of the article “How Chiropractic Can Help you.”
4.13 The GCC Code of Practice 8.14 states: “No publicity shall employ any words, phrases or illustrations which suggest a guarantee that any condition would be cured”. There are many instances in the Website where Dr Jensen repeatedly states chiropractic is not a treatment for a given condition, specifically to avoid misleading the public. The Website does state conditions may be helped by a spinal adjustment if the condition is related to a vertebral subluxation and nerve interference. The rationale he has used to justify this claim is the neurological relationships with the Vertebral Subluxation Complex “VSC” and the many symptoms people present with. There is much scientific evidence and case studies to support his rationale, not least from Dr Byfield’s own book ‘Chiropractic Manipulation Skills’ (under cross examination on this point Byfield tolds us he did not write that particular chapter that referred to the subluxation).
5 DIFFERENT SCHOOLS OF THOUGHT ON CHIROPRACTIC CARE
5.1 There are 60,000 chiropractors practising around the world and their training is of a similar standard. There are two major schools of thought in the chiropractic profession. The first considers chiropractic to be a limited biomedical speciality for the treatment of certain musculoskeletal disorders. The second school sees chiropractic as a separate and distinct discipline in the healing arts, focusing on removing interference to the body’s innate healing ability. These equally honourable approaches to healthcare can be traced back to Hygea and Panacea in ancient Greece.
5.2 Asklepios the god of healing had two daughters, Hygea and Panacaea. Hygea was the guardian of health who symbolised the belief that men could remain well if they lived according to reason. Panacaea achieved fame, not by teaching wisdom, but by mastering the use of the knife and the knowledge of the curative virtues of plants. As medicine has developed through history, this division in approach has been preserved with dominance afforded to intervention rather than well-being. The ‘myths’ of Hygea and Panacea symbolise the never-ending oscillation between the two different points of view.
5.3 Due to the political difficulties caused by one profession having such diametrically opposed views, The World Federation of Chiropractic (“WFC”) adopted in May 2001 the consensus definition of chiropractic that was developed by The Association of Chiropractic Colleges, the ACC chiropractic paradigm [appendix 2]. This was supported by the vast majority of national associations worldwide at the congress, and has the support of all the Chiropractic Associations on The Joint Chiropractic Committee JCC in the UK.
5.4 The ACC paradigm defines chiropractic as:-
“A health care discipline that emphasises the inherent recuperative power of the body to heal itself without the use of drugs or surgery. The practice of chiropractic focuses on the relationship between structure (primarily the spine) and function (as coordinated by the nervous system) and how that relationship affects the preservation and restoration of health.
In addition, doctors of chiropractic recognise the value and responsibility of working in cooperation with other health care practitioners when in the best interest of the patient. The Association of Chiropractic Colleges continues to foster a unique, distinct chiropractic profession that serves as a health care discipline for all. The ACC advocates a profession that generates, develops, and utilises that highest level of evidence possible in the provision of effective, prudent, and cost-conscious patient evaluation and care.”
5.5 The ACC paradigm is what constitutes “mainstream” chiropractic worldwide including the UK. There are, of course, some on the fringes of the chiropractic profession who do not subscribe to this consensus view; they are represented by small associations like The National Association of Chiropractic Medicine, in the US, and The Canadian Association of Orthopractic Manual Therapists, [appendix 7]
5.6 A survey of chiropractors by Dr Francis Wilson DC, demonstrated the broad scope of practice of most chiropractors [appendix 8]. He presented his results at the BCA and McTimoney conferences in October 2001, stating that “the majority of British chiropractors considered the management of musculoskeletal conditions, the management of organic or visceral conditions, and the management of children to be within the remit of chiropractic care”.
5.7 The broad diversity of chiropractic practice has always been recognised by the European Chiropractic Union “ECU”. The ECU consensus document (1998) states “Despite the lack of adequate scientific evidence, consensus by peer groups might support a recommendation to become a guideline. Therefore the gold standard is not the weight of scientific evidence, but a play off between what practitioners experience in clinical practice and the consensus process. The triangulation between the available evidence, discussion by practitioners of particular aspects of their work and the recommendations which are produced, makes informed debate”.
