When Forbes.com published Steven Salzberg’s article “New Medicare Data Reveal Startling $496 million wasted on Chiropractors” (April 20, 2014), a flood of mail (more than 300 comments) from chiropractors and their patients provided a wealth of evidence that subluxation-based chiropractic is alive and well despite rejection by the scientific community. Pro-chiropractic comments laced with anti-medical rhetoric and ad hominem attacks, expressed with religious fervor, failed to distinguish between generic spinal manipulation (that can be useful in the treatment of mechanical-type back and spinal problems) and chiropractic adjustments used in an attempt to restore and maintain health by correcting vertebral subluxations. No distinction was made between a real, symptomatic orthopedic subluxation and an imaginary, asymptomatic chiropractic “vertebral subluxation complex,” neither of which has been shown to be a cause of bad health. While the chiropractic profession may have some justification for objecting to any suggestion that chiropractic treatment has no value whatsoever, especially in the case of mechanical-type back pain and other musculoskeletal problems, the tone and content of many of the comments by chiropractors provide good examples of why chiropractic is so often criticized by the scientific community.
A quote in the Forbes article, from my Science-Based Medicine article “Chiropractic: A Summary of Concerns,” brought this comment from a prominent chiropractor:
…Harriet Hall, Edzard Ernst, Jann Bellamy, and other current renowned medical bigots who attack all CAM providers but turn a blind eye to the dangers of the medical profession….Steven, your chiro critics are invalid—none of them are researchers or educators, but they are just disgruntled practitioners from yesteryear. Don’t get me started on the Science-Based guys who are just haters like you—Harriet Hall, Edzard Ernst, Jann Bellamy are renown medical bigots.
Chiropractors who subscribe to the current chiropractic paradigm (which proposes that a subluxation complex will “compromise neural integrity and may influence organ system function and general health”) often attempt to equate use of chiropractic adjustments to treat health problems with spinal manipulation used in the treatment of back pain. Subluxation-based chiropractors might also refer to medical literature describing an orthopedic subluxation to support the existence of a putative chiropractic subluxation. While a case can be made for treatment to relieve musculoskeletal symptoms caused by an orthopedic subluxation, which is not a common occurrence, there is good reason to question why Medicare (or anyone) would pay for treatment of an undetectable “chiropractic subluxation” that is alleged (by chiropractors) to be so common that it is routinely entered as a diagnosis on chiropractic Medicare claims. Since Medicare coverage of chiropractic service is specifically limited to use of manual manipulation of the spine to correct a subluxation that can be demonstrated by x-ray or physical examination, it seems logical to assume that a diagnosis of “subluxation” on a chiropractic Medicare claim is rarely appropriate.
Until consensus forces chiropractic associations to publicly renounce the implausible chiropractic vertebral subluxation theory, requiring changes in state laws and the curriculum of chiropractic colleges across the board, chiropractic will continue to be defined by pseudoscience that keeps the profession marginal and isolated. In the meantime, science-based chiropractors who use manipulation appropriately will have to make an effort to separate their work from the stigma associated with inappropriate use of manipulation based on chiropractic subluxation theory.
The conflict between chiropractic and medical science won’t change until all concerned are able to meet on common ground governed by the laws of anatomy, physiology, and other basic sciences. Unfortunately, groups guided by a belief system do not often yield to facts that are contrary to a self-perpetuating dogma, making it necessary to speak out on the side of science in the best interest of persons who might become victims of such dogma.
Facts as proof vs dogma as proof
There are many legitimate studies published in peer-reviewed scientific journals supporting use of spinal manipulation as an appropriate form of manual therapy in the treatment of back pain. There is also a plethora of journals published and reviewed by chiropractors who are dedicated to promoting chiropractic subluxation theory as an approach for treating a great variety of ailments in all age groups, e.g., Journal of Vertebral Subluxation Research and Journal of Clinical Chiropractic Pediatrics. Articles in such journals are often offered as proof that treatment based on subluxation theory is effective, but few are able to withstand the scrutiny of scientific review. When Simon Singh, a British science journalist, said in a 2008 Guardian article (“Beware the Spinal Trap”) that chiropractic treatment of certain childhood ailments, endorsed by the British Chiropractic Association (BCA), was “bogus,” the BCA sued Singh for libel and presented 29 cherry-picked studies purported to support chiropractic treatment for such ailments as colic, nocturnal enuresis, otitis media, and asthma. Few of the articles were scientifically acceptable; all were of poor quality, with the totality of evidence actually negative. (See “The British Chiropractic Association Responds to Simon Singh,” Novella, Science-Based Medicine, July 8, 2009.) The BCA lost its suit against Singh.
In 2010, following the Singh suit, the General Chiropractic Council of the United Kingdom issued a declaration stating that “The chiropractic vertebral subluxation complex is an historical concept but it remains a theoretical model. It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.” The British Chiropractic Association responded by advising its members that the advice of the General Council had no bearing on scope of practice.
To date, I have seen only one credible study that has objectively examined chiropractic subluxation theory. In 2009, Timothy A. Mirtz, et al, using Hill’s criteria of causation, reported in Chiropractic and Manual Therapies (17:13) that “No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention.” Unfortunately, questions about the validity or the plausibility of chiropractic subluxation theory have not had any influence on the politics and policies of major chiropractic associations. Chiropractic associations usually respond to criticism of chiropractic care by comparing conservative care of back pain with medical care of back pain, presenting chiropractic as the superior treatment method without renouncing chiropractic subluxation theory that embraces a broad scope of health problems.
