Many chiropractors treat patients with spinal adjustments based on the theory that correction of vertebral subluxations will restore and maintain health. This article explores the controversy surrounding the practice of chiropractic and discusses some of the dangers associated with inappropriate use of spinal manipulation. The management of infants and children by subluxation-based chiropractors who do not endorse such medically accepted procedures as immunization or use of antibiotics is especially a cause for alarm. If the chiropractic profession fails to abandon the false premise upon which it is based, it will remain controversial and some aspects of chiropractic treatment will continue to be a threat to public health.
When the polio epidemic was at its peak in the mid-1950s and the Salk vaccine was being promoted for immunization against poliomyelitis, the National Chiropractic Association campaigned against polio vaccination and recommended chiropractic adjustments for preventing and treating the disease. Defending the use of the Salk vaccine, the US surgeon general issued this statement in 1958:
“During the three and one-half years [the Salk vaccine] has been in use, the effectiveness rate of 60 to 90% has been consistently maintained. Nor is there any evidence that properly vaccinated persons are losing their immunity and becoming more susceptible to polio.” 
In 1959, an article in the Journal of the National Chiropractic Association disagreed with the surgeon general:
“The test tube fight against polio has failed….The death rate has increased among children who have been vaccinated….There is no vaccine against fatigue or a traumatic lesion in the anterior cord or motor cells….In the mild, and especially in the more acute, chiropractic is supreme. Adjustments of the entire spine will break up the cord congestion, if given within the 3 days of grace given by Nature. Chiropractic aids Nature….The fatigue of acute polio can be caused by other factors, such as whooping cough and smallpox vaccines. The latter can cause vaccinosyphilis in the pure blood of children.” 
Encouraged by the leadership of the chiropractic profession, chiropractors advertised chiropractic adjustments as a method of treating and preventing polio, recommending “early treatment before it is too late.” A chiropractic organization called We Walk Again proclaimed that maximum recovery from polio was found only in chiropractic .
Time and science have proven chiropractors wrong. Today, thanks to the use of vaccination, polio has been nearly eradicated: “The present rate of polio is less than one hundredth its lowest level before oral immunization programs began, and public health officials have predicted worldwide eradication by the year 2000.”  Immunization is one of the most successful public health measures ever put into effect and is responsible for the control or eradication of such deadly communicable diseases as smallpox, polio, diphtheria, and whooping cough.
Vaccination and the Chiropractic Theory
Leaning on the theory that correcting “vertebral subluxations” will cure and prevent disease by removing “nerve interference” and boosting the body’s immune system, many chiropractors still oppose vaccination, fluoridation, and other mandatory public health measures. Despite the historical success of vaccination, neither of the two major chiropractic associations supports mandatory vaccination. The American Chiropractic Association (ACA), the larger of the two, admits that vaccination has been shown to be a clinically practical public health preventive procedure for certain viral and microbial diseases but advises that the use of vaccines is not without risk. Failing to emphasize that the benefit of vaccination outweighs risk over the population as a whole, “the association supports each individual’s right to freedom of choice in his/her own health care based on informed awareness of the benefits and possible effects of vaccination.” 
The International Chiropractic Association (ICA) does not acknowledge any benefit in vaccination and openly opposes compulsory vaccination. The ICA actually markets a book called Vaccination: 100 Years of Orthodox Research Shows that Vaccines Represent a Medical Assault on the Immune System.
The ICA’s current policy toward immunization states:
The International Chiropractic Association recognizes that the use of vaccines is not without risk….
The ICA supports each individual’s right to select his or her own health care and to be made aware of the possible adverse effects of vaccines upon a human body. In accordance with such principles and based upon the individual’s right to freedom of choice, the ICA is opposed to compulsory programs which infringe upon such rights .
A former president of the ICA said in 1993, “I am a firm opponent of artificial immunization and the antiquated germ theory on which it is based.”  In 1997, promoting the ICA point of view, a popular publisher of patient education materials advised chiropractors: “When chiropractors embrace vaccination, they are turning their backs on their philosophy, on their purpose, on their reason for being.” 
