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This is a scam. Beware!
{{pp-move-vandalism|small=yes}}
]
'''Chiropractic''' (from ] ''chiro-'' χειρο- "hand-" + ''praktikós'' πρακτικός "concerned with action") is a ] ] that focuses on diagnosis, treatment and prevention of mechanical disorders of the ] and their effects on the ] and general health, with special emphasis on the spine.<ref name=Nelson/> It emphasizes ] including ] and other joint and ] manipulation, and includes exercises and health and lifestyle counseling.<ref name=ccestandards/> Traditionally, it assumes that a ] or ] dysfunction can interfere with the body's function and its innate ability to heal itself.<ref name=History-PPC/>

] founded chiropractic in the 1890s and his son ] helped to expand it in the early 20th century.<ref name=Martin/> It has two main groups: "straights", now the minority, emphasize ], ], ]s, and subluxation as the leading cause of all disease; "mixers" are more open to mainstream and alternative medical techniques such as exercise, massage, nutritional supplements, and ].<ref name=Kaptchuk-Eisenberg/> Chiropractic is well established in the U.S., Canada and Australia.<ref name=global-strategy/>

For most of its existence chiropractic has battled with ], sustained by ideas such as subluxation that are considered significant barriers to scientific progress within chiropractic.<ref name=History-Primer/> ] remains controversial among chiropractors.<ref name=Busse/> In recent decades chiropractic has gained more legitimacy and greater acceptance among physicians and ]s and has had a strong political base and sustained demand for services,<ref name=Cooper/> and ] has been used to review research studies and generate ].<ref name=Villanueva-Russell/> Opinions differ as to the ] of chiropractic treatment<ref name=DeVocht/> and the efficacy and cost-effectiveness of maintenance chiropractic care are unknown.<ref name=Leboeuf-Yde-C/> Although spinal manipulation can have serious ] in rare cases,<ref name=Ernst-adverse/> chiropractic care is generally safe when employed skillfully and appropriately.<ref name=WHO-guidelines/>
{{Alternative medical systems}}

== Philosophy ==
Although a wide diversity of belief exists among chiropractors,<ref name=Keating05/> they share the principle that the ] and health are related in a fundamental way, and this relationship is mediated through the nervous system.<ref>{{cite book |author= Gay RE, Nelson CF |chapter= Chiropractic philosophy |chapterurl=http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=altrehab.section.336 |editor= Wainapel SF, Fast A (eds.) |title= Alternative Medicine and Rehabilitation: a Guide for Practitioners |date=2003 |isbn=1-888799-66-8 |location= New York |publisher= ]}}</ref> Chiropractors pay attention to the ], structure and function of the spine, its effects on the ] and ]s, and the role these systems play in preventing disease and restoring health.<ref name=ACA-history>{{cite web |title= History of chiropractic care |author= ] |accessdate=2008-02-21 |url=http://acatoday.org/level2_css.cfm?T1ID=13&T2ID=62}}</ref>

{| align="right" style="border:2px solid; background:#f4f4f4"
|+ '''Two chiropractic belief system constructs'''
! THE TESTABLE PRINCIPLE
! &nbsp;
! THE UNTESTABLE METAPHOR
|-
|align=center | ]
|
|align=center | ]
|-
|align=center | ↓
|
|align=center | ↓
|-
|align=center | Restoration of Structural Integrity
|
|align=center | ]
|-
|align=center | ↓
|
|align=center | ↓
|-
|align=center | Improvement of Health Status
|
|align=center | ]
|-
| &nbsp;
|-
| '''''MATERIALISTIC:'''''
| &nbsp;&nbsp;&nbsp;
| '''''VITALISTIC:'''''
|-
| — operational definitions possible
|
| — origin of holism in chiropractic
|-
| — lends itself to scientific inquiry
|
| — cannot be proven or disproven
|-
|align=center colspan=3 | ''taken from Mootz & Phillips 1997''<ref name="Chiro Beliefs"/>
|}
Chiropractic philosophy goes beyond manipulating the spine. Like ] and several other forms of ], chiropractic assumes that all aspects of a patient's health are interconnected, which leads to the following perspectives:<ref name="Chiro Beliefs">{{cite book |chapterurl=http://chiroweb.com/archives/ahcpr/chapter2.htm |chapter= Chiropractic belief systems |author= Mootz RD, Phillips RB |date=1997 |title= Chiropractic in the United States: Training, Practice, and Research |pages=9–16 |editor= Cherkin DC, Mootz RD (eds.) |accessdate=2008-02-14 |version= AHCPR Pub No. 98-N002 |location= Rockville, MD |publisher= ] |oclc=39856366}}</ref>

*''']''' treats the patient as a whole, and appreciates the multifactorial nature of influences (structural, chemical, and psychological) on the nervous system, recognizing dynamics between lifestyle, environment, and health.

*'''Conservativism''' considers the risks of clinical interventions when balancing them against their benefits. It emphasizes ] treatment to minimize risk, and avoids ] and ].<ref name=ACA-history/>

*''']''' emphasizes the body's inherent self-healing abilities. Chiropractic's early notion of ] can be thought of as a metaphor for homeostasis.<ref name=Keating05/>

*A '''patient-centered''' approach focuses on the patient rather than the disease, preventing unnecessary barriers in the doctor-patient encounter. The patient is considered to be indispensable in, and ultimately responsible for, the maintenance of health.<ref name=Keating05/>

Chiropractic's early philosophy was rooted in spiritual inspiration and ]. A philosophy based on deduction from irrefutable doctrine 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. This "straight" philosophy, taught to generations of chiropractors, rejected the inferential reasoning of the scientific method,<ref name=Keating05/> and relied on deductions from ] principles rather than on the ] of science.<ref name="Chiro Beliefs"/>

As chiropractic has matured, most practitioners accept the importance of scientific research into chiropractic.<ref name=Keating05>{{cite book |author= Keating JC Jr |chapter= Philosophy in chiropractic |pages=77–98 |title= Principles and Practice of Chiropractic |edition= 3rd ed. |editor= Haldeman S, Dagenais S, Budgell B ''et al.'' (eds.) |publisher=] |date=2005 |isbn=0-07-137534-1}}</ref> Balancing the dualism between the metaphysics of their predecessors and the materialistic reductionism of science, their belief systems blend experience, conviction, critical thinking, open-mindedness, and appreciation of the natural order. They emphasize the testable principle that structure affects function, and the untestable metaphor that life is self-sustaining. Their goal is to establish and maintain an organism-environment dynamic conducive to functional well-being of the whole person.<ref name="Chiro Beliefs"/>

=== Schools of thought and practice styles ===
{| class="wikitable" align="right" style="margin: 1em 0 1em 1em"
|+ Range of belief perspectives in chiropractic
! perspective attribute
! colspan=2 | potential belief endpoints
|-
| align=right | scope of practice:
| align=right | narrow ("straight") ←||→ broad ("mixer")
|-
| align=right | diagnostic approach:
| align=right | intuitive ←||→ analytical
|-
| align=right | philosophic orientation:
| align=right | vitalistic ←||→ materialistic
|-
| align=right | scientific orientation:
| align=right | descriptive ←||→ experimental
|-
| align=right | process orientation:
| align=right | implicit ←||→ explicit
|-
| align=right | practice attitude:
| align=right | doctor/model-centered ←||→ patient/situation-centered
|-
| align=right | professional integration:
| align=right | separate and distinct ←||→ integrated into mainstream
|-
| align=center colspan=3 |''taken from Mootz & Phillips 1997''<ref name="Chiro Beliefs"/>
|}
Common themes to chiropractic care include holistic, conservative and non-medication approaches via ].<ref>{{cite journal |url=http://chiroweb.com/archives/21/19/10.html |title=Surveys now and then |journal= ] |volume=21 |issue=19 |author=Keating J Jr. |date=2003}}</ref> Still, significant differences exist amongst the practice styles, claims and beliefs between various chiropractors.<ref name=Healey>{{cite journal |url=http://chiroweb.com/archives/08/21/13.html |title= It's where you put the period |journal= Dyn Chiropr |volume=8 |issue=21 |author= Healey JW |date=1990}}</ref>

''Straight'' chiropractors adhere to the philosophical principles set forth by D. D. and B. J. Palmer, and retain ] definitions and ] qualities. Straight chiropractors believe that vertebral subluxation leads to interference with an "]" within the human nervous system and is a primary underlying risk factor for almost any disease. Straights view the medical diagnosis of patient complaints (which they consider to be the "secondary effects" of subluxations) to be unnecessary for treatment. Thus, straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not "mix" other types of therapies.<ref name=History-Primer/> Their philosophy and explanations are metaphysical in nature and prefer to use traditional chiropractic lexicon (i.e. perform spinal analysis, detect subluxation, correct with adjustment, etc.). They prefer to remain separate and distinct from mainstream health care.

