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Chiropractic (from Greek chiro- χειρο- "hand-" + praktikós πρακτικός "concerned with action") is a complementary and alternative medicine health care profession whose purpose is to diagnose and treat mechanical disorders of the spine and musculoskeletal system with the intention of affecting the nervous system and improving health. Chiropractic uses manual treatments including spinal adjustment and other joint and soft-tissue manipulation. Historically, it is based on the premise that a vertebral subluxation or spinal joint dysfunction can interfere with the nervous system and result in many different conditions of diminished health. Today, chiropractors differ on how much emphasis should be placed on subluxation, with some entirely rejecting the concept and instead focusing on the relationship between structure and function and the impact of structure on neurological mechanisms.

Chiropractors, known as Doctors of Chiropractic or chiropractic doctors/physicians, in some jurisdictions, use a combination of treatments which are predicated on the specific needs of the individual patient. A chiropractor can develop and carry out a comprehensive treatment/management plan which can include spinal adjustments, soft tissue therapy, prescription of exercises, and health and lifestyle counseling.

Chiropractic was founded in 1895 by D. D. Palmer in the USA, and is now practiced in more than 100 countries. Since its inception, Chiropractic has been the subject of controversy, criticism, and attacks, particularly regarding the metaphysical approach espoused by its founders and currently maintained by principle based (straight) chiropractors. Controversy has come from philosophical conflicts within the profession, critics outside the profession, and from researchers in the scientific community. This same criticism may have been the catalyst that allowed some within the profession to take a more neuromuscular approach in their educational standards (see Council on Chiropractic Education), leading them away from the more metaphysical explanations of their predecessors towards more scientific ones.

Chiropractors have historically fallen into two main groups, "straights" and "mixers," though "objective straights" and "reformers," who are minority groups, are recent off-shoots from the straight and mixer models, respectively. Each group shares some common themes such as conservative, natural, preventative and non-invasive approaches to health care. Significant differences regarding scope of practice, claims made about spinal manipulation, and beliefs regarding professional integration, differentiate the various schools of thought and practice styles held within the profession.

Philosophy

Contemporary chiropractic belief systems vary along a spectrum that ranges from deduction from vitalistic roots to the materialism of science. Between these two extremes can be found principles such as "vitalism, holism, naturalism, therapeutic conservatism, critical rationalism, and thoughts from the phenomenological and humanistic paradigms."

Vitalism, the belief that living things contain an element that cannot be explained through matter, and materialism, the belief that all things have material explanations, have been debated since the time of Plato and Aristotle, continuing into the 20th century, legally and politically differentiating early chiropractic from allopathic medicine and thereby helping ensure professional autonomy. Today's individual chiropractor balances this dualism by emphasizing both the tangible, testable principle that structure affects function, and the untestable, metaphorical recognition that life is self-sustaining. The chiropractor's purpose is to foster the establishment and maintenance of an organism-environment dynamic that is the most conducive to functional well-being of the person as a whole.

Whether vitalist, naturalist, or materialist, a holistic practitioner takes a patient-centered approach, appreciates the multifactorial nature of influences (i.e. structural, chemical, and psychological) on the functioning of the body in health and disease, and recognizes the dynamics and interplay between lifestyle, environment, and health. Holism is not unique to chiropractic philosophy, as it pervades throughout most complementary and alternative methods and the allied health care professions. This is also consistent with the biopsychosocial approach emphasized by both chiropractic and medicine.

Therapeutic conservative, naturopathic and naturalist elements suggest that lowered "host resistance" of the body facilitates the disease process and natural interventions are directed towards strengthening the host in its effort to battle disease and return to homeostasis. Chiropractic care primarily uses manipulation rather than medications and surgery.

Chiropractors also commonly use nutrition, exercise, patient education, health promotion and lifestyle counseling as part of their holistic outlook towards preventive health care. Chiropractic's claim to improve health by improving biomechanical and neural function by the manual correction of joint and soft tissue dysfunctions of the neuromusculoskeletal system differentiates it from mainstream medicine and other complementary and alternative medicine (CAM) disciplines, but has been a part of osteopathy and many eastern medicine interventions. All chiropractic paradigms emphasize the spine as their focus, but their rationales for treatment vary depending on their particular belief system.

