Every health care profession has its glittering jewels and its warts. If we really want the noble chiropractic profession to obtain the positive image and respect that it deserves, it is up to us to acknowledge and critique the shortcomings and foibles of our colleagues, and to hold ourselves to high professional standards. To do otherwise, even under the well-intentioned but short-sighted guise of professional fraternity, is to invite public criticism from our detractors, who have in the past displayed our "warts" under bright illumination with a magnifying glass. It is my intention, in writing the following critique, to call attention to a presentation that I view as potentially embarrassing to the profession solely as a goad toward improvement, and not as an attack on an individual.
In the January 27, 1997 issue of Dynamic Chiropractic, we were treated to an exploration of the work of Dr. Alf Breig, neurosurgeon. This exploration was brought to us by Dr. Jesse Jutkowitz, chiropractor. I was intrigued immediately by the title: "Dr. Breig's Research: What We Need to Do to Effectively Use His Data. The Research Data of the Neurosurgeon Who Demonstrated Multiple Sclerosis and Other 'Diseases' of That Type Are Caused by Biomechanical Pathologies Rather than Immune System Disorders or Heredity." I did not know that degenerative neurologic diseases had been demonstrated to be of biomechanical origin (and thus readily addressed by traditional chiropractic care). I knew that if this claim were true, it would be of great import, so I studied the article carefully, checked Dr. Jutkowitz's Internet site as suggested, and then procured the work of Alf Breig so that I could learn from it directly.
While Dr. Breig's work is elegant, and dramatically demonstrates the basics of the biomechanics of tensile stresses within the spinal cord, I was very disappointed to learn that there is no data in the work to support Dr. Jutkowitz's contentions. An analysis and rebuttal of Dr. Jutkowitz's article is presented below.
Dr. Jutkowitz tells us, "The basic question being asked is: If Dr. Breig determined that multiple sclerosis, ALS, and other etiologies of that type have structural etiologies and can be successfully treated structurally, why can't chiropractic seem to help these people on a consistent predictable basis? The answer is to remember that the research was done by a neurosurgeon." When I read this I had great difficulty in understanding how the fact that basic research was conducted by a neurosurgeon could result in a lack of consistent treatment outcome by chiropractors. I decided not to pursue this linguistic non sequitur, and instead explored the work of Alf Breig directly to see if in fact he had provided evidence that "multiple sclerosis, ALS and other [diagnostic entities] of that type have structural etiologies that can be successfully treated structurally."
Actually, Dr. Jutkowitz has fundamentally misrepresented Dr. Breig's work. Dr. Breig "tentatively ascribed" the neurologic effects seen in MS patients on flexion of the neck as being due to "pressure of the sclerotic changes in the spinal cord tissues on the neighboring pathways."1 It was Dr. Breig's hypothesis that glial scars in the cord secondary to MS created foci of abnormal mechanical stress on flexion. Dr. Breig makes no claim whatsoever in his book with regard to having established mechanical stress as being the etiology of degenerative neurologic conditions. And, despite Dr. Jutkowitz's characterization of Breig's work, I could not find a single mention of ALS, or any presumed autoimmune or genetic condition other than MS anywhere in it.
With regard to Breig's treatment of such conditions, Dr. Jutkowitz states: "He was quite successful, but the medical profession held onto its 'disease' concept so strongly that Breig's work has been all but ignored." Actually, Breig's book describes only three MS cases that he treated,2 one in 1961, the second in 1962 and the third in 1972. Aside from the extremely small number of cases, the clinical outcome of the treatment could be described by no rational person as "quite successful."
The first patient described noted sensory improvements, and motor changes that had no functional significance (barely visible toe movements that could be repeated 3-4 times on a single occasion). Five months postoperative the patient had again deteriorated to nearly preoperative status. Breig discontinued follow-up, and notes the patient died of MS "some years later."
The second case is described as having postoperative sensory and motor improvements, but the nature and extent of these improvements are not given. The patient was discharged eight days post-op, and Breig never heard from her again.
The third case was given a "tentative" (and questionable) diagnosis of MS. He had developed progressive neurologic symptoms beginning 6 weeks after jumping from a burning building, and was found on myelography to have large C4/5 and C5/6 herniations and mid-thoracic cord atrophy. He experienced no improvement from an initial surgery, gradual postoperative improvement from a second procedure, reversal of those improvements within three months, and no significant improvement from a third procedure. There was no follow-up after the third procedure. Given this extremely small patient base and the equivocal results obtained, ascribing the medical profession's failure to wholeheartedly adopt Dr. Breig's techniques as due to a strict adherence to a "disease" concept is quite incredible.
There were some biomechanical aspects of spinal cord tensioning discussed by Dr. Jutkowitz that also deserve attention. "While Dr. Breig did experiments definitively showing this fact [the existence of cord tension?] using both live subjects during surgery and cadavers, as a personal demonstration of this one can flex their head on their neck while standing and then squatting, which flexes the lumbar spine. Noting the feeling of tension on the posterior aspect of the head (virtually none in most people standing) increases greatly in the squat position." Dr. Breig's experiments to demonstrate traction of the lumbar spinal roots by flexion of the cervical spine are simple, elegant and compelling. However, the simple experiment that Dr. Jutkowitz proposes you perform will in fact demonstrate to you that due to the overlapping nature of the erector spinae, you will become aware of greater tension on the cervical musculature with head flexion in a squatting posture. It is doubtful that this phenomenon is related to spinal cord stretching, which doesn't become apparent to most people until you flex the entire spine, flex the hip, extend the knee, and possibly add dorsiflexion of the ankle.
