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v t e

Chiropractic is a complementary and alternative health care profession which focuses on diagnosing, treating, and preventing mechanical disorders of the musculoskeletal system, their effects on the nervous system, and on general health. Chiropractic contends that spinal joint misalignments, which chiropractors call vertebral subluxations, can interfere with the nervous system and result in diminished health. Chiropractic's vertebral subluxation, whose existence is disputed by some scientists, should not be confused with other forms of subluxation.

Chiropractors may specialize in treating low back problems or sports injuries, or may combine chiropractic with manipulation of the extremities, physiotherapy, nutrition, or exercises to increase spinal strength or improve overall health. They may also use other complementary and alternative methods as a part of a holistic treatment approach. Chiropractors are not trained or licensed to prescribe drugs or, for the most part, to perform surgery. Depending on the country or state in which the Chiropractic school is located, they may be offered some training in minor surgery. They are trained to recognize signs of cancer, diabetes, and infectious diseases and refer these patients to medical physicians for specialized or concomitant care.

There is evidence that spinal manipulation, a technique used by chiropractors, can be effective in the treatment of acute low back pain, tension headaches and certain musculoskeletal issues. There are no objective controlled trials with definitive conclusions for or against chiropractic claims concerning other health benefits.

Introduction

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

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

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

The initial chiropractic technique was manipulation of the spine (called adjustment) and remains the primary technique. Chiropractic's contribution to the field of manipulative therapies is the concept of applying a precise adjustment to a specific affected vertebra rather than the generalized maneuvers of the early osteopaths. The use of spinal manipulation in an attempt to correct the theoretical vertebral subluxation remains solely a chiropractic endeavor.

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

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

Spinal adjustments, chiropractic's primary technique, might provide short-term relief of certain forms of back and neck pain, headaches, and other spine-related conditions, but studies show conflicting results. For example, a systematic review (1997) noted "Strong evidence was found for the effectiveness of spinal manipulation, back schools and exercise therapy, especially for short-term effects." However, another systematic review (2006) concluded "Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment." A big contention with these reports is that spinal manipulation performed by a variety of practitioners other than chiropractors are included and thus attibuting the results to chiropractic is misleading.

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

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

Although chiropractic has gained more acceptance in the last 40 years as a treatment for certain back, neck and other spine-related problems, resulting in increased usage, statistics in the later years have shown some variations from these trends: student enrollments fell 39.9% between 1996 and 2002, and the percentage of the adult population that uses chiropractic fell by 25% from 1997 to 2002. As of 2006, the statistics for student enrollments and the demand for chiropractic treatment seem to be rising again in the United States. Additionally, referrals to chiropractors by general medicine practitioners seems to be on the rise outside the Untied States.

History

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

The first chiropractic adjustment

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

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

Early growth

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

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

Changing political and healthcare environment

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

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

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

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

Osteopathy vs chiropractic

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

Medicine vs chiropractic

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

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

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

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

BJ Palmer re-develops chiropractic

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

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

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

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

Straight vs Mixer

State laws to protect chiropractic eventually occurred in all fifty states in the US, but it was a hard fought struggle. Certainly Medical Examining Boards worked to keep all healthcare practices under their legal control, but an internal struggle among DC's on how to structure the laws significantly complicated the process. Initially, the UCA, led by BJ Palmer, opposed state licensure altogether. Palmer feared such regulation would lead to allopathic control of the profession. The UCA eventually caved in, but BJ remained strong in the opinion that examining boards should be composed exclusively of chiropractors (not mixers), and the educational standards to be adhered to were the same as the Palmer School. A "Model Bill" was drafted in 1922 to present to all states that did not yet have a law. They embarked on a method of "cleaning house" of mixers by warning state associations to purge their mixing members or face competition by the formation of a new "straight" association in their state.