Chiropractic philosophy also stresses the importance of prevention and primarily utilizes a pro-active approach and a wellness model to achieve this goal. For some, prevention includes a concept of "maintenance care" which attempts to "detect and correct" structural imbalances of the neuromusculoskeletal system while in its primary, or functional state. The objective is early identification of mechanical dysfunctions to prevent subsequent deterioration which would result in permanent pathological changes.

In summary, the major premises regarding the philosophy of chiropractic include:

• Holism

• noninvasive, emphasizes patient's inherent recuperative abilities
• recognizes dynamics between lifestyle, environment, and health
• spine and health are related in an important and fundamental way, and this relationship is mediated through the nervous system.
• recognizes the centrality of the nervous system and its intimate relationship with both the structural and regulatory capacities of the body
• appreciates the multifactorial nature of influences (structural, chemical, and psychological) on the nervous system

• Conservatism

• balances the benefits against the risks of clinical interventions
• emphasizes noninvasive treatments to minimize risk with a preference to avoid surgery and medication
• recognizes as imperative the need to monitor progress and effectiveness through appropriate diagnostic procedures
• prevents unnecessary barriers in the doctor-patient encounter

• Manual and biopsychosocial approaches

• strives toward early intervention, emphasizing timely diagnosis and treatment, reversible conditions before loss of functionality
• emphasizes a patient-centered model whereby the patient is considered to be indispensable in, and ultimately responsible for, the maintenance of health.
• approach of improving health through influencing function through structure primarily via manual therapies

Manipulative treatment techniques

The medicinal use of spinal manipulation can be traced back over 3000 years to ancient Chinese writings. Hippocrates, the "father of medicine" used manipulative techniques, as did the ancient Egyptians and many other cultures. A modern reemphasis on manipulative therapy occurred in the late 1800s in North America with the emergence of the Osteopathic and Chiropractic professions. While some manipulative procedures now associated with chiropractic care can be traced back to ancient times, the modern profession of chiropractic was founded by Daniel David Palmer in 1895 in Davenport, Iowa. Over the years, the chiropractic profession has developed hundreds of manipulative techniques, but critics suggest that certain "specialized" techniques are dubious and lack plausible scientific rationale. Spinal manipulative therapy gained recognition by mainstream medicine during the 1980’s with supporters such as James Cyriax, MD, John McM. Mennell, M.D., Scott Haldeman, D.C., Ph.D., M.D. and recently many other physicians who hold academic and clinical appointments at medical and chiropractic colleges and with multidisciplinary research and professional organizations supporting spinal manipulative therapy. Today manipulative therapy is becoming more mainstream and is employed by medical specialists (e.g. physiatrists, orthopedists, sports medicine practitioners), and some osteopathic physicians, physical therapists and athletic trainers Despite this increased interest from conventional medicine, chiropractors still perform over 90% of all spinal and joint manipulations and consider themselves to be the expert providers of spinal adjustment, manipulation and other manual treatments.

The United States' National Board of Chiropractic Examiners has rated the following as the most frequently used techniques, here listed with the percentages of chiropractors who use them and patients who are treated with them:

Technique	% of Chiropractors using technique	% of Patients treated with technique
1. Diversified	96.2	71.5
2. Extremity manipulating/adjusting	95.4	46.8
3. Activator Methods	69.9	23.9
4. Thompson	61.3	28.2
5. Gonstead	57.2	26.2
6. Cox Flexion/Distraction	56.5	23.5
7. Sacro Occipital Technique	49.6	15.3
8. Manipulative/Adjustive Instruments	40.3	15.7
9. Cranial	38.0	10.3
10. Applied kinesiology	37.6	12.9
11. NIMMO/Receptor Tonus	33.6	13.4
12. Logan Basic	26.0	5.2
13. Palmer upper cervical (Hole-in-One)	25.7	6.7
14. Pierce-Stillwagon	15.4	5.1
15. Meric	15.1	4.3
16. Other	12.5	10.4

Manipulation under anesthesia or MUA is a specialized procedure that requires direct medical supervision and typically occurs in hospitals. MDs administer general anaesthesia and DCs administer spinal manipulation. Typically, it is performed on patients who have failed to respond to other forms of treatment.

