Well-reasoned criticism of chiropractic quackery has triggered an angry response from the profession. The criticism took place during a segment ("Adjusting the joints") of Scientific American Frontiers (SAF) that was broadcast beginning June 4th on Public Broadcasting System stations throughout the country.and can be viewed on the SAF Web site. The program acknowledged that spinal manipulation might be useful for acute low back pain [1]. But it also noted that chiropractic's basic theory is nonsense and that neck manipulation can be dangerous. The parts that upset the chiropractors are summarized on the SAF Web site:
Invented by Daniel Palmer in 1895, chiropractic aims to correct blocked nerves -- what Palmer claimed were the cause of all disease -- by re-aligning the spine. But as former chiropractor John Badanes tells Alan [Alda], chiropractic has no basis in anatomy. Conducting a typical examination, Badanes explains how patients and chiropractors alike can misinterpret the popping sound that accompanies spinal adjustments. In fact it's dissolved gas being released in the joint fluid (the same thing that happens when you crack your knuckles) and not a sign that vertebrae are changing position -- an anatomical impossibility.
Like Badanes, physician Robert Baratz, [president] of the National Council Against Health Fraud, takes issue with chiropractic. Baratz is concerned about the risk of injury during neck manipulation, which can place severe strain on a vertebral artery, leading to blood clotting and stroke. Although chiropractors maintain this type of injury is very rare, a recent Canadian study estimated that 20 percent of all strokes caused by artery damage could be a result of neck manipulation. That figure translates into more than 1,300 strokes a year in the United States [2].
Chiropractors almost never accept or react constructively to criticism. When specific wrongdoings are exposed, they typically claim that their critics are biased, the criticism is unbalanced, and that the medical profession does things that are much worse. Within three days, the two largest chiropractic groups did exactly that and urged their members to flood PBS officials with protest messages [3,4].
On June 7, the American Chiropractic Association's president sent letters to PBS officials which said (in part):
I find it ironic that a program titled "Scientific American Frontiers" would completely ignore the scientific foundation of the chiropractic profession. The chiropractic portion of the June 4 episode titled "A Different Way to Heal?" irresponsibly characterized chiropractic care -- a legitimate, research-based form of health care -- as a fraudulent hoax.
I am also disappointed that you chose a group of admitted chiropractic antagonists, representatives of the National Council Against Health Fraud (NCAHF), as your "expert" health care sources. The NCAHF Web site describes chiropractic as "America's homegrown health care cult."1 The producers of your program could not have expected objectivity from this organization. And as a viewer of public television, I expect more reliable information than what the program offered.
I must also take you to task on the format of the program itself. The program did not offer any of your pro-chiropractic guests an opportunity to rebut the foolish statements made by the NCAHF group and former doctor of chiropractic John Badanes. This would be the legal equivalent to a jury trial in which the plaintiff's attorney is the only counsel permitted to make a closing statement to the jury. Secondly, through just a little research, you would have learned that an ACA representative would make the most logical pro-chiropractic guest for the program. Excluding the nation's largest chiropractic organization from the discussion is irresponsible. . . .
A more balanced segment would have featured representatives from the ACA and the scientific community discussing the numerous studies throughout the world that have shown chiropractic care to be effective and safe for a variety of conditions. Instead, the program's aim clearly appeared to be to discredit chiropractic, with NCAHF operating as a more-than-willing partner. . . .
During the program, Robert Baratz of NCAHF errantly claimed that there is no scientific basis for chiropractic care. This is simply not true. . . .
Your program also failed to cite any of the countless examples of chiropractic's successful integration into today's health care system. . . .
Despite such convincing evidence, some organizations such as NCAHF continue to question the legitimacy of chiropractic and other forms of alternative medicine. . . .
Far too many patients -- young and old -- have their pain treated with medication that may have side effects that do not correct the underlying source of their problem.
The ACA believes that patients have the right to know about the health risks associated with any type of treatment, including chiropractic. However, health care consumers should be aware that the risks associated with chiropractic treatment are infinitesimally low.
