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Chiropractic is a complementary and alternative health care profession which focuses on diagnosing, treating, and preventing mechanical disorders of the musculoskeletal system, their effects on the nervous system and general health. Chiropractors believe that these misalignments, or subluxations, interfere with the body's self-regulating mechanisms via the nervous system resulting in bodily dysfunction.

A chiropractor may specialize in treating low back problems or sports injuries, or may combine chiropractic with manipulation of the extremities, physiotherapy, nutrition, or exercises to increase spinal strength or improve overall health. He/she may also use other complementary and alternative methods as a part of a holistic treatment approach. They do not prescribe drugs or perform surgery. They are trained to recognize signs of cancer, diabetes, and infectious diseases and refer these patients to medical physicians for specialized or concomitant care.

While there is evidence that spinal manipulation can be effective against acute low back pain and tension headaches, many other claims concerning health benefits are anecdotal and either lack support from or are refuted by objective controlled trials.

Introduction

Chiropractic was founded in 1895 by Daniel David Palmer, based on the belief that all health problems could be prevented or treated using "adjustments" of the spine, and sometimes other joints, to correct what he termed "subluxations". He, and later his son, BJ Palmer, proposed that subluxations were misaligned vertebrae which caused nerve compression that interfered with the transmission of what he termed Innate intelligence. This interference interrupted the proper flow of Innate Intelligence from "above, down, inside, and out" to the organ to which it traveled. As a result, the human body would experience "dis-ease" or disharmony which would result in loss of health. He compared this process to stepping on a hose that slowed the flow of water to a garden. If you take your foot off the hose, the flow returns to normal and the garden will flourish.

While the "pinched garden hose theory" has mostly been abandoned, it is still used in a modified form by some chiropractors to explain vertebral subluxation. However, the concept of the subluxation, for which there is disputed scientific evidence, remains integral to typical chiropractic practice, and in 2003 90% of chiropractors believed the vertebral subluxation complex played a significant role in all or most diseases, and practiced accordingly. The remainder limited their practices to the care of musculoskeletal problems.

Today, there are 17 accredited chiropractic colleges in the USA and two in Canada, and an estimated 70,000 chiropractors in the United States, 5000 in Canada, 2500 in Australia, 1300 in the United Kingdom, and smaller numbers in about 50 other countries. In the USA and Canada, licensed individuals who practice chiropractic are commonly referred to as chiropractors, doctors of chiropractic, (DC) or chiropractic physicians. Most patients who visit a chiropractor do so initially because of symptoms arising from musculoskeletal problems, especially low back and neck pain, although most chiropractors say they concern themselves with the overall health of the patient.

The initial chiropractic technique was manipulation of the spine (called adjustment) and remains the primary technique. The chiropractic adjustment differs from other manipulative techniques in its precision and accuracy in correcting vertebral subluxations. Today's chiropractor may continue to adhere to the strict tenets of Palmer and use only spinal adjustments or he/she may also include a broad range of methods, short of drugs and surgery, that are directed at correcting subluxations and/or relieving musculoskeletal pain. Some doctors of chiropractic employ chiropractic assistants to work as office staff and perform therapeutic activities and may also employ massage and physiotherapists as adjuncts to chiropractic care. According to a 2002 survey released in 2004 by the National Center for Complementary and Alternative Medicine, chiropractic was the fourth most commonly used complementary and alternative medicine therapy among adults in the USA. (7.5%). It has evolved so the treatment consists of 100’s of different techniques. The U.S. Department of Labor's Occupational Outlook Handbook said:

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

Spinal adjustments, chiropractic's primary technique, may provide short-term relief of certain forms of back and neck pain, headaches, and other spine-related conditions, but studies show conflicting results. For example, a systematic review (1997) noted "Strong evidence was found for the effectiveness of spinal manipulation, back schools and exercise therapy, especially for short-term effects." However, a more recent (2006) systematic review concluded "Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment."

Chiropractic may be able to show it can be a partner in today's cost-conscious healthcare environment. A 2005 study stated that "the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs." Chiropractic is also used by some professional athletes. The U.S. Olympic Medical Services Staff includes doctors of chiropractic who work with medical doctors.

There are four main groups of chiropractors, known as "traditional straights", "objective straights", "mixers", and "reform". All groups, except reform, treat patients using a subluxation based treatment system. Differences are based on the philosophy for adjusting, claims made about the effects of those adjustments, and various additional treatments or sub-specialities provided. See Modern Chiropractic Groups.

Although chiropractic has gained more acceptance in the last 40 years as an appropriate treatment for certain back, neck and other spine-related problems, resulting in increased usage , statistics in the later years have shown some variations from these trends: student enrollments fell 39.9% between 1996 and 2002, and the percentage of the adult population that uses chiropractic fell by 25% from 1997 to 2002. The statistics for student enrollments seem to be rising again, while patient use statistics are still uncertain.

