Dr. Mercola's Comments: I am an avid believer in the chiropractic philosophy, which places a strong emphasis on the body's intrisinic (innate) healing wisdom and far less reliance on band-aids like drugs and surgery. But how does the science behind chiropractic actually work toward that goal to achieve true healing? Dr. Alex Vasquez has written an enlightening two-part article that explains the "nuts and bolts" of science of chiropractic, both past and present and describes its true value to your health. Dr. Vasquez is one of the pioneers of the profession as he will likely be the first chiropractor to actually have ND and MD degrees. He obtained his ND from Bastyr University and is scheduled to start an MD medical school next year. By Alex Vasquez, DC, ND In contrast, chiropractic, osteopathic and naturopathic physicians receive extensive training in the management of outpatient musculoskeletal disorders during their course of graduate healthcare training, which typically lasts from 4-6 years. In accord with this comprehensive training in musculoskeletal management, numerous sources of evidence demonstrate chiropractic management is much safer and less expensive than allopathic medical treatments, particularly for low-back pain. In their extensive review of the literature, Manga et al (34) published in 1993 that chiropractic management of low-back pain is superior to allopathic medical management in terms of greater safety, greater effectiveness and reduced cost. They concluded: "There is an overwhelming body of evidence indicating that chiropractic management of low-back pain is more cost-effective than medical management." "There would be highly significant cost savings if more management of LBP (low-back pain) was transferred from medical physicians to chiropractors." In a randomized trial involving 741 patients, Meade et al (35) showed, "Chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain ... The benefit of chiropractic treatment became more evident throughout the follow up period. Secondary outcome measures also showed that chiropractic was more beneficial." A three-year follow-up study by these same authors (36) in 1995 showed, "At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low-back pain as they would in day to day practice those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals." Most recently, in 2004 Legorreta et al (37) reported the availability of chiropractic care was associated with significant cost savings among 700,000 patients with chiropractic coverage compared to 1 million patients whose insurance coverage was limited to allopathic medical treatments. A simple extrapolation of the average savings per patient in this study ($208 annual savings associated with chiropractic coverage) to the U.S. population (295 million citizens in 2005) (38) suggests that, if fully implemented on a nationwide basis, America could save more than $61 billion per year in healthcare annual expenses by ensuring chiropractic for all citizens in contrast to failing to provide such coverage. Obviously, an extrapolation such as this should consider other variables, such as the relatively higher prevalence of injury and death among patients treated with drugs and surgery. (39,40) A literature review by Dabbs and Lauretti (41) showed spinal manipulation is safer than the use of NSAIDs in the treatment of neck pain. Contrasting the rates of manipulation-associated cerebrovascular accidents to the dangers of medical and surgical treatments for spinal disorders, Rosner (42) noted, "These rates are 400 times lower than the death rates observed from gastrointestinal bleeding due to the use of nonsteroidal anti-inflammatory drugs and 700 times lower than the overall mortality rate for spinal surgery." Similarly, in his review of the literature comparing the safety of chiropractic manipulation in patients with low-back pain associated with lumbar disc herniation, Oliphant (43) showed that, "The apparent safety of spinal manipulation, especially when compared with other (medically) accepted treatments for (lumbar disk herniation), should stimulate its use in the conservative treatment plan of (lumbar disk herniation)." Spinal Manipulation: The Mechanisms of Action, Safety and Results Applied to either the spine or peripheral joints, high-velocity low-amplitude joint manipulation appears to have numerous physical and physiological effects, including, but not limited to, the following: Releasing entrapped intraarticular menisci and synovial folds. Acutely reducing intradiscal pressure, thus promoting replacement of decentralized disc material. Stretching of deep periarticular muscles to break the cycle of chronic autonomous muscle contraction by lengthening the muscles and thereby releasing excessive actin-myosin binding. Promoting restoration of proper kinesthesia and proprioception. Promoting