''Mixer'' chiropractors "mix" diagnostic and treatment approaches from naturopathic, osteopathic, medical, and chiropractic viewpoints. Unlike straight chiropractors, mixers believe subluxation is one of many causes of disease, and they incorporate mainstream medical diagnostics and employ myriad treatments including joint and soft tissue manipulation, electromodalities, physiotherapeutic modalities, exercise-rehabilitation and various complementary and alternative approaches such as ], ], ], ], and ]. Mixers tend to be open to mainstream medicine,<ref name=Kaptchuk-Eisenberg>{{cite journal |journal= ] |date=1998 |volume=158 |issue=20 |pages=2215–24 |title= Chiropractic: origins, controversies, and contributions |author= Kaptchuk TJ, Eisenberg DM |pmid=9818801 |url=http://archinte.ama-assn.org/cgi/content/full/158/20/2215 |doi= 10.1001/archinte.158.20.2215}}</ref> and are the majority group.<ref>{{cite journal |journal=] |date=1985 |volume=9 |issue=4 |pages=353–82 |title=Adjustment, the hands and healing |author=Coulehan JL |pmid=2934224}}</ref>

=== Vertebral subluxation ===
{{main|Vertebral subluxation}}
Palmer hypothesized that vertebral joint misalignments, which he termed ''vertebral subluxations'', interfered with the body's function and its inborn (innate) ability to heal itself.<ref name=History-PPC>{{cite book |author= ] |chapter= A brief history of the chiropractic profession |pages=23–64 |title= Principles and Practice of Chiropractic |edition= 3rd ed. |editor= Haldeman S, Dagenais S, Budgell B ''et al.'' (eds.) |publisher=McGraw-Hill |date=2005 |isbn=0-07-137534-1}}</ref> 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. D.D. Palmer, using a ] approach, imbued the term ''subluxation'' with a metaphysical and ] meaning. He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic.<ref>{{cite web |url=http://chiro.org/Plus/History/Persons/PalmerDD/PalmerDD's_Forgotten_Theories1995.pdf |format=PDF |title= D.D. Palmer's forgotten theories of chiropractic |author= Keating JC Jr |publisher= ] |date=1995 |accessdate=2008-05-14}}</ref> This concept was later expanded upon by his son, B.J. Palmer and was instrumental in providing the legal basis of differentiating chiropractic medicine 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."<ref name=Palmer1910>{{cite book |author= Palmer DD |title= The Chiropractor's Adjuster: Text-book of the Science, Art and Philosophy of Chiropractic for Students and Practitioners |location=Portland, OR |publisher= Portland Printing House Co |date=1910 |oclc=17205743}}</ref>

The concept of subluxation remains unsubstantiated and largely untested, and a debate about whether to keep it in the chiropractic paradigm has been ongoing for decades.<ref name=Keating-subluxation/> In general, critics of traditional subluxation-based chiropractic (including chiropractors) are skeptical of its clinical value, ] 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.<ref name=Keating-subluxation>{{cite journal |journal= ] |date=2005 |volume=13 |pages=17 |title= Subluxation: dogma or science? |author= Keating JC Jr, Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF |doi=10.1186/1746-1340-13-17 |pmid=16092955 |url=http://chiroandosteo.com/content/13/1/17}}</ref> This is still a continuing source of debate within the chiropractic profession as well, with some schools of chiropractic (for example, ]<ref name=Palmer-edu>{{cite web |url=http://www.palmer.edu/general_content.aspx?id=2630 |title=Palmer College of Chiropractic, General Information |accessdate=2008-03-24}}</ref>) still teaching the traditional/straight subluxation-based chiropractic, while others (for example, ]<ref>{{cite web |url=http://cmcc.ca/PDF/2006/CMCC_Calendar06to07.pdf |format=PDF |title= Undergraduate and graduate programs 2006–2007 |publisher= ] |date=2006 |accessdate=2008-07-05}}</ref>) have moved towards an ] chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions.<ref>{{cite journal |journal=] |date=2000 |volume=14 |issue=2 |pages=71–7 |title=A Survey of the Use of Evidence-Based Health Care in Chiropractic College Clinics |author=Kevin A. Rose, Alan Adams |url=http://www.journalchiroed.com/2000/JCEFall2000Rose.PDF |format=PDF}}</ref><ref>{{cite journal |journal= ] |date=2006 |volume=14 |issue=2 |pages=E14–8 |title= Can chiropractors and evidence-based manual therapists work together? an opinion from a veteran chiropractor |author= Homola S |url=http://jmmtonline.com/documents/HomolaV14N2E.pdf |format=PDF}}</ref> A 2003 survey of North American chiropractors found that 88% wanted to retain the term ''vertebral subluxation complex'', and that when asked to estimate the percent of visceral ailments that subluxation significantly contributes to, the mean response was 62%.<ref name=McDonald/> In 2005, ''subluxation'' was defined by the ] as "a lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. It is essentially a functional entity, which may influence biomechanical and neural integrity.… This definition is different from the current medical definition, in which subluxation is a significant structural displacement, and therefore visible on static imaging studies."<ref name=WHO-guidelines>{{cite paper |author= World Health Organization |date=2005 |title= WHO guidelines on basic training and safety in chiropractic |url=http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf |format=PDF |id= ISBN 92 4 159371 7|accessdate=2008-02-29}}</ref>

== Scope of practice ==

Chiropractors are primary-contact health care practitioners who emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery,<ref name=WHO-guidelines/> with special emphasis on the spine.<ref name=Nelson>{{cite journal |journal= Chiropr Osteopat |date=2005 |volume=13 |pages=9 |title= Chiropractic as spine care: a model for the profession |author= Nelson CF, Lawrence DJ, Triano JJ ''et al.'' |doi=10.1186/1746-1340-13-9 |pmid=16000175 |url=http://chiroandosteo.com/content/13/1/9}}</ref> Although chiropractors have many attributes of ] providers, chiropractic has more of the attributes of a medical specialty like ].<ref name=Meeker-Haldeman>{{cite journal |journal= ] |date=2002 |volume=136 |issue=3 |pages=216–27 |title= Chiropractic: a profession at the crossroads of mainstream and alternative medicine |author= Meeker WC, Haldeman S |pmid=11827498 |url=http://www.annals.org/cgi/reprint/136/3/216.pdf |format=PDF}}</ref> The practice of chiropractic medicine involves a range of diagnostic methods including skeletal imaging, observational and tactile assessments, orthopedic and neurological evaluation, laboratory tests,<ref name=WHO-guidelines/> and specialized tests.<ref name=ccestandards>{{cite web |url=http://cce-usa.org/uploads/File/2007%20January%20STANDARDS.pdf |format=PDF |title= Standards for Doctor of Chiropractic programs and requirements for institutional status |publisher= The Council on Chiropractic Education |date=2007 |accessdate=2008-02-14}}</ref> A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider.<ref name=Meeker-Haldeman/> Common patient management involves:

*] and other manual therapies to the joints and soft tissues
*rehabilitative exercises
*health promotion
*electrical modalities
*conservative and complementary procedures
*lifestyle counseling.<ref>{{cite book |last=Haldeman |first=Scott |coauthors= Chapman-Smith, David, Petersen, Donald, Jr. |title= Guidelines for Chiropractic Quality and Practice Parameters |publisher=] |location= Sudbury, MA |pages=111–3 |date=2004|isbn=0-7637-2921-3}}</ref>

Chiropractors generally cannot write ]s; a 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for ]s.<ref name=McDonald>{{cite book |author= McDonald WP, Durkin KF, Pfefer M ''et al.'' |date=2003 |title= How Chiropractors Think and Practice: The Survey of North American Chiropractors |location= Ada, OH |publisher= Institute for Social Research, Ohio Northern University |isbn=0972805559}} Summarized in: {{cite journal |journal= Semin Integr Med |date=2004 |volume=2 |issue=3 |pages=92–8 |title= How chiropractors think and practice: the survey of North American chiropractors |author= McDonald WP, Durkin KF, Pfefer M |doi=10.1016/j.sigm.2004.07.002 |laydate=2003-06-02 |laysummary=http://chiroweb.com/archives/21/12/19.html |laysource= Dyn Chiropr}}</ref> A notable exception is the state of ] which is considered to have an "expansive" scope of practice of chiropractic, which allows chiropractors to prescribe over-the-counter substances and perform minor surgery.<ref name="LegOR">{{cite web |url=http://www.leg.state.or.us/ors/684.html |title=Chapter 684 — Chiropractors |publisher= ] |accessdate=2008-05-08}}</ref> In some locations chiropractors (DCs) and ] (DVMs) with additional training and certification can practice ] which includes the diagnosis, treatment and rehabilitation of injured animals.<ref name="VetChiro1">{{cite web |url=http://www.veterinarychiropractic.ca/faq.htm |title=Canadian Animal Chiropractic Certification Program frequently asked questions |accessdate=2008-05-08}}</ref><ref name="RMIT1">{{cite web |url=http://www.rmit.edu.au/browse/Study%20at%20RMIT%2FTypes%20of%20study%2FPostgraduate%20Programs%2F;ID=MC030;STATUS=A |title=RMIT - Animal Chiropractic – Master of Chiropractic Science incorporating Graduate Diploma |publisher=] |accessdate=2008-05-09 |last= |first=}}</ref> However, the official position of the ] is that applying manipulative techniques to animals does not constitute chiropractic and that ''veterinary chiropractic'' is a misnomer.<ref>{{cite web |url=http://amerchiro.org/level2_css.cfm?T1ID=10&T2ID=117#107 |accessdate=2008-07-05 |title= 'Veterinary' chiropractic |date=1994 |author= ACA House of Delegates |publisher= American Chiropractic Association}}</ref>

Chiropractic medicine is established in the ], ], and ], and is present to a lesser extent in many other countries.<ref name=global-strategy>{{cite web |url=http://chiropracticdiplomatic.com/strategies/global_strategy.pdf |format=PDF |title= Global professional strategy for chiropractic |author= Tetrault M |publisher= ] |date=2004 |accessdate=2008-04-18}}</ref> Similar to other primary contact health providers, chiropractors can specialize in different areas of chiropractic medicine. The most common post-graduate diplomate programs include ], ], clinical sciences, ] sciences, ] and ] which generally require 2–3 additional years of additional post graduate study and passing competency examinations.<ref>Chiropractic training:
*{{cite book|last=Pybus|first=Beverly, E.|coauthors=Cairns, Carol, S.|others=C|title=A Guide to AHP Credentialing |publisher=] |pages=241–3 |isbn=1-57839-478-3 |accessdate=2008-04-16}}
*{{cite book |chapterurl=http://chiroweb.com/archives/ahcpr/chapter3.htm |chapter= Chiropractic training |author= Coulter ID, Adams AH, Sandefur R |date=1997 |title= Chiropractic in the United States: Training, Practice, and Research |pages=9–16 |editor= Cherkin DC, Mootz RD (eds.) |url=http://curziechiropractic.com/forms/ahcpr/uschiros.pdf |accessdate=2008-05-11 |version= AHCPR Pub No. 98-N002 |location= Rockville, MD |publisher= Agency for Health Care Policy and Research |oclc=39856366}}
*{{cite journal |author= Mestan MA, Taylor JA, Blackshaw GL, McDonald JC |date=2006 |title= Commentary: establishing an accredited Master of Science in Diagnostic Imaging degree at a chiropractic college |journal= ] |volume=29 |issue=5 |pages=410–3 |pmid=16762672 |doi=10.1016/j.jmpt.2006.04.008}}</ref>

=== Treatment techniques ===
{| class="wikitable sortable" align="right" style="margin: 1em 0 1em 1em"
|+Procedures received by more than 1/3 of patients of licensed U.S. chiropractors (2003 survey)<ref name=NBCE_techniques>{{cite book |title= Job Analysis of Chiropractic |chapter= Professional functions and treatment procedures |year=2005 |pages=121–38 |author= Christensen MG, Kollasch MW |location= Greeley, CO |publisher= ] |chapterurl=http://nbce.org/pdfs/chapter_10.pdf |format=PDF |accessdate=2008-03-14 |isbn=1-884457-05-3}}</ref>
|-
!procedure
!% of <br> DCs <br> using <br> it
!% of <br> patients <br> getting <br> it
|-
|] <br> (full-spine manipulation)
|align="center"|96.2
|align="center"|71.5
|-
|]/] <br> promotion
|align="center"|98.3
|align="center"|64.9
|-
|Corrective or therapeutic <br> exercise
|align="center"|98.3
|align="center"|63.2
|-
|]/] advice
|align="center"|97.3
|align="center"|61.9
|-
|] strategies
|align="center"|96.6
|align="center"|60.6
|-
|]
|align="center"|96.6
|align="center"|57.9
|-
|Changing risky/unhealthy <br> behaviors
|align="center"|96.6
|align="center"|54.9
|-
|] <br> recommendations
|align="center"|97.7
|align="center"|51.8
|-
|]/] <br> recommendations
|align="center"|96.4
|align="center"|50.1
|-
|]
|align="center"|94.5
|align="center"|48.5
|-
|Extremity adjusting
|align="center"|95.4
|align="center"|46.8
|-
|]
|align="center"|91.0
|align="center"|45.3
|-
|]/ <br> early ] advice
|align="center"|90.8
|align="center"|39.7
|-
|}
{{Main|Chiropractic treatment techniques|Spinal adjustment}}
], which chiropractors call "spinal adjustment" or "chiropractic adjustment", is the most common treatment used in chiropractic care;<ref name=NBCE_techniques/> in the U.S., chiropractors perform over 90% of all manipulative treatments.<ref>{{cite web |url=http://nccam.nih.gov/health/chiropractic/chiropractic05.pdf |format=PDF |title= About chiropractic and its use in treating low-back pain |accessdate=2008-03-24 |date=2005 |publisher=]}}</ref> Spinal manipulation is a passive manual maneuver during which a three-joint complex is taken past the normal physiological range of movement without exceeding the anatomical boundary limit; its defining factor is a dynamic thrust, a sudden force that causes an audible release and attempts to increase a joint's range of motion.<!-- <ref name=ACA-SMP/> --> More generally, ] (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; in chiropractic care SMT most commonly takes the form of spinal manipulation.<ref name=ACA-SMP>{{cite web |url=http://acatoday.org/pdf/spinal_manipulation_policy.pdf |format=PDF |title= Spinal manipulation policy statement |author= Winkler K, Hegetschweiler-Goertz C, Jackson PS ''et al.'' |accessdate=2008-05-24 |date=2003 |publisher= American Chiropractic Association}}</ref> The medicinal use of spinal manipulation can be traced back over 3000 years to ancient Chinese writings. ], the "father of medicine" used manipulative techniques,<ref name=Swedlo>{{cite conference |url=http://www.hom.ucalgary.ca/Dayspapers2002.pdf |format=PDF |booktitle= Proc 11th Annual History of Medicine Days |editor= Whitelaw WA (ed.) |title= The historical development of chiropractic |publisher= ] |pages= 55–58 |author= Swedlo DC |date=2002 |accessdate=2008-05-14}}</ref> as did the ancient Egyptians and many other cultures. A modern re-emphasis on ] occurred in the late 19th century in North America with the emergence of the ] and chiropractic medicine.<ref name=Keating-pathways>{{cite journal |journal= J Manipulative Physiol Ther |date=2003 |volume=26 |issue=5 |pages=300–21 |title= Several pathways in the evolution of chiropractic manipulation |author= Keating JC Jr |doi=10.1016/S0161-4754(02)54125-7 |pmid=12819626}}</ref> SMT gained mainstream recognition during the 1980s.<ref>{{cite web |url=http://muaphysicians.com/historical.html |publisher= International MUA Academy of Physicians |title= Manipulation under anesthesia: historical considerations |author= Francis RS |date=2005 |accessdate=2008-07-06}}</ref> Chiropractors consider themselves to be expertly qualified providers of spinal adjustment, manipulation and other manual treatments.<ref name="wfc-identity">{{cite web |title= WFC consultation on the identity of the chiropractic profession |author= World Federation of Chiropractic |date=2005 |url=http://www.wfc.org/website/wfc/Website.nsf/WebPage/IdentityConsultation?OpenDocument&ppos=2&spos=5&rsn=y |accessdate=2008-02-14}}</ref>

