Arthur Borneman, a 74-year-old Quincy man, had a pain in the neck. He tried painkillers, months of therapy at a rehab hospital, massage, exercise, even a dental specialist in case the problem was jaw pain.
To his surprise, the dentist urged him to see a chiropractor, but Borneman said he “had no faith in chiropractors.”
Still, figuring he had nothing to lose, Borneman went to Barry Freedman, a Quincy chiropractor who practices with his daughter, Gabrielle. Four weeks after his first visit, Borneman says, “I am much better. I feel like living again.”
Joan Doody, 33, a nurse from Needham who hurt her back lifting patients, offers a similar testimonial after seeing Michael Frustaci, a chiropractor in Wellesley and Brookline who quickly “adjusted” her spine and sent her happily on her way.
Despite many such stories from satisfied clients and some evidence that “back-cracking,” or spinal manipulation, is safe and effective for some types of back pain, chiropractic therapy is one of the most contentious of the alternative medicine practices now sweeping America.
There are still major grudges between chiropractors and doctors, several years after the chiropractors won a 16-year court battle to get the American Medical Association to stop trying to eliminate the chiropractic competition by refusing to refer patients or accept patients referred by chiropractors.
And there’s heated debate within the profession as well. Some, like Frustaci, think chiropractors should stick to manipulating the spine to ease sore backs and other musculo-skeletal problems. This is both “highly effective,” he says, and precisely what chiropractors learn in their specialized, four-year training.
Others, like Freedman, say that even though though they do not have M.D.degrees, most chiropractors “look at themselves as primary-care providers.They can diagnose whether the patient can benefit from chiropractic and/or whether they need a consultation from another doctor.”
And chiropractors still face criticism from many quarters, including the California-based National Council Against Health Fraud whose president, William Jarvis, a health education specialist, puts his criticism bluntly:
Chiropractic “is so bizarre, so dangerous and so bad that even when you just tell the straightforward truth about it, people think you are exaggerating.”
Even defining the basic concept of chiropractic is up for grabs — the notion that “subluxations,” or tiny misalignments of spinal vertebrae, are real phenomena that show up on X-rays, cause virtually all disease and can be forced back into aligment with a thrust of the hands.
This belief began with the founder of the movement, Daniel David Palmer, an Iowa grocer who more than 100 years ago claimed to cure a man of hearing loss by manipulating his spine. This is highly unlikely because the nerves for hearing all lie within the skull.
Furthermore, chiropractors have never been able to show that subluxations even exist, says Jarvis. No one has been able to correlate back pain with specific spinal misalignments, and many people with back pain have perfectly normal spinal X-rays, while some with abnormal X-rays have no pain.
The debate over subluxations has been so heated that, over a decade ago, chiropractor Ron Slaughter and like-minded souls founded their own group, the National Association for Chiropractic Medicine, to renounce what Slaughter calls “the historical, philosophical hypothesis that subluxation is the cause of all disease, which it surely is not.
“Subluxation is a metaphysical disease. . .and consequently, chiropractic today is practically a religion.”
Yet for all that, there’s no denying its popularity.
Last year, 22 million Americans went to a chiropractor, according to the
American Chiropractic Association, and half of all HMOs, or health maintenance organizations, now include a chiropractic benefit. In fact, despite lingering animosity, some doctors now refer patients to chiropractors, and most health insurers now cover the service, which runs about $35 a visit.
That’s partly because some research suggests spinal manipulation — a forceful thrust on the backbone — may help.
At RAND, a nonprofit think tank in Santa Monica, Calif., medical sociologist Ian Coulter and others conducted two meta-analyses in which they pooled data from various studies on manipulation for pain in the lower back and the neck.
Manipulation is defined as moving a joint to the limit of its range of motion and is often characterized by a popping sound, caused by escaping gases in the joint. Mobilization is moving the joint within its range of motion.
Although chiropractors helped fund the RAND study, the researchers focused on manipulation itself, not on who does it. In practice, chiropractors do the most spinal manipulations, but osteopaths (whose training is similar to that of M.D.s), physical therapists and others do, too.
The first RAND report, which became part of a 1994 report by the government’s Agency for Health Care Policy and Research, found positive but “not overwhelming” evidence that manipulation eases acute low back pain, says Coulter. There was was too little evidence to draw conclusions on chronic low back pain.
In a second report last year, the RAND team found that manipulation and mobilization both work for acute neck pain, though, again, the evidence on chronic pain was inconclusive. More recently, a Quebec study on whiplash and related injuries found that manipulation does seem to help with neck pain.
The RAND research also suggests that spinal manipulation is safe, says Coulter, with a “very low complication rate” — one in every one to two million adjustments.
Dr. Scott Haldeman, a chiropractor who is also a clinical neurologist at the University of California at Irvine Medical Center, concurs.
Haldeman acknowledges there is a small risk of stroke after manipulation because sudden twisting — even a quick turn of the head while driving or tipping the head back for a beauty salon shampoo — can injure arteries inside the vertebrae.
But this is “extraordinarily rare,” he says, and others note that it probably happens only to people who have a rare, hard to diagnose, anatomical abnormality. Still, Jarvis notes that over the years there have been reports of more than 100 strokes after spinal manipulation, and one recent California study, he says, found 56 strokes related to manipulation in just two years.
But Coulter says his team looked hard for examples of manipulation-related strokes and found very few.
It may also be dangerous to have any kind of manipulation too often, because ligaments along the spine may get stretched too far. And you should be wary of spinal manipulation if you have a suspected fracture, rheumatoid arthritis, severe osteoporosis, a bleeding disorder and any spinal infection or inflammation.
It’s still an open question whether chiropractic treatment, even with very gentle pressure, is appropriate for children.
Some say no, but Haldeman, whose father was a chiropractor, says he had his first adjustment “when I was a baby” and adds that he “treated my kids when they were young.”
In the end, it’s an individual decision whether to try chiropractic and if so, with whom. If you choose it, though, one rule of thumb is to steer clear of a chiropractor who says you need endless treatments.
In most cases, says Frustaci, people “don’t need more than six manipulations for any given episode of pain.” In fact, most bouts of back pain go away on their own in about four weeks.
You should also be skeptical of a chiropractor who tries to sell you vitamins, as some do, notes Haldeman.
And while Jerome McAndrews, spokesman for theAmerican Chiropractic Association, insists chiropractors “are trained in the full scope of diagnosis to the level of a general family practitioner,” others advise taking medical problems that are not obviously related to the spine to a physician.
Frustaci makes no bones about chiropractic’s limits: “My wife is a physician. There’s things I know I have no clue about, that my training doesn’t even come close to.”
You might also question a chiropractor who seems too eager to take X-rays.Although Medicare insists on X-rays to prove that “subluxation” is present, Frustaci says, this is odd, given the ongoing debate on whether subluxation even exists.
It is also a red flag if your practitioner has so much faith in chiropractic
that he or she advises you not to have your kids immunized against common childhood diseases.
As with so many other things, Jarvis says, it’s a case of “buyer beware.”