Every week I get a number of email alerts about various online medical journals. Each email represents the opportunity for blogging material though many are deathly dull.

Several of the journals I receive alerts from are in the AltMed domain and I sometimes wonder why I bother looking through them at all. The mix is usually some proportion of “Survey of x population using y alternative modality” often merely chronicling the depressing rise of AltMed/CAM in general use (either actual or claimed depending on your definition of CAM).

The rest are often boringly conventional in their attempt to be scientific having titles like “Effects of vitamin E suplementation on renal non-enzymatic antioxidants in young rats submitted to exhaustive exercise stress“. These I don’t bother with. I just don’t have the expertise to parse them with any reliability.

Then there are the odd gems, either for comedic value or because they offer an alternative perspective on alternative medicine.

Recently one of the later came down the intertubes and into my in-box. Published in BioMed Central’s journal “Chiropractic & Manual Therapies”, the article is entitled “The Five Eras of Chiropractic & the future of chiropractic as seen through the eyes of a participant observer”.

The paper starts with a potted history of Chiropractic and the environment that it was founded and grew up in to the present. The early days could be seen as Chiropractic’s first opportunity to start down the science based path. In 1910 the “Flexner Report” on medical education was published and with it’s acceptance by the medical educational community came legitimation to those who abided by it’s recommendations. As well as:

…generous funding via the Rockefeller Foundation while schools that did not assent, simply ceased operation due to lack of funding. The result was that, by 1930, only 76 of the 168 medical schools remained.

The impact on Chiropractic is characterised thusly:

In part because of the rejection of science by a significant element within the chiropractic profession, and in part because the Flexner Report dismissed the chiropractors as “unconscionable quacks who should be dealt with by the public prosecutor and the grand jury”, the chiropractic profession bypassed the era of educational reform.

The early twentieth century therefore saw a great deal of animosity towards the nascent Chiropractic practice and the emerging scientific medicine of the time. Indeed the author argues that this conflict essentially shaped Chiropractic as we know it today. In order to defend Chiropractic from the legal attacks being made on it it was necessary to develop a definition of Chiropractic that would insulate it from charges of practising medicine without a licence, charges that were common against Chiropractors of the time.

This is related as involving four simple concepts:

1. Chiropractic is not medicine; chiropractic has a “separate and distinct philosophy and practice”.
2. Chiropractors do not diagnose, but analyze the spine for the  cause of dis-ease.
3. Chiropractors do not “treat,” but adjust the spine for the cause of dis-ease.
4. The Chiropractic profession has been built upon success in cases where medical doctors failed.

Putting aside the obvious sophistry in these concepts (how might we define the difference between diagnosis and “analyz[ing] … for the  cause of dis-ease” or between treatment and “adjust[ing] the spine for the cause of dis-ease“?) it is argued then that the very fact of opposition by the medical establishment helped to solidify the tenets and practice of Chiropractic:

During this journey, the chiropractic community developed and embraced a distinct lexicon and rationale toward health and its maintenance in order to emphasise the difference between medicine and chiropractic. Thus the “philosophy of chiropractic” became “an unyielding dogma”.

With this legal history at it’s back Chiropractic moved into the next period of it’s history where it was the focus of a co-ordinated and sustained attack by the medical establishment in the form of the AMA.

Carrying out the opposition to Chiropractic was the “Committee on Quackery”:

The Committee on Quackery was well funded, and operated a highly successful campaign that was centred on three main strategies:
1. An ethics based boycott, which deemed it unethical for AMA members to have professional dealings with chiropractors;
2. Convincing other organizations to adopt or adapt the AMA’s anti-chiropractic policy; and
3. Instituting a comprehensive political campaign to thwart chiropractic progress on several fronts, including but not limited to education, research and insurance funding.

This campaign was put to an end in 1987 thanks to a permanent injunction ordered against the AMA, after a lawsuit was levelled against it by a number of Chiropractors. At this point it’s difficult not to see the Chiropractic as a beleaguered philosophy deserving of empathy on behalf of it’s persecuted adherents.

Emerging from this legal victory Chiropractic has been slowly edging it’s way into mainstream acceptance with the development of Chiropractic based courses in universities and a surge in chiropractic research. Unfortunately the steadfast refusal of many Chiropractors to relinquish the unscientific concepts of old has meant that as a profession they are still looked upon with disdain:

Chiropractic’s problem is that subluxation based chiropractors 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 health . And this, at a time when the profession has just entered The Era of Chiropractic Opportunity.”

The opportunity discussed is that of the ever growing need for specialists in musculoskeletal care. As the worlds population ages the demand for providers who are proficient in the treatment of pack pain/musculoskeletal disorders will only increase.

It is into this world that the Chiropractic profession must be re-born as the evidence based providers of musculoskeletal care that are needed. The problem is that if Chiropractic insists on holding onto the non-scientific notions of DD Palmer then it voluntarily relegates itself to the back waters of medical practice.

This then is the proper focus of the article: where Chiropractic will go from here.

Least attractive to the author is the prospect that the practice will stay on it’s current trajectory, keeping the outdated concepts that it was founded upon and denying the very science that would confer upon them the legitimacy they crave.

Two options are given as alternatives to this “Status Quo” approach: one is to definitively split the profession into those that follow the traditional method of chiropractic practice, so-called “Straight Chiropractic”, and those who are willing to discard tradition and step into the light of science and evidence based practice.

The second and preferred option is to move forward with a united front, ditching along the way those parts of Chiropractic that are unsound and unproven. This is also recognised as the most difficult route for the profession, requiring near superhuman commitment from the individuals and organisations that make up the world’s Chiropractic profession:

Escaping from the dogma house will require extraordinary cooperation amongst all aspects of the profession. Organizations such as the World Federation of Chiropractic and all major chiropractic associations will need to agree upon and adopt a position statement identifying the chiropractic subluxation as an historical construct that remains a hypothesis, which cannot form the basis for patient care until and unless there is a body of scientific evidence to support it.

If the profession is to gain the trust of the consuming public it must, of necessity, become truly self-policing.

Only in this way will chiropractic generate the cultural authority required for recognition as a group worthy of the title “Profession”.

No longer can we cast a blind eye. By our silence we are giving consent.

Should Chiropractic refuse to move properly into the 21st Century then the consequences for it as a whole may be dire, leaving it’s future as a force in medical practice in doubt.

The chiropractic profession can choose to be illiterate, but it will do so at its peril. It is realized that thinking is hard and that those who are unaccustomed to thinking may even find it unpleasant. On the other hand, thinkers have always found it rather fun and there are no confirmed reports of anyone dying or being seriously injured by thinking. Thinking may necessitate changing our minds – which may not be a bad thing. At the very least the profession owes it to its patients.

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