Dr. Peter A Ford, DC
It has been interesting to read the opposing viewpoints of Drs. Allan Halowski and Mark Bodnar in the September and December 2004 issues of the JCCA. How we define ourselves as a profession determines our direction forward. I believe this subject is so important I would like to see it debated all the way into our teaching colleges because clearly there is disparity in our profession that does not augur well for the future. Last year I studied medical acupuncture in the Department of Anaesthesia at Mc-Master Medical School in Ontario. Several final year chiropractic and medical students had been allowed to take the course which involves a thorough anatomy review with emphasis on the soft tissue component of M. S. K. pain syndromes relative to needle insertion. One day, the chiropractic students and I got into conversation. On being questioned, I described how my thirty years of clinical experience had served to confirm what I had been taught in chiropractic college (A. E. C. C. 1972), that axial skeleton asymmetry and associated vertebral subluxations were, in most cases, responsible for soft tissue disorders.
One of the students asked me amusedly why on earth anyone would want to look at bones! I was taken aback that the question would even be posed. I therefore endeavored to explain the importance of identifying, clinically and radiographically, regional and segmental spinal misalignment, congenital joint asymmetries, vertebral listheses, pelvic unlevelling and other relevant osseous features and how such information must be correlated for effective spinal adjustments.
I was looked at as if I had lost touch with reality, and the students proceeded to inform me that soft tissues were the determinant of any osseous distortion and treatment should reflect that. Consequently, emphasis should be placed on treating the soft tissues, leaving manipulation of the joints as simply one of several therapeutic options and that this was the “up to date” practice of chiropractic.
I felt disparaged and patronized. Apparently, all these years, I had missed the point entirely and had not kept up with progress in the profession. Before returning to class I retorted that it was my understanding that ligaments and muscles are strung on an osseous template and that the shape of this bony framework must surely be a primary determinant of soft tissue imbalance.
With my reasoning challenged by obviously academically very bright students, I was relieved to hear the course presenter, Dr. Alexander Claraco, M. D. – Professor and Sports Medicine Specialist at McMaster, point out the underlying importance of axial and appendicular skeletal asymmetry and its effect on soft tissues since they “run like strings across our framework” !
It seems to me therefore that the chiropractic students had dismissed as “out of date” one of the fundamentals of chiropractic (and osteopathic) practice, that structure governs function. We did not discuss vertebral subluxation, so as far as I know, these young chiropractors feel as does Dr. Bodnar, that spinal joint dysfunction as a source of insult to the nervous system in the broader context of neurophysiology is a fallacy. Apparently “NMS Specialist” is the goal to be aimed at if we are to progress as a profession in a scientific manner. This new and improved chiropractor would add soft tissue therapies, maybe acupuncture and medications where appropriate to the existing manipulative armamentarium.
In my opinion this is fine as far as it goes. The problem as I see it, is that in the name of scientific progress, the primary goal of the chiropractor, which is the treatment of vertebral subluxations, is relegated to providing therapy for musculo-skeletal pain syndromes; joint manipulation being regarded as a useful but not particularly essential treatment option. This is a far cry from endeavoring to assist internal regulatory mechanisms via the autonomic nervous system with a view to enhancing the general health and vitality of the various systems of the human body. It is also a far cry from recognizing the important role the nervous system plays in health and the adverse effects that can result from a significant disruption of alignment and function of the vertebral column.
The skepticism toward the vertebral subluxation displayed by some “modern” chiropractors would, I believe, be allayed if the work of medical specialists in the field of manipulative medicine were to be made required reading in Chiropractic College. I provide a few examples to make my point:
Example 1 – John F. Bourdillon M. D. FRCS. (U. K.) Professor, College of Osteopathic Medicine, Michigan State University. In the 5th edition of his book “Spinal Manipulation, Appleton & Lange 1987. Quote: “The start of chiropractic is said to date from a specific incident when Palmer manipulated the thoracic vertebrae of a Negro porter and by this means cured him of deafness from which he had suffered for some years. On the face of it, this is a fantastic and totally unacceptable claim. As a result of personal experience however, there is no doubt in my mind that somatic dysfunction in joints in the upper thoracic spine can affect the function of the inner ear, presumably by way of its sympathetic innervation.”
