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Abstract
Many chiropractors treat patients with spinal adjustments based on the theory that correction of vertebral subluxations will restore and maintain health. This paper explores the controversy surrounding the practice of chiropractic and discusses some of the dangers associated with inappropriate use of spinal manipulation. Treatment of infants and children by subluxation-based chiropractors who do not endorse such medically accepted procedures as immunization or use of antibiotics is especially a cause for alarm. Explaining the scientifically rejected chiropractic subluxation therapy and describing some of the questionable treatment methods based on this theory, a veteran chiropractic reformer concludes that if the chiropractic profession fails to abandon the false premise upon which it is based, it will remain controversial and some aspects of chiropractic treatment will continue to be a threat to public health.
... Not only is it unethical [88] it is totally inappropriate. Some chiropractors have even gone so far as to suggest that subluxation based practice is a threat to the public health [91]. Given the best available evidence I suspect chiropractors marketing their care in this fashion could be faced with the unenviable task of defending against an allegation of unconscionable conduct under Australian Consumer Law. ...
Aim
This paper examines appeal to fear in general: its perceived positive aspects, its negative characteristics, its appropriate as well as its fallacious use.
Background
Appeal to fear is a commonly used marketing method that attempts to change behaviour by creating anxiety in those receiving a fearful message. It is regularly used in public health initiatives such as anti-smoking, anti-drunk driving campaigns as well as in hypertension awareness campaigns. Some chiropractors appear to use appeal to fear to promote subluxation awareness and thereby encourage the use of chiropractic treatment.
Research supporting its use is equivocal; nevertheless, when used judiciously, appeal to fear probably has sufficient strengths to warrant its continued conditional use. When used to promote care for which there is no supporting evidence, its use is fallacious.
Discussion
Appeal to fear has been used in health promotion campaigns for sixty years or more with the intent of modifying behaviours. While there is evidence to suggest that appeal to fear may motivate some individuals to modify offending behaviour or adopt recommended behaviour there is growing resistance to the use of appeal to fear on ethical and psychological grounds. Using appeal to fear as a tool of persuasion can be valid or fallacious depending on the truth of the premises within the argument.
When used to raise awareness about genuine health concerns such as smoking, drunk driving and hypertension appeal to fear is considered to be a valid approach with certain caveats. However, when appeal to fear, not based on evidence or reason, is used as motivator to get others to accept unnecessary interventions for unproven disorders, the use of appeal to fear is fallacious.
Conclusion
In spite of the evidence against its use, it seems likely that appeal to fear will continue to be used in conjunction with other public awareness initiatives to modify recognized detrimental behaviours such as smoking and drunk driving as well as silent killers such as hypertension. However, when used to promote a treatment that has no evidentiary basis such as subluxation based practice in chiropractic the appeal to fear is a fallacy and must be stopped.
... Chiropractic's problem is that subluxation based chir- opractors [59] are not only deluding themselves, they are indoctrinating patients into believing in a purportedly dangerous mythical entity, and that without regular adjustments, patients will not only fail to reach their full potential, they will likely suffer serious health problems. Some authors have suggested that this may be a threat to public health606162. And this, at a time when the profession has just entered The Era of Chiropractic Opportunity. ...
Chiropractic has endured a turbulent history, marked by tremendous advances in areas such as education and licensing while marred by interprofessional conflict and a poor public image. The prolonged interprofessional conflict was instrumental in shaping the culture of chiropractic. These obstacles have long-since been removed although there are lingering effects from them.
This article examines the chiropractic profession's history by dividing it into five Eras and suggests that there are three options available for the future of the profession. One: maintaining the status quo. Two: uniting under an evidence based scientific approach as partners in the health care delivery system that has buried the "one-cause, one-cure" sacred cow. The steps required to achieve this outcome are outlined. Three: openly dividing the profession into evidence based practitioners and subluxation based practitioners. Adopting this option would allow each branch of the profession to move forward in the health care delivery system unhindered by the other.
It is unclear which option the profession will choose and whether the profession is mature enough to follow option two remains to be seen. What is evident is that the time to act is now.
