Misplaced Pages

Revision as of 16:08, 19 September 2006

Part of a series on
Alternative medicine
General information Alternative medicine History Terminology Alternative veterinary medicine Quackery (health fraud) Rise of modern medicine Pseudoscience Antiscience Skepticism Scientific Therapeutic nihilism
Fringe medicine and science Acupressure Acupuncture Alkaline diet Anthroposophic medicine Apitherapy Applied kinesiology Aromatherapy Association for Research and Enlightenment Auriculotherapy Bates method Biological terrain assessment Black salve Bodywork Bone-setting Bowen technique Breathwork Fake COVID-19 treatments Camel urine Cancer treatments Charcoal cleanse Chiropractic Chiropractic treatment techniques Vertebral subluxation Christian Science Chromotherapy Colloidal silver Colon cleansing Coffee enema Colorpuncture Conversion therapy Craniosacral therapy Crystal healing Cupping therapy Dental amalgam controversy Detoxification Foot detox Dry needling Ear candling Energy medicine Correactology Esoteric energy Reiki Therapeutic touch Estrogen dominance Fabunan Antiviral Injection Facilitated communication FasciaBlaster Feldenkrais Method Functional medicine Hair analysis Holistic dentistry Hologram bracelet Homeopathy Bach flower remedies Hydrotherapy Hypnotherapy Ionized jewelry Iridology Jilly Juice Lightning Process Lymphotherapy Magnet therapy Manual therapy Manual lymphatic drainage Medical intuitive Megavitamin therapy Mesmerism Mind–body interventions MMS Myofascial release NAET Naturopathy Oil pulling Orgone Orthomolecular medicine Orthopathy Osteomyology Osteopathy Ozone therapy Parapsychology Phrenology Postural Integration Psychic surgery Psychodermatology Quantum healing Radionics Rapid prompting method Reflexology RBOP Rolfing Scientific racism ThetaHealing Thomsonianism Thought Field Therapy Urophagia Vaginal steaming Vegetotherapy Vision therapy Vitalism Young blood transfusion Zero balancing
Controversies Big Pharma conspiracy theories HIV/AIDS denialism OPV AIDS hypothesis Anti-vaccinationism Vaccine misinformation Vaccines and autism MMR vaccine and autism in chiropractic Water fluoridation controversy COVID-19 misinformation Turbo cancer
Classifications Alternative medical systems Mind–body intervention Biologically based therapy Manipulative methods Energy therapy
Traditional medicine African Muti Southern Africa Ayurveda Dosha MVAH Balneotherapy Brazilian Bush medicine Cambodian Chinese Blood stasis Chinese herbology Dit da Gua sha Gill plate trade Long gu Meridian Moxibustion Pressure point Qi San Jiao Tui na Zang-fu Chumash Curandero Faith healing Herbal medicine Hilot Iranian Jamu Kayakalpa Kambo Japanese Korean Maya Mien Shiang Mongolian Naftalan oil Prophetic medicine Shamanism Shiatsu Siddha Sri Lankan Thai massage Tibetan Unani Vietnamese
Alternative diagnoses Adrenal fatigue Aerotoxic syndrome Candida hypersensitivity Chronic Lyme disease Electromagnetic hypersensitivity Heavy legs Leaky gut syndrome Multiple chemical sensitivity Vertebral subluxation Wilson's temperature syndrome
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's premise is that spinal joint misalignments, which chiropractors call vertebral subluxations, can interfere with the nervous system and result in diminished health. The conventional use of the term subluxation in medicine does not typically include any relationship to general health, and is therefore different from chiropractic's vertebral subluxation.

Some chiropractors specialize in treating low back problems or sports injuries, or combine chiropractic with manipulation of the extremities, physiotherapy modalities, nutrition, or exercises to increase spinal strength or improve overall health. Some also use other complementary and alternative methods as a part of a holistic treatment approach. Chiropractors are not trained or licensed to prescribe drugs. Depending on the country or state in which the Chiropractic school is located, some train in minor surgery. When indicated, the doctor of chiropractic consults with, co-manages, or refers to other health care providers.

