The Getting of Respect: American Chiropractors Are Stillfighting for Recognition From Medical Doctors

BY ELLEN RUPPEL SHELL

As A TEENAGER, I occasionally spent an evening baby-sitting for the daughter of a chiropractor. My father, a pediatrician, dubbed these evenings “a night at the quack’s.” At the time I thought he was joking, but as it turns out, he was merely spouting the official opinion of his trade organization, the American Medical Association. The AMA had in fact formed a Committee on Quackery in 1963 to deal with what it considered to be the chiropractic problem. Thirteen years later five chiropractors responded by filing an antitrust suit.

Last September the suit was finally decided. A federal district court judge, Susan Getzendanner, found that the AMA was guilty of conspiracy in “restraint of trade” against the chiropractic profession, that it had unlawfully deprived chiropractors of association with medical doctors, and that by calling them “unscientific cultists” it had eroded the credibility of the profession. The Committee on Quackery was disbanded in 1975, but the AMA continued its official anti-chiropractic efforts until 1980. Getzendanner found that the AMA had “never acknowledged the lawlessness of its past conduct” and that to this day “there has never been an affirmative statement by the AMA that it is ethical to associate with chiropractors.”

The AMA is appealing this decision. Dr. Alan Nelson, the chairman of the board of trustees of the AMA and an internist in Salt Lake City, contends that chiropractic is not scientifically based and that in some cases it can be dangerous. Meanwhile, more people than ever—something like 11 million a year—are seeking the help of chiropractors, most of them for the treatment of low back pain.

There are hundreds of different causes for low back pain. Tumors, infections, ruptured disks, and fractures are a few of the unhappier possibilities, and all of these require skilled medical intervention. But the vast majority of back-pain sufferers have what is called an idiopathic condition—there is no apparent cause for their pain. No treatment approach for idiopathic back pain can truly be called scientific, and of the so far non-scientific approaches, chiropractic appears to be among the most effective.

CHIROPRACTIC IS based on the theory that many disorders of the body are traceable to a misalignment of the spinal column and a concomitant disruption of the nervous system. This is a very old idea, and intuitively it makes a good deal of sense. The spinal cord is a pathway along which messages are carried to organs throughout the body; altering this pathway could well affect the transfer of information and, subsequently, the health of the organs. Chiropractors claim to be able to feel partial dislocations, or “subluxations,” of the joints, which, they say, may be responsible for any number of disorders. The main therapeutic method used by chiropractors is spinal manipulation (they also treat other parts of the body), in which the vertebral segments of the spine are adjusted to correct these subluxations, release compression, and improve nerve transmission. There is no proof that any of this occurs—subluxations do not appear on x-rays, and according to Alan Nelson there is no evidence that subluxations are associated with any underlying illness. Nor is there solid evidence that manipulation significantly alters the spinal pathway. Nonetheless, preliminary clinical evidence indicates that chiropractic is more effective than, say, simple massage for cases of acute back pain. There is also evidence that victims of acute back pain who get the help of chiropractors recover more quickly than those who do not.

Dr. Gerald Leisman, a neurologist who also has a Ph.D. in biomedical engineering, is the chief of the research division of New York Chiropractic College, in Glen Head. Leisman, who is not a chiropractor, says that the process of detecting subluxations is deductive, not scientific, just as is any method of determining a treatment for idiopathic pain. “When I was playing clinical neurologist, I saw at least three thousand patients who suffered from low back pain,” he says. “Generally, the diagnosis was radiculopathy, or irritation of the nerve roots. But there is no scientific way to establish what such a diagnosis means, because irritation, per se, cannot be measured. Subluxation and irritation are not the same, but they are related concepts. There are demonstrable physical states associated with subluxations, and it is possible to show that after a manipulation these states are changed.”

Like many doctors sympathetic to the chiropractic approach, Leisman was trained in Britain, where, he says, chiropractors do not compete with doctors and are treated with a good deal less skepticism than they receive in the United States. In Britain chiropractors are an integral part of the national health-care system, and doctors frequently refer patients to them. Until 1980 the AMA deemed it “unethical” for an American doctor to refer a patient to a chiropractor, and any doctor who did so risked losing his AMA membership. The AMA says that its motive for ostracizing chiropractic was a noble one— that it believed that the dangers of chiropractic outweighed the benefits.

“There is no question that our committee [on quackery] tried to educate the public in good faith,” says Kirk Johnson, the AMA general counsel. “Our motive was patient care. Our campaign went on too long, and it went too far, but we are not going to apologize for it. It’s as old as medicine that unscientific practices are things that doctors will not associate themselves with. The attitude in the early seventies was, Aren’t we allowed to have ethical rules regarding the treatment of patients? To the extent that there has been a stigma against chiropractic, many doctors thought that it was probably earned.”

The AMA dropped its official position on chiropractors in 1980, four years after the antitrust suit was filed, and referring patients to chiropractors is no longer deemed unethical by the association. Still, doctors generally prefer not to comment on chiropractic, and most of those who would speak to me about it said that they would not refer their patients to chiropractors. Dr. Aubrey Swartz, an orthopedic surgeon and the founding executive director of the American Back Society, says that while chiropractors are generally eager to share information with orthopedists, few orthopedists will cooperate with chiropractors. “Frequently chiropractors and orthopedic surgeons share the same patients, but the surgeon will refuse to recognize the chiropractor,” he says. “The doctors are frustrated and angry—they believe chiropractors to be illegitimate. But naturally it is not in the best interest of the patient for the two not to communicate.”

