Chiropractic

Template:Alternative medical systems Chiropractic is a complementary and alternative health care profession that focuses on treating and preventing mechanical disorders of the musculoskeletal system in an effort to improve body posture and motion with the intent of improving overall health and function. Chiropractors emphasize their belief that a patient's health is compromised when spinal injuries, which some call vertebral subluxations, interfere with the body's ability to maintain adequate posture and joint function. They assert that, when neglected, these conditions can lead to accelerated degenerative changes such as arthritis and, by interfering with the nervous system, result in many different conditions of poor health. In conventional medicine, the term subluxation is not be used until these joints show a more obvious pattern of pain and misalignment.

Chiropractors treat patients with various manual and mechanical methods called spinal adjustments. The primary method used by most chiropractors involves manipulation of the spine: a high velocity, low amplitude thrust that usually causes a 'popping' sound. The sound is thought to be from a form of cavitation within the fluid filled diarthrodial joints. During a manipulation, the force applied separates the surfaces of the encapsulated joint cavity creating a relative vacuum within the joint space. In this environment, the naturally dissolved gases found in all bodily fluids turn into a bubble, creating a rapid vibration, and a sound is heard. The effects of this bubble will remain within the joint for hours while it is slowly reabsorbed. This procedure is performed by osteopaths and physiotherapists as well as by chiropractors; despite the different treatment goals, the actual procedures performed are very similar. Chiropractors aim to apply a precise adjustment to a specific affected vertebra, as distinct from the more generalized maneuvers of the early osteopaths.

Some chiropractors specialize in musculoskeletal problems or sports injuries, others combine chiropractic with physiotherapy, nutrition, or exercise. Some also use other complementary and alternative methods. However, chiropractors do not prescribe drugs; they believe that this is the province of conventional medicine, while their role is to pursue drug-free alternative treatments, but some are trained in minor surgery. When indicated, the doctor of chiropractic (DC) consults with, or refers to, other health care providers.

Chiropractic was founded in 1895 by Daniel David Palmer, who proposed that all health problems could be treated using "adjustments" to correct "subluxations." He proposed that subluxations were misaligned vertebrae which compressed spinal nerves, interfering with the transmission of what he called Innate intelligence. As a result, the human body would experience 'dis-ease' or disharmony. He compared this 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 to their patients. Most chiropractors still believe that the vertebral subluxation complex is important in most if not all diseases..

Today, there are 17 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 UK, and smaller numbers in about 50 other countries. In the USA and Canada, licensed practitioners of chiropractic are usually referred to as 'chiropractors', 'doctors of chiropractic',(DC) or 'chiropractic physicians'. There are several specialty certifications awarded.Accredited Programs

Chiropractic vertebral subluxation

The human spine is a column of 24 bony vertebrae, each interconnected by an intricate maze of muscles, ligaments and connective tissue to the vertebra above and the vertebra below. The result is a remarkably mobile structure that allows for amazing combinations of movement while protecting the spinal cord, a delicate bundle of spinal nerves that is the pathway of communication between the brain and the body. The strength of the athlete and the agility of the gymnast are testaments of the durability and resilience that is built into its design. Today, all chiropractors are trained to detect alterations in position and/or function between these segments, aiming to identify areas of the spine that are at risk of injury or degeneration as a result of this abnormal position or motion. They use terms such as subluxation, vertebral subluxation, and vertebral subluxation complex (VSC) to describe these. Some chiropractors believe that even tiny changes in position or function can alter the information transmitted between the brain and body, and can result in ill health, and in the worst cases, reduced resistance to disease. They work to improve spinal alignment and function in an effort to maximize performance and health.

