Constructing a philosophy of chiropractic: evolving worldviews and postmodern core()

Defining chiropractic professional identity: A concept analysis

BACKGROUND

The concept of professional identity within chiropractic is often discussed and debated, however in the field to date, there is no formal definition of chiropractic professional identity (CPI). This article aims to create a coherent definition of CPI and to formalise the conceptual domains that may encompass it.

METHODS

Using the Walker and Avant (2005) process, a concept analysis methodology was employed to clarify the diffuse concept of CPI. This method initially involved selecting the concept (CPI), determining the aims and purpose of the analysis, identifying concept uses, and defining attributes. This was achieved from a critical literature review of professional identity across health disciplines. Chiropractic-related model, borderline and contrary cases were used to exemplify characteristics of CPI. The antecedents required to inform CPI, consequences of having, and ways to measure the concept of CPI were evaluated.

RESULTS

From the concept analysis data, CPI was found to encompass six broad attributes or domains: knowledge and understanding of professional ethics and standards of practice, chiropractic history, practice philosophy and motivations, the roles and expertise of a chiropractor, professional pride and attitude, and professional engagement and interaction behaviours. These domains were not mutually exclusive and may overlap.

CONCLUSION

A conceptual definition of CPI may bring together members and groups within the profession and promote intra-professional understanding across other disciplines. The CPI definition derived from this concept analysis is: 'A chiropractor's self-perception and ownership of their practice philosophies, roles and functions, and their pride, engagement, and knowledge of their profession'.

The Conatus Doctrine: A Rational Interpretation of Innate Intelligence

OBJECTIVE

The objective of this article is to reinterpret metaphysical concepts found in chiropractic historic teachings by comparing these to the philosophical system of Baruch Spinoza.

DISCUSSION

Universal intelligence and innate intelligence are components of the historic and traditional philosophy of chiropractic. These concepts have offered a unique clinical perspective at the cost of committing to an a priori assumption that some see as untenable. The meaning of universal and innate intelligence may be reinterpreted through an understanding of life and health as offered by the conatus doctrine of Baruch Spinoza. The conatus doctrine defines within a formal system the striving and endurance of living beings to remain in unique forms. The reinterpretation offered in this article provides a rationally defensible concept closely tied to contemporary definitions of vitalism, which see life as potentiality striving against inertia and entropy. In its striving, life manifests itself by originating meaning out of information.

CONCLUSION

Though the product of early-modern rationalism, Spinoza's conatus doctrine offers a contemporary interpretation of an aspect of living beings congruent with established notions within the philosophy of chiropractic. Concepts in Spinoza's work that concern substance and monism offer clarifying perspectives on concepts in the philosophy of chiropractic that may help resolve conflicts concerning spiritualism and naturalism.

Reframing a debate in chiropractic

The chiropractic profession is 125 years old and has evolved a culture beset with internal conflict. The internal ructions have been particularly noticeable during the last 20 years. The recent resignation of the entire World Federation of Chiropractic Research Committee has again focussed the conflicting views and goals of the “wellness” and “evidence” factions within the profession. These polarising viewpoints are worsening to the degree that there are calls for the profession to break into two separate entities. Key to the recognition of the differences within the profession is the recognition of title for particular sub populations of patients presenting to chiropractors. For many of the sub populations such as sport or paediatrics there has grown appropriate post professional specialist educational training sometimes leading to a protected title. However, this is not occurring in that group of practitioners that choose to focus on wellness care. A recommendation is made that wellness chiropractic be viewed as a post professional specialty program within chiropractic, as it is in medicine and elsewhere, and that recognition follow after appropriate post professional educational programs have been completed, as is customary in the other special interest groups. In order to do so, consensus will be required from all stakeholders within the profession on the level, scope and depth of such programs. Furthermore, it is possible that different jurisdictions around the world may require different post graduate educational levels based on local competitive, legal and professional circumstances. In such cases, transitioning to the higher level over a period of time may be undertaken. Recognition of the wellness specialty by the profession would allow for vertical integration with other healthcare providers as well as help bridge a gap between the entrepreneur and academic groups that would be responsible for creating these programs at tertiary education institutions. Finally, should these programs acquire evidence to underpin them, a process that would be taught within the programs, it is likely that recognition of an extended scope of practice would occur increasing the appeal of chiropractic to the public.

