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Chiropractic: from Greek chiro- χειρο- "hand-"
+ praktikós πρακτικός "concerned with action"

Chiropractic is a health care approach and profession that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine, under the hypothesis that these disorders affect general health via the nervous system. It is generally considered to be complementary and alternative medicine, a characterization that many chiropractors reject. The main treatment involves manual therapy including manipulation of the spine, other joints, and soft tissue; treatment also includes exercises and health and lifestyle counseling. Traditionally, chiropractic assumes that a vertebral subluxation or spinal joint dysfunction interferes with the body's function and its innate intelligence, a notion that brings ridicule from mainstream science and medicine.

D.D. Palmer founded chiropractic in the 1890s and his son B.J. Palmer helped to expand it in the early 20th century. It has two main groups: "straights", now the minority, emphasize vitalism, innate intelligence and spinal adjustments, and consider subluxations to be the leading cause of all disease; "mixers" are more open to mainstream and alternative medical techniques such as exercise, massage, nutritional supplements, and acupuncture. Chiropractic is well established in the U.S., Canada and Australia.

For most of its existence, chiropractic has battled with mainstream medicine, sustained by ideas such as subluxation that are not based on solid science. Vaccination remains controversial among chiropractors. The American Medical Association called chiropractic an "unscientific cult" and boycotted it until losing a 1987 antitrust case. Chiropractic has had a strong political base and sustained demand for services; in recent decades, it has gained more legitimacy and greater acceptance among medical physicians and health plans, and evidence-based medicine has been used to review research studies and generate practice guidelines. Many studies of treatments used by chiropractors have been conducted, with conflicting results. Collectively, systematic reviews of this research have not demonstrated that spinal manipulation is effective, with the possible exception of treatment of back pain. The efficacy and cost-effectiveness of maintenance chiropractic care are unknown. Although spinal manipulation can have serious complications in rare cases, chiropractic care is generally safe when employed skillfully and appropriately.

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Philosophy

Chiropractic's early philosophy was rooted in vitalism, spiritual inspiration and rationalism. 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, rejects the inferential reasoning of the scientific method, and relies on deductions from vitalistic first principles rather than on the materialism of science. However, most practitioners currently accept the importance of scientific research into chiropractic, and most practitioners are "mixers" who attempt to combine the materialistic reductionism of science with the metaphysics of their predecessors and with the holistic paradigm of wellness; a 2008 commentary proposed that chiropractic actively divorce itself from the straight philosophy as part of a campaign to eliminate untestable dogma and engage in critical thinking and evidence-based research.

Although a wide diversity of ideas currently exists among chiropractors, they share the belief that the spine and health are related in a fundamental way, and that this relationship is mediated through the nervous system. Chiropractors study the biomechanics, structure and function of the spine, along with what they say are its effects on the musculoskeletal and nervous systems and its role in health and disease.

Chiropractic philosophy includes the following perspectives:

• Holism assumes that health is affected by everything in people's complex environments; some sources also include a spiritual or existential dimension. In contrast, reductionism in chiropractic reduces causes and cures of health problems to a single factor, vertebral subluxation.

• Conservatism considers the risks of clinical interventions when balancing them against their benefits. It emphasizes noninvasive treatment to minimize risk, and avoids surgery and medication.

• Homeostasis emphasizes the body's inherent self-healing abilities. Chiropractic's early notion of innate intelligence can be thought of as a metaphor for homeostasis.

• Straights tend to use an approach that focuses on the chiropractor's perspective and the treatment model, whereas mixers tend to focus on the patient and the patient's situation.

Straights and mixers

Chiropractic is often described as two professions masquerading as one. Unlike the distinction between podiatry (a science-based profession for foot disorders) and foot reflexology (an unscientific philosophy which posits that many disorders arise from the feet), in chiropractic the two professions attempt to live under one roof.

Straight chiropractors adhere to the philosophical principles set forth by D.D. and B.J. Palmer, and retain metaphysical definitions and vitalistic qualities. Straight chiropractors believe that vertebral subluxation leads to interference with an "Innate Intelligence" exerted via the human nervous system and is a primary underlying risk factor for 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 chiropractic treatment. Thus, straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not "mix" other types of therapies. Their philosophy and explanations are metaphysical in nature and prefer to use traditional chiropractic lexicon (i.e. 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 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 many treatments including conventional techniques of physical therapy such as exercise, massage, ice packs, and moist heat, along with nutritional supplements, acupuncture, homeopathy, herbal remedies, and biofeedback. Mixers tend to be open to mainstream medicine and are the majority group.

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. 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 vitalistic approach, imbued the term subluxation with a metaphysical and philosophical meaning. He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic. 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."

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. In general, critics of traditional subluxation-based chiropractic (including chiropractors) are skeptical of its clinical value, dogmatic beliefs and metaphysical approach. While straight chiropractic still retains the traditional vitalistic construct espoused by the founders, evidence-based chiropractic suggests that a mechanistic view will allow chiropractic care to become integrated into the wider health care community. This is still a continuing source of debate within the chiropractic profession as well, with some schools of chiropractic still teaching the traditional/straight subluxation-based chiropractic, while others have moved towards an evidence-based chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions.

