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One of the earliest systems of health care in the United States to use manual healing methods was osteopathic medicine. To its practitioners and to much of the public, the manual healing methods of osteopathic medicine are mainstream processes, but some people consider them alternative.
The principles and philosophy of osteopathy integrate health and illness, emphasizing four major areas:
• Structure and function are interdependent. Furthermore, behavior is an intermingled complex in which psychosocial influences can affect both anatomy (structure) and physiology (function). All these relationships are fundamentally designed to work in harmony.
• The body has the ability to heal itself, and the role of the osteopathic physician is to enhance the healing process as much as possible.~ • Diseases, impairments, and disabilities arise from disruptions of the normal interactions of anatomy, physiology, and behavior.
• Appropriate treatment is based on the ability to understand, diagnose, and treat--by whatever methods are available--including manually applied procedures. When hands-on procedures are used to identify somatic dysfunction (see the glossary), the practitioner then determines whether the pattern of somatic dysfunction that is observed can be related to any visceral (that is, related to the internal body organs), neuromusculoskeletal, or--occasionally--behavioral dysfunction.
American osteopathic medicine was begun by Andrew Taylor Still (1828-1917). Still was a physician of his period, trained mainly through apprenticeships. It is said that he attended a medical school in Kansas City, MO, for one semester but found it boring and irrelevant (Gevitz, 1980). As a result of many adverse experiences with then contemporary medical ~practices, including the death of several family members from untreatable meningitis and pneumonia, Still began a personal search for improved methods to treat diseases and restore health (Gevitz, 1980; Schiotz, 1958). This empirical approach continues to be used by many osteopathic physicians.
Development and use of osteopathically oriented manipulative skills began around the time of Still's search (Carlson, 1975; Gevitz, 1980), but how he developed his system that combined "lightning bone setting" with the magnetic healing concepts of Mesmer is not clear (Hood, 1871).
It seems likely that his knowledge (of manipulation) was derived from simply observing the work of another practitioner in the field. However he learned these methods, Still soon afterwards made an important discovery, namely, that the sudden flexion and extension procedures peculiar to the spinal area were not limited to orthopedic problems; furthermore, they constituted a more reliable means of healing than simply rubbing the spine (Gevitz, 1980).~Whatever the circumstances, Still began his new health profession in 1874, before beginning his use of manipulation, which he was reported to use somewhat later in that decade (Gevitz, 1980). After advertising and working as both a magnetic healer and a lightning bone setter, he began writing about his ideas (Still, 1899). Ultimately, he founded his first school, the American School of Osteopathy, in 1892 at Kirksville, MO, to improve on existing surgical and obstetrical practices. The original emphasis was on observing the relationship between structure and function. He incorporated assumptions that manual restoration of normal anatomic relationships leads to physiological improvements. This reasoning included by definition a spectrum not only of health issues but of specific recommendations for disease and obstetrical interventions. Some examples from osteopathic literature include discussions dealing with labor and delivery, postoperative ileus (bowel) paralysis, asthma, otitis media (middle ear infection), hypertension, coronary artery disease, back pain, neck pain, diabetes, trauma of all kinds, migraine headache, and stress-related illnesses (Downing, 1935; Kuchera and Kuchera, 1990; Sleszynski and Kelso, 1993).
Osteopathy spread to England in the 1920s when John Littlejohn emigrated from Chicago to ~London, establishing the British School of Osteopathy, the first of several such schools. The expansion continued as continental European practitioners studied at the British schools in the 1930s and 1940s.
Historically, many currently popular manual medical techniques--with the exceptions of "energy" techniques, massage, and high-velocity maneuvers (Hood, 1871)--originated within American osteopathy and spread elsewhere. Among those techniques are manual methods applied in other medically oriented systems and also activities of alternative health care providers. Examples include muscle energy and postisometric relaxation concepts, which were originally developed and codified by Fred Mitchell, Sr. and Paul Kimberly; fascial-myofascial release and visceral techniques, developed by A.T. Still and others, including Charles Neidner; cranial-craniosacral techniques, William G. Sutherland (Sutherland, 1990); strain and counterstrain, Lawrence Jones; and thoracic pump and lymphatic techniques, A.T. Still, Gordon Zink, and several contemporaries. (Most of these techniques are described briefly in the "Osteopathic Education" section.)
~In many instances, contemporary practices of these methods throughout the world are extensions and refinements of original osteopathic concepts. Other systems, such as chiropractic, Swedish massage, Cyriax (Great Britain), Mennell (Great Britain), Lewit (Czech Republic), Dvorak (Switzerland), and several German systems also have influenced current practices, both in the United States and elsewhere. Two current osteopathically based examples are advances in myofascial release and fascial unwinding maneuvers and in "energy"-based practices arising from basic cranial concepts, codified by both Sutherland and Harold Magoun, Sr. (Magoun, 1976; Sutherland, 1990).