] or MUA is a specialized manipulative procedure that typically occurs in hospitals administered under general anesthesia.<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2005 |volume=28 |issue=7 |pages=526–33 |title= Manipulation under anesthesia: a report of four cases |author= Cremata E, Collins S, Clauson W, Solinger AB, Roberts ES |doi=10.1016/j.jmpt.2005.07.011 |pmid=16182028}}</ref> Typically, it is performed on patients who have failed to respond to other forms of treatment.<ref>{{cite journal |journal=J Manipulative Physiol Ther |date=2000 |volume=23 |issue=2 |pages=127–9 |title=Manipulation under joint anesthesia/analgesia: a proposed interdisciplinary treatment approach for recalcitrant spinal axis pain of synovial joint origin |author=Michaelsen MR |doi=10.1016/S0161-4754(00)90082-4 |pmid=10714542 |url=http://www.jmptonline.org/article/S0161-4754(00)90082-4/abstract}}</ref>

== Education, licensing, and regulation ==

{{main|Chiropractic education|List of chiropractic schools|}}

Chiropractors obtain a ] in the field of chiropractic medicine.<ref name=edlite>{{cite web |url=http://ed.gov/about/offices/list/ous/international/usnei/us/edlite-professional-studies.html |title= First-professional studies |publisher= U.S. Network for Education Information, ] |accessdate=2008-07-05}}</ref> The U.S. and Canada require a minimum 90 semester hours of undergraduate education as a prerequisite for chiropractic school, and at least 4200 instructional hours (or the equivalent) of full‐time chiropractic education for matriculation through an accredited chiropractic program.<ref name=ccestandards/><ref>{{cite web |url=http://www.cfcrb.org/english/pdf/Standards_for_Doctor_of_Chiropractic_Programmes.pdf |format=PDF |title=Standards for Doctor of Chiropractic Programmes |date=2006-10-21 |publisher=] |accessdate=2008-06-13}}</ref> The ] (WHO) guidelines suggest three major full-time educational paths culminating in either a ] 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.<ref name=WHO-guidelines/>

Upon graduation, there may be a requirement to pass national, state, or provincial board examinations before being ] to practice in a particular jurisdiction.<ref>{{cite web |url=http://life.edu/Current_Students/licensure.asp |title= State chiropractic licensure |accessdate=2008-07-05 |date=2007 |publisher= ]}}</ref><ref>{{cite web |url=http://www.cfcrb.org/english/becoming.html |title=CFCREAB - Becoming a Chiropractor |publisher=Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards |date=2008|accessdate=2008-06-13}}</ref> Depending on the location, ] may be required to renew these licenses.<ref>{{cite journal |pmc=1839972 |title= Continuing health education in Canada |author= Grod JP |journal= ] |volume=50 |issue=1 |pages=14–7 |year=2006 |pmid=17549163}}</ref><ref>{{cite journal |journal= Chiropr Osteopat |date=2005 |volume=13 |pages=22 |title= An online survey of chiropractors' opinions of Continuing Education |author= Stuber KJ, Grod JP, Smith DL, Powers P |url=http://chiroandosteo.com/content/13/1/22 |pmid=16242035 |doi=10.1186/1746-1340-13-22}}</ref>

In the U.S., chiropractic schools are accredited through the ] (CCE) while the General Chiropractic Council (GCC) is the statutory governmental body responsible for the regulation of chiropractic in the UK.<ref>{{cite web |title= The Council on Chiropractic Education (CCE) |url=http://cce-usa.org/ |publisher= The Council on Chiropractic Education |accessdate=2008-07-05}}</ref><ref>{{cite web |url=http://www.gcc-uk.org/page.cfm |title=The General Chiropractic Council |format= |work= |accessdate=2008-07-26}}</ref> 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.<ref>{{cite web |url=http://cceintl.org/id15.html |title=History and Purpose of The Councils on Chiropractic Education International |date=2005 |publisher=] |accessdate=2008-06-13}}</ref> Today, there are 18 accredited Doctor of Chiropractic programs in the U.S.,<ref>{{cite web |title= Accredited Doctor of Chiropractic programs |url=http://cce-usa.org/adcp.php |publisher= The Council on Chiropractic Education |accessdate=2008-02-22}}</ref> 2 in Canada,<ref>{{cite web |url=http://www.chirofed.ca/english/accreditation.html |title= CFCREAB - Accreditation of Educational Programmes |date=2008 |publisher= Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards |accessdate=2008-05-28}}</ref> and 4 in Europe.<ref>{{cite web |url=http://cce-europe.org/institutions.php |title= Institutions holding ''Accredited Status'' with the Council |publisher= ] |date=2008-06-11 |accessdate=2008-06-28}}</ref> 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.<ref name=DeVocht/> Chiropractic education in the U.S. is divided into straight or mixer educational curricula depending on the philosophy of the institution.<ref name=edlite/>

Regulatory colleges and chiropractic boards in the U.S., Canada, and Australia are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.<ref>{{cite web |url=http://www.ccachiro.org/Client/cca/cca.nsf/web/Facts%20%26%20FAQs |title= Facts & FAQs |publisher= Canadian Chiropractic Association |date=2008 |accessdate=2008-05-08}}</ref><ref>{{cite web |url=http://www.fclb.org/boards.htm |title= Chiropractic regulatory boards |publisher= ] |location= Greeley, CO |accessdate=2008-06-30}}</ref> There are an estimated 53,000 chiropractors in the U.S. (2006),<ref name=BLS/> 6526 in Canada (2006),<ref>{{cite web |url=http://www.ccachiro.org/Client/cca/cca.nsf/web/Number%20of%20Licensed%20Chiropractors%20in%20Canada?OpenDocument |title= Number of Licensed Chiropractors in Canada |publisher= Canadian Chiropractic Association |date=2006 |accessdate=2008-05-28}}</ref> 2500 in Australia (2000),<ref name=Campbell/> and 1,500 in the UK (2000).<ref>{{cite book |title= The Chiropractic Profession: Its Education, Practice, Research and Future Directions |author= Chapman-Smith D |date=2000 |chapter= Current status of the profession |isbn=1-892734-02-8 |publisher=] |location= West Des Moines, IA}}</ref>

