Chiropractic/Draft

Most recent approved version: Chiropractic

Chiropractic is a complementary and alternative health care profession that aims to heal using manual therapies on the spine and extremities. While chiropractors treat all types of musculoskeletal problems, their defining theory is that they can affect body function by locating and correcting what they call subluxations of the spine. Subluxations are treated with "spinal adjustments" that are intended to help improve body posture and joint mobility. Chiropractors also treat some conditions that they believe originate with a subluxation, but which physicians, nurses, and other allied health science professionals consider to be wholly unrelated to disorders of the spine.

In the health sciences, subluxation always means that there is a physical dislocation such that the part is completely out of place. In chiropractic subluxations, this is almost never the case. Unless otherwise specified, the word 'subluxation' in this article uses the chiropractic definition.

Introduction

Chiropractic was founded in 1895 by Daniel David Palmer (DD Palmer), who practiced healing in the rural heartland of the United States without medical training, and (like many trained medical doctors of the time) without formal education in science. Once, while in conversation, he gave a friend a hearty slap on the back and both noted a sudden improvement in the man's hearing after a "pop" in his spine. From this, Palmer arrived at a theory of disease, and its treatment. Postulating that a misaligned spine might impair the flow of natural 'healing power' (or "Innate Intelligence") from mind to body, he named these theoretical misalignments "subluxations". Speculating that blockage of spiritual energy might allow 'dis-ease' or disharmony, and healing might occur of the block was removed, he developed methods of "cracking" the back. He promoted his methods of healing to be like watering a garden, the misaligned spinal joint was like a crimp in a hose that slows the flow of water: uncrimp the hose, the flow returns, and the garden will flourish. While the 'pinched garden hose theory' has mostly been abandoned, the metaphor is sometimes still used by chiropractors to explain the concept of subluxations to patients. Today, chiropractors use several types of manual therapies and spinal adjustments mostly to treat conditions such as low back pain, neck pain and headaches. Some no longer use the word subluxation to describe the spinal conditions that they treat, but most still think that the spine has a role in all health and disease.

Palmer's theories have never been accepted outside chiropractic, but some of his methods have been supported by large studies published in the health science literature. Chiropractic manipulation relieves back pain as well as conventional treatment with physical therapy, and patients tend to be more satisfied with chiropractic care (even though chiropractic care does not include the use of pain-relieving drugs),while the overall cost of care is similar. However, for general medical conditions, like allergy, there is no agreement that chiropractic is any more efficacious than placebo. Chiropractic treatment of adults (and especially children) for these general medical conditions has been contentious both within the profession and between chiropractic and conventional medicine.

There are about 70,000 chiropractors in the USA, 5000 in Canada, 2500 in Australia, 1300 in the UK, and smaller numbers in about 50 other countries. Some chiropractors specialize in musculoskeletal problems or sports injuries, others combine chiropractic with physiotherapy, nutrition, exercise, or other complementary and alternative (CAM) methods. Chiropractors do not prescribe drugs or perform surgery, and do not recommend 'over-the-counter' medications. They believe that this is the province of conventional medicine, while their role is to pursue drug-free alternative treatments in an effort to avoid the need for surgery.

Chiropractic in practice

Chiropractors consider that disc degeneration is a result of chronic subluxation (in the chiropractic sense). Osteoarthrits is one form of arthritis that chiropractors work to prevent or improve. The left image shows two normal vertebrae and the disc in between. The right image shows lost disc spacing and degenerative disease of a disc and vertebrae.

Most patients who visit a chiropractor for the first time do so for low back pain, neck pain and headaches. Chiropractors will take note of the patient's chief complaint as well as a survey for symptoms arising from other body systems. A thorough patient and family history, review of organ systems and a physical examination are part of a complete evaluation by a chiropractor, but these are done in a chiropractic manner and are not the same as a medical history and physical as done by a physician. Posture and spinal function are evaluated, and laboratory tests to evaluate blood and urine may be requested. Chiropractors may also perform X-rays, order MRI, CT scans, or other imaging studies, or might refer to physicians for tests. When examining the patient, the chiropractor palpates the spine to feel the contour of the deep muscles that run between the vertebrae (the multifidus and erector spinae muscles) and assesses their symmetry and flexibility. If an area feels tight, hard or bony, the chiropractor checks to see if the vertebral joint below it moves properly. If it is stiff or unusually mobile, the area is identified as a 'trouble spot' or subluxation, which might reflect a new or an old injury, or a postural abnormality. Often, the patient identifies that same spot by pain felt during the palpation. The chiropractor is likely to suspect that this joint might cause problems if neglected, and will adjust it in an effort to prevent these and alleviate present symptoms.

