Journal of Chiropractic Humanities 1998; 8: 71–76 ~ FULL TEXT
Cheryl Hawk, D.C., Ph.D.
Palmer Center for Chiropractic Research
741 Brady Street
Davenport, IA 52803
Chiropractic has made great advances in its acceptance by the general public and the biomedical establishment in recent years. However, the medical establishment still views chiropractic as a procedure - spinal manipulation - rather than as a profession which operates based on a unique approach to health care. This article provides a rationale and support for chiropractic as a profession that offers a unique approach to health care, based on the chiropractic belief system and the interpretation of the chiropractic clinical encounter developed by medical anthropologists. Requirements and implications for the future development of the profession in this direction are discussed.
Key Indexing Terms: Chiropractic, Medical Anthropology
From the Full-Text Article:
Chiropractic has made great advances
in its acceptance by the general public
and by the biomedical establishment in
recent years. This rise in status accompanies,
but is not wholly attributable
to, the blossoming of complementary
and alternative therapies on the health
care scene. Eisenberg’s seminal report
on the use of “unconventional”
(complementary and alternative) health
care practices in the U.S. indicated that
approximately one-third of Americans
had used some type of complementary
practice in 1993, and that chiropractic,
used by 10% of Americans, was the
most common of those practices. 
The 1994 Robert Wood Johnson Access
to Care Survey also showed chiropractic
to be the most commonly used
complementary therapy, used by 6% of
Americans, compared to 0.4% using
acupuncture.  Furthermore, in the
only survey to date of U.S. medical
practitioners (in the Chesapeake Bay
area of the U S), 49% considered chiropractic
to be “a legitimate medical
practice,” while 46% considered it to
be “alternative medicine;” 56% had
referred patients for chiropractic treatment. 
Procedure or Profession?
However, even though the medical
establishment apparently accepts chiropractic
at an unprecedented level, it
still views chiropractic as a procedure - spinal
manipulation - rather than as a
profession which operates based on a
unique approach to health care, and
may entail a number of procedures
within its model of health care and
scope of practice. [4, 5] In its taxonomy
of complementary practices, the
Office of Alternative Medicine (OM)
of the National Institutes of Health
places chiropractic under “manual
healing” rather than “alternative systems,”
in which naturopathy is placed,
although it also employs manual
therapy among other procedures. 
This is at odds with chiropractors’ own
opinions of the profession; chiropractors
consider themselves to be primary
providers of health services. 
Which is it? Is chiropractic synonymous
with spinal manipulation? Or is chiropractic
a complete system of health care? If it is the former, then it can be
done by other health professionals
such as family physicians, physiatrists,
or physical therapists. Spinal manipulation
could then be added to the armamentarium
of medical therapies and
accepted as mainstream rather than
complementary or alternative.
If chiropractic is a complete system of
health care, then it must have more to
offer than the procedure of spinal manipulation.
Spinal manipulation, or to
use the correct term used by the profession,
chiropractic adjustment, may
be considered the centerpiece of chiropractic’s
therapeutic options. However,
its application must be informed by a
unique approach to healing and health
that is distinct from, although not necessarily
at odds with, the medical
model. For it is the philosophy, the
intuitive knowledge - the belief system that
differentiates a complete system
from a procedure.
Chiropractic Philosophy and Belief system
For its first hundred years, chiropractic
evolved along its frequently rocky path
and grew strong because of its philosophy
and belief system, which provided
a unique perspective of healing and
Essential components of the traditional chiropractic belief system are:
1) ability of the body to heal itself
2) the central role of the nervous system in regulating health, and
3) the importance of the relationship between structure, as expressed through the
musculoskeletal system, to function, as
expressed through the nervous system. 