The more liberal ACA allows inclusion of physical therapy and other treatment methods (which often include such questionable methods as herbology and acupuncture) in a “mixed” practice, while the ICA advocates limiting treatment to use of spinal adjustments, which is called “straight” chiropractic. These differences prevent unification of the two associations.
A 1992 survey revealed that 37% of 178 chiropractors who responded agreed that “there is no scientific proof that immunization prevents infectious disease.” Of these respondents, 24% were members of the ACA and 65% were members of the ICA. Only 14% of all the respondents agreed that the chiropractic profession should fully support the American Public Health Association’s immunization policies for children and adults .
Although fewer chiropractors openly oppose vaccination today, the number who do is significant. With chiropractic colleges still teaching the subluxation theory (that correction of vertebral subluxations will boost the immune system as well as restore and maintain health), there will continue to be chiropractors who oppose vaccination and other mandatory public health measures. As an “alternative healing method” based on the vertebral subluxation theory, the name of the game is indoctrination in the belief that spinal adjustments are superior to medical treatment for many forms of disease. Opposing vaccination and similar public health measures is an inherent part of chiropractic philosophy. “By opposing immunization,” says one chiropractic reformer, “chiropractic assures that it will not become assimilated into the health-care mainstream.” 
There is reason enough to reject chiropractic health care that is based on the vertebral subluxation theory. When promotion of this theory threatens public health by opposing vaccination and other measures that protect all of us from preventable diseases contracted by others, there is cause for alarm, especially when the theory is espoused by chiropractors who specialize in “chiropractic paediatrics”. Since much of what chiropractors do today is still based on the subluxation theory, it is essential to understand what is meant by the term and how chiropractors have managed to sell their theory to the public.
The Mysterious Vertebral Subluxation
Chiropractors have been adjusting vertebral subluxations since 1895 when D. D. Palmer, a magnetic healer, declared that “95% of diseases are caused by displaced vertebrae; the remainder by luxations of other joints.”  Today, all 16 North American chiropractic colleges agree that “chiropractic is concerned with the preservation and restoration of health and focuses particular attention on the subluxation.” 
In 1996, 16 chiropractic college presidents signed a position paper defining a subluxation as “a complex of functional and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.”  A 1997 pamphlet for laypersons, published by the Foundation for Chiropractic Education and Research, explained what is meant by a “subluxation complex”:
What the above means is that a subluxation is a joint problem (whether a problem with the way the joint is functioning, a physical problem with the joint, or a combination of these) that affects the function of the nerves and can therefore affect the body’s organs and general health….Chiropractors believe that if joints function properly nerves will function properly and the body will be able to keep itself healthy .
Although some chiropractors no longer support the vertebral subluxation theory , the theory is still being taught in chiropractic colleges and still forms the basis for the average chiropractor’s practice. There is no scientific evidence to indicate that vertebral misalignment or any dysfunction in structures of the spinal column is a cause of disease .
Subluxations and “Nerve Interference”
The original chiropractic subluxation theory proposed that misalignment of a vertebra obstructed nerve flow by pinching spinal nerves. Today, a subluxation is called a “subluxation complex” and is defined in many ways under more than 100 different names (such as a segmental dysfunction or a neurobiomechanical lesion). The Foundation for Chiropractic Education and Research defines a subluxation as “changes in nerve, muscle, connective, and vascular tissues which are understood to accompany the kinesiologic aberrations of spinal articulations.”  Noting that such subluxations “may not be detectable by any of the current technological methods,” the proof of the existence of a subluxation is described as being reflected in reversal of “a variety of physiological phenomena.” In other words, if the patient gets better following a spinal adjustment, that is proof that a subluxation or some other spinal problem has been corrected.
It seems likely that many of the explanations chiropractors use to explain the effects of a spinal adjustment, such as a reflex global response  or an increase in white cell respiration , can also apply to other forms of everyday stimulation, such as an accidental bump, a deep massage, or a cold shower. But there is no reason to believe that such temporary physiological effects have anything to do with the cause and cure of disease, as postulated in the chiropractic subluxation theory.