There is both evidence for and evidence against spinal manipulation, a technique used by chiropractors, 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 his assertion 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 named 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.

Palmer's initial chiropractic treatment consisted solely of the use of manipulation of the spine, and this procedure remains the primary technique in today's chiropractic adjustment. 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.

Spinal manipulation, a primary part of most chiropractic adjustments, has been shown to 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." Studies that evaluate spinal manipulation performed by a variety of practitioners other than chiropractors may be potentially misleading.

Some contemporary chiropractors continue to adhere to the strict tenets of Palmer and use only spinal adjustments, while others 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.

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.

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. 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.

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.

There have been some studies of the cost-effectiveness of chiropractic. 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.

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 United States.

Chiropractic’s approach to healthcare

According to Robert Mootz DC and Reed Phillips DC, Phd, although chiropractic has much in common with other health professions, its philosophical approach distinguishes it from modern medicine. Chiropractic philosophy involves what has been described as a "contextual, naturopathic approach" to health care. The traditional, "allopathic" or "medical" model considers disease as generally the result of some external influence, such as a toxin, a parasite, an allergen, or an infectious agent: the solution is to counter the perceived environmental factor (e.g., using an antibiotic for a bacterial infection). By contrast, the naturopathic approach considers that lowered "host resistance" is necessary for disease to occur, so the appropriate solution is to direct treatment to strengthen the host, regardless of the environment. In contemporary clinical practice, one can find elements of both naturopathic and allopathic philosophy among all types of providers. The degree to which a practitioner emphases different tenents of these philosophies is one factor that determines the manner in which they practice.

Chiropractic Perspectives That Reflect a Holistic Approach to Patient Care

• noninvasive, emphasizes patient's inherent recuperative abilities

• recognizes dynamics between lifestyle, environment, and health

• emphasizes understanding the cause of illness in an effort to eradicate, rather than palliate, associated symptoms

• recognizes the centrality of the nervous system and its intimate relationship with both the structural and regulatory capacities of the body

• appreciates the multifactorial nature of influences (structural, chemical, and psychological) on the nervous system

• balances the benefits against the risks of clinical interventions

• recognizes as imperative the need to monitor progress and effectiveness through appropriate diagnostic procedures

• prevents unnecessary barriers in the doctor-patient encounter

• emphasizes a patient-centered, hands-on approach intent on influencing function through structure

• strives toward early intervention, emphasizing timely diagnosis and treatment of functional, reversible conditions

Source:AHCPR Chapter 2 Chiropractic Belief Systems, Robert D. Mootz DC; Reed B. Phillips DC, PhD

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 sold through doctors of medicine, most were sold directly to consumers by lay people, some of whom used very 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 felt inclined to become a physician; the market alone determined who would prove successful 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, many men entered practice, leading to an 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 their nature and their dangers. 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 AMA 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 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, Davenport MD, Heinrich Matthey started a campaign against drugless healers in Iowa. 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 doctors 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 need 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 in about 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 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."

His influence over the next several years further divided the Mixers, or those who mixed chiropractic with other cures, from those who practiced chiropractic by itself, or Straight..

DD Palmer's last years

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."

Straight vs Mixer

State laws to regulate and protect chiropractic practice were eventually introduced in all fifty states in the US, but it was a hard-fought struggle. 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 that 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 (one of the early precursors to today's ACA). Though born out of necessity to defend against the UCA attacks, the ACA's stated purposes were to advance education and research for chiropractic. Its growth was initially stunted by its resolution to recognize physio-therapy and other modalities as pertaining to chiropractic. What growth did occur was credited to its second president, Frank R.Margetts, DC with support from his alma mater, National Chiropractic College. He insisted that no college administrator could hold an official position in the association, essentially giving doctors in the field a collective voice. But a disagreement within the UCA in 1924 turned the tide for the ACA. BJ was still working to purge mixers from practicing chiropractic. He saw a new invention by Dossa D. Evans, the "Neurocalometer" (NCM), as the answer to all of straight chiropractic's (and particularly PSC's) legal and financial problems. Being the owner of the patent on the NCM, he planned to limit the number of NCMs to 5000 and lease them only to graduates of the Palmer related schools who were members of the UCA. He then claimed that the NCM was the only way to accurately locate subluxations, preventing over 20,000 mixer chiropractors from being able to defend their method of practice.