Journalism in the public interest
Few among us in the general public are able to evaluate the research published by chiropractic organizations and journals, often distributed by “press releases” and provided as a “public service” to newspapers and television stations. When there is a negative response to news that chiropractic is effective in treating a variety of health problems, chiropractors may respond by providing a long list of articles providing “facts about chiropractic,” published in chiropractic journals, offering “proof” that chiropractic can treat more than just back trouble. As in the case of the BCA-Singh suit dealing with childhood ailments, however, few of these articles would withstand scientific analysis, despite being viewed favorably by the public.
Judging from the increasing popularity of alternative medicine, science seems to be losing its battle against scams, quackery, and pseudoscience. The simple explanations offered by alternative medicine practitioners who offer anecdotes and testimonials as proof that their treatments are effective are appealing to persons who are unable to recognize the signs of pseudoscience and to entrepreneurs and health-care providers who can benefit financially from integration of questionable but popular treatment methods. Until the public as a whole is more well-informed and better educated in science and critical thinking, it will be necessary for science journalists to make every effort to protect the public by speaking out about the methods of charlatans, vendors, and well-meaning but misinformed practitioners and groups who offer inappropriate treatment to persons who are sick, in pain, or disabled.
When I write articles critical of chiropractic subluxation theory and inappropriate use of manipulation by subluxation-based chiropractors, I always make an effort to support the use of spinal manipulation as a form of manual therapy in the treatment of back trouble and related neuromusculoskeletal problems, no matter who uses such treatment. Unfortunately, chiropractic subluxation theory continues to be supported by a significant number of chiropractors, making it difficult to find a chiropractor who uses manipulation appropriately. Few chiropractors openly criticize subluxation-based chiropractic; those who do may claim that chiropractors who subscribe to subluxation theory are in the minority. The response of chiropractors to criticism of subluxation-based chiropractic, however, appears to indicate that the majority of chiropractors have not abandoned subluxation theory.
Despite the condemnation proffered by colleagues who view me as a hostile critic of chiropractic, I have always felt compelled to speak out against harmful or useless treatment methods used by practitioners who represent my profession. I have no objections to the work of science-based chiropractors who limit their treatment to care of musculoskeletal problems. I simply want to see spinal manipulation used appropriately by chiropractors and others who use manual therapy. I have always made an effort to be truthful to the best of my ability when people came to me for help or advice. When I published Bonesetting, Chiropractic, and Cultism in 1963, renouncing subluxation theory, I stood alone, knowing that publication of the book placed me in jeopardy of losing my license and my livelihood. Chiropractic journals refused to publish my articles. When the National Association for Chiropractic Medicine (NACM) was formed in 1983, members were required to renounce subluxation theory. The NACM provided opportunity for reform of the chiropractic profession and a safe haven for scientifically-oriented chiropractors. The association was able to attract only about one hundred members, however, and has since disbanded. I suspect that such an association today would not be any more successful than the NACM was in 1986 when I was a member.
The paper trail of a “chiropractic heretic”
Although my Bonesetting the book was reviewed by the Library Journal in 1964, it was never reviewed by a chiropractic association. When it was reviewed by Joe Keating, Ph.D., in 1990, he concluded with this statement:
Although chiropractors may take exception to Dr. Homola’s over-estimation of the scientific status of medicine, the historical value of his review of the state of chiropractic in 1963 is unmistakable. The good doctor has since authored and co-authored a number of widely read books on diet, exercise and nutrition, and continues in private practice (limited to “neuromusculoskeletal” disorders) in northern Florida. Perhaps the profession will finally seek out this seer before his most dire predictions come to pass.
— Dynamic Chiropractic, January 3, 1990
Today, many members of the chiropractic profession still view me as “the turncoat” who wrote Bonesetting, Chiropractic, and Cultism. I suspect that my demise will be celebrated by subluxation-based chiropractors who have contributed to my file of hate mail over the years. Hopefully, the paper trail I leave behind will show that I always acted in the best interest of the public and my patients by following the guidelines of science. I will rest in peace knowing that my views were well received by the scientific community and that much of the criticism I endured came from persons who felt threatened by scientific scrutiny of a belief system that governed their lives and their livelihood. A collection of letters in my file (Letters to a Chiropractic Heretic) contains notes from chiropractors who harbored views similar to mine and who were encouraged by my work but were reluctant to speak out for fear of ostracism.
I am comforted by the public support of a few outspoken individuals in my profession, such as Timothy A. Mirtz, Ph.D., D.C., who recently offered this response to criticism of one of my Science-Based Medicine articles:
Dr. Homola is indeed a DC himself with a long history of writing in the profession. In fact, his book, Bonesetting, Chiropractic, and Cultism was written in 1963. It is a magnificent read and if you read it today you would think he would be talking about today….I believe we owe him a debt for being the first to essentially speak out about the madness that we all find embarrassing. He is and should be honored as the Godfather of Chiropractic Reform.
Thank you, Dr. Mirtz. And thanks to all those who have supported me over the years, especially the scientific community that gave me a platform for my views. Publication of my articles on chiropractic in such peer-reviewed medical journals as Archives of Family Medicine and Clinical Orthopaedics and Related Research following my retirement from the practice of chiropractic belie the accusations of critics who say that I am simply an ignorant, disgruntled practitioner of yesteryear. In a stand diametrically opposed to the views of my chiropractic detractors, I am proud to be associated with such “medical bigots” as Harriet Hall, Edzard Ernst, and Jann Bellamy. And I am honored to be among the “haters” who write for Science-Based Medicine.
Sam Homola is a retired chiropractor who has been expressing his views about the benefits of appropriate use of spinal manipulation (as opposed to use of such treatment based on chiropractic subluxation theory) since publication of his book Bonesetting, Chiropractic, and Cultism in 1963. He retired from private practice in 1998. His many posts for ScienceBasedMedicine.org are archived here.