The same word subluxation is used by both physicians and chiropractors, but with entirely different meanings. The chiropractor uses this term to refer to a hypothetical phenomenon that cannot always be directly observed, but whose existence is inferred from the symptoms of the patient. Because chiropractors often use very simple 'holistic' explanations for their patients, referring to vague 'forces' that are not described in current biology, physicians are often skeptical. A physician only refers to a body part as 'having a subluxation' if it can be objectively demonstrated that it is out of its functional position. Thus, when a radiologist reads a spinal x-ray as 'showing subluxation of a vertebra', he or she always means that a bone in the spinal column is visibly displaced on the image; for example, a pediatrician calls the elbow joint of a child as subluxed in the condition 'nursemaid’s elbow' only if the lower arm bones are pulled out of the joint capsule and the child cannot move the forearm. A chiropractor on the other hand may diagnose a subluxation by manual palpation - recognising that when specific pressure is applied to one joint in isolation, it didn't move or have an 'elastic feel' like those above and below it. Whether such subtle changes are of any functional significance is at the heart of the scientific controversy about chiropractic. The differing use of the term subluxation has contributed to the hostility of much of organized medicine towards chiropractic. A patient may feel benefit from a chiropractor's treatment of his back pain, but when he next sees his physician, and announces that the chiropracter 'fixed my subluxation', that physician may view the chiropracter as a fraud, rather than a healing arts practitioner who may be onto something useful - after all, she'd reviewed the scan of the patients back and knows that there was no subluxation!

For DD Palmer, 'subluxation' began as a simple observation of what he considered 'cause and effect'; this was then slowly and methodically developed into an idea with both a metaphysical and a philosophical meaning. Because half of the nervous system is sensory and the other half motor, he postulated that living things had an Innate intelligence, a 'spiritual energy' or 'life force' that received sensory information and made a decision as to what the motor nerves should convey. He thought that subluxations interfered with this, and that by fixing them, all diseases could be treated. By invoking the concept of a healing energy, he added a level of untestability to his idea. He qualified this by noting that knowledge of Innate Intelligence was not essential to the competent practice of chiropractic, so long as they were able to locate and adjust subluxations.

The idea that all diseases were the result of a subluxation was consistent with the common thinking of the day, that there was one cause for disease, but there are deep divisions within the profession about the wisdom of retaining these terms. In 1998, Lon Morgan, a reform chiropractor, wrote that Innate Intelligence originates in "borrowed mystical and occult practices of a bygone era"; he described it as untestable and unverifiable, and as a holdover from a time when insufficient scientific understanding existed to explain human physiological processes, clearly religious in nature, and harmful to normal scientific activity.

According to Meridel Gatterman DC, "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." Anthony Rosner of the Foundation for Chiropractic Education and Research suggests that there is no reason to discard the concept completely, if it is treated as a 'provisional' concept that will undergo continuous and extensive modification over time.

Perhaps the lack of scientific recognition of the chiropracter’s meaning of subluxation is due to lack of a focused study by biologists. Arguments have been made that the theoretical basis of the maneuvers in chiropractic deserve more scientific investigation, but, with few exceptions, chiropractors are not trained in science or in formal research methods.

Chiropractic approach to healthcare

"For every chiropractor, there is an equal and opposite chiropractor"

The traditional, 'medical' or 'allopathic' approach to health care regards disease as usually the result of some external influence, such as a toxin, parasite, allergen, or infectious agent: the solution is to counter that influence (e.g. using an antibiotic for a bacterial infection). By contrast, chiropractic involves a naturopathic approach, believing that lowered 'host resistance' is necessary for disease to occur, so the answer is to strengthen the host. Contemporary chiropractors take several different approaches to patient care. These differences are reflected in different professional associations, though most DCs do not belong to any association.

• Traditional Straights accept DD Palmer's view that vertebral subluxation is a risk factor for most diseases. They do not try to diagnose complaints, which they consider to be "secondary effects"; instead, they screen patients for "red flags" of serious disease. This has been contentious, as accreditation standards require that differential diagnosis is taught in all chiropractic programs, and several chiropractic licensing boards require that patient complaints are diagnosed before they receive care. Many traditional straights belong to the International Chiropractors Association.
• Mixers use more diverse diagnostic and treatment approaches, including naturopathic remedies and physical therapy devices. Many belong to the American Chiropractic Association, and all the major groups in Europe are part of the European Chiropractors Union.
• Objective Straights focus on correcting vertebral subluxations. They typically do not diagnose patient complaints, or refer to other professionals, but they encourage their patients to consult 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". Many belong to the Federation of Straight Chiropractic Organizations and the World Chiropractic Alliance.
• Reform chiropractors, also a minority, are mostly mixers who use manipulation to treat osteoarthritis and other musculoskeletal conditions. They do not subscribe to Palmer philosophy or to vertebral subluxation theory. They are similar in practice to mixers, although they tend not to use complementary and alternative methods.