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. BJ Palmer moved on to form the Chiropractic Health Bureau (today's ICA) along with his staunchest supporters. Membership in the UCA dropped while the ACA membership rose. In 1930, the ACA and UCA joined to form the National Chiropractic Association (NCA). The NCA developed a Committee on Educational Standards (CES), making John J. Nugent DC responsible for increasing the educational standards for the profession. The years of consolidation or closing of unacceptable schools while developing the new educational standards earned Nugent the nickname "Chiropractic's Abraham Flexnor" from his admirers and "Chiropractic's Anti-christ" from his adversaries. The CES evolved into today's Council on Chiropractic Education (CCE), and was granted the status of chiropractic's accrediting body by the US Department of Education. Nugent was also later instrumental in the Chiropractic Research Foundation (CRF), today's Foundation for Chiropractic Education and Research (FCER). The differences in state laws that exist today can be traced back to these early legal struggles.

The movement toward scientific reform

By the late 1950s, healthcare in the US had made a major transformation. Scientific medicine had discovered penicillin and the polio vaccine was restoring hope to millions. The homeopathic physician had all but vanished as a result of antiquackery efforts of the medical trust and leadership efforts of the AMA. BJ reduced the adjustment to HIO (Hole In One - the adjustment of only the atlas), while mixers continued to add and refine new proprietary techniques to find and reduce subluxations and improve health. Osteopathy in the US developed parallel to medicine and dropped its reliance on spinal manipulation to treat illness. Within chiropractic, a similar movement to reform its tenents was advanced. Beginning in 1963, second generation chiropractor, Samuel Homola, wrote extensively on the subject of limiting the use of spinal manipulation. He made a strong pitch to define chiropractic as a medical specialty focusing on conservative care of musculoskeletal conditions. His sentiments echoed those of the NCA Chairman of the Board (C.O. Watkins DC) twenty years earlier: "If we will not develop a scientific organization to test our own methods, organized medicine will usurp our privilege. When it discovers a method of value, medical science will adopt it and incorporate it into scientific medical practice." Homola promptly lost his membership in the ACA and his position was openly rejected by both straight and mixer associations.

AMA plans to eliminate chiropractic

On November 2, 1963, the AMA Board of Reagents created the Committee on Quackery with its specific written goals of first containing and then eliminating chiropractic. Doyle Taylor, the Director of the AMA Department of Investigation, and Secretary of its Committee on Quackery outlined the steps to be taken:

1. that chiropractic coverage in Medicare is not obtained;

2. that recognition or listing by the U.S. Office of Education of a chiropractic accrediting agency is not achieved;

3. to encourage continued separation of the two national associations; and

4. to encourage state medical societies to take the initiative in their state legislatures in regard to legislation that might affect the practice of chiropractic.

The AMA distributed propaganda to the nations teachers and guidance councilors, eliminating the inclusion of chiropractic from the U.S Department of Labor's Health Careers Guidebook, and establishing specific educational guidelines for medical schools regarding the "hazards to individuals from the unscientific cult of chiropractic." They worked both publicly and politically to insure that chiropractic failed as a profession.

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. He qualified his vitalistic construct by noting that knowledge of Innate Intelligence was not essential to the competent practice of chiropractic. 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.

The vitalistic concepts implied an intelligent governing entity that were readily perceived as spiritual constructs by many both inside and outside the profession. Chiropractors used these metaphorical concepts to rationalize their way of thinking about the body’s self-healing capacity.

In 1998 Lon Morgan DC, a reform chiropractor, wrote that:"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."

Meridel I. Gatterman DC, educator and writer observed:

"The word subluxation has been ... embodied with a multitude of meaning by chiropractors during the past one hundred years. To some it has become the holy word; to others, an albatross to be discarded ... to add to the confusion, more than 100 synonyms for subluxation have been used. Why then do we persist in using the term when it has become so overburdened with clinical, political,and philosophical ... significance ... that the concept that once helped to hold a young profession together now divides it and keeps it quarrelling over basic semantics? The obvious answer is: The concept of subluxation is central to chiropractic."

