D.D. Palmer Daniel David Palmer or D.D. Palmer was the founder of modern Chiropractic founded chiropractic in the 1890s and his son B.J. Palmer Bartlett Joshua Palmer (September 10, 1881-May 21, 1961) was a pioneer of Chiropractic helped to expand it in the early 20th century.^[7] It has two main groups: "straights", now the minority, emphasize vitalism Vitalism has a long history in medical philosophies: most traditional healing practices posited that disease was the result of some imbalance in the vital energies which distinguish living from non-living matter. In the Western tradition founded by Hippocrates, these vital forces were associated with the four temperaments and humours; Eastern, innate intelligence Innate Intelligence is a chiropractic term to describe the organizing properties of living things. It was originally coined by Daniel David Palmer, the founder of chiropractic. This vitalistic concept states that all life contains Innate Intelligence and that this force is responsible for the organization, maintenance and healing of the body and spinal adjustments Spinal adjustment and chiropractic adjustment are terms used by chiropractors to describe their approaches to spinal manipulation, as well as some osteopaths, who use the term adjustment, and consider subluxations to be the leading cause of all disease; "mixers" are more open to mainstream and alternative medical techniques such as exercise, massage, nutritional supplements, and acupuncture Acupuncture is a technique of inserting and manipulating fine filiform needles into specific points on the body to relieve pain or for therapeutic purposes. The word acupuncture comes from the Latin acus, "needle", and pungere, "to prick". In Standard Mandarin, 針砭 (a related word, 針灸 (zhēn jiǔ), refers to acupuncture.^[8] Chiropractic is well established in the U.S., Canada and Australia.^[9]

For most of its existence, chiropractic has battled with mainstream medicine Medicine is the art and science of healing. It encompasses a range of health care practices evolved to maintain and restore health by the prevention and treatment of illness, sustained by ideas such as subluxation^[10] that are not based on solid science.^[11] Vaccination Vaccination is the administration of antigenic material to produce immunity to a disease. Vaccines can prevent or ameliorate the effects of infection by a pathogen. Vaccination is generally considered to be the most effective and cost-effective method of preventing infectious diseases. The material administrated can either be live but weakened remains controversial among chiropractors.^[12] The American Medical Association The American Medical Association , founded in 1847 and incorporated 1897, is the largest association of physicians and medical students in the United States. The AMA's mission claims to promote the art and science of medicine for the betterment of the public health, to advance the interests of physicians and their patients, to promote public called chiropractic an "unscientific cult"^[13] and boycotted it until losing a 1987 antitrust United States antitrust law is the body of laws that prohibits anti-competitive behavior and unfair business practices. Antitrust laws are designed to encourage competition in the marketplace. These competition laws make illegal certain practices deemed to hurt businesses or consumers or both, or generally to violate standards of ethical behavior case.^[14] Chiropractic has had a strong political base and sustained demand for services; in recent decades, it has gained more legitimacy and greater acceptance among medical physicians A physician, medical practitioner, doctor of medicine, or medical doctor practices medicine, and is concerned with maintaining or restoring human health through the study, diagnosis, and treatment of disease and injury. This is accomplished through a detailed knowledge of anatomy, physiology, diseases and treatment — the science of medicine — and health plans Health insurance is insurance that pays for medical expenses. It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. It may be provided through a government-sponsored social insurance program, or from private insurance companies. It may be purchased on a group basis or purchased by,^[14] and evidence-based medicine Evidence-based medicine aims to apply evidence gained from the scientific method to certain parts of medical practice. It seeks to assess the quality of evidence relevant to the risks and benefits of treatments (including lack of treatment). According to the Centre for Evidence-Based Medicine, "Evidence-based medicine is the conscientious, has been used to review research studies and generate practice guidelines A medical guideline is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare. Such documents have been in use for thousands of years during the entire history of medicine. However, in contrast to previous approaches, which were often based on tradition or authority,.^[15] Many studies of treatments used by chiropractors have been conducted, with conflicting results. Collectively, systematic reviews A systematic review is a literature review focused on a single question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine. An understanding of systematic reviews and how to of this research have not demonstrated that spinal manipulation is effective In a healthcare context, efficacy indicates the capacity for beneficial change of a given intervention (e.g. a medicine, medical device, surgical procedure, or a public health intervention), with the possible exception of treatment of back pain Back pain is pain felt in the back that usually originates from the muscles, nerves, bones, joints or other structures in the spine.^[11] The efficacy and cost-effectiveness of maintenance chiropractic care are unknown.^[16] Although spinal manipulation can have serious complications Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A medical treatment, such as drugs or surgery may in rare cases,^[17][18] chiropractic care is generally safe when employed skillfully and appropriately.^[19]

