A History of Chiropractic Science

1
A History of Chiropractic Science

• Johnson, Greene Keating

2
Science? What Science?

• In the 1920's through the 1960's there were many
  unpublished or non-peer reviewed cases
• "Science" and "Research" were used in
  chiropractic publications, however, the
  scientific method was either poorly adhered to or
  not used at all

3
Science? What Science?

• Money for science?
• Not when you need to stay alive!
• Money that was available in chiropractic was
  focused on ensuring the survival of the profession

4
Survival

• Money was needed for
• Legally pursuing licensing laws
  
• Defending chiropractors who had been jailed for
  practicing medicine without a license
• Keeping the chiropractic colleges afloat through
  the Great Depression and World Wars

5
Survival

• The Universal Chiropractic Association was
  created to help fight for the legalization of
  chiropractic
• Money was needed for legal, not research,
  purposes

6
Survival

• Chiropractors suffered persecution under
  licensing laws
• Many chiropractors suffered the stigma of going
  to jail rather than paying the fine
• The monies would have been used to further
  persecute chiropractic

7
Survival

• Chiropractic students did not have access to
  student loans as allopathic students did
• This created hardship on both chiropracticstudent
  s and colleges

8
Survival

• Named techniques were fighting for the
  practitioner's dollar
  
• Any funding that did occur came from the private
  practitioner
• Government funding for research was non-existent

9
Survival

• For chiropractic, money was directed to the most
  vital items at the time
• No money was left for supporting scientific
  research efforts

10
Science resource crisis

• Most chiropractic students were not educated
  enough to appreciate reading the literature, let
  alone, contribute to it
• Practitioners were trained neither to read nor to
  contribute to the efforts of science and research

11
Science resource crisis

• This left a heavy load upon an already taxed
  source, the chiropractic faculty
• The result was a deficit in the realm of
  scholarship and science
• There was a desire, but no infrastructure
• Much criticism came from outside and inside the
  profession with a call to increase chiropractic
  science

12
Science resource crisis

• Many had high hopes to do real research, but
  few had the skills and infrastructure to complete
  the task
• The burden fell on the for-profit collegeswho
  were ill-equipped to carry out the task
• The resources were not available

13
Early attempts at science

• 1925 Chiropractic Statistics (a pamphlet)
• descriptive data for 110 diseases
• 99,976 patients
  
• 412 treating chiropractors
• 84.59 recovered, 14.96 unchanged, 0.85 died

14
Early attempts at science

• Problems with Chiropractic Statistics
• No valid measurements
• Poor methodology
• Not a reproducible study
• Data not published in a scientific journal

15
Early attempts at science

• 1938 What Chiropractic is Doing (a hard bound
  book)
• A collection of testimonials
• Published for marketing "chiropractic science

16
Early attempts at science

• Problems with What Chiropractic is Doing
• Not experimental nor sound observational studies
• No outcome measures
• Created a false sense of security for doctors in
  the field, they thought that this was good
  enough

17
Early attempts at science

• 1932 Lillard Marshall, D.C. (President and
  founder of the NCA) published a pamphlet
• Case series
• Several hundred adolescent inmates 10-20 yrs old
• Volunteer doctors provided chiropractic care

18
Early attempts at science

• Problems with Marshall's pamphlet
• Poor study methods
• No detailed records
• Type of care and outcomes not described
• Due to these problems, the study was poorly
  received by the government and health care
  community thus did not reflect well on
  chiropractic

19
Marshall's findings
Keating JC Jr, Green BN, Johnson CD. "Research"
and "science" in the first half of the
chiropractic century.J Manipulative Physiol
Ther. 1995 Jul-Aug18(6)357-78.
20
Early attempts at science

• 1935 - 1961 B.J. Palmer Chiropractic Clinic
• Two divisions a medical side for diagnosis only
  and a chiropractic side for diagnosis and
  treatment
• Patients were required to go through both to
  fight against claims of misdiagnosis