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 disorders of internal organs (such as the heart, the lungs, or the stomach) that subluxation significantly contributes to, the mean response was 62%. In 2005, subluxation was defined by the World Health Organization as "a lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. It is essentially a functional entity, which may influence biomechanical and neural integrity." This differs from the medical definition of subluxation as a significant structural displacement, which can be seen with static imaging techniques such as X-rays. Attorney David Chapman-Smith, Secretary-General of the World Federation of Chiropractic, has stated that "subluxations are not structural entities and cannot be detected on x‑ray."

Scope of practice

Chiropractors, also known as doctors of chiropractic or chiropractic physicians in many jurisdictions, emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery, with special emphasis on the spine. Chiropractic combines aspects from mainstream and alternative medicine: although chiropractors have many attributes of primary care providers, chiropractic has more of the attributes of a medical specialty like dentistry or podiatry. It has been proposed that chiropractors specialize in nonsurgical spine care, instead of attempting to also treat other problems, but the more expansive view of chiropractic is still widespread. Mainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be complementary and alternative medicine (CAM); however, a 2008 study reported that 31% of surveyed chiropractors categorized chiropractic as CAM, 27% as integrated medicine, and 12% as mainstream medicine.

The practice of chiropractic medicine involves a range of diagnostic methods including skeletal imaging, observational and tactile assessments, and orthopedic and neurological evaluation. A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider. Common patient management involves spinal manipulation (SM) and other manual therapies to the joints and soft tissues, rehabilitative exercises, health promotion, electrical modalities, complementary procedures, and lifestyle counseling.

Chiropractors are not licensed to write medical prescriptions or perform major surgery in the U.S. Their scope of practice varies by state in areas such as conducting laboratory tests or diagnostic procedures, dispensing dietary supplements, and using other therapies such as homeopathy and acupuncture; in Oregon they can become certified to perform minor surgery and to deliver children via natural childbirth. A 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for over-the-counter drugs. A related field, veterinary chiropractic, applies manual therapies to animals and is recognized in a few U.S. states, but is not recognized by the American Chiropractic Association as being chiropractic.

Chiropractic overlaps with several other manual-therapy professions, including massage therapy, osteopathy, and physical therapy. Chiropractic is autonomous and competitive with mainstream medicine and osteopathy outside the U.S. remains primarily a manual medical system; physical therapists work alongside and cooperate with mainstream medicine, and osteopathic medicine in the U.S. has merged with the medical profession. Members distinguish these competing professions with rhetorical strategies that include claims that, compared to other professions, chiropractors heavily emphasize spinal manipulation, tend to use firmer manipulative techniques, and promote maintenance care; that osteopaths use a wider variety of treatment procedures; and that physical therapists emphasize machinery and exercise.

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

Treatment techniques

Spinal manipulation, which chiropractors call "spinal adjustment" or "chiropractic adjustment", is the most common treatment used in chiropractic care; in the U.S., chiropractors perform over 90% of all manipulative treatments. Spinal manipulation is a passive manual maneuver during which a three-joint complex is taken past the normal range of movement, but not so far as to dislocate or damage the joint; its defining factor is a dynamic thrust, which is a sudden force that causes an audible release and attempts to increase a joint's range of motion. More generally, spinal manipulative therapy (SMT) describes techniques where the hands are used to manipulate, massage, mobilize, adjust, stimulate, apply traction to, or otherwise influence the spine and related tissues; in chiropractic care SMT most commonly takes the form of spinal manipulation.

There are several schools of chiropractic adjustive techniques, although most chiropractors mix techniques from several schools. The following adjustive procedures were received by more than 20% of patients of licensed U.S. chiropractors in a 2003 survey: Diversified technique (full-spine manipulation), extremity adjusting, Activator technique (which uses a spring loaded tool to deliver precise adjustments to the spine), Thompson Technique, Gonstead (which looks at the whole spine with the philosophy that a vertebral misalignment may affect other areas of the spine, emphasizing the mechanical aspects of the spine), Cox/flexion-distraction (a gentle, non-force adjusting procedure which mixes chiropractic principles with osteopathic principles and utilizes specialized adjusting tables with movable parts), adjustive instrument, Sacro-Occipital Technique (which models the spine as a torsion bar), Nimmo Receptor-Tonus Technique, and Applied Kinesiology (which emphasises "muscle testing" as a diagnostic tool). Medicine-assisted manipulation, such as manipulation under anesthesia, involves sedation or local anesthetic and is done by a team that includes an anesthesiologist; a 2008 systematic review did not find enough evidence to make recommendations about its use for chronic low back pain.

