Chiropractic is a form of alternative medicine that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine, under the belief that these disorders affect general health via the nervous system. Many chiropractors reject being characterized as complementary and alternative medicine (CAM). It is a healthcare profession, and although chiropractors have many similarities to primary care providers, they are more similar to a medical specialty like dentistry or podiatry. The main chiropractic treatment technique involves manual therapy, especially manipulation of the spine, other joints, and soft tissues; treatment may also include exercises and health and lifestyle counseling. Traditional chiropractic assumes that a vertebral subluxation or spinal joint dysfunction interferes with the body's function and its innate intelligence. A large number of chiropractors want to separate themselves from the traditional vitalistic concept of innate intelligence.
Many studies of treatments used by chiropractors have been conducted, with conflicting results. Systematic reviews of this research have not found evidence that chiropractic manipulation is effective, with the possible exception of treatment for back pain. A critical evaluation found that collectively, spinal manipulation was ineffective for any condition. A Cochrane review found very low to moderate evidence that spinal manipulation therapy was any more effective than inert interventions, sham SMT or as an adjunct therapy for acute low back pain. Spinal manipulation may be cost-effective for sub-acute or chronic low back pain but the results for acute low back pain were insufficient. The efficacy and cost-effectiveness of maintenance chiropractic care are unknown. The evidence suggests that spinal manipulation therapy is safe but the rate of adverse events is unknown as there is under-reporting. It is frequently associated with mild to moderate adverse effects, with serious or fatal complications in rare cases. There is controversy surrounding the level of risk of stroke from cervical manipulation. It has been suggested that the relationship is causative, but this is disputed by many chiropractors, who believe the association between chiropractic therapy and vertebrobasilar artery stroke is unproven.
Chiropractic is well established in the U.S., Canada and Australia. It overlaps with other manual-therapy professions, including massage therapy, osteopathy, and physical therapy. Back and neck pain are the specialties of chiropractic but many chiropractors treat ailments other than musculoskeletal issues. Most who seek chiropractic care do so for low back pain.
D.D. Palmer founded chiropractic in the 1890s, and his son B.J. Palmer helped to expand it in the early 20th century. It has two main groups: "straights", now the minority, emphasize vitalism, innate intelligence and spinal adjustments, and consider vertebral subluxations to be the cause of all disease; "mixers", the majority, are more open to mainstream views and conventional medical techniques, such as exercise, massage, and ice therapy. Throughout its history, chiropractic has been controversial. For most of its existence it has been at odds with mainstream medicine, sustained by pseudoscientific ideas such as subluxation and innate intelligence that are not based on solid science. Despite the overwhelming evidence that vaccination is an effective public health intervention, among chiropractors there are significant disagreements over the subject, which has led to negative impacts on both public vaccination and mainstream acceptance of chiropractic. The American Medical Association called chiropractic an "unscientific cult" in 1966 and boycotted it until losing an antitrust case in 1987. 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 and health plans in the U.S., and evidence-based medicine has been used to review research studies and generate practice guidelines. The practice remains at a crossroads between science and ideological dogma.
- 1 Conceptual basis
- 2 Scope of practice
- 3 Treatments
- 4 Education, licensing, and regulation
- 5 Reception
- 6 History
- 7 Public health
- 8 Controversy
- 9 References
- 10 Further reading
- 11 External links
Chiropractic is a form of alternative medicine which focuses on manipulation of the musculoskeletal system, especially the spine. Its founder, D.D. Palmer, called it "a science of healing without drugs".
|The testable principle||The untestable metaphor|
|Chiropractic adjustment||Universal Intelligence|
|Restoration of structural integrity||Innate intelligence|
|Improvement of health status||Body physiology|
|— Operational definitions possible||— Origin of holism in chiropractic|
|— Lends itself to scientific inquiry||— Cannot be proven or disproven|
|Taken from Mootz & Phillips 1997|
Chiropractic's origins lie in the folk medicine of bonesetting, and as it evolved it incorporated vitalism, spiritual inspiration and rationalism. Its early philosophy was based on deduction from irrefutable doctrine 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 of the scientific method, and relies on deductions from vitalistic first principles rather than on the materialism of science. However, most practitioners tend to incorporate scientific research into chiropractic, 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. A 2008 commentary proposed that chiropractic actively divorce itself from the straight philosophy as part of a campaign to eliminate untestable dogma and engage in critical thinking and evidence-based research.
Although a wide diversity of ideas exist among chiropractors, they share the belief that the spine and health are related in a fundamental way, and that this relationship is mediated through the nervous system. Chiropractors examine the biomechanics, structure and function of the spine, along with its effects on the musculoskeletal and nervous systems and what they believe to be its role in health and disease. Some chiropactors say spinal manipulation can have an effect of a variety of ailments such as irritable bowel syndrome and asthma.