A Vitalism Ethos and the Chiropractic Health Care Paradigm

OBJECTIVE

The purposes of this article are to describe the development of vitalism from its earliest Hellenistic form to that of a contemporary vitalism ethos and to propose the importance of vitalism in the philosophy of chiropractic and the chiropractic health care paradigm.

DISCUSSION

A review of the history of vitalism is offered to clarify the use of the term within the chiropractic literature and to provide a defensible position for vitalism as a foundation for future research in the philosophy of chiropractic. The founder of chiropractic, Daniel David Palmer, drew heavily from spiritualism and vitalism in his construction of early chiropractic philosophy. As chiropractic practice and philosophy have evolved, that vitalistic foundation has become a polemic used by factions within the profession, resulting in political challenges. The controversy within chiropractic mirrors similar debates within academic philosophy regarding vitalism. The philosophy of vitalism has developed beyond its classical constructs, emerging as an ethos amenable to informing research within clinical applications and a perspective capable of informing the identity of chiropractic.

CONCLUSION

Exploring the broad historical context of vitalism may allow for an understanding of the plurality of vitalist ideas and a clarification of the concept within chiropractic literature. Adopting vitalism within the philosophy of chiropractic as an ethos based on the work of Georges Canguilhem provides a view of life as fundamentally original, adaptable, and unpredictable, and therefore not sufficiently understood in purely reductionist terms.

Moving towards a contemporary chiropractic professional identity

Since the inception of the chiropractic profession, debate has continued on differing practice objectives and philosophical approaches to patient care. While the political and academic leaders of the profession continue to dominate the discourse, little is known on the perspectives of the everyday practising chiropractor on their professional identity. In this paper, professional identity within the profession of chiropractic was evaluated using a systematised search strategy of the literature from the year 2000 through to May 2019. Initially 562 articles were sourced, of which 24 met the criteria for review. The review confirmed three previously stated professional identity subgroups; two polarised approaches and a centrist or mixed view. The musculoskeletal biomedical approach is in contrast to the vertebral subluxation vitalistic practice approach. Whilst these three main chiropractic identity subtypes exist, within the literature the terminology used to describe them differs. Research aimed at categorising the chiropractic profession identity into exclusive subtypes found that at least 20% of chiropractors have an exclusive vertebral subluxation focus. However, deeper exploration of the literature shows that vertebral subluxation is an important practice consideration for up to 70% of chiropractors. Patient care with a musculoskeletal spine focus is dominant in clinical practice. This review found that practising chiropractors consider themselves to be primary care or primary contact practitioners with a broad scope of practice across a number of patient groups not limited to musculoskeletal management. Across the research, there is a marked difference in the categories of practice objectives evaluated, and future research could examine the relatedness of these. Additionally, future research could explore the professional identity construct over time and within different practice contexts to help facilitate the progression of the profession.

Doing the Same Thing and Expecting a Different Outcome: It Is Time for a Questioning Philosophy and Theory-Driven Chiropractic Research

OBJECTIVE

The purpose of this commentary is to discuss the philosophical and hypothetical underpinnings of chiropractic and consider whether there is a need for chiropractic to have a questioning philosophy and theory-driven process to guide future scientific endeavors in the profession.