Philosophy

Chiropractic's early philosophy was rooted in vitalism Vitalism has a long history in medical philosophies: most traditional healing practices posited that disease was the result of some imbalance in the vital energies which distinguish living from non-living matter. In the Western tradition founded by Hippocrates, these vital forces were associated with the four temperaments and humours; Eastern, spiritual inspiration Spirituality is matters of the spirit, a concept often but not necessarily tied to to a spirit world, a multidimensional reality and one or more deities. Spiritual matters regard humankind's ultimate nature and purpose, not as material biological organisms, but as spirits or energy with an eternal relationship beyond the bodily senses, time and and rationalism In epistemology and in its modern sense, rationalism is "any view appealing to reason as a source of knowledge or justification" . In more technical terms it is a method or a theory "in which the criterion of the truth is not sensory but intellectual and deductive" (Bourke 263). Different degrees of emphasis on this method or. A philosophy based on deduction Deductive reasoning, sometimes called deductive logic, is reasoning which constructs or evaluates deductive arguments. In logic, an argument is said to be deductive when the truth of the conclusion is purported to follow necessarily or be a logical consequence of the premises and its corresponding conditional is a necessary truth. Deductive from irrefutable doctrine Dogma is the established belief or doctrine held by a religion, ideology or any kind of organization: it is authoritative and not to be disputed, doubted or diverged from. The term derives from Greek δόγμα "that which seems to one, opinion or belief" and that from δοκέω , "to think, to suppose, to imagine". The plural helped distinguish chiropractic from medicine, provided it with legal and political defenses against claims of practicing medicine without a license, and allowed chiropractors to establish themselves as an autonomous profession. This "straight" philosophy, taught to generations of chiropractors, rejects the inferential reasoning The process by which a conclusion is inferred from multiple observations is called inductive reasoning. The conclusion may be correct or incorrect, or correct, or correct to within a certain degree of accuracy, or correct in certain situations. Conclusions inferred from multiple observations may be tested by additional observations of the scientific method Scientific method refers to bodies of techniques for investigating phenomena, acquiring new knowledge, or correcting and integrating previous knowledge. To be termed scientific, a method of inquiry must be based on gathering observable, empirical and measurable evidence subject to specific principles of reasoning. A scientific method consists of,^[21] and relies on deductions from vitalistic first principles rather than on the materialism The philosophy of materialism holds that the only thing that exists is matter, and is considered a form of physicalism. Fundamentally, all things are composed of material and all phenomena are the result of material interactions; therefore, matter is the only substance. As a theory, materialism belongs to the class of monist ontology. As such, it of science.^[20] However, most practitioners currently accept the importance of scientific research into chiropractic,^[21] and most practitioners are "mixers" who attempt to combine the materialistic reductionism of science with the metaphysics of their predecessors and with the holistic paradigm of wellness Holistic health is a philosophy of medical care that views physical and mental and spiritual aspects of life as closely interconnected and equally important approaches to treatment. While frequently associated with alternative medicine, it may also be used in medical practice as part of a broad view of patient care;^[20] a 2008 commentary proposed that chiropractic actively divorce itself from the straight philosophy as part of a campaign to eliminate untestable Testability, a property applying to an empirical hypothesis, involves two components: the logical property that is variously described as contingency, defeasibility, or falsifiability, which means that counterexamples to the hypothesis are logically possible, and (2) the practical feasibility of observing a reproducible series of such dogma and engage in critical thinking and evidence-based research.^[22]

Although a wide diversity of ideas currently exists among chiropractors,^[21] they share the belief that the spine In human anatomy, the vertebral column is a column usually consisting of 24 vertebrae, the sacrum, intervertebral discs, and the coccyx situated in the dorsal aspect of the torso, separated by spinal discs. It houses the spinal cord in its spinal canal and health are related in a fundamental way, and that this relationship is mediated through the nervous system.^[23] Chiropractors study the biomechanics Biomechanics is the application of mechanical principles to living organisms. This includes bioengineering, the research and analysis of the mechanics of living organisms and the application of engineering principles to and from biological systems. This research and analysis can be carried forth on multiple levels, from the molecular, wherein, structure and function of the spine, along with what they say are its effects on the musculoskeletal The human musculoskeletal system is an organ system that gives humans the ability to move using the muscular and skeletal systems. The musculoskeletal system provides form, stability, and movement to the human body and nervous systems and its role in health and disease.^[24]

Chiropractic philosophy includes the following perspectives:^[20]

• Holism assumes that health is affected by everything in people's complex environments; some sources also include a spiritual or existential dimension.^[25] In contrast, reductionism in chiropractic reduces causes and cures of health problems to a single factor, vertebral subluxation.^[22]

• Conservatism considers the risks of clinical interventions when balancing them against their benefits. It emphasizes noninvasive treatment to minimize risk, and avoids surgery and medication.^[24]

• Homeostasis emphasizes the body's inherent self-healing abilities. Chiropractic's early notion of innate intelligence can be thought of as a metaphor for homeostasis.^[21]

• Straights tend to use an approach that focuses on the chiropractor's perspective and the treatment model, whereas mixers tend to focus on the patient and the patient's situation.^[20]

Straights and mixers

Chiropractic is often described as two professions masquerading as one. Unlike the distinction between podiatry (a science-based profession for foot disorders) and foot reflexology (an unscientific philosophy which posits that many disorders arise from the feet), in chiropractic the two professions attempt to live under one roof.^[22]

