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Wikipedia

Chiropractic

April 10, 2023

Chiropractic is a form of alternative medicine[1] concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially of the spine.[2] It has esoteric origins[3] and is based on several pseudoscientific ideas.[4]

Chiropractic
Alternative medicine
A chiropractor performing a vertebral adjustment
ClaimsVertebral subluxation, spinal adjustment, Innate Intelligence
RisksVertebral artery dissection (stroke), compression fracture, death
Related fieldsOsteopathy, vitalism
Original proponentsD. D. Palmer
Subsequent proponentsB. J. Palmer
MeSHD002684

Many chiropractors, especially those in the field's early history, have proposed that mechanical disorders of the joints, especially of the spine, affect general health,[2] and that regular manipulation of the spine (spinal adjustment) improves general health. The main chiropractic treatment technique involves manual therapy, especially manipulation of the spine, other joints, and soft tissues, but may also include exercises and health and lifestyle counseling.[5] A chiropractor may have a Doctor of Chiropractic (D.C.) degree and be referred to as "doctor" but is not a Doctor of Medicine (M.D.).[6][7] While many chiropractors view themselves as primary care providers,[8][9] chiropractic clinical training does not meet the requirements for that designation.[2]

Systematic reviews of controlled clinical studies of treatments used by chiropractors have found no evidence that chiropractic manipulation is effective, with the possible exception of treatment for back pain.[8] A 2011 critical evaluation of 45 systematic reviews concluded that the data included in the study "fail[ed] to demonstrate convincingly that spinal manipulation is an effective intervention for any condition."[10] Spinal manipulation may be cost-effective for sub-acute or chronic low back pain, but the results for acute low back pain were insufficient.[11] No compelling evidence exists to indicate that maintenance chiropractic care adequately prevents symptoms or diseases.[12]

There is not sufficient data to establish the safety of chiropractic manipulations.[13] It is frequently associated with mild to moderate adverse effects, with serious or fatal complications in rare cases.[14] There is controversy regarding the degree of risk of vertebral artery dissection, which can lead to stroke and death, from cervical manipulation.[15] Several deaths have been associated with this technique[14] and it has been suggested that the relationship is causative,[16][17] a claim which is disputed by many chiropractors.[17]

Chiropractic is well established in the United States, Canada, and Australia.[18] It overlaps with other manual-therapy professions such as osteopathy and physical therapy.[19] Most who seek chiropractic care do so for low back pain.[20] Back and neck pain are considered the specialties of chiropractic, but many chiropractors treat ailments other than musculoskeletal issues.[8] Chiropractic has two main groups: "straights", now the minority, emphasize vitalism, "Innate Intelligence", and consider vertebral subluxations to be the cause of all disease; and "mixers", the majority, are more open to mainstream views and conventional medical techniques, such as exercise, massage, and ice therapy.[21]

D. D. Palmer founded chiropractic in the 1890s,[22] after saying he received it from "the other world";[23] Palmer maintained that the tenets of chiropractic were passed along to him by a doctor who had died 50 years previously.[24] His son B. J. Palmer helped to expand chiropractic in the early 20th century.[22] Throughout its history, chiropractic has been controversial.[25][26] Its foundation is at odds with evidence-based medicine, and has been sustained by pseudoscientific ideas such as vertebral subluxation and Innate Intelligence.[27] Despite the overwhelming evidence that vaccination is an effective public health intervention, among chiropractors there are significant disagreements over the subject,[28] which has led to negative impacts on both public vaccination and mainstream acceptance of chiropractic.[29] The American Medical Association called chiropractic an "unscientific cult" in 1966[30] and boycotted it until losing an antitrust case in 1987.[9] Chiropractic has had a strong political base and sustained demand for services. In the last decades of the twentieth century, it gained more legitimacy and greater acceptance among conventional physicians and health plans in the United States.[9] During the COVID-19 pandemic, chiropractic professional associations advised chiropractors to adhere to CDC, WHO, and local health department guidance.[31][32] Despite these recommendations, a small but vocal and influential number of chiropractors spread vaccine misinformation.[33]

Conceptual basis

Philosophy

Chiropractic is generally categorized as complementary and alternative medicine (CAM),[1] which focuses on manipulation of the musculoskeletal system, especially the spine.[2] Its founder, D. D. Palmer, called it "a science of healing without drugs".[8]

Chiropractic's origins lie in the folk medicine of bonesetting,[8] and as it evolved it incorporated vitalism, spiritual inspiration and rationalism.[34] Its early philosophy was based on deduction from irrefutable doctrine, which helped distinguish chiropractic from medicine, provided it with legal and political defenses against claims of practicing medicine without a license, and allowed chiropractors to establish themselves as an autonomous profession.[34] This "straight" philosophy, taught to generations of chiropractors, rejects the inferential reasoning of the scientific method,[34] and relies on deductions from vitalistic first principles rather than on the materialism of science.[35] However, most practitioners tend to incorporate scientific research into chiropractic,[34] and most practitioners are "mixers" who attempt to combine the materialistic reductionism of science with the metaphysics of their predecessors and with the holistic paradigm of wellness.[35] A 2008 commentary proposed that chiropractic actively divorce itself from the straight philosophy as part of a campaign to eliminate untestable dogma and engage in critical thinking and evidence-based research.[36]

Two chiropractic belief system constructs
The testable principle The untestable metaphor
Chiropractic adjustment

↓

Restoration of structural integrity

↓

Improvement of health status

Universal intelligence

↓

Innate intelligence

↓

Body physiology

Materialistic: Vitalistic:
  • Operational definitions possible
  • Lends itself to scientific inquiry
  • Origin of holism in chiropractic
  • Cannot be proven or disproven
Taken from Mootz & Phillips 1997[35]

Although a wide diversity of ideas exist among chiropractors,[34] they share the belief that the spine and health are related in a fundamental way, and that this relationship is mediated through the nervous system.[37] Some chiropractors claim spinal manipulation can have an effect on a variety of ailments such as irritable bowel syndrome and asthma.[38]

Chiropractic philosophy includes the following perspectives:[35]

Holism assumes that health is affected by everything in an individual's environment; some sources also include a spiritual or existential dimension.[39] In contrast, reductionism in chiropractic reduces causes and cures of health problems to a single factor, vertebral subluxation.[36] Homeostasis emphasizes the body's inherent self-healing abilities. Chiropractic's early notion of innate intelligence can be thought of as a metaphor for homeostasis.[34]

A large number of chiropractors fear that if they do not separate themselves from the traditional vitalistic concept of innate intelligence, chiropractic will continue to be seen as a fringe profession.[21] A variant of chiropractic called naprapathy originated in Chicago in the early twentieth century.[40][41] It holds that manual manipulation of soft tissue can reduce "interference" in the body and thus improve health.[41]

Straights and mixers

Range of belief perspectives in chiropractic
Perspective attribute Potential belief endpoints
Scope of practice: narrow ("straight") ← → broad ("mixer")
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
Taken from Mootz & Phillips 1997[35]

Straight chiropractors adhere to the philosophical principles set forth by D. D. and B. J. Palmer, and retain metaphysical definitions and vitalistic qualities.[42] Straight chiropractors believe that vertebral subluxation leads to interference with an "innate intelligence" exerted via the human nervous system and is a primary underlying risk factor for many diseases.[42] Straights view the medical diagnosis of patient complaints, which they consider to be the "secondary effects" of subluxations, to be unnecessary for chiropractic treatment.[42] Thus, straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not "mix" other types of therapies into their practice style.[42] Their philosophy and explanations are metaphysical in nature and they prefer to use traditional chiropractic lexicon terminology such as "perform spinal analysis", "detect subluxation", "correct with adjustment".[21] They prefer to remain separate and distinct from mainstream health care.[21] Although considered the minority group, "they have been able to transform their status as purists and heirs of the lineage into influence dramatically out of proportion to their numbers."[21]

Mixer chiropractors "mix" diagnostic and treatment approaches from chiropractic, medical or osteopathic viewpoints and make up the majority of chiropractors.[21] Unlike straight chiropractors, mixers believe subluxation is one of many causes of disease, and hence they tend to be open to mainstream medicine.[21] Many of them incorporate mainstream medical diagnostics and employ conventional treatments including techniques of physical therapy such as exercise, stretching, massage, ice packs, electrical muscle stimulation, therapeutic ultrasound, and moist heat.[21] Some mixers also use techniques from alternative medicine, including nutritional supplements, acupuncture, homeopathy, herbal remedies, and biofeedback.[21]

Although mixers are the majority group, many of them retain belief in vertebral subluxation as shown in a 2003 survey of 1,100 North American chiropractors, which found that 88 percent wanted to retain the term "vertebral subluxation complex", and that when asked to estimate the percent of disorders of internal organs that subluxation significantly contributes to, the mean response was 62 percent.[43] A 2008 survey of 6,000 American chiropractors demonstrated that most chiropractors seem to believe that a subluxation-based clinical approach may be of limited utility for addressing visceral disorders, and greatly favored non-subluxation-based clinical approaches for such conditions.[44] The same survey showed that most chiropractors generally believed that the majority of their clinical approach for addressing musculoskeletal/biomechanical disorders such as back pain was based on subluxation.[44] Chiropractors often offer conventional therapies such as physical therapy and lifestyle counseling, and it may for the lay person be difficult to distinguish the unscientific from the scientific.[45]

Vertebral subluxation

Main article: Vertebral subluxation
Not to be confused with subluxation, the medical condition.

In science-based medicine, the term "subluxation" refers to an incomplete or partial dislocation of a joint, from the Latin luxare for 'dislocate'.[46][47] While medical doctors use the term exclusively to refer to physical dislocations, Chiropractic founder D. D. Palmer imbued the word subluxation with a metaphysical and philosophical meaning drawn from pseudoscientific traditions such as Vitalism.[48]

Palmer claimed that vertebral subluxations interfered with the body's function and its inborn ability to heal itself.[49] D. D. Palmer repudiated his earlier theory that vertebral subluxations caused pinched nerves in the intervertebral spaces in favor of subluxations causing altered nerve vibration, either too tense or too slack, affecting the tone (health) of the end organ.[48] He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic.[48] This concept was later expanded upon by his son, B. J. Palmer, and was instrumental in providing the legal basis of differentiating chiropractic from conventional medicine. In 1910, D. D. Palmer theorized that the nervous system controlled health:

Physiologists divide nerve-fibers, which form the nerves, into two classes, afferent and efferent. Impressions are made on the peripheral afferent fiber-endings; these create sensations that are transmitted to the center of the nervous system. Efferent nerve-fibers carry impulses out from the center to their endings. Most of these go to muscles and are therefore called motor impulses; some are secretory and enter glands; a portion are inhibitory, their function being to restrain secretion. Thus, nerves carry impulses outward and sensations inward. The activity of these nerves, or rather their fibers, may become excited or allayed by impingement, the result being a modification of functionality – too much or not enough action – which is disease.[50]

 
Chiropractors use x-ray radiography to examine the bone structure of a patient.

Vertebral subluxation, a core concept of traditional chiropractic, remains unsubstantiated and largely untested, and a debate about whether to keep it in the chiropractic paradigm has been ongoing for decades.[51] In general, critics of traditional subluxation-based chiropractic (including chiropractors) are skeptical of its clinical value, dogmatic beliefs and metaphysical approach. While straight chiropractic still retains the traditional vitalistic construct espoused by the founders, evidence-based chiropractic suggests that a mechanistic view will allow chiropractic care to become integrated into the wider health care community.[51] This is still a continuing source of debate within the chiropractic profession as well, with some schools of chiropractic still teaching the traditional/straight subluxation-based chiropractic, while others have moved towards an evidence-based chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions.[52][53]

In 2005, the chiropractic subluxation was defined by the World Health Organization 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.[54] It is essentially a functional entity, which may influence biomechanical and neural integrity."[54] This differs from the medical definition of subluxation as a significant structural displacement, which can be seen with static imaging techniques such as X-rays.[54] The use of X-ray imaging in the case of vertebral subluxation exposes patients to harmful ionizing radiation for no evidentially supported reason.[55][56] The 2008 book Trick or Treatment states "X-rays can reveal neither the subluxations nor the innate intelligence associated with chiropractic philosophy, because they do not exist."[57] Attorney David Chapman-Smith, Secretary-General of the World Federation of Chiropractic, has stated that "Medical critics have asked how there can be a subluxation if it cannot be seen on X-ray. The answer is that the chiropractic subluxation is essentially a functional entity, not structural, and is therefore no more visible on static X-ray than a limp or headache or any other functional problem."[58] The General Chiropractic Council, the statutory regulatory body for chiropractors in the United Kingdom, states that the chiropractic vertebral subluxation complex "is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease."[59]

As of 2014, the US National Board of Chiropractic Examiners states "The specific focus of chiropractic practice is known as the chiropractic subluxation or joint dysfunction. A subluxation is a health concern that manifests in the skeletal joints, and, through complex anatomical and physiological relationships, affects the nervous system and may lead to reduced function, disability or illness."[60][27]

Pseudoscience versus spinal manipulation therapy

Main articles: Spinal adjustment and Spinal manipulation

While some chiropractors limit their practice to short-term treatment of musculoskeletal conditions, many falsely claim to be able treat a myriad of other conditions.[61][62] Some dissuade patients from seeking medical care, others have pretended to be qualified to act as a family doctor.[61]

Quackwatch, an alternative medicine watchdog, cautions against seeing chiropractors who:[61][63]

  • Treat young children
  • Discourage immunization
  • Pretend to be a family doctor
  • Take full spine X-rays
  • Promote unproven dietary supplements
  • Are antagonistic to scientific medicine
  • Claim to treat non-musculoskeletal problems

Writing for the Skeptical Inquirer, one physician cautioned against seeing even chiropractors who solely claim to treat musculoskeletal conditions:

I think Spinal Manipulation Therapy (SMT) is a reasonable option for patients to try ... But I could not in good conscience refer a patient to a chiropractor... When chiropractic is effective, what is effective is not 'chiropractic': it is SMT. SMT is also offered by physical therapists, DOs, and others. These are science-based providers ... If I thought a patient might benefit from manipulation, I would rather refer him or her to a science-based provider.[61]

