Chiropractic: an introduction.

Abstract

In a little more than 100 years chiropractic has emerged from what was considered a fringe healing art in the American Midwest to the largest alternative health care system in the United States, and a mainstream health care at that.

Nearly 35 million Americans visit the approximately 55,000 Doctors of Chiropractic (D.C.) each year. Approximately 14,000 students are presently enrolled in the 16 U.S. chiropractic colleges. Chiropractic colleges also exist in Japan, Australia, Canada, England, France, Denmark, and South Africa.

To better understand chiropractic's success we will review its discovery, philosophical foundation, proposed models of action, and some examples of clinical results. All have played a role in its survival, growth, and expansion into the most popular non-medical health care system in the United States and the world.

Chiropractic is the Largest Alternative Health Care System in the United States.

People visit chiropractors for various reasons. Many, of course, see D.C.s for help with a disease or condition, viewing chiropractic as a drug-free approach to their problems, often after first exploring medical care. Others use chiropractic as a method of health maintenance, to prevent disease while others (including many amateur, professional, and Olympic athletes) use chiropractic to enhance their health and performance. Yet a fourth reason is that people are attracted to chiropractic because its philosophy is more in harmony with their own values, beliefs, and philosophical orientations toward health and life. (1)

The Discovery of Chiropractic ("Harvey, Can you Hear Me?")

September 18th, 1895, Davenport, Iowa. D. D. Palmer, a successful magnetic healer, learned that Harvey Lillard, his janitor, had become deaf 17 years earlier. Lillard said something "gave" in his back and he lost his hearing. Palmer examined the man's spine and found "a vertebra racked from its normal position." Palmer adjusted the vertebra back into place "using the spinous process as a lever and soon the man could hear as before." His curiosity piqued, he examined other patients' spines:

   Shortly after this relief from deafness,
   I had a case of heart trouble,
   which was not improving. I
   examined the spine and found a
   displaced vertebra pressing
   against the nerves, which innervate
   the heart. I adjusted the vertebra
   and gave immediate relief.
   Then I began to reason if two diseases
   so dissimilar as deafness
   and heart trouble, came from
   impingement, a pressure on
   nerves, were not other diseases
   due to a similar cause? (2)

Such was the discovery of chiropractic. In many ways it was a rediscovery of the ancient art of spinal care found in nearly every culture and practiced since time immemorial.

Palmer recognized his discovery as part of the vitalistic tradition of healing, thus ensuring that chiropractic would remain separate and distinct from (and in conflict with) allopathy and its mechanistic philosophy.

Vitalism (Empiricism) vs. Mechanism (Rationalism)

Medical historian Harris L. Coulter, Ph.D. in his four-volume magnum opus Divided Legacy reveals the continuing 2,500-year struggle between two internally logical yet contrasting systems of healing philosophy, vitalism (also known as Empiricism) and mechanism (also known as Rationalism). They differ markedly on concepts such as "disease," "cause," and "symptom," the principles of therapy, the relationship between theory and practice--in a word, all elements of a medical philosophy. Throughout history the pendulum of acceptance and power has swung between them. Mechanism's recent domination began at the turn of this century but its limitations and extremes have resulted in many individuals turning to the vitalist approach found in many alternative healing practices gaining wide acceptance today. Indeed, we appear to be in a transition period today. Historically the swing to vitalism has helped spark needed reforms in mechanism.

Although commonly believed that vitalism is about life energies--anima, elan vital, prana, pneuma, chi, and the like, it is really about biological laws. Vitalism states that the laws governing living organisms differ from those of lifeless matter. The organism is reactive, at all times coping with, and attempting to overcome, the stresses that impinge upon it from outside. It behaves purposively, the nature and form of its reaction being determined by the specific environmental stress it encounters. It responds to challenge, which no aggregate or assembly of non-living substances can ever do.

This does not mean that organic matter possesses unique features that differ from inorganic matter, after all chemists are able to create "organic" molecules; urea was synthesized over 100 years ago.

Among chiropractic's vitalist assumptions are the following:

* The body is intelligent and behaves in a purposive way. There is something inside living creatures that causes them to respond and learn--things a mere collection of chemicals can never do. To mechanists the body is a collection of chemicals obeying general laws of chemistry, physics, and mechanics.