Straight chiropractors adhere to the philosophical principles set forth by D.D. and B.J. Palmer, and retain metaphysical definitions and vitalistic qualities. Straight chiropractors believe that vertebral subluxation leads to interference with an "Innate Intelligence" exerted via the human nervous system and is a primary underlying risk factor for almost any disease. Straights view the medical diagnosis of patient complaints (which they consider to be the "secondary effects" of subluxations) to be unnecessary for chiropractic treatment. Thus, straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not "mix" other types of therapies.^[26] Their philosophy and explanations are metaphysical in nature and prefer to use traditional chiropractic lexicon (i.e. perform spinal analysis, detect subluxation, correct with adjustment, etc.). They prefer to remain separate and distinct from mainstream health care.

Mixer chiropractors "mix" diagnostic and treatment approaches from osteopathic, medical, and chiropractic viewpoints. Unlike straight chiropractors, mixers believe subluxation is one of many causes of disease, and they incorporate mainstream medical diagnostics and employ many treatments including conventional techniques of physical therapy such as exercise, massage, ice packs, and moist heat, along with nutritional supplements, acupuncture, homeopathy, herbal remedies, and biofeedback. Mixers tend to be open to mainstream medicine and are the majority group.^[8]

Vertebral subluxation

Palmer hypothesized that vertebral joint misalignments, which he termed vertebral subluxations, interfered with the body's function and its inborn (innate) ability to heal itself.^[5] D.D. Palmer repudiated his earlier theory that vertebral subluxations caused pinched nerves in the intervertebral spaces in favor of subluxations causing altered nerve vibration, either too tense or too slack, affecting the tone (health) of the end organ. D.D. Palmer, using a vitalistic approach, imbued the term subluxation with a metaphysical and philosophical meaning. He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic.^[27] This concept was later expanded upon by his son, B.J. Palmer and was instrumental in providing the legal basis of differentiating chiropractic medicine from conventional medicine. In 1910, D.D. Palmer theorized that the nervous system controlled health:

"Physiologists divide nerve-fibers, which form the nerves, into two classes, afferent and efferent. Impressions are made on the peripheral afferent fiber-endings; these create sensations that are transmitted to the center of the nervous system. Efferent nerve-fibers carry impulses out from the center to their endings. Most of these go to muscles and are therefore called motor impulses; some are secretory and enter glands; a portion are inhibitory their function being to restrain secretion. Thus, nerves carry impulses outward and sensations inward. The activity of these nerves, or rather their fibers, may become excited or allayed by impingement, the result being a modification of functionality—too much or not enough action—which is disease."^[28]

The concept of subluxation remains unsubstantiated and largely untested, and a debate about whether to keep it in the chiropractic paradigm has been ongoing for decades.^[6] In general, critics of traditional subluxation-based chiropractic (including chiropractors) are skeptical of its clinical value, dogmatic beliefs and metaphysical approach. While straight chiropractic still retains the traditional vitalistic construct espoused by the founders, evidence-based chiropractic suggests that a mechanistic view will allow chiropractic care to become integrated into the wider health care community.^[6] This is still a continuing source of debate within the chiropractic profession as well, with some schools of chiropractic still teaching the traditional/straight subluxation-based chiropractic, while others have moved towards an evidence-based chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions.^[29][30]

A 2003 survey of North American chiropractors found that 88% wanted to retain the term vertebral subluxation complex, and that when asked to estimate the percent of disorders of internal organs (such as the heart, the lungs, or the stomach) that subluxation significantly contributes to, the mean response was 62%.^[31] In 2005, subluxation was defined by the World Health Organization as "a lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. It is essentially a functional entity, which may influence biomechanical and neural integrity." This differs from the medical definition of subluxation as a significant structural displacement, which can be seen with static imaging techniques such as X-rays.^[19] Attorney David Chapman-Smith, Secretary-General of the World Federation of Chiropractic, has stated that "subluxations are not structural entities and cannot be detected on x‑ray."^[32]

Scope of practice

Chiropractors, also known as doctors of chiropractic or chiropractic physicians in many jurisdictions,^[33] emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery,^[19] with special emphasis on the spine.^[1] Chiropractic combines aspects from mainstream and alternative medicine: although chiropractors have many attributes of primary care providers, chiropractic has more of the attributes of a medical specialty like dentistry or podiatry.^[34] It has been proposed that chiropractors specialize in nonsurgical spine care, instead of attempting to also treat other problems,^[22][34] but the more expansive view of chiropractic is still widespread.^[35] Mainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be complementary and alternative medicine (CAM);^[2] however, a 2008 study reported that 31% of surveyed chiropractors categorized chiropractic as CAM, 27% as integrated medicine, and 12% as mainstream medicine.^[3]