Many other procedures are used by chiropractors for treating the spine, other joints and tissues, and general health issues. The following procedures were received by more than 1/3 of patients of licensed U.S. chiropractors in a 2003 survey: Diversified technique (full-spine manipulation; mentioned in previous paragraph), physical fitness/exercise promotion, corrective or therapeutic exercise, ergonomic/postural advice, self-care strategies, activities of daily living, changing risky/unhealthy behaviors, nutritional/dietary recommendations, relaxation/stress reduction recommendations, ice pack/cryotherapy, extremity adjusting (also mentioned in previous paragraph), trigger point therapy, and disease prevention/early screening advice.

Education, licensing, and regulation

Chiropractors obtain a first professional degree in the field of chiropractic. In the United States, 90 semester hours or about two years of undergraduate education are pre-requisite for entrance to chiropractic school. Canada requires a minimum three years 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. The World Health Organization (WHO) guidelines suggest three major full-time educational paths culminating in either a DC, DCM, BSc, or MSc degree. Besides the full-time paths, they also suggest a conversion program for people with other health care education and limited training programs for regions where no legislation governs chiropractic.

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

Chiropractic is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries. In the U.S., chiropractic schools are accredited through the Council on Chiropractic Education (CCE) while the General Chiropractic Council (GCC) is the statutory governmental body responsible for the regulation of chiropractic in the UK. 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. Today, there are 18 accredited Doctor of Chiropractic programs in the U.S., 2 in Canada, 6 in Australasia, and 4 in Europe. 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.

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. There are an estimated 53,000 chiropractors in the U.S. (2006), 7,000 in Canada (2009), 2,500 in Australia (2000), and 1,500 in the UK (2000).

A 2008 commentary proposed that the chiropractic profession actively regulate itself to combat abuse, fraud, and quackery, which are more prevalent in chiropractic than in other health care professions, violating the social contract between patients and physicians. Unsubstantiated claims about the efficacy of chiropractic have continued to be made by individual chiropractors and chiropractic associations. The largest chiropractic associations in the U.S. and Canada distributed patient brochures which contained unsubstantiated claims. Chiropractors, especially in America, have a reputation for unnecessarily treating patients. In many circumstances the focus seems to be put on economics instead of health care. Sustained chiropractic care is promoted as a preventative tool but unnecessary manipulation could possibly present a risk to patients. Some chiropractors are concerned by the routine unjustified claims chiropractors have made. A study of California disciplinary statistics during 1997–2000 reported 4.5 disciplinary actions per 1000 chiropractors per year, compared to 2.27 for MDs; the incident rate for fraud was 9 times greater among chiropractors (1.99 per 1000 chiropractors per year) than among MDs (0.20).

Utilization, satisfaction rates, and third party coverage

In the U.S., chiropractic is the largest alternative medical profession, and is the third largest doctored profession, behind medicine and dentistry. The percentage of population that utilizes chiropractic care at any given time generally falls into a range from 6% to 12% in the U.S. and Canada, with a global high of 20% in Alberta. Chiropractors are the most common CAM providers for children and adolescents, who consume up to 14% of all visits to chiropractors. The vast majority who seek chiropractic care do so for relief from back and neck pain and other neuromusculoskeletal complaints; most do so specifically for low back pain. Practitioners such as chiropractors are often used as a complementary form of care to primary medical intervention. Satisfaction rates are typically higher for chiropractic care compared to medical care, with a 1998 U.S. survey reporting 83% of persons satisfied or very satisfied with their care; quality of communication seems to be a consistent predictor of patient satisfaction with chiropractors.

Chiropractic does not have the same level of mainstream credibility as other healthcare professions. Public perception of chiropractic compares unfavorably with mainstream medicine with regard to ethics and honesty: in a 2006 Gallup Poll of U.S. adults, chiropractors rated last among seven health care professions for being very high or high in honesty and ethical standards, with 36% of poll respondents rating chiropractors very high or high; the corresponding ratings for other professions ranged from 62% for dentists to 84% for nurses.

Utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient. The use of chiropractic declined from 9.9% of U.S. adults in 1997 to 7.4% in 2002; this was the largest relative decrease among CAM professions, which overall had a stable use rate. Employment of U.S. chiropractors is expected to increase 14% between 2006 and 2016, faster than the average for all occupations.

In the U.S., most states require insurers to cover chiropractic care, and most HMOs cover these services. In Canada, there is lack of coverage under the universal public health insurance system. In Australia, most private health insurance funds cover chiropractic care, and the federal government funds chiropractic care when the patient is referred by a medical practitioner.

History

Chiropractic was founded in the 1890s by Daniel David (D.D.) Palmer in Davenport, Iowa. Palmer, a magnetic healer, hypothesized that manual manipulation of the spine could cure disease. Chiropractic competed with its predecessor osteopathy, another medical system based on magnetic healing and founded by a charismatic midwesterner in opposition to conventional medicine; however, where osteopathic postulated improved blood flow via manipulation, chiropractic postulated improved neural transmissions. Although initially keeping chiropractic a family secret, in 1898 Palmer began teaching it to a few students at his new Palmer School of Chiropractic. One student, his son Bartlett Joshua (B.J.) Palmer, became committed to promoting chiropractic, took over the Palmer School in 1906, and rapidly expanded its enrollment. 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. Early chiropractors believed that all disease was caused by interruptions in the flow of innate intelligence, a vital 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 legal protection under the U.S. constitution, but decided against it partly to avoid confusion with Christian Science. Early chiropractors also tapped into the Populist movement, emphasizing craft, hard work, competition, and advertisement, aligning themselves with the common man against intellectuals and trusts, among which they included the American Medical Association (AMA).