Demographics. As of 1993, this country had more than 32,000 American-educated and licensed doctors of osteopathy (D.O.s), some in every State. They perform all aspects of medical care, including all specialties and family practice. Sixteen colleges and schools graduate approximately 1,500 D.O.s annually. While graduates make up about 5 percent of the country's physician population, the profession is responsible for approximately 10 percent of total health care delivery in the United States. More than 60 percent of osteopathic physicians are involved in primary care areas--family medicine, pediatrics, ~internal medicine, and obstetrics-gynecology (Annual Directory, 1993).
Many osteopathic physicians from a variety of disciplines regularly incorporate structural diagnosis of abnormalities of musculoskeletal function and manual medical treatments in their day-to-day activities.1 Ironically, because of current attitudes among third-party payers toward physician use of manual medicine, many are not paid for these services. Much of the reluctance to pay is based on a lack of adequately funded research, particularly relating to outcome measures. From an osteopathic perspective, what is considered "alternative" by most of the medical and research establishment is mainstream for the average D.O. (Gevitz, 1980; Grad, 1979; Schiotz, 1958).
Osteopathic education. Basic American osteopathic education (Gershenow, 1985) includes substantial emphasis on osteopathic philosophy and principles including extensive manually oriented training designed to develop manual medicine diagnosis and treatment skills. The profession generally refers to the latter as structural diagnosis and manipulative treatment. These skills have been used by osteopathic physicians for more than 100 years in a context ~of total patient care.
The Education Council on Osteopathic Principles, representing the 16 osteopathic colleges, is currently contributing to osteopathic education through three principal projects: the 1982 publication of an updated glossary of osteopathic terminology; development of a core curriculum for osteopathic principles; and development of state-of-the-art textbook chapters highlighting the uses of palpatory diagnosis (use of touch) and manipulative treatment in multiple clinical disciplines.
Basic palpation and structural diagnosis and treatment skills are emphasized in preclinical American osteopathic education, and eight major manual medical methods are taught in osteopathic colleges. These eight methods are as follows:
1. Soft-tissue techniques that enhance muscle relaxation and circulation of body fluids.
2. Isometric and isotonic techniques (often referred to as muscle energy or postisometric ~relaxation) that focus primarily on restoring physiological movements to altered joint mechanics.
3. Articulatory techniques (also called joint play and manipulation without impulse) that emphasize restoration of intrinsic joint mobility.
4. High-velocity, low-amplitude techniques (also called manipulation with impulse), designed to restore the symmetry of the movements associated with the vertebral joints.
5. Myofascial release techniques (also called fascial release techniques) that use combinations of so-called direct and indirect methods (see the glossary) to modify problems of individual and interactively related muscle groups and surrounding or covering (myofascial) tissues.
6. Functional techniques that emphasize treatment of restrictive patterns in joint, myofascial, and neural systems, using "ease," "bind," "sensing," and "motor" hands (see the ~glossary) as proprioceptive (see the glossary) diagnostic concepts.
7. Strain and counterstrain techniques, designed to locate sore places at specific sites on the body, tender points that relate to specific patterns of abnormal joint movement. The points are "turned off" by moving the body or limb to a treatment position that quiets painful feedback. The position is held for 90 seconds. Reevaluation typically reveals improvement in movement and a decrease in local pain.
8. Cranial techniques (also called craniosacral techniques) that highlight the manual ability to assess and release tensions associated with subtle, reciprocating cranial (head) and sacral (tailbone) oscillations. These movements are thought to arise from a complex combination of dural (covering) and ligamentous (fibrous connecting tissue) relationships in the spinal network. Adams and Heisey have documented movement of cranial bones in studies using cats. They found cerebrospinal fluid waves having various frequencies and amplitudes (Adams et al., 1992; Heisey and Adams, 1993). Opportunities for research in this area abound.~A number of continuously evolving diagnostic and treatment systems that are osteopathically oriented and manually based incorporate various of these eight manual techniques. Some systems are meant to stand on their own, while others are integrated to a greater or lesser extent with medically (i.e., allopathically) oriented decisionmaking.
Postdoctoral training, certification, and fellowship status in manual medicine are available to American osteopathic graduates, approximately 35 postdoctoral positions are available each year. Programs last 1 to 4 years. One-year fellowships are available for D.O.s and M.D.s who have finished a previously approved residency. Standalone 2-year programs leading to manual medicine certification are available in several colleges. Interdisciplinary 3-and 4-year programs that combine some of the many specialties and subspecialties are also available. The most popular are combinations of manual medicine with either family practice or physical medicine and rehabilitation.
Total patient care. Osteopathic physicians are involved in all aspects of total patient care (Northup, 1966), including structural diagnosis and manipulative treatment. Manipulative ~treatment is commonly used, especially by osteopathic family physicians, as adjunctive care for systemic illness and for various neuromusculoskeletal problems, such as low back, head, and neck pain. In this context, a wide variety of hands-on and--in some situations--"energy" applications are used in a range of disciplines, including family practice, pediatrics, geriatrics, physical medicine, surgery of all kinds, physical medicine and rehabilitation, neurology, rheumatology, pulmonology, and sometimes behavioral medicine and psychiatry. A few disciplines have conducted research using manual methods (Reynolds et al., 1993; Sleszynski and Kelso, 1993), but many questions remain.
