By Dr. Christopher Kent and Dr. Patrick Gentempo, Jr. Paraspinal EMG scanning is becoming a popular technique in chiropractic. It is a useful tool for measuring c
By Dr. Christopher Kent and Dr. Patrick Gentempo, Jr.
Although chiropractic has been rated one of the top career choices in the United States by independent authors, it is no secret that our chiropractic profession is at the crossroads.
The last 20 years have seen radical changes in the profession. Against tremendous odds, we have achieved inclusion in most health insurance programs. Licensure was obtained in the last “holdout” states. Federal accreditation has resulted in a revolution in chiropractic education. Refereed, peerreviewed scientific journals have been created to disseminate the growing body of knowledge specific to our profession. Exciting new technologies to objectively evaluate the spine and nervous system, including CT scans, MRI, thermography, video fluoroscopy, EMG, and evoked potentials have been developed and made available to the chiropractor.
These have been tremendous victories, won against great odds. The profession and those we serve can justly be proud. Yet in our quest for recognition, certain factions within the profession seem to have lost sight of why we sought such recognition in the first placeto get chiropractic’s unique contribution to human health disseminated as widely as possible.
In losing sight of the purpose, these factions have initiated policies and processes that are actually antithetical to the purpose.
It has been claimed by some that chiropractic should become a limited branch of medicine, such as dentistry or podiatry. These individuals propose that chiropractors limit their activities to the treatment of musculoskeletal disorders.
Still others feel that chiropractic should consist of the general practice of medicine, including the use of drugs, minor surgery and obstetrics.
Other chiropractors perceive their profession as a “holistic” alternative to traditional medicine and incorporate a wide range of naturopathic treatments. A growing number of chiropractors are encouraging their colleagues to abandon chiropractic terminology, such as “vertebral subluxation,” “analysis,” and “adjustment.” They perceive the chiropractor as but one of many practitioners who employ “manipulative therapy” in the treatment of facet joint dysfunction.
A disturbing number of D.C.s regard acknowledgment of the universal and Innate Intelligence as “religion.” [1,2,3] In short, a perception that medicine is “scientific” and chiropractic is “unproven” seems to pervade a growing element of our profession. This perspective has resulted in a low perceived value of our unique principle and practice.
Science vs. scientism
Science provides investigators with a useful method of inquiry.
Scientific methods have led the healing arts from a world of anecdotal observation, myth and superstition.
However, doctors must not lose sight of the fact that science is not the only valid method of inquiry. Further, it must be realized that while predictability may be considered in designing clinical strategies, all that ultimately matters is what is effective for a given patient in a specific circumstance. Educational institutions producing health care providers must guard against graduating practitioners who are automatons following flowcharts rather than thinking, feeling, human beings.
Although science is not an enemy of chiropractic, scientism most certainly is. Scientism limits all fields of human inquiry to contemporary technology.
Smith states that scientism “refers to an uncritical idolization of sciencethe belief that only science can solve human problems, that only science has value.” Holton observed that “Scientism divides all thought into two categories: scientific thought and nonsense.” [4,5]
What’s wrong with that? A practitioner of science 100 years ago would be forced to declare cosmic waves, viruses, and DNA “unproven” concepts. Such a scientist, bound by the limitations of the technology of the times, would be unable to “prove” or “disprove” the existence of such things. Our hypothetical scientist might go one step farther and deny the possibility of their existence, active as some of them may have been in the dynamics of health and disease! Scientism is a scourge which blinds the visionary and manacles the philosopher.
Aldous Huxley was acutely aware of the folly of limiting all human inquiry to the scientific method. He stated, “The real charm of the intellectual lifethe life devoted to erudition, to scientific research, to philosophy, to aesthetics, to criticismis its easiness. It’s the substitution of simple intellectual schemata for the complexities of reality; of still and formal death for the bewildering movement of life.” [6] Science has a place in chiropracticscientism does not.
Just as scientism limits human inquiry to available technology, bad science, characterized by questionable research designs, leads to faulty conclusions. For example, some critics of chiropractic claimed that it was impossible for subtle disrelationships termed “subluxations” to produce enough pressure on neural structures to alter their function. Through a process of “rationalism” based on animal studies, and a poorly designed study using human cadavers, it was concluded that chiropractic theory was false.
In the first case, animal studies on peripheral nerves revealed that pressures ranging from 100 to more than 1000 mm Hg were required to produce a significant conduction block. [7,8,9] These studies were performed on peripheral nerves, not nerves at their point of exit at the intervertebral foramina. And the issues of cord pressure, CSF dynamics, biochemical changes, and piezoelectric potentials were not addressed.
The reasoning was simple: The pressures required to block animal peripheral nerves are greater than those we think might occur at human intervertebral foramina. Therefore, there is no scientific basis for chiropractic.
The second design was equally flawed, although it emerged from a “prestigious” Ivy League institution. Here, cadaver spines were fitted with electrodes to determine if nerve roots touched the bony boundaries of the IVF when the spines were taken through ranges of motion. Of course, they didn’t, “disproving the chiropractic theory.” [10]
The point is that bad science leads to faulty conclusions. And any scientific inquiry is limited by the technology available to the investigator, the design of the experiment, the analysis of the data, and the conclusions drawn from the data. In short, if you can’t reliably measure something, you can’t investigate it scientifically.