The practice of chiropractic medicine involves a range of diagnostic methods including skeletal imaging, observational and tactile assessments, and orthopedic and neurological evaluation.^[19] A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider.^[34] Common patient management involves spinal manipulation (SM) and other manual therapies to the joints and soft tissues, rehabilitative exercises, health promotion, electrical modalities, complementary procedures, and lifestyle counseling.^[4]

Chiropractors cannot write medical prescriptions or perform major surgery. In the U.S. their scope of practice varies by state in areas such as conducting laboratory tests or diagnostic procedures, dispensing dietary supplements, and using other therapies such as homeopathy and acupuncture; in the state of Oregon they can become certified to perform minor surgery and to deliver children via natural childbirth.^[36] A 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for over-the-counter drugs.^[31] A related field, veterinary chiropractic, applies manual therapies to animals and is recognized in a few U.S. states,^[37] but is not recognized by the American Chiropractic Association as being chiropractic.^[38]

Chiropractic overlaps with several other manual-therapy professions, including massage therapy, osteopathy, and physical therapy.^[39] Chiropractic is autonomous and competitive with mainstream medicine^[40] and osteopathy outside the U.S. remains primarily a manual medical system;^[41] physical therapists work alongside and cooperate with mainstream medicine, and osteopathic medicine in the U.S. has merged with the medical profession.^[40] Members distinguish these competing professions with rhetorical strategies that include claims that, compared to other professions, chiropractors heavily emphasize spinal manipulation, tend to use firmer manipulative techniques, and promote maintenance care; that osteopaths use a wider variety of treatment procedures; and that physical therapists emphasize machinery and exercise.^[39]

No single profession "owns" spinal manipulation and there is little consensus as to which profession should administer SM, raising concerns by chiropractors that orthodox medical physicians could "steal" SM procedures from chiropractors. A focus on evidence-based SM research has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.^[15] Some U.S. states prohibit physical therapists from performing SM, some states allow them to do it only if they have completed chiropractic training, and some states allow only chiropractors to perform SM, or only chiropractors and physicians. Bills to further prohibit non-chiropractors from performing SM are regularly introduced into state legislatures and are opposed by physical therapist organizations.^[42]

Treatment techniques

Spinal manipulation, which chiropractors call "spinal adjustment" or "chiropractic adjustment", is the most common treatment used in chiropractic care;^[43] in the U.S., chiropractors perform over 90% of all manipulative treatments.^[44] Spinal manipulation is a passive manual maneuver during which a three-joint complex is taken past the normal range of movement, but not so far as to dislocate or damage the joint; its defining factor is a dynamic thrust, which is a sudden force that causes an audible release and attempts to increase a joint's range of motion. More generally, spinal manipulative therapy (SMT) describes techniques where the hands are used to manipulate, massage, mobilize, adjust, stimulate, apply traction to, or otherwise influence the spine and related tissues; in chiropractic care SMT most commonly takes the form of spinal manipulation.^[45]

There are several schools of chiropractic adjustive techniques, although most chiropractors mix techniques from several schools. The following adjustive procedures were received by more than 20% of patients of licensed U.S. chiropractors in a 2003 survey:^[43] Diversified technique (full-spine manipulation), extremity adjusting, Activator technique (which uses a spring loaded tool to deliver precise adjustments to the spine), Thompson Technique, Gonstead (which looks at the whole spine with the philosophy that a vertebral misalignment may affect other areas of the spine, emphasizing the mechanical aspects of the spine), Cox/flexion-distraction (a gentle, non-force adjusting procedure which mixes chiropractic principles with osteopathic principles and utilizes specialized adjusting tables with movable parts), adjustive instrument, Sacro-Occipital Technique (which models the spine as a torsion bar), Nimmo Receptor-Tonus Technique, and Applied Kinesiology (which emphasises "muscle testing" as a diagnostic tool).^[46] Medicine-assisted manipulation, such as manipulation under anesthesia, involves sedation or local anesthetic and is done by a team that includes an anesthesiologist; a 2008 systematic review did not find enough evidence to make recommendations about its use for chronic low back pain.^[47]

Many other procedures are used by chiropractors for treating the spine, other joints and tissues, and general health issues. The following procedures were received by more than 1/3 of patients of licensed U.S. chiropractors in a 2003 survey: Diversified technique (full-spine manipulation; mentioned in previous paragraph), physical fitness/exercise promotion, corrective or therapeutic exercise, ergonomic/postural advice, self-care strategies, activities of daily living, changing risky/unhealthy behaviors, nutritional/dietary recommendations, relaxation/stress reduction recommendations, ice pack/cryotherapy, extremity adjusting (also mentioned in previous paragraph), trigger point therapy, and disease prevention/early screening advice.^[43]

Education, licensing, and regulation

Chiropractors obtain a first professional degree in the field of chiropractic.^[48] In the United States, 90 semester hours or about two years of undergraduate education are pre-requisite for entrance to chiropractic school.^{[citation needed]} Canada requires a minimum three years of undergraduate education as a prerequisite for chiropractic school, and at least 4200 instructional hours (or the equivalent) of full‐time chiropractic education for matriculation through an accredited chiropractic program.^[49] The World Health Organization (WHO) guidelines suggest three major full-time educational paths culminating in either a DC, DCM, BSc, or MSc degree. Besides the full-time paths, they also suggest a conversion program for people with other health care education and limited training programs for regions where no legislation governs chiropractic.^[19]

