Skip to main content

Archived Comments for: Chiropractic as spine care: a model for the profession

Back to article

  1. Models of Chiropractic Care

    Mark Morningstar, The Pettibon Institute

    20 September 2005

    Dear Editor,

    I read with interest the article by Nelson et al titled, "Chiropractic as spine care: a model for the profession." I feel that the article is well written and understandable even to many lay people; perhaps those who influence our scope of practice and our place in modern healthcare will take notice.

    After reading the paper, I do feel that their critique of established models contains assumptions that our current body of collective evidence cannot yet confirm or deny. In order to properly address these assumptions, I would like to address them in order by which they appear in the paper.

    The first point is the authors' assertion that those with "scoliotic, osteophytic, degenerated" spines can "so often result in no clinical problems." While much of the literature suggests this relationship, this in and of itself does not invalidate the "Palmer Postulates." Scoliosis patients, for example, do have ongoing pathophysiologic processes (i.e. reduced pulmonary function). Specifically, reduced chest wall compliance and vital capacity are inversely correlated down to a Cobb angle of 10 degrees [1]. Children with even mild scoliosis demonstrate reduced exercise capacity, despite a normal resting vital capacity [2,3]. Reduced exercise capacity is a better predictor of mortality rate than diabetes, heart disease, and smoking [4,5]. Although this is specific for scoliosis patients, the lack of obvious clinical disorders does not make a patient healthy. Rather than assume that the absence of acute clinical presentation is a marker of health, perhaps future chiropractic research will endeavor to further understand the relationships between subclinical spinal pathophysiology and patient health.

    Based upon this assumption, the authors suggested that a "disinterested party, dispassionately examining the evidence available today regarding the relationship between the spine and health, or structure/function relationship, would arrive at the following conclusion:

    The human organism is highly resilient and broadly adaptable to a wide range of structural imperfections, and it is only after a rather high threshold of deformity is surpassed, that function is degraded."

    Again, taking the previous example into account, this 'conclusion' may not be accurate. Scoliosis is perhaps the epitome of spinal dysfunction, and compromises function long before a "high threshold of deformity is surpassed." Also, I am curious to know how the authors know what a "disinterested party" would conclude, given that they themselves are not disinterested parties.

    Concerning the primary care model, whether intentional or not, the issue of public safety was not addressed. This should be a core issue for any health profession with portal of entry status. While specific attempt was made to differentiate "primary care" from "portal of entry" status, both entail the necessity of the provider to determine whether a presenting condition is within the provider's scope of practice. The arguments presented by the authors are insufficient to promote a "halfway" concept of spine care. In the model of spine care they propose, it may be more appropriate to support either portal of entry status with primary care intentions, or a model wherein chiropractic is a referral specialty similar to physical therapy, physical medicine, or orthopedics. Under the latter, the patient would have already had a complete examination to exclude non-spinal causes. The authors also did not provide evidence to refute the encouraging findings reported by Sarnat and Winterstein [6], where they showed significant reductions in health care spending combined with good clinical outcomes using our "limited" therapeutic armamentarium. Their model also suggests that it may not be necessary to "educate" the general public about chiropractic to increase access to underserved portions of our population. This may ultimately rest with third party payers instead.

    Finally, in addressing their spine care model, care for extraspinal musculoskeletal conditions would be de-emphasized. Again, this may be either an assumption or a misinterpretation of the literature. For example, the authors report that <5% of chiropractic patients present with this type of problem. The authors fail to differentiate between how often patients report extraspinal dysfunction in chiropractic offices from the their actual incidence. For example, the incidence of headaches in dental offices may go underreported, because patients may not be aware that headaches can be caused by malocclusion or TMD. This is probably due to public perception, as the authors suggest. However, if subclinical extraspinal dysfunction is causing acute spinal dysfunction, it is appropriate for the DC to address both issues. While I concede that the evidence in this particular area is scant, the authors cannot conclude the opposite despite the lack of evidence. Rather, they should conclude that chiropractic treatment of extraspinal disorders does not have enough evidence, pro or con, to determine their clinical significance in the authors' spine care model.