Practice styles and schools of thought

Common themes in chiropractic care are conservative, non-invasive, non-medication approaches via manual therapy. Nonetheless, there are significant differences amongst the practice styles, claims and beliefs between various practitioners. Those differences are reflected in the varied viewpoints of multiple national practice associations. There are four practice styles and schools of thought among chiropractors.

Straight chiropractors are the oldest movement. They adhere to the philosophical principles set forth by D. D. and B. J. Palmer, retain metaphysical definitions and vitalistic qualities. Straight chiropractors suggest that vertebral subluxation leads to interference with of Innate intelligence within the human nervous system and is a primary underlying risk factor for almost any disease. Straights view the medical diagnosis of patient complaints (which they consider to be the "secondary effects" of subluxations) to be unnecessary for treatment. Thus, straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not "mix" other types of therapies. Their philosophy and explanations are metaphysical in nature and prefer to use traditional chiropractic lexicon (i.e. subluxation, adjustment, spinal analysis, etc). They prefer to remain separate and distinct from mainstream health care and claim they are not competing with medicine because they do not share the same objective.

Mixer chiropractors are an early offshoot of the straight movement. This branch "mixes" diagnostic and treatment approaches from naturopathic, osteopathic, medical, and chiropractic viewpoints. Unlike straight chiropractors, mixer chiropractors incorporate mainstream medical diagnostics and employ a myriad of treatments including joint and soft tissue manipulation, electromodalities, physical therapy, exercise-rehabilitation and other complementary and alternative approaches such as acupuncture. They tend to focus more on the neuromusculoskeletal system but also treat non-neuromusculoskeletal conditions as well. Mixers tend to use more mainstream scientific methods and descriptions as opposed to metaphysical ones, but a minority of practitioners still employ questionable techniques and devices regarded as dubious by the scientific and medical communities. In contrast to straight chiropractors, mixers generally want to be integrated into mainstream health care via integrative medicine.

Objective Straight chiropractors, a minority group, is differentiated from traditional straights mainly by the claims made. While traditional straights claimed that chiropractic adjustments are a plausible treatment for a wide range of diseases, objective straights only focus on the correction of chiropractic vertebral subluxations. Their guiding principles are summed up as: "We do not want to diagnose and treat diseases, even diseases of the spine." and "We do not want chiropractic to be practiced as an alternative to medicine." They encourage their patients "to see a medical physician if they indicate that they want to be treated for the symptoms they are experiencing or if they would like a medical diagnosis to determine the cause of their symptoms." Most objective straights limit treatment to spinal adjustments.

Reform chiropractors are a recent evidence-based off-shoot of mixers who use scientifically-oriented methods and protocols in the treatment of neuromusculoskeletal disorders. Reform minded chiropractors have rejected traditional Palmer philosophy yet retain the holistic, conservative and naturopathic beliefs of chiropractic. Reform DCs are beginning to be integrated into mainstream health care and generally favour an expansion of scope of practice to include limited prescription rights. They do not subscribe to the Palmer philosophy of Innate Intelligence and vertebral subluxations, do not believe that spinal joint dysfunction causes organic or systemic disease, and tend not to use alternative medicine methods.

Perspective Attribute	Potential Belief Endpoints
Scope of practice:	narrow <-- --> broad
Diagnostic approach:	intuitive <-- --> analytical
Philosophic orientation:	vitalistic <-- --> materialistic
Scientific orientation:	descriptive <-- --> experimental
Process orientation:	implicit <-- --> explicit
Practice attitude:	doctor/model-centered <-- --> patient-situation-centered
Professional integration :	separate and distinct <-- --> integrated into mainstream
Table 2. The different schools of thought within chiropractic can be differentiated according to their philosophical constructs that fall somewhere within the extremes of these categories. Source: Phillips RB, Mootz RD. Contemporary chiropractic philosophy. In Haldeman S (ed). Principles and Practice of Chiropractic, 2nd Ed. Norwalk, CT: Appleton & Lange, 1992. Chart reprinted from Keating J (1995), D.D. Palmer's Forgotten Theories of Chiropractic

It is generally not within the scope of practice of chiropractors to write medical prescriptions. A notable exception is the state of Oregon, which allows chiropractors with minor additional qualification to prescribe over-the-counter drugs. Traditionally, chiropractors have opposed prescription drugs, but recently a majority of North American chiropractors have supported limited prescription rights.