* Illness is seen as a reactive, curative response and symptoms as beneficial phenomena which should not be suppressed or eliminated. To mechanists the symptom is intrinsically harmful and must be removed or combated.

* Vitalist therapeutics seek to strengthen the patient's powers of resistance and compensate for the predisposition to become ill. Mechanism is far less interested in the body's resistance or predisposition. In general, mechanism is more concerned with the "disease" than with the host organism. (3)

Thus, chiropractors do not limit their care to patients with certain conditions, but instead to all individuals, no matter what their presenting symptoms, who have spinal distortions interfering with their nervous system interrupting their connection to the innate (or inborn) intelligence that runs their body. Free of spinal nerve interference the individual must benefit.

The Vertebral Subluxation Complex 

Palmer's "displaced vertebrae ... [causing] impingement, a pressure on nerves" has evolved today into the vertebral subluxation complex (VSC), a multi-component clinical phenomenon that can be located through spinal analysis and adjusted (corrected) using chiropractic clinical protocols.

The heart and soul of chiropractic, the vertebral subluxation complex, defies easy description. Indeed, nearly 300 synonyms or metaphors in the chiropractic and biomedical literature are used to describe this condition.

The general consensus is that the vertebral subluxation complex or VSC (commonly referred to as a "vertebral subluxation" or "subluxation") consists of two primary components--a biomechanical disrelationship and a disturbance of nerve function (and many secondary components). The challenge of integrating these components into a comprehensive model remains a source of controversy and for that reason various models of the VSC exist. Following are some common VSC models:

The Five Component Model of the Vertebral Subluxation Complex:

1. Spinal Kinesiopathology

This is a structural component. It is any variance from normal within the biomechanics of spinal joint function, including alignment and motion irregularities. Examples are hypomobility (fixation), hypermobility, compensation reaction, loss of joint play, and loss of central axis of motion. Long-standing spinal kinesiopathology may lead to subluxation degeneration. (See below).

2. Neuropathology 

This is a nervous system involvement. As a result of spinal kinesiopathology, the spinal cord nerve roots, spinal nerves, ganglia, other nerve fibers, and related structures (meninges) are impinged, compressed, or otherwise irritated leading to dis-ease--disharmony in the body as a whole. For example, chronic excessive afferent impulses from acute and chronically stressed (or traumatized) mechanoreceptive, proprioceptive and nociceptive fibers in and around the spinal column (joints, articular capsules, muscles, ligaments, tendons, discs, etc.) may initiate pathologic spinal cord reflexes in motor and sympathetic efferents. Stimulation of sympathetic efferents may decrease the lumen of blood vessels in internal organs and adversely affect tissue oxygenation and increase free radical production. Additionally, afferent mechanoreceptor impulses travel up the cord to the cerebellum and thalamus, affecting thalamic summation and integration and cortical representation.

3. Myopathology

Muscle involvement generally follows joint and nerve alteration. Neuropathology creates adverse patterns of neural spinal learning resulting in chronic gait and postural alterations. Muscles begin to exhibit hypertonic, hypotonic, spasm, contracted, and/or degenerative states. An inefficient relationship with gravity results in excess energy expenditures and asymmetrical muscle relationships resulting in fatigue and increased joint wear and tear (osteoarthritis/spinal degeneration).

4. Histopathology 

This involves inflammation, edema, and swelling of surrounding tissue due to VSC stress or trauma. Eventually this results in long-term degeneration of the spine and associated tissues. Fibrosis will usually be found at the articulation (periarticular fibrosis), around the nerve (perineural fibrosis), and under the epineurium of the nerve (intraneural fibrosis) contributing to joint and neurologic pathology. Inflammatogenic agents are released that may result in chemical radiculitis with resulting cellular changes. In addition, the structural distortions may result in meningeal or dural tension (or tethering) and can cause cerebral spinal fluid (CSF) disruption further affecting neurophysiology.

5. Pathophysiology

Chronic stress results in disturbed homeostasis. Organic pathology may become obvious only after years of nervous system/ homeostatic dysfunction. Disc herniation may occur after years of VSC damage. Pain, a response to mechanical or chemical irritation of the spinal nerves, nerve roots, articular structures, and disc tissue may occur immediately with VSC creation or only after a critical amount of damage to tissues or organs has been reached.