History

In 1885, the world was well into the second industrial revolution, marked by innovation and creativity. Health care had recently emerged from the drastic practice of heroic medicine and was well into an age of alternatives. All varieties of treatments and cures including scientific medicine, vitalism, herbalism, magnetism and leeches, lances, tinctures and patent medicines were developing and competing to be the new method for the century. Neither consumers nor many practitioners had much knowledge of either the causes of, or cures for, illnesses. Allopathy, fueled by Louis Pasteur's refutal of the centuries old spontaneous generation theory in 1859, was growing rapidly. German bacteriologist, Robert Koch formulated his postulates bringing some much-needed scientific clarity to what was then a very confused field. Drugs, medicines and quack cures were becoming more prevalent and were mostly unregulated. Concerned about what he saw as the abusive nature of drugging, MD Andrew Taylor Still , ventured into magnetic healing (meaning hypnotism then) and bonesetting in 1875. He opened the American School of Osteopathy (ASO) in Kirksville, Missouri in 1892. Daniel David Palmer (DD Palmer), a teacher, grocer turned magnetic healer opened his office of magnetic healing in Davenport, Iowa in 1886. After nine successful years, DD Palmer gave the first chiropractic adjustment to a deaf janitor, Harvey Lillard, on September 18,1895.

The first chiropractic adjustment

Palmer and his patient Harvey Lillard gave differing accounts of when and how Palmer began to experiment with spinal manipulation. Palmer recalled an incident in 1895 when he was investigating the medical history of a deaf man, Harvey Lillard. Lillard informed Palmer that while working in a cramped area seventeen years earlier, he felt a 'pop' in his back, and had been nearly deaf ever since. Palmer’s examination found a sore lump which indicated spinal misalignment and a possible cause of Lillard's deafness. Palmer corrected the misalignment, and Lillard could then hear the wheels of the horse-drawn carts in the street below. Palmer said there was nothing accidental about this, as it was accomplished with an object in view, and the expected result was obtained. There was nothing 'crude" about this adjustment; it was specific so much so that no chiropractor has equalled it.

Palmer's version was disputed by Lillard's daughter, Valdeenia Lillard Simons. She said that her father told her that he was telling jokes to a friend in the hall outside Palmer's office and, Palmer, who had been reading, joined them. When Lillard reached the punch line, Palmer, laughing heartily, slapped Lillard on the back with the hand holding the heavy book he had been reading. A few days later, Lillard told Palmer that his hearing seemed better. Palmer then decided to explore manipulation as an expansion of his magnetic healing practice. Simons said "the compact was that if they can make it, then they both would share. But, it didn't happen."

Early growth

After the case of Harvey Lillard, Palmer stated: "I had a case of heart trouble which was not improving. I examined the spine and found a displaced vertebra pressing against the nerves which innervate the heart. I adjusted the vertebra and gave immediate relief -- nothing "accidental" or "crude" about this. Then I began to reason if two diseases, so dissimilar as deafness and heart trouble, came from impingement, a pressure on nerves, were not other disease due to a similar cause? Thus the science (knowledge) and art (adjusting) of Chiropractic were formed at that time."

DD Palmer asked a patient and friend, Rev. Samuel Weed, to help him name his discovery. He suggested combining the words cheiros and praktikos (meaning "done by hand") to describe Palmer's treatment method, creating the term chiropractic. In 1896, DD added a school to his magnetic healing infirmary, and began to teach others his method. It would be become known as Palmer School of Chiropractic (PSC, now Palmer College of Chiropractic). Among the first graduates were Andrew P. Davis MD,DO, William A. Seally,MD, BJ Palmer (DD's son), Solon M. Langworthy, John Howard, and Shegataro Morikubo. Langworthy moved to Cedar Rapids, Iowa and opened the second chiropractic school in 1903, the American School of Chiropractic & Nature Cure (ASC & NC) combining it with what would become naturapathic cures and osteopathy. DD Palmer, who was not interested in mixing chiropractic with other cures, turned down an offer to be a partner.

Changing political and healthcare environment

The early 19th century had seen the rise of patent medicine and the nostrum trade. Although some remedies were marketed through doctors of medicine, most were sold directly to consumers by lay people with the use of questionable advertising claims. The addictive, and sometimes toxic, effects of some remedies, especially morphine and mercury-based cures (known as quicksilver or quacksilver in German), prompted the popular rise of alternative and less dangerous methods of homeopathy and eclectic medicine. In the mid 1800's, as the germ theory struggled to replace the metaphysical causes of disease, the search for invisible microbes required the world to embrace the scientific method as a way to discover the cause of disease.

In the USA, licensing for healthcare professionals had all but vanished around the Civil War, leaving the profession open to anyone who had the inclination to become a physician. The market alone determined who would prove successful in the field and who would not. Medical schools were plentiful, inexpensive and mostly privately owned. With free entry into the profession, and education in medicine cheap and readily available, large numbers of men entered practice. This led to a overabundance of practitioners which ultimately drove down the individual physician's income. In 1847, the American Medical Association was formed and established higher standards for preliminary medical education and for the degree of MD. At the time, most medical practitioners were not able to meet the stringent standards, so a "grandfather clause" was included. The effect was to limit the number of new practitioners.

In 1849, the AMA established a board to analyze quack remedies and nostrums and to enlighten the public about the nature and dangers of such remedies. Relationships were developed with pharmaceutical companies in an effort to curb the patent medicine crisis and consolidate the patient base around the medical doctor. By the turn of the century, the AMA had created a Committee on National Legislation to represent the Association's interest in Washington and re-organized as the national organization of state and local associations. Intense political pressure by the AMA resulted in unlimited and unrestricted licensing only for medical physicians that were trained in AMA-endorsed colleges. By 1901, state medical boards were created in almost every state requiring licentiates to provide a diploma from an AMA approved medical college. By 1910, the AMA was a powerful national force; this was the beginning of organized medicine..

