published 5/10/07, updated 1/02/10

Review of Inside Chiropractic: A Patient’s Guide, a book by Samuel Homola

An essential guide for anyone who likes a good spine crunch, but suspects that the chiropractic profession might be imperfect

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

Samuel Homola. Inside Chiropractic: A Patient’s Guide. Prometheus Books, 1999.

Pros: relentlessly rational, reasonable and compelling, with fascinating anecdotes about the most alarming problems with 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 an infamously 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 really is a bit shocking.

Several passages that are likely to cause readers to make amazed noises or read excerpts out loud to anyone willing to listen.

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 serious 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

His book does not argue that everything chiropractors do is wrong, and so 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 parades before your eyes the questionable stuff that chiropractors believe, practice and sell. There were many moments when I read things that truly horrified me, such as this passage he quoted:

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

It’s possible that Homola may be just a little too cynical at times. 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: we are so focussed 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.

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 questionable: a lot of previously mainstream therapies have turned out not to be based on strong evidence at all. 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 therapies.

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!

What’s the salamander about?