Mixers, disturbed by the edicts of the PSC having so much influence in their daily practice, came together to create the American Chiropractic Association (no relation to today's ACA) whose purpose was to advance education and research and was designed according to standards set by the National School of Chiropractic headed by John J. Nugent, D.C. and supported by other practicing mixers in the field. But it was a disagreement in 1924 about Dossa D. Evans, DC's newly invented Neurocalimeter (NCM) that turned the tide. BJ, still working to purge mixers from practicing chiropractic, saw this new diagnostic machine as the answer to all of chiropractic's (and particularly PSC's) legal and financial problems. He claimed that the NCM was the only way to accurately locate subluxations. Being the owner of the patent on the NCM, he planned to limit the number of NCMs and leased them only to graduates of the Palmer related schools who were members of the UCA, effectively limiting the practice of chiropractic only to straights. There was an immediate uproar among practicing DC's. Even Tom Moore, BJ's long time ally and president of the UCA displayed his dismay by resigning his post (though he was later reinstated). BJ reluctantly resigned his post as treasurer ending his relationship with the UCA. In 1930 the ACA and UCA would join to form the National Chiropractic Association (today's ACA) while BJ Palmer would move on to form the Chiropractic Health Bureau (today's ICA). The differences in state laws that exist today can be traced back to these early legal struggles. While BJ worked to protect and develop chiropractic around the Palmer school, DD Palmer continued to develop his techniques from Oregon. In 1910 he theorised that nerves control health:

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

Before his sudden and controversial death in 1913, DD Palmer often voiced concern for BJ Palmer's management of chiropractic. He challenged BJ's methods and philosophy and made every effort to regain control of chiropractic. He 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 and noted,

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

During the long fought battle for licensure in California, in a letter dated 1911, he wrote of his philosophy for chiropractic and hinted at his plan for the legal defense of chiropractic:

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

Wilk et al. vs the American Medical Association

Main article: Wilk v. American Medical Association

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

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

The judge in the Wilk case said, "Evidence at the trial showed that the defendants took active steps, often covert, to undermine chiropractic educational institutions, conceal evidence of the usefulness of chiropractic care, undercut insurance programs for patients of chiropractors, subvert government inquiries into the efficacy of chiropractic, engage in a massive disinformation campaign to discredit and destabilize the chiropractic profession and engage in numerous other activities to maintain a medical physician monopoly over health care in this country." She then said that chiropractors clearly wanted "a judicial pronouncement that chiropractic is a valid, efficacious, even scientific health care service." She said no "well designed, controlled, scientific study" had been done, and concluded "I decline to pronounce chiropractic valid or invalid on anecdotal evidence" even though "the anecdotal evidence in the record favors chiropractors".

Chiropractic vertebral subluxation

Main article: Vertebral subluxation

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

In 1998 Lon Morgan DC, a reform chiropractor, writing in the Journal of the Canadian Chiropractic Association said,

"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."

Scientific investigation of chiropractic

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

During chiropractic's early evolution, influences from both straight and mixer concepts were incorporated into its construct. The result is that chiropractic possesses both materialistic qualities that lend themselves to scientific investigation and vitalistic qualities that do not (Table 1). DD Palmer qualified his vitalistic construct noting that knowledge of Innate Intelligence is not essential to the competent practice of chiropractic.

Attributed to the lack of federal funding, legitimate scientific research in chiropractic has only recently become fully established. In 1994 and 1995, half of all grant funding to chiropractic researchers was from the U.S. Health Resources and Services Administration (7 grants totalling $2.3 million). The Foundation for Chiropractic Education and Research (11 grants totalling $881,000) and the Consortium for Chiropractic Research (4 grants totalling $519,000) accounted for the majority of the remainder. As of 1997, there are 14 peer-reviewed chiropractic journals in English which publish the results of chiropractic research, including The Journal of Manipulative and Physiological Therapeutics, Topics in Clinical Chiropractic, and the Journal of Chiropractic Humanities. Scientific journals have also published chiropractic research.

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

Thus, chiropractors have historically relied mostly upon their own clinical experience and the shared experience of their colleagues, as reported in case studies, to direct their treatment methods. In this they are not different to the practice in much of conventional medicine.

University of Saskatchewan sociologist Leslie Biggs interviewed 600 Canadian chiropractors in 1997, and found that, while 86% felt that chiropractic methods needed to be validated, 74% of them did not believe that controlled clinical trials were the best way to evaluate chiropractic. Also noted was 68% believed that most diseases are caused by spinal malalignment, yet only 30% agreed that subluxation was the cause of many diseases.