The mysterious and elusive chiropractic subluxation is obviously not the same as a medically recognized orthopedic subluxation, a partial dislocation, which causes pain and loss of mobility but does not cause disease or ill health. The truth is that slight misalignment of a vertebra has no effect on spinal nerves. When a spinal nerve is pinched, compressed, or irritated by a bony spur, a herniated disc, a thickened ligament, or some other pathological process, there may be pain, numbness, muscle weakness, and other symptoms in the skin and musculoskeletal structures supplied by the affected nerve. But this has no effect on visceral function or general health. Injury to a spinal nerve may result in some autonomic disturbance in the portion of the skin supplied by the damaged nerve, but visceral functions are protected by a widespread, overlapping nerve supply from a number of sympathetic (autonomic) ganglia located outside the spinal column.
Anatomy of the Nervous System
There are 31 pairs of spinal nerves; 26 of these pass through movable vertebral segments. Five pairs of spinal nerves (accompanied by some parasympathetic fibers) pass through solid bony openings in the sacrum. There are an additional 12 pairs of cranial nerves which pass through bony openings in the base of the skull (including the 10th cranial parasympathetic vagus nerve, which travels down to supply visceral structures in the thorax and abdomen). The parasympathetic portion of the autonomic nervous system is well protected at its bony outlets and is not affected by slight misalignment of a vertebra, as suggested by the chiropractic subluxation theory. Nor is it accessible to manipulation of the spine.
There is plenty of room for the passage of spinal nerves and blood vessels through the fat-padded foraminal openings between the vertebrae. It cannot be imagined that slight displacement of a normal vertebra will place pressure on a spinal nerve. This was proven conclusively 25 years ago by experiments performed by Edmund S. Crelin, PhD, a prominent anatomist at Yale University. Using dissected spines with ligaments attached and the spinal nerves exposed, he used a drill press to bend and twist the spine. Using an ohm meter to record any contact between wired spinal nerves and the foraminal openings, he found that vertebrae could not be displaced enough to stretch or impinge a spinal nerve unless the force was great enough to break the spine. Crelin concluded: “This experimental study demonstrates conclusively that the subluxation of a vertebra as defined by chiropractic — the exertion of pressure on a spinal nerve which by interfering with the planned expression of Innate Intelligence produces pathology — does not occur.” 
Spinal nerves are commonly pinched by bony spurs and herniated discs, causing musculoskeletal symptoms without any effect on visceral function. Even when the spinal cord is severed below the level of the fourth cervical vertebra, shutting off the flow of nerve impulses to spinal nerves, paralysis of musculoskeletal structures occurs from the neck down but the autonomic nervous system continues to maintain function of the body’s organs. If a transverse cord lesion occurs above the level of C5, however, disruption of parasympathetic nerve supply from the brain stem may cause death as a result of respiratory failure ,
Insignificant Vertebral Misalignment
In view of the complex and fail-safe overlapping of the autonomic nervous system and the chemical reactions that occur in tissue fluids to maintain visceral functions, it becomes apparent that slight misalignment of a single vertebra is not likely to be a significant factor in the cause of disease. That the chiropractic version of vertebral subluxations may not exist at all is reflected in the fact that interexaminer reliability is low when chiropractors attempt to locate subluxations. Except in cases of gross misalignment caused by disc degeneration and other structural abnormalities, or in cases where chiropractors are using the Meric system, which simply assigns a certain vertebra to a specific organ or disease (used by 23.4% of chiropractors) , few chiropractors find the same subluxations when attempting to relate a specific subluxation to a disease process.
In 1964, the National Association of Letter Carriers (NALC) asked representatives of both the American Chiropractic Association and the International Chiropractic Association to identify subluxations in 20 sets of X-rays submitted by chiropractors who had previously identified 1 to 6 subluxations in each set of X-rays. According to the NALC: “One after the other, each film was placed in the view box. The chiropractic representatives, including a radiologist of their own selection, were invited to point out the subluxations. Not a single one was identified. Nor did the chiropractic representatives offer a solitary comment.” 