relaxation of paraspinal muscles by stretching facet joint capsules. Promoting relaxation of paraspinal muscles via "postactivation depression," which is the temporary depletion of contractile neurotransmitters. Temporarily elevating plasma beta-endorphins. Temporarily enhancing phagocytic ability of neutrophils and monocytes. Activation of the diffuse descending pain inhibitory system located in the periaqueductal gray matter (an important aspect of nociceptive inhibition by intense sensory/mechanoreceptor stimulation, which will be discussed in a following section for its relevance to neurogenic inflammation). While this list of mechanisms-of-action is certainly not complete, for the purposes of this paper, it is sufficient to have established that, indeed, joint manipulation in general and spinal manipulation in particular have objective mechanistic effects that correlate with their clinical benefits. Additional details are provided in numerous published reviews and primary research (44,45,46,47,48,49,50) and by Leach (51), whose extensive description of the mechanisms of action of spinal manipulative therapy is unsurpassed. Given such a wide base of experimental and clinical support published in peer-reviewed journals and widely-available textbooks, denigrations directed toward spinal manipulation on the grounds that it is "unscientific" or "unsupported by research" are unfounded and are indicative of selective ignorance. The clinical benefits and cost-effectiveness of chiropractic management of musculoskeletal conditions is extensively documented. Spinal manipulation generally shows superior safety compared to drug and surgical treatment of back and neck pain and is also well established. (52,53,54,55,56,57,58) Adjunctive therapies such as post-isometric relaxation (59) and correction of myofascial dysfunction (60) can lead to tremendous and rapid reductions in musculoskeletal pain without the hazards and expense associated with pharmaceutical drugs. The nonmusculoskeletal benefits of musculoskeletal/spinal manipulation include improved pulmonary function and/or quality of life in patients with asthma (61,62,63,64) and improvement or restoration of vision in patients with post-traumatic visual loss. (65,66,67,68,69,70,71,72) More research is required to quantify the potential benefits of spinal manipulation in patients with wide-ranging conditions such as epilepsy (73,74), attention-deficit hyperactivity disorder (75,76) and Parkinson's disease. (77) Given that most pharmaceutical drugs work on single biochemical pathways, spinal manipulation is discordant with the medical/drug paradigm because its effects are numerous (rather than singular) and physical and physiological (rather than biochemical). Thus, when viewed through the allopathic/pharmaceutical lens, spinal manipulation -- like acupuncture and other physical modalities -- will be viewed as "unscientific" and "does not make sense." In this case, the fault lies with the viewer and the lens, not with the object. Research documenting the systemic and "nonmusculoskeletal" benefits of spinal manipulation mandates our concept of "musculoskeletal" must be expanded to appreciate that musculoskeletal interventions benefit nonmusculoskeletal body systems and physiologic processes. This conceptual expansion applies also to soft tissue therapeutics such as massage, which can reduce adolescent aggression (78), improve outcome in preterm infants, (79) alleviate premenstrual syndrome (80) and increase serotonin and dopamine levels in patients with low-back pain. (81) Conclusions Relegating the modern chiropractic profession to a marginalized position in the healthcare arena, simply because some (not all) of the founding assumptions of the profession circa 1903 have since been determined to be simplistic or inaccurate, would be as ridiculous as it would be to castigate the entire allopathic profession as incompetent simply because their forbearers utilized treatments such as: Bloodletting The administration of "therapeutic" mercury Refusing to care for African-Americans with syphilis More recently, injections of cancer cells into hospital patients without their consent for the sake of conducting research on the course of the disease (82) It is a malicious act to continue denigrating (and thereby restricting) the modern chiropractic profession based on scientific shortcomings that were inherent in all of the healthcare professions 100 years ago, or even 40 years ago. To this day, the American Medical Association continues to berate the entire chiropractic profession based on controversial and politically influenced reports that found "deficits" in chiropractic education in the 1960s. These shortcomings, that occurred more than 40 years ago, are used as justification to restrict the profession even now. (83) Furthermore, since it appears most