Depending on the country or state in which a chiropractic school is located, some chiropractors may obtain additional training to perform minor surgery, obstetrics and proctology. When indicated, the doctor of chiropractic consults with, co-manages with, or refers to other health care providers. According to a 2002 survey by the National Center for Complementary and Alternative Medicine, chiropractic care was among the ten most commonly-used Complementary and Alternative Medicine (CAM) therapies among adults in the USA. The U.S. Department of Labor's Occupational Outlook Handbook suggests that chiropractic care will increasingly play an important role in health care:

"Because chiropractors emphasize the importance of healthy lifestyles and do not prescribe drugs or perform surgery, chiropractic care is appealing to many health-conscious Americans. Chiropractic treatment of the back, neck, extremities, and joints has become more accepted as a result of research and changing attitudes about alternative, noninvasive health care practices."

History

D.D. Palmer gave the first spinal adjustment to a deaf janitor, Harvey Lillard, on September 18, 1895, reportedly resulting in a restoration of the man's hearing. Palmer had discovered that manual manipulation of the spine could result in improved neurological function. Friend and Rev. Samuel Weed suggested combining the words cheiros and praktikos (meaning "done by hand") and chiropractic was born. Palmer claimed that vertebral joint misalignments, which he termed "Subluxations" interfered with the body's function and its inborn ability to heal itself. This concept was later expanded upon by his son, B.J. Palmer.

D.D. Palmer, using a vitalistic approach, imbued the term subluxation with a metaphysical and philosophical meaning. He held that a malposition of spinal bones, which protect the spinal cord and nerve roots, interfered with the transmission of nerve impulses. Because half of the nervous system is sensory and the other half motor (control), he postulated that living things had an Innate intelligence, a kind of "spiritual energy" or life force that received the sensory information from the various parts of the body and made a decision as to what the motor nerves should convey. D.D. Palmer claimed that subluxations interfered with this innate intelligence, and that by fixing them, all diseases could be treated.

Early on, the Palmers described this concept as similar to applying pressure to a water hose that supplies a garden: relieve the pressure and the garden flourishes. It was later theorized that a vertebral subluxation was a misaligned vertebra that pinched a nerve. They thought that this interfered with the information the nerve was transmitting between the central nervous system and the structures of the body. He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic.

In 1996, the vertebral subluxation was defined as "a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health", though this definition has come under critique both internally and externally for its ambiguity. More recently, in 2005, the World Health Organization defined the vertebral subluxation as "A lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. It is essentially a functional entity, which may influence biomechanical and neural integrity." Nevertheless, the debate about the need to remove the concept of subluxation from the chiropractic paradigm has been ongoing since the mid 1960s. While straights hold firmly to the term and its vitalistic construct, reformers suggest that the mechanistic model will allow chiropractic to better integrate into mainstream medicine without making claims inherent in the term. Anthony Rosner PhD, director of education and research at the Foundation for Chiropractic Education and Research (FCER) considered subluxation and the concept of Occam's razor. He suggests

"there is no obvious reason to discard the concept of subluxation, while at the same time maintaining that it is not a rigid entity, but rather an important model and concept; a work in progress that undoubtedly will undergo extensive modification as our concepts of light or psychoanalysis have evolved over half a century."

In general, critics of chiropractic subluxation are skeptical on its clinical value and philosophical merits. This is still a continuing source of contention within the chiropractic profession as well, with certain chiropractic schools still teaching the straight/traditional metaphysical model of subluxation while others have moved towards a scientific and evidence-based model.

Note the difference between a chiropractic subluxation and its use in Medicine and Ophthalmology. See subluxation.

Medical opposition

In 1899, a medical doctor in Davenport, USA, named Heinrich Matthey started a campaign against drugless practitioners. D.D. Palmer insisted that his techniques did not need the same courses or license as medical doctors, as his graduates did not prescribe drugs, perform surgery or evaluate laboratory diagnostics. However, in 1906, D.D. Palmer was convicted for practicing medicine without a license. In response, B.J. created the Universal Chiropractic Association (UCA) for the purpose of protecting its members by covering their legal expenses should they get arrested for practicing medicine.