Is the chiropractic subluxation theory a threat to public health? It would certainly seem so. Unless the chiropractic profession abandons the subluxation theory and evolves into a properly limited specialty in the use of manual therapy and other physical treatment methods in the care of musculoskeletal problems, inappropriate use of spinal manipulation will continue. And chiropractors will continue to order unnecessary X-ray examination and maintenance care that requires use of unproven and possibly harmful treatment methods.
Limitations and Dangers of Chiropractic Manipulation
As a vaguely defined treatment approach with a broad scope of practice, chiropractic remains controversial and may pose a threat for persons who cannot distinguish between appropriate and inappropriate use of spinal manipulation. Reviews of the literature have revealed evidence that spinal manipulation may be of value in treating some types of back pain . There are many good chiropractors who offer effective treatment for back pain and other musculoskeletal problems. But few chiropractors limit their practice to the care of mechanical-type problems; most offer spinal manipulation as a method of restoring and maintaining health. Chiropractors’ use of a variety of unproven treatment methods and adjustive techniques make chiropractic treatment even more problematic. Some techniques entail physical risk while others pose risk by diverting the patient away from proper medical care for visceral problems.
A 1991 survey by the National Board of Chiropractic Examiners found that 26% of chiropractors “specialize” in adjusting the upper cervical spine as a method of treating visceral disease and back pain . Cervical manipulation is not often indicated. Inappropriate use of such treatment poses risk of injury to vertebral arteries in the neck. A RAND study reported in 1996 that only 11.1% of reported indications for cervical manipulation were considered appropriate . The rate of vertebrobasilar accidents and other complications that occur as a result of cervical manipulation was estimated to be 1.46 per l 000 000 manipulations. These numbers are more significant when it is realized that each patient receives a large number of manipulations, most of which may be unnecessary, thus increasing the risk of stroke per patient.
Risk may outweigh benefit when 88.9% of all cervical manipulations cannot be labeled as appropriate. Some observers feel that cervical manipulation involving extreme rotation of the top 2 cervical vertebrae should never be done. In many cases, the desired effect of cervical manipulation can be obtained through rest, exercise, mobilization, traction, and other methods of treatment. Obviously, the use of cervical manipulation and its dangers should be subjected to intense scrutiny. The incidence of stroke following cervical manipulation may be much higher than indicated when reviewing the existing literature. Many cases of stroke caused by cervical manipulation may not be recorded as such because patients don’t always report previous manipulations they may have received. All patients reporting stroke symptoms should be asked if they have undergone recent cervical manipulation.
Gimmicks and Ineffective Treatment Methods
A few chiropractors do not perform hands-on spinal manipulation. Surveys indicate that the average chiropractor uses 5 or more different manipulative techniques , if not to meet the competition of chiropractors who offer a particular technique then to be able to use a different technique if the patient does not get better. This reduces chances of losing the patient to another chiropractor.
It has been reported that 51.2% of chiropractors include use of a handheld, spring-loaded Activator mallet to tap “misaligned” vertebrae back into place , an apparently ineffective treatment method that may have nothing to offer but a placebo effect. I know many chiropractors who use such an instrument. Such treatment is not an effective replacement for appropriate use of hands-on spinal manipulation under the proper indications.
At least 97 different adjustive techniques have been used by chiropractors in recent years , including such dubious methods as applied kinesiology, reportedly used by 37.2% of chiropractors . Applied kinesiology is a nonsensical method of testing muscle strength to detect diseases and deficiencies that may then be treated with spinal adjustments or nutritional supplements. (Chiropractors who manipulate specific vertebrae as a treatment for disease prefer to call the treatment a spinal adjustment rather than a spinal manipulation.)
In many cases, the only thing the various adjustive techniques have in common is that they are all unproven and all are claimed to be most effective for removing “nerve interference.” Using a plethora of inconsistent adjustive techniques and producing “results” that cannot be replicated, chiropractors are holding on to the subluxation theory in order to maintain their status as “alternative” primary care physicians in a “separate and distinct profession.” Chiropractors continue to offer treatment to persons of all ages for a variety of organic and musculoskeletal ailments. The greatest threat may be to infants and children whose parents are lured by claims that spinal adjustments at an early age can prevent the development of disease and that vaccination may not be necessary.
