Mixed Messages

“We’re just rehearsing who we think we are…” – Karl Schubach

How does one reconcile their identity as a representative of a profession so misunderstood, controversial and sectarian as chiropractic?

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In a recent article published in Chiropractic & Osteopathy[1], Keating et al discuss the difficulties dogma-masquerading-as-science has created for the chiropractic profession, especially in the US where chiropractic education has yet to integrate itself into greater academia.   The authors specifically indict the subluxation concept as a hypothetical “house of cards” that works to deconstruct our special paradigmatic authority in an evolving science-based healthcare environment.  This, it turns out, is not an uncommon plight from Keating who has published additional literature[2],[3],[4] citing modern chiropractic dogma as the partial evolution of a legal defense used to establish professional distinctness starting with the Shegataro Morikubo trial in 1907.   Other authors have argued that our continued adherence to an admittedly antiquated and dogmatic principle that has yet to be clearly validated has been the primary reason that chiropractors have remained marginalized, scrutinized and ridiculed for years, while other non-allopathic professions such as Podiatry and Osteopathy have flourished[5].

As I have discussed in earlier blog entries, the chiropractic profession has hit somewhat of a critical mass, standing at the cusp of a major paradigm shift in healthcare delivery and educational evolution.  At the 30th World Congress of Chiropractic Students in New Zealand, Bruce Lipton discussed the cyclical nature of paradigm evolution and suggested that the chiropractic profession will be poised at the front of the new healthcare movement as society begins to embrace a renewed appreciation for vitalism…sure, if only we could address our inherent identity crisis.  Don Murphy[5] argues that we can no longer afford to masquerade as a two unique professions under one roof.  He and Keating[6] argue that Chiropractic is, merely, what it is as defined in our slowly growing research base and despite our personal biases, we cannot allow ourselves to be swayed by personally satisfying, albeit alienating and possibly dangerously damaging pseudoscience.

In the context of WHO, an organization that strives to create recommendations for universal standards by which healthcare practitioners are deemed qualified, subluxation is a fairly troublesome phenomenon to quantify.  While the ACA, ICA, ACC, NBCE and WFC all acknowledge the existence of and define subluxation as a clinical entity, as does a good majority of the profession[7], little to none of the available literature supports these assertions in the traditional sense.  We may extrapolate on the meaning of DD Palmer’s original understanding of subluxation in his historical context based on some of the new, more compelling neuroscience literature that is available (see below), but the conjecture that subluxation is the “cause of all dis-ease” is far from validated, especially in the context of policy writing.  Just as we cannot allow professions such as allopathic medicine to make invalidated conjectural statements in their guidelines, so too must we behave within the framework of our scientific paradigm.

With this said and despite the lack of gold standard research directly validating the existence of subluxation, something must be said for clinical expertise.  My clinical and research experience tells me that we have a strong foundation to stand on in defense of the outcomes we observe with our patients, but I refuse to take academic conclusions at face value.  Contrary to Keating’s and Murphy’s apparent conclusions, I do believe there is an answer to the questions that the subluxation hypothesis poses, but it might not turn out to be what we had expected.  Research conducted by neuroscientists like Paul Bach-Y-Rita, Mike Merzanich, Edward Taub, and Vilayanur Ramachandran[8] as well as chiropractic scholars like Philip Bolton[9],[10],[11], David Seaman[12], Fred Carrick[13],[14],[15] and Heidi Taylor and Bernadette Murphy[16],[17],[18],[19],[20], suggest that we may have misinterpreted our care to be spine care when in fact it is really brain care.  The implications for clinical applications in neuroplasticity-oriented physical medicine are vast but are so poorly understood in chiropractic academia that it may be years before they are fully explored clinically.  I suspect we will discover that Palmer had the right idea but for the wrong reasons, which means that we could be limiting our potential by avoiding critical introspection.

As I have intimated in a previous post, major problems in our profession’s educational structure include overwhelming lack of emphasis on scientific appraisal, concomitant apathy amongst faculty towards lifelong learning and a history of grossly exaggerated extrapolation touted as truth in a clinical setting (for further exploration of this issue I would direct you to http://mollymerirobinson.wordpress.com).  We as a profession tend to believe whatever suits us because the lack of validation for our central dogma attacks what philosophers like Immanuel Kant, Soren Kierkegaard, Martin Heidegger and Jean-Paul Sartre have called our “world-view,” so we resort to religion in the same way Freud suggests we turn to God in his 1913 work Totem and Taboo.  I have commonly said having written my undergraduate thesis on American religious phenomena that one cannot expect to argue rationally in an “a-rational” context.  Heidegger argued almost 90 years ago that an individual person’s world-view is developed as an accumulation of subjective experiences and is therefore irrelevant without validation through scientific discovery, which should, ideally, be devoid of personal bias.  Such world-views carry both a promise of empowerment and simultaneous myopia.  While they help us reach our individual destinations on the road to personal truth their usefulness ends without appraisal, especially when they stand in opposition to logic.  In this vein, Don Murphy[5] argues that critical appraisal is the necessary price we must pay to accept the criteria of the “social contract” we agree to uphold with society in exchange for our clinical doctorates.  My feeling is that when one can successfully argue the clinical validity of subluxation to an academic neuroscientist, one is qualified to stand on it as a philosophical foundation; otherwise, that person is merely a priest practicing theology without a license.