== Utilization and satisfaction rates ==

In the U.S., chiropractic is the largest alternative medical profession,<ref name=Kaptchuk-Eisenberg/> and is the third largest doctored profession, behind ] and ].<ref>{{cite web |url=http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102184948.html |title= Establishing a database of U.S. chiropractic health manpower data: furthering the development of research infrastructure.|coauthors= Smith M, Morschhauser S |publisher= ] |accessdate=2008-05-06}}</ref> The percentage of population that utilize chiropractic care at any given time generally fall into a range from 6% to 12% in the U.S. and Canada,<ref name=Lawrence-Meeker/> with a global high of 20% in ].<ref name="Crownfield">{{cite journal |url=http://chiroweb.com/archives/25/06/02.html |title= Chiropractic in Alberta: a model of consumer utilization and satisfaction |journal= Dyn Chiropr |volume=25 |issue=6 |author= Crownfield PW |date=2007}}</ref> The vast majority who seek chiropractic care do so for relief from back and neck pain and other neuromusculoskeletal complaints;<ref>{{cite journal |journal= ] |date=2006 |volume=6 |issue=49 |title= A comparative analysis of chiropractic and general practitioner patients in North America: findings from the joint Canada/United States Survey of Health, 2002–03 |author= Hurwitz EL, Chiang LM |doi=10.1186/1472-6963-6-49 |pmid=16600038 |url=http://www.biomedcentral.com/1472-6963/6/49 |pages=49}}</ref> most do so specifically for low back pain.<!-- <ref name=Lawrence-Meeker/> --> ] (CAM) practitioners such as chiropractors are often used as a complementary form of care to primary medical intervention.<ref name=Lawrence-Meeker>{{cite journal |journal= Chiropr Osteopat |date=2007 |volume=15 |title= Chiropractic and CAM utilization: a descriptive review |author= Lawrence DJ, Meeker WC |doi=10.1186/1746-1340-15-2 |pmid=17241465 |url=http://chiroandosteo.com/content/15/1/2 |pages=2}}</ref> Satisfaction rates are typically higher for chiropractic care compared to medical care, with quality of communication seeming to be a consistent predictor of patient satisfaction with chiropractors.<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=6 |pages=455–62 |title= Factors associated with patient satisfaction with chiropractic care: survey and review of the literature |author= Gaumer G |doi=10.1016/j.jmpt.2006.06.013 |pmid=16904491}}</ref> Despite high patient satisfaction scores, utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient.<ref>{{cite book |author= Chapman-Smith DA, Cleveland CS III |chapter= International status, standards, and education of the chiropractic profession |pages=111–34 |title= Principles and Practice of Chiropractic |edition= 3rd ed. |editor= Haldeman S, Dagenais S, Budgell B ''et al.'' (eds.) |publisher=McGraw-Hill |date=2005 |isbn=0-07-137534-1}}</ref> The use of chiropractic is growing modestly; CAM as a whole is seeing wholesale increases.<ref name=Lawrence-Meeker/> Employment of U.S. chiropractors is expected to increase 14% between 2006 and 2016, faster than the average for all occupations.<ref name=BLS>{{cite web |url=http://www.bls.gov/oco/ocos071.htm |title=Chiropractors |publisher= ] |accessdate=2008-07-05 |date=2007}}</ref> A 2008 survey stated that 69% of DC chiropractors disagree with the categorization of chiropractic as CAM, with 27% having some preference for the term "integrated medicine."<ref>{{cite journal |journal= ] |date=2008 |volume=14 |issue=4 |pages=361–8 |title= Do chiropractors identify with complementary and alternative medicine? results of a survey |doi=10.1089/acm.2007.0766 |pmid=18435599 |url=http://www.liebertonline.com/doi/abs/10.1089/acm.2007.0766 |author= Redwood D, Hawk C, Cambron J, Vinjamury SP, Bedard J}}</ref>

== History ==
{{main|Chiropractic history}}

]

Chiropractic was founded in the 1890s by ] in ]. Palmer, a ], hypothesized that manual manipulation of the spine could cure disease. Although initially keeping the theory a family secret, in 1898 he began teaching it to a few students at his new ]. One student, his son ], became committed to promoting chiropractic, took over the Palmer School in 1906, and rapidly expanded its enrollment.<ref name=Martin>{{cite journal |journal= ] |author= Martin SC |date=1993 |volume=34 |issue=4 |pages=808–34 |title= Chiropractic and the social context of medical technology, 1895-1925 |doi=10.2307/3106416 |pmid=11623404}}</ref> Prosecutions and incarcerations of chiropractors for practicing medicine without a license grew common, and 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.<ref name=History-Primer/> Early chiropractors believed that all disease was caused by interruptions in the flow of ], a ] nervous energy or life force that represented God's presence in man; chiropractic leaders often invoked religious imagery and moral traditions. D.D. and B.J. both seriously considered declaring chiropractic a religion, which might have provided ], but decided against it partly to avoid confusion with ].<ref name=Martin/><ref>{{cite web |url=http://chiro.org/Plus/History/Persons/PalmerDD/PalmerDD's_Religion-of-Chiro.pdf |format=PDF |author= Palmer DD |title= Letter to P.W. Johnson, D.C. |date=1911-05-04 |accessdate=2008-06-29}}</ref> Early chiropractors also tapped into the ] movement, emphasizing craft, hard work, competition, and advertisement, aligning themselves with the common man against intellectuals and ], among which they included the ] (AMA).<ref name=Martin/>

]
Although D.D. and B.J. were "straight" and disdained the use of instruments, some early chiropractors, whom B.J. scornfully called "mixers", advocated use of instruments. In 1910 B.J. changed course and endorsed ] as necessary for diagnosis; this resulted in a significant exodus from the Palmer School of the more conservative faculty and students. The mixer camp grew until by 1924 B.J. estimated that only 3,000 of the U.S.'s 25,000 chiropractors remained straight.<!-- <ref name=Martin/> --> That year, B.J.'s promotion of the neurocalometer, a new temperature-sensing device, was another sign of chiropractic's gradual acceptance of medical technology, although it was highly controversial among B.J.'s fellow straights.<!-- <ref name=Martin/> --> Despite heavy opposition by organized medicine, by the 1930s chiropractic was the largest alternative healing profession in the U.S.<ref name=Martin/> The longstanding feud between chiropractors and medical doctors continued for decades. Until 1983, the AMA labeled chiropractic "an unscientific ]" and held that it was unethical for medical doctors to associate with an "unscientific practitioner".<ref>{{cite journal |journal= ] |date=1989 |volume=79 |issue=11 |pages=1569–70 |title= AMA policy on chiropractic |author= Cherkin D |pmid=2817179 |pmc=1349822}}</ref> This culminated in a landmark 1987 decision, ], 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.<ref name=Cooper/>