Chiropractic Treatment of Children
An outrageous but typical example of the danger of the chiropractic theory put into practice was brought to my attention recently when I received a copy of a letter requesting information about chiropractic treatment of children. A Florida father was concerned about the treatment his 3 children (ages 7, 2, and 1) were receiving from his estranged wife’s chiropractor. Each child was being treated 3 times a week with an average billing of $120 per week. The 7-year-old was being treated for cerebral palsy and the 1-year-old for ear infection. The insurance billing described the treatment as “spinal disorder care.”
In my 43 years of practice as a chiropractor, I have heard such stories many times. Some chiropractors recruit families with children who are then placed on lifetime “maintenance care” to maintain “optimum health.”
A front-page article in the March 18, 1993, issue of the Wall Street Journal castigated chiropractors for offering treatment to children as a method of expanding their practice. Labeling chiropractic as “a 19th-century philosophy wearing the white smock of science,” the article condemned chiropractic for treating children for “legions of childhood afflictions” and for not supporting immunization .
In response, the American Chiropractic Association placed a full-page ad in the March 22, 1993, issue of the Wall Street Journal claiming that the article focused on an “isolated number of sensational and tragic occurrences.” Denying any wrongdoing by chiropractors, the ACA response was designed more to protect the image of the chiropractic profession than to protect the public. Chiropractors are trained to diagnose, the ad said, and are “obligated — morally and professionally — to refer all patients to medical doctors and other specialists when treatment is outside their scope of practice.” The ad also denied that chiropractors use spinal manipulation as a substitute for vaccination or for the use of antibiotics in treating infections, despite the fact that many chiropractors claim to do so. The ACA maintained that no single healing art has all the answers to the many health problems affecting mankind and that it is the right of patients to select the health-care provider of their choice. “Today,” the ad concluded, “conscientious health practitioners work as a team for the benefit of the patient.”
It is the consensus of medical and scientific opinion that chiropractors should not be allowed to treat infants and children. Using a limited treatment method based on the subluxation theory, chiropractors do not have adequate training in the diagnosis and treatment of pediatric ailments. And they do not have recourse to antibiotics and other medical treatment methods that are essential in combating potentially fatal or crippling illnesses. Yet, according to a special report in the November 1993 issue of Pediatric Management, children account for an estimated 20 million visits to chiropractors each year, compared to 87 million visits to pediatricians (in 1989) . Many of these children are receiving spinal adjustments for ear infection and other common and often self-limiting childhood ailments.
Chiropractors were caught red-handed treating infants and children for ear infections and other ailments when ABC-TV’s 20/20 secretly videotaped visits to 17 chiropractors who professed to treat children. Television viewers were astonished when the program was aired on February 4, 1994, as chiropractors were shown diagnosing and treating ear infections with a variety of nonsensical methods based on a variety of causes, ranging from subluxated vertebrae to nutritional deficiency, weak glands, food sensitivity, and a short leg. Two chiropractors differed on which leg was shorter. One infant with recurring ear infection was taken to several chiropractors, two of whom used surrogate muscle testing in which the diagnosis was made by using applied kinesiology to test strength in the mother’s arm while she was in contact with the infant. Although a pediatrician had determined beforehand that the children’s ear infections could be handled with antibiotics or would eventually be outgrown, all the chiropractors offered treatment lasting from several weeks to a lifetime.
It is not hard to find chiropractors who treat infants and children. Despite such articles as those in the Wall Street Journal, the chiropractic movement to treat children is growing. According to the International Chiropractic Association, whose Council on Chiropractic Pediatrics offers the profession’s only Board Certified Diplomate in Chiropractic Pediatrics: “The Council on Chiropractic Pediatrics is one of the fastest growing specialty groups of the International Chiropractic Association.” 