Chiropractic has seen considerable controversy and criticism. 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 X-rays 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. 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. Despite heavy opposition by organized medicine, by the 1930s chiropractic was the largest alternative healing profession in the U.S. The longstanding feud between chiropractors and medical doctors continued for decades. The AMA labeled chiropractic an "unscientific cult" in 1966, and until 1980 held that it was unethical for medical doctors to associate with "unscientific practitioners". This culminated in a landmark 1987 decision, Wilk v. AMA, in which the court found that the AMA had engaged in unreasonable restraint of trade and conspiracy, and which ended the AMA's de facto boycott of chiropractic.

Serious research to test chiropractic theories did not begin until the 1970s, and is continuing to be hampered by what are characterized as antiscientific and pseudoscientific ideas that sustained the profession in its long battle with organized medicine. 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. In recent decades chiropractic gained legitimacy and greater acceptance by medical physicians and health plans, and enjoyed a strong political base and sustained demand for services. However, its future seemed uncertain: as the number of practitioners grew, evidence-based medicine insisted on treatments with demonstrated value, managed care restricted payment, and competition grew from massage therapists and other health professions. The profession responded by marketing natural products and devices more aggressively, and by reaching deeper into alternative medicine and primary care.

Evidence basis

The principles of evidence-based medicine 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 managed care. Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs what is considered by many chiropractic researchers to be antiscientific reasoning and unsubstantiated claims, that have been called ethically suspect when they let practitioners maintain their beliefs to patients' detriment. A 2007 survey of Alberta chiropractors found that they do not consistently apply research in practice, which may have resulted from a lack of research education and skills. Evidence-based chiropractors possess the ability to apply research in practice. Continued education enhances the scientific knowledge of the practitioner.

Effectiveness

Opinions differ as to the efficacy of chiropractic treatment. Many controlled clinical studies of spinal manipulation (SM) are available, but their results disagree, and they are typically of low quality. Health claims made by chiropractors about using manipulation for pediatric health conditions are supported by only low levels of scientific evidence that does not demonstrate clinically relevant benefits. 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, but a 2008 supportive review found serious flaws in the critical approach and found that SM and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments. Most research has focused on spinal manipulation (SM) in general, rather than solely on chiropractic SM. A 2002 review of randomized clinical trials of SM was criticized for not distinguishing between studies of SM in general, and studies on chiropractic SM in particular; however the review's authors stated that they did not consider this difference to be a significant point as research on SM is equally useful regardless of which practitioner provides it.

There is a wide range of ways to measure treatment outcomes. Chiropractic care, like all medical treatment, benefits from the placebo response. It is hard to construct a trustworthy placebo for clinical trials of spinal manipulative therapy (SMT), as experts often disagree about whether a proposed placebo actually has no effect. The efficacy of maintenance care in chiropractic is unknown.

Available evidence covers the following conditions:

• Low back pain. There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain. A 2008 review found strong evidence that SM is similar in effect to medical care with exercise. A 2007 review found good evidence that SM is moderately effective for low back pain lasting more than 4 weeks; a 2008 literature synthesis found good evidence supporting SM for low back pain regardless of duration. Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review found that SM or mobilization is no more or less effective than other standard interventions for back pain. Methods for formulating treatment guidelines for low back pain differ significantly between countries, casting some doubt on their reliability.

• Whiplash and other neck pain. There is no overall consensus on manual therapies for neck pain. 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 acupuncture 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 prognosis. A 2007 review found that SM and mobilization are effective for neck pain. Of three systematic reviews of SM published between 2000 and May 2005, one reached a positive conclusion, and a 2004 Cochrane review found that SM and mobilization are beneficial only when combined with exercise. A 2005 review found consistent evidence supporting mobilization for acute whiplash, and limited evidence supporting SM for whiplash.

• Headache. A 2006 review found no rigorous evidence supporting SM or other manual therapies for tension headache. A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine. 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. Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of SM.

• Other. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs, and limited or fair evidence supporting chiropractic management of leg conditions. There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine) and no scientific data for idiopathic adolescent scoliosis. 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 asthma, cervicogenic dizziness, and baby colic, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizziness, high blood pressure, and vision conditions. Other reviews have found no evidence of benefit for asthma, baby colic, bedwetting, carpal tunnel syndrome, fibromyalgia, kinetic imbalance due to suboccipital strain (KISS) in infants, menstrual cramps, or pelvic and back pain during pregnancy.