Chiropractic philosophy includes the following perspectives:
Holism assumes that health is affected by everything in an individual's environment; some sources also include a spiritual or existential dimension. In contrast, reductionism in chiropractic reduces causes and cures of health problems to a single factor, vertebral subluxation. 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. 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. 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.
Straights and mixers
|perspective attribute||potential belief endpoints|
|scope of practice:||narrow ("straight") ←||→ broad ("mixer")|
|diagnostic approach:||intuitive ←||→ analytical|
|philosophic orientation:||vitalistic ←||→ materialistic|
|scientific orientation:||descriptive ←||→ experimental|
|process orientation:||implicit ←||→ explicit|
|practice attitude:||doctor/model-centered ←||→ patient/situation-centered|
|professional integration:||separate and distinct ←||→ integrated into mainstream|
|Taken from Mootz & Phillips 1997|
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 many diseases. 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 into their practice style. Their philosophy and explanations are metaphysical in nature and they prefer to use traditional chiropractic lexicon terminology (i.e. perform spinal analysis, detect subluxation, correct with adjustment, etc.). They prefer to remain separate and distinct from mainstream health care. Although considered the minority group, "they have been able to transform their status as purists and heirs of the lineage into influence dramatically out of proportion to their numbers."
Mixer chiropractors "mix" diagnostic and treatment approaches from chiropractic, medical and/or osteopathic viewpoints and make up the majority of chiropractors. Unlike straight chiropractors, mixers believe subluxation is one of many causes of disease, and hence they tend to be open to mainstream medicine. Many of them incorporate mainstream medical diagnostics and employ conventional treatments including techniques of physical therapy such as exercise, stretching, massage, ice packs, electrical muscle stimulation, therapeutic ultrasound, and moist heat. Some mixers also use techniques from alternative medicine, including nutritional supplements, acupuncture, homeopathy, herbal remedies, and biofeedback.
Although mixers are the majority group, many of them retain belief in vertebral subluxation as shown in a 2003 survey of 1100 North American chiropractors, which 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%. A 2008 survey of 6000 American chiropractors demonstrated that most chiropractors seem to believe that a subluxation-based clinical approach may be of limited utility for addressing visceral disorders, and greatly favored non-subluxation-based clinical approaches for such conditions. The same survey showed that most chiropractors generally believed that the majority of their clinical approach for addressing musculoskeletal/biomechanical disorders such as back pain was based on 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. 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. This concept was later expanded upon by his son, B.J. Palmer, and was instrumental in providing the legal basis of differentiating chiropractic 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."
Vertebral subluxation, a core concept of traditional chiropractic, remains unsubstantiated and largely untested, and a debate about whether to keep it in the chiropractic paradigm has been ongoing for decades. 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. 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.
In 2005, the chiropractic 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. The 2008 book Trick or Treatment states "X-rays can reveal neither the subluxations nor the innate intelligence associated with chiropractic philosophy, because they do not exist." Attorney David Chapman-Smith, Secretary-General of the World Federation of Chiropractic, has stated that "Medical critics have asked how there can be a subluxation if it cannot be seen on x-ray. The answer is that the chiropractic subluxation is essentially a functional entity, not structural, and is therefore no more visible on static x-ray than a limp or headache or any other functional problem." The General Chiropractic Council, the statutory regulatory body for chiropractors in the United Kingdom, states that the chiropractic vertebral subluxation complex "is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease."
Scope of practice
Chiropractors emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery, with special emphasis on the spine. Back and neck pain are the specialties of chiropractic but many chiropractors treat ailments other than musculoskeletal issues. There is a range of opinions among chiropractors: some believed that treatment should be confined to the spine, or back and neck pain; others disagreed. For example, while one 2009 survey of American chiropractors had found that 73% classified themselves as "back pain/musculoskeletal specialists", the label "back and neck pain specialists" was regarded by 47% of them as a least desirable description in a 2005 international survey. Chiropractic combines aspects from mainstream and alternative medicine, and there is no agreement about how to define the profession: although chiropractors have many attributes of primary care providers, chiropractic has more of the attributes of a medical specialty like dentistry or podiatry. It has been proposed that chiropractors specialize in nonsurgical spine care, instead of attempting to also treat other problems, but the more expansive view of chiropractic is still widespread. Mainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be complementary and alternative medicine (CAM); and a 2008 study reported that 31% of surveyed chiropractors categorized chiropractic as CAM, 27% as integrated medicine, and 12% as mainstream medicine.