Research base. Since its inception, the osteopathic profession has maintained and pursued active research in many areas. This work has usually been published in the Journal of the American Osteopathic Association, which until recently was not listed in Index Medicus. Present activities designing research tend to be directed toward evaluating (1) long-term effects of somatic dysfunctions and facilitated segments in disease states and (2) the outcome resulting from the use of manipulative treatment.
~An extensive body of work supports a physiological basis for using osteopathic techniques in both musculoskeletal and nonmusculoskeletal problems. Of particular interest are studies dealing with
• interactions between internal body organs and neuromuscular structures,
• alterations in reflex thresholds,
• reliability of physician palpatory skills (inter-rater reliability studies), and
• effects of manipulative treatments on disease processes and a variety of physiological functions.
Early work performed by Louisa Burns demonstrated that spinal strain has adverse effects on both functional and motor neuron levels (Burns, 1917). Later work by Denslow and Korr demonstrated long-lasting, highly individual patterns of spinal hyperexcitability ~associated with neuromuscular and various visceral dysfunctions. This research led to the concept of the "facilitated segment" (fig. 1; also see "facilitation" in the glossary), which has been associated with a variety of clinical problems (Denslow et al., 1947; Korr, 1947, 1955). The concept of the facilitated segment is that repeated stimulation produces hyperactive responses, resulting in improper functioning of some body part.
By considering function along with structure, osteopathic theory has included conjecture on the role of the body's communication systems--nervous, circulatory, and endocrine--in initiating somatic dysfunction and causing additional responses in the body. Some early research (Northup, 1970) supports this supposition with regard to reflexes having a role in mediating both the origin of somatic dysfunctions and the effects of manipulative treatment. Osteopathic medicine needs continuing basic research on the role of the nervous system in establishing and maintaining somatic dysfunctions and effecting interactions with the rest of the body.
Figure 1 demonstrates potential effects of repeated facilitation; that is, inducing a hyperactive ~response, leading to somatic dysfunction. The term facilitation is usually used to describe enhancement or reinforcement of otherwise subthreshold neuronal activities that stimulate effector units to inappropriately carry out whatever action they are programmed to do. Examples of effector sites are muscle bundles, muscle groups, viscera, and other neural units and networks. Osteopathic treatment is designed to raise these stimulus thresholds so that the stimulatory event is less likely to occur.
More recent examples of osteopathic research include a preliminary assessment of the effectiveness of manipulative treatment for paresthesias (abnormal sensations) with peripheral nerve involvement (Larson et al., 1980) and thermographic studies of skin temperature in patients receiving manipulative treatment for peripheral nerve problems (Kappler and Kelso, 1984; Larson, 1984). Thermography was selected as a promising method to study segmental facilitation of sympathetic nerves without invading the body (as would be required if needle electrodes were used). Initial studies have been complicated, however, by the number of variables affecting skin-level circulation, including circulatory patterns, local influences, and local shunting. If methods can be developed to identify the ~effects of these variables, then thermography may prove useful for detecting changes in the sympathetic nervous system that affect skin-level circulation.
Other current clinical research projects that examine the effects of manual treatments have researched their effects on postoperative pulmonary flow rates (Sleszinski and Kelso, 1993), pain management (Zhu et al., 1993), and electromyographic changes associated with manual treatments. If vibration is applied to muscles near the spine or these paraspinal muscles contract voluntarily, weakened electrical potentials are observed in the cerebrum, the main part of the human brain. This finding suggests that muscle spindle receptors are responsible for providing signals that cause the early components of magnetically evoked brain potentials. The brain's evoked potentials return to normal amplitude (1) when the muscle spasm subsides after a period of time and (2) after spinal manipulative therapy is applied (Zhu et al., 1993).
Additional research on the interaction of visceral and somatic structures (Eble, 1960) has supported clinical findings that palpation of neuromuscular structures can help identify ~visceral disturbances (Johnston, 1992; Kelso et al., 1980) and that manual procedures can help restore both visceral and neuromuscular (somatic) functions (Buerger and Greenman, 1985; Korr, 1978; Northup, 1970). The latter include situations involving low back pain (Hoehler et al., 1981), neurological development in children (Frymann et al., 1992), carpal tunnel syndrome (Sucher, 1993), postoperative collapsed lung (Sleszynski and Kelso, 1993), and burning pain in an extremity (Levine, 1991). Moreover, in some preliminary observations with cadavers, Reynolds and Ward (Ward, 1994) found that palpatory diagnoses tended to correlate with radiographic and autopsy data.
One example of the diagnostic potential of osteopathic palpation is the studies of Johnston and colleagues (Johnston et al., 1980, 1982b), comparing subjects with normal and high blood pressure. A significant number of the hypertensive patients were shown to have a stable pattern of musculoskeletal findings in the cervicothoracic spinal region. This finding suggests that osteopathic diagnoses could contribute to identifying internal difficulties.