Chiropractors believe that restoring
normal structural relationships in
the spine through specific application
of force contributes to optimal functioning
of the nervous system, which in
turn has a central regulating effect on
other body systems. Furthermore, other
elements - physiological, psychological,
and environmental that have bearing
on the body’s ability to heal itself and
the smooth functioning of the nervous
system are also considered essential in
This is a holistic and
patient-centered viewpoint. Within the
context of a close doctor-patient relationship,
where the doctor views the
patient as a whole person, not simply a
spine, chiropractic adjustments are
applied, frequently in conjunction with
other noninvasive therapies. These include
“mainstream” therapies such as
nutrition and lifestyle counseling and
corrective exercise, as well as complementary
therapies such as massage,
acupressure, homeopathy, and herbal
medicine. [7, 8]
Chiropractic Is More Than Spinal Manipulation
Clearly, this view of chiropractic belief
and practice includes more than spinal
manipulation. Chiropractors know they
do more than spinal manipulation.
Their patients know they do more than
spinal manipulation. In fact, many
medical practitioners and the general
public know it as well. Interviews with
medical practitioners and laypeople
who had never used chiropractic indicated
that some of their negative attitudes
about chiropractic were associated
with chiropractors’ use of
nutrition, nutritional supplements, and
physical therapy modalities since these
interviewees felt that the sphere of
chiropractic should encompass only
spinal manipulation. [9, 10] Why,
then, does chiropractic continue to be
“officially” recognized as synonymous
with spinal manipulation? Why do most
of the clinical trials involving chiropractic
equate chiropractic and spinal
Reductionism is the short answer to
this question. Reductionism, in which
the whole is never more than the sum
of its parts, and in which often a part
becomes all that is recognized of the
whole, reduces chiropractic to spinal
manipulation. Reductionism allows
chiropractic to fit securely into the
medical model, by removing the “big
picture.” Reductionism is operating
whenever chiropractors, researchers,
other health professionals, or the public
focus on only one aspect of the
entire gestalt that makes chiropractic
unique.  Reductionism is easy; it
is much easier to say that chiropractors
are “back doctors,” that what they
do is “fix a bone out of place,” than
to describe the principles stated above.
However, reductionism is often useful,
and even necessary, in research settings
because it narrows reality to a
manageable scope that allows single
factors to be studied at a given time.
As long as research is conducted with
an understanding of this limitation, that
reality is always greater than the sum
of its parts, reductionism serves a useful
function and new knowledge can be
gained through a thoughtful analysis of
It is much harder and sometimes impossible
to study reality without isolating
individual aspects. Thus it is much
harder to describe what chiropractors
actually do, as is illustrated in the ensuing
discussion, rather than simply to
say they manipulate the spine. However,
it is essential that the complexity
of reality not be discounted. Thus this
discussion illustrates that chiropractic,
far from being synonymous with spinal
manipulation, represents a complex
and characteristic dynamic between
doctor and patient, one which has been
analyzed by medical anthropologists
without a heavy reliance on references
to spinal manipulation at all. [11, 12]
Elements of the Chiropractic Encounter
The specific components of the chiropractic
encounter, as described by
Coulehan , are:
acceptance and validation of the patient and his or her problem
acceptable expectations and explanations for the course of treatment
concrete and convincing clinical actions, and
a plan for the positive engagement of the patient in treatment.
These components are discussed below.
Acceptance and Validation.
of the patient, in the sense of
demonstrating positive regard and appreciation
for his or her feelings and
beliefs, is considered to be a core
quality for successful doctor-patient
interactions. [12-14] Chiropractors
are sensitive to the need to form a
bond of mutual acceptance with their
patients, in which both accept and
accommodate the other’s belief system. [12, 15, 16] Chiropractors tend to
relate to patients in a more personal
and egalitarian manner than do medical
doctors, using common language
and genuineness, i.e., being oneself
without resorting to the “physician
role”. [12, 14, 17, 18] Furthermore,
the patient’s sense of acceptance is
enhanced by the traditional chiropractic
approach of treating the patient
rather than the disease, which stems
from the theoretical basis of chiropractic,
in which the body is viewed as a
whole and illness as a lack of harmony
of body systems. [19, 20] In general,
patients’ satisfaction with health care
has been linked to the doctor’s ability to be considerate, treat them as persons,
and to treat them with respect
without “talking down” to them. 
