Observations of a Forensic Chiropractor

One look at his spine model told me all I needed to know about his testimony. He would tell the jury that “subluxations” —alleged or minor misalignments of vertebrae that he would claim pinched one or more spinal nerves—were continuing to cause his patient’s pain. He would demonstrate this to the jury by twisting his spine model just so, showing how the hard bones choked the delicate nerves. This is what had happened to the plaintiff as a result of the rear-end collision, he would testify. This is why she continued to have neck and back pain more than two years later, despite all the chiropractic treatments he had administered. Moreover, it justified all the treatment she had received, explained her permanent disability, and accounted for the necessity of ongoing chiropractic care indefinitely. He would say he had waged a valiant effort to correct those misalignments, but her injuries were serious, permanent, and would require lifelong chiropractic care to keep her pain to a minimum and allow her to perform her normal daily activities.

The plaintiff’s chronic pain was undoubtedly a burden to her, but to her chiropractor and—if she prevailed at trial—her lawyer, her ongoing symptoms and permanent partial disability would make their cash registers ring. A jury award would go toward the medical bills left after her own car insurance stopped paying. After her lawyer was paid his share, there might be something left over for her [1].

My testimony, on the other hand, would focus on the treatments this chiropractor gave to his patient; how they were excessively frequent, how the course of care was unnecessarily prolonged, and how the various therapies of heat, ultrasound, electric muscle stimulation, and traction had no curative value and lacked scientific evidence of efficacy. I would explain to the jury that a lengthy course of treatment such as this, which included massage and spinal manipulation, was likely to cause patients to become dependent on chiropractors. And I would explain how active care such as exercise empowered patients to become self-reliant. Furthermore, I would cite scientific studies to back up my opinions. Finally, I would state that the plaintiff was probably injured by the accident, but, based on a review of the medical records and my own examination findings, the injuries were not as serious as her chiropractor claimed. She could improve further, perhaps even recover completely, if she received instruction in an exercise program appropriate for her injuries and performed the exercises on her own every day. In addition, a short course of counseling could disabuse her of her beliefs in the severity and permanency of her condition and help her to become independent of passive treatments. This opinion was also supported by scientific evidence.

I was surprised by this chiropractor’s salesman-like glad-to-see-you handshake. Chiropractors generally think their colleagues who give opinions adverse to their own are hired guns whose testimony is bought by insurance companies, so his hardy greeting seemed out of place. Although it is rare to encounter the plaintiff’s treating chiropractor at these proceedings, when it does happen I am usually greeted only by a nod or a cursory handshake or completely shunned. The term most often used by chiropractors for forensic consultants like me is “insurance whore.” They claim that we care more for the money we are paid than about the patient’s welfare, and that we lack the know-how to perform spinal adjustments adequately, so we must rely on the income derived from ratting out other chiropractors. In short, we are viewed as traitors to the profession.

Chiropractors who provide competent medical-legal services have a different perspective, one that is more nuanced and considers many more factors in the evaluation of a patient’s condition. Plaintiffs’ lawyers sometimes ask if I ever agree with the treating chiropractor. Of course, but cases in which I do agree would be settled rather than go to arbitration or trial. Such cases are rare because, far more often than not:

• The treating chiropractor is wrong. Wrong about the diagnosis. Wrong about the prognosis. And wrong about the choice and duration of treatment.
• The case history does not convey the information necessary to properly document the injury.
• The patient’s past medical history, especially regarding prior injuries and chiropractic treatments, is concealed.
• The physical examination is aimed at proving the patient was injured and thus requires chiropractic care rather than evaluating all possible causes of the complaints and making an accurate diagnosis.
• The prescribed therapies are intended to continue frequently for a protracted time.
• The chiropractor’s chart notes are difficult to interpret because they are illegible, written in code, and/or include computer-generated boilerplate.
• The patient’s chiropractor will try to make the patient’s injuries appear far worse than they really are, necessitating a prolonged period of treatment, extensive time off work, some degree of permanent physical impairment, and a lifelong need for “supportive” chiropractic care.

Is it any wonder that my conclusions disagree with the treating chiropractor in the majority of cases? Patients are portrayed not only as victims of these auto collisions [2], but also as the targets of insurance companies and their hired professional guns. In fact, they often end up at the mercy of the treating chiropractors and trial lawyers.

