By Scott Haldeman, D.C., M.D., Ph.D.
Reprinted from FCER Advance, Winter 2001 issue.I have had the privilege of being associated with chiropractic and chiropractic ideas all of my life through my father and grandmother, both of whom were practicing chiropractors. I have also been lucky to have participated in one of the most exciting phases in the evolution of chiropractic over the past 35 years. I thought that it would be of interest to younger researchers and clinicians to present my views on how the profession has evolved to its current position in society and how this evolution has impacted our understanding of chiropractic. I plan to discuss how we can put the changes in the role of science over the past 100 years in perspective and how these changes are likely to impact our lives as researchers, chiropractors, and physicians studying and treating patients with spinal disorders.
Chiropractic, in its early stages, had some very colorful and interesting theoretical perceptions. The most widely quoted theory was that one could seek chiropractic care for anything that was wrong and that chiropractic would make it better. It was also widely believed that everybody should be seeing a chiropractor on a regular basis even if they were healthy. This concept led to the situation where chiropractors became outcasts to the medical system. These claims were often repeated in flamboyant advertising in newspapers and resulted in complete separation of chiropractic from the rest of the world of health care that was unable to accept this point of view without some research support. The last 2 decades have seen a dramatic change to a situation where chiropractors are now widely accepted and have high quality scientific meetings that are often cosponsored by medical institutions. Chiropractic has spread from the United States throughout the world to the point where there are now more chiropractic colleges outside the U.S. than inside the U.S. The acceptance of chiropractic has been so successful that the annual conferences by the World Federation of Chiropractic are cosponsored by the World Health Organization (WHO). As further indication of the acceptance of chiropractic, a WHO Collaborating Center Task Force on the Cervical Spine and Related Disorders has been established, with a number of individuals with chiropractic training included on the various panels. Chiropractic has moved rapidly from the outskirts into the mainstream of health care. The independent reviews of research and clinical practice by such agencies and commissions as the AHCPR, the New Zealand commission, the Australian, Danish and British guidelines for treating people with back pain or spinal problems have included input by chiropractic authorities and many of the procedures practiced by chiropractors have received favorable recommendation. How has this happened?
In the early part of the Twentieth Century, there were many traditional treatment approaches that had been offered to patients for years. Manipulation had been practiced almost since the beginning of recorded history. The practice of medicine consisted primarily of a variety of herbs, extracts and metals which had been handed down from practitioner to practitioner with limited effectiveness. Surgery consisted of crude methods of treating injuries and wounds and attempts to remove diseased organs and drain infections. All of these traditional practices were based on clinical tradition and experience and almost all of the theory supporting their use was speculative with very little scientific support. Clinicians of the day were required to speculate or postulate on the mechanism by which these treatments could be successful. When patients said they felt better after treatment, it was considered a good treatment. Clinicians had to guess at the reason they were treating in a certain way based primarily on their training and experience rather than any true evidence to support the treatment approach.
Treatment of spinal disorders at the beginning of the Twentieth Century consisted of mobilization or immobilization of the spine. Basically, the patient was placed in a brace with bed rest or given manipulation and exercise. The theories referred to restoring motion and thereby relieving inflammation, putting vertebrae in place and relieving neuro-vascular compression or interference. Classic chiropractic theory of that time described the effect of the adjustment in terms of putting vertebrae in place and reducing nerve compression. Classic osteopathic theory referred to putting vertebrae in place and thereby reducing vascular compression. The theory held by many medical practitioners suggested that manipulation increased vertebral motion and somehow reduced inflammation.
Despite the lack of research there was a general recognition by chiropractors of the importance of science. One of the points I want to make is that the emphasis on science and research within chiropractic is not something that has only occurred in the last two decades. There has always been an interest in scientific investigation by chiropractic institutions and leaders it’s just that the understanding of scientific principle and the training and resources available for scientific investigation was very limited. D. D. Palmer made this point by defining chiropractic as "the science of healing without drugs." One difference between chiropractic theory and that held by the mainstream medical community during the early years of the Twentieth Century was the incorporation of vitalistic concepts into the perception of the mechanism of healing. Chiropractors, and in different terms naturopaths, osteopaths, and homeopaths, supported the position that the body had the innate ability to cure itself if given the specific treatment offered by these clinicians. It was not necessary to know exactly how this happened. The promotion of these concepts was occurring at a time when the mainstream health professions were intensely trying to make some sense of the physiological and pathological processes through which the body could become diseased and treated.