5.8 The spirit of consensus was highlighted in a letter to the profession by Dr Peter Dixon, former President of the BCA and now President of the European Chiropractic Union [appendix 9].
“One of our great strengths as a profession is the diversity that is Chiropractic. It is not possible to absolutely define what it is to be a Chiropractor, and we must all accept that there are differences in the way we were educated, the way we choose to interpret that knowledge and the way we then handle our practices as a result. None of us has the right to criticise another’s style, unless there is the potential for injury to the patients being treated”. He went on to say “People are not idiots, and surely they would not continue to generate referrals to any practice if they were not experiencing benefits”. I am sure this also applies to the Parker Clinic.
5.9 The Report attempts to define the scope of chiropractic practice. However, the Standard of Proficiency Required for the Competent and Safe Practice of Chiropractic states at Section 1 paragraph 1 [Appendix 10] that:-.
“Chiropractic is an independent primary health care profession. In common with other such professions, the law does not attempt to define precisely what is the scope of chiropractic”.
5.10 The Report states on page 9 that “claims regarding the benefits of spinal manipulative therapy must be limited to the known evidence for musculoskeletal symptom patterns”. This approach may well help integrate chiropractic into the NHS, but if the welfare of the patient is to be paramount, then the principal objective should be helping the individual who presents at the chiropractic clinic.
5.11 The chiropractic profession has limited funds for research and has tended to focus its research on mechanical back, neck pain and headache as stated in the Report. It goes on to say that less than 5% of the people visiting a chiropractic clinic have non-neuromusculoskeletal complaints. Therefore there is a greater need to concentrate on this area of chiropractic care when marketing chiropractic, to increase public awareness that chiropractic is more than just a treatment for back and neck pain.
5.12 If through clinical experience a chiropractor thinks he or she may be able to help a condition even though academics have not produced data for “peer review” publications. In my opinion there is an ethical duty for the chiropractor to offer chiropractic care and explain the theory behind it. The alternative is to wait for the evidence and as recognised by the Report “inadvertently excluding useful therapeutic options that may otherwise benefit patient well being”. (According to scientists in the US it is theoretically impossible to hit a baseball at 90 mph, yet it happens all the time [appendix 11]) science does not have all the answers. In my opinion the solution for both points of view within the chiropractic profession is to embrace the principles of consensus outlined by the ACC Paradigm.
5.13 The ACC Paradigm [appendix 2]
Considering the ACC paradigm in greater detail:
The ACC is committed to greater public service through reaching consensus on the following issues, which are important to the chiropractic profession.
· Continued enhancement of educational curricula;
· Strengthening chiropractic research;
· Participating and providing leadership in the development of health care policy;
· Fostering relationships with other health care providers;
· Affirming professional confidence and conduct;
· Increasing public awareness regarding the benefits of chiropractic care.
5.14 The consensus statement represents the broad diversity of chiropractic college missions in the United States and the UK with the possible exception of the Welsh Institute who focus on an evidence based best practice paradigm.
5.15 The Chiropractic Paradigm is as follows:
PURPOSE. The purpose of chiropractic is to optimise health.
PRINCIPLE. The body’s innate recuperative power is affected by and
integrated through the nervous system.
PRACTICE. The practice of chiropractic includes establishing a diagnosis, facilitating neurological and biomechanical integrity through appropriate chiropractic case management, and promoting health.
FOUNDATION. The foundation of chiropractic includes philosophy, science, art, knowledge, and clinical experience.
IMPACTS. The chiropractic paradigm directly influences the following: education; research; health care policy and leadership; relationships with other health care providers; professional stature; public awareness and perceptions; and patient health through quality care.
5.16 The Subluxation is explained within the ACC paradigm as follows: –
“Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence.”
5.17 To survive, neurons need activation and fuel. Mechanoreceptors in the spinal joints need to be active. Lack of activation will eventually result in trans neural degeneration which affects the function of neurons. The homologous relationship of the neurons in the spinal cord means any pathway to the brain can be affected by dysfunction. This is the mechanism to explain how DD Palmer, the founder of chiropractic, improved the hearing of Harvey Lilard with a spinal adjustment. Thinking DD Palmer had discovered a cure for deafness, deaf people came to him to have their hearing restored. It was not a cure for deafness but it helped other conditions, their headaches, their dizziness, their neck pain and so a profession was founded over a hundred years ago.