    Mark W. Morningstar, D.C.

    1. Bowen RM. Respiratory management in scoliosis. In: Moe's Textbook of Scoliosis and Other Spinal Deformities, 3rd ed. WB Saunders, Philadelphia PA.

    2. Szeinberg A, Canny GJ, Rashed N, Veneruso G, Levison H. Forced VC and maximal respiratory pressures in patients with mild and moderate scoliosis. Pediatric Pulmonology 1988;4:8-12.

    3. Chong KC, Letts RM, Cumming GR. Influence of spinal curvature on exercise capacity. J Pediatr Orthop 1981;1:251-254.

    4. Balady GF. Survival of the fittest-more evidence. N Eng J Med 2002;346:852-854.

    5. Myers J, Prakash M, Froelicher V, et al. Exercise capacity and mortality among men referred for exercise testing. N Eng J Med 2002;346:793-801

    6. Sarnat RL, Winterstein JF. Clinical and cost outcomes of an integrative IPA. J Manipulative Physiol Ther 2004;27:336-347.

    Competing interests

    None declared

  2. Some Corrections and Thoughts

    Robert Affolter, Chiropractic First

    18 April 2006

    Dear Editor:

    Although I can agree with some of the points made in the article, a number of factual errors need to be corrected. I agree with the authors that chiropractors have the ethical duty of veracity and the ethical duty of fidelity with regards to patient encounters. However I extend those ethical duties to inter-professional relationships as well. As chiropractors we profess to be members of the chiropractic profession. As such, we profess to have more knowledge of chiropractic than laity and also members of other professions. It is therefore imperative when we write in scholarly or scientific journals that we adhere to our duties of veracity and fidelity.

    I also agree that one of the philosophical pillars of science is skepticism. It is important that we give conventional biology the same scrutiny that we provide our profession.

    In this article, Nelson et al begin by constructing a straw man. The straw man consists of their chiropractic hypothesis. The hypothesis is that there is a fundamental relationship between the spine and health, that mechanical disorders of the spine can degrade health, and that correction of the disorder brings about a restoration of health. The authors refer to their hypothesis as Palmer's Postulates, although I find no resemblance to the thinking of D. D. Palmer and Nelson et al provide no references. They attacked the concept of Innate Intelligence as a separate component of Palmer's Postulates. I will come back to the Innate Intelligence argument shortly.

    Once the straw man is constructed, the attack begins. Nelson et al state that Palmer's Postulates fail because they are not the answer to a question based on a set of observations or facts which are not already explained by current theory. Nelson et al conjecture possible questions based on their straw man hypothesis.

    According to D. D. Palmer, "One question was always uppermost in my mind in my search for the cause of disease. I desired to know why one person was ailing and his associate, eating at the same table, working in the same shop, at the same bench, was not. Why, what difference was there in the two persons that caused one to have pneumonia, catarrh, typhoid or rheumatism, while his partner, similarly situated, escaped?"[1]

    There we have the question D. D. Palmer attempted to answer. The hypothesis that germs cause disease did not answer his question as the people mentioned could all be assumed to be exposed to the same germs.

    D. D. Palmer’s hypothesis:

    "The amount of nerve tension determines health or disease. In health there is normal tension, known as tone, the normal activity, strength and excitability of the various organs and functions as observed in a state of health. The kind of disease depends upon what nerves are too tense or too slack.[2]

    "Functions performed in a normal manner and amount result in health. Diseases are conditions resulting from either an excess or deficiency of functionating.[2]

    "Spirit soul and body compose the being, the source of mentality. Innate and Educated, two mentalities, look after the welfare of the body physically and its surrounding environments."[2]

    Contrary to the contention of Nelson et al, we see that D. D. Palmer did have a question he sought to answer. In my opinion his answer did provide an explanation which was lacking.