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

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

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

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

Bandolier found limited evidence that spinal manipulative therapy (not specifically chiropractic) might reduce the frequency and intensity of migraine attacks, but the evidence that spinal manipulation is better than amitriptyline, or adds to the effects of amitriptyline, is insubstantial for the treatment of migraine, though it suggests that "spinal manipulative therapy might be worth trying for some patients with migraine or tension headaches."

According to Bandolier, based on a small, poor quality set of trials, there is no convincing evidence for long-term benefits of chiropractic interventions for acute or chronic, despite some positive overall findings in this systematic review of low back pain clinical data. There might be some short-term pain relief, especially in patients with acute pain. However, the British Medical Journal noted in a study on long-term low-back problems "...improvement in all patients at three years was about 29% more in those treated by chiropractors than in those treated by the hospitals. The beneficial effect of chiropractic on pain was particularly clear." And a 1994 study published by the U.S. Agency for Health Care Policy and Research (AHCPR) and the U.S. Department of Health and Human Services endorses spinal manipulation for acute low back pain in adults in its Clinical Practice Guideline.

The first significant recognition of the appropriateness of spinal manipulation for low back pain was performed by the RAND Corporation. The RAND reports marked the first time that representatives of the medical community went on record stating that spinal manipulation is an appropriate treatment for certain low-back pain conditions. This meta-analysis of 22 controlled experiments concluded that certain forms of spinal manipulation were successful in treating certain types of lower back pain. Some chiropractors seized upon these results as proof that chiropractic hypotheses was sound and that chiropractic had reliable results; in fact, the authors of the report said no such thing. RAND's studies were about spinal manipulation, not chiropractic specifically, and dealt with appropriateness, which is a measure of net benefit and harms. Comparative efficacy of chiropractic and other treatments was not explicitly dealt with. In 1993 Dr. Paul Shekelle wrote an article rebuking some chiropractic doctors for making false claims about RAND's research: :...we have become aware of numerous instances where our results have been seriously misrepresented by chiropractors writing for their local paper or writing letters to the editor....

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

In 1997, chiropractic historian Joseph Keating Jr., PhD described chiropractic as a science, antiscience and pseudoscience. "Although available scientific data support chiropractic's principle intervention method (the manipulation of patients with lower back pain), the doubting, skeptical attitudes of science do not predominate in chiropractic education or among practitioners", Chiropractic's culture has "nurtured antiscientific attitudes and activities." "A combination of uncritical rationalism and uncritical empiricism has been bolstered by the proliferation of pseudoscience journals of chiropractic wherein poor quality research and exuberant over-interpretation of results masquerade as science and provide false confidence about the value of various chiropractic techniques".

Keating qualifies his statement concerning science in chiropractic noting that "this does not detract from the research that has been conducted. Nor does this shortfall in hard scientific data for subluxation disallow the meaningfulness of a science of chiropractic." He reminds us that we "would not reject psychiatry as science on the grounds that Freud's theories of anxiety, repression, or the unconscious have not been adequately tested. We would not reject the meaningfulness of a science of medicine on the grounds that most medical procedures have not been experimentally validated. Nor should we apply such standards to chiropractic as a determiner of its scientific viability ."

American Medical Association

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

Specifically about chiropractic it said,

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

And in 1992, the AMA issued this statement regarding their code of ethics for medical doctors associating with chiropractors:

"It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient. A physician may refer a patient for diagnostic or therapeutic services to a chiropractor permitted by law to furnish such services whenever the physician believes that this may benefit his or her patient. Physicians may also ethically teach in recognized schools of chiropractic. (V, VI)"

British Medical Association

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

The Manga Report

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

Workers' Compensation studies

A 1998 study of 10,652 Florida workers' compensation cases was conducted by Steve Wolk, Ph.D., and reported by the Foundation for Chiropractic Education and Research. It was concluded that "a claimant with a back-related injury, when initially treated by a chiropractor versus a medical doctor, is less likely to become temporarily disabled, or if disabled, remains disabled for a shorter period of time; and claimants treated by medical doctors were hospitalized at a much higher rate than claimants treated by chiropractors."

A 1991 study of Oregon Workers' Compensation Claims examined 201 randomly selected workers' compensation cases that involved low back injuries that were disabling. Study found individuals who visited DCs less often initially went to the hospital for their injuries than those visiting MDs. Those who visited DCs often had a history of chronic back pain.