Another issue that osteopathic researchers have addressed is the accuracy of their ~examinations of patients before and after manipulative treatment, including whether such observations are consistent among a group of osteopathic physicians. Several studies (Beal et al., 1980, 1982; Johnston, 1982a; Johnston et al., 1982a, 1982c, 1983; McConnell et al., 1980) have been conducted in which osteopathic physicians working independently have used a mutually agreed-upon test procedure. These studies of inter-rater reliability look for correlations in the observations of two or more independent raters. Results suggest that when there is prior training or agreement on which tests to use and what is clinically significant with respect to findings, inter-rater agreement can be achieved consistently. This ability to reach agreement becomes particularly important as the basis for establishing a method of setting up controlled clinical trials to determine the success of manipulative treatments.
Virtually all osteopathically oriented research has been funded from the private sector, mainly through the bureau of research of the American Osteopathic Association. The largest grant to date, $400,000, is for evaluating outcomes associated with the use of manipulation for back pain in a Chicago health maintenance organization population. This is a 3-year ~prospective study conducted by two osteopathic physicians specializing in musculoskeletal medicine. Patients having acute back pain with and without sciatica (pain radiating downward into the leg) are randomized into the project so that some receive manipulative care while others receive "standard" medical care. Clinical outcomes are evaluated by uninvolved clinicians. Preliminary data are expected in late 1994.
Barriers and key issues. Historically, Federal research initiatives relevant to osteopathic medicine (for example, from the National Institute of Neurological Disorders and Stroke at the National Institutes of Health (NIH) or from the Centers for Disease Control and Prevention) have been controlled by traditionally defined disciplines and their expert panels. Manual-methods research panels are not among them, and the result is a lack of genuine peer review capability. This sociological fact of life has inhibited development and understanding of the manual medicine field, even though public acceptance has been and continues to be high throughout the world.
Some major issues to be considered in trying to improve osteopathic research opportunities ~are the following:
• Selecting appropriate patient populations in which to study the effects of manual manipulation.
• Arranging for knowledgeable peer review and research guidance, including (1) ensuring that persons with osteopathic experience serve on peer review panels (see also the "Peer Review" chapter) and (2) determining appropriate procedures for measuring success of osteopathic treatments.
• Establishing whether previous inter-rater agreement studies support the use of the inter-rater agreement method in osteopathic and other kinds of research.
• Making previous osteopathic research more accessible (for example, the recent inclusion of the Journal of the American Osteopathic Association in Index Medicus), which could educate other investigators about osteopathic issues and possibly lead to collaborative ~research. (See also the "Research Databases" chapter.)
• Ensuring that osteopathic clinician-researchers are part of any research team so that persons inexperienced with osteopathic diagnosis and treatment do not conduct the work improperly. Additional training in planning, conducting, evaluating, and reporting clinical research should be made available to the osteopathic clinicians.
• Setting up a review process to integrate available information from outside the osteopathic profession with osteopathically based research on the structure-function relationship. Included would be research, for example, on homeostasis; short-, intermediate-, and long-term responses to different stressors; and adaptation to changes in internal and external environment. Useful new research questions are likely to result.
• Documenting anecdotal observations of patients and osteopathic clinicians who treat the somatic component of medical and health-related problems to tabulate patient benefits that include relief from stress and improvement in function and well-being. Attention should ~be paid to all patient health outcomes, not just short-term benefits from manipulation; for example, reducing health risks, improving health maintenance, and modifying adaptive responses would be included.
• Designing and conducting research to support or refute the use of palpatory examination and manipulative treatment for the somatic component of dysfunction and illness. Also researching the role of the somatic system; identifying the nature and effects of somatic dysfunctions and their incidence, prevalence, and effects on acute illness and long-term health; and any changes in those effects resulting from treatment.
• Developing alternative research designs for safety and efficacy studies that do not require blind controls for manual procedures. (See also the "Research Methodologies" chapter.) There are both practical and ethical reasons not to use blind controls for a hands-on procedure. One alternative is to use naive patients who lack any expectation that the treatment will be beneficial.
~ • Developing and integrating cost-benefit research that compares the use of palpatory examination and manipulative treatment with mainstream health care and disease management procedures. Common examples include headaches of all kinds, back pain, allergy, asthma, many orthopedic problems, postoperative and posttraumatic effects of all kinds, and various rheumatologic diseases.
Chiropractic science is concerned with investigating the relationship between structure (primarily of the spine) and function (primarily of the nervous system) of the human body in order to restore and preserve health. Chiropractic medicine addresses how to apply this knowledge to diagnose and treat structural dysfunctions that affect the nervous system.
Chiropractic philosophy and practice emphasize four major points:
• The human body has an innate self-healing ability and seeks to maintain homeostasis ~(see the glossary), or balance.
• The nervous system is highly developed in humans and influences all other systems in the body, thereby playing a significant role in health and disease.
• The presence of joint dysfunction and subluxation (see the glossary) may interfere with the ability of the neuromusculoskeletal system to act efficiently and may lead to or be a concomitant of disease.