Serious research to test chiropractic theories did not begin until the 1970s, and was hampered by the chiropractic philosophy that sustained the profession in its long battle with organized medicine.<!-- <ref name=History-Primer/> duplicate of next ref --> 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.<ref name=History-Primer>{{cite web |title= Chiropractic history: a primer |author= Keating JC Jr, Cleveland CS III, Menke M |url=http://data.memberclicks.com/site/ahc/ChiroHistoryPrimer.pdf |format=PDF |date=2005 |accessdate=2008-06-16 |publisher= Association for the History of Chiropractic}}</ref> In recent decades chiropractic gained legitimacy and greater acceptance by physicians and ]s, and enjoyed a strong political base and sustained demand for services. However, its future seemed uncertain: as the number of practitioners grew, ] insisted on treatments with demonstrated value, ] restricted payment, and competition grew from ]s and other health professions. The profession responded by marketing natural products and devices more aggressively, and by reaching deeper into ] and ].<ref name=Cooper>{{cite journal |journal= ] |date=2003 |volume=81 |issue=1 |pages=107–38 |title= Chiropractic in the United States: trends and issues |author= Cooper RA, McKee HJ |doi=10.1111/1468-0009.00040 |pmid=12669653}}</ref>

== Evidence basis ==
{{POV-section|POV tag on evidence basis|date=February 2008}}
{{Synthesis|section|topic=Chiropractic effectiveness|talksection=SYN and implicit conclusions|date=June 2008}}
The principles of ] have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under ].<ref name=Villanueva-Russell/> Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs what chiropractic historian ]<!-- This is misleading to state it was only Keating. --> calls "antiscientific" reasoning and unsubstantiated claims.<ref name=Keating-subluxation/><ref name=Keating-1997>{{cite journal |author= Keating JC Jr |journal= ] |volume=21 |issue=4 |pages=37–43 |url=http://findarticles.com/p/articles/mi_m2843/is_n4_v21/ai_19727577 |title= Chiropractic: science and antiscience and pseudoscience side by side |date=1997 |accessdate=2008-05-10}}</ref><ref>{{cite book |author= Phillips RB |chapter= The evolution of vitalism and materialism and its impact on philosophy |pages=65–76 |title= Principles and Practice of Chiropractic |edition= 3rd ed. |editor= Haldeman S, Dagenais S, Budgell B ''et al.'' (eds.) |publisher=] |date=2005 |isbn=0-07-137534-1}}</ref>. A 2007 survey of ] chiropractors found that they do not consistently apply research in practice, which may have resulted from a lack of research education and skills.<ref>{{cite journal |journal= J Manipulative Physiol Ther |year=2007 |volume=30 |issue=2 |pages=109–15 |title= How important is research-based practice to chiropractors and massage therapists? |author= Suter E, Vanderheyden LC, Trojan LS, Verhoef MJ, Armitage GD |doi=10.1016/j.jmpt.2006.12.013 |pmid=17320731}}</ref> Evidence-based chiropractors possess the ability to apply research in practice. Continued education enhances the scientific knowledge of the practitioner.<ref>{{cite journal |journal= Chiropr Osteopat |year=2006 |volume=14 |pages=18 |title= Effectiveness of an evidence-based chiropractic continuing education workshop on participant knowledge of evidence-based health care |author= Feise RJ, Grod JP, Taylor-Vaisey A |pmid=16930482 |url=http://chiroandosteo.com/content/14/1/18 |doi=10.1186/1746-1340-14-18}}</ref>

=== Effectiveness ===

The ] of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Opinions differ as to the ] of chiropractic treatment; many other medical procedures also lack rigorous proof of effectiveness.<ref name=DeVocht>{{cite journal |journal= ] |date=2006 |volume=444 |pages=243–9 |title= History and overview of theories and methods of chiropractic: a counterpoint |author= DeVocht JW |doi=10.1097/01.blo.0000203460.89887.8d |pmid=16523145}}</ref> Chiropractic care, like all medical treatment, benefits from the ].<ref>{{cite journal |journal= Ann Intern Med |date=2002 |volume=136 |issue=11 |pages=817–25 |title= The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance? |author= Kaptchuk TJ |pmid=12044130 |url=http://annals.org/cgi/reprint/136/11/817.pdf |format=PDF}}</ref> The efficacy of maintenance care in chiropractic is unknown.<ref name=Leboeuf-Yde-C>{{cite journal |journal= Chiropr Osteopat |date=2008 |volume=16 |issue=1 |pages=3 |title= Maintenance care in chiropractic - what do we know? |author= Leboeuf-Yde C, Hestbæk L |doi=10.1186/1746-1340-16-3 |pmid=18466623 |url=http://chiroandosteo.com/content/pdf/1746-1340-16-3.pdf |format=PDF}}</ref>

Research has focused on ] (SM) in general,<ref>{{cite journal |journal= Ann Intern Med |date=2002 |volume=137 |issue=8 |pages=702 |title= Chiropractic: in response |author= Meeker WC, Haldeman S |url=http://annals.org/cgi/reprint/137/8/701.pdf |format=PDF}}</ref> rather than specifically on chiropractic SM.<ref name=Villanueva-Russell/> There is little consensus as to who should administer the SM, raising concerns by chiropractors that orthodox medical physicians could "steal" SM procedures from chiropractors; the focus on SM has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.<ref name=Villanueva-Russell>{{cite journal |journal= ] |date=2005 |volume=60 |issue=3 |pages=545–61 |title= Evidence-based medicine and its implications for the profession of chiropractic |author= Villanueva-Russell Y |doi=10.1016/j.socscimed.2004.05.017 |pmid=15550303}}</ref> Many controlled clinical studies of SM are available, but their results disagree,<ref name=Ernst-Canter>{{cite journal |journal= J R Soc Med |date=2006 |volume=99 |issue=4 |pages=192–6 |title= A systematic review of systematic reviews of spinal manipulation |author= Ernst E, Canter PH |doi=10.1258/jrsm.99.4.192 |pmid=16574972 |url=http://www.jrsm.org/cgi/content/full/99/4/192}}</ref> and they are typically of low quality.<ref>
Quality of SM studies:
*{{cite journal |journal= ] |date=2006 |volume=36 |issue=3 |pages=160–9 |title= Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type headache, migraine, and cervicogenic headache |author= Fernández-de-las-Peñas C, Alonso-Blanco C, San-Roman J, Miangolarra-Page JC |pmid=16596892}}
*{{cite journal |journal=] |date=2008 |volume=33 |issue=8 |pages=914–8 |title= The use of expertise-based randomized controlled trials to assess spinal manipulation and acupuncture for low back pain: a systematic review |author= Johnston BC, da Costa BR, Devereaux PJ, Akl EA, Busse JW; Expertise-Based RCT Working Group |doi=10.1097/BRS.0b013e31816b4be4 |pmid=18404113}}
</ref> It is hard to construct a trustworthy placebo for clinical trials of ] (SMT), as experts often disagree whether a proposed placebo actually has no effect.<ref>{{cite journal |journal= ] |date=2006 |volume=52 |issue=2 |pages=135–8 |title= Selecting an appropriate placebo for a trial of spinal manipulative therapy |author= Hancock MJ, Maher CG, Latimer J, McAuley JH |pmid=16764551 |url=http://www.physiotherapy.asn.au/AJP/52-2/AustJPhysiotherv52i2Hancock.pdf |format=PDF}}</ref> Although a 2008 critical review found that with the possible exception of back pain, chiropractic SM has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference,<ref name=Ernst-2008>{{cite journal |journal= ] |date=2008 |volume=35 |issue=5 |pages=544–62 |title= Chiropractic: a critical evaluation |author= Ernst E |doi=10.1016/j.jpainsymman.2007.07.004 |pmid=18280103}}</ref> a 2008 supportive review found serious flaws in the critical approach, and found that SM and ] are at least as effective for chronic low back pain as other efficacious and commonly used treatments.<ref name=Bronfort-2008/>

Available evidence covers the following conditions:

* ''']'''. There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain; methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the guidelines' reliability.<ref name=Murphy>{{cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=7 |pages=576–81, 581.e1–2 |title= Inconsistent grading of evidence across countries: a review of low back pain guidelines |author= Murphy AYMT, van Teijlingen ER, Gobbi MO |doi=10.1016/j.jmpt.2006.07.005 |pmid=16949948}}</ref> A 2007 U.S. guideline weakly recommended SM as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,<ref>{{cite journal |journal= Ann Intern Med |date=2007 |volume=147 |issue=7 |pages=492–504 |title= Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline |author= Chou R, Huffman LH; American Pain Society; American College of Physicians |pmid=17909210 |url=http://annals.org/cgi/content/full/147/7/492}}</ref> whereas the Swedish guideline for low back pain was updated in 2002 to no longer suggest considering SMT for acute low back pain for patients needing additional help, possibly because the guideline's recommendations were based on a high evidence level.<ref name=Murphy/> A 2008 review found strong evidence that SM is similar in effect to medical care with exercise, and moderate evidence that SM is similar to ] and other forms of conventional care.<ref name=Bronfort-2008>{{cite journal |journal= ] |date=2008 |volume=8 |issue=1 |pages=213–25 |title= Evidence-informed management of chronic low back pain with spinal manipulation and mobilization |author= Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S |doi=10.1016/j.spinee.2007.10.023 |pmid=18164469}}</ref> A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain.<ref name=Meeker-2007>{{cite web |title= Chiropractic management of low back pain and low back related leg complaints |author= Meeker W, Branson R, Bronfort G ''et al.'' |url=http://ccgpp.org/lowbackliterature.pdf |format=PDF |date=2007 |accessdate=2008-03-13 |publisher= ]}}</ref> Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 ] review<ref>{{cite journal |journal= ] |date=2004 |issue=1 |pages=CD000447 |title= Spinal manipulative therapy for low back pain |author= Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG |doi=10.1002/14651858.CD000447.pub2 |pmid=14973958}}</ref> stated that SM or mobilization is no more or less effective than other standard interventions for back pain.<ref name=Ernst-Canter/> A 2005 systematic review found that exercise appears to be slightly effective for chronic low back pain, and that it is no more effective than no treatment or other conservative treatments for acute low back pain.<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2005 |issue=3 |pages=CD000335 |title= Exercise therapy for treatment of non-specific low back pain |author= Hayden JA, van Tulder MW, Malmivaara A, Koes BW |doi=10.1002/14651858.CD000335.pub2 |pmid=16034851}}</ref>

* '''] and other ]'''. There is no overall consensus on manual therapies for neck pain.<ref name=Vernon>{{cite journal |journal= ] |date=2007 |volume=43 |issue=1 |pages=91–118 |title= Manual therapy for neck pain: an overview of randomized clinical trials and systematic reviews |author= Vernon H, Humphreys BK |pmid=17369783 |url=http://www.minervamedica.it/pdf/R33Y2007/R33Y2007N01A0091.pdf |format=PDF}}</ref> A 2008 review found evidence that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SM, mobilization, supervised exercise, low-level laser therapy and perhaps ] are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves ].<ref name=Hurwitz-2008/> A 2007 review found that SM and mobilization are effective for neck pain.<ref name=Vernon/> Of three systematic reviews of SM published between 2000 and May 2005, one reached a positive conclusion, and a 2004 Cochrane review (<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2004 |issue=1 |pages=CD004249 |title= Manipulation and mobilisation for mechanical neck disorders |author= Gross AR, Hoving JL, Haines TA ''et al.'' |doi=10.1002/14651858.CD004249.pub2 |pmid=14974063}}</ref>) found that SM and mobilization are beneficial only when combined with exercise, the benefits being pain relief, functional improvement, and global perceived effect for subacute/chronic mechanical neck disorder.<ref name=Ernst-Canter/> A 2005 review found consistent evidence supporting mobilization for acute whiplash, and limited evidence supporting SM for whiplash.<ref>{{cite journal |journal= ] |date=2005 |volume=10 |issue=1 |pages=21–32 |title= Treatment of whiplash-associated disorders—part I: non-invasive interventions |author= Conlin A, Bhogal S, Sequeira K, Teasell R |pmid=15782244}}</ref>

* ''']'''. A 2006 review found no rigorous evidence supporting SM or other manual therapies for ].<ref>{{cite journal |journal= ] |date=2006 |volume=22 |issue=3 |pages=278–85 |title= Are manual therapies effective in reducing pain from tension-type headache?: a systematic review |author= Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA |doi=10.1097/01.ajp.0000173017.64741.86 |pmid=16514329}}</ref> 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 ].<ref>{{cite journal |journal=] |date=2005 |volume=45 |issue=6 |pages=738–46 |title= Physical treatments for headache: a structured review |doi=10.1111/j.1526-4610.2005.05141.x |author= Biondi DM |pmid=15953306}}</ref> A 2004 review found that SM may be effective for migraine and tension headache, and SM and neck exercises may be effective for cervicogenic headache.<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2004 |issue=3 |pages=CD001878 |title= Non-invasive physical treatments for chronic/recurrent headache |author= Bronfort G, Nilsson N, Haas M ''et al.'' |doi=10.1002/14651858.CD001878.pub2 |pmid=15266458}}</ref> Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of SM.<ref name=Ernst-Canter/>

* '''Other'''. There is a small amount of research into the efficacy of chiropractic treatment for ]s,<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2008 |volume=31 |issue=2 |pages=146–59 |title= Chiropractic treatment of upper extremity conditions: a systematic review |author= McHardy A, Hoskins W, Pollard H, Onley R, Windsham R |doi=10.1016/j.jmpt.2007.12.004 |pmid=18328941}}</ref> and a lack of higher-quality publications supporting chiropractic management of ] conditions.<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=8 |pages=658–71 |title= Chiropractic treatment of lower extremity conditions: a literature review |author= Hoskins W, McHardy A, Pollard H, Windsham R, Onley R |doi=10.1016/j.jmpt.2006.08.004 |pmid=17045100}}</ref> A 2007 literature synthesis found fair evidence supporting assurance and advice to stay active for ] and ] in the leg.<ref name=Meeker-2007/> There is very weak evidence for chiropractic care for adult ] (curved or rotated spine)<ref>{{cite journal |journal=Spine |date=2007 |volume=32 |issue= 19 Suppl |pages=S130–4 |title= A systematic literature review of nonsurgical treatment in adult scoliosis |author= Everett CR, Patel RK |doi=10.1097/BRS.0b013e318134ea88 |pmid=17728680}}</ref> and no scientific data for ] adolescent scoliosis.<ref>{{cite journal |journal=]|date=2008 |volume=3 |pages=2 |title= Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review |author= Romano M, Negrini S |doi=10.1186/1748-7161-3-2 |pmid=18211702 |url=http://scoliosisjournal.com/content/3/1/2}}</ref> 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 ], and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ]/], ]s, and ] conditions.<ref name=Hawk>{{cite journal |journal= J Altern Complement Med |date=2007 |volume=13 |issue=5 |pages=491–512 |title= Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research |author= Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW |doi=10.1089/acm.2007.7088 |pmid=17604553}}</ref> Other reviews have found no evidence of benefit for baby colic,<ref>{{cite journal |journal= ] |date=2007 |volume=19 |issue=8 |pages=26 |title= Effectiveness of chiropractic treatment for infantile colic |author= Kingston H |pmid=17970361}}</ref> ],<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2005 |issue=2 |pages=CD005230 |title= Complementary and miscellaneous interventions for nocturnal enuresis in children |author= Glazener CM, Evans JH, Cheuk DK |doi=10.1002/14651858.CD005230 |pmid=15846744}}</ref> ],<ref>{{cite journal |journal= ] |date=2006 |volume=12 |issue=1 |pages=47–57 |title= Complementary and alternative medical therapies in fibromyalgia |author= Sarac AJ, Gur A |pmid=16454724 |doi= 10.2174/138161206775193262}}</ref> or ].<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2006 |issue=3 |pages=CD002119 |title= Spinal manipulation for primary and secondary dysmenorrhoea |author= Proctor ML, Hing W, Johnson TC, Murphy PA |doi=10.1002/14651858.CD002119.pub3 |pmid=16855988}}</ref>