Just before 1881, the teaching profession had begun significant changes as well. Advances in chemistry and science in Germany created strong incentives to create markets for the sale of their new products. By 1895, the new "Kulturopolitik" ideology of "First teach them; then sell them" had begun creating the political pressure necessary to improve teaching in science and math in schools and colleges in the US. The medical schools were the first to suffer the attack; they were ridiculed as being obsolete -- inadequate -- and inefficient. The crisis attracted the attention of some of the world's richest men. In 1901 the "Rockefeller Institute for Medical Research" was started by John D. Rockefeller. By 1906, the AMA’s Council on Medical Education had created a list of unacceptable schools that in 1910, as a result of the Flexner Report financed by the Carnegie Foundation, closed hundreds of private medical and homeopathic schools and named Johns Hopkins as the model school. The AMA had created the nonprofit federally subsidized university hospital setting as the new teaching facility of the medical profession, effectively gaining control of all federal healthcare research and student aid.

Osteopathy vs chiropractic

As there was no constitutional protection or patent for new discoveries in the fields of knowledge, the claims for the drugless healing professions took on a life of their own. In 1896, DD Palmer's first descriptions for chiropractic were strikingly similar to Andrew Still's principles of osteopathy established a decade earlier. Both described the body as a "machine" whose parts could be manipulated to effect a drugless cure. Both professed to effect the blood and nerves and promote health, though Palmer stated he concentrated on reducing "heat" from friction of the misaligned parts and Still claimed to enhance the flow of blood. As word spread about the new doctor of drugless healing in Iowa, osteopaths began a campaign to protect what they perceived as their rights to their profession. Political efforts on the state level resulted in laws protecting the practice of osteopathy.

Medicine vs chiropractic

In September 1899, the campaign against all drugless healers in Iowa was initiated by Davenport MD, Heinrich Matthey. Suddenly the existing state law, which referred to the healing arts, was severely denounced. The demand was made for a change in the statute to prevent any drugless healer practicing in the state. Matthey warned that health education could no longer be entrusted to anyone but the doctor of medicine. Osteopathic schools across the country responded immediately by developing a program of college inspection and accreditation. pg11 DD Palmer, whose school had just graduated its 7th student, insisted that his new science did not require the same courses or license as medicine as his graduates did not prescribe drugs or evaluate blood or urine. However, in 1901, DD was charged with misrepresenting to a student a course in Chiropractic which was not a real science. He persisted in his strong stance against licensure citing freedom of choice as his cause. He would be arrested twice more by 1906 and though he contended that he was not practicing medicine, he was convicted for professing he could cure disease without a license in medicine or osteopathy.

Dr. Solon Langworthy, who continued to mix chiropractic at the ASC&NC, took a different route for chiropractic. He improved classrooms and provided a curriculum of study instead of the single course. He narrowed the scope of chiropractic to the treatment of the spine and nerve, leaving blood to the osteopath, and began to refer to the brain as the "life force". He was the first to use the word subluxation to describe the misalignment that narrowed the "spinal windows" (or intervertebral foramina) and interrupted the nerve energy. In 1906, Dr. Langworthy published the very first book on Chiropractic, which was called "Modernized Chiropractic" -- "Special Philosophy -- A Distinct System". He brought chiropractic into the scientific arena.

DD responded to Langworthy with malice concerning the mixing of chiropractic and even managed to get the Governor of Minnesota to veto legislation that would have allowed ASC&NC students to practice in his state. But he did accept some of the concepts laid out by Langworthy. He introduced the concept of Innate Intelligence circa 1904. Innate, he believed, was an intelligent entity which directed all the functions of the body, and used the nervous system to exert its influence. (Keating et al., writing for the Association for the History of Chiropractic)

After DD's conviction in 1906 and spending time in jail, he was forced to turn over his interests in the PSC to BJ's new wife Mabel and relocate first to Oklahoma and then to California. BJ Palmer was now in charge of the PSC, the Fountainhead of Chiropractic.

BJ Palmer re-develops chiropractic

Prosecution of DCs for unlicensed practice after the conviction of DD Palmer and a previous charge against BJ Palmer resulted in BJ and several Palmer graduates creating the Universal Chiropractic Association (UCA). It's initial purpose was to be a protective mechanism for its members by covering all legal expenses should they get arrested. Its first case came in 1907 when Shegataro Morikubo, DC, of Wisconsin was charged with unlicensed practice of osteopathy. It was a test of the new osteopathic law. In an ironic twist using mixer Langworthy's book Modernized Chiropractic, attorney Tom Moore was able to legally differentiate chiropractic from osteopathy based on the differences in the philosophy of chiropractic's "supremacy of the nerve" versus osteopath's "supremacy of the artery". Morikubo was freed and the victory would forever reshape the development of the chiropractic profession. From that point on, chiropractic was called a science, an art and a philosophy and BJ Palmer became the "Philosopher of Chiropractic".

