Health care is becoming increasingly evidence-based

Over the past decades, governments, society and patients have an increasing expectation of an evidence-based approach to health care and as the knowlege base has become larger and more widely accepted, the space available for alternative modalities has become smaller [1,2,3,4]. This has resulted in a greater contrast between mainstream and fringe medicine. Also, in the musculoskeletal area there are now different demands on indications for treatment and positive outcomes than what was seen only a few decades ago [5]. Increasingly legislation is being bought to bear to enforce such approaches. Chiropractors have for many years balanced at the crossroads between mainstream and alternative medicine, so this development poses particular challenges for chiropractic organisations, who have tried to cater for both [6,7,8]. Although chiropractors, officially, are part of the evidence-based movement in relation to musculoskeletal problems, we were late adopters, and some are not prepared to adopt this approach at all.

The consequences for chiropractors

To the public, chiropractors are known to be ‘back pain clinicians’ [9,10,11,12]. This is potentially a good niche, because back pain is one of the lagest public health problems, negatively affecting hundreds of millions of people. The number of years people live with disability has increased globally by 52% since 1990 [13, 14].The recent Lancet Low Back Pain Series pointed to the gap between what is known and what is being practiced, and called for a de-medicalisation of back pain and promotion of public health approaches in order to reverse this trajectory [15, 16]. Chiropractors appear to be well placed to respond to this call and become relevant in mainstream healthcare globally.

Divisions within the chiropractic profession

As is the case with professions generally, chiropractic has always had subgroups, some further toward the fringe and others closer to mainstream healthcare. Chiropractic arose out of a vitalistic tradition. D.D. Palmer, the founder of chiropractic, declared that 95% of all disease was caused by subluxated vertebrae and that the remaining 5% was caused by slight displacements of bones other than those in the spine [17]. An early split developed between the vitalists and those who developed towards a more scientific approach, and divisions remain. It is estimated that approximately 20% of the profession in Canada still adheres to a vitalistic explanation for how they practice [18, 19]. Despite the presence of these factions, chiropractic has gradually become a global healthcare profession [20], and in some jurisdictions chiropractors are regarded as mainstream healthcare providers, as part of national health systems or reimbursed with public or private insurance funds. In places where chiropractors have adopted modern evidence-based principles, external stakeholders have determined that chiropractic practice accords with modern healthcare principles and should be included among legitimate healthcare practitioners [21, 22]. Nevertheless, there is a continuing divide between ‘evidence-friendly’ and ‘traditional’ chiropractors, which has become more visible in recent years, as the focus on back pain and musculoskeletal health has increased and a wealth of new evidence in the area has emerged. Unfortunately, these disparate voices reflecting different approaches confuse external stakeholders and threaten the credibility of the chiropractic profession.

Describing this division is not simply academic; those aligned with evidence-based ideals have the greatest probability of being further integrated into healthcare systems in the years to come. In contrast, chiropractors, who have traditional ideas of the spine being a source of all or most diseases, are unlikely to make this journey, in the absence of evidence to substantiate their claims. The result is a profession torn between those looking to the future and those wedded to the founding claims of the past. The evidence-friendly chiropractors feel that the claims and activities by the ‘traditionalists’ slows or hinders the development of the profession and there is evidence to substantiate this.

Here are some examples of this problem, as seen from the perspective of the evidence-friendly group:

In Canada, vitalist practitioners have been shown to be more likely to have anti-vaccination beliefs, and their attitudes about radiographic imaging are inconsistent with current evidence/ guideline-based care [19]. As such, vitalistic providers were less likely to receive referrals from other health providers [23].

In Florida, U.S.A., attempts to establish a university-based education in chiropractic were stopped in 2005 because of opposition and lobbying from the traditional group [24].

In 2009 in the UK, a systematic survey of chiropractic websites was done by a group motivated by displeasure at unsupported claims of chiropractors, and formal complaints were lodged with the General Chiropractic Council. Although most chiropractors were found not guilty, thousands of work-hours and much stress was caused [25, 26]. The content of these web sites was subsequently changed.

In 2012, the treatment of children based on traditional chiropractic ‘diagnoses’ at the student chiropractic clinics at the Royal Melbourne Institute of Technology in Australia, a university-based chiropractic course, at the time lead by a well-known traditionally-oriented chiropractor, brought down both fury and ridicule on chiropractic. It also resulted in a new movement called ‘Friends of Science’, who wage war on university education involving non-evidence-based alternative medicine, notably chiropractic. This severely threatened at least two chiropractic undergraduate courses [27, 28].

In 2013, attempts to establish a university-based education in chiropractic in Sweden were stopped following a debate that exposed unsupported claims on the websites of some chiropractors [29].