Upon graduation, there may be a requirement to pass national, state, or provincial board examinations before being licensed to practice in a particular jurisdiction.^[50][51] Depending on the location, continuing education may be required to renew these licenses.^[52][53] Specialty training is available through part-time postgraduate education programs such as chiropractic orthopedics and sports chiropractic, and through full-time residency programs such as radiology or orthopedics.^[54]

Chiropractic is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries.^[9] In the U.S., chiropractic schools are accredited through the Council on Chiropractic Education (CCE) while the General Chiropractic Council (GCC) is the statutory governmental body responsible for the regulation of chiropractic in the UK.^[55][56] CCEs in the U.S., Canada, Australia and Europe have joined to form CCE-International (CCE-I) as a model of accreditation standards with the goal of having credentials portable internationally.^[57] Today, there are 18 accredited Doctor of Chiropractic programs in the U.S.,^[58] 2 in Canada,^[59] 6 in Australasia,^[60] and 4 in Europe.^[61] All but one of the chiropractic colleges in the U.S. are privately funded, but in several other countries they are in government-sponsored universities and colleges.^[62]

Regulatory colleges and chiropractic boards in the U.S., Canada, and Australia are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.^[63][64] There are an estimated 53,000 chiropractors in the U.S. (2006),^[65] 7,000 in Canada (2009),^[66] 2,500 in Australia (2000),^[67] and 1,500 in the UK (2000).^[68]

A 2008 commentary proposed that the chiropractic profession actively regulate itself to combat abuse, fraud, and quackery, which are more prevalent in chiropractic than in other health care professions, violating the social contract between patients and physicians.^[22] Unsubstantiated claims about the efficacy of chiropractic have continued to be made by individual chiropractors and chiropractic associations.^[11] The largest chiropractic associations in the U.S. and Canada distributed patient brochures which contained unsubstantiated claims.^[69] Chiropractors, especially in America, have a reputation for unnecessarily treating patients. In many circumstances the focus seems to be put on economics instead of health care.^[70] Sustained chiropractic care is promoted as a preventative tool but unnecessary manipulation could possibly present a risk to patients. Some chiropractors are concerned by the routine unjustified claims chiropractors have made.^[11] A study of California disciplinary statistics during 1997–2000 reported 4.5 disciplinary actions per 1000 chiropractors per year, compared to 2.27 for MDs; the incident rate for fraud was 9 times greater among chiropractors (1.99 per 1000 chiropractors per year) than among MDs (0.20).^[71]

Utilization, satisfaction rates, and third party coverage

In the U.S., chiropractic is the largest alternative medical profession,^[8] and is the third largest doctored profession, behind medicine and dentistry.^[72] The percentage of population that utilizes chiropractic care at any given time generally falls into a range from 6% to 12% in the U.S. and Canada,^[73] with a global high of 20% in Alberta.^[74] Chiropractors are the most common CAM providers for children and adolescents, who consume up to 14% of all visits to chiropractors.^[75] The vast majority who seek chiropractic care do so for relief from back and neck pain and other neuromusculoskeletal complaints;^[76] most do so specifically for low back pain. Practitioners such as chiropractors are often used as a complementary form of care to primary medical intervention.^[73] Satisfaction rates are typically higher for chiropractic care compared to medical care, with a 1998 U.S. survey reporting 83% of persons satisfied or very satisfied with their care; quality of communication seems to be a consistent predictor of patient satisfaction with chiropractors.^[77]

Chiropractic does not have the same level of mainstream credibility as other healthcare professions. Public perception of chiropractic compares unfavorably with mainstream medicine with regard to ethics and honesty: in a 2006 Gallup Poll of U.S. adults, chiropractors rated last among seven health care professions for being very high or high in honesty and ethical standards, with 36% of poll respondents rating chiropractors very high or high; the corresponding ratings for other professions ranged from 62% for dentists to 84% for nurses.^[22][78][79]

Utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient.^[2] The use of chiropractic declined from 9.9% of U.S. adults in 1997 to 7.4% in 2002; this was the largest relative decrease among CAM professions, which overall had a stable use rate.^[80] Employment of U.S. chiropractors is expected to increase 14% between 2006 and 2016, faster than the average for all occupations.^[65]

In the U.S., most states require insurers to cover chiropractic care, and most HMOs cover these services.^[75] In Canada, there is lack of coverage under the universal public health insurance system.^[81] In Australia, most private health insurance funds cover chiropractic care, and the federal government funds chiropractic care when the patient is referred by a medical practitioner.^[82]