History

(see also article on Daniel David Palmer

In 1885, as health care emerged from the era of heroic medicine, scientific medicine, herbalism, magnetism and leeches, lances, tinctures and patent medicines were all in competition, and neither patients nor many practitioners had much knowledge of either the causes of, or cures for, illnesses. Drugs, medicines and quack cures were becoming more common and were mostly unregulated. Concerned about what he saw as the abusive nature of drugging, Andrew Taylor Still ventured into 'magnetic healing' and bonesetting in 1875. He opened the American School of Osteopathy in Missouri in 1892.

Daniel David Palmer (DD Palmer), a teacher and grocer turned magnetic healer, opened his office of magnetic healing in Davenport, Iowa in 1886. Nine years later, on September 18, 1895, he gave the first chiropractic adjustment to a deaf janitor, Harvey Lillard. Palmer and Lillard subsequently gave different accounts of this first experiment with spinal manipulation. According to Palmer, Lillard had told him that, while working in a cramped area seventeen years earlier, he had felt a 'pop' in his back and had since been virtually deaf. Palmer found a sore lump that indicated spinal misalignment, he corrected the misalignment, after which Lillard could then "hear the wheels of the horse-drawn carts" in the street below. However, Lillard's daughter, Valdeenia Lillard Simons, said that her father told her that he was joking with a friend in the hall outside Palmer's office when Palmer joined them. As Lillard reached the punchline, Palmer, laughing heartily, slapped Lillard on the back with the heavy book he had been reading. A few days later, Lillard's hearing seemed better, and Palmer decided to explore manipulation as an expansion of his magnetic healing practice. Simons said "the compact was that if they can make [something of] it, then they both would share. But, it didn't happen."

After the event, 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, the Reverend Samuel Weed, to help him name his discovery; he suggested combining the words cheiros and praktikos (meaning 'done by hand'). In 1896, DD Palmer added a school to his magnetic healing infirmary and began to teach others the new "chiropractic"; it would be become the Palmer School (now College) of Chiropractic. Among the first graduates were his son, BJ Palmer, Solon Langworthy, John Howard, and Shegataro Morikubo. Langworthy moved to Cedar Rapids, Iowa and opened in 1903, the 'American School of Chiropractic & Nature Cure', combining chiropractic with osteopathy and other natural cures from the newly developing field of naturapathy. DD Palmer, who was not interested in mixing chiropractic with other cures, refused the offer of a partnership.

Changing political and healthcare environment

The country needs fewer and better doctors; ...the way to get them better is to produce fewer. Abraham Flexner[7]

The early 19th century saw the rise of patent medicine and the nostrum trade. Some remedies were sold by doctors of medicine, but most were sold by lay people, often using very dubious advertising claims. The addictive or toxic effects of some remedies, especially morphine and mercury-based cures (quicksilver or quacksilber in German), prompted the rise of the alternative remedies of homeopathy and eclectic medicine, that were less dangerous and probably no more ineffective in most cases. In the USA, licensing for healthcare professionals had all but vanished around the Civil War, leaving the profession open to anyone who declared themselves to be a physician; the market alone determined who would succeed and who would fail. Medical schools were plentiful, inexpensive and mostly privately owned, leading to an overabundance of practitioners. In 1847, the American Medical Association (AMA) was formed and established higher standards for medical education, limiting the number of new practitioners.

In 1849, the AMA established a board to analyze quack remedies and to educate the public about their dangers. By the turn of the century, the AMA were represented in Washington by a Committee on National Legislation, and after intense political pressure, medical boards were formed in almost every state requiring licentiates to provide a diploma from an AMA-approved college. By 1906, the AMA’s Council on Medical Education had drawn up a list of unacceptable schools, and in 1910, as a result of the Flexner Report financed by the Carnegie Foundation, hundreds of private medical and homeopathic schools were closed. The AMA had created the nonprofit, federally subsidized university hospital setting as the new teaching facility of the medical profession, with Johns Hopkins as the model school, effectively gaining control of federal healthcare research and student aid.

Medicine, osteopathy, and chiropractic; the three rivals

With no patent protection for new discoveries, claims for the drugless healing professions proliferated. In 1896, DD Palmer's first descriptions for chiropractic were very similar to Andrew Still's principles of osteopathy from a decade earlier: both described the body as a 'machine' whose parts could be manipulated to effect a drugless cure, and both claimed to affect the blood and nerves and promote health. However, Palmer stated that he concentrated on reducing 'heat' from friction of the misaligned parts, while Still claimed to enhance the flow of blood. As news spread about the new doctor of drugless healing in Iowa, osteopaths began to campaign to protect osteopathy.