A second part of the Oregon Workers' Compensation reported on the loss of time for individuals who visited DCs and those who visited MDs for treatment of low back pain. Median missed days of work for individuals with similar severity of injury was 9.0 days for those visiting DCs and 11.5 for individuals visiting MDs. Individuals visiting chiropractors more often returned to work having missed one week or less of work days. There was no difference in time lost for individuals visiting DCs and MDs with no previous history of low back pain. The median of days missed of work for individuals who had chronic back pain and visited MDs was 34.5 days while the median of days missed of work for those visiting DCs was 9 days.

A 1989 study analyzed data on Iowa state record from individuals in Iowa who filed claims for back or neck injuries in 1984. The study compared benefits and the cost of care received by individuals from MDs, DCs and DOs. There was a focus on individuals who missed days of work and were compensated because of their injuries. Individuals who visited DCs missed on average at least 2.3 days less than individuals who visited MDs and 3.8 days less than individuals who saw DOs. Less money was dispersed as employment compensation on average for individuals who visited DCs. On average, the disability compensation paid to workers for those who visited DCs was $263.66, $617.85 for those who visited MDs, and was $1565.05 for those who visited DOs.

In 1989, a survey administered by Daniel C. Cherkin, Ph.D., and Frederick A. MacCornack, Ph.D., concluded that patients receiving care from health maintenance organizations (HMOs) within the state of Washington were three times as likely to report satisfaction with care from chiropractors as they were with care from other physicians. The patients were also more likely to believe that their chiropractor was concerned about them.

Safety

As with all interventions, there are risks associated with spinal manipulation. Although extremely rare, these include vertebrobasilar accidents, strokes, disc herniations, vertebral fracture, and cauda equina syndrome, according to Harrison's. However, nothing more than a temporal relationship has ever been established in relation to severe complications and chiropractic intervention. Chiropractic continues to be one of the safest health professions and chiropractors have some of the lowest malpractice insurance premiums in the health care industry.

The greatest risk involves manipulation of the first two vertebra of the cervical spine, particularly passive rotation of the neck, known as the "master cervical" or "rotary break", which has been claimed to be linked to trauma, paralysis, strokes, and death, though this claim has never been adequately established. Serious complications after manipulation of the cervical spine are estimated to be very rare (1 in 3-4 million manipulations or fewer). This estimate is based on international studies of millions of chiropractic cervical adjustments from 1965 to the present day. The "one in a million" estimate is echoed in an extensive review of spinal manipulation performed by the RAND corporation. However, in another study, Dvorak cites figures of 1 in 400,000, while Jaskoviak reported approximately 5 million cervical manipulations from 1965 to 1980 at The National College of Chiropractic Clinic in Chicago, without a single case of vertebral artery stroke or serious injury . Less conservative treatments such as neck surgery are also often used for conditions similar to the conditions chiropractors treat using spinal adjustments. Cervical spine surgery has a 3-4% rate of complication and 4,000-10,000 deaths per million neck surgeries.

Statistics for the percentage of incidents that are reported vary; the RAND study, for example, assumed that only 1 in 10 cases would have been reported. Dr. Edzard Ernst surveyed neurologists in Britain for cases of serious neurological complication occurring within 24 hours of cervical spinal manipulation (not specifically performed by a chiropractor) during the previous year; 35 cases had been seen by the 24 who responded, but none had been reported. His survey led him to conclude that underreporting was closer to 100%, rendering estimates "nonsensical." Ernst adds that "survey data are never free from bias, and we would certainly not claim that our results are conclusive."

A 2001 study in the medical journal Stroke found that vertebrobasilar accidents (VBAs) are five times more likely in those aged <45 years who had visited a chiropractor in the week before the VBA, compared to controls who had not visited a chiropractor. No significant associations were found for those aged >45 years. The authors go on to conclude; "While our analysis is consistent with a positive association in young adults, potential sources of bias are also discussed. The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment."

Other considerations pertaining to stroke concern the utilization of cervical manipulation to treat conditions for which it is not indicated. In 1996 Coulter et al. from the Rand corporation surveyed a group of 4 MDs, 4DCs and 1 MD/DC to evaluate the risk versus benefit of manipulation or mobilization of the cervical spine (not necessarily performed by a chiropractor). After having them look at over 700 conditions, there was consensus in only 11.1% of those conditions that cervical manipulation or mobilization was appropriate.