• Treatment is based on the chiropractic physician's ability to diagnose and treat existing pathologies and dysfunctions by appropriate manual and physiological procedures.
The chiropractic physician relies heavily on hands-on procedures using touch (palpation) to determine both structural and functional joint "dysrelationships." These hands-on procedures are carried out alongside more traditional forms of diagnostic assessment. By training and by law, chiropractic physicians use manual procedures and interventions, not surgical or ~chemotherapeutic ones.
History and context. While manipulative medicine has been practiced for millennia, the chiropractic profession is only now preparing for its centennial. The profession was founded in the 1890s when Daniel David (D.D.) Palmer, a grocer and magnetic healer, applied his knowledge of the nervous system and manual therapies, thrusting on a thoracic vertebra to restore the hearing of Harvey Lillard, a local janitor. While Palmer was not the first to practice manual thrusting, he was the first to use the bony projections, or processes, of the vertebrae (specifically, the spinous and transverse processes) as levers for the manual contact.
Within 2 years of this initial discovery, Palmer had founded his Chiropractic School and Cure, while at the same time developing the concept of subluxation, a type of partial joint dislocation, as a causal factor in disease. For these reasons, D.D. Palmer is known as the Founder.
~By 1902, Palmer's son Bartlett Joshua (B.J.) had enrolled in his father's school; he gained operational control by late 1904, and by 1906, D.D. Palmer was no longer associated with the college he had founded. The year 1906 also saw the development of the schism that still exists in the profession today; several faculty members, including John Howard, left Palmer College because of deep differences with B.J. Palmer (who came to be known as the Developer) over the role of subluxation in disease. By that time, B.J. was espousing subluxation as the cause of all disease; John Howard, however, saw a need for what he considered to be a more rational alternative to such thinking and focused his new National School of Chiropractic around a broad-based educational program incorporating basic and clinical sciences, laboratory work, dissection, and clinical care (Beideman, 1983).
From 1910 to 1920, many other chiropractic colleges came into existence; some followed the lead of B.J. Palmer in a "straight" form of chiropractic, while others followed the lead of Howard in developing "mixer" programs. The development of the profession could not have occurred without the missionary zeal of B.J. Palmer, who led his namesake college for 54 years. But others helped to advance the profession as well, including Carl Cleveland, Earl Homewood, Fred Illi, Joseph Janse, Herbert Lee, and Claude Watkins.
What these innovators did--in addition to all their educational and scientific advancements--was to place disease in a different context involving the concept of subluxation (Bergmann et al., 1993). Some factors are common to chiropractic and allopathic medicine. Both recognize the existence of bacteria and other "germs" and their role in creating disease; both mandate that a susceptible host be present along with the germ. Both also accept that the host's susceptibility depends on many factors. But only in the chiropractic model is the presence of subluxation stressed as an important factor; the contention of chiropractic is that since the subluxation can serve as a noxious irritant to the body, its removal becomes critical for restoring optimal health.
Chiropractors are responsible for the development and refinement of manual therapies, particularly those known as high velocity, short amplitude. Within the purview of these therapies, many systems have been developed concerning how to apply the various procedures. Examples include:~ • sacrooccipital technique, originally developed by Major B. De Jarnette;
• activator technique, developed and advanced by Arlan Fuhr;
• diversified technique, which comes from many sources--including manual medicine (physician John Mennell), and various chiropractors, including Arnold Hauser and Joseph Janse--and which was developed largely in the National College of Chiropractic;
• Thompson terminal point technique, developed by J. Clay Thompson;
• flexion-distraction technique, developed from original osteopathic concepts by James Cox (this is not a traditional thrusting procedure);
• Gonstead technique, developed by Clarence Gonstead; and
• applied kinesiology, developed by George Goodheart.~This list is by no means exhaustive; other innovators include L. John Fay, Henri Gillet, and John Grostic.
Today's common chiropractic procedures are refinements of systems developed during the past half-century, both in diagnosis (the motion palpation of Fay and Gillet, for example [Gillet and Liekens, 1984; Schaefer and Fay, 1989]) and in therapy.
Today chiropractic procedures are being examined by researchers from most of the chiropractic colleges, who also are receiving input from field-based chiropractors. Standards of care are being determined by coalitions of chiropractors, including practitioners, academics, researchers, and administrators. One group has already produced a set of guidelines called the Mercy Conference guidelines (Haldeman et al., 1992).
In reaching their decisions concerning practice parameters and standards of care, the various groups of chiropractors have been participating in consensus-development procedures (Hansen et al., 1992).~Demographics. In 1993 more than 45,000 licensed chiropractors were practicing in the United States alone. Licensing occurs in every State in the Union as well as in many foreign countries. Chiropractors provide various aspects of health care but cannot use surgery or drugs; they have several specialty areas, such as radiology, orthopedics, neurology, and sports medicine. Seventeen American chiropractic colleges graduate more than 2,000 chiropractors annually; colleges also exist in Canada, Australia, England, France, and Japan. Some other foreign countries are considering them (e.g., South Africa, Italy, and Germany). Chiropractors currently see 12 percent to 15 percent of the U.S. population, and most professionals practice in private office settings, usually solo.