After making a diagnosis, and discussing it with the patient,the chiropracter obtains informed consent, and treats according to guidelines set by national and local consensus panels, such as the Mercy Guidelines. In accordance with these guidelines, no ethical chiropractor will ever claim to be able to cure cancer, metabolic disorders such as diabetes, or infectious diseases, although they might treat patients who have these conditions, to relieve pain or provide a feeling of well-being.

Manipulation can cause a rapid release of gas from the joint fluid. See animation.

The most common adjustment involves manipulating the spine with a fast but gentle thrust that usually causes a 'popping' sound. The sound is thought to be from a form of cavitation in 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, gases that are naturally dissolved in all bodily fluids form a bubble (as when gas is released from a carbonated drink when it is opened), creating a rapid vibration, and a sound is heard. The effects of the bubble within the joint continue for hours while it is slowly reabsorbed. During this time, the joint is able to move more freely and stimulates the nerves surrounding the joint capsule.

Other techniques for analyzing and adjusting subluxations were developed in the last century, and not all include cavitation-type spinal manipulation. The 'Activator Technique' uses a hand-held percussion instrument, the 'Thompson Technique' uses a special table with sections that drop, and the Cox Flexion Distraction technique uses a table that tractions the lower back and is specifically for treating lumbar disc herniations and facet-related injuries.

Subluxation and Innate Intelligence

Modern chiropractors are still committed to the healing art begun by Palmer, but some feel that the 19th century concepts of Innate Intelligence and subluxation are too vague to remain useful. In 1998, Lon Morgan wrote that the concept of Innate Intelligence originates in "borrowed mystical and occult practices of a bygone era"; he described it as untestable and unverifiable, and harmful to progress within the profession. Others argue that these concepts remain useful as metaphors for physiological processes that are poorly understood, and because they help them to see their patients as more than the 'sum of their parts'. They believe that trying to explain all the complex processes that combine to make a human being function in terms of biology misses things that are important for understanding what makes him or her healthy. Meridel Gatterman said of 'subluxation', "To some it has become the holy word; to others, an albatross to be discarded ... Why then do we persist in using the term when ... the concept that once helped to hold a young profession together now divides it? ...The obvious answer is: The concept of subluxation is central to chiropractic." Anthony Rosner suggested that there is no reason to discard the concept of subluxation if it is treated as a 'provisional' concept that will undergo continuous modification.

Chiropractic approach to healthcare

ACC Chiropractic/Medical Management Model

Contemporary chiropractors take diverse approaches to patient care, ranging from a "holistic" and naturopathic approach to being integrated as a musculoskletal specialist in the conventional medical model. These differences are reflected in different professional associations.

• Traditional Straights hold that 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. 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 and offer general health care to both adults and children. Traditional straights teach their patients that vaccinations in childhood are dangerous, and are sceptical of pharmacology and medicine.
• 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 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 prefer to integrate their skills into contemporary medicine and do not subscribe to Palmer philosophy or vertebral subluxation theory, and tend not to use CAM methods.

Chiropractic education, licensing and regulation

Palmer Chiropractic College with a bust of DD Palmer (center)

When chiropractic began, licensing for the American health professions was just beginning, and most physicians learned their trades 'on the job', much as an apprentice would learn a trade today. DD Palmer began teaching his technique in three-month courses; and no secondary school education, let alone college attendance, was needed to enroll. This was not very different from some schools of medicine of that time, many of which were taught by single individuals and were open to any student who could meet the tuition payment.

In the 1920's and 30's, chiropractic developed educational standards that raised the quality of their schools, and over the years, these became progressively more stringent. U.S. students today must meet a minimum prerequisite course of study of 90 semester hours from an accredited college or university, including biology, psychology, and physics. Chiropractic programs require at least 4,200 hours of instruction in subjects including physiology and anatomical studies, including 8 months of human dissection, and students undertake a research project in their third year. The final two years cover manipulation and spinal adjustment and give experience in physical and laboratory diagnosis, orthopedics, neurology, geriatrics, physiotherapy, and nutrition. After this, to qualify for licensure, graduates must pass four examinations from the National Board of Chiropractic Examiners and satisfy State-specific requirements.

There are now 17 chiropractic colleges in the USA, four in the UK, two in Canada and another 9 internationally. Chiropractic colleges also offer postdoctoral training leading to 'diplomate' status in particular specialties. In the USA, this training is overseen by the Council on Chiropractic Education. Each state has its own licensing board, overseen by a Federation of Chiropractic Licensing Boards, which handle any necessary disciplinary actions. Unlike medicine, in the USA, laws governing the practice of chiropractic vary from state to state and, as a result, procedures used by chiropractors vary as well.

In the UK, chiropractic is regulated by the General Chiropractic Council (GCC), a statutory body with regulatory powers established by an Act of Parliament in 1994 . The GCC is charged with maintaining standards and enforcing professional discipline, and it is illegal for anyone to represent themselves as a chiropractor in the UK unless they are registered with the GCC.