Most people see chiropractors as specialists in manual musculoskeletal medicine, essentially back doctors or “bone doctors.” This perspective is reinforced by chiropractic diagnostic and treatment methods: X-rays are used to visualize the bones of the spine, and the vertebrae are manipulated (“adjusted”) to restore normal alignment and motion. A typical reason to see a chiropractor would be for a “bone out of place” causing a “pinched nerve.” If the patient improved she would say her chiropractor popped the bone back into place and relieved the nerve pressure. Chiropractors encourage this simplistic thinking. Most chiropractors’ understanding of what they do is not much more complex.

Many patients who seek relief from neck and back pain are subjected to a bait-and-switch strategy because a lot of chiropractors believe themselves to be something very different from a back doctor or physical therapist, and the result is far more insidious.

Chiropractic Dogma

Since its origin in the late 19th century, chiropractic’s fundamental aim has been to remove interference to the body’s innate ability to heal itself in order to remain healthy. That interference might be described as the Big Black Boot Stepping on the Little Green Garden Hose. The boot is a slightly misaligned vertebra—a subluxation—and the hose is a nerve extending from the spinal cord through an opening between the misplaced vertebra and the one above or below it to its target organ or tissue somewhere in the body. When Innate Intelligence, a presumptive vitalistic force residing in the brain (the water traveling through the garden hose), is prevented from being transmitted through the afflicted nerve by a subluxation, the result is disease, which early chiropractors called dis-ease, perhaps because they sought to distinguish themselves from medical doctors who diagnosed disease. Thus, using reverse logic, any health problem the patient presents is due to one or more vertebral subluxations, and the indicated treatment is always spinal adjustments. This ideology has spawned various and often contradictory methods of spinal analysis to detect subluxations. It has also resulted in hundreds of methods for adjusting or correcting them, techniques that range from a forceful thrust delivered manually to a light-as-a-feather touch and may involve handheld instruments and mechanical or pneumatic adjusting tables. 

D.D. Palmer, chiropractic’s founder, postulated that “vertebral subluxations” interfered with “Innate Intelligence” more than 125 years ago. But in all the ensuing years, scientific inquiry has failed to demonstrate that minor spinal misalignments adversely affect health—via the nervous system or by any other anatomical or physiological mechanism, with the possible exception of back pain—or that the chiropractic correction of such “subluxations” benefits anything besides a chiropractor’s income. Yet surveys have shown that most chiropractors maintain a firm belief in Palmer’s concepts despite a lack of scientific evidence to support them. In 2006, in a randomized sample of US chiropractors, 70% of practitioners said their clinical practices were “subluxation-centered” and 59% agreed that the concept of subluxation was important to their clinical care decisions [3]. In 2015, a survey of North American chiropractic students reported that more than 60% agreed or strongly agreed that the emphasis of chiropractic intervention is to eliminate vertebral subluxations [4]. Scientific-minded chiropractors regard Palmer’s concepts as irrational [5]. But attempts to remove the term subluxation from the chiropractic lexicon invariably meet harsh opposition from sectors of the profession.

I don’t mean to suggest that spinal manipulation is without virtue. Research has demonstrated its benefit for some types of headache, neck pain, and back pain [6]. A portion of the chiropractic profession has in recent years focused more on its role as non-drug musculoskeletal specialists. As a result, since about 1990, there has been greater inclusion of chiropractors in  Kaiser Permanente, United Healthcare, Regence BlueCross BlueShield, and many other managed programs, but such care has by necessity been tightly controlled.

About Dr. Burke

J. Michael Burke, D.C., has been a chiropractor for more than 40 years. His career has included private practice, forensic consulting in injury cases, teaching at a chiropractic college, and co-founding a chiropractic managed-care organization that served many healthcare plans. He currently blogs at at Michael Burke’s Back Issues.

Footnotes

1. A 2004 study by the Insurance Research Council found that people with auto accident injuries who hired an attorney were less likely to be satisfied with their settlement than those not represented by an attorney. Fewer than half of those who hired an attorney were satisfied with their total payment compared to almost 75% without an attorney.
2. In my experience it is quite unusual for the person who caused the collision to claim disabling pain and prolonged disability.
3. Smith M, Carber L. Survey of US Chiropractor Attitudes and Behaviors about Subluxation. Journal of Chiropractic Humanities. 2008;15:19–26.
4. Gliedt J, Hawk C, Anderson M. Chiropractic identity, role and future: a survey of North American chiropractic students. Chiropractic and Manual Therapies. 2015;23(4)
5. Walker B. The new chiropractic. Chiropractic & Manual Therapies 24:26, 2016.
6. Bronfort G, Hass M, Evans R, Leninger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy. 2010;18(3).