The next 15 years saw the opening of 30 additional chiropractic schools, including John Howard's National School of Chiropractic (now the National University of Health Sciences) that moved to Chicago, Illinois. Each school attempted to develop its own identity, while BJ Palmer continued to develop the philosophy behind his father's discovery. Concerning the more than 15000 prosecutions of chiropractors fought the first 30 years, BJ would later note:

"We are always mindful of those early days when UCA...used various expedients to defeat medical court prosecutions. We legally squirmed this way and that, here and there. We did not diagnose, treat, or cure disease. We analyzed, adjusted cause, and Innate in patient cured. All were professional matters of fact in science, therefore justifiable in legal use to defeat medical trials and convictions."pg5

His influence over the next several years further defined the Mixers of chiropractic and those who practiced it Straight..

Straight vs Mixer

State laws to protect the practice of chiropractic eventually occurred in all fifty states in the US, but it was a hard fought struggle. Certainly Medical Examining Boards worked to keep all healthcare practices under their legal control, but an internal struggle among DC's on how to structure the laws significantly complicated the process. Initially, the UCA, led by B.J. Palmer, opposed state licensure altogether. Palmer feared such regulation would lead to allopathic control of the profession. The UCA eventually caved in, but B.J. remained strong in the opinion that examining boards should be composed exclusively of chiropractors (not mixers), and the educational standards to be adhered to were the same as the Palmer School. A "Model Bill" was drafted to present to all states that did not yet have a law. They embarked on a method of "cleaning house" of mixers by warning state associations to purge their mixing members or face competition by the formation of a new "straight" association in their state.

Mixers created the American Chiropractic Association (no relation to today's ACA) whose purpose was to advance education and research and was designed according to standards set by the National School of Chiropractic and supported by other practicing mixers. Years later the ACA and UCA would join to form the National Chiropractic Association (today's ACA) while BJ Palmer would move on to form the Chiropractic Health Bureau (today's ICA). The differences in state laws that exists today can be traced back to these early legal struggles.

While BJ worked to protect and develop chiropractic around the Palmer school, DD Palmer continued his investigation and development of his science from Oregon. In his 1910 book, he described the concepts that would make up his theory that the nerve controls 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 which 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 functionating—too much or not enough action—which is disease."

Before his sudden and controversial death in 1913, DD Palmer frequently voiced his concern for BJ Palmer's management of chiropractic. He openly challenged BJ's methods and philosophy and made every effort to regain control of his science of chiropractic. In a letter dated 1911, he wrote of his philosophy for chiropractic and hinted at his plan for the legal defense of chiropractic.

"You ask, what I think will be the final outcome of our law getting. It will be that we will have to build a boat similar to Christian Science and hoist a religious flag. I have received chiropractic from the other world, similar as did Mrs. Eddy. No other one has laid claim to that, NOT EVEN B.J. Exemption clauses instead of chiro laws by all means, and LET THAT EXEMPTION BE THE RIGHT TO PRACTICE OUR RELIGION. But we must have a religious head, one who is the founder, as did Christ, Mohamed, Jo. Smith, Mrs. Eddy, Martin Luther and other who have founded religions. I am the fountain head. I am the founder of chiropractic in its science, in its art, in its philosophy and in its religious phase. Now, if chiropractors desire to claim me as their head, their leader, the way is clear. My writings have been gradually steering in that direction until now it is time to assume that we have the same right to as has Christian scientists."

DD Palmer's effort to find a single cause for all disease led him to say:

"A subluxated vertebra . . . is the cause of 95 percent of all diseases. . . . The other five percent is caused by displaced joints other than those of the vertebral column."

Wilk et al. vs the American Medical Association

Before 1980, Principle 3 of the American Medical Association Principles of Medical Ethics stated: "A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily professionally associate with anyone who violates this principle." Until 1983, the AMA held that it was unethical for medical doctors to associate with an "unscientific practitioner," and labeled chiropractic "an unscientific cult."

As a result of this policy, an antitrust suit was brought against the AMA and other medical associations in 1976 - Wilk et al vs American Medical Association et al. - by Wilk and other chiropractors. The landmark lawsuit ended in 1987 when the Federal Appeals Court found the AMA guilty of conspiracy and restraint of trade; the Joint Council on Accreditation of Hospitals and the American College of Physicians were exonerated. The court recognized that the AMA had to show its concern for patients, but was not persuaded that this objective could not have been satisfied in a manner less restrictive of competition, for instance by public education campaigns. The AMA then lost its appeal to the Supreme Court and had to allow its members to collaborate with chiropractors.

The judge in the Wilk case said that the AMA had covered up research on the effectiveness of chiropractic for back pain. She then said that chiropractors clearly wanted "a judicial pronouncement that chiropractic is a valid, efficacious, even scientific health care service." She said no "well designed, controlled, scientific study" had been done, and concluded "I decline to pronounce chiropractic valid or invalid on anecdotal evidence."

Chiropractic subluxation

D.D. Palmer, using a vitalistic approach, imbued the term "subluxation" with a metaphysical and philosophical meaning. He held that a malposition of spinal bones, which protect the spinal cord and nerve roots, interferred with the transmission of nerve impulses. Because half of the nervous system is sensory and the other half motor (control), he postulated that living things had an innate intelligence, a kind of spiritual energy or life force that received the sensory information from the various parts of the body and made a decision as to what the motor nerves should convey. Thus, it was the job of the innate intelligence to determine the proper motor nerve impulses. D.D. Palmer claimed that subluxations interfered with the proper desire of this innate intelligence, and that by fixing them, all diseases could be treated. The idea that all diseases were the result of a subluxation was in-line with the common thinking of the day; that there was one cause for disease.