5.18 In the Report, Dr Byfield criticises the use of the word “subluxation” in the Website throughout, (specifically at pages 9,10,16 at, section 7 paragraph 1(vi), and 6(iii). However, the term can be found in most Chiropractic textbooks, including ‘Chiropractic Manipulative Skills’ which was edited by Dr Byfield in 1996. Dr Byfield states on pages 26-27: –
"For chiropractors however, segmental instability is but one clinical entity that we may encounter. Closer to home is the spinal fixation, subluxation, dysarthrosis or biomechanical dysfunction, that we locate in almost all our patients. Call it what you will, what it represents is a perceived reduction in relative segmental motion"[emphasis added]
5.19 In the Website Dr Jensen chooses to call it a vertebral subluxation. In the Report Dr. Byfield views the VSC as a clinical myth. A view shared with The Orthopractic Manual Therapy Association of Canada [appendix 7]. Dr Byfield’s new book appears to be directed at manual therapists generally rather than chiropractors.
5.20 According to Meridel Gatterman, in her book Subluxation – Foundations of chiropractic (1996), more than one hundred synonyms have been used for subluxation [appendix 12]. Gatterman describes the subluxation complex or VSC as a “theoretical model of motion segment dysfunction that incorporates the complex interactions of pathologic changes in nerve, muscle, ligamentous, vascular, and connective tissues” [appendix 13]. She goes on to say that the VSC supports DD Palmer’s original hypothesis that the neurological component of the subluxation is the cornerstone of chiropractic theory. The subluxation complex provides a structure for better understanding the foundation of chiropractic theory and provides a paradigm for chiropractic education and research.
5.21 The subluxation has been adopted as the “chiropractic lesion” by the World Federation of Chiropractic Congress in Paris in May 2001 and the vast majority of its member associations. Although the BCA abstained from the vote to allow time for discussion among its members. In my opinion The BCA will endorse the paradigm at the Special General Meeting being arranged to vote on it, George Carruthers the BCA president has recommended it to the members. McTimoney Association; Scottish Chiropractic Association; and The United Chiropractic Association, all endorse the ACC paradigm.
5.22 In his book Dr Byfield would appear to agree with many of the theories regarding the effects of segmental dysfunction or subluxation, on a wide variety of conditions. These claims are in line with the subluxation theory as presented on Dr Jensen’s Website. Dr Byfield states in his book: on Pages 206-207
“Mechanical dysfunction of the cervical spine has been reported to be an important aetiological factor in the presentation of certain types of headache, migraine, acceleration/deceleration syndrome, shoulder and arm pain, tinnitus, autonomic nervous system disturbance, including disorders of equilibrium, cervical migraine, vertigo and cervical angina.
“The importance of the cervical spine in maintaining postural equilibrium and coordinating head and eye movements has been well established and documented. Furthermore it is almost impossible for all other systems of the nervous system to function normally when their is lack of stability, coordination and purposeful movement patterns at the cervical level of the body. This suggests that restoration of mechanical function of the cervical spine should be considered an element in all rehabilitation programmes as a result of the overall neurological implications on the entire body”.
"Manipulation of the cervical spine has a significant effect on the tone on lumbopelvic musculature therefore the normal mechanical function of the cervical spine becomes an important consideration in the restoration of total body movement and posture".
Page 176 “Thoracic manipulation takes an additional importance from a neurological perspective, with its relationship to the sympathetic ganglion chain”.
5.23 To gain an insight into the matrix of ideology, politics and philosophy of health, out of which the broad scope of practice referred to in the Website is based, I will address the concept in the context of contemporary health promotion and the parallels with chiropractic as defined by the ACC paradigm should become apparent.