Finally, we are particularly concerned that your biased, misleading and malicious attack has severely and wrongfully damaged the reputation of the chiropractic profession and chiropractic colleges. We urge that you reconsider the assertions made in your program given the damaging effects they have had on the profession and on these institutions, and that you publicly withdraw the assertions with an apology to this association and to the nation's chiropractic colleges [4].
Curiously, the ACA letter contained a paragraph attacking me, even though I was not involved in any way on the planning or production of the program. The full text of the ACA letter and Dr. Baratz's analysis of it are posted elsewhere on Chirobase.
The International Chiropractors Association called for "an immediate and universal response from the chiropractic community to protest the on-going broadcast of a grossly distorted and internationally damaging depiction of the science and practice of chiropractic." Its message, posted to the group's Web site, stated (in part):
This program is supposedly looking at alternative approaches to health care. It is clear, however, that the producers were anything but objective when gathering their material. Both the script and the clips included are designed to distort the public's understanding of chiropractic in a most negative and damaging way.
In the broadcast that first aired on June 4th, hosted by well-known celebrity Alan Alda, chiropractic is represented as being unscientific, religion-based and extremely dangerous, all representations which are insulting and damaging to the 55,000 doctors of chiropractic who are licensed doctor-level health care providers and the millions of patients who are under their care. The producers of this show made an obvious decision to seek out chiropractic's most virulent critics, presenting their assertions as fact, and characterizing the few positive aspects of chiropractic noted in the show, such as the enthusiastic testimonial of a patient, as unreliable and lacking in validity.
"It is crystal clear that from start to finish, the objective of this production was to project the most negative picture of chiropractic possible," said ICA President Dr. D.D. Humber. "The carefully crafted, demeaning language, the complete distortion of the most basic facts about chiropractic and the absence of any reference to any of the landmark elements of chiropractic's validity, from state licensure and Medicare inclusion to any of the hundreds of studies that provide compelling evidence of chiropractic's effectiveness, reveal the editorial mission of this production." . . .
"The outrage that chiropractors have every right to feel at the scurrilous and deceitful attack through this broadcast must be compounded by the knowledge that it is our money that is being used to perpetrate this injustice," said Dr. Humber. ICA also urges every concerned citizen to make sure as part of any communication with local PBS stations to let them know of the economic impact this incident will have. The ICA is calling on the 55,000 doctors of chiropractic in the U.S., the 100,000 others they employ, chiropractic students and the tens of millions of people of all ages to whom doctors of chiropractic effectively and safely provide care, to withhold all donations until PBS corrects the damage it has done to a worthy and noble profession. ICA also urges the chiropractic community to let their state legislative representatives and Members of Congress know how they feel about the abuse of the public trust displayed by PBS in this damaging broadcast. PBS holds a tax-exempt status as well as receiving hundreds of millions of dollars in taxpayers' money. . . . [4].
On June 11, SAF's producers issued the following response:
The Scientific American Frontiers episode, "A Different Way to Heal" set out to examine some widely used approaches to health care in the rapidly expanding field of alternative medicine. The aim throughout the program was to ask what science has to say about these alternative approaches and their respective underlying theories.
The segment entitled "Adjusting the Joints" explored the subject of chiropractic as a healing art and science. The segment delved into the origin and theory of chiropractic, presented a number of specific techniques via trained chiropractors and their patients, and raised questions about some aspects of chiropractic, including evidence for the underlying principle of "subluxations" and the connection between spine alignment and health, methods of diagnosis, and the safety of certain forms of neck adjustment.
The segment did not claim that chiropractic is fraudulent and did not attempt to prove or disprove that chiropractic "works," but it does state that chiropractic has no basis in science. This conclusion is entirely justified by both current research and generally accepted views of human anatomy.