The World Chiropractic Alliance (WCA), an organization of straight chiropractors who believe that the chiropractic adjustment is sufficient in the treatment of most ailments, reports that there is “overwhelming evidence” that spinal adjustments should begin at birth and continue for life . WCA’s mission is to “promote a vertebral subluxation-free world.” The president of the WCA is also editor and publisher of the Chiropractic Journal, “read and respected by more doctors of chiropractic than any other professional publication in the world.”
In 1996 the Chiropractic Journal published Chiropractic First, The Fastest Growing Healthcare Choice . . . Before Drugs or Surgery. This book recommends that everyone should be checked for nerve interference from birth. Chiropractic care is recommended for children who have any of these symptoms:
Fever, colic, croup, allergies, wheezing, poor posture, stomach ache, hearing loss, neck/back pain, leg/hip/foot pain, numbness, headaches, coughs/colds, asthma, bed wetting, bronchitis, constipation, weakness/fatigue, ear infections, skin problems, one leg shorter, irritability, neck aches, nervousness, learning disorders, sinus problems, eye problems, scoliosis, arthritis, fatigue, pain in joints, shoulder/arm pain, poor concentration .
The market for chiropractic treatment of children is so great that some practice-building programs for chiropractors are based on pediatric care. A chiropractic research foundation called the Traumatic Birth Research Foundation, for example, which claims to be committed to locating and correcting vertebral subluxations in newborn babies, is being promoted as “the most cost-effective, innovative chiropractic marketing program to come along in years.” Chiropractors are encouraged to invite mothers and mothers-to-be to participate in a “chiropractic mothers and mothers-to-be program” to spread the word about the benefits of chiropractic manipulation for newborn babies. The message conveyed is that failure to correct spinal subluxations at birth could result in disease later in life .
Criticism by Consumer Reports
In view of such outrageous claims made by some chiropractors, it is not surprising that consumer advocates criticize chiropractors. Consumer Reports has published two articles on chiropractic, one in 1975 and one in 1994, both drawing negative conclusions about chiropractic as a method of dealing with health and disease. In the 1994 article, titled “Chiropractors,” the editors concluded that “manipulation is a widely accepted therapy, but chiropractic is not just a set of techniques for manipulating the spine; it is a belief system that credits the spine with a major role in health and disease….If chiropractors limited themselves to treating back pain and other neuromusculoskeletal problems, they might win a broader measure of acceptance from medical doctors.” 
Denouncing valid criticism in order to retain popular support among portions of the public who find the subluxation theory appealing, the chiropractic profession maintains the status quo. It continues to draw fire from scientists and consumer advocates who are morally and ethically obligated to speak out about the dangers of the chiropractic theory.
Chiropractic Theory and Maintenance Care
Chiropractic maintenance care consisting of regular spinal adjustments is an integral part of the chiropractic subluxation theory. Most chiropractors agree that such care is helpful in treating and preventing visceral and musculoskeletal problems in all age groups, with treatment sometimes beginning shortly after birth. One recent study reported that 90% of all chiropractors believe that maintenance care will optimize health, while 88% believe that such care will prevent conditions from developing. The average number of maintenance care visits was 14.4 per year, representing an estimated 23% of all practice incomes .
In my opinion, use of spinal adjustments as a method of prevention is unnecessary treatment that subjects the patient to unnecessary risk. When used by chiropractors who treat every patient with upper cervical manipulation, the risk is much greater. In the case of children, such treatment should be considered fraudulent or illegal.
Patient Education and Practice Building
Because of the suspicion the public has about the practice of chiropractic, the demand for patient education materials and practice-building courses for use by chiropractors has created a lucrative business opportunity for chiropractic entrepreneurs. Chiropractic journals and newspapers are filled with ads selling tapes, books, and seminars on how to attract new patients and build a million-dollar practice, all espousing the vertebral subluxation theory. The newest twist in practice-building is the “integrated” chiropractic office in which there is an MD or a DO on staff to sign insurance claim forms for conditions and procedures not normally covered under chiropractic care.