In the mid-1990's, the Association of Chiropractic Colleges redefined a subluxation as a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system and general health. In 1997 the Foundation for Chiropractic Education and Research defined a subluxation as a joint problem (whether a problem with the way the joint is functioning, a physical problem with the joint, or a combination of any of these) that affects the function of nerves and therefore affects the body's organs and general health.

In 1998, Lon Morgan, D.C., wrote, in the Journal of the Canadian Chiropractic Association,

"Innate Intelligence clearly has its origins in borrowed mystical and occult practices of a bygone era. It remains untestable and unverifiable and has an unacceptably high penalty/benefit ratio for the chiropractic profession. The chiropractic concept of Innate Intelligence is an anachronistic holdover from a time when insufficient scientific understanding existed to explain human physiological processes. It is clearly religious in nature and must be considered harmful to normal scientific activity."

Today, chiropractors use the concept of Innate Intelligence to describe the body's self-healing physiology; accordingly, they hold that healthcare interventions should consider the person as a whole and that conservative (non-invasive) treatment approaches should be used where possible.

Philosophy of the subluxation

Both chiropractic and mainstream medicine hold that much of the body is controlled by nerve impulses sent to and from the brain along the spinal cord. Whether the brain commanding the foot to move, the foot signaling the brain that it is in pain, or even a simple patellar reflex, the spinal cord is involved. Outgoing impulses from the brain pass down the spinal cord and exit through the appropriate spinal nerve branch held between the vertebrae on either side of the spinal cord. There are 31 pairs of spinal nerves that emerge from the spinal cord; all of which are housed by vertebrae. If the vertebrae are misaligned (subluxated), chiropractic doctors believe that a spinal nerve can be squeezed, pinched, or otherwise adversely affected and therefore message flow can be compromised. By aligning the vertebrae and removing restrictions on the spinal nerves, chiropractic claims to allow the spinal cord to more effectively relay messages to and from the brain; thus promoting better health.

Scientific investigation of chiropractic

While there is continuing research, and continuing debate about the effectiveness of chiropractic for the many conditions in which it is applied, chiropractic care seems to be most effective in treating acute low back pain and tension headaches. When testing the efficacy of health treatments, double blind studies are needed for the highest standards of scientific rigour. These are designed so that neither the patient nor the doctor know whether they are using the actual treatment or a placebo (or "sham") treatment. However, this is not possible in testing chiropractic because chiropractic treatment involves a manipulation; no "sham" procedure can be devised easily for this, and even if the patient is unaware whether the treatment is a real procedure or a sham procedure, the doctor cannot be unaware. Thus there is the potential for "observer bias" - the tendency to see what you expect to see, and also the potential for the patient to wish to report benefits to "please" the doctor. This is a problem not confined to chiropractic - many other medical treatments similarly are not amenable to double-blind placebo-controlled trials, indeed this is true for all surgical procedures. It is also a very real problem in evaluating treatments; even when there are objective outcome measures, the placebo effect can be very substantial indeed.

Thus, chiropractors have historically relied mostly upon their own clinical experience and the shared experience of their colleagues, as reported in case studies, to direct their treatment methods. In this they are not different to the practice in much of conventional medicine. However a bigger difference is that conventional medical treatments, especially new treatments, often have a stronger scientific foundation, in that their rationale is supported by experiments that analyse their mechanisms of action in detail.

University of Saskatchewan sociologist Leslie Biggs interviewed 600 Canadian chiropractors in 1997, and found that, while 86% felt that chiropractic methods needed to be validated, 74% of them did not believe that controlled clinical trials were the best way to evaluate chiropractic. Also noted was 68% believed that most diseases are caused by spinal malalignment, yet only 30% agreed that subluxation was the cause of many diseases. With this in mind, there are three problem areas: a failure to show efficacy for the conditions treated; an implausible mechanisms of action; and the use of invalid biomechanical assessments.

When a valid mechanism of action is not determined, it would be sufficient for a profession to present evidence showing benefit for the claims made. There is scientific agreement that, wherever applicable, an evidence based medicine framework should be used to assess health outcomes, and that systematic reviews with strict protocols are an important part of objectively evaluating the efficacy of treatments. Where evidence from such reviews is lacking, this does not necessarily mean that the treatment is ineffective, only that the case for a benefit of treatment may not have been rigorously established.

Organisations such as the Cochrane Collaboration and Bandolier publish such reviews. A 2005 editorial in The Journal of Manipulative and Physiological Therapeutics, "The Cochrane Collaboration: is it relevant for doctors of chiropractic?", proposed that involvement in Cochrane collaboration would be a way for chiropractic to gain greater acceptance within medicine. The collaboration has 11,500 contributors from more than 90 countries organised in 50 review groups. For chiropractic, relevant review groups include the Back Group; the Bone, Joint, and Muscle Trauma Group; the Musculoskeletal Group; and the Neuromuscular Disease Group. The editorial states:

"For example, a chiropractor may provide conservative care supported by a Cochrane review to a patient with carpal tunnel syndrome. If the patient's symptoms become progressive, the doctor may consider referring the patient for surgery using a recent Cochrane review that examined new surgical techniques compared with traditional open surgery for the said condition.”"

