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The Evolution of Chiropractic — Science & Theory
By
Scott Haldeman, D.C., M.D., Ph.D.
Excerpt
from Keynote Presentation September 21, 2000
2000
International Conference on Spinal Manipulation
Reprinted from FCER Advance, Winter 2001
issue.
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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.
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