There is also evidence that traditional chiropractors feel aggrieved by the evidence-friendly group, because they think that ‘real’ chiropractic is being denigrated or squandered.

And here are some examples of the problem as seen from the perspective of the traditional group:

Evidence-friendly chiropractors are seen as unfaithful to the traditional tenets of chiropractic (i.e. subluxation as a basis for changes in health).

Evidence-friendly chiropractors side with the ‘enemy’, i.e. medical doctors, research scientists, sceptics, etc.

Evidence for this is extensive, but a few examples from current chiropractic websites include the following:

‘Straight [traditional] chiropractors consider the medical diagnosis of disease to be unnecessary because they view these conditions as secondary effects of vertebral subluxations. In essence, they believe that disease symptoms will disappear once the underlying subluxations have been corrected properly. Most straight chiropractors do not wish to have any association with mainstream health care’ [30].

‘Chiropractic’s new normal should look a lot like its old normal. You know, the one centered on our only unique service to mankind: the detection, correction and management of vertebral subluxation’ [31].

‘If you choose the more allopathic path of chiropractic medicine, your practice style will be different. You’ll befriend orthopedists and other medical practitioners, supplying a form of physical medicine. You’ll add various therapies, decompression, orthotics, stretches, exercises, rehab and other adjunctive services to support your spinal manipulations. ……you will be reduced to proper lifting, pillow recommendations and maybe even weight loss’ [32].

Given the slates of problems observed by these two groups, the question for the profession to face is, what can be done about it?

One solution: Trying to unite a divided profession

In response to this division, various chiropractic organisations have since long made great efforts to try to bring the various factions closer together by appreciating and respecting each other’s differences. One such unifying attempt from the European Chipractors’ Union (ECU) was the slogan ‘celebrating diversity’ used in connection for the 2016 ECU conference [33]. However, it is not evident that this diversity should be celebrated. We do not see ‘diversity’ as a strength for either of the two main factions of chiropractors, or more importantly for patients, who must employ a caveat emptor approach to finding a chiropractor.

A more recent approach that we are seeing now is that various organisations, who for decades have supported unity between factions at all costs, are now focusing strongly on evidence as the basis for chiropractic practice rather than on unity. One example is the American Chiropractic Association (ACA) that recently adopted the mainstream, broad-consensus ‘Choosing Wisely’ campaign, and the World Federation of Chiropractic (WFC) that recently signaled a policy shift by abandoning attempts at ‘unity’ [7] and focusing on ‘on the creation of trust, legitimacy and promoting the best available care’ [34, 35]. This tactic changes the focus from the chiropractor, to where the focus of any legitimate healthcare profession should be, on the patient. The end results should, hopefully, be a general shift towards a more modern approach and away from old traditions.

Another solution: Creating a permanent division through “professional divorce”

In this commentary, we explore another solution to this historic division. One that does not involve uniting both sides, but one that acknowledges that when a division is too great to reconcile, decoupling may be the best way forward for all involved. In this paper, we explore the similarities between couples and professions, examine what happens when they become estranged, and consider how the solutions established by our society for marital disagreement may also be the key to doing what is best for both groups. Uppermost in our minds in this process is what is best for the ‘children’, i.e. patients.

What makes spouses happy, or at least content, in their marriages?

Obviously, there are many and varied reasons for making married couples happy and functional. Love, affection, and sex [36] are important initiators for many marriages and helpful to maintain the relationship also in the long run. To produce, provide for, and ensure the survival of offspring is another uniting aspect [37]. A feeling of togetherness, defined as easy communication, similar habits, hobbies, activities, and the ability for constructive problem-solving makes living together pleasant, as does a common history, and a similar background [36, 38]. Solidarity provides a strong cornerstone in successful marriages [39], as does the concept of being a happy family and the status associated with this in society [40]. Clearly, being in a stable financial situation would help make a couple more trouble-free and hence invite fewer problems and result in less risk of disenchantment and disagreements that potentially can lead to a split [41, 42].

Why may couples stay together when things go bad?

These reasons for content marriages are hardly surprising. However, why some couples choose to stay together, when the relationship has gone sour and there is no love left between the parties, is relevant to this discussion.

Respect for each other, morality, religion, politics, and business interests may be some reasons for remaining, as well as the wish not to hurt the other partner [37]. Some prefer to wait ‘till the children have grown up’ [39] and in others it is the fear of the unknown including concerns about potential economic hardship [42]. It is also well known that feelings and relationships can have their ups and downs, so some may simply ‘hang around’ hoping for better times [41].

Additionally, when marriages are clearly dysfunctional and the two partners would be better off on their own, it is not uncommon for one of the two to make promises to change (e.g. no more extra-marital sex, more time spent with the family, no more fighting, no more violence) [43, 44]. Kindness, wishful thinking, memories of happy early days, and financial weakness could also be reasons why the aggrieved partner may give the marriage another chance, and perhaps another and another.