Scope of practice

 
A treatment table at a chiropractic office

Chiropractors emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery,[54] with special emphasis on the spine.[2] Back and neck pain are the specialties of chiropractic but many chiropractors treat ailments other than musculoskeletal issues.[8] There is a range of opinions among chiropractors: some believed that treatment should be confined to the spine, or back and neck pain; others disagreed.[64] For example, while one 2009 survey of American chiropractors had found that 73% classified themselves as "back pain/musculoskeletal specialists", the label "back and neck pain specialists" was regarded by 47% of them as a least desirable description in a 2005 international survey.[64] Chiropractic combines aspects from mainstream and alternative medicine, and there is no agreement about how to define the profession: although chiropractors have many attributes of primary care providers, chiropractic has more attributes of a medical specialty like dentistry or podiatry.[65] It has been proposed that chiropractors specialize in nonsurgical spine care, instead of attempting to also treat other problems,[36][65] but the more expansive view of chiropractic is still widespread.[66]

Mainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be complementary and alternative medicine (CAM);[1] and a 2008 study reported that 31% of surveyed chiropractors categorized chiropractic as CAM, 27% as integrated medicine, and 12% as mainstream medicine.[67] Many chiropractors believe they are primary care providers,[8][9] including US[68] and UK chiropractors,[69] but the length, breadth, and depth of chiropractic clinical training do not support the requirements to be considered primary care providers,[2] so their role on primary care is limited and disputed.[2][9]

Chiropractic overlaps with several other forms of manual therapy, including massage therapy, osteopathy, physical therapy, and sports medicine.[19][70] Chiropractic is autonomous from and competitive with mainstream medicine,[71] and osteopathy outside the US remains primarily a manual medical system;[72] physical therapists work alongside and cooperate with mainstream medicine, and osteopathic medicine in the U.S. has merged with the medical profession.[71] Practitioners may distinguish these competing approaches through claims that, compared to other therapists, chiropractors heavily emphasize spinal manipulation, tend to use firmer manipulative techniques, and promote maintenance care; that osteopaths use a wider variety of treatment procedures; and that physical therapists emphasize machinery and exercise.[19]

Chiropractic diagnosis may involve a range of methods including skeletal imaging, observational and tactile assessments, and orthopedic and neurological evaluation.[54] A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider.[65] Common patient management involves spinal manipulation (SM) and other manual therapies to the joints and soft tissues, rehabilitative exercises, health promotion, electrical modalities, complementary procedures, and lifestyle advice.[5]

 
A chiropractic adjustment of a horse

Chiropractors are not normally licensed to write medical prescriptions or perform major surgery in the United States[73] (although New Mexico has become the first US state to allow "advanced practice" trained chiropractors to prescribe certain medications[74][75]). In the US, their scope of practice varies by state, based on inconsistent views of chiropractic care: some states, such as Iowa, broadly allow treatment of "human ailments"; some, such as Delaware, use vague concepts such as "transition of nerve energy" to define scope of practice; others, such as New Jersey, specify a severely narrowed scope.[76] US states also differ over whether chiropractors may conduct laboratory tests or diagnostic procedures, dispense dietary supplements, or use other therapies such as homeopathy and acupuncture; in Oregon they can become certified to perform minor surgery and to deliver children via natural childbirth.[73] A 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for over-the-counter drugs.[43] A 2010 survey found that 72% of Swiss chiropractors considered their ability to prescribe nonprescription medication as an advantage for chiropractic treatment.[77]

A related field, veterinary chiropractic, applies manual therapies to animals and is recognized in many US states,[78] but is not recognized by the American Chiropractic Association as being chiropractic.[79] It remains controversial within certain segments of the veterinary and chiropractic professions.[80]

No single profession "owns" spinal manipulation and there is little consensus as to which profession should administer SM, raising concerns by chiropractors that other medical physicians could "steal" SM procedures from chiropractors.[81] A focus on evidence-based SM research has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.[81] Two US states (Washington and Arkansas) prohibit physical therapists from performing SM,[82] some states allow them to do it only if they have completed advanced training in SM, and some states allow only chiropractors to perform SM, or only chiropractors and physicians. Bills to further prohibit non-chiropractors from performing SM are regularly introduced into state legislatures and are opposed by physical therapist organizations.[83]

Treatments

Main articles: Chiropractic treatment techniques and Spinal adjustment
 
A chiropractor performs an adjustment on a patient.

Spinal manipulation, which chiropractors call "spinal adjustment" or "chiropractic adjustment", is the most common treatment used in chiropractic care.[84] Spinal manipulation is a passive manual maneuver during which a three-joint complex is taken past the normal range of movement, but not so far as to dislocate or damage the joint.[85] Its defining factor is a dynamic thrust, which is a sudden force that causes an audible release and attempts to increase a joint's range of motion.[85] High-velocity, low-amplitude spinal manipulation (HVLA-SM) thrusts have physiological effects that signal neural discharge from paraspinal muscle tissues, depending on duration and amplitude of the thrust are factors of the degree in paraspinal muscle spindles activation.[86] Clinical skill in employing HVLA-SM thrusts depends on the ability of the practitioner to handle the duration and magnitude of the load.[86] More generally, spinal manipulative therapy (SMT) describes techniques where the hands are used to manipulate, massage, mobilize, adjust, stimulate, apply traction to, or otherwise influence the spine and related tissues.[85]

There are several schools of chiropractic adjustive techniques, although most chiropractors mix techniques from several schools. The following adjustive procedures were received by more than 10% of patients of licensed US chiropractors in a 2003 survey:[84] Diversified technique (full-spine manipulation, employing various techniques), extremity adjusting, Activator technique (which uses a spring-loaded tool to deliver precise adjustments to the spine), Thompson Technique (which relies on a drop table and detailed procedural protocols), Gonstead (which emphasizes evaluating the spine along with specific adjustment that avoids rotational vectors), Cox/flexion-distraction (a gentle, low-force adjusting procedure which mixes chiropractic with osteopathic principles and utilizes specialized adjusting tables with movable parts), adjustive instrument, Sacro-Occipital Technique (which models the spine as a torsion bar), Nimmo Receptor-Tonus Technique, applied kinesiology (which emphasises "muscle testing" as a diagnostic tool), and cranial.[87] Chiropractic biophysics technique uses inverse functions of rotations during spinal manipulation.[88] Koren Specific Technique (KST) may use their hands, or they may use an electric device known as an "ArthroStim" for assessment and spinal manipulations.[89] Insurers in the US and UK that cover other chiropractic techniques exclude KST from coverage because they consider it to be "experimental and investigational".[89][90][91][92] Medicine-assisted manipulation, such as manipulation under anesthesia, involves sedation or local anesthetic and is done by a team that includes an anesthesiologist; a 2008 systematic review did not find enough evidence to make recommendations about its use for chronic low back pain.[93]

 
Lumbar, cervical and thoracic chiropractic spinal manipulation

Many other procedures are used by chiropractors for treating the spine, other joints and tissues, and general health issues. The following procedures were received by more than one-third of patients of licensed US chiropractors in a 2003 survey: Diversified technique (full-spine manipulation; mentioned in previous paragraph), physical fitness/exercise promotion, corrective or therapeutic exercise, ergonomic/postural advice, self-care strategies, activities of daily living, changing risky/unhealthy behaviors, nutritional/dietary recommendations, relaxation/stress reduction recommendations, ice pack/cryotherapy, extremity adjusting (also mentioned in previous paragraph), trigger point therapy, and disease prevention/early screening advice.[84]

A 2010 study describing Belgian chiropractors and their patients found chiropractors in Belgium mostly focus on neuromusculoskeletal complaints in adult patients, with emphasis on the spine.[94] The diversified technique is the most often applied technique at 93%, followed by the Activator mechanical-assisted technique at 41%.[94] A 2009 study assessing chiropractic students giving or receiving spinal manipulations while attending a United States chiropractic college found Diversified, Gonstead, and upper cervical manipulations are frequently used methods.[95]

Practice guidelines

Reviews of research studies within the chiropractic community have been used to generate practice guidelines outlining standards that specify which chiropractic treatments are legitimate (i.e. supported by evidence) and conceivably reimbursable under managed care health payment systems.[81] Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs antiscientific reasoning and makes unsubstantiated claims.[2][27][51][96][97] Chiropractic remains at a crossroads, and that in order to progress it would need to embrace science; the promotion by some for it to be a cure-all was both "misguided and irrational".[98] A 2007 survey of Alberta chiropractors found that they do not consistently apply research in practice, which may have resulted from a lack of research education and skills.[99] Specific guidelines concerning the treatment of nonspecific (i.e., unknown cause) low back pain are inconsistent between countries.[100]

Effectiveness

Numerous controlled clinical studies of treatments used by chiropractors have been conducted, with varied results.[8] There is no conclusive evidence that chiropractic manipulative treatment is effective for the treatment of any medical condition, except perhaps for certain kinds of back pain.[8][10]

Generally, the research carried out into the effectiveness of chiropractic has been of poor quality.[101][102] Research published by chiropractors is distinctly biased: reviews of SM for back pain tended to find positive conclusions when authored by chiropractors, while reviews by mainstream authors did not.[8]

There is a wide range of ways to measure treatment outcomes.[103] Chiropractic care benefits from the placebo response,[104] but it is difficult to construct a trustworthy placebo for clinical trials of spinal manipulative therapy (SMT).[105] The efficacy of maintenance care in chiropractic is unknown.[106]

Available evidence covers the following conditions:

  • Low back pain. A 2013 Cochrane review found very low to moderate evidence that SMT was no more effective than inert interventions, sham SMT or as an adjunct therapy for acute low back pain.[107] The same review found that SMT appears to be no better than other recommended therapies.[107] A 2012 overview of systematic reviews found that collectively, SM failed to show it is an effective intervention for pain.[108] A 2011 Cochrane review found strong evidence that suggests there is no clinically meaningful difference between SMT and other treatments for reducing pain and improving function for chronic low back pain.[109] A 2010 Cochrane review found no difference between the effects of combined chiropractic treatments and other treatments for chronic or mixed duration low back pain.[110] A 2010 systematic review found that most studies suggest SMT achieves equivalent or superior improvement in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up.[111]
  • Radiculopathy. A 2013 systematic review and meta-analysis found a statistically significant improvement in overall recovery from sciatica following SM, when compared to usual care, and suggested that SM may be considered.[112] There is moderate quality evidence to support the use of SM for the treatment of acute lumbar radiculopathy[113] and acute lumbar disc herniation with associated radiculopathy.[114] There is low or very low evidence supporting SM for chronic lumbar spine-related extremity symptoms and cervical spine-related extremity symptoms of any duration and no evidence exists for the treatment of thoracic radiculopathy.[113]
  • Whiplash and other neck pain. There is no consensus on the effectiveness of manual therapies for neck pain.[115] A 2013 systematic review found that the data suggests that there are minimal short- and long-term treatment differences when comparing manipulation or mobilization of the cervical spine to physical therapy or exercise for neck pain improvement.[116] A 2013 systematic review found that although there is insufficient evidence that thoracic SM is more effective than other treatments, it is a suitable intervention to treat some patients with non-specific neck pain.[117] A 2011 systematic review found that thoracic SM may offer short-term improvement for the treatment of acute or subacute mechanical neck pain; although the body of literature is still weak.[118] A 2010 Cochrane review found low quality evidence that suggests cervical manipulation may offer better short-term pain relief than a control for neck pain, and moderate evidence that cervical manipulation and mobilization produced similar effects on pain, function and patient satisfaction.[119] A 2010 systematic review found low level evidence that suggests chiropractic care improves cervical range of motion and pain in the management of whiplash.[120]
  • Headache. There is conflicting evidence surrounding the use of chiropractic SMT for the treatment and prevention of migraine headaches.[121][122] A 2006 review found no rigorous evidence supporting SM or other manual therapies for tension headache.[123] A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.[124]
  • Extremity conditions. A 2011 systematic review and meta-analysis concluded that the addition of manual mobilizations to an exercise program for the treatment of knee osteoarthritis resulted in better pain relief than a supervised exercise program alone and suggested that manual therapists consider adding manual mobilization to optimize supervised active exercise programs.[125] There is silver level evidence that manual therapy is more effective than exercise for the treatment of hip osteoarthritis, however this evidence could be considered to be inconclusive.[126] There is a small amount of research into the efficacy of chiropractic treatment for upper limbs,[127] limited to low level evidence supporting chiropractic management of shoulder pain[128] and limited or fair evidence supporting chiropractic management of leg conditions.[129]
  • Other. A 2012 systematic review found insufficient low bias evidence to support the use of spinal manipulation as a therapy for the treatment of hypertension.[130] A 2011 systematic review found moderate evidence to support the use of manual therapy for cervicogenic dizziness.[131] There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine)[132] and no scientific data for idiopathic adolescent scoliosis.[133] A 2007 systematic review found that few studies of chiropractic care for nonmusculoskeletal conditions are available, and they are typically not of high quality; it also found that the entire clinical encounter of chiropractic care (as opposed to just SM) provides benefit to patients with cervicogenic dizziness, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizziness, high blood pressure, and vision conditions.[134] Other reviews have found no evidence of significant benefit for asthma,[135][136] baby colic,[137][138] bedwetting,[139] carpal tunnel syndrome,[140] fibromyalgia,[141] gastrointestinal disorders,[142] kinetic imbalance due to suboccipital strain (KISS) in infants,[137][143] menstrual cramps,[144] insomnia,[145] postmenopausal symptoms,[145] or pelvic and back pain during pregnancy.[146] As there is no evidence of effectiveness or safety for cervical manipulation for baby colic, it is not endorsed.[147]

Safety

 
Chiropractic adjustment on children

The World Health Organization found chiropractic care in general is safe when employed skillfully and appropriately.[54] There is not sufficient data to establish the safety of chiropractic manipulations.[13] Manipulation is regarded as relatively safe but complications can arise, and it has known adverse effects, risks and contraindications.[54] Absolute contraindications to spinal manipulative therapy are conditions that should not be manipulated; these contraindications include rheumatoid arthritis and conditions known to result in unstable joints.[54] Relative contraindications are conditions where increased risk is acceptable in some situations and where low-force and soft-tissue techniques are treatments of choice; these contraindications include osteoporosis.[54] Although most contraindications apply only to manipulation of the affected region, some neurological signs indicate referral to emergency medical services; these include sudden and severe headache or neck pain unlike that previously experienced.[148] Indirect risks of chiropractic involve delayed or missed diagnoses through consulting a chiropractor.[8]