Chiropractic overlaps with several other forms of manual therapy, including massage therapy, osteopathy, physical therapy, and sports medicine. Chiropractic is autonomous from and competitive with mainstream medicine, and osteopathy outside the US remains primarily a manual medical system; physical therapists work alongside and cooperate with mainstream medicine, and osteopathic medicine in the U.S. has merged with the medical profession. Practitioners may distinguish these competing approaches through claims that, compared to other therapists, 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.
Chiropractic diagnosis may involve a range of methods including skeletal imaging, observational and tactile assessments, and orthopedic and neurological evaluation. A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider. 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 advice.
Chiropractors are not normally licensed to write medical prescriptions or perform major surgery in the United States, (although New Mexico has become the first US state to allow "advanced practice" trained chiropractors to prescribe certain medications.). In the US, their scope of practice varies by state, based on inconsistent views of chiropractic care: some states, such as Iowa, broadly allow treatment of "human ailments"; some, such as Delaware, use vague concepts such as "transition of nerve energy" to define scope of practice; others, such as New Jersey, specify a severely narrowed scope. US states also differ over whether chiropractors may conduct laboratory tests or diagnostic procedures, dispense dietary supplements, or use other therapies such as homeopathy and acupuncture; in Oregon they can become certified to perform minor surgery and to deliver children via natural childbirth. A 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for over-the-counter drugs. A 2010 survey found 72% of Switzerland chiropractors judged the current allowance in Switzerland to prescribing nonprescription medication as an advantage for chiropractic treatment.
A related field, veterinary chiropractic, applies manual therapies to animals and is recognized in a few US states, but is not recognized by the American Chiropractic Association as being chiropractic. It remains controversial within certain segments of the veterinary, and chiropractic profession.
No single profession "owns" spinal manipulation and there is little consensus as to which profession should administer SM, raising concerns by chiropractors that other 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. Two U.S. states (Washington and Arkansas) prohibit physical therapists from performing SM, some states allow them to do it only if they have completed advanced training in SM, 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.
Spinal manipulation, which chiropractors call "spinal adjustment" or "chiropractic adjustment", is the most common treatment used in chiropractic care. 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. High-velocity, low-amplitude spinal manipulation (HVLA-SM) thrusts have physiological effects that signal neural discharge from paraspinal muscle tissues, depending on duration and amplitude of the thrust are factors of the degree in paraspinal muscle spindles activation. Clinical skill in employing HVLA-SM thrusts depends on the ability of the practitioner to handle the duration and magnitude of the load. 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.
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 10% of patients of licensed U.S. chiropractors in a 2003 survey: Diversified technique (full-spine manipulation, employing various techniques), extremity adjusting, Activator technique (which uses a spring-loaded tool to deliver precise adjustments to the spine), Thompson Technique (which relies on a drop table and detailed procedural protocols), Gonstead (which emphasizes evaluating the spine along with specific adjustment that avoids rotational vectors), Cox/flexion-distraction (a gentle, low-force adjusting procedure which mixes chiropractic 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, Applied Kinesiology (which emphasises "muscle testing" as a diagnostic tool), and cranial. 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.
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 one-third 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.
A 2010 study describing Belgium chiropractors and their patients found chiropractors in Belgium mostly focus on neuromusculoskeletal complaints in adult patients, with emphasis on the spine. The diversified technique is the most often applied technique at 93%, followed by the Activator mechanical-assisted technique at 41%. A 2009 study assessing chiropractic students giving or receiving spinal manipulations while attending a U.S. chiropractic college found Diversified, Gonstead, and upper cervical manipulations are frequently used methods.
Reviews of research studies within the chiropractic community have been used to generate practice guidelines outlining standards that specify which chiropractic treatments are "legitimate" (i.e., supported by evidence) and conceivably reimbursable under managed care health payment systems. Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs antiscientific reasoning and makes unsubstantiated claims. Chiropractic remains at a crossroads, and that in order to progress it would need to embrace science; the promotion by some for it to be a cure-all was both "misguided and irrational". 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.
Opinions differ as to the efficacy of chiropractic treatment. Many controlled clinical studies of spinal manipulation (SM) have been conducted, but their results often disagree and they are typically of low methodological quality. An independent review of National Center for Complementary and Alternative Medicine-funded studies on chiropractic manipulation for musculoskeletal issues found their quality was generally questionable, several randomised clinical trials did not report adverse effects and the majority was not described in enough detail to allow duplication. A 2011 systematic review of systematic reviews found that collectively, spinal manipulation failed to show it is effective for any condition. A 2008 review found that with the possible exception of back pain, chiropractic manipulation has not been shown to be effective for any medical condition. Health claims made by chiropractors regarding use of manipulation for pediatric health conditions are supported by only low levels of scientific evidence that does not demonstrate clinically relevant benefits. Most research has focused on spinal manipulation in general, rather than solely on chiropractic manipulation.