5.24 The Report states on page 19 “Chiropractors claim to have a role in health promotion, but typically this role is attributed to patient education and advice rather than to spinal manipulation”. This statement demonstrates the reductionist philosophy that the report also applies to subluxation-based chiropractic. In my opinion, subluxation based chiropractors could have a major role to play in health promotion.
5.25 In his book “Rethinking Health Promotion” Professor Theo MacDonald (1998) explained that health promotion should not be seen as a “separate” discipline, rather a symbiotic relationship between different approaches to health “to effectively support the empowerment of individuals and communities”.
5.26 The most common definition of health promotion comes from the Ottawa Charter for Health Promotion (1987). It stated that “health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and be able to change or cope with their environment”.
5.27 Health is seen as a positive concept, emphasising psychosocial factors as well as the physical capabilities reaching an equilibrium of physical, social and environmental factors which contribute to the optimum well being of the individual. This concept of health integrates ideas of community and individual contributions to health promotion by focusing on empowering individuals, by the development of their self-esteem so that they assume control over their health.
5.28 According to MacDonald “health promotion claims a distinct intellectual territory for itself in the following respects”. Health enhancement should include many approaches that do not rely on medical targeting of disease. Health education is the transparent communication of health information. Health empowerment encourages individuals to assert their own autonomy and have the self-confidence to assert their own health care agendas. Health is social as much as individual.
5.29 The philosophy of health care Dr Jensen describes in the Website recognises illness as multifactorial and the need for a holistic approach to health care. The health care provider is seen as an educator, a facilitator of optimal well-being using the least intervention possible. The emphasis is on caring as opposed to treatment of symptoms. According to Jameson in “Topics in Clinical Chiropractic” (1996) health can be promoted by creating an environment where well-being is optimally expressed. While the environment that permits expression of optimum health is unique to each individual, there are general principals that can be universally applied – clean water, safe food, a supportive network of personal relationships and effective coping skills that contribute to optimal well being.
5.30 Dr Byfield represents the modernist/biomechanical/musculoskeletal school of thought and Dr Jensen belongs to the philosophical/holistic/vitalist school. This distinction is central to an understanding of the information contained in the Website and it is in line with progressive thinking on health. That is not to say that chiropractors belonging to the philosophical school see it as an alternative or substitute for medical care. Medicine’s role is in the treatment of disease. Heart attacks, operable tumours or life threatening accidents, for these conditions medical care is paramount, nevertheless medical practitioners need to understand when the application of medical care is appropriate and acknowledge that prescription of medicine is not a cure, and sometimes even harms the patient [appendix 24, 25, 26, 26b]. In my opinion wellness should be the goal of all health care professionals.
5.31 A growing number of scientists claim that we are in the midst of a scientific revolution, a major paradigm shift with tremendous implications for how we deal with health and disease, according to eminent neuroscientist, Candace Pert who wrote “Molecules of Emotion” (1999). She states: –
“Reductionism Cartesian thought is now in the process of adding something very new and exciting – and holistic – emotions, the connection of mind, body and spirit” (page 18)
5.32 She refers to body/mind intelligence, an intelligence to seek wellness, one that can potentially keep us disease-free without the modern high tech medical intervention we now rely on.
5.33 Dr David St George a consultant in public health medicine and a senior lecturer in Clinical Epidemiology at the Royal Free Hospital, echoed this view at a Wessex CPD lecture for chiropractors two years ago. Dr St George also stated in “The Homeopath” in 1994 [appendix 24] “the time has come for complementary medicine to turn away from the need to obtain legitimacy from orthodox medicine by adopting its paradigm and research methods.
5.34 Chiropractic is based upon a philosophical premise that there is universal intelligence in all matter, which accounts for all of its atomic properties and activities, thus maintaining it in existence (Ralph Stevenson 1926: Chiropractic text book). Living matter on the other hand consists of molecules that are bonded together in an organised pattern, existing not as independent units but as part of a co-ordinated structure.
5.35 Most health professions accept the concept of an inborn wisdom, which runs and heals the body. But acknowledging it and making it a fundamental tenet of the philosophy and practise are entirely different. History reveals the philosophical underpinnings upon which chiropractic and medicine respectively rest. Throughout history the pendulum of acceptance and power has swung between them, with mechanism’s recent domination (in the form of allopathy).