In conjunction with acceptance, the
chiropractor validates the patient’s
health problem, often serving to legitimize
the sick role of patients whose
complaints were not considered “real”
by medical doctors. [12, 22] Traditional
and popular healing systems, of
which chiropractic is an example, have
been noted to deal more willingly and
successfully with illness, or the patient’s
perception of his or her experience
than does biomedicine, which
focuses on disease and discounts illness. 
Expectations and Explanations.
discussed above, an essential, perhaps
the essential feature of chiropractic is
its characteristic belief system. Chiropractors
tend to have strong belief in
their approach to care, another characteristic
they share with other indigenous
healers. [12, 24] Thus they are
able to convincingly communicate their
expectations of efficacy to the patient,
and instill similar positive expectations
in patients both through their own
belief and through the type of explanations
they present. In studies of patient
satisfaction, provision of understandable
explanations for conditions and
treatments is an important factor contributing
to the high level of patient
satisfaction with chiropractic care. [12, 25-28] In Cherkin and MacCornacks
study of satisfaction with low back pain
care by family practice physicians and
chiropractors, 53% of chiropractic
patients were very satisfied with the
amount of information they received
about their pain, as opposed to 17% of
family practice patients.  Chiropractic
patients also were more likely
to report receiving information on recovery
time and instructions for self
care. Chiropractors tend to explain the
patient’s condition in nontechnical
terms, using analogies that are acceptable to patients and easy to understand,
attributing physical symptoms to
physical causes.  Most chiropractors (80-90%) use a visual aid such
as an X-ray, illustration, diagram, or
model of the spine to explain the patient’s
problem, which not only clarifies
the explanation but further validates
the reality of the complaint. [12, 18, 27]
action revolves around physical touch.
The physical exam as well as the treatment
involve manipulation and mobilization
of the patient’s body, and make
it clear that the chiropractor is “doing
something”.  Chiropractic has
even been characterized as a method
of treating illness by physical touch.  The therapeutic value of touch
has been well established and is not
unique to chiropractic; it is generally
viewed as a “placebo” effect. [12, 25, 30] The effects of spinal manipulation
are often attributed to this “placebo”
However, chiropractors believe that the
chiropractic adjustment has a specific
corrective effect on an area of spinal
dysfunction (the subluxation). Although
this lesion and the effects of its correction
have yet to be well documented
through rigorous investigations ,
there is some evidence from clinical
trials, using control groups given treatments
employing physical touch like
light massage, that indicates an effect
of spinal manipulation beyond that of
the general effect of touch alone. 
However, the undoubted ability of
“hands-on” treatments to create an
atmosphere of caring, intimacy, reassurance,
and comfort has a definite, if
nonspecific, positive impact not only
on patient psychology but on physiology
as well. For example, in a study of
diet-induced atherosclerosis in rabbits,
the animals that had been handled and
petted by one researcher had significantly
less plaque formation. [33-35]
Plan for Engagement of Patient in Treatment.
The active involvement of
the patient in a health partnership is
an important part of chiropractic care.  Although chiropractic manipulation
is termed “passive” care, in that
the manipulation is done by the doctor
to the patient, the partnership between
doctor and patient that extends beyond
spinal manipulation requires conscious
participation and cooperation, primarily
through patient “buy-in” of the
chiropractic belief system.  Furthermore,
chiropractors frequently give
patients instructions for lifestyle modifications
and stress the importance of
providing the body with optimal conditions
for healing. [9, 12, 17, 36, 37]
Interaction Analysis of the Chiropractic Clinical Encounter.
interaction analysis, using a standard
method for content analysis
(Bale’s method), of one chiropractor’s
relationship with his patients supports
the idea that chiropractic practice is a
distinct approach to patient care,
rather than simply the delivery of spinal
manipulation.  Although this
study investigated only one chiropractor’s
patient interactions (with 57 patients,
8 of whom were new), the patients
representative of the chiropractor’s
patient population, and his practice
characteristics appear similar to those
of many chiropractors. [12, 16] Oths
targeted information exchange and
affect (both verbal and nonverbal) as
the primary elements of clinical communication,
based on studies of patient
satisfaction with medical care. [36, 38]
Patients, especially those with chronic
conditions such as low back pain, have
been shown to be particularly dissatisfied
with their medical physicians’ affective
behavior, as well as the quality
of information on their condition.
dissatisfaction often results in a change
in provider to an alternative therapy,
particularly chiropractic. [36, 38] Oths
analyzed the clinical encounter in five
phases: intake, orthopedic examination,
consultation, spinal manipulation treatment,
and reexamination. Table 1 summarizes
the communication patterns by
clinical phase. Clearly, a positive affect
was a large component of the doctor’s
verbal exchange with patients, particularly
during the treatment phase, which
one may infer must contribute to a
positive treatment effect.