Its first case came in 1907, when Shegataro Morikubo, DC was charged with unlicensed practice of osteopathic medicine in Wisconsin. Morikubo was freed using the defense that chiropractic philosophy was different from osteopathic philosophy. The victory reshaped the development of the chiropractic profession, which then marketed itself as a science, an art and a philosophy. This began a longstanding feud between chiropractors and medical doctors that would culminate in the mid 1980's in a landmark case, Wilk et al. vs American Medical Association (AMA). Until 1983, the AMA held that it was unethical for medical doctors to associate with an "unscientific practitioner," and labeled chiropractic "an unscientific cult."

Wilk et al. vs. American Medical Association

Chester A. Wilk, DC from Chicago initiated an antitrust suit against the AMA and other medical associations in 1976 - Wilk et al. vs AMA et al.. The landmark lawsuit ended in 1987 when the US District Court found the AMA guilty of conspiracy and restraint of trade; the Joint Council on Accreditation of Hospitals and the American College of Physicians were exonerated. The court recognized that the AMA had to show its concern for patients, but was not persuaded that this could not have been achieved in a manner less restrictive of competition, for instance by public education campaigns. The AMA lost its appeal to the Supreme Court, and could no longer prevent medical physicians from collaborating with chiropractors. Judge Susan Getzendanner, who presided over the Wilk case, opined:

"Evidence at the trial showed that the defendants took active steps, often covert, to undermine chiropractic educational institutions, conceal evidence of the usefulness of chiropractic care, undercut insurance programs for patients of chiropractors, subvert government inquiries into the efficacy of chiropractic, engage in a massive disinformation campaign to discredit and destabilize the chiropractic profession and engage in numerous other activities to maintain a medical physician monopoly over health care in this country."

Movement toward science

In 1975, the National Institutes of Health brought chiropractors, osteopaths, medical doctors and Ph.D. scientists together in a conference on spinal manipulation to develop strategies to study the effects of spinal manipulation. In 1978, the Journal of Manipulative & Physiological Therapeutics (JMPT) was launched, and in 1981 it was included in the National Library of Medicine's Index Medicus. Joseph Keating dates the birth of chiropractic as a science to a 1983 commentary in the JMPT entitled "Notes from the (chiropractic college) underground" in which Kenneth F. DeBoer, then an instructor in basic science at Palmer College in Iowa, revealed the power of a scholarly journal (JMPT) to empower faculty at the chiropractic schools. DeBoer's opinion piece demonstrated the faculty's authority to challenge the status quo, to publicly address relevant, albeit sensitive, issues related to research, training and skepticism at chiropractic colleges, and to produce "cultural change" within the chiropractic schools so as to increase research and professional standards. It was a rallying call for chiropractic scientists and scholars.

Scientific inquiry

The Testable Principle	The Untestable Metaphor
Chiropractic Adjustment	Universal Intelligence
Restoration of structural integrity	Innate Intelligence
Improvement of Health Status	Body Physiology
Materialistic	Vitalistic
Operational definitions possible	Origin of Holism in chiropractic
lends itself to scientific inquiry	cannot be proved or disproved
Table 1. Two chiropractic system constructs. Source: Phillips RB, Mootz RD. Contemporary chiropractic philosophy. In Haldeman S (ed). Principles and Practice of Chiropractic, 2nd Ed. Norwalk, CT: Appleton & Lange, 1992. Chart reprinted from Keating J (1995), D.D. Palmer's Forgotten Theories of Chiropractic

Chiropractic researchers Robert Mootz and Reed Phillips suggest that, in chiropractic's early years, influences from both straight and mixer concepts were incorporated into its construct. They conclude that chiropractic has both materialistic qualities that lend themselves to scientific investigation and vitalistic qualities that do not (Table 1).