Subluxation Degeneration Model

Long-standing VSC damage causes a progressive process known as subluxation or spinal degeneration. Degeneration often begins at the intervertebral disc (often diagnosed as intervertebral osteochondrosis or spondylosis), progresses to the vertebral body and joints (osteoarthritis), and spreads to nearby soft tissue. Compensation and adaptation occur and degeneration can extend above and below the original site of involvement. The entire spine must adapt as the body shifts in relation to gravity.

Spinal degeneration can cause spinal cord compression via disc protrusion, ligamentum flavum hypertrophy/corrugation or osteophytosis, and nerve root compression via disc protrusion or osteophytosis. Blurred vision, tinnitus, vertigo, temporary deafness, shoulder and arm pain, and trophic changes from sympathetic system impairment are also associated with spinal degeneration.

Clinical observations indicate that spinal adjustments appear to restore normal joint mobility, arrest, prevent (and possibly reverse) spinal degeneration, and de-activate pathological spinal cord reflexes.

Neurodystrophic Model

The VSC results in abnormal autonomic outflow and altered trophic function that is stressful to the viscera and other body structures. This leads to "lowered tissue resistance" and ultimate visceral degeneration. I. M. Korr's experiments on spinal "lesions" (analogous to the VSC) showed that they created exaggerated sympathetic activity as well as exaggerated paraspinal muscle tone. Koor found that high sympathetic tone may alter organ and tissue responses to hormones, infectious agents, and blood components. (4)

Immune function is regulated at least in part by the sympathetic system. Sympathetic nerve endings densely innervate lymphoid tissue such as the spleen, lymph nodes, and thymus and form direct contact with white blood cells. If nerves are removed from the spleen or the lymph nodes, immune response is interrupted.

Causes of the VSC

The VSC is caused by any physical, chemical, or emotional stress to which the body/mind cannot adapt. Clinical experience suggests that the VSC is caused by birth trauma as well as the many falls of infancy and childhood. It is not unusual for a parent to claim that his or her child's health and/or emotional wellbeing changed after a trauma. Among other activities implicated in VSC creation are repeated micro-stress or micro-trauma from work positions or sports, dental work, pregnancy, and poor sleeping position. Clinical experience reveals that the majority of the population has long-standing, uncorrected vertebral subluxations.

Chiropractic Spinal Analysis

The chiropractic profession has developed many creative methods to analyze the spine for the VSC. Since the VSC is a two-headed beast, a structural and neurological phenomenon, both components should be analyzed.

Structural analytical tools include (but are not limited to) X-ray, posture, and gait analysis, vertebral challenge, and muscle, bone, and motion palpation (analysis of joint movement and joint play).

Neurological analytical tools used to measure the subtle changes that accompany the VSC include (but are not limited to) thermal scans, dual probe thermocouple scans, surface EMG, leg length discrepancy, muscle strength testing, and body balance tests.

Position of analysis appears to be important. For example, a patient whose spine was subluxated in a car accident may reveal a relatively normal spine on a standing X-ray but a highly distorted spine when X-rayed sitting--the position of injury.

Chiropractic Spinal Adjustment Techniques

Chiropractic's unique addition to health care is the spinal adjustment, a specialized procedure to realign the body structure to reduce or eliminate abnormal neural stress.

It is of utmost important to recognize that compensatory misalignments to the original or major subluxated area exist. Often the correction of a "major" subluxation will result in spontaneous or gradual correction of minor subluxations. Adjusting or correcting a compensation without first addressing the major subluxation may exacerbate a patient's structural state and increase VSC damage.

There are approximately 100 chiropractic technique systems.

Clinical Observations

Chiropractic has survived because of patient satisfaction. Chiropractic successes with conditions as diverse as bed-wetting, allergies, migraines, musculoskeletal pain, sciatica, bronchial asthma, headaches and migraines, learning disorders, chronic pain, dysmenorrhea, infertility, colic, blindness and vision problems, digestive disorders, and many others abound in the chiropractic literature. However, it must be remembered that the purpose of the spinal adjustment is the correction of the VSC, not the treatment of conditions. The studies below are a small sampling of the clinical literature on chiropractic, and although they may have various methodological limitations, such as small sampling, selection bias, and other defects, it must be borne in mind that chiropractic, as a vitalistic healing art, may not be amenable to the testing procedures of the randomized controlled clinical trials.