    Nelson et al state, "However, there is no evidence that Palmer undertook any sort of systematic exploration of the spine/health relationship following his epiphany."

    However, according to D. D. Palmer, "Shortly after this relief from deafness, I had a case of heart trouble which was not improving. I examined the spine and found a displaced vertebra pressing against the nerves which innervate the heart. I adjusted the vertebra and gave immediate relief--nothing "accidental" or "crude" about this. Then I began to reason if two diseases, so dissimilar as deafness and heart trouble, came from impingement, a pressure on nerves, were not other disease due to a similar cause? Thus the science (knowledge) and art (adjusting) of Chiropractic were formed at that time. I then began a systematic investigation for the cause of all diseases and have been amply rewarded."[3]

    In addition to his clinical investigations, D. D. Palmer continued his scholarly investigations of anatomy and physiology. We now know that the anatomy, physiology and surgical references used in his 1910 text were accurate and that D. D. Palmer likely had a knowledge of anatomy and physiology superior to many medical doctors of his day.[4]

    Nelson et al go on to state, "The problem, simply, is that there is no need for Palmer's Postulates. There never has been a set of facts or phenomena concerning the relationship between the spine and health that require Palmer's Postulants to understand them. The spine/health theory does not rest on any foundation of careful, comprehensive, and reliable observational data."

    Remember that the spine/health theory is the authors' straw man not D. D. Palmer's thinking.

    Nelson et al continue with the following conclusion: "The human organism is highly resilient and broadly adaptable to a wide range of structural imperfections, and it is only after a rather high threshold of deformity is surpassed, that function is degraded."

    In my opinion the human body has no such ability. A corpse does not adapt. It is not resilient. Life is necessary for adaptation to occur. Let us return now to our discussion of Innate Intelligence.

    Nelson et al claim that Innate Intelligence should be rejected in favor of the conventional view of biology. They claim that vitalism (Innate Intelligence) was discarded in the 18th century with the invention of the microscope. However they want to agree that there is such a thing as a healing power of nature. They seem to define nature as the body's natural healing mechanisms.

    The conventional view of biology follows from Newtonian physics. The thinking is that through the interaction of matter life evolved. As life continued to evolve intelligence emerged. As I have explained elsewhere, such thinking is contrary to logic. [5]

    The product cannot affect the producer. Something cannot create itself. If mind is the result of the activity of the brain, mind can have no effect on the body. In order for us to have independent actions, self-determination, adaptation and placebo effects, intelligence must be independent of the body. Innate Intelligence explains those phenomena.

    Contrary to the contention of Nelson et al, I do see a need for Palmer's thinking. The phenomenon of adaptation is one observation which my definition of chiropractic seeks to explain.

    In my opinion, D. D. Palmer's genius was that intelligence is required for adaptation. He reasoned that what is generally considered to be life is intelligent. He reasoned that intelligence uses the nervous system as a primary means of controlling adaptation through the use of tone and that subluxation alters the tone of the nervous system and results in too much or too little function. He contended that too much or too little function is disease.

    If those postulates are correct, and if D. D. Palmer’s defintion of subluxation is found to be valid, then a person without subluxation will be more likely to adapt to the stressors of life. A person with subluxation will be less likely to adapt to the stressors of life. The corollary of this is that if a chiropractor can examine a person and find a problem which is limiting the person's ability to adapt, then I believe people should be examined on a regular basis to correct that problem when it exists. Nelson et al are fond of the dental analogy. Just as a dentist recommends regular examinations, I believe (given the caveats above) the chiropractor should recommend similar spinal hygiene.

    Nelson et al state "Beyond musculoskeletal conditions, there are very few conditions for which manual therapies provide optimal effectiveness. The vast majority of human health problems that require an intervention do not fall within the chiropractic therapy spectrum. Chiropractic cannot simultaneously retain its limited set of therapies and pursue primary-care status."

    As stated previously chiropractic care seeks to improve a person's ability to adapt. No matter what the condition, if the ability to adapt can be improved by a chiropractic adjustment, then the patient may benefit.