Discussions concerning the necessity of removing the concept of subluxation from the chiropractic paradigm have been ongoing since the mid 1960's. While straights hold firmly to the term and its vitalistic construct, reformers suggest that the mechanistic model will allow chiropractic to better integrate into mainstream medicine without making the claims that are inherent in the term. Anthony Rosner PhD, director of education and research at the Foundation for Chiropractic Education and Research (FCER) considered subluxation and the concept of Occam's razor. He suggests "there is no obvious reason to discard the concept of subluxation, while at the same time maintaining that it is not a rigid entity, but rather an important model and concept; a work in progress that undoubtedly will undergo extensive modification as our concepts of light or psychoanalysis have evolved over half a century."

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

Chiropractic researchers Robert Mootz and Reed Phillips suggest that, during chiropractic's early evolution, influences from both straight and mixer concepts were incorporated into its construct. They conclude that chiropractic possesses both materialistic qualities that lend themselves to scientific investigation and vitalistic qualities that do not (Table 1).

With relatively little federal funding, academic scientific research in chiropractic has only recently become established in the USA. 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. By 1997, there were 14 peer-reviewed chiropractic journals in English that specifically encourage the publication of the results of chiropractic research, including The Journal of Manipulative and Physiological Therapeutics, Topics in Clinical Chiropractic, and the Journal of Chiropractic Humanities. However, of these, only The Journal of Manipulative and Physiological Therapeutics is included in Index Medicus. Research into chiropractic, whether conducted in Universities or in chiropractic colleges, is however often published in many other scientific journals.

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. Moreover, 68% believed that "most diseases are caused by spinal malalignment", although 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." A 1994 study 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 some 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 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 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". However, In 1998, after reviewing the articles published in the Journal of Manipulative and Physiological Therapeutics from 1989-1996, he concluded, "substantial increases in scholarly activities within the chiropractic profession are suggested by the growth in scholarly products published in the discipline's most distinguished periodical (JMPT). Increases in controlled outcome studies, collaboration among chiropractic institutions, contributions from nonchiropractors, contributions from nonchiropractic institutions and funding for research suggest a degree of professional maturation and growing interest in the content of the discipline."

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

In 1998, a study of 10,652 Florida workers' compensation cases conducted by Steve Wolk, PhD was reported by the Foundation for Chiropractic Education and Research. He 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 fewer than individuals who visited MDs, and 3.8 days fewer 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 $1565.05 for those who visited DOs.

In 1989, a survey by Daniel C. Cherkin PhD and Frederick A. MacCornack PhD, 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.

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."

Safety

Chiropractic is one of the safest health professions and chiropractors have some of the lowest malpractice insurance premiums in the health care industry. As with all interventions, there are risks associated with spinal manipulation. According to Harrison's, these include vertebrobasilar accidents (VBA), strokes, spinal disc herniation, vertebral fracture, and cauda equina syndrome. A 1996 Danish study determined that the greatest risk is with manipulation of the first two vertebra of the cervical spine, particularly passive rotation of the neck, known as the "master cervical" or "rotary break."

Serious complications after manipulation of the cervical spine are estimated to be 1 in 3-4 million manipulations or fewer, based on international studies of millions of chiropractic cervical adjustments from 1965 to the present. The RAND corporation's extensive review of spinal manipulation estimated "one in a million." Dvorak cites figures of 1 in 400,000, while Jaskoviak reported no vertebral artery strokes or serious injury in approximately 5 million cervical manipulations from 1965 to 1980 at The National College of Chiropractic Clinic in Chicago. By contrast, cervical spine surgery, an alternative to spinal manipulation for neck pain and radiating arm pain, has a 3-4% rate of complication and 4,000-10,000 deaths per million neck surgeries.