History

See Chiropractic History for a more detailed account

The dawning of the 19th century saw the decline of blood letting and leeches of heroic medicine and the rise of remedies in the form of family owned patent medicine and the nostrum trade. Some remedies were sold by doctors of medicine, but most were sold by lay people, often using dubious advertising claims. The addictive or toxic effects of many of these remedies, especially morphine and mercury-based cures, and the harsh laxatives and emetics, prompted the rise of the alternative remedies of homeopathy and eclectic medicine. These treatments were better tolerated and were usually at least no more ineffective. In the USA, licensing for medical professionals had all but vanished around the Civil War, leaving the profession open to anyone who declared themselves to be a physician. By 1885, purveyers of scientific medicine, herbalism, magnetism and leeches, lances, tinctures and patent medicines were all in competition, and, with no patent protection for new discoveries, claims among the healing professions proliferated. Neither patients nor many practitioners had much knowledge of either the causes of, or cures for, illnesses, and quack cures were becoming more common and were mostly unregulated.

DD Palmer opened his office of magnetic healing in Davenport, Iowa in 1886. Nine years later, on September 18, 1895, he treated a deaf janitor, Harvey Lillard. 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 claimed to have found a sore lump that indicated spinal misalignment, and corrected the misalignment; after which Lillard could then "hear the wheels of the horse-drawn carts" in the street below. Lillard's daughter related the incident somewhat differently. She reported that her father mentioned 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 a healing practice.

Palmer himself described the next phase: "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 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 become the Palmer School (now College) of Chiropractic. DD Palmer's first descriptions for chiropractic were very similar to Andrew Still's earlier principles of osteopathy: both described the body as a 'machine' whose parts could be manipulated to effect a drugless cure. However, Palmer stated that he concentrated on reducing 'heat' from friction of the misaligned parts, while Still claimed to enhance the flow of blood.

Medicine, osteopathy, and chiropractic; the three rivals of the late 19th century

In the late 19th century, there was increasing concern that the health professions, including medicine, osteopathy, homeopathy, and chiropractic, lacked quality controls, such as minimum standards for education and clinical experience. While some "medical schools" that conferred an MD degree demanded little more than payment of tuition in order to certify a graduate, others were fully-fledged portions of established universities. In 1899, a Davenport physician, Heinrich Matthey, began a campaign to change the law in Iowa to prevent "drugless healers", such as osteopaths and chiropractors from practicing there. 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 graduates did not need the same training as medicine, as they did not prescribe drugs. Nevertheless, he was arrested and convicted for claiming that he could cure disease when he had no license to practise either medicine or osteopathy.

The American Medical Association (AMA) had been formed in 1847 to raise standards in medical education. After intense political pressure, medical boards were formed in almost every state, requiring licentiates to have a diploma from an AMA-approved college. By 1906, the AMA had drawn up a list of schools whose standards they considered to be unacceptable, and in 1910, as a result of the Flexner Report, hundreds of private medical and homeopathic schools were closed. These schools all had a curriculum considered to be substandard in scholarship in science. Medicine in the USA had entered a new era medical education was now primarily university based, and all schools set high admission standards. At the same time, licensing requirements for medical practice were strengthened and public health standards were set by physicians with advanced knowledge of bacteriology and laboratory science.

By the early 20th century, several states in the USA had established Boards of Health, some of which became involved in the regulation of health professionals. Several had high requirements for acceptance of students, and only certified MDs that could pass a demanding course of study that included human anatomy with cadaver dissection, Latin, and laboratory science. Palmer's chiropractic school was not university based, had low requirements for admission and offered little or no training in science.

After his arrest and conviction, Palmer closed and sold his school to his son BJ Palmer, who eventually subsequently was instrumental in the creation of the 'Universal Chiropractic Association' to provide legal defense for its members; its first case (of more than 15000 over 30 years) was in 1907, when Shegataro Morikubo DC of Wisconsin was charged with unlicensed practice of osteopathy. Attorney Tom Morris 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 shaped the development of chiropractic, which then marketed itself as a science, an art and a philosophy.

The American Medical Association's plans to eliminate chiropractic

For the next fifty years, organized medicine and academic medicine (the teaching and research faculty of the medical schools and university associated residency training programs) fought to keep a high standard of education and stringent criteria for practice within medicine. There was a sense that the future of the healing arts lay in science, and that scientific research might eventually conquer disease. Such hopes were strengthened by successes like the polio vaccine. While science was embraced, health remedies that lay outside of medicine were viewed as anachronistic "quackery" by the AMA. Although many clinical practices in medicine were based on empiric teaching rather than science, other empiric practices, like chiropractic, were disdained by many MDs . Additionally, there was some element of business rivalry between Medicine and what would come to be called alternative medicine, including chiropractic.