There is a wide range of ways to measure treatment outcomes. Chiropractic care, like all medical treatment, benefits from the placebo response. It is difficult 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. The efficacy of maintenance care in chiropractic is unknown.
Available evidence covers the following conditions:
- Low back pain. A 2013 Cochrane review found very low to moderate evidence that SMT was no more effective than inert interventions, sham SMT or as an adjunct therapy for acute low back pain. The same review found that SMT appears to be no better than other recommended therapies. A 2012 overview of systematic reviews found that collectively, SM failed to show it is an effective intervention for pain. A 2011 Cochrane review found strong evidence that suggests there is no clinically meaningful difference between SMT and other treatments for reducing pain and improving function for chronic low back pain. A 2010 Cochrane review found no current evidence to support or refute a clinically significant difference between the effects of combined chiropractic interventions and other interventions for chronic or mixed duration low back pain. A 2010 systematic review found that most studies suggest SMT achieves equivalent or superior improvement in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up. A 2008 review found strong evidence that SM is similar in effect to medical care with exercise. A 2008 literature synthesis found good evidence supporting SM for low back pain regardless of duration. Specific guidelines concerning the treatment of nonspecific (i.e., unknown cause) low back pain are inconsistent between countries.
- Radiculopathy. A 2013 systematic review and meta-analysis found a statistically significant improvement in overall recovery from sciatica following SM, when compared to usual care, and suggested that SM may be considered. There is moderate quality evidence to support the use of SM for the treatment of acute lumbar radiculopathy and acute lumbar disc herniation with associated radiculopathy. There is low or very low evidence supporting SM for chronic lumbar spine-related extremity symptoms and cervical spine-related extremity symptoms of any duration and no evidence exists for the treatment of thoracic radiculopathy.
- Whiplash and other neck pain. There is no consensus on the effectiveness of manual therapies for neck pain. A 2013 systematic review found that the data suggests that there are minimal short- and long-term treatment differences when comparing manipulation or mobilization of the cervical spine to physical therapy or exercise for neck pain improvement. A 2013 systematic review found that although there is insufficient evidence that thoracic SM is more effective than other treatments, it is a suitable intervention to treat some patients with non-specific neck pain. A 2011 systematic review found that thoracic SM may offer short-term improvement for the treatment of acute or subacute mechanical neck pain; although the body of literature is still weak. A 2010 Cochrane review found low quality evidence that suggests cervical manipulation may offer better short-term pain relief than a control for neck pain, and moderate evidence that cervical manipulation and mobilization produced similar effects on pain, function and patient satisfaction. A 2010 systematic review found low level evidence that suggests chiropractic care improves cervical range of motion and pain in the management of whiplash. A 2009 systematic review of controlled clinical trials found no evidence that chiropractic SM is effective for whiplash injury. A 2008 review found evidence that suggests that manual therapy and exercise are more effective than alternative strategies for neck pain but none of these treatments is clearly superior. A 2007 review found that SM and mobilization are effective for neck pain. A 2005 review found consistent evidence supporting mobilization for acute whiplash, and limited evidence supporting SM for whiplash.
- Headache. A 2011 systematic review found evidence that suggests that chiropractic SMT might be as effective as propranolol or topiramate in the prevention of migraine headaches. A 2011 systematic review found evidence that does not support the use of SM for the treatment of migraine headaches. A 2006 review found no rigorous evidence supporting SM or other manual therapies for tension headache. 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. A 2004 Cochrane review found evidence that suggests SM may be effective for migraine, tension headache and cervicogenic headache.
- Extremity conditions. A 2011 systematic review and meta-analysis concluded that the addition of manual mobilizations to an exercise program for the treatment of knee osteoarthritis resulted in better pain relief then a supervised exercise program alone and suggested that manual therapists consider adding manual mobilisation to optimise supervised active exercise programs. There is silver level evidence that manual therapy is more effective than exercise for the treatment of hip osteoarthritis, however this evidence could be considered to be inconclusive. A 2008 systematic review found that the addition of cervical spine mobilization to a treatment regimen for lateral epicondylosis (tennis elbow) resulted in significantly better pain relief and functional improvements in both the short and long-term. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs, limited to low level evidence supporting chiropractic management of shoulder pain and limited or fair evidence supporting chiropractic management of leg conditions.