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

A New Zealand Commission report in 1979 supported the safety of chiropractic; the report said "We are satisfied that chiropractic treatment in New Zealand is remarkably safe." (Report of the Commission of Inquiry Into Chiropractic 1979:p 77). According to the researchers, "By the end of the inquiry we found ourselves irresistibly and with complete unanimity drawn to the conclusion that modern chiropractic is a soundly based and valuable branch of the health care in a specialized area." However, the judge in the Wilk v. American Medical Association case; described this report as "unsatisfactory", and a review of the report by the United States Congress' Office of Technology Assessment found 'serious problems' in its treatment of safety and efficacy issues.

Following a 1993 study, researchers J. David Cassidy, D.C., Hayno Thiel, D.C., M.S., and W. Kirkaldy Willis, M.D., of the Back Pain Clinic at the Royal University Hospital in Saskatchewan concluded that "the treatment of lumbar intervertebral disk herniation by side posture manipulation is both safe and effective."

Chiropractic education, licensing, and regulation

United States

Graduates of chiropractic school receive the degree Doctor of Chiropractic (DC) are referred to as "doctor", and are eligible to seek licensure in all jurisdictions. The Council on Chiropractic Education (CCE) sets minimum guidelines for chiropractic colleges, but additional requirements may be needed for a license depending on the jurisdiction where a chiropractor chooses to practice. Currently, all 19 chiropractic institutions are accredited by the CCE. In 1991, University of Bridgeport established its College of Chiropractic, becoming the first chiropractic school in the United States affiliated with a university.

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

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

Australia

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

United Kingdom

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

Practice styles and schools of thought

Contemporary chiropractic can be divided into several approaches to patient care. All chiropractic approaches are based on non-invasive, non-medication approaches, with many based on the use of manipulation as a treatment for mechanical musculoskeletal dysfunction of the spine and extremities. The majority of chiropractors advertise themselves as primary care doctors and consider themselves part of alternative health care, however there can be great differences between practitioners. Straight chiropractors make the broadest claims and promote chiropractic as a method for preventing and treating organic diseases while mixer chiropractors restrict their practice to problems of the musculoskeletal system.(Homola, 2002:311). The differences between straights and mixers are reflected in the formation of multiple national practice associations.

1. Traditional Straight chiropractors are the oldest movement. This group adheres to the tenents set forth by DD and BJ Palmer; that vertebral subluxation leads to interference of the human nervous system and is a primary underlying risk factor for almost any disease. Straight chiropractors view the diagnosis of patient complaints, which are considered secondary effects, to be unnecessary for treatment. Instead, patients are typically screened for red flags of serious disease and treated based on a practitioner's preferred chiropractic technique. This stance against diagnosing patient complaints has been a source of contention between mixer chiropractors and straight chiropractors because accreditation standards mandate that differential diagnosis be taught in all chiropractic programs so that patient care is safe and relevant to their complaints. Additionally, several state chiropractic licensing boards mandate that patient complaints be diagnosed before receiving care. The most popular national association for traditional straight chiropractors is the International Chiropractors Association (ICA).
2. Mixing chiropractors are an early offshoot of the straight movement. This branch originated from naturopathic, osteopathic, medical, and even chiropractic doctors who attended the Palmer College of Chiropractic and then re-organized the treatment system to include more diagnostic and treatment approaches. They eventually split from the traditional straight group and formed various other chiropractic schools including the National College of Chiropractic. Their treatments may include naturopathic remedies, physical therapy devices, or other CAM methods. While still subluxation based, mixer chiropractors also treat problems associated with both the spine and extremities, including musculoskeletal issues such as pain and decreased range of motion. Mixer chiropractors describe vertebral subluxations as a form of joint dysfunction or osteoarthritis. Diagnosis is made after ruling out other known disorders and noting general signs of mechanical dysfunction in the spine. They tend to be members of the American Chiropractors Association, and all the major groups in Europe are also in membership of the European Chiropractors Union.
3. Objective Straight chiropractors are a recent off-shoot of the traditional straights and are a minority group. This group is differentiated from traditional straights mainly by the claims made. While traditional straights claimed that chiropractic adjustments are a plausible treatment for a wide range of diseases, objective straight chiropractors only focus on the correction of chiropractic vertebral subluxations. Like other straights, Objective straights typically do not diagnose patient complaints or refer to other professionals, but they do encourage their patients "to see a medical physician if they indicate that they want to be treated for the symptoms they are experiencing or if they would like a medical diagnosis to determine the cause of their symptoms". Most objective straight chiropractors limit treatment to spinal adjustments. Objective Straight chiropractors tend to be members of the Federation of Straight Chiropractic Organization (FSCO) and the World Chiropractic Alliance (WCA).
4. Reform chiropractors, also a minority group, are made up primarily of mixers who advocate the use of chiropractic as a treatment of osteoarthritis and musculoskeletal conditions. They do not subscribe to Palmer philosophy or the vertebral subluxation theory. Instead they recommend the use of palpation and manipulation to identify and treat painful joints which may contain adhesions. This group is very similar in practice to mixer chiropractors.