In 1963, the AMA formed a 'Committee on Quackery' that began a campaign to eliminate chiropractic, and set out to forbid its members from working with chiropractors on the basis of the AMA 'Principles of Medical Ethics'. Until 1980, these 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." As a result, in 1976, a Chicago chiropractor, Chester Wilk, and three others brought an antitrust suit against the AMA (see Wilk et al vs AMA et al.). In 1987, the Federal Appeals Court found the AMA guilty of conspiracy and restraint of trade. The AMA lost its appeal to the Supreme Court.

In her judgement, (ref) Judge Susan Getzendanner strongly criticised the AMA campaign, saying that the AMA had taken: "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." [13] She described the Committee on Quackery as essentially comprising doctors who had volunteered to serve because of their belief that chiropractic should be eliminated. Evidence was given to the Committee that chiropractic was more effective than the medical profession for certain problems, and that some medical physicians believed that chiropractors were better trained to deal with musculoskeletal problems than most medical physicians. However, the Committee did not follow up any of these studies or opinions. At the trial, most witnesses who appeared on behalf of the AMA agreed that some chiropractic treatment is efficacious. The court recognized that some chiropractic practices lacked a scientific basis, and that the AMA had a duty to show its concern for patients, but was not persuaded that this could not have been achieved in a way that was less restrictive of competition, for instance by public education campaigns.

In 1992, the AMA declared "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." This opened doors for members of the AMA to collaborate more openly with chiropractors in patient care as well as allowing better communication between the two professions, both within their learning institutions and for general research purposes.

Efficacy

In 1978, the Journal of Manipulative & Physiological Therapeutics (JMPT) was launched. Keating dates the birth of chiropractic as a science to a 1983 commentary in the Journal which describes the power of this journal to enable faculty at chiropractic schools to challenge the status quo, to publicly address issues related to research, training and skepticism, and to raise professional standards. By 1997, there were 14 peer-reviewed journals that specifically encourage chiropractic research, with the JMPT indexed in Index Medicus. With some federal funding, the claims of chiropractic began to be tested by large, objective clinical trials, providing a stronger evidence base for assessing these claims.

In 1997, an AMA report discussing chiropractic stated that "manipulation has ... 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, found that it had higher patient satisfaction levels, and said that "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." Since then, several large randomized studies have confirmed that not only is manual therapy at least as good as these conventional medical treatments of back pain, but that patients tend to be more satisfied with chiropractic care and that the overall cost is similar. Evidence of efficacy also comes from studies of patient satisfaction and workers' compensation cases; these suggest that most patients are very satisfied 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 physicians.

There have been trials of chiropractic claims for other health benefits, but mostly these have been small and flawed in various ways, and so it is not possible to draw any definitive conclusions from them. A 2005 editorial in the JMPT proposed that more involvement in the Cochrane Collaboration, which co-ordinates evidence-based analysis of health interventions, would be a way for chiropractic to gain better acceptance within medicine.

Safety

As with all interventions, there are risks. In spinal manipulation risks include: vertebrobasilar accidents, strokes, spinal disc herniation, vertebral fracture, and cauda equina syndrome. A 1996 study showed that the greatest risk is from manipulation of the first two vertebra of the spine, particularly passive rotation of the neck. Serious complications have been reported to be 1 in a million manipulations or fewer, but there is uncertainty about how these are recorded; a survey in 2002 of neurologists in the UK concluded that underreporting rendered estimates 'nonsensical'.

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, general practitioners, osteopaths, physiotherapists, a wife, a blind masseur, and an Indian barber had all been incorrectly attributed to chiropractors.

Critical views of Chiropractic

See Critical views of Chiropractic for a detailed account.

In its 100-year history, chiropractic has been under frequent attack from osteopathy, from 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 chiropractors. Although the profession has survived, and indeed thrived, the profession itself has voiced many of these same criticisms in a move to reform chiropractic from within. Nevertheless, at present, although many family physicians in the USA are willing to refer their patients to chiropractors, chiropractic is not integrated into hospital-based medicine. Many hospital-based physicians and academic scientists remain skeptical about the scientific foundations of chiropractic as well as its efficacy for conditions other than some directly associated with the spine, and are concerned that some chiropractors may not always recognise serious medical conditions that affect some of their patients. They therefore remain concerned that some patients who choose to be treated by chiropractors may be denying themselves the benefits of more efficacious treatment by conventional medicine. They are also concerned at occasional examples of abuses by individual chiropractors.

See also

• Chiropractic History
• Spinal adjustment
• Spinal manipulation
• Vertebral subluxation
• Chiropractic education
• Council on Chiropractic Education
• Federation of Chiropractic Licensing Boards
• Critical views of Chiropractic

External links

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