History

Chiropractic was founded in the 1890s by Daniel David (D.D.) Palmer in Davenport, Iowa. Palmer, a magnetic healer, hypothesized that manual manipulation of the spine could cure disease. Chiropractic competed with its predecessor osteopathy, another medical system based on magnetic healing and founded by a charismatic midwesterner in opposition to conventional medicine; however, where osteopathic postulated improved blood flow via manipulation, chiropractic postulated improved neural transmissions.^[83] Although initially keeping chiropractic a family secret, in 1898 Palmer began teaching it to a few students at his new Palmer School of Chiropractic. One student, his son Bartlett Joshua (B.J.) Palmer, became committed to promoting chiropractic, took over the Palmer School in 1906, and rapidly expanded its enrollment.^[7] Prosecutions and incarcerations of chiropractors for practicing medicine without a license grew common, and to defend against medical statutes B.J. argued that chiropractic was separate and distinct from medicine, asserting that chiropractors "analyzed" rather than "diagnosed", and "adjusted" subluxations rather than "treated" disease.^[26] Early chiropractors believed that all disease was caused by interruptions in the flow of innate intelligence, a vital nervous energy or life force that represented God's presence in man; chiropractic leaders often invoked religious imagery and moral traditions. D.D. and B.J. both seriously considered declaring chiropractic a religion, which might have provided legal protection under the U.S. constitution, but decided against it partly to avoid confusion with Christian Science.^[7][84] Early chiropractors also tapped into the Populist movement, emphasizing craft, hard work, competition, and advertisement, aligning themselves with the common man against intellectuals and trusts, among which they included the American Medical Association (AMA).^[7]

Chiropractic has seen considerable controversy and criticism. Although D.D. and B.J. were "straight" and disdained the use of instruments, some early chiropractors, whom B.J. scornfully called "mixers", advocated use of instruments. In 1910 B.J. changed course and endorsed X-rays as necessary for diagnosis; this resulted in a significant exodus from the Palmer School of the more conservative faculty and students. The mixer camp grew until by 1924 B.J. estimated that only 3,000 of the U.S.'s 25,000 chiropractors remained straight. That year, B.J.'s promotion of the neurocalometer, a new temperature-sensing device, was another sign of chiropractic's gradual acceptance of medical technology, although it was highly controversial among B.J.'s fellow straights. Despite heavy opposition by organized medicine, by the 1930s chiropractic was the largest alternative healing profession in the U.S.^[7] The longstanding feud between chiropractors and medical doctors continued for decades. The AMA labeled chiropractic an "unscientific cult" in 1966,^[13] and until 1980 held that it was unethical for medical doctors to associate with "unscientific practitioners".^[85] This culminated in a landmark 1987 decision, Wilk v. AMA, in which the court found that the AMA had engaged in unreasonable restraint of trade and conspiracy, and which ended the AMA's de facto boycott of chiropractic.^[14]

Serious research to test chiropractic theories did not begin until the 1970s, and is continuing to be hampered by what are characterized as antiscientific and pseudoscientific ideas that sustained the profession in its long battle with organized medicine. By the mid 1990s there was a growing scholarly interest in chiropractic, which helped efforts to improve service quality and establish clinical guidelines that recommended manual therapies for acute low back pain.^[26] In recent decades chiropractic gained legitimacy and greater acceptance by medical physicians and health plans, and enjoyed a strong political base and sustained demand for services. However, its future seemed uncertain: as the number of practitioners grew, evidence-based medicine insisted on treatments with demonstrated value, managed care restricted payment, and competition grew from massage therapists and other health professions. The profession responded by marketing natural products and devices more aggressively, and by reaching deeper into alternative medicine and primary care.^[14]

Evidence basis

The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under managed care.^[15] Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs what is considered by many chiropractic researchers to be antiscientific reasoning and unsubstantiated claims,^{[1][6][10][86]} that have been called ethically suspect when they let practitioners maintain their beliefs to patients' detriment.^[1] A 2007 survey of Alberta chiropractors found that they do not consistently apply research in practice, which may have resulted from a lack of research education and skills.^[87] Evidence-based chiropractors possess the ability to apply research in practice. Continued education enhances the scientific knowledge of the practitioner.^[88]

Effectiveness

Opinions differ as to the efficacy of chiropractic treatment.^[62] Many controlled clinical studies of spinal manipulation (SM) are available, but their results disagree,^[89] and they are typically of low quality.^[90] Health claims made by chiropractors about using manipulation for pediatric health conditions are supported by only low levels of scientific evidence^[75][91] that does not demonstrate clinically relevant benefits.^[92] A 2008 critical review found that with the possible exception of back pain, chiropractic SM has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference,^[11] but a 2008 supportive review found serious flaws in the critical approach and found that SM and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments.^[93] Most research has focused on spinal manipulation (SM) in general,^[94] rather than solely on chiropractic SM.^[15] A 2002 review of randomized clinical trials of SM^[34] was criticized for not distinguishing between studies of SM in general, and studies on chiropractic SM in particular;^[95] however the review's authors stated that they did not consider this difference to be a significant point as research on SM is equally useful regardless of which practitioner provides it.^[94]