Spinal manipulation is associated with frequent, mild and temporary adverse effects,[14][148] including new or worsening pain or stiffness in the affected region.[149] They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours;[13] adverse reactions appear to be more common following manipulation than mobilization.[150] The most frequently stated adverse effects are mild headache, soreness, and briefly elevated pain fatigue.[151] Chiropractic is correlated with a very high incidence of minor adverse effects.[8] Rarely,[54] spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death; these can occur in adults[14] and children.[152] Estimates vary widely for the incidence of these complications,[13] and the actual incidence is unknown, due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke, which is a particular concern.[14] Adverse effects are poorly reported in recent studies investigating chiropractic manipulations.[153] A 2016 systematic review concludes that the level of reporting is unsuitable and unacceptable.[154] Reports of serious adverse events have occurred, resulting from spinal manipulation therapy of the lumbopelvic region.[155] Estimates for serious adverse events vary from 5 strokes per 100,000 manipulations to 1.46 serious adverse events per 10 million manipulations and 2.68 deaths per 10 million manipulations, though it was determined that there was inadequate data to be conclusive.[13] Several case reports show temporal associations between interventions and potentially serious complications.[156] The published medical literature contains reports of 26 deaths since 1934 following chiropractic manipulations and many more seem to remain unpublished.[17]

Vertebrobasilar artery stroke (VAS) is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.[156][157] Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (CMT) and VAS.[158] There is insufficient evidence to support a strong association or no association between cervical manipulation and stroke.[15] While the biomechanical evidence is not sufficient to support the statement that CMT causes cervical artery dissection (CD), clinical reports suggest that mechanical forces have a part in a substantial number of CDs and the majority of population controlled studies found an association between CMT and VAS in young people.[159] It is strongly recommended that practitioners consider the plausibility of CD as a symptom, and people can be informed of the association between CD and CMT before administrating manipulation of the cervical spine.[159] There is controversy regarding the degree of risk of stroke from cervical manipulation.[15] Many chiropractors state that, the association between chiropractic therapy and vertebral arterial dissection is not proven.[17] However, it has been suggested that the causality between chiropractic cervical manipulation beyond the normal range of motion and vascular accidents is probable[17] or definite.[16] There is very low evidence supporting a small association between internal carotid artery dissection and chiropractic neck manipulation.[160] The incidence of internal carotid artery dissection following cervical spine manipulation is unknown.[161] The literature infrequently reports helpful data to better understand the association between cervical manipulative therapy, cervical artery dissection and stroke.[162] The limited evidence is inconclusive that chiropractic spinal manipulation therapy is not a cause of intracranial hypotension.[163] Cervical intradural disc herniation is very rare following spinal manipulation therapy.[164]

Chiropractors, like other primary care providers, sometimes employ diagnostic imaging techniques such as X-rays and CT scans that rely on ionizing radiation.[165] Although there is no clear evidence for the practice, some chiropractors may still X-ray a patient several times a year.[57] Practice guidelines aim to reduce unnecessary radiation exposure,[165] which increases cancer risk in proportion to the amount of radiation received.[166] Research suggests that radiology instruction given at chiropractic schools worldwide seem to be evidence-based.[56] Although, there seems to be a disparity between some schools and available evidence regarding the aspect of radiography for patients with acute low back pain without an indication of a serious disease, which may contribute to chiropractic overuse of radiography for low back pain.[56]

Risk-benefit

A 2012 systematic review concluded that no accurate assessment of risk-benefit exists for cervical manipulation.[15] A 2010 systematic review stated that there is no good evidence to assume that neck manipulation is an effective treatment for any medical condition and suggested a precautionary principle in healthcare for chiropractic intervention even if a causality with vertebral artery dissection after neck manipulation were merely a remote possibility.[17] The same review concluded that the risk of death from manipulations to the neck outweighs the benefits.[17] Chiropractors have criticized this conclusion, claiming that the author did not evaluate the potential benefits of spinal manipulation.[167] Edzard Ernst stated "This detail was not the subject of my review. I do, however, refer to such evaluations and should add that a report recently commissioned by the General Chiropractic Council did not support many of the outlandish claims made by many chiropractors across the world."[167] A 1999 review of 177 previously reported cases published between 1925 and 1997 in which injuries were attributed to manipulation of the cervical spine (MCS) concluded that "The literature does not demonstrate that the benefits of MCS outweigh the risks." The professions associated with each injury were assessed. Physical therapists (PT) were involved in less than 2% of all cases, with no deaths caused by PTs. Chiropractors were involved in a little more than 60% of all cases, including 32 deaths.[168]

A 2009 review evaluating maintenance chiropractic care found that spinal manipulation is associated with considerable harm and no compelling evidence exists to indicate that it adequately prevents symptoms or diseases, thus the risk-benefit is not evidently favorable.[12]

Cost-effectiveness

A 2012 systematic review suggested that the use of spine manipulation in clinical practice is a cost-effective treatment when used alone or in combination with other treatment approaches.[169] A 2011 systematic review found evidence supporting the cost-effectiveness of using spinal manipulation for the treatment of sub-acute or chronic low back pain; the results for acute low back pain were insufficient.[11]

A 2006 systematic cost-effectiveness review found that the reported cost-effectiveness of spinal manipulation in the United Kingdom compared favorably with other treatments for back pain, but that reports were based on data from clinical trials without placebo controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain.[170] A 2005 American systematic review of economic evaluations of conservative treatments for low back pain found that significant quality problems in available studies meant that definite conclusions could not be drawn about the most cost-effective intervention.[171] The cost-effectiveness of maintenance chiropractic care is unknown.[106][non-primary source needed]

Analysis of a clinical and cost utilization data from the years 2003 to 2005 by an integrative medicine independent physician association (IPA) which looked the chiropractic services utilization found that the clinical and cost utilization of chiropractic services based on 70,274 member-months over a 7-year period decreased patient costs associate with the following use of services by 60% for in-hospital admissions, 59% for hospital days, 62% for outpatient surgeries and procedures, and 85% for pharmaceutical costs when compared with conventional medicine (visit to a medical doctor primary care provider) IPA performance for the same health maintenance organization product in the same geography and time frame.[172]

Education, licensing, and regulation

Main articles: Chiropractic education and List of chiropractic schools

Requirements vary between countries. In the U.S. chiropractors obtain a non-medical accredited diploma in the field of chiropractic.[173] Chiropractic education in the U.S. has been criticized for failing to meet generally accepted standards of evidence-based medicine.[174] The curriculum content of North American chiropractic and medical colleges with regard to basic and clinical sciences has little similarity, both in the kinds of subjects offered and in the time assigned to each subject.[175] Accredited chiropractic programs in the U.S. require that applicants have 90 semester hours of undergraduate education with a grade point average of at least 3.0 on a 4.0 scale. Many programs require at least three years of undergraduate education, and more are requiring a bachelor's degree.[176] Canada requires a minimum three years of undergraduate education for applicants, and at least 4200 instructional hours (or the equivalent) of full‐time chiropractic education for matriculation through an accredited chiropractic program.[177] Graduates of the Canadian Memorial Chiropractic College (CMCC) are formally recognized to have at least 7–8 years of university level education.[178][179] The World Health Organization (WHO) guidelines suggest three major full-time educational paths culminating in either a DC, DCM, BSc, or MSc degree. Besides the full-time paths, they also suggest a conversion program for people with other health care education and limited training programs for regions where no legislation governs chiropractic.[54]

Upon graduation, there may be a requirement to pass national, state, or provincial board examinations before being licensed to practice in a particular jurisdiction.[180][181] Depending on the location, continuing education may be required to renew these licenses.[182][183] Specialty training is available through part-time postgraduate education programs such as chiropractic orthopedics and sports chiropractic, and through full-time residency programs such as radiology or orthopedics.[184]

In the U.S., chiropractic schools are accredited through the Council on Chiropractic Education (CCE) while the General Chiropractic Council (GCC) is the statutory governmental body responsible for the regulation of chiropractic in the UK.[185][186] The U.S. CCE requires a mixing curriculum, which means a straight-educated chiropractor may not be eligible for licensing in states requiring CCE accreditation.[76] CCEs in the U.S., Canada, Australia and Europe have joined to form CCE-International (CCE-I) as a model of accreditation standards with the goal of having credentials portable internationally.[187] Today, there are 18 accredited Doctor of Chiropractic programs in the U.S.,[188] 2 in Canada,[189] 6 in Australasia,[190] and 5 in Europe.[191] All but one of the chiropractic colleges in the U.S. are privately funded, but in several other countries they are in government-sponsored universities and colleges.[25] Of the two chiropractic colleges in Canada, one is publicly funded (UQTR) and one is privately funded (CMCC). In 2005, CMCC was granted the privilege of offering a professional health care degree under the Post-secondary Education Choice and Excellence Act, which sets the program within the hierarchy of education in Canada as comparable to that of other primary contact health care professions such as medicine, dentistry and optometry.[178][179]

Regulatory colleges and chiropractic boards in the U.S., Canada, Mexico, and Australia are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.[192][193] There are an estimated 49,000 chiropractors in the U.S. (2008),[194] 6,500 in Canada (2010),[195] 2,500 in Australia (2000),[29] and 1,500 in the UK (2000).[196]

Chiropractors often argue that this education is as good as or better than medical physicians', but most chiropractic training is confined to classrooms with much time spent learning theory, adjustment, and marketing.[76] The fourth year of chiropractic education persistently showed the highest stress levels.[197] Every student, irrespective of year, experienced different ranges of stress when studying.[197] The chiropractic leaders and colleges have had internal struggles.[198] Rather than cooperation, there has been infighting between different factions.[198] A number of actions were posturing due to the confidential nature of the chiropractic colleges in an attempt to enroll students.[198][clarification needed]

Ethics

Main article: Chiropractic professional ethics

The chiropractic oath is a modern variation of the classical Hippocratic Oath historically taken by physicians and other healthcare professionals swearing to practice their professions ethically.[199] The American Chiropractic Association (ACA) has an ethical code "based upon the acknowledgement that the social contract dictates the profession's responsibilities to the patient, the public, and the profession; and upholds the fundamental principle that the paramount purpose of the chiropractic doctor's professional services shall be to benefit the patient."[200] The International Chiropractor's Association (ICA) also has a set of professional canons.[201]

A 2008 commentary proposed that the chiropractic profession actively regulate itself to combat abuse, fraud, and quackery, which are more prevalent in chiropractic than in other health care professions, violating the social contract between patients and physicians.[36] According to a 2015 Gallup poll of U.S. adults, the perception of chiropractors is generally favorable; two-thirds of American adults agree that chiropractors have their patient's best interest in mind and more than half also agree that most chiropractors are trustworthy. Less than 10% of US adults disagreed with the statement that chiropractors were trustworthy.[202][203]

 
The charity Sense about Science launched a campaign to draw attention to the BCA legal case against science writer Simon Singh.[204] In 2009, a number of organizations and public figures signed a statement entitled "The law has no place in scientific disputes".[205]

Chiropractors, especially in America, have a reputation for unnecessarily treating patients.[57] In many circumstances the focus seems to be put on economics instead of health care.[57] Sustained chiropractic care is promoted as a preventive tool, but unnecessary manipulation could possibly present a risk to patients.[8] Some chiropractors are concerned by the routine unjustified claims chiropractors have made.[8] A 2010 analysis of chiropractic websites found the majority of chiropractors and their associations made claims of effectiveness not supported by scientific evidence, while 28% of chiropractor websites advocate lower back pain care, which has some sound evidence.[206]

The US Office of the Inspector General (OIG) estimated that for calendar year 2013, 82% of payments to chiropractors under Medicare Part B, a total of $359 million, did not comply with Medicare requirements.[207] There have been at least 15 OIG reports about chiropractic billing irregularities since 1986.[207]

In 2009, a backlash to the libel suit filed by the British Chiropractic Association (BCA) against Simon Singh inspired the filing of formal complaints of false advertising against more than 500 individual chiropractors within one 24-hour period,[208][209] prompting the McTimoney Chiropractic Association to write to its members advising them to remove leaflets that make claims about whiplash and colic from their practice, to be wary of new patients and telephone inquiries, and telling their members: "If you have a website, take it down NOW" and "Finally, we strongly suggest you do NOT discuss this with others, especially patients."[208] An editorial in Nature suggested that the BCA may have been trying to suppress debate and that this use of English libel law was a burden on the right to freedom of expression, which is protected by the European Convention on Human Rights.[210] The libel case ended with the BCA withdrawing its suit in 2010.[211][212]

Reception

Chiropractic is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries.[18] It is viewed as a marginal and non-clinically–proven attempt at complementary and alternative medicine, which has not integrated into mainstream medicine.[64]

Australia

In Australia, there are approximately 2488 chiropractors, or one chiropractor for every 7980 people.[213] Most private health insurance funds in Australia cover chiropractic care, and the federal government funds chiropractic care when the patient is referred by a medical practitioner.[214] In 2014, the chiropractic profession had a registered workforce of 4,684 practitioners in Australia represented by two major organizations – the Chiropractors' Association of Australia (CAA) and the Chiropractic and Osteopathic College of Australasia (COCA).[215] Annual expenditure on chiropractic care (alone or combined with osteopathy) in Australia is estimated to be between AUD$750–988 million with musculoskeletal complaints such as back and neck pain making up the bulk of consultations; and proportional expenditure is similar to that found in other countries.[215] While Medicare (the Australian publicly funded universal health care system) coverage of chiropractic services is limited to only those directed by a medical referral to assist chronic disease management, most private health insurers in Australia do provide partial reimbursement for a wider range of chiropractic services in addition to limited third party payments for workers compensation and motor vehicle accidents.[215]

Of the 2,005 chiropractors who participated in a 2015 survey, 62.4% were male and the average age was 42.1 (SD = 12.1) years.[215] Nearly all chiropractors (97.1%) had a bachelor's degree or higher, with the majority of chiropractor's highest professional qualification being a bachelor or double bachelor's degree (34.6%), followed by a master's degree (32.7%), Doctor of Chiropractic (28.9%) or PhD (0.9%).[215] Only a small number of chiropractor's highest professional qualification was a diploma (2.1%) or advanced diploma (0.8%).[215]