In September 1899, a Davenport MD, Heinrich Matthey, began a campaign against drugless healers in Iowa. He sought to change the state law (which referred to 'the healing arts') to prevent drugless healers from practicing in the state, arguing that health education could not be entrusted to anyone but doctors of medicine. Osteopathic schools responded by developing a program of college inspection and accreditation, but 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. Nevertheless, in 1901, he was charged with misrepresenting to a student a course in chiropractic which was not a real science. He persisted in his opposition to licensing, arguing for freedom of choice, and was arrested twice more by 1906. Although he denied that what he practiced was medicine, he was convicted for claiming that he could cure disease when he had no license to practise either medicine or osteopathy.

At the 'American School of Chiropractic & Nature Cure', Solon Langworthy narrowed the scope of chiropractic to the treatment of the spine and nerve 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' (intervertebral foramina) and interrupted the nerve energy. In 1906, he published the first book on chiropractic, Modernized Chiropractic - Special Philosophy; A Distinct System. DD Palmer objected vigorously about the mixing of chiropractic, and persuaded the Governor of Minnesota to veto legislation that would have allowed Langworthy's students to practice there. But he did accept some of Langworthy's concepts: in about 1904, he introduced the concept of Innate Intelligence, an 'intelligent entity' that directed all the functions of the body, and which used the nervous system to exert its influence.

BJ Palmer re-develops chiropractic

After DD Palmer's conviction, he turned his interests in the 'Palmer School of Chiropractic' (the 'Fountainhead') over to his son, BJ Palmer and wife Mabel. The conviction of DD Palmer and a previous charge against BJ Palmer prompted the creation of the 'Universal Chiropractic Association'; its initial purpose was to provide for legal defense of members should they get arrested, and its first case was in 1907, when Shegataro Morikubo DC of Wisconsin was charged with unlicensed practice of osteopathy. In an ironic twist, using mixer Langworthy's book Modernized Chiropractic, attorney Tom Moore legally differentiated chiropractic from osteopathy by the differences in the philosophy of chiropractic's 'supremacy of the nerve' and osteopathy's 'supremacy of the artery'. Morikubo was freed, and the victory reshaped the development of chiropractic, which then marketed itself as a science, an art and a philosophy. In the next 15 years, 30 more chiropractic schools opened, including John Howard's National School of Chiropractic (now the National University of Health Sciences) that moved to Chicago, Illinois. Each school developed its own identity, while BJ Palmer became the 'Philosopher of Chiropractic'. Of the more than 15000 prosecutions of chiropractors that were fought in the first 30 years, BJ Palmer later said:

"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."

BJ Palmer's influence over the next few years further divided mixers (who mixed chiropractic with other cures) from straights (who practiced chiropractic alone). While he continued at the Palmer school, his father develop his ideas from Oregon. In 1910, DD Palmer proposed that: "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 challenged his son's methods and philosophy, and tried to regain control of chiropractic. He repudiated his earlier theory that vertebral subluxations caused pinched nerves in favor of subluxations causing altered "nerve vibration", and declared that "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 battle for licensure in California, he wrote of his philosophy for chiropractic, and hinted at a plan for its legal defense:

"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."

Straight vs Mixer

State laws to regulate and protect chiropractic practice were eventually introduced in all states in the USA, but it was a hard-fought struggle. Medical Examining Boards tried to keep all healthcare practices under their control, and disagreement between DC's complicated the process. Initially, the UCA opposed state regulation altogether, fearing that it would lead to allopathic control of the profession. The UCA eventually conceded, but BJ Palmer continued to argue that examining boards should be composed exclusively of chiropractors (not mixers), and that the educational standards to be adhered should be the same as those of the Palmer School. In 1922, a 'model bill' was drafted to present to all states that did not yet have a law. They embarked on a process of 'cleaning house' of mixers, warning state associations to purge their mixing members or face competition from a new 'straight' association.

In response, mixers founded the American Chiropractic Association. Its growth was initially stunted by its resolution to recognize physiotherapy and other modalities as related to chiropractic, but in 1924, a disagreement within the UCA turned the tide. BJ Palmer was still trying to purge mixers from chiropractic, and he saw a new invention by Dossa D. Evans, the Neurocalometer, as the answer to straight chiropractic's legal and financial problems. As the owner of the patent on the Neurocalometer, he planned to limit it to 5000, and lease them only to graduates of the Palmer related schools who were members of the UCA. He then claimed that the Neurocalometer was the only way to accurately locate subluxations, preventing over 20,000 mixers from being able to defend their method of practice.