allopathic medical doctors have received inadequate training in fundamental musculoskeletal medicine (27-30), they would, therefore, not be expected to be aware of the complex physiological effects of spinal manipulation and modern integrative chiropractic care [reviewed previously see Leach (84), Haldeman (85), Bergman et al (86) and Vasquez (87) for more details]. In a noteworthy critique of his own profession, former JAMA editor George Lundberg MD (88) -- even though he admits to having been taught essentially nothing but misinformation about chiropractic in his formal medical education -- had an occasion of uncommon insight which allowed him to distinguish pre-scientific chiropractic theory from contemporary chiropractic practice. He writes, "Putting aside my early bias against chiropractic, it is important for me to note the distinction between theory and practice. [Early chiropractic theory] may be one thing, but [the modern chiropractic profession] may be something entirely different." Likewise, it is incumbent upon policymakers and other healthcare professionals to relinquish their simplistic and inaccurate perceptions of the chiropractic profession and to access current articles and texts so that they can become informed of the developments that have modernized the chiropractic profession in the course of the past 100 years since its inception. Selective misunderstanding and intentional ignorance of chiropractic by medical organizations and policymakers serves only to maintain the status quo and justify resistance to the full inclusion of chiropractic physicians into the healthcare system despite overwhelming and consistent evidence that chiropractic care is safe, effective and more cost-effective than the allopathic management of back pain. Dr. Vasquez, DC, ND, is the author of Integrative Orthopedics, a textbook for doctors. Footnotes << Previous [ Part 1, Part 2 ] Related Articles: Why Chiropractic? Happy Birthday Chiropractic! Vitalism--Turn Your Power On! Two Tried-and-True Tips for Pain Relief Six Tips to Choosing a Wellness Chiropractor The Evolving Science of Chiropractic Philosophy
I am an avid believer in the chiropractic philosophy, which places a strong emphasis on the body's intrisinic (innate) healing wisdom and far less reliance on band-aids like drugs and surgery.
But how does the science behind chiropractic actually work toward that goal to achieve true healing? Dr. Alex Vasquez has written an enlightening two-part article that explains the "nuts and bolts" of science of chiropractic, both past and present and describes its true value to your health. Dr. Vasquez is one of the pioneers of the profession as he will likely be the first chiropractor to actually have ND and MD degrees. He obtained his ND from Bastyr University and is scheduled to start an MD medical school next year.
By Alex Vasquez, DC, ND
In contrast, chiropractic, osteopathic and naturopathic physicians receive extensive training in the management of outpatient musculoskeletal disorders during their course of graduate healthcare training, which typically lasts from 4-6 years. In accord with this comprehensive training in musculoskeletal management, numerous sources of evidence demonstrate chiropractic management is much safer and less expensive than allopathic medical treatments, particularly for low-back pain.
In their extensive review of the literature, Manga et al (34) published in 1993 that chiropractic management of low-back pain is superior to allopathic medical management in terms of greater safety, greater effectiveness and reduced cost. They concluded:
"There is an overwhelming body of evidence indicating that chiropractic management of low-back pain is more cost-effective than medical management."
"There would be highly significant cost savings if more management of LBP (low-back pain) was transferred from medical physicians to chiropractors."
In a randomized trial involving 741 patients, Meade et al (35) showed, "Chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain ... The benefit of chiropractic treatment became more evident throughout the follow up period. Secondary outcome measures also showed that chiropractic was more beneficial."
A three-year follow-up study by these same authors (36) in 1995 showed, "At three years the results confirm the findings of an earlier report that when chiropractic or hospital therapists treat patients with low-back pain as they would in day to day practice those treated by chiropractic derive more benefit and long term satisfaction than those treated by hospitals."
Most recently, in 2004 Legorreta et al (37) reported the availability of chiropractic care was associated with significant cost savings among 700,000 patients with chiropractic coverage compared to 1 million patients whose insurance coverage was limited to allopathic medical treatments.