DISCUSSION

The earliest beliefs of the chiropractic founders centered on chiropractic vertebral subluxation but differed on whether this was a static, bone-out-of-place misalignment or a lesion whereby joints had lost their normal direction or range of motion. More recently, new hypotheses such as dyskinesia, inflammation, and neuroplasticity attempt to explain the purported clinical effects of chiropractic. Yet practitioners and students advocate for both traditional viewpoints that typically tout misalignment and embrace a science of chiropractic. I propose that chiropractors should not have to choose between philosophy and science. Instead, they should advocate for adoption of a modern questioning philosophy that not only informs their clinical questions and drives their theories, but also that is in turn influenced by outcomes from their research. Such a questioning philosophy is in stark contrast with the dogma that some have mislabeled as "philosophy" in the profession. I recommend that a review of chiropractic hypotheses and a theory-driven research process is needed to help guide the profession's research agenda given its wide range of clinical activities and limited resources. As the chiropractic profession increasingly embraces evidence-informed practice, enhanced integration within the wider health care community may then result in further gains in utilization.

CONCLUSION

Theory-driven research that results from and subsequently informs a questioning philosophy may expose truths related to practice behaviors, activities, and outcomes, and spur more complete integration of chiropractic within the wider health care community.

Chiropractors' Perspectives on the Meaning and Assessment of Quality of Life Within Their Practice in New Zealand: An Exploratory Qualitative Study

OBJECTIVE

The purpose of this study was to gain an understanding on what quality of life (QOL) and its assessment means to chiropractors in everyday practice.

METHODS

This study captured chiropractors' perspectives on the QOL construct and its assessment using a qualitative descriptive methodology that comprised 2 focus groups, each with 4 participants using semi-structured, open-ended questioning. Participants from Aotearoa, New Zealand, were also asked to evaluate 4 QOL patient-reported outcome measurements from a clinical perspective.

RESULTS

Two of the participants were faculty at the New Zealand College of Chiropractic, 5 were in full-time practice, and 1 was practicing part time. Using qualitative content analysis, 3 main themes were identified. These chiropractors perceived that patients have misconceptions about how chiropractic can affect QOL. They lacked clarity in communicating QOL and its related concepts to establish a clinically meaningful patient encounter. Finally, there is uncertainty in how and when to measure QOL, which appears to affect how they discuss and assess QOL in practice.

CONCLUSION

There is a complex combination of factors that makes communication regarding QOL challenging. This exploratory qualitative study helps to understand the challenges faced in how and when to communicate and assess QOL more effectively in chiropractic practice.

Are personnel with a past history of mental disorders disproportionately vulnerable to the effects of deployment-related trauma? A cross-sectional study of Canadian military personnel

BACKGROUND

Past mental disorders predict future disorders, both in the presence and absence of trauma exposure. However, it is not clear whether those with past mental disorders are disproportionately vulnerable to the negative effects of a given level of trauma.

METHODS

The data source was the 2013 Canadian Forces Mental Health Survey (CFMHS), of which 1820 respondents had deployed only once in their military careers-all in support of the mission in Afghanistan. The primary outcomes were past 12-month depression and past 12-month PTSD. Multivariate logistic regression was performed for each outcome variable, looking primarily for differences in the marginal effect of deployment-related trauma in those with and without a pre-deployment history of each disorder.

RESULTS

A history of each pre-deployment disorder did indeed interact with deployment-related trauma with respect to the corresponding past 12-month disorder. In addition, pre-deployment history of depression and of PTSD interacted with each other, though only for the outcome of past 12-month PTSD. The average marginal effect of deployment-related trauma on past 12-month PTSD was highest in those with a pre-deployment history of depression in the absence of a pre-deployment history of PTSD. This group was twice as vulnerable to post-deployment PTSD relative to those without a pre-deployment history of both disorders and four times as vulnerable to post-deployment PTSD relative to those with a pre-deployment history of both disorders. No significant differences were seen in the marginal effects of trauma on past 12-month depression in the presence or absence of a pre-deployment history of that disorder.

CONCLUSION

There is modest differential vulnerability to past 12-month PTSD as a function of deployment-related trauma in those who had a pre-deployment history of PTSD or depression when compared to those who did and did not have a pre-deployment history of one or both disorders.

The Chiropractic Vertebral Subluxation Part 5: The First Research Era From 1928 to 1949

OBJECTIVE

The purpose of this paper is to review and discuss the history of chiropractic vertebral subluxation theories between 1928 and 1949.