United Kingdom

In the United Kingdom, there are over 2,000 chiropractors, representing one chiropractor per 29,206 people.[213] Chiropractic is available on the National Health Service in some areas, such as Cornwall, where the treatment is only available for neck or back pain.[216]

A 2010 study by questionnaire presented to UK chiropractors indicated only 45% of chiropractors disclosed to patients the serious risk associated with manipulation of the cervical spine and that 46% believed there was possibility patients would refuse treatment if the risks were correctly explained. However 80% acknowledged the ethical/moral responsibility to disclose risk to patients.[217]

United States and Canada

The percentage of the population that utilizes chiropractic care at any given time generally falls into a range from 6% to 12% in the U.S. and Canada,[218] with a global high of 20% in Alberta in 2006.[219] In 2008, chiropractors were reported to be the most common CAM providers for children and adolescents, these patients representing up to 14% of all visits to chiropractors.[220]

There were around 50,330 chiropractors practicing in North America in 2000.[213] In 2008, this has increased by almost 20% to around 60,000 chiropractors.[8] In 2002–03, the majority of those who sought chiropractic did so for relief from back and neck pain and other neuromusculoskeletal complaints;[20] most do so specifically for low back pain.[20][218] The majority of U.S. chiropractors participate in some form of managed care.[9] Although the majority of U.S. chiropractors view themselves as specialists in neuromusculoskeletal conditions, many also consider chiropractic as a type of primary care.[9] In the majority of cases, the care that chiropractors and physicians provide divides the market, however for some, their care is complementary.[9]

In the U.S., chiropractors perform over 90% of all manipulative treatments.[221] Satisfaction rates are typically higher for chiropractic care compared to medical care, with a 1998 U.S. survey reporting 83% of respondents satisfied or very satisfied with their care; quality of communication seems to be a consistent predictor of patient satisfaction with chiropractors.[222]

Utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient.[1] The use of chiropractic declined from 9.9% of U.S. adults in 1997 to 7.4% in 2002; this was the largest relative decrease among CAM professions, which overall had a stable use rate.[223] As of 2007 7% of the U.S. population is being reached by chiropractic.[224] They were the third largest medical profession in the US in 2002, following physicians and dentists.[225] Employment of U.S. chiropractors was expected to increase 14% between 2006 and 2016, faster than the average for all occupations.[194]

In the U.S., most states require insurers to cover chiropractic care, and most HMOs cover these services.[220]

History

Main article: History of chiropractic
 
Daniel David (D. D.) Palmer, founder of chiropractic

Chiropractic's origins lie in the folk medicine practice of bonesetting, in which untrained practitioners engaged in joint manipulation or resetting fractured bones.[8] Chiropractic was founded in 1895 by Daniel David (D. D.) Palmer in Davenport, Iowa. Palmer, a magnetic healer, hypothesized that manual manipulation of the spine could cure disease.[226] The first chiropractic patient of D. D. Palmer was Harvey Lillard, a worker in the building where Palmer's office was located.[42] He claimed that he had severely reduced hearing for 17 years, which started shortly following a "pop" in his spine.[42] A few days following his adjustment, Lillard claimed his hearing was almost completely restored.[42] Another of Palmer's patients, Samuel Weed, coined the term chiropractic, from Greek χειρο- chiro- 'hand' (itself from χείρ cheir 'hand') and πρακτικός praktikos 'practical'.[227][228] Chiropractic is classified as a field of pseudomedicine on account of its esoteric origins.[3]

Chiropractic competed with its predecessor osteopathy, another medical system based on magnetic healing; both systems were founded by charismatic midwesterners in opposition to the conventional medicine of the day, and both postulated that manipulation improved health.[226] Although initially keeping chiropractic a family secret, in 1898 Palmer began teaching it to a few students at his new Palmer School of Chiropractic.[22] One student, his son Bartlett Joshua (B. J.) Palmer, became committed to promoting chiropractic, took over the Palmer School in 1906, and rapidly expanded its enrollment.[22]

Early chiropractors believed that all disease was caused by interruptions in the flow of innate intelligence, a vitalistic nervous energy or life force that represented God's presence in man; chiropractic leaders often invoked religious imagery and moral traditions.[22] D. D. Palmer said he "received chiropractic from the other world".[23] D. D. and B. J. both seriously considered declaring chiropractic a religion, which might have provided legal protection under the U.S. constitution, but decided against it partly to avoid confusion with Christian Science.[22][23] Early chiropractors also tapped into the Populist movement, emphasizing craft, hard work, competition, and advertisement, aligning themselves with the common man against intellectuals and trusts, among which they included the American Medical Association (AMA).[22]

 
B. J. Palmer, early developer of chiropractic

Chiropractic has seen considerable controversy and criticism.[25][26] Although D. D. and B. J. were "straight" and disdained the use of instruments, some early chiropractors, whom B. J. scornfully called "mixers", advocated the use of instruments.[22] In 1910, B. J. changed course and endorsed X-rays as necessary for diagnosis; this resulted in a significant exodus from the Palmer School of the more conservative faculty and students.[22] The mixer camp grew until by 1924 B. J. estimated that only 3,000 of the United States' 25,000 chiropractors remained straight.[22] That year, B. J.'s invention and promotion of the neurocalometer, a temperature-sensing device, was highly controversial among B. J.'s fellow straights. By the 1930s, chiropractic was the largest alternative healing profession in the U.S.[22]

 
Harvey Lillard, first chiropractic patient

Chiropractors faced heavy opposition from organized medicine.[42] D. D. Palmer was jailed in 1907 for practicing medicine without a license.[229][full citation needed] Thousands of chiropractors were prosecuted for practicing medicine without a license, and D. D. and many other chiropractors were jailed.[42] To defend against medical statutes, B. J. argued that chiropractic was separate and distinct from medicine, asserting that chiropractors "analyzed" rather than "diagnosed", and "adjusted" subluxations rather than "treated" disease.[42] B. J. cofounded the Universal Chiropractors' Association (UCA) to provide legal services to arrested chiropractors.[42] Although the UCA won their first test case in Wisconsin in 1907, prosecutions instigated by state medical boards became increasingly common and in many cases were successful. In response, chiropractors conducted political campaigns to secure separate licensing statutes, eventually succeeding in all fifty states, from Kansas in 1913 through Louisiana in 1974.[42] The longstanding feud between chiropractors and medical doctors continued for decades. The AMA labeled chiropractic an "unscientific cult" in 1966,[30] and until 1980 advised its members that it was unethical for medical doctors to associate with "unscientific practitioners".[230] This culminated in a landmark 1987 decision, Wilk v. AMA, in which the court found that the AMA had engaged in unreasonable restraint of trade and conspiracy, and which ended the AMA's de facto boycott of chiropractic.[9]

Serious research to test chiropractic theories did not begin until the 1970s, and is continuing to be hampered by antiscientific and pseudoscientific ideas that sustained the profession in its long battle with organized medicine.[42] By the mid-1990s there was a growing scholarly interest in chiropractic, which helped efforts to improve service quality and establish clinical guidelines that recommended manual therapies for acute low back pain.[42] In recent decades chiropractic gained legitimacy and greater acceptance by medical physicians and health plans, and enjoyed a strong political base and sustained demand for services.[9] However, its future seemed uncertain: as the number of practitioners grew, evidence-based medicine insisted on treatments with demonstrated value, managed care restricted payment, and competition grew from massage therapists and other health professions.[9] The profession responded by marketing natural products and devices more aggressively, and by reaching deeper into alternative medicine and primary care.[9]

Public health

Further information: Vaccine controversy § Alternative medicine, and Water fluoridation controversy

Some chiropractors oppose vaccination and water fluoridation, which are common public health practices.[36] Within the chiropractic community there are significant disagreements about vaccination, one of the most cost-effective public health interventions available.[231] Most chiropractic writings on vaccination focus on its negative aspects,[28] claiming that it is hazardous, ineffective, and unnecessary.[29] Some chiropractors have embraced vaccination, but a significant portion of the profession rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that vaccines interfere with healing.[29] The extent to which anti-vaccination views perpetuate the current chiropractic profession is uncertain.[28] The American Chiropractic Association and the International Chiropractors 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.[29] The Canadian Chiropractic Association supports vaccination;[28] a survey in Alberta in 2002 found that 25% of chiropractors advised patients for, and 27% against, vaccinating themselves or their children.[232]

Early opposition to water fluoridation included chiropractors, some of whom continue to oppose it as being incompatible with chiropractic philosophy and an infringement of personal freedom. Other chiropractors have actively promoted fluoridation, and several chiropractic organizations have endorsed scientific principles of public health.[233] In addition to traditional chiropractic opposition to water fluoridation and vaccination, chiropractors' attempts to establish a positive reputation for their public health role are also compromised by their reputation for recommending repetitive lifelong chiropractic treatment.[36]

Controversy

Main article: Chiropractic controversy and criticism

Throughout its history chiropractic has been the subject of internal and external controversy and criticism.[21][234] According to Daniel D. Palmer, the founder of chiropractic, subluxation is the sole cause of disease and manipulation is the cure for all diseases of the human race.[8][50] A 2003 profession-wide survey[43] found "most chiropractors (whether 'straights' or 'mixers') still hold views of innate intelligence and of the cause and cure of disease (not just back pain) consistent with those of the Palmers."[235] A critical evaluation stated "Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today."[8] Chiropractors, including D. D. Palmer, were jailed for practicing medicine without a license.[8] For most of its existence, chiropractic has battled with mainstream medicine, sustained by antiscientific and pseudoscientific ideas such as subluxation.[42] Collectively, systematic reviews have not demonstrated that spinal manipulation, the main treatment method employed by chiropractors, is effective for any medical condition, with the possible exception of treatment for back pain.[8] Chiropractic remains controversial, though to a lesser extent than in past years.[25]

See also

References

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  2. ^ a b c d e f g h Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T (2005). "Chiropractic as spine care: a model for the profession". Chiropractic & Osteopathy. 13 (1): 9. doi:10.1186/1746-1340-13-9. PMC 1185558. PMID 16000175.
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    • Ernst, Edzard (2009-04-01). "Complementary/alternative medicine: engulfed by postmodernism, anti-science and regressive thinking". The British Journal of General Practice. 59 (561): 298–301. doi:10.3399/bjgp09X420482. ISSN 0960-1643. PMC 2662117. PMID 19341568.
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    • Williams, William F. (2000). Encyclopedia of Pseudoscience: From Alien Abductions to Zone Therapy. Facts on File Inc. p. 51. ISBN 1-57958-207-9
  5. ^ a b Mootz RD, Shekelle PG (1997). "Content of practice". In Cherkin DC, Mootz RD (eds.). Chiropractic in the United States: Training, Practice, and Research. Rockville, MD: Agency for Health Care Policy and Research. pp. 67–91. OCLC 39856366. AHCPR Pub No. 98-N002.
  6. ^ "The DC as PCP? Drug Wars Resume – Science-Based Medicine". sciencebasedmedicine.org. 2019-12-18. from the original on 2019-12-18. Retrieved 2020-03-27.
  7. ^ Bellamy, Jann (December 20, 2018). "Legislative Alchemy 2018: Chiropractors rebranding as primary care physicians continues". sciencebasedmedicine.org. from the original on December 19, 2019. Retrieved 2019-12-18.
  8. ^ a b c d e f g h i j k l m n o p q r s t Ernst E (May 2008). "Chiropractic: a critical evaluation". Journal of Pain and Symptom Management. 35 (5): 544–62. doi:10.1016/j.jpainsymman.2007.07.004. PMID 18280103.
  9. ^ a b c d e f g h i j k l Cooper RA, McKee HJ (2003). "Chiropractic in the United States: trends and issues". Milbank Quarterly. 81 (1): 107–38, table of contents. doi:10.1111/1468-0009.00040. PMC 2690192. PMID 12669653.
  10. ^ a b Posadzki P, Ernst E (2011). "Spinal manipulation: an update of a systematic review of systematic reviews". The New Zealand Medical Journal. 124 (1340): 55–71. PMID 21952385.
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Further reading

  • Long PH (2013). Barrett S (ed.). Chiropractic Abuse: An Insider's Lament. American Council on Science & Health. ISBN 978-0-9727094-9-1.
  • Homola S (2002). "Chiropractic: Conventional or Alternative Healing?". In Shermer M (ed.). The Skeptic Encyclopedia of Pseudoscience. Vol. 1. ABC-CLIO. pp. 308–. ISBN 978-1-57607-653-8.
  • Menke JM (January 2014). "Do Manual Therapies Help Low Back Pain?: A Comparative Effectiveness Meta-Analysis". Spine (Meta-analysis). 39 (7): E463–72. doi:10.1097/BRS.0000000000000230. PMID 24480940. S2CID 25497624.