Introduction to Chiropractic: A Natural Method of Healthcare (written by a former chairman of the board of governors of the American Chiropractic Association) is one of the profession’s most popular and sophisticated patient education manuals. Without mentioning any specific disease and with a subtle approach, the manual explains that malfunctions (subluxations) that interfere with nerve supply to the organs and tissues are causative factors in many disease processes:
“Locating minor spinal deviations early, before they interfere with a proper functioning of the nervous system and produce symptoms, will greatly assist your body in remaining healthy….Regular spinal adjustments are a part of your body’s defense against illness….The conditions which doctors of chiropractic treat can be as varied and as vast as the nervous system itself.” 
Dynamic Essentials, a very popular practice-building course, is conducted by the president and founder of Life Chiropractic College, who said in a journal published by his college: “I have never found any justification for doing anything for, or to, a patient who has come to me for chiropractic care, other than doing the best job possible of adjusting that patient’s spine.”  His practice-building manual tells chiropractors how to convince patients they need chiropractic care and then how to “seal the patient in” for lifetime care. If the patient asks, “But will I have to continue with chiropractic care as long as I live?” the recommended reply is: “(Chuckling) No ma’am, you won’t have to continue it as long as you live. Only as long as you want to stay healthy.” 
A practice-building consultant who authored 1001 Ways to Attract New Patients and How to Become a Million Dollar a Year Practitioner advises that the key to wealth is to expand the variety of conditions treated, find subluxations, reduce them, and then keep them reduced with regular spinal adjustments .
Maintenance care is emphasized in the popular Singer Enterprises approach to practice building. Publications and audio tapes on “How to Create Lifetime Patients” advise chiropractors that once subluxations are corrected and symptoms have been relieved, patients should be encouraged to pay an annual fee for maintenance care. Since lifetime care is the goal, chiropractors are advised to regularly explain that “nerve interference will remain and people need adjustments because nothing else really works to make people well.” 
The great number of practice-building courses, all designed to promote the subluxation theory and create new patients, probably reflect better than anything else the problems with chiropractic care. Some of these courses appear to knowingly incorporate deception, which is willingly accepted by chiropractors. Many practice-building consultants lecture at chiropractic schools and conventions.
As long as the chiropractic profession continues to base chiropractic treatment on the unproven vertebral subluxation theory, there will continue to be opposition from medical scientists as well as criticism by consumer advocates. Reacting defensively to such opposition, some chiropractors feel that the approach of some practice builders is necessary for the survival of chiropractic, since referral of patients from science-based health-care practitioners is rare. Unless the chiropractic profession proves the subluxation theory or abandons the idea that adjusting the spine will restore and maintain health, it will remain controversial and some aspects of it will remain a threat to public health. And without the support of medical scientists and public health officials, chiropractors will continue to seek public acceptance rather than scientific support. Failure of chiropractors to criticize the pseudoscience in chiropractic (concentrating more on public relations than on promoting public health) perpetuates chiropractic dogma and fails to challenge chiropractors who exploit spinal manipulation.
According to a 1996 survey of 2280 chiropractors, with 1245 responding, only 3% of the respondents felt that increasing the ability of the profession to conduct its own research was a high priority. The survey report concluded: “Practicing chiropractors in the United States feel that the acceptance of chiropractic, primarily by patients and other health care professionals, is the most important research objective.” 
Many chiropractors feel that they qualify as primary care physicians capable of handling a broad scope of human ailments . Such claims should increase concern about chiropractors who base their practice on the vertebral subluxation theory.
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Dr. Homola is a second-generation chiropractor who has dedicated himself to defining the proper limits on chiropractic and to educating consumers and professionals about the field. His 1963 book Bonesetting, Chiropractic, and Cultism supported the appropriate use of spinal manipulation but renounced chiropractic dogma. His 1999 book Inside Chiropractic: A Patient’s Guide provides an incisive look at chiropractic’s history, benefits, and shortcomings. Now retired after 43 years of practice, he lives in Panama City, Florida. This article is slightly modified from its original version in the Winter 2001 issue of Scientific Review of Alternative Medicine
This article was posted on December 22, 2002.