Finally, when things go wrong in a marriage, another strategy is that one partner has too much to lose so they simply tolerate the problem – perhaps this is the closest analogy of where the chiropractic profession has been in the past 25 years. Doubtlessly though, both parts are unhappy with the present arrangement.

Why may couples choose to divorce?

Instead of choosing to remain in a relationship for any number of reasons, there are obviously many couples who decide to separate [45, 46]. The reasons for divorce have been a major topic of research and have been comprehensively reviewed elsewhere [46]. This review summarises longitudinal studies that identify the predictors of marital disruption as being domestic violence, frequent conflict, and infidelity, the number of perceived relationship problems, and low levels of love, trust and commitment between spouses. Minimising the difficulties, confronting relationships by using benevolent cognitions such as ‘better the devil you know’ only allows relationships to worsen over time [47]. Although divorces are always difficult, the outcome is often better for both partners in the long run, offering possibilies for a more self-actualised existence [48,49,50].

Signs that the chiropractic profession is an unhappy marriage

The two main factions in the chiropractic profession still ‘live at the same address’. By this we mean that they present themselves to others under the same family name, have institutions that try to enforce the same international and national Standards of Accreditation of chiropractic programmes for both so that patients are dealt with in fairly standardised ways, and there are regulations for chiropractic educations to ensure a reasonable common level of graduates.

Nevertheless, there are definite signs that the situation may be intolerable for many chiropractors on both sides. We have identified reasons for unhappiness, and listed those in Table 1. These reasons are based on our observations of what happens in the field and are thus personal opinions, not easily documented from scientific evidence. Therefore, the items listed have not been referenced. Nevertheless we believe that most of our colleagues will acknowledge these issues and that they resemble very much those described above in reasons for divorce among couples.

Table 1 A list of signs of incompatibility between the evidence-friendly and traditional factions in chiropractic, described as it would be in an unhappy marriage, as seen from the evidence-friendly view point Full size table

Why then are these two groups still joined together in their professional marriage?

Although there are many indications of unhappiness and also great attempts to improve the chiropractic marriage, no obvious signs of a formal splitting up are visible. Nevertheless, there are many reasons for some marriages to persist despite obvious difficulties and differences. The reasons for the chiropractic profession staying together may be analogous, and, as seen from our viewpoint, some of these are listed in Table 2 below:

Table 2 Possible reasons for the continued marriage between evidence-friendly and traditionalist chiropractors Full size table

The ‘middle group’

Chiropractors sit on a spectrum, and the majority fall in the middle and practice with a ‘you-never-know who and what will respond to spinal manipulation’ attitude, yet with only some attachments to chiropractic tradition. Chiropractors in this group probably just want to get on with their work, not paying too much attention to the bickering going on. They do not engage politically, they rarely appear at seminars or general assemblies, and they do not take sides. Thus this middle group accepts or at least tolerates much of the statements and activities by the traditionalist groups. Importantly, the middle group does not seem to consider illogical and unsubstantiated claims to be of real danger to the profession and if they are troubled by them, they do not voice this publically, maybe because they think that ‘the more the stronger’ or simply because of apathy.

In our opinion, this middle ground is becoming increasingly harder to reconcile and thus difficult to hold, as the marital difficulties inevitably play out more openly, because of the increasing general public interest in chiropractic [51,52,53,54]. Therefore, we contend that members of the middle group will eventually have to choose sides between adhering to a scope of evidence-friendly practice relating to musculoskeletal problems or to a traditional approach aiming at treating a multitude of conditions through spinal manipulation. Increasingly, this position reminds us of the saying ‘The standard you walk past is the standard you accept’, since acquiescence makes it possible for groups of chiropractors to practice outside the logical framework of today’s scientific concepts and sometimes even outside the law. Virtually every chiropractor knows of other chiropractors who x-ray every patient, or sign patients up to long contracts, or dubious ‘family plans’, or pre-payment plans, or use high-pressure sales tactics, or advertise unsubstantiated claims, yet very few report these breaches [55]. This ‘silent majority’ may in fact be responsible for the inertia and acceptance of traditionalist paradigms (seen from the evidence-friendly side) and the gradual destruction of traditional values (seen by the traditional chiropractors).

Chiropractors are not the only family in the neighbourhood. There are other families i.e., other manual therapeutic professions, who are engaged in ongoing positive positioning, who are willing, able and evidence centred to fill the societal need for conservative approaches to musculoskeletal care. It is likely that this time window of opportunity for chiropractors is limited and closing. Much like climate change perhaps the tipping point has already been breached. The time for action may never be more appropriate than now.