Samuel Homola. Inside chiropractic: a patient’s guide. Prometheus Books, 1999.
Pros: relentlessly rational, reasonable and compelling, with fascinating anecdotes about some questionable practices in the chiropractic profession.
Cons: possibly throws the baby out with the bathwater here and there, but nothing serious.
This book review praises a book that criticizes chiropractic, and in so doing I imply criticism of the chiropractic profession. However, I do not believe that all chiropractors are “bad,” and this review expresses only my opinion, based on my own professional experience, training, and interpretation of the evidence.
On with the review
Many chiropractors do not like Samuel Homola. He is a chiropractic Judas, a thorn deep in the side of old-school chiropractors. As Homola has written, “The chiropractic profession has little tolerance for dissension.” But as much as he has irritated some chiropractors, he must be something of a inspiration to others, as he is to me. I aspire to be as rational, as knowledgeable, as determined to speak the truth as Homola seems to be. Both Homola and his co-author, Dr. Stephen Barrett, are amazingly educated, competent, and accomplished people.
My own profession often disappoints me in the same way that Homola is disappointed in his. I was in a massage therapy office recently that had Scientology posters on the walls, and a large collection of crystals. One of my colleagues serious suggested that I should seek the assistance of an expensive psychic for a minor hand pain problem. One of my patients, a teenaged girl, told me how a massage therapist had “interviewed her stomach” at great length, telling her that it was necessary to “ask her organs” why she was feeling badly!
These were all government-certified health care professionals. I will let you draw your own conclusions from such observations.
I was in a massage therapy office recently that had Scientology posters on the walls.
Homola argues that a significant percentage of chiropractors have difficulty thinking critically about their own profession. Not only do such chiropractors offer up a wide variety of therapies of questionable value, they do it with a hard-selling style that has earned them more critics than my own relatively inoffensive profession (we massage therapists are infamously mild-mannered). And so, although perhaps I could write a book questioning scientifically unsupportable practices in my own profession, it would never be as interesting as Dr. Homola’s book: chiropractors offer more controversial services, and they do it in a more “interesting” way.
Homola rationally and thoroughly questions and challenges the rationale for chiropractic methods. He does this in language suitable for curious patients, including a lot of colourful historical narrative detail that adds pleasure to reading the book, including several passages that are likely to cause readers to make amazed noises or read excerpts out loud to anyone willing to listen — the history of chiropractic is colourful.
Something for everyone
Although clearly writing a guide for patients, Dr. Homola also goes into enough detail to satisfy health care professionals as well. Most of the services traditionally offered by chiropractors are so competently deconstructed that any reader will be left with doubts about their value.
For instance, he reviews an anatomical study of a spine that graphically demonstrates that it is actually physically impossible to “pinch” nerve roots in the way that chiropractors claim — the pictures and description are highly persuasive. Homola clearly believes and shows that the chiropractic profession has failed to prove beyond a reasonable doubt that the therapy provides the benefits they have claimed to offer.
There is one notable exception in this torrent of criticism …
A little credit where credit is due
Homola gives credit where it is due, defending the appropriate use of chiropractic adjustments (spinal manipulative therapy) to treat certain kinds of spinal and joint pain. He proposes that this is the kind of chiropractic care that should define (and limit) the profession: the responsible, scientific chiropractor should be a spine care specialist, treating neck and back pain (and possibly some other joint problems) almost exclusively, and routinely referring patients to doctors and other specialists rather than claiming to treat virtually any condition, as some chiropractors do now.
Other than this one positive note, however, the book enumerates several things that chiropractors believe, practice, and sell that raised my eyebrows. Consider this example:
Following manipulation the patient said, “Oh, that was awful, something terrible has happened to me. That’s awful. Let me up. I don’t want anymore; I can’t stand anymore.” The chiropractor then said “you will be all right. Let me get this other one.” The patient then said “I have had enough, don’t, stop.” The chiropractor continued to manipulate the patient. Immediately following the adjustment she was unable to walk, her vision was impaired, she vomited, and she had a partial paralysis of the throat and vocal cords.
Vertebrobasilar stroke following manipulation, by A Terrett
Oh, dear. The book is full of similar examples. Of course it’s possible to dredge up awful examples of the behaviour of any kind of health care professional — just today I heard a story in the news about a physician who threw a cancer patients’ files at her when she asked to see them. But Homola effectively argues that stories like this are too common, and essentially an inevitable by-product of the “culture” of chiropractic.
A missed opportunity
Is Homola just a little too cynical at times? Maybe. He is absolutely correct to criticize, but he may have thrown a little bit of baby out with the bathwater. This is a public relations mistake that many hardened skeptics make — including myself. We are so focused on emphasizing what science knows that we sometimes make it seem like science is a done deal, an unassailable and complete body of knowledge … which of course it is not. In fact we are living in a golden age of musculoskeletal research, with a steady flow of interesting new scientific discoveries that are overturning conventional wisdom about injury healing, soft tissue dysfunction, pain syndromes, back pain, and much more.
And yet it was also Homola’s strong skeptical attitude that was one of the most important factors in my own education as a critical thinker. His presentation of the evidence was a revelation to me. Mired in the world of alt-med, I’d never really seen that kind of rigorous criticism before. I was just starting to write that way myself back then, clumsily cherry picking the evidence to make my points, and then along comes Dr. Homola and he’s doing it right: a strong critical analysis of the central claims of chiropractic. It might turn off many readers, but it certainly worked on me. And now, years later, I’m out there trying to do the same for my colleagues, and I get mail more or less constantly from massage therapists around the world who are telling me, “Hey, wow, I didn’t know anyone else thought that was bogus too!”
Three examples of revising what is “known” about pain problems: (1) The understanding of knee problems as “structural” is under siege as new evidence rolls in every day that tissue homeostasis is what really matters; (2) a litany of medical back pain myths, still so prevalent in the 80s and 90s, finally seems to be fading away, thanks to the research and educational efforts of prominent medical experts like Drs. Nikolai Bogduk and Richard Deyo; (3) exotic pain conditions like fibromyalgia and complex regional pain syndrome, misunderstood to the point of denying their existence just twenty years ago, are now reasonably well described, and have major implications for our understanding of many other pain problems.
I think Homola is probably fully aware of this and simply didn’t choose to write about it, but I think it was a missed opportunity. Some the facts that he holds up as examples of evidence-based treatments are themselves a bit out-of-date and could be questioned: some previously mainstream therapies have turned out not to be based on strong evidence at all, and some will turn out to be quite wrong as research advances, and many readers will know this (or suspect it), and the book appears weaker to critics as a result. With a little more elbow grease, Homola could have done a better job of showcasing scientific thinking, emphasizing that it is a dynamic “work in progress” with exciting potential not only to debunk alternative therapies, but also to debunk many mainstream therapies … and to ultimately validate a few emerging approaches to therapy.
Fortunately, it isn’t necessary for science to “know everything” before we can judge the efficacy of the treatment that chiropractors do, any more than we have to know everything to know that the world isn’t flat.
Nevertheless, essential reading
Homola’s book is an essential patient guide. If you feel the need for chiropractic adjustment, but want to be able to spot questionable chiropractic methods, please read this book!