Statistics that evaluate the reliability of negative incident reporting for spinal manipulation (not necessarily performed by chiropractors) 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 (also 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. He concluded that underreporting was closer to 100%, rendering estimates "nonsensical." The NHS Centre for Reviews and Dissemination, based at the University of York agreed that the survey had methodological problems with data collection. Both NHS and Ernst noted that bias is a problem with the survey method of data collection.

A 2001 study in the medical journal Stroke found that vertebrobasilar accidents (VBAs) were 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 concluded; "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." The NHS notes that this case control study collected data objectively by using administrative data, which means that there is less recall bias than survey studies, but the data were collected retrospectively and probably contained inaccuracies. It also notes that the diagnosis codes used to identify participants with stroke had broad inclusion criteria and the application of codes across chiropractic offices was not standardised, meaning it was not possible to determine if the patient had received cervical spinal manipulation as part of their treatment.

Other considerations pertaining to stroke concern the use 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 risks and benefits 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.

In considering the issue of potential bias, few studies of 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 vs 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 DC, Hayno Thiel DC, MS, and W. Kirkaldy Willis MD, 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.

To qualify for licensure, graduates must pass 4 examinations from the National Board of Chiropractic Examiners and complete State specific requirements; most State boards require at least 2 years of undergraduate education, and an increasing number require a 4-year bachelor’s degree. All licensing boards in the US 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.

Federation of Chiropractic Licensing Boards

Main article: Federation of Chiropractic Licensing Boards

The FCLB is a conglomeration of all 50 US state licensing boards and the District of Columbia. It also includes several Canadian provinces and US territories. Its stated purpose is to protect the public and to serve the member boards by promoting excellence in chiropractic regulation.

Each state has a regulatory board that is appointed by its Governor. The board's responsibilities include:

• to investigate consumer complaints;
• to oversee the general application of health care laws;
• to help update and develop regulations which better define appropriate conduct by professionals and clarify what the consumer may expect;
• to continually review required credentials for doctors to practice safely, effectively, and ethically;
• to apply appropriate disciplinary action or retraining to doctors who may have broken the public trust through violation of statute or regulation;
• to function in the global regulatory community to assist other professions or jurisdictions affected by chiropractic.

The requirements to enter licensed chiropractic practice are defined by laws and regulations designed to protect the public's health, safety and welfare.

An essential part of the regulatory board's responsibility is to discipline and/or retrain doctors who step outside law and regulation. After sufficient inquiry determines a doctor has committed an offense, the severity of the offense will determine what sanctions are appropriate:

• Formal letter of reprimand
• Fine
• Probation
• Suspension
• Revocation of License
• Retraining / re-examination
• Other appropriate sanctions

The public may contact the licensing board in each jurisdiction to determine the status of the doctor's license. The Federation also maintains an on-line, international databank, known as CIN-BAD. This databank carries information on public actions by chiropractic regulatory agencies related to licenses of individual practitioners. It also lists doctors prohibited from receiving Medicare reimbursement due to federal sanctions imposed by U.S. Department of Health & Human Services. Members of the public may use a query form to request a search of the database.

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. Most chiropractors advertise themselves as primary care doctors and consider themselves part of alternative health care, but there can be large 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, but most chiropractors are not members of any national organization.