5.36 Chiropractic’s vitalist assumptions are outlined by Tedd Koren in his article in Science & Medicine Sep 1999 [appendix 14 page 42] they include:
· The body is intelligent and behaves in a purposive way. There is something inside living creatures which causes them to respond and learn things, that a mere collection of chemicals can never do. To mechanists the body is a collection of chemicals obeying general laws of chemistry, physics and mechanics.
· Illness is seen as a reactive, curative response and symptoms as beneficial phenomena which should not be suppressed or eliminated. To mechanists the symptom is intrinsically harmful and must be removed or combated.
· Vitalist therapeutics seek to strengthen the patient’s powers of resistance and compensate for the predisposition to become ill. Mechanism is far less interested in the body’s resistance or predisposition, in general, mechanism is more concerned with treating the “disease” than with the host organism.
5.37 Chiropractic, as a vitalist healing philosophy, science and art is not limited to patients with certain conditions, but instead to all individuals, no matter what their presenting symptoms, who have vertebral subluxation complex (VSC), spinal distortions which interfere with the function of the nervous system. If chiropractic is to have a role in health promotion the most effective method by which to judge this art should be determined. Chiropractors have long noticed that spinal adjustments affect people in many ways, so how may we best evaluate such an intervention.
5.38 If the purpose of the spinal adjustment is the correction of the VSC and not the treatment of named conditions, then chiropractic, along with other vitalist healing arts, may not be amenable to the same testing procedures of the (medical/pharmaceutical) randomised controlled clinical trial. Outcome studies hold promise because they highlight the holistic approach in caring for the person who may or may not have a named disease rather than the “disease entity” which is a mechanistic approach. Some studies that have been done to support the holistic claims of chiropractic [appendix 15].
There followed discussion about the individual claims and then the conclusion.
6 General Comments on the Report
6.1 I am of the opinion that the Report represents an extremely narrow account of part of broad scope of practice that most chiropractors adhere to in the UK and the rest of the world.
The Report does not recognise the need for flexibility in defining the chiropractic paradigm, and how attitudes to patient empowerment are changing among healthcare professionals as stated by the BMJ in August [appendix 16]. “Healthcare professionals must recognise that they do not hold a privileged position from which they alone recognise all medical truths. Medical paradigms come and go, and medicine often develops new paradigms to support the continuation of certain practices when faced with conflicting data.”
6.2 The Report states that it is “not a complete systematic review of the available literature for all subject areas but mainly to provide a representative sample of the more recent literature pertaining to neuromusculoskeletal medicine.” In other words a representative sample chosen by Dr Byfield, The NHS Centre for Reviews and Dissemination (CRD) 1996 describes a systematic review as “ the process of systematically locating, appraising and synthesising evidence from scientific literature in order to obtain a reliable overview.” They differ from traditional reviews by having a scientific design therefore reducing bias and systematic error and promoting reliability.
6.3 The Report does not seem to recognise that “the rigid insistence on controlled trials as the sole source evidence on effectiveness that characterised the beginnings of the evidence based healthcare movement is fading”. [appendix 17]
6.4 There are 35 instances where the Report has misquoted or misinterpreted the Website: 1v,vi,vii,viii. 2i. 3ii,iv. 5i,ii,ii,v,viii,ix. 6i. 6biii. 7i,iii,iv,v. 8i. 10vi. 11i. 12i,iv. 13ii,iii,iv,v. 15v. 16ii,iv. 17viii.
6.5 Regarding treatment, the GCC Standard of Proficiency Required for the Competent and Safe Practice of Chiropractic Care states at section 5.1 [appendix 10]: –
“A chiropractor must be competent to select the appropriate treatment for the individual patient and be proficient in its delivery. A chiropractor should be competent to recognise the risk or contra-indications associated with any treatments. A chiropractor should also know and understand the theories underlying such treatments.”
Dr Jensen has explained the theory behind correcting the VSC throughout the Website in basic language that members of the public can understand. The Website was not intended for peer review.