The Cochrane Collaboration found insufficient evidence to support or refute that manual therapy is beneficial for asthma. Carpal tunnel syndrometrials have not shown benefit from diuretics, non-steroidal anti-inflammatory drugs, magnets, laser acupuncture, exercise or chiropractic and there is not enough evidence to show the effects of spinal manipulation for painful menstrual periods.

Bandolier found limited evidence that spinal manipulative therapy might reduce the frequency and intensity of migraine attacks, but the evidence that spinal manipulation is better than amitriptyline, or adds to the effects of amitriptyline, is insubstantial for the treatment of migraine, though it suggests that "spinal manipulative therapy might be worth trying for some patients with migraine or tension headaches."

Based on a small, poor quality set of trials, there is no convincing evidence for long-term benefits of chiropractic interventions for acute or chronic low back pain. There might be some short-term pain relief, especially in patients with acute pain.

There is much conflict in the results of chiropractic research. For instance, many chiropractors claim to treat infantile colic. According to a 1999 survey of the Ontario Chiropractic Association (representing 83% of chiropractors in Ontario), 46% treated children for colic. In 1999 a randomized controlled clinical trial with a blinded observer suggested that there is evidence that spinal manipulation may help infantile colic. However, in 2001, a Norwegian double-blind study said “Chiropractic spinal manipulation is no more effective than placebo in the treatment of infantile colic.”

American Medical Association

In 1997, the following statement was adopted as policy of the American Medical Association (AMA) after a report on a number of alternative therapies:

Specifically about chiropractic, "Manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints",

and on alternative therapies in general, "There is little evidence to confirm the safety or efficacy of most alternative therapies. Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies."

Safety

As with all interventions, there are risksassociated with spinal manipulation. Although rare, these include vertebrobasilar accidents, strokes, disc herniations, vertebral fracture, and cauda equina syndrome, according to Harrison's. Compared to mobilization by physical therapists, chiropractic has been found to have the same effectivness but with more side effects. The greatest risk involves cervical manipulation in the first two segment bones of the cervical spine, particularly passive rotation of the neck, known as the "master cervical" or "rotary break", which is thought to be linked to trauma, paralysis, strokes, and death.

Nothing more than a temporal relationship has ever been established in relation to severe complications and chiropractic intervention. Chiropractic continues to be one of the safest health professions and chiropractors have some of the lowest malpractice insurance premiums in the health care industry.

Documented serious complications after manipulation of the cervical spine are very rare (1 in 3-4 million manipulations or fewer). This estimate is based on international studies of millions of chiropractic cervical adjustments from 1965 to the present day. The "one in a million" estimate is echoed in an extensive review of spinal manipulation performed by the RAND corporation. However, in another study, Dvorak cites figures of 1 in 400,000, while Jaskoviak reported approximately 5 million cervical manipulations from 1965 to 1980 at The National College of Chiropractic Clinic in Chicago, without a single case of vertebral artery stroke or serious injury . Less conservative treatments such as neck surgery are also often used for conditions similar to the conditions chiropractors treat using spinal adjustments. Cervical spine surgery has a 3-4% rate of complication and 4,000-10,000 deaths per million neck surgeries.

However, it is difficult to be sure what percentage of incidents are reported; the RAND study, for example, assumed that only 1 in 10 cases would have been reported. Dr Edzard Ernst surveyed neurologists in Britain for cases of serious neurological complication occurring within 24 hours of cervical spinal manipulation during the past year; 35 cases had been seen by the 24 who responded, but none had been reported. His survey led him to conclude that underreporting was closer to 100%, rendering estimates "nonsensical."

A 2001 study in the medical journal Stroke found that vertebrobasilar accidents (VBAs) are five times more likely in those aged <45 years who had visited a chiropractor in the week before the VBA, compared to controls who had not visited a chiropractor.

A New Zealand Commission report in 1979 supportedthe safety of chiropractic; the report said "We are satisfied that chiropractic treatment in New Zealand is remarkably safe." (Report of the Commission of Inquiry Into Chiropractic 1979:p 77). However, the judge in the Wilk v. American Medical Association case; described this report as "unsatisfactory", and a review of the report by the United States Congress' Office of Technology Assessment found 'serious problems' in its treatment of safety and efficacy issues.

Few studies that deal with the stroke issue and cervical manipulation take into account the difference between "manipulation" and the "chiropractic adjustment". According to "a research report in the Journal of Manipulative and Physiological Therapeutics, "manipulations" administered by a Kung Fu practitioner, GPs, osteopaths, physiotherapists, a wife, a blind masseur, and an Indian barber had been incorrectly attributed to chiropractors." The report goes on to say, "The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a non-chiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader's opinion of chiropractic and chiropractors." (Terrett AGJ: Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. JMPT 1995;18:203) Chiropractic adjustments are set apart from manipulation due to their precision and specificity . While there are nearly 200 different chiropractic techniques, which vary considerably in their application, and such differences have never been taken into account in relation to safety issues.

Chiropractic education, licensing, and regulation

United States

Graduates of chiropractic school receive the degree Doctor of Chiropractic (D.C.) are referred to as "doctor", and are eligible to seek licensure in all jurisdictions. The Council on Chiropractic Education (CCE) sets minimum guidelines for chiropractic colleges, but additional requirements may be needed for a license depending on the jurisdiction where a chiropractor chooses to practice. Currently, all 19 chiropractic institutions are accredited by the CCE.