Most chiropractic physicians incorporate structural diagnosis into their practice and use manual adjusting therapies as their main treatment mode. Today, most third-party payers accept chiropractic services, though they did not always. Increased chiropractic research has helped to allay the reluctance of insurance companies toward chiropractic, and the recent development of professional standards of care has opened new avenues for chiropractic coverage.~Chiropractic education. Today's chiropractic educational program is a 5-year curriculum that emphasizes chiropractic philosophy, basic and clinical science, and clinical care in outpatient settings. Standard forms of medical diagnosis are heavily detailed, with additional workloads in structural and functional diagnosis and chiropractic technique. All chiropractic colleges require at least 2 years of college education prior to matriculation, as well as a series of courses (e.g., chemistry, physics) meeting criteria set by the Council of Chiropractic Education (CCE).
Manual therapies include any procedure during which the hands are used to palpate, diagnose, mobilize, adjust, or manipulate the somatic or visceral structures of the body. There are two broad groups--joint manipulation procedures and soft-tissue manipulation procedures. Adjustments are the most commonly applied chiropractic therapy within either group. The most common forms of adjustment taught in chiropractic colleges are the diversified, Gonstead, activator, and sacrooccipital techniques.
Today CCE accredits chiropractic colleges on the professional level, while regional ~accreditation also occurs. All CCE-accredited colleges teach a comprehensive program that incorporates elements of basic science (physiology, anatomy, and biochemistry); clinical science (such as laboratory diagnosis, radiology, orthopedics, and nutrition); and clinical experience (e.g., patient management in the clinical setting). In addition, the profession offers postdoctoral training in a wide range of disciplines, with orthopedics and radiology the most popular. In this country, some hospital training has recently become available to chiropractic students and residents; such training has been available in Canada since 1975.
Research base. The chiropractic profession has performed rigorous research since its early days. However, at least in one sense, the research within the profession is still very much in its infancy, because the profession "lost" much of its early work for lack of an appropriate forum in which to publish it. Today the Journal of Manipulative and Physiological Therapeutics is the sole chiropractic research publication indexed in Index Medicus, Current Contents, BIOSIS, and Excerpta Medica. However, other journals such as Spine, which is indexed in the major medical data bases, do public chiropractic-related research.
~Current chiropractic research interests include back and other pain, somatovisceral disorders, and reliability studies.
Back and other pain. Recent emphasis in research trials has been on manipulation and back pain, manipulation and various organic disturbances, and reliability and validity. In 1984, Brunarski identified 50 trials of spinal manipulation (Brunarski, 1985); the number has increased since then. Studies by Bergquist-Ullman and Larsson (1977), Godfrey et al. (1984), Hadler et al. (1987), Mathews et al. (1987), and Waagen et al. (1986) were all important in establishing a definitive role for manipulation in the management of low back pain. The argument for including chiropractic in British National Health Service coverage was based on recent work by Meade et al. (1990), comparing chiropractic care to hospital outpatient care. The research of Koes (1992) served a similar role in the Netherlands. Further, the RAND report (cited in Haldeman et al., 1992), a recent and large undertaking examining all published literature on the use of manipulation for low back pain, made definitive comments regarding its use in specific situations.
~The RAND report found that manipulation was effective in the following five situations: (1) acute low back pain without evidence of neurological involvement or sciatic nerve irritation; (2) acute low back pain with sciatic nerve irritation; (3) acute low back pain with minor neurological findings and sciatic nerve root irritation (although there was some conflicting evidence); (4) subacute low back pain with no evidence of neurological involvement or sciatic irritation; and (5) subacute low back pain with minor neurological findings and major neurological findings. In other situations, the literature was found to present too many conflicts to determine effectiveness of manipulation.
Besides these trials, research has examined patient perceptual issues in the use of chiropractic care. Notable here is the research of Cherkin and MacCornack (1989), who reported that patients seeing chiropractors for low back pain were happier with the treatment they received than were similar patients seeing medical doctors for similar problems.
Studies examining manipulation for pain other than low back pain include work of Barker ~(1983) on thoracic pain; Molea et al. (1987) on postexercise muscle soreness; Terrett and Vernon (1984) on paraspinal cutaneous pain tolerance; Vernon (1982) on headache; Jirout (1985) on C2-C3 vertebral dysfunction; and Parker et al. (1978) on migraine.
Somatovisceral disorders. One area that is gaining in research interest is the type O disorder (O for organic, as opposed to M for musculoskeletal). Much of the early impetus for studies of type O disorders came from osteopathic research examining somatic dysfunction. Examples of this work include studies by Johnston et al. (1985) and Vorro and Johnston (1987) using kinematic and electromyographic instrumentation to investigate clinical signs of somatic dysfunction. Johnston developed a way to detect "mirror image asymmetries," a presumed indicator of the presence of somatic dysfunction (the osteopathic spinal lesion). He laid out palpatory procedures to look for these asymmetries and later refined his concepts in a series of three papers (Johnston, 1988a, 1988b, 1988c) discussing palpatory diagnosis.