Dr. Bourdillon passed away a few years ago. A sixth textbook described as a revised edition was published in 2002 by his colleagues and previous students, Edward Isaacs M. D, Professor of Neurology and Mark Bockhout MS, PT, Associate Professor of Physical Medicine. I purchased this book and was dismayed to find that all reference to physiological dysfunction via the ANS had been deleted in the revised edition. Presumably this has been done in the name of scientific progress, a misperception regrettably similarly held by some chiropractors.
Example 2 – Dr. Paul Sherwood M. A. M. B. B. Ch Cardiologist London, U. K. The following is the abstract from his paper entitled “Effective Prevention of Coronary Heart Attacks” published in the American Journal of Acupuncture 1984 and in the Digest of Chiropractic 1985. Quote: “ Atheroma of the coronary arteries does not satisfactorily explain a number of phenomena associated with a coronary heart attack. A theory is presented that most coronary attacks are caused by a spasm of the coronary artery triggered by malfunction of the stellate ganglion. A state of congestion, brought about by upper thoracic back trouble, sensitizes the ganglion either to an increase in the congestion around it or to a sudden change in it activity. A means of routine assessment for the probability of a coronary attack is described from a combination of the symptoms and signs of hypo sympathetic activity and upper thoracic spine trouble. Successful treatment of the back trouble – mainly with physical medicine – tends to prevent further attacks in coronary sufferers for many years and also improves the cardiac circulation by relaxing the constant element of arterial spasm. Thus, the treatment is also of value in cases of coronary insufficiency”.
Dr. Sherwood goes on to describe two types of adjustive technique that he uses and specifies the facet joints as the main source of irritation to the stellate ganglion. He also describes how the diminished activity of the sympathetic ganglia produces a selective vagal overactivity, the most common unbalance causing hyperactivity and hypermobility of the stomach leading to gastritis and peptic ulcer along with further physiological constriction of the coronary arteries.
Example 3 – Benjamin Kigler M. D. Paediatrician and Medical Director, Beth Israel Health Centre, New York. NBC News release “Spinal Manipulation May Help Treat Ear Infection” September 2003. Quote – “The middle ear is drained by the eustachian tube which sits between a set of the skull bones. If these bones get a little out of position or a little bit tight, the tubes get clogged and the child is very prone to collect fluid in the middle ear leading to an ear infection. Children who had osteopathic manipulation had a much lower frequency of needing repeated antibiotics and getting tubes placed in their ears”.
Dr. Kigler goes on to say that he recommends children who suffer repeated ear infections try manipulation before considering tube placement.
Example 4 – Researchers Drs. Wiberg, Nordsteen and Nilsson MD, PhD, University of Southern Denmark, 1999. Trial results published in JMPT. A ten year study concluded that the chiropractic management of newborns with infantile colic is safe and effective. Three hypotheses based on current science were proferred to explain the benefit of manipulation.
Referred pain from spinal joint dysfunction mistaken as infantile colic.
Spinal joint dysfunction causing somato-visceral reflexes leading to altered neurophysiological effects in the G. I. tract.
A mild digestive disorder producing a viscero-somatic reflex causing spasm of the paraspinal muscles and consequent development of vertebral joint dysfunction. Here again in this study we have highly qualified medical doctors explaining changed physiology and ill-health based on altered neurological reflex activity associated with vertebral column dysfunction.
There is no excuse for chiropractors to suggest that the one hundred year old theories of Palmer should be retired to the history books. The fact is that modern research and the personal experience of eminent authorities in manipulative medicine are in most cases confirming the scientific basis of chiropractic.
“Evidence based medicine” has become the fashionable buzz phrase in recent years. The implication is that in the absence of a randomized prospective study no credibility can be given to a therapeutic measure. This is actually not true science, which has always been a blend of intellectual endeavor and intuitive inspiration. Dr. John Bourdillon gives a good example in his Introduction to his “Spinal Manipulation” 5th edition 1992. Paraphrased: As an educational tool the anecdotal method assumes that the practising physician who is roughly right is preferable to one who is precisely wrong.
