He approached me with his right hand outstretched, a car salesman smile on his young face. I stood up from the bench in the courthouse hallway to meet his handshake. “How’s it going?” he asked enthusiastically as he pumped my arm. I knew what his question meant; it wasn’t How are you? or How’s your day been? No, he was asking me about my chiropractic practice. Those three words were a code for other questions like How many patient visits was I averaging? How many new patients did I see? How fast was my practice growing? How much more did I gross this year? Was I educating my patients to return for life-long care? Were they referring their relatives and friends? Were they coming back for the right reasons? These questions all have to do with measures of practice success which, after all, is what chiropractic practice is all about. None concern favorable patient outcomes — the beneficial results we hope will result from medical treatments. Like an evangelical out to convert sinners, he assumed I was a devoted member of the faith.
In his other hand he held a full-size model of a human spine. He was in court to give expert witness testimony on behalf of his patient, a young woman who had been injured in an auto accident. I was there to testify in the same case, but for the other side, the person who caused the accident. I had been retained by the defendant’s insurance company. The plaintiff’s chiropractor was behaving as if I was a former school chum he had run into at a class reunion. Did he not understand that I was not his friend, that my testimony would contradict his own?
One look at his spine model told me all I needed to know about his testimony. He would tell the jury how subluxations—small, usually imaginary misalignments of vertebrae believed to pinch spinal nerves—were continuing to cause his patient’s pain. He would demonstrate this to the jury by twisting his spine model just so, showing them how the hard bones choked the delicate nerves. This is what had happened to the plaintiff as a result of the rear-end collision, he would testify. This is why she continued to have neck and back pain more than two years later, despite all the chiropractic treatments he had administered. Moreover, it justified all the treatment she had received, explained her permanent disability, and accounted for the necessity of ongoing chiropractic care indefinitely. He would say he had waged a valiant effort to correct those misalignments, but her injuries were serious, permanent, and would require lifelong chiropractic care to keep her pain to a minimum and allow her to perform her normal daily activities.
The plaintiff’s chronic pain was undoubtedly a burden to her, but to her chiropractor and, if she prevailed at trial, her lawyer, her ongoing symptoms and permanent partial disability made their cash registers ring. A jury award would go toward the medical bills left after her own car insurance stopped paying. After her lawyer was paid his share, there might be something left over for herself. (1)
My testimony, on the other hand, would focus on the treatments this chiropractor gave to his patient; how they were excessively frequent, how the course of care was unnecessarily prolonged, and how the various therapies of heat, ultrasound, electric muscle stimulation, and traction had no curative value and lacked scientific evidence of their efficacy. I would explain to the jury that a lengthy course of treatment such as this, which included massage and spinal manipulation, was likely to cause patients to become dependent on chiropractors, and I would explain how active care such as exercise empowered patients to become self-reliant. Furthermore, I would cite scientific studies to back up my opinions. Finally, I would state that the plaintiff was probably injured by the accident but, based on a review of the medical records and my own examination findings, the injuries were not as serious as her chiropractor claimed. She could improve further, perhaps even recover completely, if she received instruction in an exercise program appropriate for her injuries and performed the exercises on her own every day. In addition, a short course of counseling could disabuse her of her beliefs in the severity and permanency of her condition and help her to become independent of passive treatments. This opinion was also supported by scientific evidence.
I was surprised by this chiropractor’s salesman-like glad-to-see-you handshake because chiropractors generally think their colleagues who give opinions adverse to their own are hired guns whose testimony is bought and paid for by insurance companies, so his hardy greeting seemed out of place. Although it is rare to encounter the plaintiff’s treating chiropractor at these proceedings, when it does happen I am more often than not greeted only by a nod or a cursory handshake if not completely shunned. The term most often used by chiropractors for forensic consultants such as myself is insurance whore. It seems chiropractors understand other chiropractors who do medical-legal consulting in only one or two ways. They think forensic chiropractors care more for the money they are being paid than for the patient’s welfare, and they believe we don’t have the know-how to perform spinal adjustments adequately, so we must rely on the income derived from ratting out other chiropractors. In short, we are viewed as traitors to the profession.
Chiropractors who perform these medical-legal services have a different perspective, one that is more nuanced and considers many more factors in the evaluation of a patient’s condition. Plaintiffs’ lawyers sometimes ask if I ever agree with the treating chiropractor. Of course, in those cases when I do agree, which are rare, the case would be settled rather than go to arbitration or trial. Such cases are rare because, far more often than not, the treating chiropractor is wrong. Wrong about the diagnosis. Wrong about the prognosis. And wrong about the choice and duration of treatment. The case history does not convey the information necessary to properly document the injury. The patient’s past medical history, especially regarding prior injuries and chiropractic treatments, is concealed, the physical examination is performed for the purpose of proving the patient was injured and thus requires chiropractic care rather than evaluating all possible causes of the complaints and making an accurate diagnosis, and the prescribed therapies are intended to continue frequently for a protracted time. And all of the above are documented in a manner antithetical to clinical reasoning. The cumulative effect is to make the patient’s injuries appear far worse than they really are, necessitating a prolonged period of treatment, extensive time off work, some degree of permanent physical impairment, and a lifelong need for supportive chiropractic care. Is it any wonder that my conclusions disagree with the treating chiropractor in the majority of cases? Patients are portrayed not only as victims of these auto collisions (2) but also as the targets of insurance companies and their hired professional guns. In fact, they often end up at the mercy of the treating chiropractors and trial lawyers.