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 traditional straights, objective straights typically do not diagnose patient complaints. They also don't 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 straights limit treatment to spinal adjustments. Objective Straights 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 manipulation as a treatment for osteoarthritis and other 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. Association of Chiropractic Colleges, Chiropractic Paradigm
2. The Council on Chiropractic Education (2006), Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status available online
3. ^ Ernst E (2006) A systematic review of systematic reviews of spinal manipulation J R Soc Med 99:192-6 Available on-line Cite error: The named reference "Ernst E" was defined multiple times with different content (see the help page).
4. ^ 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) Cite error: The named reference "Duke" was defined multiple times with different content (see the help page).
5. Balon J. (1998) A Comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma. New Eng J Med 339:1013-20 available online
6. McDonald W (2003) How Chiropractors Think and Practice: The Survey of North American Chiropractors. Institute for Social Research, Ohio Northern University
7. 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.
8. ^ Terrett AGJ (1995) Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. J Manipulative Phys Ther 18:203. PubMed - PMID: 7636409
9. 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
10. Complementary and Alternative Medicine Use Among Adults: United States, 2002 (Report), May 27 2004, available online (PDF format)
11. Burton, Bernard. "Chiropractic Management of Low Back Pain." Cleveland Clinic: Spinal Care 2000 Symposium. March 30, 2000.
12. ^ Bureau of Labor Statistics, Occupational Outlook Handbook
13. 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
14. Chiropractic in the Winter Olympics
15. National Center for Education Statistics, Integrated Postsecondary Education Data System, Retrieved online 8/15/2004 at Quoted here:
16. Tindle HA (2005) Trends in use of complementary and alternative medicine by US adults: 1997-2002 Altern Ther Health Med 11:42-9
17. Chiropractic Patients in Denmark 2002: An Expanded Description and Comparison With 1999 Survey, J Manipulative Physiol Ther 29: 419-424 (July 2006) available online
18. Black D (1990)Inner Wisdom: The Challenge of Contextual Healing. Springville, UT: Tapestry Press
19. ^ AHCPR Chapter II Chiropractic Belief Systems
20. "The Chiropractic Profession and Its Research and Education Programs", Final Report, pg 41, Florida State University, MGT of America, December 2000
21. Autobiography of Andrew Still
22. Still National Osteopathic Museum
23. ^ Keating J. D.D. Palmer's Lifeline
24. ^ Palmer DD (1910) The Science, Art and Philosophy of Chiropractic Portland, Oregon: Portland Printing House Company
25. Daniel David Palmer short history
26. Westbrooks B (1982) The troubled legacy of Harvey Lillard: the black experience in chiropractic. Chiropractic History 2:46­53
27. ^ Keating J. Chiropractic History: A Primer,Sutherland Companies
28. ^ 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
29. ^ AMA Web site,AMA History 1847 - 1899,Retrieved May 27,2006
30. Healthcare history timeline
31. ^ Lerner, Cyrus. Report on the history of chiropractic (unpublished manuscript, L.E. Lee papers, Palmer College Library Archives)
32. Keating J. (1999), Tom Moore Defender of Chiropractic Part 1, Dynamic Chiropractic
33. Keating J. BJ Palmer Chonology
34. Keating J.(1996).Early Palmer Theories of Dis-ease
35. Palmer D.D. (1911). D.D. Palmer's Religion of Chiropractic
36. ^ Phillips R (1998), Education and the Chiropractic Profession, Dynamic Chiropractic
38. Chiropractic History Archives Neurocalometer
39. Homola S (2006), Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor
40. Keating J (1990), A Guest Review by Joseph C. Keating, Jr, PhD. Associate Professor, Palmer College of Chiropractic-West Dynamic Chiropractic
41. Phillips R (2003), Dynamic Chiropractic Truth and the Politics of knowledge
42. ^ Wilk vs American Medical Association Summary
43. ^ Keating J (1995), D.D. Palmer's Forgotten Theories of Chiropractic, A Presentation to the Canadian Memorial Chiropractic College