- Other. A 2012 systematic review found insufficient low bias evidence to support the use of spinal manipulation as a therapy for the treatment of hypertension. A 2011 systematic review found moderate evidence to support the use of manual therapy for cervicogenic dizziness. There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine) and no scientific data for idiopathic adolescent scoliosis. 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 cervicogenic dizziness, 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. Other reviews have found no evidence of significant benefit for asthma, baby colic, bedwetting, carpal tunnel syndrome, fibromyalgia, gastrointestinal disorders, kinetic imbalance due to suboccipital strain (KISS) in infants, menstrual cramps, or pelvic and back pain during pregnancy.
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. 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. Indirect risks of chiropractic involve delayed or missed diagnoses through consulting a chiropractor.
Spinal manipulation is associated with frequent, mild and temporary adverse effects, including new or worsening pain or stiffness in the affected region. 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; adverse reactions appear to be more common following manipulation than mobilization. Chiropractic is correlated with a very high incidence of minor adverse effects. Chiropractic are more commonly associated with serious related adverse effects than other professionals following manipulation. Rarely, 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 and children. Estimates vary widely for the incidence of these complications, 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. Adverse effects are poorly reported in recent studies investigating chiropractic manipulations. Reports of serious adverse events have occurred, resulting from spinal manipulation therapy of the lumbopelvic region. Estimates for serious adverse events vary from 5 strokes per 100,000 manipulations to 1.46 serious adverse events per 10 million manipulations and 2.68 deaths per 10 million manipulations, though it was determined that there was inadequate data to be conclusive. Several case reports show temporal associations between interventions and potentially serious complications. The published medical literature contains reports of 26 deaths since 1934 following chiropractic manipulations and many more seem to remain unpublished. Vertebrobasilar artery stroke (VAS) 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. Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (CMT) and VAS. There is insufficient evidence to support a strong association or no association between cervical manipulation and stroke. While the biomechanical evidence is not sufficient to support the statement that CMT causes cervical artery dissection (CD), clinical reports suggest that mechanical forces have a part in a substantial number of CDs and the majority of population controlled studies found an association between CMT and VAS in young people. It is strongly recommended that practitioners consider the plausibility of CD as a symptom, and people can be informed of the association between CD and CMT before administrating manipulation of the cervical spine. There is controversy in regard to the level of risk of stroke from cervical manipulation. Many chiropractors state that, the association between chiropractic therapy and vertebral arterial dissection is not proven. However, it has been suggested that the causality between chiropractic cervical manipulation beyond the normal range of motion and vascular accidents is probable or definite. The incidence of internal carotid artery dissection following cervical spine manipulation is unknown. The literature infrequently reports helpful data to better understand the association between cervical manipulative therapy, cervical artery dissection and stroke. The limited evidence is inconclusive that chiropractic spinal manipulation therapy is not a cause of intracranial hypotension.
Chiropractors, like other primary care providers, sometimes employ diagnostic imaging techniques such as X-rays and CT scans that rely on ionizing radiation. Although there is no clear evidence for the practice, some chiropractors may still X-ray a patient several times a year. Practice guidelines aim to reduce unnecessary radiation exposure, which increases cancer risk in proportion to the amount of radiation received. Research suggests that radiology instruction given at chiropractic schools worldwide seem to be evidence-based. Although, there seems to be a disparity between some schools and available evidence regarding the aspect of radiography for patients with acute low back pain without an indication of a serious disease, which may contribute to chiropractic overuse of radiography for low back pain.
A 2012 systematic review concluded that no accurate assessment of risk-benefit exists for cervical manipulation. A 2012 summary stated that, "The best evidence suggests that SMT, whether it be for neck or low back pain, is a safe and effective therapy. At a population level, the benefits still outweigh the risks." A 2010 systematic review stated that there is no good evidence to assume that neck manipulation is an effective treatment for any medical condition and suggested a precautionary principle in healthcare for chiropractic intervention even if a causality with vertebral artery dissection after neck manipulation were merely a remote possibility. The same review concluded that the risk of death from manipulations to the neck outweighs the benefits. Chiropractors have criticized this conclusion, claiming that the author did not evaluate the potential benefits of spinal manipulation. Edzard Ernst stated "This detail was not the subject of my review. I do, however, refer to such evaluations and should add that a report recently commissioned by the General Chiropractic Council did not support many of the outlandish claims made by many chiropractors across the world."