6.6 Many of the criticisms directed at the Website also apply to most of the BCA promotional leaflets, and all the other UK chiropractic associations and websites and promotional material in most GP surgeries [Appendix 6].
vi) Vertebral Subluxation
The Report states “chiropractic is not devoted entirely to correcting vertebral subluxations.” The word “entirely” has been added. What is stated in the Website is “chiropractic is devoted to correcting abnormal spinal structural conditions called vertebral subluxations or spinal nerve stress which cause abnormal spine and joint motion and nervous system stress”. This is very much in line with the description Dr Byfield gave in his book “spinal fixation, subluxation, dysarthrosis or biomechanical dysfunction, that we locate in almost all our patients. Call it what you will, what it represents is a perceived reduction in relative segmental motion" (page 27)
The Report refers to the statement “uncorrected vertebral subluxations can cause many health conditions and prevent or interfere with the normal healing process”, and describes this as being misleading. The Website actually states “subluxations can cause or contribute to many health conditions”. “Can” and “contribute” are the operative words here. By leaving out “contribute” the Report has the effect of implying that the Website is suggesting a definite cause and effect from the subluxation which, in my opinion, it is not.
I see no reason why chiropractors should not speculate on the effects of the vertebral subluxation complex on general health. Numerous examples of the effects of somatic (muscles) or visceral (organs) sensations on visceral function mediated and regulated by the autonomic nervous system can be cited [appendix 21]. The medical profession is also looking at the connection [appendix 21a] unfortunately in many instances the neurophysiologic mechanisms are poorly understood. Nevertheless, according to Meridel Gaterman, therapeutic intervention that alters somatic or visceral function may have effects in body systems apparently remote from the site of the applied therapy. A growing body of evidence suggests that there exists a close correlation between somatic functions and visceral functions.
Currently it is not possible to determine exact systemic consequences of the vertebral subluxation complex. What we do know is that spinal manipulation, which is used by chiropractors to correct subluxations, elicits some very specific effects involved in immune responses and other physiologic roles as well A study by Banks et al (1997), on quality of life and well-being, a self reported retrospective characterisation of 2818 patients under chiropractic care revealed that chiropractic recipients reported significant improvement in overall quality of life [appendix 22]. The reported outcomes reflected a large positive clinical effect in every health-related domain investigated: physical state, mental/emotional state, stress and life enjoyment. Moreover, patients who had been under care the longest time reported greatest perceived improvement in wellness. The “Textbook of Clinical Chiropractic” edited by Gregory Plaugher presents an algorithm for the chiropractic management of a patient with visceral concomitant [appendix 22a].
Other studies are referred to on page 45. In one of them Coulter et al (1996) investigated the value of chiropractic care in persons 75 years and over. Out of a population of 414, a small sub population of 23 (5.65%) reported receiving chiropractic care. Those under chiropractic care had better overall health and a higher quality of life compared to non-chiropractic users. The chiropractic users were less likely to have been hospitalised, less likely to have used a nursing home, more likely to report a better health status, had fewer chronic conditions, were more likely to exercise vigorously, more likely to be mobile in the community, and less likely to use prescription drugs than non-chiropractic users. In addition, 87% of chiropractic users described their health status as good to excellent, compared with 67.8% of non-chiropractic patients.
Physiotherapists are now also exploring the neurophysiological effects following spinal manipulative therapy
8.3 The problem within the chiropractic profession has been that two schools of thought have completely different ideas on how the profession should progress. For years musculoskeletal pain relief has been seen as the coin “of the realm” in its quest for legitimacy. According to Masarsky 2001, narrowing the professions focus to musculoskeletal pain made licensure possible in Canada’s Ontairo province. In Australia, intense pressure has been placed on practitioners who mention non-musculoskeletal pain in their advertising, despite supportive research findings and the widely held belief among the nation’s practitioners that chiropractic care can improve visceral function.
8.4 In the landmark 1979 report on chiropractic in New Zealand, the Commission of Inquiry noted that much of the medical opposition to chiropractic had to do with claims that adjustments could influence the course of systemic visceral (type O) disorders.