DISCUSSION

Theories during this period grew in complexity and developed in 4 primary ways: upper cervical models, reflex models, global models, and models based on the work of Speransky. Authors, theorists, and technique developers during this time included B. J. Palmer, R. J. Watkins, Galen Price, John Hurley, Hugh Logan, Major Bertrand DeJarnette, Richard Van Rumpt, Roy Ashton, Joseph Janse, Henri Gillet, James Firth, and J. R. Verner. At least 8 perspectives on chiropractic vertebral subluxation were advanced through research, modeling, and applied clinical methods. By understanding the complexity of this period and analyzing the research, the modern practitioner will be able to appreciate this era. The foundations of modern clinical practice and theoretical applications have roots in this period.

CONCLUSION

Theories during this period developed in levels of complexity, expanding existing models and clinical practice methods. The theories and research from this period had an effect on the chiropractic profession for the subsequent decades.

The Chiropractic Vertebral Subluxation Part 3: Complexity and Identity From 1908 to 1915

OBJECTIVE

The purpose of this paper is to review and discuss the history of chiropractic vertebral subluxation (CVS) between 1908 and 1915.

DISCUSSION

Evidence from the works of Daniel D. Palmer, Bartlett J. Palmer, Joy Loban, Willard Carver, James Firth, Alva Gregory, John Howard, Arthur Forster, and Harold Swanberg demonstrates that chiropractic during this period was characterized by increasingly complex theories of CVS, which contributed to defining the profession. Critiques of CVS as a central identifier of the profession begin with this early period when students of D. D. Palmer's early graduates became school leaders and theorists. Textbooks were self-published during this period, including D. D. Palmer's final works, 4 books from his son B. J. Palmer, and texts from their students. Chiropractic graduates of subsequent schools also contributed to emerging writings and concepts. Chiropractic vertebral subluxation was central to nearly all texts and schools. There was disagreement about what defined chiropractic, and various schools taught different practices. However, the theories from this period had an important role in the evolution of thought in the profession.

CONCLUSION

Theories presented from 1908 through 1915 built upon previous concepts from earlier years of chiropractic. The plethora of books and ideas about CVS from these early pioneers shaped the profession, and some of these viewpoints still have relevance today.

The Chiropractic Vertebral Subluxation Part 4: New Perspectives and Theorists From 1916 to 1927

OBJECTIVE

The purpose of this paper is to review and discuss the history of chiropractic vertebral subluxation (CVS) between the years 1916 and 1927.

DISCUSSION

Theories during this period were shaped by many chiropractic school leaders and instructors. Unique contributions to theories during this period come primarily from 4 authors, John Craven, Jim Drain, Shelby Riley, and Ralph Stephenson. This period included the first thermographic instrumentation in chiropractic, which led to one of Craven's modifications of CVS theory. He also added to the literature about spinal cord pressure and developed the restoration cycle. Drain and Stephenson also expanded on the cord pressure models of CVS. Drain wrote, in plain language, of many central B. J. Palmer theories and developed protocols for acute and chronic CVS. Stephenson made several contributions to models, including his expansion on B. J. Palmer's theory of momentum of dis-ease. Stephenson's main contribution to theory was likely his vertemere cycle, which was a precursor to proprioceptive models. Riley's combination of Gregory's theories with zone therapy had a significant impact on several reflex theories.

CONCLUSION

Chiropractic vertebral subluxation theory during this period grew in complexity and demonstrated several new perspectives on CVS, which may be still relevant today.

The Chiropractic Vertebral Subluxation Part 1: Introduction

OBJECTIVE

The objective of this article is to present a rationale for the need of a history of chiropractic vertebral subluxation (CVS) theory based on primary sources.

DISCUSSION

There is a dichotomy in the chiropractic profession around subluxation terminology, which has many facets. The literature around this topic spans social, economic, cultural, and scientific questions. By developing a rationale for a historical perspective of CVS theory, including the tracking of the historical development of ideas throughout the profession, a foundation for future discourse may emerge.