=== Safety ===

Chiropractic care in general is safe when employed skillfully and appropriately. Manipulation is regarded as relatively safe, but as with all therapeutic interventions, complications can arise, and it has known adverse effects, risks and contraindications. <!-- <ref name=WHO-guidelines/> --> Absolute ]s to spinal manipulative therapy are conditions that should not be manipulated; these contraindications include ] and conditions known to result in unstable joints. 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 ].<ref name=WHO-guidelines/> Although most contraindications apply only to manipulation of the affected region, some neurological signs indicate referral to ]; these include sudden and severe ] or ] unlike that previously experienced.<ref name=CCA-CFCREAB-CPG>{{cite journal |journal= J Can Chiropr Assoc |date=2005 |volume=49 |issue=3 |pages=158–209 |title= Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash |author= Anderson-Peacock E, Blouin JS, Bryans R ''et al.'' |url=http://www.jcca-online.org/Client/cca/jcca.nsf/objects/jcca-v49-3-158/$file/jcca-v49-3-158.pdf |format=PDF}}<br/>&nbsp;• {{cite journal |journal= J Can Chiropr Assoc |date=2008 |volume=52 |issue=1 |pages=7–8 |title= A clinical practice guideline update from The CCA•CFCREAB-CPG |author= Anderson-Peacock E, Bryans B, Descarreaux M ''et al.'' |url=http://www.jcca-online.org/Client/cca/JCCA.nsf/objects/JCCA_March_2008_52_1/$file/jcca-v52-1-007.pdf |format=PDF}}</ref>

Spinal manipulation is associated with frequent, mild and temporary ],<ref name=Ernst-adverse/><ref name=CCA-CFCREAB-CPG/> including new or worsening pain or stiffness in the affected region.<ref name=Thiel>{{cite journal |journal=Spine |date=2007 |volume=32 |issue=21 |pages=2375–8 |title= Safety of chiropractic manipulation of the cervical spine: a prospective national survey |author= Thiel HW, Bolton JE, Docherty S, Portlock JC |pmid=17906581}}</ref> They have been estimated to occur in 34% to 55% of patients, with 80% of them disappearing within 24 hours.<ref name=CCA-CFCREAB-CPG/> Rarely, 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<ref name=Ernst-adverse>{{cite journal |journal= ] |date=2007 |volume=100 |issue=7 |pages=330–8 |title= Adverse effects of spinal manipulation: a systematic review |author= Ernst E |pmid=17606755 |url=http://www.jrsm.org/cgi/content/full/100/7/330 |doi=10.1258/jrsm.100.7.330}}</ref> and children.<ref name=Vohra>{{cite journal |journal=] |date=2007 |volume=119 |issue=1 |pages=e275–83 |title= Adverse events associated with pediatric spinal manipulation: a systematic review |author= Vohra S, Johnston BC, Cramer K, Humphreys K |doi=10.1542/peds.2006-1392 |pmid=17178922 |url=http://pediatrics.aappublications.org/cgi/content/full/119/1/e275}}</ref> The ] of these complications is unknown, due to rarity, high levels of underreporting, and difficulty of linking manipulation to adverse effects such as stroke, a particular concern.<ref name=Ernst-adverse/> Several case reports show temporal associations between interventions and potentially serious complications.<!-- <ref name=Hurwitz-2008/> --> ] is ] 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.<ref name=Hurwitz-2008>{{cite journal |journal=Spine |date=2008 |volume=33 |issue= 4 Suppl |pages=S123–52 |title= Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders |author= Hurwitz EL, Carragee EJ, van der Velde G ''et al.'' |doi=10.1097/BRS.0b013e3181644b1d |pmid=18204386 |doi_brokendate=2008-06-24}}</ref> Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.<ref>{{cite journal |journal=] |date=2008 |volume=14 |issue=1 |pages=66–73 |title= Does cervical manipulative therapy cause vertebral artery dissection and stroke? |author= Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM |doi=10.1097/NRL.0b013e318164e53d |pmid=18195663}}</ref>

=== Cost-effectiveness ===

A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings.<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=9 |pages=707–25 |title= Health services research related to chiropractic: review and recommendations for research prioritization by the chiropractic profession |author= Mootz RD, Hansen DT, Breen A, Killinger LZ, Nelson C |doi=10.1016/j.jmpt.2006.09.001 |pmid=17142165}}</ref> A 2006 UK systematic ] review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain, but that reports are based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to ]s) remains uncertain.<ref>{{cite journal |journal= ] |date=2006 |volume=3 |issue=4 |pages=425–32 |title= Cost-effectiveness of complementary therapies in the United kingdom—a systematic review |author= Canter PH, Coon JT, Ernst E |doi=10.1093/ecam/nel044 |pmid=17173105 |url=http://ecam.oxfordjournals.org/cgi/content/full/3/4/425}}</ref> A 2005 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.<ref>{{cite journal |journal= ] |date=2005 |volume=19 |issue=4 |pages=671–84 |title= What is the most cost-effective treatment for patients with low back pain? a systematic review |author= van der Roer N, Goossens MEJB, Evers SMAA, van Tulder MW |doi=10.1016/j.berh.2005.03.007 |pmid=15949783}}</ref> The cost-effectiveness of maintenance chiropractic care is unknown.<ref name=Leboeuf-Yde-C/>

== Vaccination ==

Although ] is one of the most cost-effective forms of prevention against infectious disease, it remains ] within the chiropractic community.<!-- <ref name=Busse/> --> Most chiropractic writings on vaccination focus on its negative aspects,<ref name=Busse/> claiming that it is hazardous or ineffective.<ref>{{cite journal |journal=] |date=2001 |volume=20 |issue= Suppl 1 |pages=S89–93 |title= Rise in popularity of complementary and alternative medicine: reasons and consequences for vaccination |author= Ernst E |doi=10.1016/S0264-410X(01)00290-0 |pmid=11587822}}</ref> Evidence-based chiropractors have embraced vaccination, but a minority of the profession rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that diseases cannot be affected by vaccines. <!-- <ref name=Campbell/> --> The ] and the International Chiropractic Association support individual exemptions to compulsory vaccination laws, and a 1995 survey of U.S. chiropractors found that about a third believed there was no scientific proof that immunization prevents disease.<ref name=Campbell>{{cite journal |journal=Pediatrics |date=2000 |volume=105 |issue=4 |pages=e43 |title= Chiropractors and vaccination: a historical perspective |author= Campbell JB, Busse JW, Injeyan HS |pmid=10742364 |url=http://pediatrics.aappublications.org/cgi/content/full/105/4/e43 |doi= 10.1542/peds.105.4.e43}}</ref> The ] supports vaccination; surveys in Canada in 2000 and 2002 found that 40% of chiropractors supported vaccination, and that over a quarter opposed it and advised patients against vaccinating themselves or their children.<ref name=Busse>{{cite journal |journal= J Manipulative Physiol Ther |date=2005 |volume=28 |issue=5 |pages=367–73 |title= Chiropractic antivaccination arguments |author= Busse JW, Morgan L, Campbell JB |doi=10.1016/j.jmpt.2005.04.011 |pmid=15965414 |url=http://jmptonline.org/article/S0161-4754(05)00111-9/fulltext?articleId=S0899-3467%2807%2960081-0}}</ref>



== References ==
{{reflist|2}}

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Revision as of 05:28, 7 August 2008

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