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. Absolute contraindications to spinal manipulative therapy are conditions that should not be manipulated; these contraindications include rheumatoid arthritis and conditions known to result in unstable joints. Relative contraindications are conditions where increased risk is acceptable in some situations and where low-force and soft-tissue techniques are treatments of choice; these contraindications include osteoporosis. Although most contraindications apply only to manipulation of the affected region, some neurological signs indicate referral to emergency medical services; these include sudden and severe headache or neck pain unlike that previously experienced.

Spinal manipulation is associated with frequent, mild and temporary adverse effects, including new or worsening pain or stiffness in the affected region. They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours. 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 and children. Estimates vary widely for the incidence of these complications, and the actual incidence is unknown, due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke, which is a particular concern. Several case reports show temporal associations between interventions and potentially serious complications. Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions. Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.

Chiropractors sometimes employ diagnostic imaging techniques such as X-rays and CT scans that rely on ionizing radiation; practice guidelines aim to reduce unnecessary radiation exposure, which increase cancer risk in proportion to the amount of radiation received.

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. A 2006 systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation in the United Kingdom compared favorably with other treatments for back pain, but that reports were based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain. 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. The cost-effectiveness of maintenance chiropractic care is unknown.

Public health

Some chiropractors oppose vaccination and water fluoridation, which are common public health practices. Chiropractors' attempts to establish a positive reputation for their public health role are also compromised by their reputation for recommending repetitive life-long chiropractic treatment. Within the chiropractic community there are significant disagreements about vaccination, one of the most cost-effective public health interventions available. Most chiropractic writings on vaccination focus on its negative aspects, claiming that it is hazardous, ineffective, and unnecessary. Some chiropractors have embraced vaccination, but a significant portion of the profession rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that vaccines interfere with healing. The American Chiropractic Association and the International Chiropractors Association support individual exemptions to compulsory vaccination laws, and a 1995 survey of U.S. chiropractors found that about a third believed there was no scientific proof that immunization prevents disease. The Canadian Chiropractic Association supports vaccination; a survey in Alberta in 2002 found that 25% of chiropractors advised patients for, and 27% against, vaccinating themselves or their children.

Early opposition to water fluoridation included chiropractors, some of whom continue to oppose it as being incompatible with chiropractic philosophy and an infringement of personal freedom. Other chiropractors have actively promoted fluoridation, and several chiropractic organizations have endorsed scientific principles of public health.

Controversy and criticism

The core concepts of chiropractic, vertebral subluxation and spinal manipulation, are not based on sound science. The birth of chiropractic was on September 18, 1895. On this day, Daniel D. Palmer, manipulated the spine of a deaf janitor named Harvey Lillard, allegedly curing him of deafness. And his second patient, a man with heart disease was also cured. D.D. Palmer, the founder of chiropractic, defined chiropractic as "a science of healing without drugs" and considered establishing chiropractic as a religion. Chiropractic included vitalistic ideas of innate intelligence with religious attributes of universal intelligence to substitute science. Evidence suggests that D.D. Palmer had acquired knowledge of manipulative techniques from Andrew Taylor Still, the founder of osteopathy. Although D.D. Palmer combined bonesetting to give chiropractic its method, and "magnetic healing" for the theory, he acknowledged a special relation to magnetic healing when he wrote, "chiropractic was not evolved from medicine or any other method, except that of magnetic." According to D.D. Palmer subluxation is the sole cause of disease and manipulation is the cure of all disease for the human race. Chiropractic is rooted in mystical concepts, leading to internal conflicts between straights and mixers which continue to this day. Chiropractic has seen considerable controversy over its philosophy. The rivalry was not solely with conventional medicine; many osteopaths proclaimed that chiropractic was a bastardized form of osteopathy.

In 1906, D.D. Palmer was the first chiropractor who went to jail. He was jailed for practicing medicine without a license. In the 1920s hundreds of unlicensed chiropractors chose jail rather than fines. Herbert Reaver was the most jailed chiropractor in the U.S. Chiropractors were charged with not complying with the medical practice act. California chiropractors adopted the motto, "Go to jail for chiropractic." 450 chiropractors were jailed in a single year at the peak of the controversy. Many chiropractors treated fellow prisoners and visiting patients while in jail.

Some New Zealand chiropractors appeared to have used the title 'Doctor' in a New Zealand Yellow pages telephone directory in a way that implied they are registered medical practitioners, when no evidence was presented it was true. In New Zealand, chiropractors are allowed to use the title ‘doctor’ such as in the Yellow Pages under the heading of 'Chiropractors' when it is qualified to show that the title refers to their chiropractic role.