ONLY ABOUT A dozen hospitals in the United States have staff chiropractors. The National Institutes of Health and the National Science Foundation, major funding sources for research in science and medicine, have yet to fund chiropractic research. Hence chiropractors have not had access to the research facilities and funds that would allow their case to be proved or disproved. That problem is being remedied in part bby the Foundation for Chiropractic Education and Research, an independent funding organization that has picked up the tab for about seventy studies. One of these is a clinical trial being conducted by Dr. Malcolm Pope, a professor of orthopedic surgery and mechanical engineering and the director of research in orthopedics at the University of Vermont School of Medicine, which has a federally funded center for research on low back pain. Pope is comparing the relative benefits of chiropractic, massage, electrical muscle stimulation, and two types of back braces in the treatment of severe back pain.

“I have looked extensively at the literature on trials of chiropractic and found them to be very poorly done,” Pope says. “It is true that the scientific basis for chiropractic is weak, but it is nevertheless a very commonly used therapy. There is no proof that any of the treatments we are looking at are effective in the long-term management of back pain. That’s why a well-controlled study is so important.”

Dr. Rowland Hazard, an assistant professor of orthopedics who works with Pope, says that most doctors know little or nothing about chiropractors but that this lack of understanding does not keep them from holding a generally negative opinion. “Chiropractic is a very complicated field,” he says. “There are many different kinds, not only in terms of the science they believe in but in their styles of practice. Some chiropractors feel manipulation is only for spinal pain, while others believe it can be used to treat colds and diabetes. Any generalized statement about chiropractic will get you in trouble.” Hazard says that part of the appeal that chiropractors have for the public may well be in their seeming ability to pinpoint ailments that physicians would not venture to diagnose. “Most chiropractors will tell you they can make a very specific diagnosis,” he says. “They’ll take x-rays and give you what sounds like a highly technical reason why you need realignment, and why you’ll have to keep coming back for alignment for months. What they don’t tell you is that there are any number of people walking down the street who would have very similar x-rays and who have no problem.”

Hazard observes that orthopedic surgeons are in a similar bind. About fifty years ago a couple of surgeons at the Massachusetts General Hospital, in Boston, discovered the herniated disk. Disks are cushions of a jellylike substance surrounded by fibrous material that keep vertebrae from bumping into one another. As we age, the jelly dries up and can rupture through a crack in the fibrous material, sometimes hitting a nerve and causing serious pain. Generations of surgeons were taught to remove abnormal discs suspected of causing pain. But with the advent of penetrating imaging devices like the CAT scanner it gradually became clear that as many as a fifth of people between the ages of thirty and fifty have abnormal disks, yet most of them do not experience pain as a result. Also, statistics emerged showing that disk surgery was not necessarily successful in eliminating pain and, in fact, could sometimes make matters much worse. There are guidelines but no hard rules for distinguishing those who will be helped by surgery from those who won’t—just as there is no certainty that chiropractic manipulation will be effective in a given case. As one orthopedic surgeon told me, deciding whether or not to operate is a matter of judgment.

“The fact is, science is absolutely stretched when it comes to the diagnosis and treatment of back pain,” Hazard says. “A lot of people are operating way beyond what they can prove.”

TRADITIONALLY, THIS lack of hard data hasn’t been a problem for chiropractors. Chiropractic is considered by its practitioners to be a healing art, not a science, and only in the past decade or so have chiropractors themselves come to believe that they need a scientific basis for what they do. According to Stephen Wolk, the director of research for the Foundation for Chiropractic Education and Research, most chiropractors today stick to the treatment of neuromuscular and skeletal disorders, such as joint problems, headaches, and back pain, and no reputable practitioner would attempt to tackle infectious disease, diabetes, or cancer. But this is something of a departure from the not so distant past. At one time or another in its history, which extends roughly a hundred years, chiropractic has claimed to cure almost every condition afflicting man.

“Twenty years ago some chiropractors professed to do more than they could do,” says Dr. Michael Pedigo, the president of the International Chiropractic Association, the smaller of two nationwide chiropractic trade organizations, and a plaintiff in the antitrust suit. (Like dentists, chiropractors are legally entitled to call themselves doctors.) “But we’ve become more realistic. Naturally, one should be leery of a chiropractor who makes outrageous claims”if he says he can cure cancer, go elsewhere. But one should also be aware that the medical establishment exaggerates the number of chiropractors who make such claims. There are medical doctors who make unrealistic claims, but I would doubt that the AMA would appreciate it if we portrayed these few irresponsible physicians as typical of their membership.”

Chiropractors are required to attend two years of undergraduate school and four years of chiropractic college before they can be licensed by national and state boards. Nonetheless, the AMA contends that chiropractors are not qualified to diagnose. This is a sticky issue, because chiropractic procedure inappropriately applied can be disastrous. Patients with severe atherosclerosis, congenital hardening of the arteries, fractures of the spine, and rheumatoid arthritis are not candidates for chiropractic. Spinal manipulation could be lethal for them. However, chiropractors are trained to spot these problems and will refer patients to a physician if they do.

Chiropractors do not perform surgery or administer drugs, and therefore have less opportunity to do harm than doctors have. The good ones give advice on exercise and diet (most chiropractors are better versed in the fine points of nutrition than are most physicians), and many offer physical therapy as part of their treatment. Whether there is a scientific basis to chiropractic theory remains to be seen, but the fact is that, for whatever reason, many people are helped by chiropractors, at least over the short term. Despite the efforts of the medical establishment to keep them out, chiropractors are gradually edging their way into the mainstream of health care, thanks mostly, it seems, to popular demand for their services. If, as the medical community claims, the success of chiropractic is due to good politics rather than to good health care, then it is certainly politics of the grass-roots variety. Chiropractic will not go away. Nor does it seem to be in the public’s best interest that chiropractic should.