External links

April 10, 2023
chiropractic, form, alternative, medicine, concerned, with, diagnosis, treatment, prevention, mechanical, disorders, musculoskeletal, system, especially, spine, esoteric, origins, based, several, pseudoscientific, ideas, alternative, medicinea, chiropractor, p. Chiropractic is a form of alternative medicine 1 concerned with the diagnosis treatment and prevention of mechanical disorders of the musculoskeletal system especially of the spine 2 It has esoteric origins 3 and is based on several pseudoscientific ideas 4 ChiropracticAlternative medicineA chiropractor performing a vertebral adjustmentClaimsVertebral subluxation spinal adjustment Innate IntelligenceRisksVertebral artery dissection stroke compression fracture deathRelated fieldsOsteopathy vitalismOriginal proponentsD D PalmerSubsequent proponentsB J PalmerMeSHD002684Many chiropractors especially those in the field s early history have proposed that mechanical disorders of the joints especially of the spine affect general health 2 and that regular manipulation of the spine spinal adjustment improves general health The main chiropractic treatment technique involves manual therapy especially manipulation of the spine other joints and soft tissues but may also include exercises and health and lifestyle counseling 5 A chiropractor may have a Doctor of Chiropractic D C degree and be referred to as doctor but is not a Doctor of Medicine M D 6 7 While many chiropractors view themselves as primary care providers 8 9 chiropractic clinical training does not meet the requirements for that designation 2 Systematic reviews of controlled clinical studies of treatments used by chiropractors have found no evidence that chiropractic manipulation is effective with the possible exception of treatment for back pain 8 A 2011 critical evaluation of 45 systematic reviews concluded that the data included in the study fail ed to demonstrate convincingly that spinal manipulation is an effective intervention for any condition 10 Spinal manipulation may be cost effective for sub acute or chronic low back pain but the results for acute low back pain were insufficient 11 No compelling evidence exists to indicate that maintenance chiropractic care adequately prevents symptoms or diseases 12 There is not sufficient data to establish the safety of chiropractic manipulations 13 It is frequently associated with mild to moderate adverse effects with serious or fatal complications in rare cases 14 There is controversy regarding the degree of risk of vertebral artery dissection which can lead to stroke and death from cervical manipulation 15 Several deaths have been associated with this technique 14 and it has been suggested that the relationship is causative 16 17 a claim which is disputed by many chiropractors 17 Chiropractic is well established in the United States Canada and Australia 18 It overlaps with other manual therapy professions such as osteopathy and physical therapy 19 Most who seek chiropractic care do so for low back pain 20 Back and neck pain are considered the specialties of chiropractic but many chiropractors treat ailments other than musculoskeletal issues 8 Chiropractic has two main groups straights now the minority emphasize vitalism Innate Intelligence and consider vertebral subluxations to be the cause of all disease and mixers the majority are more open to mainstream views and conventional medical techniques such as exercise massage and ice therapy 21 D D Palmer founded chiropractic in the 1890s 22 after saying he received it from the other world 23 Palmer maintained that the tenets of chiropractic were passed along to him by a doctor who had died 50 years previously 24 His son B J Palmer helped to expand chiropractic in the early 20th century 22 Throughout its history chiropractic has been controversial 25 26 Its foundation is at odds with evidence based medicine and has been sustained by pseudoscientific ideas such as vertebral subluxation and Innate Intelligence 27 Despite the overwhelming evidence that vaccination is an effective public health intervention among chiropractors there are significant disagreements over the subject 28 which has led to negative impacts on both public vaccination and mainstream acceptance of chiropractic 29 The American Medical Association called chiropractic an unscientific cult in 1966 30 and boycotted it until losing an antitrust case in 1987 9 Chiropractic has had a strong political base and sustained demand for services In the last decades of the twentieth century it gained more legitimacy and greater acceptance among conventional physicians and health plans in the United States 9 During the COVID 19 pandemic chiropractic professional associations advised chiropractors to adhere to CDC WHO and local health department guidance 31 32 Despite these recommendations a small but vocal and influential number of chiropractors spread vaccine misinformation 33 Contents 1 Conceptual basis 1 1 Philosophy 1 2 Straights and mixers 1 3 Vertebral subluxation 1 4 Pseudoscience versus spinal manipulation therapy 2 Scope of practice 3 Treatments 3 1 Practice guidelines 3 2 Effectiveness 3 3 Safety 3 4 Risk benefit 3 5 Cost effectiveness 4 Education licensing and regulation 4 1 Ethics 5 Reception 5 1 Australia 5 2 United Kingdom 5 3 United States and Canada 6 History 7 Public health 8 Controversy 9 See also 10 References 11 Further reading 12 External linksConceptual basisPhilosophy Chiropractic is generally categorized as complementary and alternative medicine CAM 1 which focuses on manipulation of the musculoskeletal system especially the spine 2 Its founder D D Palmer called it a science of healing without drugs 8 Chiropractic s origins lie in the folk medicine of bonesetting 8 and as it evolved it incorporated vitalism spiritual inspiration and rationalism 34 Its early philosophy was based on deduction from irrefutable doctrine which helped distinguish chiropractic from medicine provided it with legal and political defenses against claims of practicing medicine without a license and allowed chiropractors to establish themselves as an autonomous profession 34 This straight philosophy taught to generations of chiropractors rejects the inferential reasoning of the scientific method 34 and relies on deductions from vitalistic first principles rather than on the materialism of science 35 However most practitioners tend to incorporate scientific research into chiropractic 34 and most practitioners are mixers who attempt to combine the materialistic reductionism of science with the metaphysics of their predecessors and with the holistic paradigm of wellness 35 A 2008 commentary proposed that chiropractic actively divorce itself from the straight philosophy as part of a campaign to eliminate untestable dogma and engage in critical thinking and evidence based research 36 Two chiropractic belief system constructs The testable principle The untestable metaphorChiropractic adjustment Restoration of structural integrity Improvement of health status Universal intelligence Innate intelligence Body physiologyMaterialistic Vitalistic Operational definitions possibleLends itself to scientific inquiry Origin of holism in chiropracticCannot be proven or disprovenTaken from Mootz amp Phillips 1997 35 Although a wide diversity of ideas exist among chiropractors 34 they share the belief that the spine and health are related in a fundamental way and that this relationship is mediated through the nervous system 37 Some chiropractors claim spinal manipulation can have an effect on a variety of ailments such as irritable bowel syndrome and asthma 38 Chiropractic philosophy includes the following perspectives 35 Holism assumes that health is affected by everything in an individual s environment some sources also include a spiritual or existential dimension 39 In contrast reductionism in chiropractic reduces causes and cures of health problems to a single factor vertebral subluxation 36 Homeostasis emphasizes the body s inherent self healing abilities Chiropractic s early notion of innate intelligence can be thought of as a metaphor for homeostasis 34 A large number of chiropractors fear that if they do not separate themselves from the traditional vitalistic concept of innate intelligence chiropractic will continue to be seen as a fringe profession 21 A variant of chiropractic called naprapathy originated in Chicago in the early twentieth century 40 41 It holds that manual manipulation of soft tissue can reduce interference in the body and thus improve health 41 Straights and mixers Range of belief perspectives in chiropractic Perspective attribute Potential belief endpointsScope of practice narrow straight broad mixer Diagnostic approach intuitive analyticalPhilosophic orientation vitalistic materialisticScientific orientation descriptive experimentalProcess orientation implicit explicitPractice attitude doctor model centered patient situation centeredProfessional integration separate and distinct integrated into mainstreamTaken from Mootz amp Phillips 1997 35 Straight chiropractors adhere to the philosophical principles set forth by D D and B J Palmer and retain metaphysical definitions and vitalistic qualities 42 Straight chiropractors believe that vertebral subluxation leads to interference with an innate intelligence exerted via the human nervous system and is a primary underlying risk factor for many diseases 42 Straights view the medical diagnosis of patient complaints which they consider to be the secondary effects of subluxations to be unnecessary for chiropractic treatment 42 Thus straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not mix other types of therapies into their practice style 42 Their philosophy and explanations are metaphysical in nature and they prefer to use traditional chiropractic lexicon terminology such as perform spinal analysis detect subluxation correct with adjustment 21 They prefer to remain separate and distinct from mainstream health care 21 Although considered the minority group they have been able to transform their status as purists and heirs of the lineage into influence dramatically out of proportion to their numbers 21 Mixer chiropractors mix diagnostic and treatment approaches from chiropractic medical or osteopathic viewpoints and make up the majority of chiropractors 21 Unlike straight chiropractors mixers believe subluxation is one of many causes of disease and hence they tend to be open to mainstream medicine 21 Many of them incorporate mainstream medical diagnostics and employ conventional treatments including techniques of physical therapy such as exercise stretching massage ice packs electrical muscle stimulation therapeutic ultrasound and moist heat 21 Some mixers also use techniques from alternative medicine including nutritional supplements acupuncture homeopathy herbal remedies and biofeedback 21 Although mixers are the majority group many of them retain belief in vertebral subluxation as shown in a 2003 survey of 1 100 North American chiropractors which found that 88 percent wanted to retain the term vertebral subluxation complex and that when asked to estimate the percent of disorders of internal organs that subluxation significantly contributes to the mean response was 62 percent 43 A 2008 survey of 6 000 American chiropractors demonstrated that most chiropractors seem to believe that a subluxation based clinical approach may be of limited utility for addressing visceral disorders and greatly favored non subluxation based clinical approaches for such conditions 44 The same survey showed that most chiropractors generally believed that the majority of their clinical approach for addressing musculoskeletal biomechanical disorders such as back pain was based on subluxation 44 Chiropractors often offer conventional therapies such as physical therapy and lifestyle counseling and it may for the lay person be difficult to distinguish the unscientific from the scientific 45 Vertebral subluxation Main article Vertebral subluxation Not to be confused with subluxation the medical condition In science based medicine the term subluxation refers to an incomplete or partial dislocation of a joint from the Latin luxare for dislocate 46 47 While medical doctors use the term exclusively to refer to physical dislocations Chiropractic founder D D Palmer imbued the word subluxation with a metaphysical and philosophical meaning drawn from pseudoscientific traditions such as Vitalism 48 Palmer claimed that vertebral subluxations interfered with the body s function and its inborn ability to heal itself 49 D D Palmer repudiated his earlier theory that vertebral subluxations caused pinched nerves in the intervertebral spaces in favor of subluxations causing altered nerve vibration either too tense or too slack affecting the tone health of the end organ 48 He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic 48 This concept was later expanded upon by his son B J Palmer and was instrumental in providing the legal basis of differentiating chiropractic from conventional medicine In 1910 D D Palmer theorized that the nervous system controlled health Physiologists divide nerve fibers which form the nerves into two classes afferent and efferent Impressions are made on the peripheral afferent fiber endings these create sensations that are transmitted to the center of the nervous system Efferent nerve fibers carry impulses out from the center to their endings Most of these go to muscles and are therefore called motor impulses some are secretory and enter glands a portion are inhibitory their function being to restrain secretion Thus nerves carry impulses outward and sensations inward The activity of these nerves or rather their fibers may become excited or allayed by impingement the result being a modification of functionality too much or not enough action which is disease 50 Chiropractors use x ray radiography to examine the bone structure of a patient Vertebral subluxation a core concept of traditional chiropractic remains unsubstantiated and largely untested and a debate about whether to keep it in the chiropractic paradigm has been ongoing for decades 51 In general critics of traditional subluxation based chiropractic including chiropractors are skeptical of its clinical value dogmatic beliefs and metaphysical approach While straight chiropractic still retains the traditional vitalistic construct espoused by the founders evidence based chiropractic suggests that a mechanistic view will allow chiropractic care to become integrated into the wider health care community 51 This is still a continuing source of debate within the chiropractic profession as well with some schools of chiropractic still teaching the traditional straight subluxation based chiropractic while others have moved towards an evidence based chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions 52 53 In 2005 the chiropractic subluxation was defined by the World Health Organization 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 54 It is essentially a functional entity which may influence biomechanical and neural integrity 54 This differs from the medical definition of subluxation as a significant structural displacement which can be seen with static imaging techniques such as X rays 54 The use of X ray imaging in the case of vertebral subluxation exposes patients to harmful ionizing radiation for no evidentially supported reason 55 56 The 2008 book Trick or Treatment states X rays can reveal neither the subluxations nor the innate intelligence associated with chiropractic philosophy because they do not exist 57 Attorney David Chapman Smith Secretary General of the World Federation of Chiropractic has stated that Medical critics have asked how there can be a subluxation if it cannot be seen on X ray The answer is that the chiropractic subluxation is essentially a functional entity not structural and is therefore no more visible on static X ray than a limp or headache or any other functional problem 58 The General Chiropractic Council the statutory regulatory body for chiropractors in the United Kingdom states that the chiropractic vertebral subluxation complex is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease 59 As of 2014 the US National Board of Chiropractic Examiners states The specific focus of chiropractic practice is known as the chiropractic subluxation or joint dysfunction A subluxation is a health concern that manifests in the skeletal joints and through complex anatomical and physiological relationships affects the nervous system and may lead to reduced function disability or illness 60 27 Pseudoscience versus spinal manipulation therapy Main articles Spinal adjustment and Spinal manipulation While some chiropractors limit their practice to short term treatment of musculoskeletal conditions many falsely claim to be able treat a myriad of other conditions 61 62 Some dissuade patients from seeking medical care others have pretended to be qualified to act as a family doctor 61 Quackwatch an alternative medicine watchdog cautions against seeing chiropractors who 61 63 Treat young children Discourage immunization Pretend to be a family doctor Take full spine X rays Promote unproven dietary supplements Are antagonistic to scientific medicine Claim to treat non musculoskeletal problemsWriting for the Skeptical Inquirer one physician cautioned against seeing even chiropractors who solely claim to treat musculoskeletal conditions I think Spinal Manipulation Therapy SMT is a reasonable option for patients to try But I could not in good conscience refer a patient to a chiropractor When chiropractic is effective what is effective is not chiropractic it is SMT SMT is also offered by physical therapists DOs and others These are science based providers If I thought a patient might benefit from manipulation I would rather refer him or her to a science based provider 61 Scope of practice A treatment table at a chiropractic office Chiropractors emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery 54 with special emphasis on the spine 2 Back and neck pain are the specialties of chiropractic but many chiropractors treat ailments other than musculoskeletal issues 8 There is a range of opinions among chiropractors some believed that treatment should