UK chiropractic organizations and their members make numerous claims which are not supported by scientific evidence. Many chiropractors adhere to ideas which are against science and most seemingly violate important principles of ethical behaviour on a regular basis. The advice chiropractors gave to their patients is often misleading and dangerous. On 19 April 2008, Simon Singh wrote an article in the The Guardian which resulted in him being sued for libel by the British Chiropractic Association. Singh wrote in The Guardian criticising the claims made by chiropractors about the efficacy of spinal manipulation in treating childhood ailments, among other things. He suggested there was "not a jot" of evidence to support such interventions for these ailments, and argued that the British Chiropractic Association "happily promotes bogus treatments". The suit is ongoing, with Singh stating that he will "contest the action vigorously... There is an important issue of freedom of speech at stake." The article developed the theme of Singh's recently published book Trick or Treatment? Alternative Medicine on Trial, making various claims about the usefulness of chiropractic. Commentators suggest this ruling could set a precedent to restrict freedom of speech to criticise alternative medicine. The charity Sense About Science has launched a campaign to draw attention to this particular case. They have issued a statement entitled "The law has no place in scientific disputes", which has been signed by myriad signers representing science, journalism, publishing, arts, humanities, entertainment, skeptics, campaign groups and law. As of June 13, 2009, over 10,000 have signed.

Not all criticism originated from critics in the medical profession. Some chiropractors are cautiously calling for reform. The concept of subluxation remains unsubstantiated and largely untested, and has been debated about whether to keep it in the chiropractic paradigm for decades. The cost, effectiveness, and safety, of spinal manipulation are uncertain. Quackwatch is critical of chiropractic; its founder, Stephen Barrett, has written that it is "absurd" to think that chiropractors are qualified to be primary care providers and considers applied kinesiology to be a "term most commonly used to identify a pseudoscientific system of muscle-testing and therapy". Lon Morgan, DC, a reform chiropractor, expressed his view of Innate Intelligence this way: "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." William T. Jarvis, Ph.D. stated: "Chiropractic is a controversial health-care system that has been legalized throughout the United States and in several other countries. In the United States in 1984, roughly 10.7 million people made 163 million office visits to 30,000 chiropractors. More than three fourths of the states require insurance companies to include chiropractic services in health and accident policies. The federal government pays for limited chiropractic services under Medicare, Medicaid, and its vocational rehabilitation program, and the Internal Revenue Service allows a medical deduction for chiropractic services. Chiropractors cite such facts as evidence of "recognition." However, these are merely business statistics and legal arrangements that have nothing to do with chiropractic's scientific validity."