44. Morgan L (1998) Innate intelligence: its origins and problems J Can Chir Ass 42:35-41 available online
45. Gatterman MI. Foundations of the Chiropractic Subluxation. Baltimore: Williams and Wilkins, 1988:6. referenced in
46. Rosner A (2006) Occam's razor and subluxation: a close shave, Dynamic Chiropractic Aug 2006
47. Chirofind.com Chiropractic Research
48. Biggs L (2002) Measuring philosophy: a philosophy index'' JCCA
49. French S, Green S. "The Cochrane Collaboration: is it relevant for doctors of chiropractic?". J Manipulative Physiol Ther. 28: 641–2. PMID 16326231.
50. 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
51. Meade et al. (1995)Brit Med J,
52. Shekelle PM. (1993) RAND misquoted. ACA J Chir 30:59–63
53. Verhoef MJ,Costa Papadopoulos C. Survey of Canadian chiropractors’involvement in the treatment of patients under the age of 18.
54. Wiberg JMM, Nordsteen J, Nilsson N. (1999) 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 22:517-22
55. Olafsdottir E, Forshei S, Fluge G, Markestad T. (2001) Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Arch Dis Child 84:138-141.
56. Keating J, Caldwell S, Nguyen H, Saljooghi S, Smith B (1998). "A descriptive analysis of the Journal of Manipulative and Physiological Therapeutics, 1989-1996". J Manip Physiol Ther. 21 (8): 539–52. PMID 9798183. {{cite journal}}: Italic or bold markup not allowed in: |journal= (help)CS1 maint: multiple names: authors list (link)
57. Manga P, Angus D. (1998). Enhanced Chiropractic Coverage Under OHIP as a Means of Reducing Health Care Costs, Attaining Better Health Outcomes and Achieving Equitable Access to Health Services. Retrieved 08 29 2006, from OCA
58. Wolk S. (1988) An analysis of Florida workers' compensation medical claims for back-related injuries. J Amer Chir Ass 27:50-59
59. Nyiendo J, Lamm L. (1991) Disability low back Oregon workers' compensation claims. Part I: methodology and clinical categorization of chiropractic and medical cases. J Manip Physiol Ther 14:177-184
60. Nyiendo J. (1991) Disability low back Oregon workers' compensation claims. Part II: Time loss. J Manip Physiol Ther 14:231-239
61. Johnson M. (1989) A comparison of chiropractic, medical and osteopathic care for work-related sprains/strains. J Manip Physiol Ther 12:335-344
62. Cherkin CD, MacCornack FA, Berg AO (1988) Managing low back pain. A comparison of the beliefs and behaviours of family physicians and chiropractors.West J Med 149:475–480
63. British Medical Association, Referrals to complementary therapists
64. Klougart N, Leboeuf-Yde C, Rasmussen L. "Safety in chiropractic practice, Part I; The occurrence of cerebrovascular accidents after manipulation to the neck in Denmark from 1978-1988". J Manip Physiol Ther. 19 (6): 371–7. PMID 8864967. {{cite journal}}: Italic or bold markup not allowed in: |journal= (help)CS1 maint: multiple names: authors list (link)
65. ^ Coulter ID, Hurwitz EL, Adams AH, et al. (1996) The appropriateness of manipulation and mobilization of the cervical spine 'Santa Monica, CA, Rand Corp: xiv . Current link
66. Lauretti W "What are the risk of chiropractic neck treatments?" retrieved online 08 028 2006 from www.chiro.org
67. Ernst E (2002). "Spinal manipulation: its safety is uncertain". CMAJ. 166 (1): 40–1. PMID 11800245. {{cite journal}}: Italic or bold markup not allowed in: |journal= (help) Original article
68. ^ NHS Evaluation of the evidence base for the adverse effects of spinal manipulation by chiropractors
69. Rothwell D, Bondy S, Williams J (2001). "Chiropractic manipulation and stroke: a population-based case-control study". Stroke. 32: 1054–60. PMID 11340209. {{cite journal}}: Italic or bold markup not allowed in: |journal= (help)CS1 maint: multiple names: authors list (link) Original article
70. Chiropractic and the Risk of Stroke retrieved 08 28 2006 WCA website
71. Cassidy J, Thiel H, Kirkaldy-Willis W (1993). "Side posture manipulation for lumbar intervertebral disk herniation". J Manip Physiol Ther. 16: 96–103. PMID 8445360. {{cite journal}}: Italic or bold markup not allowed in: |journal= (help)CS1 maint: multiple names: authors list (link)
72. ^ Federation of Chiropractic Licensing Boards Mission statement
73. James W. Healey, DC (1990) [http://www.chiroweb.com/archives/08/21/13.html It's Where You Put the Period. Dynamic Chiropractic October 10, 1990, Volume 08, Issue 21
74. 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