The dissonance between how chiropractors are perceived by the public, how they practice, and what they themselves think they do is a major driving force to the profession’s success. Most people see chiropractors as specialists in manual musculoskeletal medicine, essentially back doctors or “bone doctors.” This perspective is reinforced by chiropractic diagnostic and treatment methods: X-rays are used to visualize the bones of the spine, and the vertebrae are manipulated (“adjusted”) to restore normal alignment and motion. A typical reason to see a chiropractor would be for a “bone out of place” causing a “pinched nerve.” If the patient improved she would say her chiropractor popped the bone back into place and relieved the nerve pressure. Chiropractors encourage this simplistic thinking. Most chiropractors’ understanding of what they do is not much more complex.
Many patients who seek relief from neck and back pain are subject to a bait-and-switch stratagem because a lot of chiropractors believe themselves to be something very different from a back doctor or physical therapist, and the result is far more insidious. As far back as the late 19th century, the fundamental idea of chiropractic has been to remove interference to the body’s innate ability to heal itself and remain healthy. That interference might be described as the Big Black Boot Stepping on the Little Green Garden Hose. The boot is a slightly misaligned vertebra — a subluxation — and the hose is a nerve extending from the spinal cord through an opening between the misplaced vertebra and the one above or below it to its target organ or tissue somewhere in the body. When Innate Intelligence, a presumptive vitalistic force residing in the brain (the water traveling through the garden hose), is prevented from being transmitted through the afflicted nerve by a subluxation, the result is disease, which early chiropractors called dis-ease, perhaps because they sought to distinguish themselves from medical doctors who diagnosed disease. Thus, by a process of reverse logic, any health problem with which a patient presents is due to one or more vertebral subluxations, and the indicated treatment is always spinal adjustments. This ideology has produced various and often contradictory methods of spinal analysis to detect subluxations. It has also resulted in hundreds of methods for adjusting or correcting subluxations, techniques that range from a forceful thrust delivered manually to a light-as-a-feather touch and which can involve handheld instruments and specialized mechanical or pneumatic adjusting tables.
Chiropractors maintain a firm belief in these fundamental principles despite a dearth of scientific evidence to support them. D.D. Palmer, chiropractic’s founder, postulated the existence of vertebral subluxations and their interference to Innate Intelligence over 125 years ago, but in all the ensuing years scientific inquiry has failed to demonstrate that minor spinal misalignments adversely affect a person’s health—via the nervous system or by any other anatomical or physiological mechanism, with the possible exception of back pain—or that the chiropractic correction of hypothetical subluxations is a benefit to anything outside of a chiropractor’s income. Nonetheless, most chiropractors are adamant that their principles are supported by scientific evidence. This belief results from ignorance of the scientific method and a misunderstanding of the meaning of evidence.
This is not to say that spinal manipulation is without virtue. Research has demonstrated its benefit for several musculoskeletal problems including headache, neck pain, and back pain. (3) A portion of the chiropractic profession has in recent years focused more on its role as non-drug musculoskeletal specialists. As a result, since about 1990 there has been greater inclusion of chiropractors in managed health care plans including Kaiser Permanente, United Healthcare, Regence BlueCross BlueShield, and many others, but such care has by necessity been tightly controlled. In a randomized sample of US chiropractors, 70% of practitioners believe their clinical practices are “subluxation-centered” and 59% agree that the concept of subluxation is important to their clinical care decisions. (4) A survey of North American chiropractic students found that more than 60% agreed or strongly agreed that the emphasis of chiropractic intervention is to eliminate vertebral subluxations. (5) Attempts to remove the term subluxation from the chiropractic lexicon invariably meet harsh opposition from sectors of the profession.
Footnotes
1. A 2004 study by the Insurance Research Council found that people with auto accident injuries who hired an attorney were less likely to be satisfied with their settlement than those not represented by an attorney. Less than 50% of those who hired an attorney were satisfied with their total payment compared to almost 75% without an attorney. back
2. In my experience it is quite unusual for the person who caused the collision to claim disabling pain and prolonged disability. back
3. Bronfort G, Hass M, Evans R, Leninger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy. 2010;18(3). back
4. Smith M, Carber L. Survey of US Chiropractor Attitudes and Behaviors about Subluxation. Journal of Chiropractic Humanities. 2008;15:19–26. back
5. Gliedt J, Hawk C, Anderson M. Chiropractic identity, role and future: a survey of North American chiropractic students. Chiropractic and Manual Therapies. 2015;23(4). back