    Nelson et al state "Society grants licenses, a franchise, to a profession, not so that profession can champion its ideals, but because society wants some specific work done and it feels that granting a franchise is the best way to do it."

    I disagree. Nobel economist, Milton Friedman, stated that it is not the consumer (society) which is interested in licensure. It is the producer (the profession). Dr. Friedman looked at the medical profession in particular: “I am not saying that individual members of the medical profession, the leaders of the medical profession, or the people who are in charge of the Council on Medical Education and Hospitals deliberately go out of their way to limit entry in order to raise their own incomes. That is not the way it works. Even when such people explicitly comment on the desirability of limiting numbers to raise incomes they will always justify the policy on the grounds that if “too” many people are let in, this will lower their incomes so that they will be driven to resort to unethical practices in order to earn a “proper” income.” [6]

    Chiropractic is not unique. Every profession seeks economic gain by convincing politicians that it is in the safety interest of the public to grant licenses to the profession. The license legislation creates a barrier to entering the profession. One way to look at this is that a high barrier reduces the number of people entering the profession thereby reducing supply with the hope of increasing fees.

    Nelson et al state "The legitimate professional claim for chiropractic in the remainder of health care and public policy lie strictly within the domain of back-related pain outside the bounds of medical emergency. Credibility for the claim, either diagnostically or therapeutically, for broader role beyond the realm of this definition is lacking."

    I will combine that thinking with the following " ... until we can demonstrate that we are effective where others are not, the proposition of chiropractic as the "wellness profession" is not defensible."

    I note that Nelson et al failed to do a literature search on the effectiveness of their profession. Of 34 references, no reference is made to a single chiropractic clinical study.

    The article by Nelson et al serves as evidence that professional practice standards cannot be determined by consensus. Eight people got together and agreed on a chiropractic scope of practice with no apparent literature review. They provided “Palmer Postulates” with no reference to D. D. Palmer’s actual work and apparently without ever reading his 1910 book.

    After correcting all of these factual errors, the reader may wonder with what points I agree. I agree that chiropractors have duties of veracity and fidelity. Pursuant to those duties, it is our responsibility to understand the basic premises of our founder and the evolution of chiropractic thought. It is our responsibility to offer our ideas as possible explanations for the advancement of conventional biology. It is our responsibility to research our ideas and refine or reject our ideas as appropriate. To those ends I offer this comment to extend the debate.


    1. Palmer DD. The Science, Art and Philosophy of Chiropractic. Portland (OR): Portland Printing House Company; 1910. pg. 18

    2. Palmer DD. The Science, Art and Philosophy of Chiropractic. Portland (OR): Portland Printing House Company; 1910. pg. 19.

    3. Palmer DD. The Science, Art and Philosophy of Chiropractic. Portland (OR): Portland Printing House Company; 1910. pg. 18-19

    4. Senzon S. The Secret History of Chiropractic. D. D. Palmer's Spiritual Writings. Asheville (NC): Simon A. Senzon, 2005. pg. 44.

    URL: Http://

    5. Affolter RC. The Reality of the Mental Realm and Its Clinical Significance. Proceedings of the 2004 Conference on Philosophical Chiropractic Standards: Conference on Philosophical Chiropractic Standards., June 26-27, 2004. Minneapolis, MN.


    6. Friedman M. Capitalism & Freedom. Thirteenth Impression 1974. Chicago (IL): The University of Chicago Press; 1962. pg. 152

    Competing interests

    Philosophy Faculty of

    Post-graduate Faculty of Sherman College of Straight Chiropractic

  3. Comment on: Chiropractic as spine care: a model for the profession

    Username: vic mackey, Disqus ID: disqus_YOFZPIcl9K

    20 December 2016

    Hi, I am writing a term paper for my english class on the educational requirements for chiropractors. I found your page cited as a reference at this wikipedia page - great info and well written, its helped me a lot. Thanks!

    Competing interests