Professional organizations

• American Chiropractic Association (ACA)
• Association of Chiropractic Colleges (ACC)
• British Chiropractic Association (BCA)
• Canadian Chiropractic Association (CCA)
• Chiropractic Association of South Africa (CASF)
• Chiropractic Doctors' Association of Hong Kong (CDAHK)
• Council on Chiropractic Education - USA (CCE-USA)
• European Chiropractors' Union (ECU)
• Federation of Chiropractic Licensing Boards (FCLB)
• Federation of Straight Chiropractors and Organizations (FSCO)
• Foundation for the Advancement of Chiropractic Education (F.A.C.E.)
• Foundation for Chiropractic Education and Research (FCER)
• Hong Kong Chiropractors' Association (HKCA)
• International Chiropractic Pediatric Association (ICPA)
• International Chiropractors Association (ICA)
• Japanese Association of Chiropractors (JAC)
• National Association for Chiropractic Medicine (NACM)
• National Board of Chiropractic Examiners (NBCE)
• World Chiropractic Alliance (WCA)
• World Federation of Chiropractic (WFC)

Chiropractic schools

• See article: Chiropractic schools

Other resources

• Chiropractic History Archive - Joseph C. Keating Jr, PhD
• The Chiropractic Profession and Its Research and Education Programs
• Chiropractic in the United States: Training, Practice, and Research (1997) - Cherkin, Daniel C.; Mootz, Robert D.
• Chiropractic Resource Organization
• Chiropractic treatments for back pain - Steven G. Yeomans, DC. A Spine-health.com feature (use menu points on left side)
• Dynamic Chiropractic Online - ChiroWeb, Chiropractic news source
• National Directory of Chiropractic - Listing of Chiropractors and information on education and the profession.
• National Center for Complimentary and Alternative Medicine - National Institute of Health - Manipulative and Body-Based Practices
• The Future of Chiropractic Revisited: 2005 to 2015
• Olympic Games Inspire Optimal Athletic Care

Internal criticism

• Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor

Samuel Homola DC, a notable and outspoken dissident within the profession, expresses his opinion that evidence-based chiropractic is the only way forward.

• Chiropractic, Bonesetting, and Cultism - Samuel Homola (entire book on-line).

This book, published in 1964, contains trenchant criticism of the profession, and the following year Homola's application to renew his membership of the ACA was rejected. In 1991, David J. Redding, chairman of the ACA board of governors, welcomed Homola back to membership of the ACA, and in 1994, 30 years after its publication, the book was reviewed for the first time by a chiropractic journal.

• Chiropractic Ethics: An Oxymoron?

JC Smith, a chiropractor in private practice, writes in 1999 that ethical issues are "in dire need of debate" because of "years of intense medical misinformation/slander" and because of well publicised examples of tacky advertising, outlandish claims, sensationalism and insurance fraud.

• Chiropractic: Science and Antiscience and Pseudoscience Side by Side

Joseph C. Keating, Jr, PhD, professor at the Los Angeles College of Chiropractic and notable historian of chiropractic, warns of pseudoscientific notions that still persist in the mindsets of some chiropractors

• Faulty Logic and Non-skeptical Arguments in Chiropractic

Dr Keating critically distinguishes between sound and unsound arguments in support of chiropractic

• Critical thinking

Christopher Kent, DC president of the Council on Chiropractic Practice, advises his colleagues of the importance of high standards of evidence, noting that in the past chiropractors were too ready to accept anecdotal evidence

• Open Letter to the Profession (See Chiroweb for commentary.)

A 1992 letter from ACA attorney, George P. McAndrews, warns the chiropractic profession that advertising of scare tactic subluxation philosophy damages the newly won respect within the AMA.

• Quackery in Chiropractic -

A 1991 editorial from chiropractic trade magazine, Dynamic Chiropractic, where Joseph C. Keating Jr discusses his concerns for advertising products before they are scientifically evaluated.

• Subluxation - The Silent Killer

A 2000 commentary by Ronald Carter, DC, MA, Past President, Canadian Chiropractic Association in the Journal of the Canadian Chiropractic Association discussing his opinion that the subluxation story regardless of how it is packaged is not the answer. He suggests it is now time for the silent majority to make their voices heard and come together to present a rational and defensible model of chiropractic so that is not just included in the health care system, but an essential member of the health care team.

External criticism

• 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 (combines internal and external criticism)
• Chiropractic: Flagship of the Alternative Medicine Fleet, Part One and Part Two - Steven Novella, MD 1997

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