21
Early attempts at science

• B.J. Palmer Chiropractic Clinic collected a
  significant amount of data
• Millions of dollars were spent (in today's
  equivalent)

22
Early attempts at science

• Problems with B.J. Palmer Chiropractic Clinic
• No controlled studies
• Little critical thought in study design
• Although a lot of data was collected, nothing was
  done with it
• Information was not collected in a scientific way
  to evaluate a theory, but instead to prove that
  chiropractic works
• No publication in scientific journals

23
Early attempts at science

• Problems in chiropractic science existed in the
  mid 1900's because
• Resources were scarce
• Attempts were made without appropriate resources
  or skills
• Chiropractors did not possess the skills in the
  scientific method

24
Another call to arms

• C.O. Watkins (a Palmer graduate)
• Watkins viewed clinical research as the missing
  link in chiropractic's scientific development

25
Another call to arms

• Started the American Chiropractic Journal
• Although short lived, it provided a model for
  scholarly publishing in the profession
• Our principle aim is to assemble, correlate and
  disseminate scientific material for educational
  purposes to the chiropractic profession 1941
  C.O. Watkins

26
Another call to arms

• In 1942 the American Chiropractic Journal died
• It is speculated that the journal failed due to
• Lack of interest in reading from the profession
  (subscriptions)
• Lack of research submissions to the journal

27
Another call to arms

• Watkins proposed the creation of the Committee on
  Education (the forerunner of today's CCE)
• He proposed that educational standards be set for
  the chiropractic colleges

28
Another call to arms

• Watkins described chiropractic science 1940's
  
• Clinical research is severely lacking
  
• Basic science from medical literature is not
  enough to found the profession on
  
• Chiropractic cults are a reaction to lack of
  clinical foundation in science
  
• The average DC is not interested in or qualified
  to do basic science research

29
Another call to arms

• Watkins description cont.
• Chiropractic does not have scientific facts to
  base practice on
• Chiropractic does not have scientific facts to
  give to the public and its agencies
• Chiropractic has too much reliance on and expects
  the public to accept chiropractic solely on the
  basis of philosophy and theory

30
Another call to arms

• Watkins description cont.
• Chiropractic lacked
  
• Skills and training in research and science
• Professional organization and a common goal

31
Times of transition

• Attacks from outside the profession...
• Post WWII medical research and randomized
  controlled trials on insulin and penicillin
  created increased criticism of chiropractic as an
  unscientific cult
• Medicine used the science gap to further the
  attack on chiropractic

32
Times of transition

• The American Medical Association
  reinvigorated the attack to eliminate
  non-allopathic professions

33
Times of transition

• Undermining from within the profession...
• In the 40's and 50's B.J.'s followers in
  California would
• Object to any investigations that could
  challenge the truth of their fundamentalist
  beliefs about subluxation and adjusting.
• More cult-like chiropractic sprang up

34
Times of transition

• Cultism is like a weed in science for it saps
  the effort which should be used to advance the
  science, produces nothing of value, and a small
  amount of it in higher circles causes the rest of
  society to suspect that it exists generally
  throughout chiropractic. In other words, the
  actions of a few discredit all. 1944 C.O.
  Watkins

35
Times of transition

• In 1944 Watkins left the NCA
• He then inspired the creation of the Chiropractic
  Research Foundation (CRF)
• Today's Foundation for Chiropractic Education and
  Research (FCER)

36
CRF advertisement on page 4 of the NCAs National
Chiropractic Journal, September 1947
37
Times of transition

• CRFs purpose
  
• To receive monies for research purposes
  
• To promote science of chiropractic
  
• To promote infrastructure facilities, equipment,
  etc.
• To promote chiropractic hospitals and clinics
  
• To gather and disseminate scientific information

38
CRF advertisement on page 41 of the NCAs
National Chiropractic Journal, February 1948
39
Times of transition

• Problems with the CRF
• Focused on marketing and fundraising not on
  research
• Money went more to the colleges than research
• Lack of fundraising goals and poor public
  relations resulted in failures (often expensive
  ones)