The mid-Twentieth Century was a period of major theory development. This was a time when it appears to the casual reader that everybody was developing a new theory to explain how the spine worked and could be influenced by the various treatment approaches. The primary basis for many of these theories was pathology. There was a strong tendency to describe the disorders that could impact the spine in pathological terms. Scientific investigation was carried out in order to prove or disprove a popular theory of the time. It was not uncommon for a scientist during this period to start with a theory that had a long history and set out to scientifically prove its validity. When I decided to study for my Masters Degree, my father (who was a chiropractor) told me to "prove chiropractic" rather than to find out how the chiropractic treatment approach might be successful. Much of the research of this period was carried out to prove a particular widely held theory. Osteopaths set out to prove osteopathy, surgeons attempted to prove the basis for many surgical procedures, and so on. Similarly, clinical research during this period was undertaken to prove or disprove the validity of practices that had often been used for decades or even centuries. This process led to the development of a wide spectrum of theories—spinal irritation, focal sepsis, enchondroma, nerve root compression, disc herniation, to mention a few.
This development of theory also occurred in chiropractic institutions and at times became very disruptive and led to a loss of unity within the profession. It was comforting to many chiropractors to have a single vitalistic theory behind which all chiropractors could unite. But suddenly D. D. Palmer’s old theories of nerve irritation were revised, Joseph Janse at the National College began talking about nerve impingement, Earl Homewood was emphasizing neural reflexes, and B. J. Palmer was talking about spinal cord compression and developed the HIO theory. Other chiropractic leaders were postulating meningeal tension or vertebral fixation as the primary lesion affected by the adjustment. Suddenly there were all of these new theories and concepts as chiropractors tried to explore and explain what chiropractic was and how it worked. This led to a very difficult, conflicting, dogmatic approach to health and spinal care both within chiropractic and between chiropractors and other health care professions.
The basic thought process was the same, however, in most professions; you believed therefore you treated. If you believed that discs herniated, pain had to originate from discs, therefore treatment was surgical removal of the discs. If you believed that posture and spinal mechanics changed and were important, pain must result from abnormal posture and aberrant mechanics, and therefore treatment must be manipulation and postural exercises (or something similar). If you believed that spinal joints degenerated, pain was assumed to be from pathology in these joints, and treatment naturally consisted of manipulation, or, in the medical field, injections. If you believed that discs degenerated, pain must be from internal disc disruption, and therefore you had to fuse these discs or ablate them with various intradiscal treatments. If you believed that spinal muscles were prone to pathology, weakness, or spasm, the treatment of choice would be exercise, manipulation, or massage depending on the clinician’s perception of the procedures that would impact these muscles. This thought process caused many clinicians to start their argument with a pathological process or a theory, extrapolate these theories beyond the facts and then use it to justify their treatments. This resulted in the separation of clinicians into different and often emotionally committed theoretical camps. I’ve been to many medical and chiropractic meetings where a panel would be made up of a series of believers—the surgeon and his belief, the chiropractor and his or her belief, the osteopath and his belief. This was often called "interprofessional cooperation." Unfortunately, none of these clinicians would really talk to each other or even understand what other members of the panel with a different point of view were talking about.
During this period of history the chiropractic community continued to have a major interest in research but unfortunately was not publishing very much and was having difficulty both in reaching a consensus and presenting its point of view to the public. B. J. Palmer developed an extensive series of case reports that initially were hidden in Palmer Clinics and, I have been told, were finally buried under an elevator at the Palmer College. Many of these case series were very well documented with extensive testing including blood pressure monitoring, heart rate, blood tests, and more. The best osteological collection of spinal pathology was collected by B. J. Palmer and displayed at the college in Davenport. He also developed complex pieces of equipment to measure the effects of the adjustment—the electroencephaloeneuromentipograph being the most classic. Experimental research was also being carried out in a few of the colleges. Carl Cleveland, Jr., did some very intricate neurophysiological animal experimentation in the 1940s and 50s. It was during this period that the idea of funding research through a foundation came into being. C. O. Watkins is credited with the establishment of the Chiropractic Research Foundation in 1944, the precursor to the Foundation for Chiropractic Education and Research (FCER). When discussing research funding—and specifically FCER—it should be kept in mind that we’re talking about an institution that’s over 50 years old.