There is a wide range of ways to measure treatment outcomes.^[96] Chiropractic care, like all medical treatment, benefits from the placebo response.^[97] It is hard to construct a trustworthy placebo for clinical trials of spinal manipulative therapy (SMT), as experts often disagree about whether a proposed placebo actually has no effect.^[98] The efficacy of maintenance care in chiropractic is unknown.^[16]

Available evidence covers the following conditions:

• Low back pain. There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain.^[99] A 2008 review found strong evidence that SM is similar in effect to medical care with exercise.^[93] A 2007 review found good evidence that SM is moderately effective for low back pain lasting more than 4 weeks;^[100] a 2008 literature synthesis found good evidence supporting SM for low back pain regardless of duration.^[101] Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review^[102] found that SM or mobilization is no more or less effective than other standard interventions for back pain.^[89] Methods for formulating treatment guidelines for low back pain differ significantly between countries, casting some doubt on their reliability.^[99]

• Whiplash and other neck pain. There is no overall consensus on manual therapies for neck pain.^[103] A 2008 review found evidence that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SM, mobilization, supervised exercise, low-level laser therapy and perhaps acupuncture are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves prognosis.^[104] A 2007 review found that SM and mobilization are effective for neck pain.^[103] Of three systematic reviews of SM published between 2000 and May 2005, one reached a positive conclusion, and a 2004 Cochrane review^[105] found that SM and mobilization are beneficial only when combined with exercise.^[89] A 2005 review found consistent evidence supporting mobilization for acute whiplash, and limited evidence supporting SM for whiplash.^[106]

• Headache. A 2006 review found no rigorous evidence supporting SM or other manual therapies for tension headache.^[107] A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.^[108] A 2004 review found that SM may be effective for migraine and tension headache, and SM and neck exercises may be effective for cervicogenic headache.^[109] Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of SM.^[89]

• Other. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs,^[110] and limited or fair evidence supporting chiropractic management of leg conditions.^[111] There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine)^[112] and no scientific data for idiopathic adolescent scoliosis.^[113] A 2007 systematic review found that few studies of chiropractic care for nonmusculoskeletal conditions are available, and they are typically not of high quality; it also found that the entire clinical encounter of chiropractic care (as opposed to just SM) provides benefit to patients with asthma, cervicogenic dizziness, and baby colic, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizziness, high blood pressure, and vision conditions.^[114] Other reviews have found no evidence of benefit for asthma,^[115] baby colic,^[91][116] bedwetting,^[117] carpal tunnel syndrome,^[118] fibromyalgia,^[119] kinetic imbalance due to suboccipital strain (KISS) in infants,^[91][120] menstrual cramps,^[121] or pelvic and back pain during pregnancy.^[122]

Safety

Chiropractic care in general is safe when employed skillfully and appropriately. Manipulation is regarded as relatively safe, but as with all therapeutic interventions, complications can arise, and it has known adverse effects, risks and contraindications. Absolute contraindications to spinal manipulative therapy are conditions that should not be manipulated; these contraindications include rheumatoid arthritis and conditions known to result in unstable joints. Relative contraindications are conditions where increased risk is acceptable in some situations and where low-force and soft-tissue techniques are treatments of choice; these contraindications include osteoporosis.^[19] Although most contraindications apply only to manipulation of the affected region, some neurological signs indicate referral to emergency medical services; these include sudden and severe headache or neck pain unlike that previously experienced.^[18]

Spinal manipulation is associated with frequent, mild and temporary adverse effects,^[17][18] including new or worsening pain or stiffness in the affected region.^[123] They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours.^[124] Rarely,^[19] spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death; these can occur in adults^[17] and children.^[125] Estimates vary widely for the incidence of these complications,^[124] and the actual incidence is unknown, due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke, which is a particular concern.^[17] Several case reports show temporal associations between interventions and potentially serious complications. Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.^[104][126] Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.^[127]

Chiropractors sometimes employ diagnostic imaging techniques such as X-rays and CT scans that rely on ionizing radiation; practice guidelines aim to reduce unnecessary radiation exposure,^[128] which increase cancer risk in proportion to the amount of radiation received.^[129]

Cost-effectiveness

A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings.^[130] A 2006 systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation in the United Kingdom compared favorably with other treatments for back pain, but that reports were based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain.^[131] A 2005 systematic review of economic evaluations of conservative treatments for low back pain found that significant quality problems in available studies meant that definite conclusions could not be drawn about the most cost-effective intervention.^[132] The cost-effectiveness of maintenance chiropractic care is unknown.^[16]

Public health

Some chiropractors oppose vaccination and water fluoridation, which are common public health practices. Chiropractors' attempts to establish a positive reputation for their public health role are also compromised by their reputation for recommending repetitive life-long chiropractic treatment.^[22] Within the chiropractic community there are significant disagreements about vaccination,^[12][67] one of the most cost-effective public health interventions available.^[133] Most chiropractic writings on vaccination focus on its negative aspects,^[12] claiming that it is hazardous, ineffective, and unnecessary. Some chiropractors have embraced vaccination, but a significant portion of the profession rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that vaccines interfere with healing. The American Chiropractic Association and the International Chiropractors Association support individual exemptions to compulsory vaccination laws, and a 1995 survey of U.S. chiropractors found that about a third believed there was no scientific proof that immunization prevents disease.^[67] The Canadian Chiropractic Association supports vaccination;^[12] a survey in Alberta in 2002 found that 25% of chiropractors advised patients for, and 27% against, vaccinating themselves or their children.^[134]