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    • Phillips RB (2005). "The evolution of vitalism and materialism and its impact on philosophy". In Haldeman S, Dagenais S, Budgell B et al. (eds.) (ed.). Principles and Practice of Chiropractic (3rd ed.). McGraw-Hill. pp. 65–76. ISBN 0-07-137534-1. {{cite book}}: |editor= has generic name (help)CS1 maint: multiple names: editors list (link)
87. Suter E, Vanderheyden LC, Trojan LS, Verhoef MJ, Armitage GD (2007). "How important is research-based practice to chiropractors and massage therapists?". J Manipulative Physiol Ther. 30 (2): 109–15. doi:10.1016/j.jmpt.2006.12.013. PMID 17320731.{{cite journal}}: CS1 maint: multiple names: authors list (link)
88. Feise RJ, Grod JP, Taylor-Vaisey A (2006). "Effectiveness of an evidence-based chiropractic continuing education workshop on participant knowledge of evidence-based health care". Chiropr Osteopat. 14: 18. doi:10.1186/1746-1340-14-18. PMID 16930482.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
89. ^ Ernst E, Canter PH (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med. 99 (4): 192–6. doi:10.1258/jrsm.99.4.192. PMID 16574972. {{cite journal}}: Unknown parameter |laydate= ignored (help); Unknown parameter |laysource= ignored (help); Unknown parameter |laysummary= ignored (help)
90. Quality of SM studies:
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    • Johnston BC, da Costa BR, Devereaux PJ, Akl EA, Busse JW; Expertise-Based RCT Working Group (2008). "The use of expertise-based randomized controlled trials to assess spinal manipulation and acupuncture for low back pain: a systematic review". Spine. 33 (8): 914–8. doi:10.1097/BRS.0b013e31816b4be4. PMID 18404113.{{cite journal}}: CS1 maint: multiple names: authors list (link)
91. ^ Gotlib A, Rupert R (2008). "Chiropractic manipulation in pediatric health conditions - an updated systematic review". Chiropr Osteopat. 16: 11. doi:10.1186/1746-1340-16-11. PMID 18789139.{{cite journal}}: CS1 maint: unflagged free DOI (link)
92. Ernst E (2009). "Chiropractic manipulation, with a deliberate 'double entendre'". Arch Dis Child. 94 (6): 411. doi:10.1136/adc.2009.158170. PMID 19460920.
93. ^ Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S (2008). "Evidence-informed management of chronic low back pain with spinal manipulation and mobilization". Spine J. 8 (1): 213–25. doi:10.1016/j.spinee.2007.10.023. PMID 18164469.{{cite journal}}: CS1 maint: multiple names: authors list (link)
94. ^ Meeker WC, Haldeman S (2002). "Chiropractic: in response" (PDF). Ann Intern Med. 137 (8): 702.
95. Ernst E (2002). "Chiropractic" (PDF). Ann Intern Med. 137 (8): 701. PMID 12379081.
96. Khorsan R, Coulter ID, Hawk C, Choate CG (2008). "Measures in chiropractic research: choosing patient-based outcome assessments". J Manipulative Physiol Ther. 31 (5): 355–75. doi:10.1016/j.jmpt.2008.04.007. PMID 18558278.{{cite journal}}: CS1 maint: multiple names: authors list (link)
97. Kaptchuk TJ (2002). "The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance?" (PDF). Ann Intern Med. 136 (11): 817–25. PMID 12044130.
98. Hancock MJ, Maher CG, Latimer J, McAuley JH (2006). "Selecting an appropriate placebo for a trial of spinal manipulative therapy" (PDF). Aust J Physiother. 52 (2): 135–8. PMID 16764551.{{cite journal}}: CS1 maint: multiple names: authors list (link)
99. ^ Murphy AYMT, van Teijlingen ER, Gobbi MO (2006). "Inconsistent grading of evidence across countries: a review of low back pain guidelines". J Manipulative Physiol Ther. 29 (7): 576–81, 581.e1–2. doi:10.1016/j.jmpt.2006.07.005. PMID 16949948.{{cite journal}}: CS1 maint: multiple names: authors list (link)
100. Chou R, Huffman LH; American Pain Society; American College of Physicians (2007). "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". Ann Intern Med. 147 (7): 492–504. PMID 17909210.{{cite journal}}: CS1 maint: multiple names: authors list (link)
101. Lawrence DJ, Meeker W, Branson R; et al. (2008). "Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis". J Manipulative Physiol Ther. 31 (9): 659–74. doi:10.1016/j.jmpt.2008.10.007. PMID 19028250. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link) An earlier, freely readable version is in: Meeker W, Branson R, Bronfort G; et al. (2007). "Chiropractic management of low back pain and low back related leg complaints" (PDF). Council on Chiropractic Guidelines and Practice Parameters. Retrieved 2008-11-28. {{cite web}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
102. Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004). "Spinal manipulative therapy for low back pain". Cochrane Database Syst Rev (1): CD000447. doi:10.1002/14651858.CD000447.pub2. PMID 14973958.{{cite journal}}: CS1 maint: multiple names: authors list (link)
103. ^ Vernon H, Humphreys BK (2007). "Manual therapy for neck pain: an overview of randomized clinical trials and systematic reviews" (PDF). Eura Medicophys. 43 (1): 91–118. PMID 17369783.
104. ^ Hurwitz EL, Carragee EJ, van der Velde G; et al. (2008). "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders". Spine. 33 (4 Suppl): S123–52. doi:10.1097/BRS.0b013e3181644b1d. PMID 18204386. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help)CS1 maint: multiple names: authors list (link)
105. Gross AR, Hoving JL, Haines TA; et al. (2004). "Manipulation and mobilisation for mechanical neck disorders". Cochrane Database Syst Rev (1): CD004249. doi:10.1002/14651858.CD004249.pub2. PMID 14974063. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
106. Conlin A, Bhogal S, Sequeira K, Teasell R (2005). "Treatment of whiplash-associated disorders—part I: non-invasive interventions". Pain Res Manag. 10 (1): 21–32. PMID 15782244.{{cite journal}}: CS1 maint: multiple names: authors list (link)
107. Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA (2006). "Are manual therapies effective in reducing pain from tension-type headache?: a systematic review". Clin J Pain. 22 (3): 278–85. doi:10.1097/01.ajp.0000173017.64741.86. PMID 16514329.{{cite journal}}: CS1 maint: multiple names: authors list (link)