With relatively little federal funding, academic research in chiropractic has only recently become established in the USA. In 1994 and 1995, half of all grant funding to chiropractic researchers was from the US Health Resources and Services Administration (7 grants totaling $2.3 million). The Foundation for Chiropractic Education and Research (11 grants, $881,000) and the Consortium for Chiropractic Research (4 grants, $519,000) accounted for most of the rest. By 1997, there were 14 peer-reviewed chiropractic journals in English that encouraged the publication of chiropractic research, including The Journal of Manipulative and Physiological Therapeutics (JMPT), Topics in Clinical Chiropractic, and the Journal of Chiropractic Humanities. However, of these, only JMPT is included in Index Medicus. Research into chiropractic, whether from Universities or chiropractic colleges, is however often published in many other scientific journals.

While there is still debate about the effectiveness of chiropractic for the many conditions in which it is applied, chiropractic seems to be most effective for acute low back pain and tension headaches. One small pilot study has shown that upper cervical spinal manipulation may be beneficial for certain types of hypertension.

When testing the efficacy of health treatments, double blind studies are considered acceptable scientific rigor. These are designed so that neither the patient nor the doctor knows whether they are using the actual treatment or a placebo (or "sham") treatment. However, chiropractic treatment involves a manipulation; "sham" procedures cannot be easily devised for this, and even if the patient is unaware whether the treatment is a real or sham procedure, the doctor cannot be unaware. Thus there may be "observer bias" - the tendency to see what you expect to see, and the potential for the patient to wish to report benefits to "please" the doctor. Similarly, it is often difficult to devise a sham procedure for surgical procedures, but it is not impossible. It is also a problem in evaluating treatments; even when there are objective outcome measures, the placebo effect can be very substantial. Thus, DCs have historically relied mostly on their own clinical experience and the shared experience of their colleagues, as reported in case studies, to direct their treatment methods. Consequently there has been a call to increase qualitative research studies which can better examine the whole chiropractic clinical encounter.

The Manga Report

The Manga Report was an outcomes-study funded by the Ontario Ministry of Health and conducted by three health economists led by Professor Pran Manga. The Report supported the scientific validity, safety, efficacy, and cost-effectiveness of chiropractic for low-back pain, and found that chiropractic care had higher patient satisfaction levels than conventional alternatives. The report states that "The literature clearly and consistently shows that the major savings from chiropractic management come from fewer and lower costs of auxiliary services, fewer hospitalizations, and a highly significant reduction in chronic problems, as well as in levels and duration of disability."

Workers' Compensation studies

In 1998, a study of 10,652 Florida workers' compensation cases was conducted by Steve Wolk. He concluded that "a claimant with a back-related injury, when initially treated by a chiropractor versus a medical doctor, is less likely to become temporarily disabled, or if disabled, remains disabled for a shorter period of time; and claimants treated by medical doctors were hospitalized at a much higher rate than claimants treated by chiropractors." Similarly, a 1991 study of Oregon Workers' Compensation Claims examined 201 randomly selected workers' compensation cases that involved disabling low-back injuries: when individuals with similar injuries were compared, those who visited DCs generally missed fewer days of work than those who visited MDs.

A 1989 study analyzed data on Iowa state records from individuals who filed claims for back or neck injuries. The study compared benefits and the cost of care from MDs, DCs and DOs, focusing on individuals who had missed days of work and who had received compensation for their injuries. Individuals who visited DCs missed on average 2.3 fewer days than those who visited MDs, and 3.8 fewer days than those who saw DOs, and accordingly, less money was dispersed as employment compensation on average for individuals who visited DCs.

In 1989, a survey by Cherkin et al. concluded that patients receiving care from health maintenance organizations in the state of Washington were three times as likely to report satisfaction with care from DCs as they were with care from other physicians. The patients were also more likely to believe that their chiropractor was concerned about them.

American Medical Association (AMA)

In 1997, the following statement was adopted as policy of the AMA after a report on a number of alternative therapies. Specifically about chiropractic care it said,"Manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints." In 1992, the AMA stated "It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient. A physician may refer a patient for diagnostic or therapeutic services to a chiropractor permitted by law to furnish such services whenever the physician believes that this may benefit his or her patient. Physicians may also ethically teach in recognized schools of chiropractic. (V, VI)"

British Medical Association

The British Medical Association notes that "There is also no problem with GPs referring patients to practitioners in osteopathy and chiropractic who are registered with the relevant statutory regulatory bodies, as a similar means of redress is available to the patient."