Studies that have examined manipulation in treating hypertension include work of Fichera ~and Celander (1969), Morgan et al. (1985), and Plaugher and Bachman (1994). All of these studies demonstrated changes in blood pressure following spinal manipulation, but the changes were relatively transient. Kokjohn et al. (1992) examined manipulation to treat dysmenorrhea.
Reliability studies. Clinical trials are simply not possible unless their assessment procedures have themselves been tested and found reliable. A procedure is said to be reliable if it gives similar results when applied more than once to the same object it is measuring or when it gives similar results when applied to a series of objects with similar qualities. (See also the "Research Methodologies" chapter.) Reliability tests within chiropractic are commonly used to evaluate specific diagnostic procedures, such as motion palpation.
Motion palpation (examination for presence or absence of joint play) was first advanced by Gillet and Fay as a diagnostic procedure; it has since become a well-studied, common diagnostic procedure. Gonnella et al. (1982) used a seven-point scale to evaluate interexaminer and intraexaminer reliability, while Boline et al. (1988), Love and Brodeur ~(1987), Mior et al. (1985), Mootz et al. (1989), Nansel et al. (1989), and Wiles (1980) examined simple reproducibility. Beattie et al. (1987) studied the attraction method of measuring motion, and Lovell et al. (1989) used a flexible ruler to assess lumbar lordosis (spinal curvature, such as swayback).
Besides doing clinical studies of various chiropractic procedures, Haas (Haas, 1991; Haas et al., 1993) has made several important additions to reliability literature, even going so far as to study the reliability of reliability. Lawrence (1985) published a critique of reliability studies for measuring leg length, and Frymoyer et al. (1986) have looked at radiographic interpretation. (This list is by no means all-inclusive.)
The research described above has been accomplished largely without any Federal funding. The largest funding agency in the chiropractic profession is the Foundation for Chiropractic Education and Research, which generally has an annual research budget well below $1 million. Chiropractors have made an impressive addition to scientific knowledge despite the lack of encouragement and support by government agencies and medical personnel outside ~the chiropractic profession.
Barriers and key issues. Several barriers and key issues need to be addressed so that chiropractic research can progress:
• Lack of access to Federal funds has negatively affected the chiropractic research enterprise. Ways must be found to make funds available for chiropractic research through the various agencies. To date, no chiropractic research has been funded by NIH, although several approved studies later failed to meet funding cutoff guidelines. A Small Business Administration innovative research grant funded one study. One approach to alleviating this situation is through the workshops the Office of Alternative Medicine (OAM) is conducting on grant writing and research design. OAM's ability to fund small-scale projects is also a help. If research resources could be increased, much more could be accomplished.
• Lack of access to previous chiropractic research through indexing and databases also hampers research. As mentioned earlier, only a single solely chiropractic research ~publication is internationally indexed. (The Journal of Manipulative and Physiological Therapeutics is indexed in the former Soviet Union as well as in the Western publications previously cited.) Because other chiropractic research journals are unlikely to gain the status of indexing in a conventional database, it is necessary to consider including chiropractic research in an alternative medicine database. Meanwhile, the inclusion of CHIROLARS (Chiropractic Literature and Retrieval System) in BRS Colleague as a sub-database may help to make chiropractic literature more accessible. (For information about research databases see the "Research Databases" chapter.)
• Philosophical differences (the straight-vs.-mixer controversy) continue to split the profession without any obvious solution. Unification is a goal that may still be years away.
• Inclusion of chiropractic in any of the proposed reforms of the health care system, such as those proposed by the Clinton administration, is not assured. It may be that the decision whether to include chiropractic in a national health care plan will be driven by congressional action. Major efforts are already under way to make contact with politicians regarding this ~issue, and chiropractic input was provided to the President's Health Care Task Force.
New avenues for the chiropractic profession have become available as a result of the decision against "biomedicine's" restraint of trade in the 1991 judgment rendered in Wilk et al. v. the American Medical Association (AMA) (see the "Introduction"). While it is likely to take many years to overcome the AMA's history of opposition to chiropractic, continuing quality research and patient care will negate this opposition. The current processes by which chiropractors are reviewing standards of care and chiropractic procedures should help solidify the public standing of this field.
The qigong longevity or health exercises are a fairly recent addition to alternative health practices in the United States. Qigong exercises are similar in appearance to tijijuan (tai chi chuan), a rhythmical nonaerobic form of exercise; however, this appearance is only superficial. Qigong movement exercises do not flow from one position to another as in tai ~chi; they are done in shorter movement groups that are repeated many times. This, however, is not the essence of the practice, but only the visible form.
Qigong exercises combine repetitions of coordinated physical motions with mental concentration and directive efforts to move the qi in the body. During these exercises, which are based on slow, repetitive movements of the arms, legs, and torso, the exerciser's mind is focused on moving the qi (biofield flux) through the meridian pathways and nonmeridian pathways that were developed by the ancient Taoist (Daoist) sages.