Communication Patterns Between Chiropractor and Patients, by Clinical Phase
From patient satisfaction surveys she
administered in conjunction with her
observations, Oths concluded that the
following factors contribute to the high
levels of satisfaction and treatment
compliance shown by chiropractic patients: 
l) the initial provision of a large amount of understandable and acceptable information
on the patient’s condition,
2) the treatment approach, and
3) continued personal affective dialogue between doctor and patient.
She further comments that the pattern of supplying the patient with readily understandable explanations
of both their condition and of how chiropractic works has the effect of “manipulating a patient’s belief
structure before manipulating his or her physical structure, providing an analogous structural realignment
in both the mind and body”. [36 p. 83]
Chiropractic is at a crossroads. Its
success with the public, based on 100 years of helping people, often without
the support, protection, or approval of
established health care, has resulted in
its current position as the most commonly
used form of complementary
therapy in the U.S. Research investigations
documenting its efficacy for musculoskeletal
conditions have made it
one of the complementary practices
most acceptable to the medical community.
Chiropractic is on the verge of
complete acceptance into the health
care mainstream. The crossroad is this:
Which path will the profession take to
reach full acceptance? One path is
chiropractic is the procedure of spinal
manipulation; the other is chiropractic
is a unique approach to health and
The path of least resistance is to accept
the role of spinal manipulators,
specialists in low back pain. The OAM
and the medical establishment in general
already accept the profession in
this capacity. Chiropractors’ acceptance
of it as well could accelerate the mainstreaming
of the profession’s educational
institutions, increase its research
funding, and hasten integration on
interdisciplinary teams of medical personnel.
Many chiropractors advocate,
and have already taken this path. The
danger here is that once chiropractors
go down this path, they may become
virtually indistinguishable from the
other medical practitioners already
existing within the medical establishment.
The mission statements of most chiropractic
colleges and the attitudes expressed
in surveys of chiropractors
indicate the profession is leaning toward
the second path, acceptance of
the role of primary providers with a
distinct approach to health and health
care. [7, 8, 19] Although the foregoing
discussion provides some support and
rationale for this position, it is a far
more difficult path. It is more difficult
in terms of education, because few
chiropractic colleges now provide adequate
clinical training in a comprehensive
approach to care or training in
the scientific method to encourage
analytical thought or research productivity. [39, 40]
It is far more difficult
in terms of research, because although
there is an impressive body of evidence
supporting manipulation as a palliative
treatment of musculoskeletal conditions,
researchers have barely begun to
scratch the surface of the mystery of
the subluxation and its possible effect
on general health, which is at the heart
of chiropractic philosophy.  However,
if the profession can ground its
clinicians and researchers in both philosophy
and science, this path may
lead to the exploration of new knowledge
of how the body and mind work
as well as to the possible discovery of
previously unknown mechanisms of
healing. It may lead to a better understanding
of the complex interactions
that contribute to that dynamic known
as the healing encounter.
However, it is critical that chiropractic
institutions, faculty, and practitioners
do not just pay lip service to this path.
It requires a serious commitment to
the exploration of new knowledge
through good science and a comprehensive
approach to clinical care. It
requires a realistic, unbiased assessment
of the profession’s needs in pursuing
it. And it requires combining
science with intuition and abandoning
rhetoric in favor of dialogue. These
actions are prerequisites to travel on
this path into the second century of
chiropractic. There, it may hopefully
join the mainstream of healthcare with
its identity and integrity intact, recognized
as an important contributor to
and equal partner in the continual
growth of the art and science of healing.
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