... 6 The antivaccination stance of some chiropractic organizations, and the writings and other activities of certain chiropractors, [7][8][9][10][11][12][13] have placed the profession as a whole under scrutiny. 5,6,[14][15][16][17][18][19][20][21][22] It is therefore appropriate to consider whether or not there is any justification for such a stance. Although most public health authorities would agree that vaccination constitutes one of the most cost-effective infectious disease control measures of the last century, few, if any, would argue that there are no problems associated with their use. ...
There is evidence to indicate that upper cervical manipulation can cause stroke by injuring vertebrobasilar arteries. Many chiropractors routinely manipulate the neck as part of a treatment regimen designed to improve health by adjusting "vertebral subluxations." Physical therapy practitioners may occasionally use cervical spine manipulation in the treatment of a problem related to loss of mobility. Although stroke caused by neck manipulation is rare, it happens most often among chiropractic patients who may be subjected to unnecessary manipulation based upon untenable guidelines. This review by a retired chiropractor offers some insight into problems associated with chiropractic neck manipulation.
This survey was conducted to identify factors that may be associated with changes in knowledge and attitudes towards basic health promotion and public health concepts among chiropractic students enrolled in a course in community health.
Anonymous surveys were conducted of students before and after a second-year chiropractic college course in community health. Results were analyzed using percentages and Chi Square statistics as appropriate.
Students' knowledge of health promotion and public health concepts improved significantly by the end of the course. Students' attitudes towards these also improved, although to a lesser degree. Students indicated that they had a favorable impression of the importance of utilizing health promotion in practice and working with other public health professionals. However, vaccinations were still looked upon unfavorably by half of the students by the end of the course. Pre-class, a positive attitude towards public health concepts was associated with being female, older, Latino, having children, having a poorer perceived health status, conservative politically and religious. These differences tended to lessen by the end of the course.
A course in community health was successful in adding to students' knowledge and positive attitudes towards health promotion and public health. However, additional educational strategies are needed to ensure changes in future practice behavior, particularly in the area of vaccinations.
To evaluate the quality of Recommended Clinical Protocols and Guidelines for the Practice of Chiropractic (ICA guidelines) published by the International Chiropractors Association (ICA), August, 2000.
The Appraisal Instrument for Clinical Guidelines (Cluzeau instrument) was applied to the ICA guidelines by 10 independent experienced evaluators. An independent, global assessment was also made by each evaluator.
Mean scores (with 95% confidence limit) for each of the instrument's 3 dimensions were Rigor of Development, 27% (5.1); Context and Content, 18.3% (9.4); and Application, 2% (3.9). The unanimous global assessment was "not recommended as suitable for utilization in practice." Comparison of the ICA guideline scores with the Council on Chiropractic Practice's Clinical Practice Guideline No. 1, Vertebral Subluxation in Chiropractic Practice (CCP guidelines) scores and Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy guidelines) Cluzeau instrument-based scores revealed that the ICA guidelines received slightly higher scores than the CCP guidelines but substantially lower scores than the Mercy guidelines for all dimensions.
The ICA guidelines were assessed as not suitable for utilization in chiropractic practice.
Chiropractic is one of the most controversial and poorly defined healthcare professions with recognition and licensure in the United States. Chiropractic was started by D. D. Palmer, a magnetic healer who formulated the vertebral subluxation theory. The profession was developed by his son, B. J. Palmer. Although the definition of chiropractic as a method of correcting vertebral subluxations to restore and maintain health is questionable, spinal manipulation is of value in the treatment of some types of back pain. The chiropractic profession is still based on the vertebral subluxation theory, and has the confusing image of a back specialty capable of treating a broad scope of health problems. Despite opposition to use of spinal manipulation as a method of treating a broad scope of health problems (as opposed to the generally accepted use of manipulation in the treatment of back pain), chiropractors seek support as primary care providers in alternative medicine. It is essential to understand the theories, philosophies, and methods of chiropractic for an objective evaluation.
