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The purpose of this paper is to discuss various statements related to chiropractic identity from1 D. D. Palmer2; selected chiropractic organizations, associations, and colleges; and3 attitudes and perceptions of chiropractic from chiropractic students, practitioners, and patients.
For comparison purposes, identity statements and perceptions from the various chiropractic associations and colleges, as well as from students and patients, were explored. Identity statements for chiropractic were searched in various sources such as Palmer’s 1910 textbook, recent literature on viewpoints from chiropractic students and practitioners, and websites for chiropractic colleges and organizations. Palmer taught that the chiropractor’s focus was on vertebral subluxation. Today, a number of chiropractic colleges and organizations continue to include the vertebral subluxation model in their instruction, with a majority of students and practitioners subscribing to the model. Conversely, a number of other colleges and organizations portray chiropractic as being essentially about the treatment of back and neck pain, which is what patients associate with chiropractic. However, settling on any particular identity for the chiropractic profession will likely be met with resistance by some, given the plethora of opinions among chiropractic professionals as to what the identity of the chiropractic profession should be. Common ground between the different factions within the chiropractic profession might be found in a unifying expression such as “functional neurology.”
When a profession’s identity is not clear with respect to its area of interest and mission, then the public may be less inclined to seek its services. Identifying the chiropractic profession with a focus on vertebral subluxation would give the profession uniqueness not duplicated by other health care professions and, therefore, might legitimatize the existence of chiropractic as a health care profession. An identity having a focus on vertebral subluxation would also be consistent with the original intent of the founding of the chiropractic profession.
Two basic considerations are necessary to identify a profession1: its central area of interest and2 its mission.1 Although not the only things that identify a profession, these are necessary before other prerequisites of a profession are obtainable. Others hold that the definition of a profession pertains to its area of knowledge and boundaries of that knowledge, otherwise known as “degree of abstraction.”2
As a practical matter, identity of a profession helps guide its practitioners on scope of practice issues and informs the public on what the profession has to offer. Moreover, without a clear identity, there tends to be confusion about the profession. This confusion could manifest in the minds of patients, students, and practitioners.
Professional identity includes a self-concept of values, beliefs, and experiences.3 Moreover, the formation of a professional identity goes beyond the acquisition of certain skill sets, as it is formed mainly in social and relationship contexts.4 Having an identity that satisfies these descriptions still may not be satisfactory if that identity is not unique, separate, and distinct from those of other professions. One obstacle to achieving a clear and unified chiropractic identity has been that of “oppression,” as some in the nursing profession have observed.5 In the chiropractic context, the oppression pertains to opposition by organized medicine. Medical regulation was used against chiropractors, and many were arrested for practicing medicine without a license. The actions of the brave chiropractic pioneers, who went to jail for chiropractic to protest the charge (and who were practicing chiropractic, not medicine), helped bring about licensure in the United States. During the tumultuous days of harassment by organized medicine, chiropractic identity may have been diluted from the oppression. Another important aspect in professional identity is obtaining trust from the public that the profession serves.6 This trust requires periodic renewal of a profession’s social contract with the public.7 Without such renewal, the public will wrest the contract from the profession’s control and shift it to the “default model of the market.”7
When 2 professions have identities that are the same or overlap substantially (eg, both have back pain as their area of focus), then 1 of the professions is duplicative and therefore unnecessary. Some say that back pain is the main area of interest in chiropractic. Although back pain may not be the main area of interest in all medical practices, it certainly is included as 1 of their areas of interest. When chiropractors identify themselves as back pain specialists, or even spine specialists, they compete not only with medical practitioners, but also with osteopaths, physical therapists, massage therapists, and medicine cabinets in the homes of millions of potential patients. Others have suggested that the chiropractic identity be centered on the spine.8 However, such an identity is vague and also covered by other health professions. As Abbott has suggested, larger professions will tend to dominate the field. Thus, for the chiropractic profession, if its identity is based on neck and back pain, it is lost in the presence of much larger professions (eg, medicine) that also treat back and neck pain.2 Moreover, when the osteopathic profession merged into orthodox medicine in the late 1950s, it ceased to offer a unique service and was essentially swallowed up by the medical profession. Today, the osteopath and medical doctor are virtually indistinguishable.