Students often enter chiropractic school with a Bachelor's degree, or with three years of post-secondary education in the sciences and other appropriate coursework. However, in 2005 only one chiropractic college required a baccalaureate degree as an admission requirement. The minimum prerequisite for enrollment in a chiropractic college set forth by the CCE is 90 semester hours, and the minimum cumulative GPA for a student entering is 2.50. Commonly required classes include: psychology, biology, organic and inorganic chemistry, and physics. Other common medical classes are: anatomy or embryology, physiology, microbiology, diagnosis, neurology, x-ray, orthopedics, obstetrics/gynecology, histology, and pathology.

Chiropractic programs require at least 4,200 hours of combined classroom, laboratory, and clinical experience. The last 2 years stress courses in manipulation and spinal adjustment and provide clinical experience in physical and laboratory diagnosis, orthopedics, neurology, geriatrics, physiotherapy, and nutrition. Graduates must complete 5 years of schooling and pass 4 national board exams to complete their education. To qualify for licensure, graduates must sit State examinations; most State boards require at least 2 years of undergraduate education, and an increasing number require a 4-year bachelor’s degree. All boards require the completion of a 4-year program at an accredited college leading to the D.C. degree. Once licensed, most States require chiropractors to attend 12-48 hours of continuing education annually. Chiropractic colleges also offer postdoctoral training in neurology, orthopedics, sports injuries, nutrition, rehabilitation, industrial consulting, radiology, family practice, pediatrics, and applied chiropractic sciences. After such training, chiropractors may take exams leading to "diplomate" status in a given specialty including orthopedics, neurology and radiology.

Australia

In Australia, chiropractic is taught at three universities: RMIT in Melbourne, Murdoch University in Perth and Macquarie University in Sydney. To be registered by various state Chiropractic Registration Boards, a Bachelor of Chiropractic Science, a Bachelor of Science or health-related degree, plus the successful completion of a full-fee paying postgraduate qualifying program for the Master of Chiropractic is required.

Great Britain

In Great Britain, chiropractic currently has two colleges accredited by both the General Chiropractic Council (GCC), the UK governmental regulatory body for Chiropractic, and the European Council on Chiropractic Education. These are the Anglo European College of Chiropractic (AECC), a faculty of Bournemouth University, and the Welsh Institute of Chiropractic (WIOC) which is a faculty of Glamorgan University. The AECC graduates chiropractors with both a Batchelor of Science and a Masters degree. The WIOC, gradutes chiropractors with a Batchelor of Science (Hon). It is a legal requirement that all chiropractors in the UK register with the GCC to practice.

Modern chiropractic groups

1. Traditional Straight is the oldest movement, operating half of the accredited schools and graduating 75% of practicing chiropractors. This group adheres to the tenents set forth by DD Palmer and BJ Palmer, but have expanded the earlier theories of vertebral subluxation by suggesting alternative mechanisms. Traditional straight chiropractors accept Palmer's hypothesis that spinal adjustments remove interference to the human nervous system and improve communication between the brain and target tissues. Treatments are assumed to remove a primary underlying risk factor for disease rather than treat a patient's disease. They use differential diagnosis to rule out serious disease, but most straight chiropractors limit treatment to spinal adjustments. They tend to be members of the International Chiropractors Association (ICA).
2. Mixing These chiropractors are an early offshoot of the straight movement; their schools comprise 50% of the ones in operation, but produce only 25% of graduating chiropractors. This branch of chiropractic originated from naturopathic, osteopathic, medical, and even chiropractic doctors who attended the Palmer College of Chiropractic and then re-organized the treatment system to include more diagnostic and treatment approaches. They eventually split from the traditional straight group and formed various other chiropractic schools including the National College of Chiropractic. Their treatments may include naturopathy and physical therapy devices. While still subluxation based, mixer chiropractors also treat problems associated with both the spine and extremities, including musculoskeletal issues such as pain and decreased range of motion. Mixer chiropractors use a modified form of medical diagnosis which considers vertebral subluxations to be a form of osteoarthritis. Diagnosis is through a process of elimination after ruling out other known disorders, noting general signs of mechanical dysfunction in the spine. They tend to be members of the American Chiropractors Association, and all the major groups in Europe are also in membership of the European Chiropractors Union.
3. Objective Straight This is a recent off shoot of the traditional straights and is a minority. They differentiated themselves because the traditional straights make getting sick people well their objective, while objective straight chiropractors make the correction of vertebral subluxation their sole objective. Objective straights view the diagnosis of patient complaints as unnecessary, and avoid it if possible. They feel that a medical diagnosis is best perfomed by a medical doctor. This stance against diagnosing patient complaints has been a source of contention within the profession because accreditation standards mandate that differential diagnosis be taught in all chiropractic programs, so that the care provided to patients is safe and relevant to their complaints. Moreover, several state chiropractic licensing boards mandate that patient complaints be diagnosed before receiving care. Most straight chiropractors limit treatment to spinal adjustments. Objective chiropractors tend to be members of the Federation of Straight Chiropractic Organization (FSCO) and the World Chiropractic Alliance (WCA).
4. Reform Reform chiropractors are a small group of mixers who advocate a limited use of chiropractic primarily for treatment of osteoarthritis and musculoskeletal conditions. They reject the Palmer philosophy as well as the vertebral subluxation.