be confined to the spine or back and neck pain others disagreed 64 For example while one 2009 survey of American chiropractors had found that 73 classified themselves as back pain musculoskeletal specialists the label back and neck pain specialists was regarded by 47 of them as a least desirable description in a 2005 international survey 64 Chiropractic combines aspects from mainstream and alternative medicine and there is no agreement about how to define the profession although chiropractors have many attributes of primary care providers chiropractic has more attributes of a medical specialty like dentistry or podiatry 65 It has been proposed that chiropractors specialize in nonsurgical spine care instead of attempting to also treat other problems 36 65 but the more expansive view of chiropractic is still widespread 66 Mainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be complementary and alternative medicine CAM 1 and a 2008 study reported that 31 of surveyed chiropractors categorized chiropractic as CAM 27 as integrated medicine and 12 as mainstream medicine 67 Many chiropractors believe they are primary care providers 8 9 including US 68 and UK chiropractors 69 but the length breadth and depth of chiropractic clinical training do not support the requirements to be considered primary care providers 2 so their role on primary care is limited and disputed 2 9 Chiropractic overlaps with several other forms of manual therapy including massage therapy osteopathy physical therapy and sports medicine 19 70 Chiropractic is autonomous from and competitive with mainstream medicine 71 and osteopathy outside the US remains primarily a manual medical system 72 physical therapists work alongside and cooperate with mainstream medicine and osteopathic medicine in the U S has merged with the medical profession 71 Practitioners may distinguish these competing approaches through claims that compared to other therapists chiropractors heavily emphasize spinal manipulation tend to use firmer manipulative techniques and promote maintenance care that osteopaths use a wider variety of treatment procedures and that physical therapists emphasize machinery and exercise 19 Chiropractic diagnosis may involve a range of methods including skeletal imaging observational and tactile assessments and orthopedic and neurological evaluation 54 A chiropractor may also refer a patient to an appropriate specialist or co manage with another health care provider 65 Common patient management involves spinal manipulation SM and other manual therapies to the joints and soft tissues rehabilitative exercises health promotion electrical modalities complementary procedures and lifestyle advice 5 A chiropractic adjustment of a horse Chiropractors are not normally licensed to write medical prescriptions or perform major surgery in the United States 73 although New Mexico has become the first US state to allow advanced practice trained chiropractors to prescribe certain medications 74 75 In the US their scope of practice varies by state based on inconsistent views of chiropractic care some states such as Iowa broadly allow treatment of human ailments some such as Delaware use vague concepts such as transition of nerve energy to define scope of practice others such as New Jersey specify a severely narrowed scope 76 US states also differ over whether chiropractors may conduct laboratory tests or diagnostic procedures dispense dietary supplements or use other therapies such as homeopathy and acupuncture in Oregon they can become certified to perform minor surgery and to deliver children via natural childbirth 73 A 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for over the counter drugs 43 A 2010 survey found that 72 of Swiss chiropractors considered their ability to prescribe nonprescription medication as an advantage for chiropractic treatment 77 A related field veterinary chiropractic applies manual therapies to animals and is recognized in many US states 78 but is not recognized by the American Chiropractic Association as being chiropractic 79 It remains controversial within certain segments of the veterinary and chiropractic professions 80 No single profession owns spinal manipulation and there is little consensus as to which profession should administer SM raising concerns by chiropractors that other medical physicians could steal SM procedures from chiropractors 81 A focus on evidence based SM research has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks 81 Two US states Washington and Arkansas prohibit physical therapists from performing SM 82 some states allow them to do it only if they have completed advanced training in SM and some states allow only chiropractors to perform SM or only chiropractors and physicians Bills to further prohibit non chiropractors from performing SM are regularly introduced into state legislatures and are opposed by physical therapist organizations 83 TreatmentsMain articles Chiropractic treatment techniques and Spinal adjustment A chiropractor performs an adjustment on a patient Spinal manipulation which chiropractors call spinal adjustment or chiropractic adjustment is the most common treatment used in chiropractic care 84 Spinal manipulation is a passive manual maneuver during which a three joint complex is taken past the normal range of movement but not so far as to dislocate or damage the joint 85 Its defining factor is a dynamic thrust which is a sudden force that causes an audible release and attempts to increase a joint s range of motion 85 High velocity low amplitude spinal manipulation HVLA SM thrusts have physiological effects that signal neural discharge from paraspinal muscle tissues depending on duration and amplitude of the thrust are factors of the degree in paraspinal muscle spindles activation 86 Clinical skill in employing HVLA SM thrusts depends on the ability of the practitioner to handle the duration and magnitude of the load 86 More generally spinal manipulative therapy SMT describes techniques where the hands are used to manipulate massage mobilize adjust stimulate apply traction to or otherwise influence the spine and related tissues 85 There are several schools of chiropractic adjustive techniques although most chiropractors mix techniques from several schools The following adjustive procedures were received by more than 10 of patients of licensed US chiropractors in a 2003 survey 84 Diversified technique full spine manipulation employing various techniques extremity adjusting Activator technique which uses a spring loaded tool to deliver precise adjustments to the spine Thompson Technique which relies on a drop table and detailed procedural protocols Gonstead which emphasizes evaluating the spine along with specific adjustment that avoids rotational vectors Cox flexion distraction a gentle low force adjusting procedure which mixes chiropractic with osteopathic principles and utilizes specialized adjusting tables with movable parts adjustive instrument Sacro Occipital Technique which models the spine as a torsion bar Nimmo Receptor Tonus Technique applied kinesiology which emphasises muscle testing as a diagnostic tool and cranial 87 Chiropractic biophysics technique uses inverse functions of rotations during spinal manipulation 88 Koren Specific Technique KST may use their hands or they may use an electric device known as an ArthroStim for assessment and spinal manipulations 89 Insurers in the US and UK that cover other chiropractic techniques exclude KST from coverage because they consider it to be experimental and investigational 89 90 91 92 Medicine assisted manipulation such as manipulation under anesthesia involves sedation or local anesthetic and is done by a team that includes an anesthesiologist a 2008 systematic review did not find enough evidence to make recommendations about its use for chronic low back pain 93 Lumbar cervical and thoracic chiropractic spinal manipulation Many other procedures are used by chiropractors for treating the spine other joints and tissues and general health issues The following procedures were received by more than one third of patients of licensed US chiropractors in a 2003 survey Diversified technique full spine manipulation mentioned in previous paragraph physical fitness exercise promotion corrective or therapeutic exercise ergonomic postural advice self care strategies activities of daily living changing risky unhealthy behaviors nutritional dietary recommendations relaxation stress reduction recommendations ice pack cryotherapy extremity adjusting also mentioned in previous paragraph trigger point therapy and disease prevention early screening advice 84 A 2010 study describing Belgian chiropractors and their patients found chiropractors in Belgium mostly focus on neuromusculoskeletal complaints in adult patients with emphasis on the spine 94 The diversified technique is the most often applied technique at 93 followed by the Activator mechanical assisted technique at 41 94 A 2009 study assessing chiropractic students giving or receiving spinal manipulations while attending a United States chiropractic college found Diversified Gonstead and upper cervical manipulations are frequently used methods 95 Practice guidelines Reviews of research studies within the chiropractic community have been used to generate practice guidelines outlining standards that specify which chiropractic treatments are legitimate i e supported by evidence and conceivably reimbursable under managed care health payment systems 81 Evidence based guidelines are supported by one end of an ideological continuum among chiropractors the other end employs antiscientific reasoning and makes unsubstantiated claims 2 27 51 96 97 Chiropractic remains at a crossroads and that in order to progress it would need to embrace science the promotion by some for it to be a cure all was both misguided and irrational 98 A 2007 survey of Alberta chiropractors found that they do not consistently apply research in practice which may have resulted from a lack of research education and skills 99 Specific guidelines concerning the treatment of nonspecific i e unknown cause low back pain are inconsistent between countries 100 Effectiveness Numerous controlled clinical studies of treatments used by chiropractors have been conducted with varied results 8 There is no conclusive evidence that chiropractic manipulative treatment is effective for the treatment of any medical condition except perhaps for certain kinds of back pain 8 10 Generally the research carried out into the effectiveness of chiropractic has been of poor quality 101 102 Research published by chiropractors is distinctly biased reviews of SM for back pain tended to find positive conclusions when authored by chiropractors while reviews by mainstream authors did not 8 There is a wide range of ways to measure treatment outcomes 103 Chiropractic care benefits from the placebo response 104 but it is difficult to construct a trustworthy placebo for clinical trials of spinal manipulative therapy SMT 105 The efficacy of maintenance care in chiropractic is unknown 106 Available evidence covers the following conditions Low back pain A 2013 Cochrane review found very low to moderate evidence that SMT was no more effective than inert interventions sham SMT or as an adjunct therapy for acute low back pain 107 The same review found that SMT appears to be no better than other recommended therapies 107 A 2012 overview of systematic reviews found that collectively SM failed to show it is an effective intervention for pain 108 A 2011 Cochrane review found strong evidence that suggests there is no clinically meaningful difference between SMT and other treatments for reducing pain and improving function for chronic low back pain 109 A 2010 Cochrane review found no difference between the effects of combined chiropractic treatments and other treatments for chronic or mixed duration low back pain 110 A 2010 systematic review found that most studies suggest SMT achieves equivalent or superior improvement in pain and function when compared with other commonly used interventions for short intermediate and long term follow up 111 Radiculopathy A 2013 systematic review and meta analysis found a statistically significant improvement in overall recovery from sciatica following SM when compared to usual care and suggested that SM may be considered 112 There is moderate quality evidence to support the use of SM for the treatment of acute lumbar radiculopathy 113 and acute lumbar disc herniation with associated radiculopathy 114 There is low or very low evidence supporting SM for chronic lumbar spine related extremity symptoms and cervical spine related extremity symptoms of any duration and no evidence exists for the treatment of thoracic radiculopathy 113 Whiplash and other neck pain There is no consensus on the effectiveness of manual therapies for neck pain 115 A 2013 systematic review found that the data suggests that there are minimal short and long term treatment differences when comparing manipulation or mobilization of the cervical spine to physical therapy or exercise for neck pain improvement 116 A 2013 systematic review found that although there is insufficient evidence that thoracic SM is more effective than other treatments it is a suitable intervention to treat some patients with non specific neck pain 117 A 2011 systematic review found that thoracic SM may offer short term improvement for the treatment of acute or subacute mechanical neck pain although the body of literature is still weak 118 A 2010 Cochrane review found low quality evidence that suggests cervical manipulation may offer better short term pain relief than a control for neck pain and moderate evidence that cervical manipulation and mobilization produced similar effects on pain function and patient satisfaction 119 A 2010 systematic review found low level evidence that suggests chiropractic care improves cervical range of motion and pain in the management of whiplash 120 Headache There is conflicting evidence surrounding the use of chiropractic SMT for the treatment and prevention of migraine headaches 121 122 A 2006 review found no rigorous evidence supporting SM or other manual therapies for tension headache 123 A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache and that it was probably more effective for tension headache than for migraine 124 Extremity conditions A 2011 systematic review and meta analysis concluded that the addition of manual mobilizations to an exercise program for the treatment of knee osteoarthritis resulted in better pain relief than a supervised exercise program alone and suggested that manual therapists consider adding manual mobilization to optimize supervised active exercise programs 125 There is silver level evidence that manual therapy is more effective than exercise for the treatment of hip osteoarthritis however this evidence could be considered to be inconclusive 126 There is a small amount of research into the efficacy of chiropractic treatment for upper limbs 127 limited to low level evidence supporting chiropractic management of shoulder pain 128 and limited or fair evidence supporting chiropractic management of leg conditions 129 Other A 2012 systematic review found insufficient low bias evidence to support the use of spinal manipulation as a therapy for the treatment of hypertension 130 A 2011 systematic review found moderate evidence to support the use of manual therapy for cervicogenic dizziness 131 There is very weak evidence for chiropractic care for adult scoliosis curved or rotated spine 132 and no scientific data for idiopathic adolescent scoliosis 133 A 2007 systematic review found that few studies of chiropractic care for nonmusculoskeletal conditions are available and they are typically not of high quality it also found that the entire clinical encounter of chiropractic care as opposed to just SM provides benefit to patients with cervicogenic dizziness and that the evidence from reviews is negative or too weak to draw conclusions for a wide variety of other nonmusculoskeletal conditions including ADHD learning disabilities dizziness high blood pressure and vision conditions 134 Other reviews have found no evidence of significant benefit for asthma 135 136 baby colic 137 138 bedwetting 139 carpal tunnel syndrome 140 fibromyalgia 141 gastrointestinal disorders 142 kinetic imbalance due to suboccipital strain KISS in infants 137 143 menstrual cramps 144 insomnia 145 postmenopausal symptoms 145 or pelvic and back pain during pregnancy 146 As there is no evidence of effectiveness or safety for cervical manipulation for baby colic it is not endorsed 147 Safety Chiropractic adjustment on children The World Health Organization found chiropractic care in general is safe when employed skillfully and appropriately 54 There is not sufficient data to establish the safety of chiropractic manipulations 13 Manipulation is regarded as relatively safe but complications can arise and it has known adverse effects risks and contraindications 54 Absolute contraindications to spinal manipulative therapy are conditions that should not be manipulated these contraindications include rheumatoid arthritis and conditions known to result in unstable joints 54 Relative contraindications are conditions where increased risk is acceptable in some situations and where low force and soft tissue techniques are treatments of choice these contraindications include osteoporosis 54 Although most contraindications apply only to manipulation of the affected region some neurological signs indicate referral to emergency medical services these include sudden and severe headache or neck pain unlike that previously experienced 148 Indirect risks of chiropractic involve delayed or missed diagnoses through consulting a chiropractor 8 Spinal manipulation is associated with frequent mild and temporary adverse effects 14 148 including new or worsening pain or stiffness in the affected region 149 They have been estimated to occur in 33 to 61 of patients and frequently occur within an hour of treatment and disappear within 24 to 48 hours 13 adverse reactions appear to be more common following manipulation than mobilization 150 The most frequently stated adverse effects are mild headache soreness and briefly