8.5 There is no doubt the mechanical approach has elevated the profile of chiropractic in Europe. At the same time the biomedical model has been subject to much criticism for it’s claims regarding “scientific proof” where commercial interests were involved. Health is not like mathematics, the variables are so many there can be no absolute truth or proof. Health care practitioners must treat their patients as individuals and respect their ability to make informed choices about their health. The key to a better health service is empowering individuals to make those decisions. As Peter Dickson DC, President of the ECU said “the public is not stupid.” People are not going to go to chiropractors if they are not being helped or chiropractors are making claims to cure all disease.
8.6 A patient does not ask for proof of what a chiropractor does. Can the chiropractor prove that he cures back pain, heals headaches, fix damaged necks? No he cannot. What the average patient wants to know is can the chiropractor help. The chiropractor cannot treat cancer but could chiropractic help someone with cancer? A mechanist practitioner will probably say no. A holist practitioner will advise the client to follow the best outcome prediction for the tumour, equally important, optimise the health potential of the individual to prevent cancer cells spreading to other organs, and improve the quality of life of the individual. This is the way health care is moving as health professions recognise the limits of the biomedical approach.
8.7 Of course science is important as is mechanism particularly in the area of emergency medicine. Some chiropractors may choose to play a role in the development of a branch of manual medicine within the NHS. They should be respected for it as should chiropractors who want to help optimise the health of their communities as The Parker Clinic is doing, by asking legitimate questions of the biomedical health paradigm. The Website is also encouraging people to explore a non-invasive approach to health care rather than being subjected to more extreme interventions as a first option.
8.8 The chiropractic world the Report envisages has a role in the biomedical model of health care. However chiropractors have a choice as to whether they wish to participate. In my opinion it is not possible to force a profession as diverse as chiropractic to embrace this model against their will, the consensus in the ACC paradigm is the only way forward. In conclusion, to support this point of view I present the definitions of chiropractic in the current leaflets of the four major chiropractic associations in the UK. There are no references accompanying these claims on the respective leaflets and the Website is in complete harmony with these views.
The Scottish Chiropractic Association [appendix 67]
“Chiropractic relates to the fact that the nervous system controls all organs, tissues and cells of the body. When vital nerve communication pathways are interfered with, as can occur with a variety of structural/functional problems in the spine, pain and ill health can be the result. Research both within and outside the chiropractic profession now provides support for this concept.
Chiropractors locate areas of altered spinal function which may be causing nervous system interference and are particularly interested in a specific problem affecting the spine called, the vertebral subluxation”. (A Guide to Chiropractic)
The British Chiropractic Association [appendix 70]
“Chiropractic specialises in the diagnosis, treatment and prevention of conditions which are due to mechanical dysfunction of the joints and their effects upon the nervous system. Your chiropractor effects an improvement in your joint’s mobility, as well as nerve and muscle function. Your body’s own healing processes will then be able to continue the task of restoring your health.
Less obvious complaints can also result (from nerve irritation) such as migraines, fatigue, chest pain, infantile colic, chest and period pain. Your chiropractor has the training and experience to treat people with these conditions”. (Chirocheck; your personal assessment)
McTimoney Chiropractic Association [appendix 68]
“Chiropractic aims to correct the alignment of the bones of the spine and other joints of the body, to restore nerve function, to alleviate pain, to promote natural health. All organs and cells require nerve information to function correctly, and much nerve information is passed through the spinal cord, protected within the spinal column. Any impediment to the normal nerve supply caused by slight misalignments or malfunction of the vertebrae can therefore be the cause of the pain, discomfort and even disease, and the correction of vertebral function is thus of paramount importance”. (A Gentle Way With Back Pain)
United Chiropractic Association [appendix 69]
The nervous system has a central role in regulating, coordinating and integrating the functions of the entire organism. We recognise that interference to innate intelligence (subluxation) diminishes healing capacity, with an alteration in the dynamic interrelationship between mental, physical and social aspects of the whole person. The art of chiropractic encourages optimal expression of health by the detection, removal (adjustment) and prevention of nervous system interference. Chiropractors use drugless, minimally invasive techniques to adjust identified subluxations throughout an individual’s lifetime”. (UCA Newsletter No 1)