Is There a Method to Manipulation?

By ANDREW PURVIS

When internist Paul Shekelle was in medical school in the 1970s, the gentle art of chiropractic was widely viewed as bunk: heir to the tradition of ! bloodletting and rattlesnake oil. The American Medical Association's committee on quackery had branded the practice an "unscientific cult," and medical- school professors had obediently followed suit. The reluctance of the so- called back-crackers to submit their technique to the scrutiny of hard science served only to reinforce the official scorn. Recalls Shekelle: "They were seen as hucksters and charlatans trying to dupe the public into paying for useless care."

The public, meanwhile, seemed happy to be duped. Millions of Americans remained devoted to the healers' manipulative ways. And in recent years that enthusiasm has blossomed. About 1 in 20 Americans now sees a chiropractor during the course of a year. The number of U.S. practitioners jumped from 32,000 in the 1970s to 45,000 in 1990.

Chiropractic has even achieved a certain celebrity cachet. Quarterback Joe Montana got his brawny back manipulated on national TV (during the Superbowl pregame show). Cybill Shepherd grew so attached to her practitioner that she married him. Overseas, where chiropractic is both more popular and more widely accepted by doctors, Princess Di regularly gets her regal back cracked. And Russian ballet stars Vadim Pisarev and Marina Bogdanova reportedly would not risk an arabesque without a periodic adjustment.

Now, almost despite itself, mainstream medicine has started to take notice. Several authoritative studies have confirmed that chiropractic-style spinal manipulation is effective for the treatment of lower-back pain. Leading physicians now openly discuss the technique, and some are even referring their own patients to these once scorned colleagues. Concedes Dr. Shekelle, who directed one of the recent studies: "Their philosophy of disease is totally foreign to us. But for some conditions it sure seems to work."

The growing acceptance was apparent at this year's meeting of the American Academy of Orthopedic Surgeons, where for the first time a symposium was held on back manipulation, and about one-third of surgeons present admitted referring patients for the technique. Some 30 hospitals around the country now have chiropractors on staff, and multidisciplinary clinics that offer both medical and chiropractic care have sprung up in several urban centers. In addition, a small band of "research" chiropractors has begun testing the method in carefully designed clinical trials. "Manipulative medicine," declares Dr. Nortin Hadler, a rheumatologist at the University of North Carolina, "is no longer a taboo topic."

One reason for turnabout is that spinal manipulation has held up under study, at least for some conditions. In a report released this July by the Rand Corp., a prestigious research organization in Santa Monica, Calif., a panel of leading physicians, osteopaths and chiropractors found that chiropractic-style manipulation was helpful for a major category of patients with lower-back pain: people who are generally healthy but who had developed back trouble within the preceding two or three weeks. Another important study published last summer in the British Medical Journal compared chiropractic treatment with outpatient hospital care that included traction and various kinds of physical therapy. Its conclusion: spinal manipulation was more effective for relieving low-back aches for up to three years after diagnosis.

Such positive findings come despite the fact that no one is entirely sure how chiropractic manipulation works. Practitioners assert that they are correcting spinal "subluxations," which they describe as misalignments of vertebrae that result in damaging and often painful pressures on nerves in the spinal cord. Because nerves in the cord connect to every organ and body part, such misalignments, they say, can cause problems in the feet, hands and internal organs as well as the back.

Most doctors are skeptical of this theory. "Chiropractors may sound very authoritative," says Chicago rheumatologist Robert Katz, "but their basic understanding of the pathophysiology of the spine is simply not there." Chiropractors respond that they spend at least four years studying the subtleties of the spine, including exhaustive courses in anatomy, pathology, biochemistry and microbiology, and are in fact far more knowledgeable than many medical doctors about this anatomical region.

Whatever the benefits of manipulation and massage, many chiropractors admit that at least some of their success stems from their attentive manner and holistic approach to disease. Practitioners tend to discuss a patient's entire life-style, emphasizing stress reduction, a healthful diet, exercise and maybe even a change in work habits. Patients love it, especially after experiencing the sometimes narrow approach of medical specialists, who may thoroughly examine a body part without a hint of interest in the human being.

New York social worker Shoshana Shonfeld, 40, for instance, was crushed when , an orthopedic surgeon told her she would either have to live with chronic back pain or undergo radical disk surgery, with no guarantee of success. Then she found a chiropractor who, she recalls, "did all kinds of wonderful things." In addition to spinal manipulation, the practitioner served up a potpourri of health-care advice on everything from diet to correct posture and toning up muscles in the stomach and lower back. Now, she says, "my back is almost perfect. My body feels aligned; it feels straight."

One study in Washington State found that patients were significantly more satisfied with their chiropractor's manner than with their medical doctor's. Patients may even be too satisfied. One frequent complaint about chiropractors is that treatment goes on for too long. Patients become dependent on regular manipulation, and their therapists are all too happy to accommodate them. Alan Adams of the Los Angeles College of Chiropractors estimates that perhaps 10% to 15% of his colleagues are guilty of this.

While the vast majority of chiropractic patients are treated for back, neck and shoulder complaints as well as minor headaches, some 10% seek help for organic diseases of all sorts. Can manipulation help them? The chiropractic literature is replete with examples of astonishing cures of ulcers, hypertension, childhood asthma, blindness and even paraplegia. But individual case histories prove nothing, and organized studies are few and far between. Spinal manipulation has been shown to alter the heartbeat and the acidity of the stomach, says Peter Curtis, a medical professor at the University of North Carolina, who studied the technique, "but whether you can cure a peptic ulcer or angina is another question entirely." The A.M.A. withdrew its earlier condemnation of chiropractic as a cult in 1988 -- after federal courts ruled it an unfair restraint of trade -- but it remains adamantly opposed to broad application of chiropractic therapy.

Of course, chiropractic could restrict itself to relieving back pain and still have its hands full. By some estimates, 75% of all Americans will suffer from low-back aches at some point in their lifetime. The annual cost to U.S. society of treating the ubiquitous ailment was recently tallied at a crippling $24 billion, compared with $6 billion for AIDS and $4 billion for lung cancer. If spinal manipulation could ease even a fraction of that financial burden, remaining skeptics might be forced to stifle their misgivings or get cracking themselves.