This mental effort is coordinated with specific movements; for example, qi may be directed up the back as the arms are raised and down the front as the arms are lowered. Large amounts of internal qi are said to be developed in the process. It is estimated that there are more than 100 different forms of qigong health exercises. There are considerable differences in the styles, but all consider the mental effort to be crucial. Qigong exercises are used daily for health improvement by several million Chinese, both in the People's Republic and in Chinese communities throughout Southeast Asia.~Qigong exercises are also used by qigong masters (see the "Biofield Therapeutics" section) to increase the quantity of qi available for healing; some use it in various forms of martial arts such as gongfu (kung fu).
In China, qigong exercises have been under study for their long-term effects on a number of medical conditions, such as cancer and arthritis, and for their effects on general health. More than 32 studies were recently presented at just one major conference on the effects on general and specific states of health of exercises enhancing qigong qi (Proceedings, 1988).
Several schools and organizations in this country focus entirely on these practices. The principal ones are China Advocates, the Chinese National Chi Kung Institute, the Qigong Academy, and the Qigong Institute. The practice of qigong is gaining in popularity in the United States, both with Asians and non-Asians.
~Craniosacral therapy is a gentle, hands-on treatment method that focuses on alleviating restrictions to physiological motion of all the bones of the skull, including the face and mouth, as well as the vertebral column, sacrum, coccyx, and pelvis. Concurrently, the craniosacral therapist focuses as well on normalizing abnormal tensions and stresses in the meningeal membrane, with special attention to the outermost membrane, the dura mater, and its fascial connections. Attention is also paid to alleviating any obstacles to free movement by the cerebrospinal fluid within its membrane compartment and to normalizing and balancing perceived related energy fields. This approach is derived from experiments of John Upledger, an osteopathic physician and researcher (for example, see Upledger, 1977a and 1977b, which are discussed below).
As usually practiced, this therapy is a noninvasive treatment process that requires an uninterrupted treatment session of at least 30 minutes; often the session is extended beyond an hour. Practitioners indicate that successful treatment relies largely on the therapist's ability to facilitate the patient's own self-corrective processes within the craniosacral system. Postgraduate training in craniosacral therapy has been undertaken by a wide variety of ~physicians, dentists, and therapists. In the United States during 1993, 2,738 health care professionals completed the Upledger Institute's introductory-level workshop and seminar; 1,827 received training at the intermediate level, and 80 completed the advanced level. Training outside this country is available through the Upledger Institute Europe in the Netherlands and on a smaller scale in Japan, New Zealand, France, and Norway by American Upledger Institute teachers.
The most powerful effects of craniosacral therapy are considered to be on the function of the central nervous system, the immune system, the endocrine system, and the visceral organs via the autonomic nervous system. This therapy has been used with reported success in many cases of brain and spinal cord dysfunction. Although these successes have not been documented in formal studies, they have been observed subjectively or anecdotally by both patients and therapists. Most prominent among these success reports are cases of brain injury resulting in symptoms of spastic paralysis and seizure. Other areas of claimed success include cerebral palsy, learning disabilities, seizure disorders, depressive reactions, menstrual dysfunction, motor dysfunction, strabismus (a vision disorder), temporomandibular joint ~problems, various headaches, chronic pain problems, and chronic fatigue syndrome.
Research on tissues has documented the potential for movement between skull bones in adult humans, and pilot work with live primates has shown rhythmical movement of their skull bones. Interrater reliability studies, which look for correlations in the observations of two or more independent raters (see the "Osteopathic Medicine" section), have shown agreement between "blinded" therapists evaluating preschool-aged children ("blinding" means that the therapists making the observations did not know which children had received craniosacral therapy, nor did they know the history or problems of the children) (Upledger, 1977a). Controlled studies have shown high correlation between schoolchildren with various brain dysfunctions and specific dysfunctions of the craniosacral system; that is, the craniosacral exam scores correlated with recorded school teacher and psychologist opinions of "not normal," behavioral problems, motor coordination problems, learning disabilities, and obstetrical complications (Upledger, 1977b). Moreover, Upledger reports that a few pilot studies by dentists have demonstrated significant changes in the transverse dimension of the hard palate as well as in occlusion in response to craniosacral therapy.~At present, work is under way that appears to demonstrate fluctuations in what are called energy measurements in circuits between craniosacral therapists and patients. The circuits are established by attaching electrodes to the patient and the therapist with an ohmmeter and a voltmeter interposed in the circuits. In observations with 22 patients, measurements have ranged from more than 30 million ohms at the start of a treatment session to 448 ohms with a brain-injured child; voltages have fluctuated between 10 and 254 millivolts. Upledger's interpretation is that the elevation in resistances read with the ohmmeter correlate with the palpable resistances that craniosacral therapists feel with their hands and that the energy put into overcoming these resistances is reflected by elevations in the millivolt readings. On the basis of these preliminary studies, plans are under way to explore further whether the energetic changes measured in the circuits accompany specific landmarks in treatment processes.