108. Biondi DM (2005). "Physical treatments for headache: a structured review". Headache. 45 (6): 738–46. doi:10.1111/j.1526-4610.2005.05141.x. PMID 15953306.
109. Bronfort G, Nilsson N, Haas M; et al. (2004). "Non-invasive physical treatments for chronic/recurrent headache". Cochrane Database Syst Rev (3): CD001878. doi:10.1002/14651858.CD001878.pub2. PMID 15266458. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
110. McHardy A, Hoskins W, Pollard H, Onley R, Windsham R (2008). "Chiropractic treatment of upper extremity conditions: a systematic review". J Manipulative Physiol Ther. 31 (2): 146–59. doi:10.1016/j.jmpt.2007.12.004. PMID 18328941.{{cite journal}}: CS1 maint: multiple names: authors list (link)
111. Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W (2009). "Manipulative therapy for lower extremity conditions: expansion of literature review". J Manipulative Physiol Ther. 32 (1): 53–71. doi:10.1016/j.jmpt.2008.09.013. PMID 19121464.{{cite journal}}: CS1 maint: multiple names: authors list (link)
112. Everett CR, Patel RK (2007). "A systematic literature review of nonsurgical treatment in adult scoliosis". Spine. 32 (19 Suppl): S130–4. doi:10.1097/BRS.0b013e318134ea88. PMID 17728680.
113. Romano M, Negrini S (2008). "Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review". Scoliosis. 3: 2. doi:10.1186/1748-7161-3-2. PMID 18211702.{{cite journal}}: CS1 maint: unflagged free DOI (link)
114. Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW (2007). "Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research". J Altern Complement Med. 13 (5): 491–512. doi:10.1089/acm.2007.7088. PMID 17604553.{{cite journal}}: CS1 maint: multiple names: authors list (link)
115. Hondras MA, Linde K, Jones AP (2005). "Manual therapy for asthma". Cochrane Database Syst Rev (2): CD001002. doi:10.1002/14651858.CD001002.pub2. PMID 15846609.{{cite journal}}: CS1 maint: multiple names: authors list (link)
116. Husereau D, Clifford T, Aker P, Leduc D, Mensinkai S (2003). Spinal Manipulation for Infantile Colic (PDF). Technology report no. 42. Ottawa: Canadian Coordinating Office for Health Technology Assessment. ISBN 1-894978-11-0. Retrieved 2008-10-06.{{cite book}}: CS1 maint: multiple names: authors list (link)
117. Glazener CM, Evans JH, Cheuk DK (2005). "Complementary and miscellaneous interventions for nocturnal enuresis in children". Cochrane Database Syst Rev (2): CD005230. doi:10.1002/14651858.CD005230. PMID 15846744.{{cite journal}}: CS1 maint: multiple names: authors list (link)
118. O'Connor D, Marshall S, Massy-Westropp N (2003). "Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome". Cochrane Database Syst Rev (1): CD003219. doi:10.1002/14651858.CD003219. PMID 12535461.{{cite journal}}: CS1 maint: multiple names: authors list (link)
119. Fibromyalgia:
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     • Schneider M, Vernon H, Ko G, Lawson G, Perera J (2009). "Chiropractic management of fibromyalgia syndrome: a systematic review of the literature". J Manipulative Physiol Ther. 32 (1): 25–40. doi:10.1016/j.jmpt.2008.08.012. PMID 19121462.{{cite journal}}: CS1 maint: multiple names: authors list (link)
     • Ernst E (2009). "Chiropractic treatment for fibromyalgia: a systematic review". Clin Rheumatol. doi:10.1007/s10067-009-1217-9. PMID 19544042.
120. Brand PL, Engelbert RH, Helders PJ, Offringa M (2005). "". Ned Tijdschr Geneeskd (in Dutch). 149 (13): 703–7. PMID 15819137.{{cite journal}}: CS1 maint: multiple names: authors list (link)
121. Proctor ML, Hing W, Johnson TC, Murphy PA (2006). "Spinal manipulation for primary and secondary dysmenorrhoea". Cochrane Database Syst Rev (3): CD002119. doi:10.1002/14651858.CD002119.pub3. PMID 16855988.{{cite journal}}: CS1 maint: multiple names: authors list (link)
122. Pennick VE, Young G (2007). "Interventions for preventing and treating pelvic and back pain in pregnancy". Cochrane Database Syst Rev (2): CD001139. doi:10.1002/14651858.CD001139.pub2. PMID 17443503.
123. Thiel HW, Bolton JE, Docherty S, Portlock JC (2007). "Safety of chiropractic manipulation of the cervical spine: a prospective national survey". Spine. 32 (21): 2375–8. doi:10.1097/BRS.0b013e3181557bb1. PMID 17906581. {{cite journal}}: Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help)CS1 maint: multiple names: authors list (link)
124. ^ Gouveia LO, Castanho P, Ferreira JJ (2009). "Safety of chiropractic interventions: a systematic review". Spine. 34 (11): E405–13. doi:10.1097/BRS.0b013e3181a16d63. PMID 19444054. {{cite journal}}: Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help)CS1 maint: multiple names: authors list (link)
125. Vohra S, Johnston BC, Cramer K, Humphreys K (2007). "Adverse events associated with pediatric spinal manipulation: a systematic review". Pediatrics. 119 (1): e275–83. doi:10.1542/peds.2006-1392. PMID 17178922.{{cite journal}}: CS1 maint: multiple names: authors list (link)
126. Paciaroni M, Bogousslavsky J (2009). "Cerebrovascular complications of neck manipulation". Eur Neurol. 61 (2): 112–8. doi:10.1159/000180314. PMID 19065058.
127. Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM (2008). "Does cervical manipulative therapy cause vertebral artery dissection and stroke?". Neurologist. 14 (1): 66–73. doi:10.1097/NRL.0b013e318164e53d. PMID 18195663.{{cite journal}}: CS1 maint: multiple names: authors list (link)
128. Bussières AE, Taylor JAM, Peterson C (2008). "Diagnostic imaging practice guidelines for musculoskeletal complaints in adults—an evidence-based approach—part 3: spinal disorders". J Manipulative Physiol Ther. 31 (1): 33–88. doi:10.1016/j.jmpt.2007.11.003. PMID 18308153.{{cite journal}}: CS1 maint: multiple names: authors list (link)
129. Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation, Board on Radiation Effects Research, U.S. National Research Council (2006). Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2. Washington, DC: The National Academies Press. ISBN 0-309-09156-X.{{cite book}}: CS1 maint: multiple names: authors list (link)
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