References

1. ^ McCrory DC, et al. Evidence Report: Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache. Duke University Evidence-Based Practice Center, Durham, North Carolina, January 2001 available online (PDF format)
2. ^ Ernst E (2006) A systematic review of systematic reviews of spinal manipulation J R Soc Med 99:192-6
3. Jeffrey Balon, M.D. A Comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma. New England Journal of Medicine. Volume 339:1013-1020, October 8, 1998, Number 15 available online
4. McDonald W (2003) How Chiropractors Think and Practice: The Survey of North American Chiropractors. Institute for Social Research, Ohio Northern University
5. More Than One-Third of U.S. Adults Use Complementary and Alternative Medicine, According to New Government Survey (Press Release), May 27 2004, available online
6. Complementary and Alternative Medicine Use Among Adults: United States, 2002 (Report), May 27 2004, available online (PDF format)
7. Burton, Bernard. "Chiropractic Management of Low Back Pain." Cleveland Clinic: Spinal Care 2000 Symposium. March 30, 2000.
8. van Tulder M (1997) Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine 22:2128-56.
9. Nelson CF, Metz RD, LaBrot T (2005) Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain J Man Phys Ther 28:564-9 Abstract
10. National Center for Education Statistics, Integrated Postsecondary Education Data System, Retrieved online 8/15/2004 at Quoted here:
11. Tindle HA. (2005) Trends in use of complementary and alternative medicine by US adults: 1997-2002 Altern Ther Health Med 11:42-9
12. "The Chiropractic Profession and Its Research and Education Programs", Final Report, pg 41, Florida State University, MGT of America, December 2000
13. Keating J. D.D. Palmer's Lifeline
14. ^ Palmer DD (1910) The Science, Art and Philosophy of Chiropractic Portland, Oregon: Portland Printing House Company Cite error: The named reference "SciArtPhi" was defined multiple times with different content (see the help page).
15. Westbrooks B (1982) The troubled legacy of Harvey Lillard: the black experience in chiropractic. Chiropractic History 2:46­53
16. ^ Keating J. Chiropractic History: A Primer,Sutherland Companies
17. ^ Goodman J, Musgrave G (1992)How The Cost-Plus System Evolved Excerpted From: John C. Goodman and Gerald L. Musgrave Patient Power Washington, DC: Cato Institute W67
18. ^ AMA Web site,AMA History 1847 - 1899,Retrieved May 27,2006
19. ^ Lerner, Cyrus. Report on the history of chiropractic (unpublished manuscript, L.E. Lee papers, Palmer College Library Archives)
20. Palmer D.D. (1911). D.D. Palmer's Religion of Chiropractic
21. Assendelft WJJ, Koes BW, Van der Heijden GJMG, Bouter LM. The effectiveness of chiropractic for treatment of low back pain: An update and attempt at statistical pooling. J Manip Physiol Ther 1996; 19:499-507
22. Verhoef MJ,Costa Papadopoulos C. Survey of Canadian chiropractors’involvement in the treatment of patients under the age of 18.
23. Wiberg JMM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled clinical trial with a blinded observer. J Manip Physiol Ther 1999;22:517-22.
24. Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Arch Dis Child 2001;84:138-141.
25. Hurwitz EL, Morgenstern H, Vassilaki M, Chang LM. Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcome among patients enrolled in the UCLA Neck Pain Study.J Manip Physiol Ther 2004;27:16-25
26. Souza T (2005) Differential Diagnosis and Management for the Chiropractor, Third Edition : Protocols and Algorithms Jones and Bartlett Publishers Inc. 3rd edition

See also

• Applied kinesiology
• Manipulative therapy
• Naprapathy
• Osteopathy
• Physical therapy
• Reflexology

External links

Advocacy

Chiropractic organizations

• American Chiropractic Association (ACA)
• British Chiropractic Association (BCA)
• Canadian Chiropractic Association (CCA)
• Japanese Association of Chiropractors (JAC)
• International Chiropractors Association (ICA)
• National Association for Chiropractic Medicine
• World Chiropractic Alliance (WCA)
• World Federation of Chiropractic (WFC)
• Foundation for Chiropractic Education and Research (FCER)

Descriptions of chiropractic procedures

• Chiropractic treatments for back pain by Spine-health.com
• Glossary of Chiropractic Terms

Other resources

• Chiropractic Resource Organization
• Dynamic Chiropractic Online (ChiroWeb)
• Directory of Chiropractors in the United States
• The Chiropractic Profession and Its Research and Education Programs
• The Future of Chiropractic Revisited: 2005 to 2015

Other

• Cherkin, Daniel C.; Mootz, Robert D. (1997) Chiropractic in the United States: Training, Practice, and Research, available online
• Healey, James W. (1990) "It's Where You Put the Period", Dynamic Chiropractic, Volume 08, Issue 21 (October 10, 1990) available online

Critiques

• A Different Way To Heal? -- PBS - Scientific American Frontiers, Web Feature
• Chiropractic: science and antiscience and pseudoscience side by side -- Joseph C. Keating, Jr, PhD
• Commentary: The Specter of Dogma -- Joseph C. Keating, Jr., PhD
• Faulty Logic and Non-skeptical Arguments in Chiropractic -- Joseph C. Keating Jr, PhD
• National Council Against Health Fraud Fact Sheet on Chiropractic (2001)

• Alternative medical systems
• Chiropractic