References

1. ^ McCrory DC, et al. Evidence Report: Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache. Duke University Evidence-Based Practice Center, Durham, North Carolina, January 2001 available online (PDF format)
2. ^ Ernst E (2006) A systematic review of systematic reviews of spinal manipulation J R Soc Med 99:192-6
3. Jeffrey Balon, M.D. A Comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma. New England Journal of Medicine. Volume 339:1013-1020, October 8, 1998, Number 15 available online
4. McDonald W (2003) How Chiropractors Think and Practice: The Survey of North American Chiropractors. Institute for Social Research, Ohio Northern University
5. More Than One-Third of U.S. Adults Use Complementary and Alternative Medicine, According to New Government Survey (Press Release), May 27 2004, available online
6. Complementary and Alternative Medicine Use Among Adults: United States, 2002 (Report), May 27 2004, available online (PDF format)
7. Burton, Bernard. "Chiropractic Management of Low Back Pain." Cleveland Clinic: Spinal Care 2000 Symposium. March 30, 2000.
8. Bureau of Labor Statistics, Occupational Outlook Handbook
9. van Tulder M (1997) Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine 22:2128-56.
10. Nelson CF, Metz RD, LaBrot T (2005) Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain J Man Phys Ther 28:564-9 Abstract
11. Chiropractic in the Winter Olympics
12. National Center for Education Statistics, Integrated Postsecondary Education Data System, Retrieved online 8/15/2004 at Quoted here:
13. Tindle HA. (2005) Trends in use of complementary and alternative medicine by US adults: 1997-2002 Altern Ther Health Med 11:42-9
14. Bureau of Labor Statistics, Occupational Outlook Handbook
15. Chiropractic Patients in Denmark 2002: An Expanded Description and Comparison With 1999 Survey, Journal of Manipulative and Physiological Therapeutics, Volume 29, Issue 6, Pages 419-424 (July 2006) available online
16. "The Chiropractic Profession and Its Research and Education Programs", Final Report, pg 41, Florida State University, MGT of America, December 2000
17. ^ Keating J. D.D. Palmer's Lifeline
18. ^ Palmer DD (1910) The Science, Art and Philosophy of Chiropractic Portland, Oregon: Portland Printing House Company Cite error: The named reference "SciArtPhi" was defined multiple times with different content (see the help page).
19. Daniel David Palmer short history
20. Westbrooks B (1982) The troubled legacy of Harvey Lillard: the black experience in chiropractic. Chiropractic History 2:46­53
21. ^ Keating J. Chiropractic History: A Primer,Sutherland Companies
22. ^ Goodman J, Musgrave G (1992)How The Cost-Plus System Evolved Excerpted From: John C. Goodman and Gerald L. Musgrave Patient Power Washington, DC: Cato Institute W67
23. ^ AMA Web site,AMA History 1847 - 1899,Retrieved May 27,2006
24. Healthcare history timeline
25. ^ Lerner, Cyrus. Report on the history of chiropractic (unpublished manuscript, L.E. Lee papers, Palmer College Library Archives)
26. Keating J.(1996).Early Palmer Theories of Dis-ease
27. Palmer D.D. (1911). D.D. Palmer's Religion of Chiropractic
28. ^ Keating J (1995), D.D. Palmer's Forgotten Theories of Chiropractic, A Presentation to the Canadian Memorial Chiropractic College
29. Morgan L (1998) Innate intelligence: its origins and problems JCCA 1998; 42(1):35-41 available online
30. Assendelft WJJ, Koes BW, Van der Heijden GJMG, Bouter LM. The effectiveness of chiropractic for treatment of low back pain: An update and attempt at statistical pooling. J Manip Physiol Ther 1996; 19:499-507
31. British Medical Journal, Meade et al. (1995)
32. Shekelle PM. RAND misquoted. ACA Journal of Chiropractic 30(7):59–63, 1993.
33. Verhoef MJ,Costa Papadopoulos C. Survey of Canadian chiropractors’involvement in the treatment of patients under the age of 18.
34. Wiberg JMM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled clinical trial with a blinded observer. J Manip Physiol Ther 1999;22:517-22.
35. Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Arch Dis Child 2001;84:138-141.
36. Keating JC. Chiropractic: science and antiscience and pseudoscience, side by side. Skeptical Inquirer. 1997;21:37–43
37. British Medical Association, Referrals to complementary therapists
38. Wolk, Steve. "An Analysis of Florida Workers' Compensation Medical Claims for Back-Related Injuries." Journal of the American Chiropractic Association 1988; 27(7): 50-59.
39. Nyiendo, Joanne, Lamm, Lester. "Disability Low Back Oregon Workers' Compensaion Claims. Part I: Methodology and Clinical Categorization of Chiropractic and Medical Cases." Journal of Manipulative and Physiological Therapeutics 1991 14(3): 177-184.
40. Nyiendo, Joanne. "Disability Low Back Oregon Workers' Compensation Claims. Part II: Time Loss." Journal of Manipulative and Physiological Therapeutics 1991 14(4): 231-239.
41. Johnson, Marjorie. "A Comparison of Chiropractic, Medical and Osteopathic Care for Work-Related Sprains/Strains." Journal of Manipulative and Physiological Therapeutics 1989; 12(5): 335-344.
42. Coulter, et al. The Appropriateness of Manipulation and Mobilization of the Cervical Spine.Santa Monica, CA, Rand Corp, 1996
43. Terrett AGJ: Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. JMPT 1995;18:203
44. Souza T (2005) Differential Diagnosis and Management for the Chiropractor, Third Edition : Protocols and Algorithms Jones and Bartlett Publishers Inc. 3rd edition