Many medical and surgical remedies, such as carotid endarterectomy as a means to prevent stroke, have been used for many years based on the clinical wisdom of physicians who believed it to be necessary. Finally in 1991 the procedure was subjected to a randomized prospective study which confirmed the clinical wisdom of those physicians. I entirely agree with Dr. Bourdillon’s comments and would add that a good many surgical procedures are self-evident such as the splinting and casting of a fractured bone, extraction of a diseased tooth, draining of an abscess etc. I would include the chiropractic adjustment in this context of “self-evident based medicine” – to coin a phrase. Clinical wisdom demands that a misaligned vertebra with palpable loss of movement should have that movement restored in the appropriate direction. Experience has shown that manipulation done by hand achieves this most effectively and the procedure frequently results in not only pain relief but improved function of organ systems. The vertebral subluxation is indeed alive and well and being successfully identified and corrected by many health practitioners including medical doctors, osteopaths and, at least presently, by some chiropractors.
As to the definition of chiropractic being the detection and correction of the vertebral subluxation complex, and nothing more, Dr. Halowski does point out that he is not against adjunctive therapies. I believe he is making the point that the essence of chiropractic is the vertebral adjustment, the intent of which is more than just the relief of painful NMS conditions. The definition of dentistry for example is “the profession concerned with care and treatment of diseases of the teeth, gums and jaws”. (concise medical dictionary, Oxford Medical Publications) An all encompassing definition, but as we know historically the essence of dental practise is cavity filling and tooth extraction. Without these procedures it ceases to be dentistry no matter how many other dental hygiene procedures are utilized.
In the same dictionary the definition of chiropractic is “a system of treating diseases by manipulation, mainly of the vertebrae. It is based on the theory that most disorders can be traced to the misalignment of the spine with consequent malfunctions of nerves and muscle throughout the body”. Agree with it or not, the essence is deemed to be manipulation of the vertebral column, with intent to improve health via the nervous system. Without this it ceases to be chiropractic no matter how many other adjunctive therapies are utilized. Viewing chiropractic merely as a branch of manual medicine focused on the relief of NMS disorders is to reduce it from a system of healing, with possibilities as far reaching as the nervous system itself, to an extended form of physiotherapy i.e. physiotherapy plus manipulation. NMS Specialists already exist. They are called Neurologists, Rheumatologists and Orthopedists. The reality is we are not regarded as Specialists by the general public, we are regarded as back doctors. This is a huge difference in perception. How many times do we hear the remark “my doctor wants me to see a back Specialist if I do not get any better”? Patients realize that medical Specialists have access to sophisticated diagnostic procedures such as CAT scan, MRI, doppler flow and nerve conduction tests, and a whole range of bloodwork. They realize that as chiropractors we are good at what we do within a limited sphere. And none of those medical specialists are able to do what we do because it is not part of their training or interest. We, as a result of our chiropractic training are able to detect segmental spinal joint dysfunction and to varying degrees correct it by psychomotor dexterity that takes thousand of hours to perfect. This is aided by a thorough knowledge of biomechanics and clinical radiology. This ability should not be demeaned by us. It is hard earned and accounts for millions of patients seeking our care every year with resultant relief of pain syndromes and frequent benefit to internal regulatory mechanisms.
Chiropractors metamorphosing into NMS Specialists is unrealistic, unnecessary and in my opinion undesirable. It detracts from our training as doctors of manual medicine focused on restoring health, in some cases dramatically, such as auditory loss, the prevention of coronary artery spasm, the relieving of infantile colic and the reducing of episodes of otitis media to reiterate a few examples. The relief of musculo-skeletal pain will always be part of what we offer and we will always have a grateful public for that. What we need to do now is continue educating the public about the importance of the vital connection between our spines, nervous systems and general health. And we do not have to come across as scientific dinosaurs in the process. We have contemporary medical science, increasingly on our side. There was a time when behaving like religious zealots helped the profession survive. That is now unnecessary and inappropriate but we should continue to have courage of our convictions as we integrate into mainstream health care. I recommend the book “Medicine and Chiropractic” by C. W. Weiant, D. C. Ph. D. It is not a recent text but it provides a wealth of information from impeccable medical sources as to the validity of the tenets of our profession. This book above all others I believe should be required reading for all Chiropractic College students lest we forget what our great profession is all about.