That’s well and good, unless you are trying to investigate something for which reliable and valid measurements have not or cannot be devised. For example, we cannot measure innate intelligence. Does this mean that it is not “real” and that we should abandon the concept merely because we have no technology to detect or quantitate it? We think not.
Chiropractic research
Our profession has very limited research resources. To our credit, we have done a phenomenal job with what we have.
Unfortunately, there is a growing trend in chiropractic to embrace allopathic research designs emphasizing symptomatic rather than physiologic change. A plethora of projects are attempting to determine if “manipulative therapy” is effective in ameliorating back pain.
Chiropractic researchers have expressed enthusiasm for “paper and pencil” instruments for specific diseases and diagnostic entities which rely upon a patient’s subjective perception of symptoms. [11]
Many of these designs are inherently flawed in that they fail to adequately define the nature of the intervention applied (a basic adjustment is quite different from an atlas toggle or a lumbar roll). Worse, from a philosophical standpoint, symptoms are used as outcome criteria rather than the correction of subluxations.
It is sometimes argued that in the absence of reliable and valid indicators of subluxation, subluxationbased outcome evaluation is impossible. Indeed, this is where our initial research efforts must be directed.
Developing technologies to reliably assess the clinical manifestations of vertebral subluxation is a highpriority item. It is not an excuse, however, for failing to use existing technologies which can reliably evaluate certain components of the vertebral subluxation complex.
Chiropractic research is in very real danger of succumbing to the scientism so pervasive in the allopathic community. And by copying the experimental designs of the symptomoriented allopathic model, chiropractic’s unique nontherapeutic approach may be lost. Would it not be absurd to apply the rules of football to a baseball team claiming that, after all, both are ball games?
It is no less foolish to apply allopathic standards to chiropractic research. Even in fields other than allopathic medicine, much clinical research is essentially allopathic in nature. That is, the outcome assessment is often the effect of the experimental treatment on the patient’s subjective perception of symptoms. Chiropractic and medicine are different “games” with different objectives. As such, we play by different rules.
Chiropractic adjustment is not a subset of “manipulative therapy.” It cannot be viewed like a drug or an electrical modality which can be consistently applied without regard for the unique skills of the doctor, or the uniqueness of each interaction between a specific doctor and a specific patient. It is not just another treatment technique in a long and growing litany of treatment techniques. Nor can its value be determined by a patient’s subjective symptomatic response.
Chiropractic’s unique approach is based upon nontherapeutic objectives. The vertebral subluxation is recognized as an impediment to the expression of optimum health. Chiropractic adjustments are designed to remove interference, thus placing the patient on a “more optimum” physiologic path. Outcome assessments used to evaluate chiropractic adjustments must be based upon reliable indicators of structural and functional integrity.
Standards of care
Standards of care must be based upon such subluxationbased outcome assessments rather than amelioration of symptoms. Abnormalities can exist in the absence of symptoms! Consider asymptomatic breast cancer, asymptomatic dental caries, or the “silent killer” hypertension. Basing outcome assessments for these conditions on patient symptomatology would have disastrous results. We have technologies to detect and characterize components of the vertebral subluxation complexlet’s use the ones we have until we develop better ones.
Chiropractic is not a limited branch of physical medicine treating sprains and strains. Chiropractic is a wholebody approach which emphasizes the supremacy of the nervous system.
Our unique contribution to health care goes beyond a methodadjustment of the spine. It embraces a philosophical paradigm radically different from that of allopathy.
To forsake our philosophy, to limit our field of inquiry to science, and to deny that the spiritual component of human existence is an inherent aspect of the healing process is to deny the very basis for our existence as a separate and distinct profession.
Strengthened by increased recognition, we must now direct our efforts toward an increased awareness of why we sought that recognition. The pendulum must swing toward a renewed commitment to that which is uniquely chiropractic.
References
1. Wardwell WI: “Present and future role of the chiropractor.” In Haldeman S(ed): “Modern Developments in the Principles and Practice of Chiropractic.” AppletonCenturyCrofts. Norwalk, CT, 1980.
2. Wardwell WI: “A marginal professional role: The chiropractor.” Soc Force 30:339, 1952.
3. Wardwell WI: “The impact of spinal manipulative therapy on the health care system.” In Goldstein M (ed): “The Research Status of Spinal Manipulative Therapy.” DHEW publication (NIH) 76998, 1975.
4. Smith RF: “Prelude to Science.” Charles Scribner’s Sons. New York, NY, 1975, p. 12.
5. Holton G: “The False Images of Science.” In Young LB (ed): “The Mystery of Matter.” Oxford University Press. London, UK, 1965.
6. Huxley A: “Point Counter Point.” Quoted in Smith RF, op cit p. 8.
7. Meet WJ, Leaper WE: “The effect of pressure on conductivity of nerve and muscle.” Am J Physiol 27:308, 1911.
8. Edwards DJ, Cattell M: “Further observations on the decrement in nerve conduction.” Am J Physiol 114:359, 1928.
9. Causey G, Palmer E: “The effect of pressure on nerve conduction and nerve fiber size.” J Physiol 109:220, 1949.
10. Crelin ES: “A scientific test of the chiropractic theory.” Am Sci 61(5): 574, 1973.
11. Jansen RD: “Professional success: Measuring outcomes, not incomes.” Dynamic Chiropractic 8(9):35, 1990.