Quality of Life/Wellness (5)

Most exciting and revealing are outcome studies on quality of life or wellness. In this study a self-reported retrospective characterization of 2,818 patients under Network Chiropractic Spinal Analysis (a technique that employs gentle touches to the spine at critical points of stress to assist the body to dissipate and eliminate stored mechanical tension/energy in the neurological system to enhances self regulation) revealed that chiropractic recipients reported significant improvement in overall quality of life. The reported outcomes reflected a large positive clinical effect in every health-related domain investigated: physical state, mental/emotional state, stress, and life enjoyment. Moreover, patients who had been under care the longest time reported greatest perceived improvement in wellness.

Elderly Health (6)

A 3-year randomized trial conducted by the Rand Corporation investigated the value of chiropractic care in persons 75 years and over. Those under chiropractic care had better overall health and a higher quality of life compared to non-chiropractic users, were less likely to have been hospitalized, less likely to have used a nursing home, more likely to report a better health status, had fewer chronic conditions, were more likely to exercise vigorously, more likely to be mobile in the community, and less likely to use prescription drugs than the nonchiropractic users. In addition, 87% of chiropractic patients described their health status as good to excellent, compared to 67.8% of non-chiropractic patients.

Children's Health (7)

A total of 200 pediatricians and 200 chiropractors were randomly selected and surveyed to determine what, if any, differences were to be found in the health status of their respective children as raised under the different health care models. Survey analysis revealed that the chiropractic children had fewer ear infections compared to the medical children (20% vs. 69%), fewer allergies, less tonsillitis, less antibiotic therapy, and less medication overall.

Athletic Performance (8)

In a controlled study, male university baseball players were assessed before chiropractic care and at 5 and 14 weeks respectively. At 14 weeks significant improvement was found in muscle strength and long-jump distance in the chiropractic compared to the control group. The chiropractic group also had significant improvement in capillary counts at 5 and 14 weeks of care. The control group had increases in resting blood pressure and resting pulse rate as well as pulse rate following treadmill activity while the chiropractic group had decreases in these same measures.

AIDS (9)

While there is scant evidence to directly link the vertebral subluxation complex with immunological competence, the indirect evidence points strongly in that direction. For example, a small controlled study of HIV positive patients under chiropractic care revealed intriguing findings. Half the patients received atlas adjustments and the other half had a "sham" adjustment. Over the sixmonth study the control group experienced a 7.96% decrease in CD4 cell counts (and two deaths) while the chiropractic group experienced a 48% increase in CD4 cell counts (and no deaths).

Otitis Media (10)

A total of 332 children previously diagnosed with acute otitis media, chronic/serous otitis media, and mixed bilateral otitis media were placed under chiropractic care (age 27 days to 5 years). The number of days to normalize the otoscopic examination was for acute 6.67+/-1.9, chronic/serious 10.18+/-3.39, and mixed 10.9+/-. The average number of adjustments given was 4.0, 5.0, and 5.3 respectively. The overall occurrence rate over a six-month period from initial presentation in the office was for acute 11.02%, chronic/serious 16.34%, and for mixed 30%. Otitis media accounts for 35% of all pediatrician visits in the U.S. with over 25 million office visits a year. Chiropractic offers a drug-free approach to this modern epidemic.

Psychotherapeutics 

Shortly after chiropractic's inception, its psychotherapeutic effects were noticed. The profession eventually established chiropractic sanitaria throughout the United States. Two of the best known, Forest Park and Clear View (both of Davenport, Iowa), operated until the early 1960s and reported higher rates of satisfactory discharge and lower recidivism than similar medical institutions.

Several studies have shown chiropractic's benefit for children with emotional, behavioral, and neurological problems including anxiety, low mental stamina, inability to concentrate, hyperactivity, attention deficit disorder, and discipline problems. Children were able to decrease or eliminate Ritalin and other drugs, experience improved coordination, improved concentration, and improved mental clarity. In addition, increases in grades and higher I.Q.s were reported after chiropractic adjustments. (11)

The relationship between posture and personality inspired this author to conduct a pilot study correlating relationships between certain spinal positions and personality traits. (12)

Whiplash

A total of 57 whiplash injury patients showed significant increase in cervical flexion and extension, muscle strength, and a decrease in neck pain disability index under chiropractic care. (13)

The Future of Chiropractic

It is important that any discussion on the "integration" of chiropractic into today's health care system respects the vitalist approach of chiropractic as distinct from the mechanistic approaches of diagnosis and treatment of named diseases or conditions. All individuals, whether they have symptoms, need a healthy spine free of the VSC. Chiropractors promote periodic spinal checkups for "spinal hygiene," similar to periodic dental checkups. Individuals whose health is poor especially need a spine unburdened with the VSC.