It was in the 1970s that the first formal interaction between chiropractors and medical physicians in an academic forum took place through the auspices of the NINDS (National Institute of Neurological Disorders and Stroke) which was asked by the U.S. Congress to organize a conference on spinal manipulation. This was my first major introduction to the scientific political arena and it is when I realized that one person could have considerable impact on the direction of research and inter-professional relations. Since I had just completed my Ph.D. degree, I was asked to serve as one of the representatives on the organizing committee of this conference. I was a second year medical student living in Vancouver, British Columbia, and I found myself in a very strange situation. One day I would be taking notes in class and the next day I would by flying to Bethesda, Maryland, where I’d sit in a meeting with full professors and heads of NIH. I would then fly back to Vancouver and start taking notes in class. At our first meeting, Murray Goldstein, who chaired the conference, asked us to propose participants for the program. I went back to Vancouver and began working on the program. I drew up an entire program with the lecture topics and speakers, proposing authorities I had only dreamt of meeting. I included names such as Alf Nachemson, James Cyriax, John Mennel, William Kirkaldy-Willis, and many others, most of whom I had only read about. At the next meeting, Murray Goldstein stood up and said, "Okay, who’s brought us anything?" And I went up and proudly put my program on the table where everyone else was going to put theirs. I had hoped that some of the people and topics I had proposed would be accepted. I was however, the only member of the panel who had done any work on the program. So Murray said, "This looks good. Let’s start with what Scott’s brought us." As a result, eighty percent of the topics and speakers I had put down were invited to this meeting.
It was a very exciting meeting and it opened up the whole field of research into chiropractic and manipulation. Following the conference, one basic conclusion was reached and verbalized by Murray Goldstein in the proceedings as follows: "There are little scientific data of significance to evaluate this clinical approach to health or the treatment of disease." After everyone had presented their points of view, he basically said that chiropractors had no science that could be used to justify their clinical practice and theory and the medical profession had nothing to justify its criticisms. It was a major eye-opener. I truly believe that because of this particular meeting, the chiropractic leaders in attendance (including representatives of the ICA, ACA, and FCER), recognized that this was an unacceptable state of affairs and that it was essential that these organizations become active in stimulating chiropractic research or the profession would be doomed. I believe that it was this meeting that served as the primary stimulus for the advancement of chiropractic research in the world.
All of the other clinical groups who practice manipulation went away with negative opinions on the meeting. The osteopaths, who had led the research efforts into manipulation prior to this time, seemed to stop having an interest in the topic. The physiotherapists who practiced manipulation appeared to decide that they couldn’t do any research so they’d just continue to do what they had been doing. The medical profession seemed to take the position that "So what, we’ve proven our point—there’s no scientific basis for chiropractic—we can ignore it." And since there was nobody else who had any interest in manipulation except chiropractic, it became the only profession to evolve, producing increasing numbers of researchers and searching for sources of funding. It was this decision to advance research into the theory and practice of chiropractic that resulted in the position the profession finds itself in today—dominating the field of manipulation research and establishing validity for its practice.
Shortly after the NINDS conference, in 1979, I had the privilege of organizing a conference, sponsored by the International Chiropractors Association (ICA), which produced a textbook titled Modern Developments in the Principles and Practice of Chiropractic. Now 1979 was not that long ago, but when I wanted the textbook published (and I had major medical and international scientific authorities writing chapters), I could not get one medical publishing house to even consider publishing the text. They all gave me the same reason—"Chiropractors don’t read. They don’t buy books. And since chiropractors don’t buy books, there’s no point in publishing a textbook." Eventually, a sub-editor at Appleton-Century-Croft showed some interest because her father or grandfather had been successfully treated by a chiropractor. She called me and said, "Okay, we’ll publish it if you’ll guarantee 1,000 books up front." The ICA had the foresight—this was in the days when Joe Mazzarelli and Jerry McAndrews held senior positions in the ICA—to back the text and it sold over 25,000 copies. This text opened the door to a lot of the publishers so that today they cannot find enough chiropractic authors to write—they’re actually going from college to college to find authors to write textbooks for chiropractors.
