One-Dimensional Chiropractic: Thinking Outside of the Box

When is the last time you found yourself trying to grasp the history of an era by looking at its relics and found yourself preoccupied (if not mesmerized) by their idiosyncracies rather than their intrinsic qualities? You became immersed in the crumbling ruins of columns, the sepia finishes of daguerreotypes or the scratches and pops of Edison wax discs on your way to uncovering the essence of the past. In fact, to give an example, you progressed to the point of not even being able to believe the authentic recordings of Al Jolson or Bessie Smith unless they were accompanied by the customary hisses and crackles representing the state-of-the-art of sound reproduction. As Marshall MacLuhan would have put it, the medium became the message and you lost sight of the actual voice qualities of these seminal artists.

This scenario in many ways is what has happened to chiropractic. In its 100-plus year history, we have closely identified the art and science of chiropractic with manipulation of the spine but have often lost sight of the concept of patient homeostasis, and the practitioner's own capacity to implement a wide assortment of noninvasive, drugless therapies to regions which often lie beyond the spine.

What the public has often lost sight of is that besides providing scores of manual, articular manipulative procedures, chiropractors have historically applied nonarticular manipulative therapies such as manual reflex and muscle relaxation techniques. In addition, they may employ such nonmanual procedures as exercise and rehabilitation; nutritional counseling; electrical and thermal modalities; bracing, casts and supports; traction; and even ultrasound. All these interventions have been documented with varying amounts of supporting evidence.¹

The trouble arises when the concept of chiropractic becomes reduced to cracking the spine. This narrow perception is one-dimensional chiropractic at its worst. For starters, where does this leave the extremities? Such an approach disregards a large body of current research (much of which has been funded by FCER2) supporting the efficacy of chiropractic care in the management of cumulative trauma disorders in the extremities.^2-4 There is yet additional research published which has reported the successful application of osteopathic or ultrasonic modalities in the management of carpal tunnel syndrome.^5,6

One-dimensional chiropractic rears its ugly head in extremis when one considers the spate of papers which appeared in both the New England Journal of Medicine and the Journal of the American Medical Association.

1. The Cherkin study disingenously suggested that only a single form of side-posture manipulation shorn of extension exercises and other physical modalities constituted the whole of chiropractic management. The study concluded: "There are no clear advantages of chiropractic manipulation" for low back pain and that reimbursement for its "small benefits" was "open to question."⁷


2. The Balon study went a step further by using a sham procedure involving soft-tissue interventions in the spine, head, shoulders, ankles, feet and gluteal regions. Although improvements were seen in both the experimental and sham groups, the authors resorted to the bone-cracking stereotype of one-dimensional chiropractic. They concluded that, because there were supposedly insignificant differences between the groups with and without cavitations, "The addition of chiropractic spinal manipulation ... provided no benefit" in the treatment of childhood asthma.⁸


3. The Bove study demonstrated that, between two types of interventions carried out by the same chiropractor in response to episodic tension-type headache, there is no significant clinical difference in the improvements observed in both treatments. Unlike the Cherkin and Balon studies, this particular investigation demonstrated positive effects by two protocols which are integral to the practice of chiropractic (deep friction massage and trigger point therapy).

Unlike our brethren in the previous two studies, the authors in this research scrupulously concluded: "As an isolated intervention, spinal manipulation does not seem to have a positive effect on episodic tension-type headache."⁹ They also pointed out from their previous research that there is a positive effect of spinal manipulation in the treatment of cervicogenic headache.¹⁰ Thus, we see a powerful rationale for establishing a careful diagnosis of the types of headache presented, well within the chiropractor's area of expertise.

Unfortunately, this carefully crafted interpretation of results was mutated by no less than the editor of JAMA. In an editorial in the November 11 issue which was intended to showcase (but not necessarily support) various types of "alternative" therapies, Fontanarosa and Lundberg gave only a hit-and-run reference to the Bove study, reporting that "Chiropractic spinal manipulation is not effective for episodic tension headache."¹¹

It does not take more than a few sputtering brain cells to imagine how these three studies were interpreted by the lay press. Even though the Bove study was so much more carefully interpreted and presented fully within the context of previous research conducted by the authors, any information that could conceivably be considered to reflect positively upon chiropractic management was effectively censored. The message which inundated the public and which may unfortunately lap up to the transoms of prospective third-party payers from all these studies is simply that chiropractic is ineffective for all the conditions (low-back pain, asthma, and episodic tension-type headache) studied. As Damon Runyon might have put it, this type of distortion of scientific information is more than somewhat troubling.

The problem is basically one of communication. While the chiropractic profession talks about the importance of establishing a proper gatekeeper to health care, what we are really witnessing here is the lack of a proper gatekeeper to the media. As so eloquently concluded in a recent survey by Cheryl Hawk and her colleagues at Palmer University, "The disparity between the established view of chiropractic as synonymous with spinal manipulation and the profession's view of chiropractic as a complete system indicates a need for better interprofessional communication."¹²

At this writing, FCER and NCMIC are taking steps in an attempt to resolve this problem. A comprehensive monograph on the attributes and accomplishments of chiropractic by David Chapman-Smith is due within a few months. Additional personnel are being engaged by FCER and NCMIC to establish more systematic and periodic contacts with the major media so that the flagrant type of misinterpretations and design flaws discussed above will no longer become propagated as urban legends.

In so doing, I hope within the near future that we will no longer have to endure these hyperalgesic reactions to some of the distortions recently seen in both the medical journals and lay press. One-dimensional chiropractic, like the Edison wax disc, will then find a more appropriate resting place in an archive rather than the public forum.

References

1. Haldeman S, Chapman-Smith D, Petersen DM Jr. Guidelines for Chiropractic Quality Assurance and Practice Parameters. Proceedings of a consensus conference commissioned by the Congress of Chiropractic State Associations, held at the Mercy Conference Center, Burlingame, CA, January 25-30, 1992. Gaithersburg, MD: Aspen, 1993.
2. Davis PT, Hulbert JR, Kassak KM, Meyer JJ. Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome. A randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 1998;21(5):317-326.
3. Bonebrake AR, Fernandez JE, Dahalan JB, Marley RJ. A treatment for carpal tunnel syndrome: results of a follow-up study. Journal of Manipulative and Physiological Therapeutics 1993;16(3):125-139.
4. Mariano KA, McDougle MA, Tanksley GW. Double crush syndrome: chiropractic care of an entrapment neuropathy. Journal of Manipulative and Physiological Therapeutics 1991;14(4):262-265.
5. Sucher BM. Palpatory diagnosis and manipulative mangement of carpal tunnel syndrome. Journal of the American Osteopathic Association 1994;94(8):647-663.
6. Ebenbichler GR, Resch KL, Nicolaki P, Wiesinger GF, Uhl F, Ghanem AH, Fialka V. Ultrasound treatment for treating the carpal tunnel syndrome: randomised "sham" controlled trial. British Medical Journal 1998;316:731-735.
7. 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.
8. Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O'Shaugnessy 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.
9. Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. Journal of the American Medical Association 1998;280(18):1576-1579.
10. Nilsson N, Christensen HW, Harvisgen J. The effect of spinal manipulation in the treatment of cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 1997;20(5):326-330.
11. Fontanarosa PB, Lundberg GD. Alternative medicine meets science. Journal of the American Medical Association 1998;280(18):1618-1619.
12. Hawk C, Byrd L, Jansen RD, Long CR. Use of complementary healthcare practices among chiropractors in the United States: a survey. Alternative Therapies in Health and Medicine 1999;5(1):56-62.