elevated pain fatigue 151 Chiropractic is correlated with a very high incidence of minor adverse effects 8 Rarely 54 spinal manipulation particularly on the upper spine can also result in complications that can lead to permanent disability or death these can occur in adults 14 and children 152 Estimates vary widely for the incidence of these complications 13 and the actual incidence is unknown due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke which is a particular concern 14 Adverse effects are poorly reported in recent studies investigating chiropractic manipulations 153 A 2016 systematic review concludes that the level of reporting is unsuitable and unacceptable 154 Reports of serious adverse events have occurred resulting from spinal manipulation therapy of the lumbopelvic region 155 Estimates for serious adverse events vary from 5 strokes per 100 000 manipulations to 1 46 serious adverse events per 10 million manipulations and 2 68 deaths per 10 million manipulations though it was determined that there was inadequate data to be conclusive 13 Several case reports show temporal associations between interventions and potentially serious complications 156 The published medical literature contains reports of 26 deaths since 1934 following chiropractic manipulations and many more seem to remain unpublished 17 Vertebrobasilar artery stroke VAS is statistically associated with chiropractic services in persons under 45 years of age but it is similarly associated with general practitioner services suggesting that these associations are likely explained by preexisting conditions 156 157 Weak to moderately strong evidence supports causation as opposed to statistical association between cervical manipulative therapy CMT and VAS 158 There is insufficient evidence to support a strong association or no association between cervical manipulation and stroke 15 While the biomechanical evidence is not sufficient to support the statement that CMT causes cervical artery dissection CD clinical reports suggest that mechanical forces have a part in a substantial number of CDs and the majority of population controlled studies found an association between CMT and VAS in young people 159 It is strongly recommended that practitioners consider the plausibility of CD as a symptom and people can be informed of the association between CD and CMT before administrating manipulation of the cervical spine 159 There is controversy regarding the degree of risk of stroke from cervical manipulation 15 Many chiropractors state that the association between chiropractic therapy and vertebral arterial dissection is not proven 17 However it has been suggested that the causality between chiropractic cervical manipulation beyond the normal range of motion and vascular accidents is probable 17 or definite 16 There is very low evidence supporting a small association between internal carotid artery dissection and chiropractic neck manipulation 160 The incidence of internal carotid artery dissection following cervical spine manipulation is unknown 161 The literature infrequently reports helpful data to better understand the association between cervical manipulative therapy cervical artery dissection and stroke 162 The limited evidence is inconclusive that chiropractic spinal manipulation therapy is not a cause of intracranial hypotension 163 Cervical intradural disc herniation is very rare following spinal manipulation therapy 164 Chiropractors like other primary care providers sometimes employ diagnostic imaging techniques such as X rays and CT scans that rely on ionizing radiation 165 Although there is no clear evidence for the practice some chiropractors may still X ray a patient several times a year 57 Practice guidelines aim to reduce unnecessary radiation exposure 165 which increases cancer risk in proportion to the amount of radiation received 166 Research suggests that radiology instruction given at chiropractic schools worldwide seem to be evidence based 56 Although there seems to be a disparity between some schools and available evidence regarding the aspect of radiography for patients with acute low back pain without an indication of a serious disease which may contribute to chiropractic overuse of radiography for low back pain 56 Risk benefit A 2012 systematic review concluded that no accurate assessment of risk benefit exists for cervical manipulation 15 A 2010 systematic review stated that there is no good evidence to assume that neck manipulation is an effective treatment for any medical condition and suggested a precautionary principle in healthcare for chiropractic intervention even if a causality with vertebral artery dissection after neck manipulation were merely a remote possibility 17 The same review concluded that the risk of death from manipulations to the neck outweighs the benefits 17 Chiropractors have criticized this conclusion claiming that the author did not evaluate the potential benefits of spinal manipulation 167 Edzard Ernst stated This detail was not the subject of my review I do however refer to such evaluations and should add that a report recently commissioned by the General Chiropractic Council did not support many of the outlandish claims made by many chiropractors across the world 167 A 1999 review of 177 previously reported cases published between 1925 and 1997 in which injuries were attributed to manipulation of the cervical spine MCS concluded that The literature does not demonstrate that the benefits of MCS outweigh the risks The professions associated with each injury were assessed Physical therapists PT were involved in less than 2 of all cases with no deaths caused by PTs Chiropractors were involved in a little more than 60 of all cases including 32 deaths 168 A 2009 review evaluating maintenance chiropractic care found that spinal manipulation is associated with considerable harm and no compelling evidence exists to indicate that it adequately prevents symptoms or diseases thus the risk benefit is not evidently favorable 12 Cost effectiveness A 2012 systematic review suggested that the use of spine manipulation in clinical practice is a cost effective treatment when used alone or in combination with other treatment approaches 169 A 2011 systematic review found evidence supporting the cost effectiveness of using spinal manipulation for the treatment of sub acute or chronic low back pain the results for acute low back pain were insufficient 11 A 2006 systematic cost effectiveness review found that the reported cost effectiveness of spinal manipulation in the United Kingdom compared favorably with other treatments for back pain but that reports were based on data from clinical trials without placebo controls and that the specific cost effectiveness of the treatment as opposed to non specific effects remains uncertain 170 A 2005 American systematic review of economic evaluations of conservative treatments for low back pain found that significant quality problems in available studies meant that definite conclusions could not be drawn about the most cost effective intervention 171 The cost effectiveness of maintenance chiropractic care is unknown 106 non primary source needed Analysis of a clinical and cost utilization data from the years 2003 to 2005 by an integrative medicine independent physician association IPA which looked the chiropractic services utilization found that the clinical and cost utilization of chiropractic services based on 70 274 member months over a 7 year period decreased patient costs associate with the following use of services by 60 for in hospital admissions 59 for hospital days 62 for outpatient surgeries and procedures and 85 for pharmaceutical costs when compared with conventional medicine visit to a medical doctor primary care provider IPA performance for the same health maintenance organization product in the same geography and time frame 172 Education licensing and regulationMain articles Chiropractic education and List of chiropractic schools Requirements vary between countries In the U S chiropractors obtain a non medical accredited diploma in the field of chiropractic 173 Chiropractic education in the U S has been criticized for failing to meet generally accepted standards of evidence based medicine 174 The curriculum content of North American chiropractic and medical colleges with regard to basic and clinical sciences has little similarity both in the kinds of subjects offered and in the time assigned to each subject 175 Accredited chiropractic programs in the U S require that applicants have 90 semester hours of undergraduate education with a grade point average of at least 3 0 on a 4 0 scale Many programs require at least three years of undergraduate education and more are requiring a bachelor s degree 176 Canada requires a minimum three years of undergraduate education for applicants and at least 4200 instructional hours or the equivalent of full time chiropractic education for matriculation through an accredited chiropractic program 177 Graduates of the Canadian Memorial Chiropractic College CMCC are formally recognized to have at least 7 8 years of university level education 178 179 The World Health Organization WHO guidelines suggest three major full time educational paths culminating in either a DC DCM BSc or MSc degree Besides the full time paths they also suggest a conversion program for people with other health care education and limited training programs for regions where no legislation governs chiropractic 54 Upon graduation there may be a requirement to pass national state or provincial board examinations before being licensed to practice in a particular jurisdiction 180 181 Depending on the location continuing education may be required to renew these licenses 182 183 Specialty training is available through part time postgraduate education programs such as chiropractic orthopedics and sports chiropractic and through full time residency programs such as radiology or orthopedics 184 In the U S chiropractic schools are accredited through the Council on Chiropractic Education CCE while the General Chiropractic Council GCC is the statutory governmental body responsible for the regulation of chiropractic in the UK 185 186 The U S CCE requires a mixing curriculum which means a straight educated chiropractor may not be eligible for licensing in states requiring CCE accreditation 76 CCEs in the U S Canada Australia and Europe have joined to form CCE International CCE I as a model of accreditation standards with the goal of having credentials portable internationally 187 Today there are 18 accredited Doctor of Chiropractic programs in the U S 188 2 in Canada 189 6 in Australasia 190 and 5 in Europe 191 All but one of the chiropractic colleges in the U S are privately funded but in several other countries they are in government sponsored universities and colleges 25 Of the two chiropractic colleges in Canada one is publicly funded UQTR and one is privately funded CMCC In 2005 CMCC was granted the privilege of offering a professional health care degree under the Post secondary Education Choice and Excellence Act which sets the program within the hierarchy of education in Canada as comparable to that of other primary contact health care professions such as medicine dentistry and optometry 178 179 Regulatory colleges and chiropractic boards in the U S Canada Mexico and Australia are responsible for protecting the public standards of practice disciplinary issues quality assurance and maintenance of competency 192 193 There are an estimated 49 000 chiropractors in the U S 2008 194 6 500 in Canada 2010 195 2 500 in Australia 2000 29 and 1 500 in the UK 2000 196 Chiropractors often argue that this education is as good as or better than medical physicians but most chiropractic training is confined to classrooms with much time spent learning theory adjustment and marketing 76 The fourth year of chiropractic education persistently showed the highest stress levels 197 Every student irrespective of year experienced different ranges of stress when studying 197 The chiropractic leaders and colleges have had internal struggles 198 Rather than cooperation there has been infighting between different factions 198 A number of actions were posturing due to the confidential nature of the chiropractic colleges in an attempt to enroll students 198 clarification needed Ethics Main article Chiropractic professional ethics The chiropractic oath is a modern variation of the classical Hippocratic Oath historically taken by physicians and other healthcare professionals swearing to practice their professions ethically 199 The American Chiropractic Association ACA has an ethical code based upon the acknowledgement that the social contract dictates the profession s responsibilities to the patient the public and the profession and upholds the fundamental principle that the paramount purpose of the chiropractic doctor s professional services shall be to benefit the patient 200 The International Chiropractor s Association ICA also has a set of professional canons 201 A 2008 commentary proposed that the chiropractic profession actively regulate itself to combat abuse fraud and quackery which are more prevalent in chiropractic than in other health care professions violating the social contract between patients and physicians 36 According to a 2015 Gallup poll of U S adults the perception of chiropractors is generally favorable two thirds of American adults agree that chiropractors have their patient s best interest in mind and more than half also agree that most chiropractors are trustworthy Less than 10 of US adults disagreed with the statement that chiropractors were trustworthy 202 203 The charity Sense about Science launched a campaign to draw attention to the BCA legal case against science writer Simon Singh 204 In 2009 a number of organizations and public figures signed a statement entitled The law has no place in scientific disputes 205 Chiropractors especially in America have a reputation for unnecessarily treating patients 57 In many circumstances the focus seems to be put on economics instead of health care 57 Sustained chiropractic care is promoted as a preventive tool but unnecessary manipulation could possibly present a risk to patients 8 Some chiropractors are concerned by the routine unjustified claims chiropractors have made 8 A 2010 analysis of chiropractic websites found the majority of chiropractors and their associations made claims of effectiveness not supported by scientific evidence while 28 of chiropractor websites advocate lower back pain care which has some sound evidence 206 The US Office of the Inspector General OIG estimated that for calendar year 2013 82 of payments to chiropractors under Medicare Part B a total of 359 million did not comply with Medicare requirements 207 There have been at least 15 OIG reports about chiropractic billing irregularities since 1986 207 In 2009 a backlash to the libel suit filed by the British Chiropractic Association BCA against Simon Singh inspired the filing of formal complaints of false advertising against more than 500 individual chiropractors within one 24 hour period 208 209 prompting the McTimoney Chiropractic Association to write to its members advising them to remove leaflets that make claims about whiplash and colic from their practice to be wary of new patients and telephone inquiries and telling their members If you have a website take it down NOW and Finally we strongly suggest you do NOT discuss this with others especially patients 208 An editorial in Nature suggested that the BCA may have been trying to suppress debate and that this use of English libel law was a burden on the right to freedom of expression which is protected by the European Convention on Human Rights 210 The libel case ended with the BCA withdrawing its suit in 2010 211 212 ReceptionChiropractic is established in the U S Canada and Australia and is present to a lesser extent in many other countries 18 It is viewed as a marginal and non clinically proven attempt at complementary and alternative medicine which has not integrated into mainstream medicine 64 Australia In Australia there are approximately 2488 chiropractors or one chiropractor for every 7980 people 213 Most private health insurance funds in Australia cover chiropractic care and the federal government funds chiropractic care when the patient is referred by a medical practitioner 214 In 2014 the chiropractic profession had a registered workforce of 4 684 practitioners in Australia represented by two major organizations the Chiropractors Association of Australia CAA and the Chiropractic and Osteopathic College of Australasia COCA 215 Annual expenditure on chiropractic care alone or combined with osteopathy in Australia is estimated to be between AUD 750 988 million with musculoskeletal complaints such as back and neck pain making up the bulk of consultations and proportional expenditure is similar to that found in other countries 215 While Medicare the Australian publicly funded universal health care system coverage of chiropractic services is limited to only those directed by a medical referral to assist chronic disease management most private health insurers in Australia do provide partial reimbursement for a wider range of chiropractic services in addition to limited third party payments for workers compensation and motor vehicle accidents 215 Of the 2 005 chiropractors who participated in a 2015 survey 62 4 were male and the average age was 42 1 SD 12 1 years 215 Nearly all chiropractors 97 1 had a bachelor s degree or higher with the majority of chiropractor s highest professional qualification being a bachelor or double bachelor s degree 34 6 followed by a master s degree 32 7 Doctor of Chiropractic 28 9 or PhD 0 9 215 Only a small number of chiropractor s highest professional qualification was a diploma 2 1 or advanced diploma 0 8 215 United Kingdom In the United Kingdom there are over 2 000 chiropractors representing one chiropractor per 29 206 people 213 Chiropractic is available on the National Health Service in some areas such as Cornwall where the treatment is only available for neck or back pain 216 A 2010 study by questionnaire presented to UK chiropractors indicated only 45 of chiropractors disclosed to patients