Early opposition to water fluoridation included chiropractors, some of whom continue to oppose it as being incompatible with chiropractic philosophy and an infringement of personal freedom. Recently, other chiropractors have actively promoted fluoridation, and several chiropractic organizations have endorsed scientific principles of public health.^[135]

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90. ^ Quality of SM studies:
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105. ^ Gross AR, Hoving JL, Haines TA et al. (2004). "Manipulation and mobilisation for mechanical neck disorders". Cochrane Database Syst Rev (1): CD004249. doi:10.1002/14651858.CD004249.pub2. PMID 14974063.
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107. ^ Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA (2006). "Are manual therapies effective in reducing pain from tension-type headache?: a systematic review". Clin J Pain 22 (3): 278–85. doi:10.1097/01.ajp.0000173017.64741.86. PMID 16514329.
108. ^ Biondi DM (2005). "Physical treatments for headache: a structured review". Headache 45 (6): 738–46. doi:10.1111/j.1526-4610.2005.05141.x. PMID 15953306.
109. ^ Bronfort G, Nilsson N, Haas M et al. (2004). "Non-invasive physical treatments for chronic/recurrent headache". Cochrane Database Syst Rev (3): CD001878. doi:10.1002/14651858.CD001878.pub2. PMID 15266458.
110. ^ McHardy A, Hoskins W, Pollard H, Onley R, Windsham R (2008). "Chiropractic treatment of upper extremity conditions: a systematic review". J Manipulative Physiol Ther 31 (2): 146–59. doi:10.1016/j.jmpt.2007.12.004. PMID 18328941.
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115. ^ Hondras MA, Linde K, Jones AP (2005). "Manual therapy for asthma". Cochrane Database Syst Rev (2): CD001002. doi:10.1002/14651858.CD001002.pub2. PMID 15846609.
116. ^ Husereau D, Clifford T, Aker P, Leduc D, Mensinkai S (2003) (PDF). Spinal Manipulation for Infantile Colic. Technology report no. 42. Ottawa: Canadian Coordinating Office for Health Technology Assessment. ISBN 1-894978-11-0. http://cadth.ca/media/pdf/177_spinal_manipulation_tr_e.pdf. Retrieved on 2008-10-06.
117. ^ Glazener CM, Evans JH, Cheuk DK (2005). "Complementary and miscellaneous interventions for nocturnal enuresis in children". Cochrane Database Syst Rev (2): CD005230. doi:10.1002/14651858.CD005230. PMID 15846744.
118. ^ O'Connor D, Marshall S, Massy-Westropp N (2003). "Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome". Cochrane Database Syst Rev (1): CD003219. doi:10.1002/14651858.CD003219. PMID 12535461.
119. ^ Fibromyalgia:
     • Sarac AJ, Gur A (2006). "Complementary and alternative medical therapies in fibromyalgia". Curr Pharm Des 12 (1): 47–57. doi:10.2174/138161206775193262. PMID 16454724.
     • Schneider M, Vernon H, Ko G, Lawson G, Perera J (2009). "Chiropractic management of fibromyalgia syndrome: a systematic review of the literature". J Manipulative Physiol Ther 32 (1): 25–40. doi:10.1016/j.jmpt.2008.08.012. PMID 19121462.
     • Ernst E (2009). "Chiropractic treatment for fibromyalgia: a systematic review". Clin Rheumatol. doi:10.1007/s10067-009-1217-9. PMID 19544042.
120. ^ Brand PL, Engelbert RH, Helders PJ, Offringa M (2005). "[Systematic review of the effects of therapy in infants with the KISS-syndrome (kinetic imbalance due to suboccipital strain)]" (in Dutch). Ned Tijdschr Geneeskd 149 (13): 703–7. PMID 15819137.
121. ^ Proctor ML, Hing W, Johnson TC, Murphy PA (2006). "Spinal manipulation for primary and secondary dysmenorrhoea". Cochrane Database Syst Rev (3): CD002119. doi:10.1002/14651858.CD002119.pub3. PMID 16855988.
122. ^ Pennick VE, Young G (2007). "Interventions for preventing and treating pelvic and back pain in pregnancy". Cochrane Database Syst Rev (2): CD001139. doi:10.1002/14651858.CD001139.pub2. PMID 17443503.
123. ^ Thiel HW, Bolton JE, Docherty S, Portlock JC (2007). "Safety of chiropractic manipulation of the cervical spine: a prospective national survey". Spine 32 (21): 2375–8. doi:10.1097/BRS.0b013e3181557bb1 (inactive 2008-09-29). PMID 17906581.
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• Chiropractic at the Open Directory Project

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