The purpose of this paper is to discuss various statements related to chiropractic identity from1 D. D. Palmer2; selected chiropractic organizations (associations) and colleges; and3 attitudes and perceptions of chiropractic from chiropractic students, practitioners, and patients. The article concludes by encouraging the profession to base itself on its original intent, which is improving neurologic function by adjustment of vertebral subluxation.
For the purpose of this commentary, identity of chiropractic is considered synonymous with definition or explanation of what chiropractic is. Definitions of chiropractic, or statements that at least resembled a definition, were obtained from1 Palmer’s famous 1910 book, The Science, Art, and Philosophy of Chiropractic92; websites of national and international chiropractic organizations3; websites of chiropractic colleges listed in English by the Association of Chiropractic Colleges10; and4 internet (Bing, PubMed, and Google Scholar) searches for reported attitudes of chiropractic students, practitioners, and patients. The associations comprised the Association of Chiropractic Colleges (ACC),9 American Chiropractic Association,11 International Chiropractors Association,12 International Federation of Chiropractors and Organizations (IFCO),13 and World Federation of Chiropractic (WFC).14
Throughout Palmer’s 1910 textbook, he essentially stated that the main area of interest and therefore identity in chiropractic was analysis and adjustment of vertebral subluxation.9
Among a sample of 5 major chiropractic organizations, 2 specifically mention that chiropractic’s focus is subluxation (ACC) or vertebral subluxation (IFCO). Another organization’s statement is similar in that it mentions spinal adjustment, nervous system function, and general health, without specifically using the term subluxation (WFC) (Table 1).
A search of the internet was performed in February 2016 on how chiropractic colleges represent themselves and chiropractic identity to the public. Among the chiropractic colleges, 3 specifically mention subluxation in their description of chiropractic: Life University, Life Chiropractic College West, and Sherman College of Chiropractic. Other colleges, such as Cleveland Chiropractic College, New Zealand College of Chiropractic, and Palmer College of Chiropractic, describe subluxation with statements related to chiropractic focusing on the spine and its relationship to the nervous system. A number of other colleges mention that chiropractic pertains to general health and/or musculoskeletal conditions (Table 2).
Survey research by Gallup and Palmer College indicates that the public generally considers that chiropractic pertains to neck and back pain.15 However, 31% of those surveyed indicated that they would like to use chiropractic care even if they were asymptomatic. This suggests that about a third of potential patients are open to a wellness approach, which is a component of the vertebral subluxation model (eg, “maintenance care”).
Survey research by Gliedt et al indicates that a majority (61.4%) of chiropractic students think that “the emphasis of chiropractic intervention is to eliminate vertebral subluxations/vertebral subluxation complexes.”16
Survey research by McDonald et al indicated that 88.1% of practicing chiropractors in North America who responded to the survey answered yes to the question, “Should chiropractic retain the term vertebral subluxation complex?”17
Currently, a consensus viewpoint regarding the identity of the chiropractic profession is lacking, evidenced by the various opinions among its associations and colleges. It is unclear how these varying viewpoints came to be, considering the stated intent and identity of chiropractic as laid down by the founder of the profession. It is possible that these differing views came about simply as a preference that was different from Palmer’s original intent.