CONCLUSIONS

By using primary sources, ideas in chiropractic on the development of CVS theory are proposed. This introduction presents a basis for the need of a history of CVS theory and suggests how this work may be used to further philosophical dialogs in chiropractic.

Tone as a health concept: An analysis

STUDY DESIGN

Concept analysis.

INTRODUCTION

This paper is a report on the analysis of the concept of tone in chiropractic.

PURPOSE

The purpose of this paper is to clarify the concept of tone as originally understood by Daniel David Palmer from 1895 to 1914 and to monitor its evolution over time.

METHODS

Data was sourced from Palmer's original work, published between 1895 and 1914. A literature search from 1980 to 2016 was also performed on the online databases CINHAL, PubMed and Scopus with key terms including 'tone', 'chiropractic', 'Palmer', 'vitalism', 'health', 'homeostasis', 'holism' and 'wellness'. Finally hand-searches were conducted through chiropractic books and professional literature from 1906 to 1980 for any references to 'tone'. Rodgers' evolutionary method of analysis was used to categorise the data in relation to the surrogates, attributes, references, antecedents and consequences of tone.

RESULTS

A total of 49 references were found: five from publications by Palmer; three from the database searches, and; the remaining 41 from professional books, trade journals and websites.

MAJOR CONCLUSIONS

There is no clear interpretation of tone in the contemporary chiropractic literature. Tone is closely aligned with functional neurology and can be understood as an interface between the metaphysical and the biomedical. Using the concept of tone as a foundation for practice could strengthen the identity of the chiropractic profession.

Professional Identity at Los Angeles College of Chiropractic

OBJECTIVE

The objective of this article is to describe chiropractic professional identity as espoused by the Los Angeles College of Chiropractic.

DISCUSSION

Professional identity is a construct that begins formation prior to career selection, can be considered the backbone of health care education, and has been linked to career success. Los Angeles College of Chiropractic's professional identity is shaped by a philosophy of health care that is focused on vitalism, holism, naturalism, therapeutic conservatism, critical rationalism, phenomenology, humanism, and interprofessionalism. Other distinguishing aspects include portal-of-entry professionals with broad diagnostic skills; a focus on spine care; promotion of public-health; and delivery of manual treatments.

CONCLUSION

The chiropractic professional identity at the Los Angeles College of Chiropractic focuses on serving the needs of the people who entrust their health to its graduates and will continue to evolve on the basis of many factors, such as politics, social perceptions, and economic conditions.

Chiropractic professionalization and accreditation: an exploration of the history of conflict between worldviews through the lens of developmental structuralism

OBJECTIVE

The purpose of this commentary is to describe the conflicts in the history of chiropractic's professionalization and conflict through the path of increasing educational standards and accreditation using the lens of developmental structuralism.

DISCUSSION

Within the story of chiropractic's professionalization and accreditation lie the battles between competing worldviews. Gibbons proposed 4 periods of chiropractic's educational history; this article proposes a fifth period along with a new methodological approach to explore the complexity of chiropractic's history. The methodology draws upon constructive developmental psychology and proposes 5 levels of thinking common to the individuals from chiropractic's history. By using a psychological framework to analyze historical events, it appears that the battle within chiropractic education continues at present. Several important issues are explored: the Council on Chiropractic Education's origins in the medical paradigm and rational thinking, the pre-rational, rational, and post-rational critics of the Council on Chiropractic Education, the schools of thought that were reified or emerged from the history, as well as the more recent legal, economic, and social pressures, which helped to shape chiropractic's accreditation and professionalization.

CONCLUSION

A transrational approach, one that includes the partial truths of all perspectives, is a first step to allow for a richer understanding of how the interior worldviews, individual actions, and the exterior forces (legal, economic, political, and educational) brought forth the chiropractic clashes together. Viewing the conflicts within chiropractic from this approach may foster new educational structures to evolve.