IN 1996, THE UNITED STATES HEALTH RESOURCES AND SERVICES ADMINISTRATION awarded a contract to conduct a "National Workshop to Develop the Chiropractic Research Agenda." To inform that workshop, and to better understand their clinical environment, a representative mail survey of American chiropractors' research priorities was undertaken. The purpose of the study was to determine practicing chiropractors' needs and preferences relative to research both in general and in the short term. Scantron questionnaires were distributed by first class mail to a random sample of 2,280 chiropractors in the United States; 1,245 questionnaires were returned and analyzed. All participants were practicing chiropractors. Respondents used a five-category Likert scale to rate the relative importance of a menu of research objectives and topic areas. All rating percentages are presented, but the highest importance rating percentages are utilized for analysis. American chiropractors feel that the acceptance of chiropractic, primarily by patients and other health care professionals, should be the most important research objective. They feel that this can best be accomplished in the immediate future by basic science research on the nature of the subluxation complex and/or the physiological effects of adjustments including visceral and neuromusculoskeletal effects. In addition, very low priority was given to developing research resources, or to evaluating clinical techniques, procedures, or equipment.
The vertebral columns of six individuals were studied. Three were infants, one a full term newborn female that failed to breathe after birth; the other two, a male and a female, were full term infants who died of a respiratory disorder within a week after birth. The remainder were adults: a 35 yr old male, a 73 yr old male and a 76 yr old female. As soon as the vertebral column was excised it was immersed in a physiological saline solution at body temperature to insure maximum flexibility of its joints during the testing that immediately followed. A careful inspection both before and after the testing revealed that each vertebral column was normal for the age of the individual from which it was excised. A standard drill press was used for the tests. It had a rotating handle that allowed the forceful lowering of the chuck, to which was attached a Dillon force gauge certified to be accurate to within ± 1% of full scale reading. It was a compression model with marked dial increments of 10 pounds up to a capacity of 1,000 pounds. The range of maximum compressive force, or breaking point, that could be applied to the individual vertebrae of the cervical, thoracic and lumbar regions of the newborn and adult columns before they became irreversibly collapsed is about 2 to 7 times as big for adults as for newborns. In newborns the difference between cervical, thoracic and lumbar vertebrae is small. In adults, the lumbar are stronger.
Several theories have been put forth in attempts to explain the possible mechanisms by which patients presumed to be suffering from any of a variety of internal organ diseases are occasionally found to respond quickly and dramatically to therapies delivered to purely somatic structures (e.g., spinal manipulation). The purpose of this review is to examine the scientific bases upon which these sorts of clinical phenomenaight be interpreted.
A review was conducted of over 350 articles that have appeared in the scientific literature over the last 75 years. Initially, a MEDLINE search was performed; however, because of the variability of indexing terms employed by investigators within a wide variety of biomedical disciplines, most of this literature had to be located article by article.
At present, there have been no appropriately controlled studies that establish that spinal manipulation or any other form of somatic therapy represents a valid curative strategy for the treatment of any internal organ disease. Furthermore, current scientific knowledge also fails to support the existence of a plausible biological mechanism that could account for a causal segmentally or regionally related "somato-visceral disease" relationship. On the other hand, it has now been firmly established that somatic dysfunction is notorious in its ability to create overt signs and symptoms that can mimic, or simulate (rather than cause), internal organ disease.
The proper differential diagnosis of somatic vs. visceral dysfunction represents a challenge for both the medical and chiropractic physician. The afferent convergence mechanisms, which can create signs and symptoms that are virtually indistinguishable with respect to their somatic vs. visceral etiologies, need to be appreciated by all portal-of-entry health care providers, to insure timely referral of patients to the health specialist appropriate to their condition. Furthermore, it is not unreasonable that this somatic visceral-disease mimicry could very well account for the "cures" of presumed organ disease that have been observed over the years in response to various somatic therapies (e.g., spinal manipulation, acupuncture, Rolfing, Qi Gong, etc.) and may represent a common phenomenon that has led to "holistic" health care claims on the part of such clinical disciplines.