There was uproar among DC's, and even Tom Moore, BJ Palmer's old ally and president of the UCA, displayed his dismay by resigning. BJ Palmer resigned as treasurer, ending his relationship with the UCA, and moved on to form the 'Chiropractic Health Bureau' (today's ICA), along with his staunchest supporters. In 1930, the ACA and UCA combined to form the 'National Chiropractic Association', and made John J Nugent responsible for raising educational standards; his zeal earned him the nickname 'Chiropractic's Abraham Flexnor' from admirers and 'Chiropractic's Anti-christ' from adversaries. The CES became today's Council on Chiropractic Education, chiropractic's accrediting body. [8]

The movement toward scientific reform

By the late 1950s, healthcare in the USA had been transformed: the discovery of penicillin and development of the polio vaccine was restoring hope to millions, and the homeopathic physician had all but vanished as a result of antiquackery efforts of the AMA. BJ Palmer reduced the adjustment to 'Hole In One' - the adjustment of only the atlas, while mixers continued to add and refine new techniques to find and reduce subluxations. Osteopathy in the USA developed in parallel to medicine and stopped relying on spinal manipulation to treat illness. A similar reform movement began within chiropractic: shortly after the death of BJ Palmer in 1961, a second generation chiropractor, Samuel Homola proposed that chiropractic should focus on conservative care of musculoskeletal conditions. "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's membership in the ACA was not renewed, and his views were rejected by both straight and mixer associations.

In 1975, the National Institutes of Health brought chiropractors, osteopaths, MDs and scientists together in a conference to develop strategies to study the effects of spinal manipulation. In 1978, the Journal of Manipulative & Physiological Therapeutics (JMPT) was launched, and in 1981 was included in the National Library of Medicine's Index Medicus. Keating dates the birth of chiropractic as a science to a 1983 commentary in the Journal, in which Kenneth DeBoer, an instructor at Palmer College, revealed the power of a scholarly journal to empower faculty at the chiropractic schools. DeBoer's opinion piece demonstrated the faculty's authority to challenge the status quo, to publicly address issues related to research, training and skepticism at chiropractic colleges, and to change the cultural in chiropractic schools to increase research and professional standards. [9]

The American Medical Association plans to eliminate chiropractic

Main article: Wilk v. American Medical Association

In November 1963, the American Medical Association (AMA) formed a 'Committee on Quackery' to first contain, and then eliminate chiropractic. Doyl Taylor, Secretary of the Committee, outlined steps needed to ensure that Medicare should not cover chiropractic; to ensure that the U.S. Office of Education should not recognize a chiropractic accrediting agency; to encourage continued separation of the two national associations; and to get state medical societies to take the initiative in state legislatures in regard to legislation that might affect chiropractic. The AMA distributed propaganda to teachers and guidance counselors, eliminated 'Chiropractic' from the U.S Department of Labor's Health Careers Guidebook, and established guidelines for medical schools about the hazards of "the unscientific cult of chiropractic."

In 1966 the AMA adopted a position statement, declaring that "It is the position of the medical profession that chiropractic is an unscientific cult whose practitioners... constitute a hazard to healthcare in the United States." Until 1980, Principle 3 of the AMA Principles of Medical Ethics stated that "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." In 1975, an anonymous informant leaked internal documents about the AMA's crusade against chiropractic. To challenge the AMA, in 1976, a Chicago DC, Chester Wilk, and three other DCs brought an antitrust suit against the AMA and other medical associations - Wilk et al. vs AMA et al..

The judge in the Wilk case said that, according to the evidence given at the trial:

"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".

In 1987, 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 could not have been achieved in a manner less restrictive of competition, for instance by public education campaigns. The AMA lost its appeal to the Supreme Court, and had to allow its members to collaborate with chiropractors.

After the court victory, Wilk said, of the AMA

"They don't have to love us, but they'll have to respect us and respect the law." [10]

In 1992, the AMA finally declared that "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." [11]

Efficacy

With relatively little federal funding, academic research in chiropractic has only recently become established in the USA. By 1997, there were 14 peer-reviewed journals in English that specifically encourage the publication of chiropractic research, but only one, The Journal of Manipulative and Physiological Therapeutics (JMPT), is indexed in Index Medicus[12].