40
Times of transition

• Gains from the CRF
• Consolidation of small for-profit colleges into
  bigger non-profit colleges (e.g., SCCC and LACC)
  
• Creation of an endowment to support the Spears
  Hospital

41
Times of transition

• 1949 good intentions to increase research from
  the NCA Council On Education
• Assigned research projects to faculty members at
  chiropractic colleges

42
Times of transition

• NCAs good intentions of 1949 failed
• Faculty had few skills in science and research
• No training was provided
• Chiropractic colleges were in a poverty state
• No resources were available (equipment, labs,
  etc.)
• Few colleges were non-profit to receive grant
  money

43
Times of transition

• 1953 good intentions from Henry Higley, M.A.,
  D.C. who organized the NCA to
• Create a research center
• A center intended to collect data gathered by
  students observing in practitioners offices

44
Times of transition

• 1953 good intentions failed
• Poor participation from students and colleges
• Lack of training
• Lack of funding

45
Times of transition

• 1960's
• NCA becomes the ACA
• National Board of Chiropractic Examiners is
  established (1963)
• FCER focuses money on training faculty in science
  and research

46
Times of transition

• 1960's
• 1963 AMA states its objective was
• . . . the complete elimination of the
  chiropractic profession
• Formation of the AMA's Committee on Quackery

47
Times of transition

• 1964 Committee on Quackery
• Primary goal of the committee to contain and
  eliminate chiropractic
• (evidence from the Wilk trial 1976)

48
Times of transition

• 1967 Committee on Quackery established that it
  was unethical for a medical physician
• To associate professionally with a chiropractor
• To make referrals to a chiropractor
• To teach a chiropractor
• To practice with a chiropractor
• (published in the 1969 Opinions and Reports of
  the Judicial Council of the AMA, evidence from
  the Wilk trial 1976)

49
Times of transition

• 1970's
• FCER focuses money on training faculty in science
  and research
• Scott Haldeman, Reed Phillips, John Triano
• These chiropractic scientists go on to make a
  significant impact in the profession through
  publication and research

50
Times of transition

• 1970's.
• National College gets regional accreditation
  (1971)
• US Office of Education recognizes the CCE
• Now students can get federal fundingto attend
  chiropractic college

51
Times of transition

• 1976
• Wilk et al. case
• The AMA was charged of violating the Sherman
  Anti-Trust act in its efforts to contain and
  eliminate the chiropractic profession

52
Chiropractic science

• The birth of the modern era of chiropractic
  science was attributed to the 1975 National
  Institute of Neurological Diseases and Stroke
  (NINDS) conference on spinal manipulation
• It was the first formal interaction between
  chiropractors and medical physicians in an
  academic forum

53
Chiropractic science

• The NINDS conference was supported by the
  National Institutes of Health (NIH) and the U.S.
  Department of Health Education and Welfare
• A multidisciplinary conference (DC, MD, and DO)
  focusing on research needs concerning
  manipulation

54
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55
CH Suh, PhD - Biomechanical Aspects of Subluxation
56
Chiropractic science

• NINDS stimulated a greater awareness of the need
  for good research and science, especially in
  regard to manipulation

57
Chiropractic science

• 1978 JMPT was the first successful chiropractic
  scientific journal
• Published by the NCC
• Roy Hildebrant was the editor (previous
  Radiology chair from PCC)

58
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59
Chiropractic science

• JMPT had
• Good editing methods
• Scientific contents
• Peer reviewers from outside and inside
  chiropractic
• Blinded peer review process

60
Chiropractic science

• In 1982 JMPT received status in Index Medicus
  (Pub Med)
• Indexing was essential because
• Information that cannot be identified or
  retrieved does not exist

61
Chiropractic science

• Even though JMPT was accessible and reputable,
  only a few in the profession subscribed
  (estimated 10 to 15)
• Thus the continued struggle for the doctor in the
  field to embrace science