the serious risk associated with manipulation of the cervical spine and that 46 believed there was possibility patients would refuse treatment if the risks were correctly explained However 80 acknowledged the ethical moral responsibility to disclose risk to patients 217 United States and Canada The percentage of the population that utilizes chiropractic care at any given time generally falls into a range from 6 to 12 in the U S and Canada 218 with a global high of 20 in Alberta in 2006 219 In 2008 chiropractors were reported to be the most common CAM providers for children and adolescents these patients representing up to 14 of all visits to chiropractors 220 There were around 50 330 chiropractors practicing in North America in 2000 213 In 2008 this has increased by almost 20 to around 60 000 chiropractors 8 In 2002 03 the majority of those who sought chiropractic did so for relief from back and neck pain and other neuromusculoskeletal complaints 20 most do so specifically for low back pain 20 218 The majority of U S chiropractors participate in some form of managed care 9 Although the majority of U S chiropractors view themselves as specialists in neuromusculoskeletal conditions many also consider chiropractic as a type of primary care 9 In the majority of cases the care that chiropractors and physicians provide divides the market however for some their care is complementary 9 In the U S chiropractors perform over 90 of all manipulative treatments 221 Satisfaction rates are typically higher for chiropractic care compared to medical care with a 1998 U S survey reporting 83 of respondents satisfied or very satisfied with their care quality of communication seems to be a consistent predictor of patient satisfaction with chiropractors 222 Utilization of chiropractic care is sensitive to the costs incurred by the co payment by the patient 1 The use of chiropractic declined from 9 9 of U S adults in 1997 to 7 4 in 2002 this was the largest relative decrease among CAM professions which overall had a stable use rate 223 As of 2007 7 of the U S population is being reached by chiropractic 224 They were the third largest medical profession in the US in 2002 following physicians and dentists 225 Employment of U S chiropractors was expected to increase 14 between 2006 and 2016 faster than the average for all occupations 194 In the U S most states require insurers to cover chiropractic care and most HMOs cover these services 220 HistoryMain article History of chiropractic Daniel David D D Palmer founder of chiropractic Chiropractic s origins lie in the folk medicine practice of bonesetting in which untrained practitioners engaged in joint manipulation or resetting fractured bones 8 Chiropractic was founded in 1895 by Daniel David D D Palmer in Davenport Iowa Palmer a magnetic healer hypothesized that manual manipulation of the spine could cure disease 226 The first chiropractic patient of D D Palmer was Harvey Lillard a worker in the building where Palmer s office was located 42 He claimed that he had severely reduced hearing for 17 years which started shortly following a pop in his spine 42 A few days following his adjustment Lillard claimed his hearing was almost completely restored 42 Another of Palmer s patients Samuel Weed coined the term chiropractic from Greek xeiro chiro hand itself from xeir cheir hand and praktikos praktikos practical 227 228 Chiropractic is classified as a field of pseudomedicine on account of its esoteric origins 3 Chiropractic competed with its predecessor osteopathy another medical system based on magnetic healing both systems were founded by charismatic midwesterners in opposition to the conventional medicine of the day and both postulated that manipulation improved health 226 Although initially keeping chiropractic a family secret in 1898 Palmer began teaching it to a few students at his new Palmer School of Chiropractic 22 One student his son Bartlett Joshua B J Palmer became committed to promoting chiropractic took over the Palmer School in 1906 and rapidly expanded its enrollment 22 Early chiropractors believed that all disease was caused by interruptions in the flow of innate intelligence a vitalistic nervous energy or life force that represented God s presence in man chiropractic leaders often invoked religious imagery and moral traditions 22 D D Palmer said he received chiropractic from the other world 23 D D and B J both seriously considered declaring chiropractic a religion which might have provided legal protection under the U S constitution but decided against it partly to avoid confusion with Christian Science 22 23 Early chiropractors also tapped into the Populist movement emphasizing craft hard work competition and advertisement aligning themselves with the common man against intellectuals and trusts among which they included the American Medical Association AMA 22 B J Palmer early developer of chiropractic Chiropractic has seen considerable controversy and criticism 25 26 Although D D and B J were straight and disdained the use of instruments some early chiropractors whom B J scornfully called mixers advocated the use of instruments 22 In 1910 B J changed course and endorsed X rays as necessary for diagnosis this resulted in a significant exodus from the Palmer School of the more conservative faculty and students 22 The mixer camp grew until by 1924 B J estimated that only 3 000 of the United States 25 000 chiropractors remained straight 22 That year B J s invention and promotion of the neurocalometer a temperature sensing device was highly controversial among B J s fellow straights By the 1930s chiropractic was the largest alternative healing profession in the U S 22 Harvey Lillard first chiropractic patient Chiropractors faced heavy opposition from organized medicine 42 D D Palmer was jailed in 1907 for practicing medicine without a license 229 full citation needed Thousands of chiropractors were prosecuted for practicing medicine without a license and D D and many other chiropractors were jailed 42 To defend against medical statutes B J argued that chiropractic was separate and distinct from medicine asserting that chiropractors analyzed rather than diagnosed and adjusted subluxations rather than treated disease 42 B J cofounded the Universal Chiropractors Association UCA to provide legal services to arrested chiropractors 42 Although the UCA won their first test case in Wisconsin in 1907 prosecutions instigated by state medical boards became increasingly common and in many cases were successful In response chiropractors conducted political campaigns to secure separate licensing statutes eventually succeeding in all fifty states from Kansas in 1913 through Louisiana in 1974 42 The longstanding feud between chiropractors and medical doctors continued for decades The AMA labeled chiropractic an unscientific cult in 1966 30 and until 1980 advised its members that it was unethical for medical doctors to associate with unscientific practitioners 230 This culminated in a landmark 1987 decision Wilk v AMA in which the court found that the AMA had engaged in unreasonable restraint of trade and conspiracy and which ended the AMA s de facto boycott of chiropractic 9 Serious research to test chiropractic theories did not begin until the 1970s and is continuing to be hampered by antiscientific and pseudoscientific ideas that sustained the profession in its long battle with organized medicine 42 By the mid 1990s there was a growing scholarly interest in chiropractic which helped efforts to improve service quality and establish clinical guidelines that recommended manual therapies for acute low back pain 42 In recent decades chiropractic gained legitimacy and greater acceptance by medical physicians and health plans and enjoyed a strong political base and sustained demand for services 9 However its future seemed uncertain as the number of practitioners grew evidence based medicine insisted on treatments with demonstrated value managed care restricted payment and competition grew from massage therapists and other health professions 9 The profession responded by marketing natural products and devices more aggressively and by reaching deeper into alternative medicine and primary care 9 Public healthFurther information Vaccine controversy Alternative medicine and Water fluoridation controversy Some chiropractors oppose vaccination and water fluoridation which are common public health practices 36 Within the chiropractic community there are significant disagreements about vaccination one of the most cost effective public health interventions available 231 Most chiropractic writings on vaccination focus on its negative aspects 28 claiming that it is hazardous ineffective and unnecessary 29 Some chiropractors have embraced vaccination but a significant portion of the profession rejects it as original chiropractic philosophy traces diseases to causes in the spine and states that vaccines interfere with healing 29 The extent to which anti vaccination views perpetuate the current chiropractic profession is uncertain 28 The American Chiropractic Association and the International Chiropractors 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 29 The Canadian Chiropractic Association supports vaccination 28 a survey in Alberta in 2002 found that 25 of chiropractors advised patients for and 27 against vaccinating themselves or their children 232 Early opposition to water fluoridation included chiropractors some of whom continue to oppose it as being incompatible with chiropractic philosophy and an infringement of personal freedom Other chiropractors have actively promoted fluoridation and several chiropractic organizations have endorsed scientific principles of public health 233 In addition to traditional chiropractic opposition to water fluoridation and vaccination chiropractors attempts to establish a positive reputation for their public health role are also compromised by their reputation for recommending repetitive lifelong chiropractic treatment 36 ControversyMain article Chiropractic controversy and criticism Throughout its history chiropractic has been the subject of internal and external controversy and criticism 21 234 According to Daniel D Palmer the founder of chiropractic subluxation is the sole cause of disease and manipulation is the cure for all diseases of the human race 8 50 A 2003 profession wide survey 43 found most chiropractors whether straights or mixers still hold views of innate intelligence and of the cause and cure of disease not just back pain consistent with those of the Palmers 235 A critical evaluation stated Chiropractic is rooted in mystical concepts This led to an internal conflict within the chiropractic profession which continues today 8 Chiropractors including D D Palmer were jailed for practicing medicine without a license 8 For most of its existence chiropractic has battled with mainstream medicine sustained by antiscientific and pseudoscientific ideas such as subluxation 42 Collectively systematic reviews have not demonstrated that spinal manipulation the main treatment method employed by chiropractors is effective for any medical condition with the possible exception of treatment for back pain 8 Chiropractic remains controversial though to a lesser extent than in past years 25 See also Medicine portalChiropractic education Chiropractic schools Councils on Chiropractic Education International List of topics characterized as pseudoscience Toftness device World Federation of ChiropracticReferences a b c d Chapman Smith DA Cleveland CS III 2005 International status standards and education of the chiropractic profession In Haldeman S Dagenais S Budgell B et al eds Principles and Practice of Chiropractic 3rd ed McGraw Hill pp 111 34 ISBN 978 0 07 137534 4 a b c d e f g h Nelson CF Lawrence DJ Triano JJ Bronfort G Perle SM Metz RD Hegetschweiler K LaBrot T 2005 Chiropractic as spine care a model for the profession Chiropractic amp Osteopathy 13 1 9 doi 10 1186 1746 1340 13 9 PMC 1185558 PMID 16000175 a b Swanson ES 2015 Pseudoscience Science and Society Understanding Scientific Methodology Energy Climate and Sustainability Springer p 65 ISBN 978 3 319 21987 5 For an explanation regarding the description of chiropractic as a pseudoscience see Singh Simon Ernst Edzard 2008 The Truth About Chiropractic Therapy Trick or Treatment Alternative Medicine on Trial London Bantam Press ISBN 978 0 593 06129 9 OCLC 190777228 Hall Harriet March 11 2008 Science and Chiropractic sciencebasedmedicine org New England Skeptical Society Archived from the original on May 12 2019 Retrieved 2020 02 15 Hansson Sven Ove 2017 06 01 Science denial as a form of pseudoscience Studies in History and Philosophy of Science Part A 63 39 47 Bibcode 2017SHPSA 63 39H doi 10 1016 j shpsa 2017 05 002 ISSN 0039 3681 PMID 28629651 Ernst Edzard 2009 04 01 Complementary alternative medicine engulfed by postmodernism anti science and regressive thinking The British Journal of 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useful preventative approach Preventive Medicine 49 2 3 99 100 doi 10 1016 j ypmed 2009 05 004 PMID 19465044 a b c d e Gouveia LO Castanho P Ferreira JJ 2009 Safety of chiropractic interventions a systematic review PDF Spine 34 11 E405 13 doi 10 1097 BRS 0b013e3181a16d63 PMID 19444054 S2CID 21279308 Archived PDF from the original on 2016 09 19 a b c d e Ernst E 2007 Adverse effects of spinal manipulation a systematic review Journal of the Royal Society of Medicine 100 7 330 38 doi 10 1177 014107680710000716 PMC 1905885 PMID 17606755 Archived from the original on 2010 05 16 Christian Nordqvist 2007 07 02 Spinal Manipulation Should Not Be Routinely Used New Study Warns Med News Today a b c d Haynes MJ Vincent K Fischhoff C Bremner AP Lanlo O Hankey GJ 2012 Assessing the risk of stroke from neck manipulation a systematic review International Journal of Clinical Practice 66 10 940 47 doi 10 1111 j 1742 1241 2012 03004 x PMC 3506737 PMID 22994328 a b Ernst E 2010 Vascular accidents after 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16600038 a b c d e f g h i j Kaptchuk TJ Eisenberg DM November 1998 Chiropractic origins controversies and contributions Archives of Internal Medicine 158 20 2215 24 doi 10 1001 archinte 158 20 2215 PMID 9818801 a b c d e f g h i j k Martin SC October 1993 Chiropractic and the social context of medical technology 1895 1925 Technology and Culture 34 4 808 34 doi 10 2307 3106416 JSTOR 3106416 PMID 11623404 a b c D D Palmer s Religion of Chiropractic Letter from D D Palmer to P W Johnson D C May 4 1911 In the letter he often refers to himself with royal third person terminology and also as Old Dad Lazarus David June 30 2017 Column Chiropractic treatment a 15 billion industry has its roots in a ghost story Archived July 19 2020 at the Wayback Machine Daniel David Palmer the father of chiropractic who performed the first chiropractic adjustment in 1895 was an avid spiritualist He maintained that the notion and basic principles of chiropractic treatment were passed along to him during a seance by a long dead doctor The knowledge and philosophy given me by Dr Jim Atkinson an intelligent spiritual being appealed to my reason Palmer wrote in his memoir The Chiropractor which was published in 1914 after his death in Los Angeles Atkinson had died 50 years prior to Palmer s epiphany Los Angeles Times Retrieved September 25 2019 a b c d DeVocht JW 2006 History and overview of theories and methods of chiropractic a counterpoint Clinical Orthopaedics and Related Research 444 243 49 doi 10 1097 01 blo 0000203460 89887 8d PMID 16523145 S2CID 35775630 a b Homola S 2006 Chiropractic history and overview of theories and methods Clinical Orthopaedics and Related Research 444 236 42 doi 10 1097 01 blo 0000200258 95865 87 PMID 16446588 a b c Joseph C Keating Jr Cleveland CS III Menke M 2005 Chiropractic history a primer PDF Association for the History of Chiropractic Archived from the original PDF on 19 June 2013 Retrieved 2008 06 16 A significant and continuing barrier to scientific progress within chiropractic are the anti scientific and pseudo scientific ideas Keating 1997b which have sustained the profession throughout a century of intense struggle with political medicine Chiropractors tendency to assert the meaningfulness of various theories and methods as a counterpoint to allopathic charges of quackery has created a defensiveness which can make critical examination of chiropractic concepts difficult Keating and Mootz 1989 One example of this conundrum is the continuing controversy about the presumptive target of DCs adjustive interventions subluxation Gatterman 1995 Leach 1994 a b c d Busse JW Morgan L Campbell JB 2005 Chiropractic antivaccination arguments Journal of Manipulative and Physiological Therapeutics 28 5 367 73 doi 10 1016 j jmpt 2005 04 011 PMID 15965414 a b c d e Campbell JB Busse JW Injeyan HS 2000 Chiropractors and vaccination a historical perspective Pediatrics 105 4 e43 doi 10 1542 peds 105 4 e43 PMID 10742364 a b Johnson C Baird R 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Wisconsin contributing factors to success American Journal of Public Health 79 10 1405 1408 doi 10 2105 AJPH 79 10 1405 PMC 1350185 PMID 2782512 Jaroff Leon 27 February 2002 Back Off Chiropractors Time Retrieved 7 June 2009 Gunther Brown Candy July 7 2014 Chiropractic Is it Nature Medicine or Religion HuffPost Further readingLong PH 2013 Barrett S ed Chiropractic Abuse An Insider s Lament American Council on Science amp Health ISBN 978 0 9727094 9 1 Homola S 2002 Chiropractic Conventional or Alternative Healing In Shermer M ed The Skeptic Encyclopedia of Pseudoscience Vol 1 ABC CLIO pp 308 ISBN 978 1 57607 653 8 Menke JM January 2014 Do Manual Therapies Help Low Back Pain A Comparative Effectiveness Meta Analysis Spine Meta analysis 39 7 E463 72 doi 10 1097 BRS 0000000000000230 PMID 24480940 S2CID 25497624 External linksChiropractic at Wikipedia s sister projects Definitions from Wiktionary Media from Commons Quotations from Wikiquote Texts from Wikisource Data from Wikidata World Federation of Chiropractic website Retrieved from https en wikipedia org w index php title Chiropractic amp oldid 1147852414, wikipedia, wiki, book, books, library,

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