The end of the Twentieth Century and current times have seen another stage in the thinking of the role of research in the practice of chiropractic. This has become the era of scientific investigation. There is still a need for scientific exploration of traditional theories, but now these theories are starting to come together to form a more coherent picture. Chiropractic researchers, many of whom have spoken at ICSM conferences (including John Triano, Lynton Giles, David Cassidy, Alan Terrett, Howard Vernon, and many others), are working together in multiple academic disciplines to formulate well thought out theories on the impact of the adjustment and manipulation on the body. There is also a convergence of theories between chiropractic and medical researchers in a number of fields such as the three joint complexes, spinal disc disease and stenosis, the myofascial syndromes and central pain mechanisms.
There has been dramatic change in thought process both from a clinical and from a scientific point of view over the past 100 years. In the early years of chiropractic, practice drove theory—as B. J. used to say, "It works, therefore it is." Patients seem to benefit from chiropractic therefore an explanation, however valid or invalid, had to be developed. There was almost no science and there was certainly no clinical research at that time.
During the "middle ages" of chiropractic, theory drove science. In other words, there is a theory which was widely believed therefore what was needed was the science to prove it. Research investigation was carried out to demonstrate that the practice was valid.
Today we are starting to enter the era where science is driving theory. Scientists and clinicians are developing new theory out of the scientific knowledge that is evolving. This new theory is based on the results of prior scientific investigation. At the same time, clinical research is beginning to drive practice. What we are allowed to do in practice and what we will be permitted to do in practice in the future will be dependent upon what we can prove to be effective. Those methods of practice that are shown to be valid and effective will be permitted whereas those practices that are not shown to be valid will be discarded, not paid for, or discredited. This process of investigation should result in the development of new techniques as well as new methods of treatment. This is already happening in the practice of medicine and it’s about to happen in chiropractic—science is going to start driving the direction of clinical practice as well as theory. If chiropractors do not accept this change many will find themselves in a kind of culture shock as the demands to follow this pattern pick up momentum. It must be realized that scientific research is forming the basis of the theories that direct further research and which therefore direct clinical practice. It should allow for an evolution of the thought process on how patients should be managed to the benefit of both patients and chiropractors.
Right now chiropractors can go before any audience and say that there is sufficient science to discuss the neurological and clinical effects of the adjustment. It is no longer credible for anyone to state that "there is no scientific basis for spinal manipulation or the chiropractic adjustment." It is, however, essential that any proponent of chiropractic be very careful not to include leaps of faith and dogma when interpreting the research that is available. Unreasonable leaps of faith and dogma inhibit understanding of the physiological effects of the adjustment and slows down eventual comprehension of the value of chiropractic care. The adjustment probably has multiple effects and anybody who proposes a single theory for the effect of chiropractic care is probably a person who should be ignored. The theories on which chiropractic is based are evolving and I believe that we are entering the most exciting time in chiropractic’s theoretical history. I think we’ll find that the people who are doing research will discover physiological processes we have not yet considered and they will develop much more exciting theory than we have today. This will lead to more exciting practice and much better ways to treat—and explanations on why and how we treat—our patients in the next 10 or 20 years.
The primary factor that will determine the speed that is likely to occur is the commitment by the chiropractic profession in the research process. This requires that individual chiropractors become more involved by reading the scientific journals and attending meetings where the results of research are presented. Research, however, is dependent on financial support. The results of research will benefit chiropractors and their patients more than any other group. It is therefore essential that chiropractors financially support institutions that fund research. It is only through such funding that the theories and practice of chiropractic will continue to evolve and the practice will improve to the benefit of all chiropractic patients.