Safety

Spinal manipulation, the most common modality in chiropractic care, has been increasingly studied in recent years as critics and proponents debate the merits of its efficacy and safety. While the efficacy of spinal manipulation for the lower back has not been convincingly demonstrated, there is supportive evidence, showing some benefits for treatment of lower back pain. Moreover, spinal manipulation for the lower back appears to be relatively cost-effective. Cervical spine manipulation (upper cervical specifically) has been a source of controversy. Critics have suggested that spinal manipulation is of limited benefit and a risk factor for vertebral basilar stroke. Researchers in the scientific and medical community believe more studies are needed to properly evaluate its safety and efficacy. Chiropractors have frequently countered that cervical spinal manipulation was a safe and effective procedure compared to conventional medical approaches for neck pain syndromes.

In February 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders, comprising a group of experts to evaluate neck pain and its associated disorder, released a manuscript of their findings with recommendations and guidelines, including associated risks and benefits. With respect to the association of VBA stroke and cervical manipulation the study concluded:

1. Vertebrobasilar artery stroke is a rare event in the population.
2. There is an association between vertebrobasilar artery stroke and chiropractic visits in those under 45 years of age.
3. There is also an association between vertebrobasilar artery stroke and use of primary care physician visits in all age groups.
4. no evidence of excess risk of VBA stroke associated chiropractic care.
5. The increased risks of vertebrobasilar artery stroke associated with chiropractic and physician visits is likely explained by patients with vertebrobasilar dissection-related neck pain and headache consulting both chiropractors and primary care physicians before their VBA stroke.

A 2007 study of 50,276 chiropractic manipulations of the cervical spine conducted by the Anglo-European College of Chiropractic in the UK turned up no reports of serious adverse effects; the study concluded that the risk of serious adverse effects was, at worst, 6 per 100,000 manipulations. The most common minor side effect was fainting, dizziness, and/or light-headedness, which occurred after, at worst, 16 in 1,000 treatments. Spinal manipulation is a regulated medical intervention and can only be performed by chiropractors and a limited number of physical medicine professionals. Prior to the adminstration of spinal manipulative therapy, patients must be screened out for absolute contraindications and undergo a complete clinical exam including history, physical and at times additional specialized imaging and laboratory diagnostics. These include inflammatory arthritides, fractures, dislocations, instabilities, bone weakening disorders, tumours, infections, acute trauma as well as various circulatory and neurological disorders.

A 2005 World Health Organization report states that when "employed skilfully and appropriately, chiropractic care is safe and effective for the prevention and management of a number of health problems." The report continued, "there are however, known risks and contraindications to manual and therapeutic protocols used in chiropractic practice," and, "Contraindications to spinal manipulative therapy range from a nonindication for such an intervention, where manipulation or mobilization may do no good, but should cause no harm, to an absolute contraindication... where manipulation or mobilization could be life‐threatening."

Disputing these findings, Edzard Ernst writes that "there is convincing evidence to show that is associated with frequent, mild adverse effects as well as with serious complications of unknown incidence." Stephen Barrett of Quackwatch asserts that there is a risk of stroke associated with neck manipulation, and questions the validity of studies that find very low incidences for serious complications. And, a 2007 review in Pediatrics cautioned that spinal adjustments on children carry a risk of injury. Most patients have no adverse effects from cervical manipulation, though the risk of stroke is not zero.

Vaccination

Although vaccination is one of the most cost-effective forms of prevention against infectious disease, it remains controversial within the chiropractic community. Most chiropractic writings on vaccination focus on its negative aspects. Evidence-based chiropractors have embraced vaccination, but a minority of the profession rejects it, as traditional chiropractic philosophy traces diseases to causes in the spine and states that diseases cannot be affected by vaccines. The American Chiropractic Association and the International Chiropractic Association support individual exemptions to compulsory vaccination laws, and a 1995 survey of U.S. chiropractors found that about a third believed there was no scientific proof that immunization prevents disease. The Canadian Chiropractic Association supports vaccination; surveys in Canada in 2000 and 2002 found that 40% of chiropractors supported vaccination, and that over a quarter opposed it and advised patients against vaccinating themselves or their children.