See also

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

External links

Advocacy

Chiropractic organizations

• American Chiropractic Association (ACA)
• British Chiropractic Association (BCA)
• Canadian Chiropractic Association (CCA)
• European Chiropractors' Union (ECU)
• Hong Kong Chiropractors' Association (HKCA)
• Chiropractic Doctors' Association of Hong Kong (CDA)
• Japanese Association of Chiropractors (JAC)
• International Chiropractors Association (ICA)
• National Association for Chiropractic Medicine
• World Chiropractic Alliance (WCA)
• World Federation of Chiropractic (WFC)
• Foundation for Chiropractic Education and Research (FCER)
• Chiropractic Association of South Africa

Descriptions of chiropractic procedures

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

Other resources

• Chiropractic History Archive -- Joseph C. Keating Jr, PhD
• Chiropractic Resource Organization
• The Chiropractic Profession and Its Research and Education Programs
• The Future of Chiropractic Revisited: 2005 to 2015

Other

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

Critiques

• A Different Way To Heal? - PBS - Scientific American Frontiers, Web Feature
• Chirobase: Skeptical guide to chiropractic history, theories, and current practices - Stephen Barrett, MD, and Samuel Homola, DC
• Chiropractic - Skeptic's Dictionary, Robert Todd Carroll, PhD
• Chiropractic: science and antiscience and pseudoscience side by side - Joseph C. Keating, Jr, PhD
• Commentary: The Specter of Dogma - Joseph C. Keating, Jr., PhD
• Faulty Logic and Non-skeptical Arguments in Chiropractic - Joseph C. Keating Jr, PhD
• NCAHF on Chiropractic (2001) - William T. Jarvis, Ph.D.

• Alternative medical systems
• Alternative medicine
• Chiropractic
• Manipulative therapy