There is wide agreement that, where applicable, an evidence based medicine framework should be used to assess the outcomes of medical interventions. Where there isn't enough good evidence, as is often the case, this does not imply that the treatment is ineffective, only that the case for a benefit of treatment has not been established. A 2005 editorial in JMPT proposed that involvement in the Cochrane Collaboration would be a way for chiropractic to gain more acceptance within medicine.

The first significant recognition of the appropriateness of spinal manipulation for low back pain was a meta-analysis by the RAND Corporation. This concluded that some forms of spinal manipulation were appropriate treatments for some types of lower back pain. RAND's studies were about spinal manipulation, not chiropractic specifically, and they dealt with appropriateness, which is a measure of net benefit and harm; the efficacy of chiropractic and other treatments were not explicitly compared. In 1997, an AMA report on a number of alternative therapies, said of chiropractic that "Manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints." In 1998, The Manga Report, funded by the Ontario Ministry of Health, accepted the efficacy and cost-effectiveness of chiropractic for low-back pain, and found that chiropractic care had higher patient satisfaction levels than conventional alternatives. It stated 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." There are no objective controlled trials with definitive conclusions for or against chiropractic claims of other health benefits.

In 1997, the historian Joseph Keating Jr said that, despite scientific data supporting the manipulation of patients with lower back pain, "the doubting, skeptical attitudes of science do not predominate in chiropractic education or among practitioners". He argued that "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, he wrote "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."

Evidence of efficacy also comes from studies of patient satisfaction, and from studies of workers' compensation cases. Such evidence suggests that patients have a relatively high degree of satisfaction with chiropractic treatment, and for example, patients who consult a chiropractor for back-related problems are likely to lose fewer days at work than patients with similar complaints who consult MDs.

Safety

As with all interventions, there are risks associated with spinal manipulation: these include vertebrobasilar accidents, strokes, spinal disc herniation, vertebral fracture, and cauda equina syndrome. A 1996 Danish study showed that the greatest risk is from manipulation of the first two vertebra of the cervical spine, particularly passive rotation of the neck. Serious complications are estimated to be just 1 in a million manipulations or fewer, but there is uncertainty about how these are recorded. The RAND study assumed that only 1 in 10 cases would have been reported, but Ernst surveyed neurologists in the UK for cases of serious neurological complication occurring within 24 hours of cervical spinal manipulation (not specifically by a chiropractor), and he concluded that underreporting was close to 100%, rendering estimates 'nonsensical'. There are also some concerns about using cervical manipulation for conditions for which it is not indicated. In 1996, Coulter et al surveyed 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 looking at more than 700 conditions, there was consensus in only 11% of those conditions that cervical manipulation or mobilization was appropriate.

Few studies of stroke and cervical manipulation take account of the differences between 'manipulation' and the 'chiropractic adjustment'. According to a report in the JMPT, manipulations administered by a Kung Fu practitioner, GPs, osteopaths, physiotherapists, a wife, a blind masseur, and an Indian barber had all been incorrectly attributed to chiropractors.

Critical views of Chiropractic

In its 100-year history, chiropractic has been under frequent attack, from its rival, osteopathy, from organised conventional medicine, from scientists critical of its scientific foundations, and recently from web-based critics of its advertising tactics, and of the extravagent claims and dubious practices of some individual chiropractors. Although the profession has survived, and indeed thrived, the profession itself has voiced many of these criticisms in a move to reform chiropractic from within. Examples include:

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

Samuel Homola DC, an 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 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. [13]

• Chiropractic Ethics: An Oxymoron?

JC Smith, a DC 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 Keating Jr, professor at the Los Angeles College of Chiropractic and 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, 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 McAndrews warns the chiropractic profession that 'scare tactic' advertising of subluxation philosophy damages the newly won respect within the AMA.

• Quackery in Chiropractic -

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

• Subluxation - The Silent Killer

A 2000 commentary by Ronald Carter, Past President of the 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 time for the "silent majority" 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 links

• Chiropractic Resource Organization
• Dynamic Chiropractic Online - ChiroWeb, Chiropractic news source
• National Center for Complementary and Alternative Medicine - National Institute of Health - Manipulative and Body-Based Practices