A 2009 review evaluating maintenance chiropractic care found that spinal manipulation is routinely associated with considerable harm and no compelling evidence exists to indicate that it adequately prevents symptoms or diseases, thus the risk-benefit is not evidently favorable. A 2008 summary found that the best evidence suggests that chiropractic care is a useful therapy for subjects with neck or low-back pain for which the risks of serious adverse events should be considered negligible. A 2007 systematic review found that with uncertain efficacy and definite risks, the risk-benefit balance of spinal manipulation can't be positive. A 2006 overview of systematic reviews found the risk-benefit balance does not favor spinal manipulation over other treatments like physical therapy.
A 2012 systematic review suggested that the use of spine manipulation in clinical practice is a cost-effective treatment when used alone or in combination with other treatment approaches. A 2011 systematic review found evidence supporting the cost-effectiveness of using spinal manipulation for the treatment of sub-acute or chronic low back pain; the results for acute low back pain were insufficient. A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings.
A 2006 systematic cost-effectiveness review found that the reported cost-effectiveness of spinal 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. A 2005 American 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. The cost-effectiveness of maintenance chiropractic care is unknown.
Analysis of a clinical and cost utilization data from the years 2003 to 2005 by an integrative medicine independent physician association (IPA) which looked the chiropractic services utilization found that the clinical and cost utilization of chiropractic services based on 70,274 member-months over a 7-year period decreased patient costs associate with the following use of services by 60.2% for in-hospital admissions, 59.0% for hospital days, 62.0% for outpatient surgeries and procedures, and 85% forpharmaceutical costs when compared with conventional medicine (visit to a medical doctor primary care provider) IPA performance for the same health maintenance organization product in the same geography and time frame.
Education, licensing, and regulation
Requirements vary between countries. In the U.S. chiropractors obtain a first professional degree in the field of chiropractic. Chiropractic curricula in the U.S. have been criticized for failing to meet generally accepted standards of evidence-based medicine. The curriculum content of North American chiropractic and medical colleges with regard to basic and clinical sciences has been more similar than not, both in the kinds of subjects offered and in the time assigned to each subject. Accredited chiropractic programs in the U.S. require that applicants have 90 semester hours of undergraduate education with a grade point average of at least 3.0 on a 4.0 scale. Many programs require at least three years of undergraduate education, and more are requiring a bachelor's degree. Canada requires a minimum three years of undergraduate education for applicants, and at least 4200 instructional hours (or the equivalent) of full‐time chiropractic education for matriculation through an accredited chiropractic program. Graduates of the Canadian Memorial Chiropractic College (CMCC) are formally recognized to have at least 7–8 years of university level education. 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.
Upon graduation, there may be a requirement to pass national, state, or provincial board examinations before being licensed to practice in a particular jurisdiction. Depending on the location, continuing education may be required to renew these licenses. 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.
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. The U.S. CCE requires a mixing curriculum, which means a straight-educated chiropractor may not be eligible for licensing in states requiring CCE accreditation. 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. Today, there are 18 accredited Doctor of Chiropractic programs in the U.S., 2 in Canada, 6 in Australasia, and 5 in Europe. 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. Of the two chiropractic colleges in Canada, one is publicly funded (UQTR) and one is privately funded (CMCC). In 2005, CMCC was granted the privilege of offering a professional health care degree under the Post-secondary Education Choice and Excellence Act, which sets the program within the hierarchy of education in Canada as comparable to that of other primary contact health care professions such as medicine, dentistry and optometry.
Regulatory colleges and chiropractic boards in the U.S., Canada, Mexico, and Australia are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency. There are an estimated 49,000 chiropractors in the U.S. (2008), 6,500 in Canada (2010), 2,500 in Australia (2000), and 1,500 in the UK (2000).
Chiropractors often argue that this education is as good as or better than medical physicians', but most chiropractic training is confined to classrooms with much time spent learning theory, adjustment, and marketing. The fourth year of chiropractic education persistently showed the highest stress levels. Every student, irrespective of year, experienced different ranges of stress when studying. The chiropractic leaders and colleges have had internal struggles. Rather than cooperation, there has been infighting between different factions. A number of actions were posturing due to the confidential nature of the chiropractic colleges in an attempt to enroll students.
The chiropractic oath is a modern variation of the classical Hippocratic Oath historically taken by physicians and other healthcare professionals swearing to practice their professions ethically. The American Chiropractic Association (ACA) has an ethical code "based upon the acknowledgement that the social contract dictates the profession’s responsibilities to the patient, the public, and the profession; and upholds the fundamental principle that the paramount purpose of the chiropractic doctor's professional services shall be to benefit the patient." The International Chiropractor's Association (ICA) also has a set of professional canons.