Education, licensing, and regulation

Today, there are 15 accredited Doctor of Chiropractic programs in 18 locations in the USA and two in Canada, and an estimated 70,000 chiropractors in the USA, 6500 in Canada, 2500 in Australia, 2,381 in the UK, and smaller numbers in about 50 other countries. In the USA and Canada, licensed individuals who practice chiropractic are commonly referred to as chiropractors, doctors of chiropractic (DC), or chiropractic physicians.

See also

• Naprapathy

References

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External links

General resources

• The American Chiropractic Association
• The Canadian Chiropractic Association
• The Chiropractic Resource Organization
• "History of Chiropractic" Archive - Joseph C. Keating Jr, PhD
• DC Consult
• Index to Chiropractic Literature
• The Chiropractic Profession and Its Research and Education Programs - MGT of America, Inc. document prepared for Florida State University
• Chiropractic in the United States: Training, Practice, and Research (1997) - Cherkin, Daniel C.; Mootz, Robert D.
• Dynamic Chiropractic Online - ChiroWeb, Chiropractic news source
• The Future of Chiropractic Revisited: 2005 to 2015 - Institute for Alternative Futures
• PubMed listing of Chiropractic related articles

Internal criticism

• Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor

Samuel Homola DC, a notable and outspoken dissident within the profession, expresses his opinion that evidence-based chiropractic is the only way forward.

• Chiropractic, Bonesetting, and Cultism - Samuel Homola (entire book on-line).

This book, published in 1964, contains trenchant criticism of the profession, and the following year Homola's application to renew his membership of the ACA was rejected. In 1991, David J. Redding, chairman of the ACA board of governors, welcomed Homola back to membership of the ACA, and in 1994, 30 years after its publication, the book was reviewed for the first time by a chiropractic journal.

• Chiropractic Ethics: An Oxymoron?

JC Smith, a chiropractor in private practice, writes in 1999 that ethical issues are "in dire need of debate" because of "years of intense medical misinformation/slander" and because of well publicised examples of tacky advertising, outlandish claims, sensationalism and insurance fraud.

• Chiropractic: Science and Antiscience and Pseudoscience Side by Side

Joseph C. Keating, Jr, PhD, professor at the Los Angeles College of Chiropractic and notable historian of chiropractic, warns of pseudoscientific notions that still persist in the mindsets of some chiropractors

• Faulty Logic and Non-skeptical Arguments in Chiropractic

Dr Keating critically distinguishes between sound and unsound arguments in support of chiropractic

• Critical thinking

Christopher Kent, DC president of the Council on Chiropractic Practice, advises his colleagues of the importance of high standards of evidence, noting that in the past chiropractors were too ready to accept anecdotal evidence

• Open Letter to the Profession (See Chiroweb for commentary.)

A 1992 letter from ACA attorney, George P. McAndrews, warns the chiropractic profession that advertising of scare tactic subluxation philosophy damages the newly won respect within the AMA.

• Quackery in Chiropractic -

A 1991 editorial from chiropractic trade magazine, Dynamic Chiropractic, where Joseph C. Keating Jr discusses his concerns for advertising products before they are scientifically evaluated.

• Subluxation - The Silent Killer

A 2000 commentary by Ronald Carter, DC, MA, Past President, Canadian Chiropractic Association in the Journal of the Canadian Chiropractic Association discussing his opinion that the subluxation story regardless of how it is packaged is not the answer. He suggests it is now time for the silent majority to make their voices heard and come together to present a rational and defensible model of chiropractic so that is not just included in the health care system, but an essential member of the health care team.

External criticism

• Keeping Your Spine In Line, Adjusting the Joints, and Video - Alan Alda, PBS, Scientific American Frontiers, Web Feature (combines internal and external criticism)
• Chirobase: Skeptical guide to chiropractic history, theories, and current practices - Stephen Barrett, MD, and Samuel Homola, DC (combines internal and external criticism)
• Chiropractic: Flagship of the Alternative Medicine Fleet, Part One and Part Two - Steven Novella MD, and President of the New England Skeptical Society

• Misplaced Pages neutral point of view disputes from February 2008
• Alternative medical systems
• Alternative medicine
• Chiropractic
• Healthcare occupations
• Manipulative therapy