A simple extrapolation of the average savings per patient in this study ($208 annual savings associated with chiropractic coverage) to the U.S. population (295 million citizens in 2005) (38) suggests that, if fully implemented on a nationwide basis, America could save more than $61 billion per year in healthcare annual expenses by ensuring chiropractic for all citizens in contrast to failing to provide such coverage. Obviously, an extrapolation such as this should consider other variables, such as the relatively higher prevalence of injury and death among patients treated with drugs and surgery. (39,40)
A literature review by Dabbs and Lauretti (41) showed spinal manipulation is safer than the use of NSAIDs in the treatment of neck pain. Contrasting the rates of manipulation-associated cerebrovascular accidents to the dangers of medical and surgical treatments for spinal disorders, Rosner (42) noted, "These rates are 400 times lower than the death rates observed from gastrointestinal bleeding due to the use of nonsteroidal anti-inflammatory drugs and 700 times lower than the overall mortality rate for spinal surgery."
Similarly, in his review of the literature comparing the safety of chiropractic manipulation in patients with low-back pain associated with lumbar disc herniation, Oliphant (43) showed that, "The apparent safety of spinal manipulation, especially when compared with other (medically) accepted treatments for (lumbar disk herniation), should stimulate its use in the conservative treatment plan of (lumbar disk herniation)."
Spinal Manipulation: The Mechanisms of Action, Safety and Results
Applied to either the spine or peripheral joints, high-velocity low-amplitude joint manipulation appears to have numerous physical and physiological effects, including, but not limited to, the following:
Releasing entrapped intraarticular menisci and synovial folds.
Acutely reducing intradiscal pressure, thus promoting replacement of decentralized disc material.
Stretching of deep periarticular muscles to break the cycle of chronic autonomous muscle contraction by lengthening the muscles and thereby releasing excessive actin-myosin binding.
Promoting restoration of proper kinesthesia and proprioception.
Promoting relaxation of paraspinal muscles by stretching facet joint capsules.
Promoting relaxation of paraspinal muscles via "postactivation depression," which is the temporary depletion of contractile neurotransmitters.
Temporarily elevating plasma beta-endorphins.
Temporarily enhancing phagocytic ability of neutrophils and monocytes.
Activation of the diffuse descending pain inhibitory system located in the periaqueductal gray matter (an important aspect of nociceptive inhibition by intense sensory/mechanoreceptor stimulation, which will be discussed in a following section for its relevance to neurogenic inflammation).
While this list of mechanisms-of-action is certainly not complete, for the purposes of this paper, it is sufficient to have established that, indeed, joint manipulation in general and spinal manipulation in particular have objective mechanistic effects that correlate with their clinical benefits.
Additional details are provided in numerous published reviews and primary research (44,45,46,47,48,49,50) and by Leach (51), whose extensive description of the mechanisms of action of spinal manipulative therapy is unsurpassed. Given such a wide base of experimental and clinical support published in peer-reviewed journals and widely-available textbooks, denigrations directed toward spinal manipulation on the grounds that it is "unscientific" or "unsupported by research" are unfounded and are indicative of selective ignorance.
The clinical benefits and cost-effectiveness of chiropractic management of musculoskeletal conditions is extensively documented. Spinal manipulation generally shows superior safety compared to drug and surgical treatment of back and neck pain and is also well established. (52,53,54,55,56,57,58)
Adjunctive therapies such as post-isometric relaxation (59) and correction of myofascial dysfunction (60) can lead to tremendous and rapid reductions in musculoskeletal pain without the hazards and expense associated with pharmaceutical drugs.