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Returning to my initial question, I believe it is important for us all to remind ourselves from time to time that it is ok to acknowledge our weaknesses while maintaining our core beliefs (see previous post).  The battle over subluxation has as much of a place at WHO as does a-rational philosophical squabbling over the validation of the bible, and our transparent division puts chiropractic at risk of graduating from a private national nuisance to a public international one.  As a WHO intern whose primary task is to work towards improving global healthcare delivery, the most effective means of leaving a lasting legacy is to spend each day pondering our profession’s promise and potential while using my unique perspective and skill set as a chiropractic student to help WHO more effectively realize its goals.  I am not a chiropractic intern; I am an intern who happens to be a chiropractor.  It is not my job to promote chiropractic here, but instead to use my special subjective understanding of human physiology, clinical practice and patient care to objectively troubleshoot, strategize and problem-solve.  This is both our gift and our legacy and should be at the forefront of every doctor’s mind when determining appropriateness of care for their patients.

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[1] Keating, JC, KH Charlton, JP Grod, SM Perle, D. Sikorski, and JF Winterstein. “Subluxation: dogma or science?” Chiropractic and Osteopathy 13.17 (2005).

[2] Keating JC: Chiropractic: science and antiscience and pseudoscience, side by side. Skeptical Inquirer 1997, 21(4):37-43.

[3] Keating JC: Science and politics and the subluxation. Amer J Chiropr Med 1988, 1(3):107-10.

[4] Keating JC: Rationalism, empiricism and the philosophy of science in chiropractic. Chiropractic History 1990, 10(2):23-30.

[5] Murphy, DR, MJ Schneider, DR Seaman, SM Perle and CF Nelson.  “How can chiropractic become a respected mainstream profession?  The example of podiatry”  Chiropractic and Osteopathy 2008;16(10).

[6] Keating JC: Scientific epistemology and the status of chiropractic: we are what we do.  European J Chiropr 1993, 41(3):81-8.

[7] New study finds unity in chiropractic: surprising agreement among DCs on issues of philosophy, practice. Dynamic Chiropractic 21(12):1,8,10. 2003 (June 2).

[8] Doidge, Norman. The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science. London: Penguin (Non-Classics), 2007.

[9] Bolton, P. S., and B. S. Budgell. “Spinal manipulation and spinal mobilization influence different axial sensory beds.” Med Hypotheses 66.2 (2006): 258-62.

[10] Bolton, P. S. “Reflex effects of vertebral subluxations: the peripheral nervous system. An update.” J Manipulative Physiol Ther. 23.7 (2000): 512-13.

[11] Bolton, P. S. “The somatosensory system of the neck and its effects on the central nervous system.” J Manipulative Physiol Ther. 21.8 (1998): 553-63.

[12] Seaman, D. R., and J. F. Winterstein. “Dysafferentation: a novel term to describe the neuropathophysiological effects of joint complex dysfunction. A look at likely mechanisms of symptom generation.” J Manipulative Physiol Ther. 21.4 (1998): 267-80.

[13] Carrick, F. R. “Cervical radiculopathy: the diagnosis and treatment of pathomechanics in the cervical spine.” J Manipulative Physiol Ther. 6.3 (1983): 129-37.

[14] Carrick, F. R. “Changes in brain function after manipulation of the cervical spine.” J Manipulative Physiol Ther. 20.8 (1997): 529-45.

[15] Carrick, F. R., Oggero E, and Pagnacco G. “Posturographic changes associated with music listening.” J Altern Complement Med. 13.5 (2007): 519-26.

[16] Taylor, H. H., and B. Murphy. “Altered sensorimotor integration with cervical spine manipulation.” J Manipulative Physiol Ther. 31.2 (2008): 115-26.

[17] Haavik-Taylor, H., and B. Murphy. “Altered cortical integration of dual somatosensory input following the cessation of a 20 min period of repetitive muscle activity.” Exp Brain Res. 178.4 (2007): 488-98.

[18] Haavik-Taylor, H., and B. Murphy. “Cervical spine manipulation alters sensorimotor integration: a somatosensory evoked potential study.” Clin Neurophysiol. 118.2 (2007): 391-402.

[19] Murphy, B. A., H. Haavik-Taylor, S. A. Wilson, G. Oliphant, and K. M. Mathers. “Rapid reversible changes to multiple levels of the human somatosensory system following the cessation of repetitive contractions: a somatosensory evoked potential study.” Clin Neurophysiol. 114.8 (2003): 1531-537.

[20] Murphy, B. A., H. Haavik-Taylor, S. A. Wilson, J. A. Knight, K. M. Mathers, and S. Schug. “Changes in median nerve somatosensory transmission and motor output following transient deafferentation of the radial nerve in humans.” Clin Neurophysiol. 114.8 (2003): 1477-488.

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