The underlying principle of chiropractic theory is that there is a direct association between the shape of the spine (the alignment of the vertebrae and the spine's curvature) and disease. Chiropractors claim that health problems can be caused by "subluxations," or blockages of nerve energy, which are caused by malpositioned vertebrae. By "adjusting" vertebra- manually exerting force on the spine so as to physically displace parts of the skeleton-chiropractors say they are removing the subluxation and hence allowing the body to heal itself. We felt it was important to review the scientific evidence for the existence of subluxations, as defined by chiropractors. We reviewed the scientific literature, with the guidance of a number of qualified medical sources, and concluded that there was no such evidence available in any form which would meet generally accepted scientific standards. On the contrary, there is scientific literature failing to find subluxations and associated phenomena stretching back thirty years, as was noted in the program.
Some viewers commented that the story was biased against chiropractic. We made a serious effort to give the chiropractic profession the opportunity to present their own case. Those in the segment supporting chiropractic included: the president of one of the most established and best-known chiropractic colleges in the country; three experienced and fully licensed Doctors of Chiropractic demonstrating and explaining in detail three different widely used techniques; and a patient who expressed her satisfaction with chiropractic treatment. To counter those five pro-chiropractic individuals we presented two individuals critical of chiropractic: a medical doctor and a former Doctor of Chiropractic who practiced for many years and who taught at a major chiropractic college. We allowed each of the individuals included, both pro and con, to express their own opinions. Other factual information conveyed in the segment included direct quotations from Daniel Palmer, the founder of chiropractic, and references to specific published papers in the medical literature.
Other viewers commented that the program ignored positive studies on chiropractic and included only negative studies. While it's true that there are many studies which purport to show the benefits of chiropractic, there are in fact very few which were conducted to the highest scientific standards. In reviewing research on chiropractic we held papers to those standards and looked for rigorous, well-designed studies that appeared in solid, peer-review medical journals. Our advisor in analyzing studies on chiropractic was Dr. Wally Sampson, a retired Stanford Medical School professor and editor of The Scientific Review of Alternative Medicine. In that high-quality category there are in fact very few positive papers supporting benefits of chiropractic for particular health problems. The one area where there is significant published evidence of chiropractic benefit is in treating back pain. Valid studies have shown that chiropractic can be of benefit to back pain sufferers. However, chiropractic success rates were no greater than conventional approaches like physical therapy and exercise. Since many chiropractors use procedures that are similar to those of conventional therapies, which do not require any belief in theories of subluxation and spinal displacement, the back pain studies cannot be used to validate chiropractic theory. Because we felt the subject of chiropractic and back pain was likely to be of importance for many viewers, we created an expanded discussion of the subject on the the Scientific American Frontiers Web site with the feature entitled "Keeping the Spine in Line."
On the question of chiropractic neck adjustments and stroke, some viewers questioned the statistics we used and expressed concern that stroke risk was exaggerated. Referring to a recent Canadian study, what we said was, "20% of all strokes caused by artery damage could be a result of neck manipulation. That translates into more than 1300 strokes a year in the US." We used the phrase "artery damage" to substitute for the technical term "vertibrobasilar dissection." That being said, our narration was a precise and accurate representation of the study in question. Other viewers wished that we had cited more studies on the stroke question. Indeed, we could have if not for time constraints. One British study we would have liked to discuss looked carefully at the question of under-reporting surrounding stroke and neck manipulation. In the study, neurologists who routinely treat stroke emergencies were first surveyed to see if they ever asked patients if they'd had a chiropractic neck manipulation recently. It was found that neurologists did not ask, as a rule. Then the neurologists were instructed to ask their patients as a matter of course. The incidence of chiropractic-related stroke shot up. So this wasn't just under-reporting that the study revealed - more like zero reporting. It seems that patients and neurologists have not been making connections between events which, of course, may well be days apart. The question of under-reporting - or more accurately of simply missing cause and effect - discussed in the Canadian study as well, is clearly now beginning to get more attention in academic circles.
In summary, we believe "Adjusting the Joints" was fair, accurate and balanced and, in conjunction with the other segments of "A Different Way to Heal" contributed to a more informed public understanding of a significant trend in health care today [5].
Scientific American Frontiers and its producers did an excellent job of placing chiropractic in proper perspective. As far as I know, the program was the first national television show in which chiropractic's subluxation theory was appropriately debunked. I am very pleased to see that chiropractic's knee-jerk reaction has not intimidated SAF's producers.