Academic freedom allows for various viewpoints, even with respect to a profession’s identity. However, that freedom may come with a price, in the way of unintended consequences; the public may be confused as to what chiropractic is when faced with the variability of viewpoints. Moreover, a profession’s identity that does not make distinctions between its identity and the identities of other professions seems to invite further confusion. To this point, the WFC has recommended that the identity of the profession should be “similar in all countries.”18
I feel that this is a worthy recommendation; however, the brand that WFC suggests may be too vague, as it has a relatively high degree of abstraction when it states that chiropractors are “spinal health care experts in the health care system.”18 The quasi-vagueness here might be considered to be at odds with WFC’s call that chiropractic identity should be clear and concise.18 Nonetheless, common ground between the WFC and those within the subluxation model are suggested in its qualifying statements for chiropractic care:
I suggest that the chiropractic profession’s identity should be based on what makes it unique and what the founder of chiropractic envisioned it to be, which is adjustment of vertebral subluxations to improve neurologic function in the patient. Although some in the profession have concerns with the subluxation model, there is interest in advancing the profession by addressing these issues.19, 20 For others, the problem may be with the use of the term subluxation. For example, a former president of the National University of Health Sciences states that the purpose of chiropractic manual care is to correct a “functional articular lesion” to “produce (a) beneficial neurologic effect.”21 Labeling subluxation as a “functional articular lesion” may not necessarily affect the qualities of the entity, if that label carries the same definition as subluxation. Still, it may reduce confusion if consistent terminology were used to describe this unique chiropractic area of interest. Nonetheless, commonality between different factions within the chiropractic profession may begin to merge perhaps on unifying expressions such as “spinal adjustment and functional neurology” or “improving function of the patient’s nervous system through spinal adjustment.” To this end, in moving the argument forward, Table 3 is a compilation of terms and concepts from across the profession that have at least some semblance to the subluxation model.
A perceived problem with the subluxation model is that there are so many definitions for subluxation. Obviously there are many operational definitions for vertebral subluxation. For example, Gonstead has its protocol on how to analyze for subluxation, Activator Methods has its own operational definition, and so on. However, there may be general agreement on the concept definition for vertebral subluxation, which essentially is a minor biomechanical dysfunction in the spine that results in a neurologic disturbance.9 The various operational definitions highlight the need to include them in papers on subluxation, particularly in research papers, so that other researchers who may wish to verify findings of such studies can do so given enough detail on the methods used. It simply does not suffice to say in a research paper that the spine was examined and adjusted.
Another issue with the subluxation model is the validity and reliability of the methods used to identify it. This challenge though is not unique to the subluxation model, as validity of methods is a challenge in non-subluxation models in chiropractic. For example, the back pain model and the subluxation model may both use motion palpation as a diagnostic method, yet palpation has its own set of challenges regarding its validity (eg, some studies report low reliability).22 The remedy for such challenges is at the same time an opportunity for different factions of the profession to come together to focus on a common area to advance the profession. As President Abraham Lincoln said, “a house divided against itself cannot stand.” We must join together in our research efforts. An example from the history of chiropractic that unity on subluxation research is possible was the study conducted at the University of Colorado in the 1970s by Sharpless.23
One last example of a challenge with the subluxation model is whether subluxation has any adverse effect on health. Because there may be only some evidence along these lines (eg, the Bakris et al study on upper cervical adjustment and hypertension24), it would be disingenuous to insinuate that there is none at all. Indeed, even some of the harshest critics of the subluxation model, to their credit, state that it is a “legitimate, potentially testable, theoretical construct.”25
Settling on any particular identity for the chiropractic profession will likely be met with resistance by some, given the plethora of opinions among chiropractic professionals as to what the identity of the chiropractic profession should be. Common ground between the different factions within the chiropractic profession might be found in a unifying expression such as “spinal adjustment and functional neurology.”
A limitation to this commentary is that the colleges selected were mostly from one region, North America, the exception being the New Zealand College of Chiropractic. The international “flavor” of what chiropractic is can be viewed by the paper’s inclusion of international associations (eg, WFC and IFCO). Another limitation is that this is an opinion-based paper.
When a profession’s identity is not clear with respect to its area of interest and mission, then the public may be less inclined to seek its services. Identifying the chiropractic profession with a focus on vertebral subluxation would give the profession uniqueness not duplicated by other health care professions and therefore might legitimatize the existence of chiropractic as a health care profession. An identity having a focus on vertebral subluxation would also be consistent with the original intent of the founding of the chiropractic profession.
No funding sources or conflicts of interest were reported for this study.
Concept development (provided idea for the research): J.H.
Design (planned the methods to generate the results): J.H.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): J.H.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): J.H.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): J.H.
Literature search (performed the literature search): J.H.
Writing (responsible for writing a substantive part of the manuscript): J.H.
Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): J.H.