62
Chiropractic science

• 1982 The Index to Chiropractic Literature
• Chiropractic college librarians started an
  indexing system
• It lacked significant funding and had limited
  resources
• Thus not as substantial a resource as Index
  Medicus

63
Chiropractic science

• 1985 Consortium for Chiropractic Research
  
• Organized the 5 West coast chiropractic college
  researchers
• CCA donated 50,000/yr

64
Chiropractic science

• Problems with the CCR
• Colleges received the money and often put it in
  the general fund, thus the money did not go to
  research
• CCR died in the 1990s due to dwindling financial
  resources and a fight for control of power

65
Chiropractic science

• 1986 FCER attempts an annual research conference
  at the chiropractic colleges
  
• Conference was poorly attended, even by the
  faculty at those colleges, due to lack of
  interest
• 1986 FCER President states that FCER funds went
  unspent due to lack of worthy proposals
• Thus, skills and training still an issue

66
Chiropractic science

• 1987 Judge Getzendanner orders a permanent
  injunction against the AMA on September 25th
  requiring it to publish the court's judgment in
  JAMA (follow up from the Wilk trial)

67
Chiropractic science

• 1990 FCER holds the International Conference on
  Spinal Manipulation (ICSM) in Washington DC
• ICSM is at first an annual conference, then
  becomes a biannual conference

68
Chiropractic science

• 1994 Association of Chiropractic Colleges holds
  its first Educational Conference
  
• All ACC Colleges were represented
  
• Scholarly presentations in the field of
  chiropractic
• Proceedings published in the Journal of
  Chiropractic Education

69
Chiropractic science

• 1996 Research Agenda Conference, first annual
  conference is held
• Government funded conference
• (Funding efforts began in 1994 by HRSA)
• Purpose is to create an agenda for chiropractic
  research
• Speakers and workshops for training chiropractic
  researchers

Health Resources and Services Administration
70
Chiropractic science

• The 1990's provided the opportunities for
  foundational growth in research and science

71
Chiropractic science today

• ACC, RAC and ICSM Conferences continue to grow in
  numbers of participants and quality of research
• FCER continues to fund research fellowships for
  training

72
Chiropractic science today

• Chiropractic Peer-reviewed journals
• JMPT
  
• JCCA (Canada)
  
• CJA (Australia)
  
  
• JCE
  
• JACA (USA) etc.

73
Chiropractic science today
74
Chiropractic science

• Government money is now available for
  chiropractic research
• National Center for Complementary and Alternative
  Medicine (NCCAM)
• Health Resource and Services Agency (HRSA)
• Consortial Center for Chiropractic Research
  (CCCR)
• Funded through National Institutes of Health
  (NIH) in l997

75
Chiropractic science today

• Chiropractic college research faculty more
  collaboration
• More productivity from the colleges and from the
  field

76
Chiropractic science today

• Palmer's contributionsPalmer Center for
  Chiropractic Research PCC, PCCW, and PCCF
• 2.9 million dollars
• Largest chiropractic research center in the world
  
• 16,400 net square feet in a five-floor building
• Has received grants totaling more than 20 million
  dollars

77
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78
Chiropractic science today

• In 2000, the Federal government awarded the PCCR
  a Facilities Construction grant of 1.3 million
  to renovate the research facility, the first ever
  made to a chiropractic college
• Has allowed expansion of physical space by 60 per
  cent to 16,400 net square feet in a five-floor
  building

79
Chiropractic science today

• Experimental Research in
• Basic sciences
• Clinical studies
• Historical Studies
• Educational Studies

80
Chiropractic science today

• Research in Chiropractic
• 73 randomized controlled trials
• 43 trials of spinal manipulation LBP
• 30 found chiropractic effective
• 13 found no significant difference between groups
• 0 found chiropractic ineffective

81
Chiropractic science today

• We no longer must rely on "testimonials"
• Chiropractic manipulation is better researched
  than many medical interventions
• We now have access to training and resources and
  the future is bright