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. According to a 2006 Gallup poll of U.S. adults, when asked how they would "rate the honesty and ethical standards of people in these different fields", chiropractic compared unfavorably with mainstream medicine. When chiropractic was rated, it "rated dead last amongst healthcare professions". While 84% of respondents considered nurses' ethics "very high" or "high," only 36% felt that way about chiropractors. Other healthcare professions ranged from 38% for psychiatrists, to 62% for dentists, 69% for medical doctors, 71% for veterinarians, and 73% for druggists or pharmacists.
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. 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. A 2010 analysis of chiropractic websites found the majority of chiropractors and their associations made claims of effectiveness not supported by scientific evidence, while 28% of chiropractor websites advocate lower back pain care, which has some sound evidence.
In 2009, a backlash to the libel suit filed by the British Chiropractic Association (BCA) against Simon Singh, has inspired the filing of formal complaints of false advertising against more than 500 individual chiropractors within one 24 hour period, prompting the McTimoney Chiropractic Association to write to its members advising them to remove leaflets that make claims about whiplash and colic from their practice, to be wary of new patients and telephone inquiries, and telling their members: "If you have a website, take it down NOW." and "Finally, we strongly suggest you do NOT discuss this with others, especially patients." An editorial in Nature has suggested that the BCA may be trying to suppress debate and that this use of British libel law is a burden on the right to freedom of expression, which is protected by the European Convention on Human Rights. The libel case ended with the BCA withdrawing its suit in 2010.
Chiropractic is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries. It is viewed as a marginal complementary and alternative medicine health care profession.
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.
A 2010 questionnaire presented to UK chiropractors indicated only 45% of chiropractors disclosed with patients the serious risk associated with manipulation of the cervical spine as a direct consequence of the fear that the patient would refuse treatment despite knowing the moral responsibility.
United States and Canada
The percentage of the population that utilizes chiropractic care at any given time generally falls into a range from 6% to 12% in the U.S. and Canada, with a global high of 20% in Alberta in 2006. In 2008, chiropractors were reported to be the most common CAM providers for children and adolescents, consuming up to 14% of all visits to chiropractors. In 2002-3, the majority of those who sought chiropractic did so for relief from back and neck pain and other neuromusculoskeletal complaints; most do so specifically for low back pain. The majority of U.S. chiropractors partake in some form of managed care. Although the majority of U.S. chiropractors view themselves as specialists in neuroleptic malignant syndrome conditions, many also consider chiropractic as a type of primary care. In the majority of cases, the care that chiropractors and physicians provide divides the market, however for some, their care is complementary.
In the U.S., chiropractors perform over 90% of all manipulative treatments. Satisfaction rates are typically higher for chiropractic care compared to medical care, with a 1998 U.S. survey reporting 83% of respondents satisfied or very satisfied with their care; quality of communication seems to be a consistent predictor of patient satisfaction with chiropractors.
Utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient. 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. As of 2007 7% of the U.S. population is being reached by chiropractic. Employment of U.S. chiropractors is expected to increase 14% between 2006 and 2016, faster than the average for all occupations.
In the U.S., most states require insurers to cover chiropractic care, and most HMOs cover these services. In Canada, there is lack of coverage under the universal public health insurance system.
Chiropractic was founded in 1895 by Daniel David (D.D.) Palmer in Davenport, Iowa. Palmer, a magnetic healer, hypothesized that manual manipulation of the spine could cure disease. The first chiropractic patient of D.D. Palmer was Harvey Lillard, a worker in the building where Palmer's office was located. He claimed that he had severely reduced hearing for 17 years, which started soon following a "pop" in his spine. A few days following his adjustment, Lillard claimed his hearing was almost completely restored. Chiropractic competed with its predecessor osteopathy, another medical system based on magnetic healing and bonesetting; both systems were founded by charismatic midwesterners in opposition to the conventional medicine of the day, and both postulated that manipulation improved health. 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.
Early chiropractors believed that all disease was caused by interruptions in the flow of innate intelligence, a vitalistic 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. 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).
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 the 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 invention and promotion of the neurocalometer, a temperature-sensing device, was highly controversial among B.J.'s fellow straights. By the 1930s chiropractic was the largest alternative healing profession in the U.S.
Chiropractors faced heavy opposition from organized medicine. Thousands of chiropractors were prosecuted for practicing medicine without a license, and D.D. and many other chiropractors were jailed. 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. B.J. cofounded the Universal Chiropractors' Association (UCA) to provide legal services to arrested chiropractors. Although the UCA won their first test case in Wisconsin in 1907, prosecutions instigated by state medical boards became increasingly common and in many cases were successful. In response, chiropractors conducted political campaigns to secure separate licensing statutes, eventually succeeding in all fifty states, from Kansas in 1913 through Louisiana in 1974. The longstanding feud between chiropractors and medical doctors continued for decades. The AMA labeled chiropractic an "unscientific cult" in 1966, and until 1980 advised its members that it was unethical for medical doctors to associate with "unscientific practitioners". 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.