The nonmusculoskeletal benefits of musculoskeletal/spinal manipulation include improved pulmonary function and/or quality of life in patients with asthma (61,62,63,64) and improvement or restoration of vision in patients with post-traumatic visual loss. (65,66,67,68,69,70,71,72) More research is required to quantify the potential benefits of spinal manipulation in patients with wide-ranging conditions such as epilepsy (73,74), attention-deficit hyperactivity disorder (75,76) and Parkinson's disease. (77)
Given that most pharmaceutical drugs work on single biochemical pathways, spinal manipulation is discordant with the medical/drug paradigm because its effects are numerous (rather than singular) and physical and physiological (rather than biochemical). Thus, when viewed through the allopathic/pharmaceutical lens, spinal manipulation -- like acupuncture and other physical modalities -- will be viewed as "unscientific" and "does not make sense." In this case, the fault lies with the viewer and the lens, not with the object.
Research documenting the systemic and "nonmusculoskeletal" benefits of spinal manipulation mandates our concept of "musculoskeletal" must be expanded to appreciate that musculoskeletal interventions benefit nonmusculoskeletal body systems and physiologic processes.
This conceptual expansion applies also to soft tissue therapeutics such as massage, which can reduce adolescent aggression (78), improve outcome in preterm infants, (79) alleviate premenstrual syndrome (80) and increase serotonin and dopamine levels in patients with low-back pain. (81)
Conclusions
Relegating the modern chiropractic profession to a marginalized position in the healthcare arena, simply because some (not all) of the founding assumptions of the profession circa 1903 have since been determined to be simplistic or inaccurate, would be as ridiculous as it would be to castigate the entire allopathic profession as incompetent simply because their forbearers utilized treatments such as:
It is a malicious act to continue denigrating (and thereby restricting) the modern chiropractic profession based on scientific shortcomings that were inherent in all of the healthcare professions 100 years ago, or even 40 years ago.
To this day, the American Medical Association continues to berate the entire chiropractic profession based on controversial and politically influenced reports that found "deficits" in chiropractic education in the 1960s. These shortcomings, that occurred more than 40 years ago, are used as justification to restrict the profession even now. (83)
Furthermore, since it appears most allopathic medical doctors have received inadequate training in fundamental musculoskeletal medicine (27-30), they would, therefore, not be expected to be aware of the complex physiological effects of spinal manipulation and modern integrative chiropractic care [reviewed previously see Leach (84), Haldeman (85), Bergman et al (86) and Vasquez (87) for more details].
In a noteworthy critique of his own profession, former JAMA editor George Lundberg MD (88) -- even though he admits to having been taught essentially nothing but misinformation about chiropractic in his formal medical education -- had an occasion of uncommon insight which allowed him to distinguish pre-scientific chiropractic theory from contemporary chiropractic practice. He writes, "Putting aside my early bias against chiropractic, it is important for me to note the distinction between theory and practice. [Early chiropractic theory] may be one thing, but [the modern chiropractic profession] may be something entirely different."
Likewise, it is incumbent upon policymakers and other healthcare professionals to relinquish their simplistic and inaccurate perceptions of the chiropractic profession and to access current articles and texts so that they can become informed of the developments that have modernized the chiropractic profession in the course of the past 100 years since its inception.
Selective misunderstanding and intentional ignorance of chiropractic by medical organizations and policymakers serves only to maintain the status quo and justify resistance to the full inclusion of chiropractic physicians into the healthcare system despite overwhelming and consistent evidence that chiropractic care is safe, effective and more cost-effective than the allopathic management of back pain.
Dr. Vasquez, DC, ND, is the author of Integrative Orthopedics, a textbook for doctors.
Footnotes
Related Articles:
Why Chiropractic? Happy Birthday Chiropractic! Vitalism--Turn Your Power On! Two Tried-and-True Tips for Pain Relief Six Tips to Choosing a Wellness Chiropractor The Evolving Science of Chiropractic Philosophy
Why Chiropractic?
Happy Birthday Chiropractic!
Vitalism--Turn Your Power On!
Two Tried-and-True Tips for Pain Relief
Six Tips to Choosing a Wellness Chiropractor
The Evolving Science of Chiropractic Philosophy
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