People generally leave medical offices with as many spinal subluxations as when they entered. Therefore there needs to be interprofessional cooperation for the benefit of the patient. A wonderful model to serve as a basis of chiropractic/ medical cooperation was observed in China:

   Of the 12 departments in the hospital,
   the department of manipulation
   is visited by approximately
   98% of the hospital's 'in' and 'out-patients'
   population. Professor Jia
   Zhen explained it as the most productive
   department in the hospital
   and without it hospital stays
   'would double and beyond.' (14)

Chiropractic's unique approach to health care has much to offer today's exhausted and expensive health care industry. D. D. Palmer's challenge to the medical orthodoxy of his day remains a challenge to the orthodoxy of today:

   Pressure on nerves causes irritation
   and tension with deranged
   functions as a result. Why not
   release the pressure? Why not
   adjust causes instead of treating
   effects. Why not? (2)

Special thanks

To John Young, M.D., Ph.D. who suggested this paper and especially to my wife Beth who makes it all worth while.

For further information on chiropractic medicine:

The Association of Network Chiropractic, 444 North Main St. Longmont, CO 80501, phone: [phone], website: www.networkchiropractic. org.

References

(1.) Astin, J. A. (1998). Why patients use alternative medicine, Journal of the American Medical Association, 279(19), 1548.

(2.) Palmer, D. D. (1910). The science, art and philosophy of chiropractic. Portland, Oregon: Portland Printing House Company.

(3.) Ibid xix.

(4.) Korr, I. M. (1979). The spinal cord as organizer of disease processes: 111. Hyperactivity of sympathetic innervation as a common factor in disease. Journal of the American Osteopathic Association, 4, 232-237.

(5.) Blanks, R., Schuster, T., and Dobson, M. (1997). A retrospective assessment of network care using a survey of self-rated health, wellness and quality of life. Journal of Vertebral Subluxation Research, 1(4), 15-31.

(6.) Coulter I. D. et al. (1996). Chiropractic patients in a comprehensive home-based geriatric assessment, follow-up and health promotion program. Topics in Clinical Chiropractic, 3(2), 46-55.

(7.) Van Breda, W. M. and Van Breda, J. M. (1989). A comparative study of the health status of children raised under the health care models of chiropractic and allopathic medicine. Journal of Chiropractic Research, Summer, 5(4) 101-103.

(8.) Schwartzbauer, J. et al. (1997). Athletic performance and physiological measures in baseball players following upper cervical chiropractic care: a pilot study. Journal of Vertebral Subluxation Research, 1(4).

(9.) Selano, J. L. et al. (1994). The effects of specific upper cervical adjustments on the CD4 counts of HIV positive patients. Chiropractic Research Journal, 3(1),32-39.

(10.) Fallon J. M. (1997). The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media. Journal of Clinical Chiropractic Pediatrics, 2,(2),167-183.

(11.) Walton, E. V. (1975). Chiropractic effectiveness with emotional, learning and behavioral impairments. International Review of Chiropractic, 29(6), 2-5, 21-22.

(12.) Koren, T. and Rosenwinkel, E. (1992). Spinal patterns as predictors of personality profiles: a pilot study. International Journal of Psychosomatics, 39 (1-4) 10-17.

(13.) McCoy, H. G. and McCoy, M. (1997). A multiple parameter assessment of whiplash injury patients undergoing subluxation based chiropractic care: a retrospective study. Journal of Vertebral Subluxation Research, 1(3), 51-61.

(14.) Amaro, J. (1986). Wait till you hear about Bejing! The American Chiropractor, 8 (Jan/Feb):45.

Tedd Koren, D.C. (private practice, Pennsylvania) lectures and writes on chiropractic and contemporary health issues to professional and lay audiences. He can be reached at P.O. Box 665 Gwynedd Valley, PA 19437 or [e-mail].