Again on the subject of cord tensioning mechanics, Dr. Jutkowitz tells us, "A point to note and remember: although extension slackens the pons-cord tract, hyperextension tensions the pons-cord tract. This is analogous to what happens on lateral flexion. If the body is flexed right, bringing the body to the left will take the tension off the cord but only to the neutral point. After that point continuing to bring the body left will tension the cord." The analogy of lateral flexion to forward flexion and extension would hold true if the anterior and posterior spinal anatomy were symmetrical, as are the right and left sides.
However, as most chiropractors are aware, the anterior spinal anatomy differs significantly from the posterior. Hyperextension could theoretically put tension on the cord, but only if you can extend so far that you reverse the thoracic kyphosis and tension the cord across the posterior elements of the vertebrae. Of course, this would require removal of the thoracic spinous processes and detachment of the ribs from either the spine or the sternum. To quote Breig's work: "In full extension of the whole spine, with the body in the prone position, the slackened cord sags on to the anterior surface of the canal under gravity."3
Dr. Jutkowitz has several points to make about the clinical relevance of this hypothesis of cord-tension as a significant etiology. Unfortunately, these were mutually contradictory. "The common denominator in these conditions ... from disc conditions to various myelopathies, was that the spinal cord-brain stem was being ... even moderately stretched along its length for long periods of time." At first glance, this looked like it might be a description of the underlying cause of subluxation-induced pathology. Then I read, "Thus the literature findings of 'healthy' asymptomatic people with large lumbar disc herniations visible on MRI. No symptoms are precipitated in these people despite the apparent size and severity of the herniation, since they do little more than take the slack out of the pons-cord tract." After juxtaposing these two statements, I do not know if Dr. Jutkowitz thinks moderate cord tension can or cannot produce symptoms.
Equally difficult to fathom was "Breig's experimentation ... shows objective confirmation of the observation that there can be, and are, large biomechanical pathologies in the column which do not precipitate symptoms ... That data explains the mechanism of the well-known datum that there are minor biomechanical pathologies ... which precipitate symptoms far in excess of their apparent degree of mechanical abnormal[ity] ..." I have been completely unable to see how the existence of large biomechanical changes without symptoms explains the mechanism of minor changes producing many symptoms. This appears to be a contradiction. Unfortunately, Dr. Jutkowitz did not explain what he meant by this. Nor did he explain how Dr. Breig's experiments objectively confirm this common clinical observation. I was personally unable to find any mention of a hypothesis explaining clinical variability by Breig himself.
Dr. Jutkowitz has also attempted to put Dr. Breig's work into the context of the intellectual history of chiropractic theory. "Here we have one of the single most important findings for chiropractic [Dr. Jutkowitz's emphasis]. This mechanism of instantaneous transmission of mechanical tension and the resultant discovery and specifically delineation and demonstration beyond doubt of the effects of generating [primary] and precipitating [compensatory and symptomatic] lesions is the answer to a question that has vexed a portion of our profession for its century of existence." Putting aside my inability to find of any mention of the concept of "generating" and "precipitating" lesions in Breig's work, I can only wonder what is the question that has vexed us so, and how does this concept answer it?
In attempting to relate Breig's work to the ideas of the founder and the developer, Dr. Jutkowitz states: "What Breig has discovered totally validates D.D.'s work by clarifying mechanisms, increasing knowledge, and allowing improvement of the technology of chiropractic ... Breig's work also shows that B.J. was not completely wrong either. Each had a piece that was incomplete." If I recall correctly, D.D. said that subluxation arose from trauma, toxin and autosuggestion. I really cannot understand how this triad can be "totally validated" by the purely mechanical concept of cord traction. I am curious to learn what part of B.J.'s body of work was validated by Breig's experiments. Was it HIO? The neurocalometer? Nerve tracing?
Dr. Jutkowitz also made some very sweeping claims about his own abilities to advance the art and science of chiropractic. He said he "could objectively show what worked in chiropractic; what did not work; and what seemed to work but actually relieved the patient's pain by breaking down the patient's compensations ... while creating other compensations or worsening their overall biomechanical condition." I was very surprised to learn that a member of our profession had already done all of the comparative clinical outcome studies on chiropractic treatment and assessment methods that I had hoped would be in our future. I contacted Dr. Jutkowitz, and asked him to tell me where I could find this research described. In response, I was advised (as were all DC readers) to "visit [url=http://www.advbiother.com]http://www.advbiother.com[/url] on the Internet," and told I would find all of the relevant information on the "Theoretical Basis for Advanced BioStructural Therapy" page.
Upon visiting Dr. Jutkowitz's website, I found information of the same quality as described in this critique, and no reference other than Alf Breig's textbook. However, I did learn that for $399.95 I could get a set of video and audio tapes that would teach me the only current method for "consistency and predictability" in patient treatment and assessment by utilizing multiview, full spine pre-treatment and post-treatment x-rays in both the standing and sitting positions. I also learned that if I want to know the value of full spine films I should consult an engineer rather than a doctor, and that heels can actually improve your health and posture as long as they're less than two and a half inches tall.
While I have no grounds whatever to question Dr. Jutkowitz's motives or intentions, I feel compelled to point out that the combination of the misrepresentation of the writings of Alf Breig, the unfounded claims of assessment objectivity and treatment efficacy, and the commercialization of an educational package based on such poor scholarship creates a very negative appearance. If we chiropractors continue to tolerate operating at low standards by our colleagues, then the periodic public bashing we receive by our detractors is both predictable and deserved.
Robert W. Ward, DC, QME
References
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