Serious research to test chiropractic theories did not begin until the 1970s, and is continuing to be hampered by 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. 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.
Some chiropractors oppose vaccination and water fluoridation, which are common public health practices. Within the chiropractic community there are significant disagreements about vaccination, one of the most cost-effective public health interventions available. Most chiropractic writings on vaccination focus on its negative aspects, 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 extent to which anti-vaccination views perpetuate the current chiropractic profession is uncertain. 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. The Canadian Chiropractic Association supports vaccination; a survey in Alberta in 2002 found that 25% of chiropractors advised patients for, and 27% against, vaccinating themselves or their children.
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. Other chiropractors have actively promoted fluoridation, and several chiropractic organizations have endorsed scientific principles of public health. In addition to traditional chiropractic opposition to water fluoridation and vaccination, chiropractors' attempts to establish a positive reputation for their public health role are also compromised by their reputation for recommending repetitive lifelong chiropractic treatment.
Throughout its history chiropractic has been the subject of internal and external controversy and criticism. According to Daniel D. Palmer, the founder of chiropractic, subluxation is the sole cause of disease and manipulation is the cure for all diseases of the human race. A 2003 profession-wide survey found "most chiropractors (whether "straights" or "mixers") still hold views of Innate and of the cause and cure of disease (not just back pain) consistent with those of the Palmers." A critical evaluation stated "Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today." Chiropractors, including D.D. Palmer, were jailed for practicing medicine without a license. For most of its existence, chiropractic has battled with mainstream medicine, sustained by antiscientific and pseudoscientific ideas such as subluxation. Collectively, systematic reviews has not demonstrated that spinal manipulation, the main treatment method employed by chiropractors, is effective for any medical condition, with the possible exception of treatment for back pain. Chiropractic has been controversial, though to a lesser extent than in past years.
- Chapman-Smith DA, Cleveland CS III (2005). "International status, standards, and education of the chiropractic profession". In Haldeman S, Dagenais S, Budgell B et al. (eds.). Principles and Practice of Chiropractic (3rd ed.). McGraw-Hill. pp. 111–34. ISBN 0-07-137534-1.
- Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T (2005). "Chiropractic as spine care: a model for the profession". Chiropr Osteopat 13 (1): 9. doi:10.1186/1746-1340-13-9. PMC 1185558. PMID 16000175.
- Redwood D, Hawk C, Cambron J, Vinjamury SP, Bedard J (2008). "Do chiropractors identify with complementary and alternative medicine? results of a survey". J Altern Complement Med 14 (4): 361–8. doi:10.1089/acm.2007.0766. PMID 18435599.
- Kaptchuk TJ, Eisenberg DM (November 1998). "Chiropractic: origins, controversies, and contributions". Arch. Intern. Med. 158 (20): 2215–24. doi:10.1001/archinte.158.20.2215. PMID 9818801.
- Meeker WC, Haldeman S (2002). "Chiropractic: a profession at the crossroads of mainstream and alternative medicine" (PDF). Ann Intern Med 136 (3): 216–27. doi:10.7326/0003-4819-136-3-200202050-00010. PMID 11827498.
- Mootz RD, Shekelle PG (1997). "Content of practice". In Cherkin DC, Mootz RD (eds.). Chiropractic in the United States: Training, Practice, and Research. Rockville, MD: Agency for Health Care Policy and Research. pp. 67–91. OCLC 39856366. Retrieved 2008-10-10. AHCPR Pub No. 98-N002.
- Keating JC Jr (2005). "A brief history of the chiropractic profession". In Haldeman S, Dagenais S, Budgell B et al. (eds.). Principles and Practice of Chiropractic (3rd ed.). McGraw-Hill. pp. 23–64. ISBN 0-07-137534-1.
- DeVocht JW (2006). "History and overview of theories and methods of chiropractic: a counterpoint". Clin Orthop Relat Res 444: 243–9. doi:10.1097/01.blo.0000203460.89887.8d. PMID 16523145.
- Ernst E (2008). "Chiropractic: a critical evaluation". J Pain Symptom Manage 35 (5): 544–62. doi:10.1016/j.jpainsymman.2007.07.004. PMID 18280103.
- Posadzki P, Ernst E (2011). "Spinal manipulation: an update of a systematic review of systematic reviews". N Z Med J 124 (1340): 55–71. PMID 21952385.
- Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW (February 2013). "Spinal manipulative therapy for acute low back pain: an update of the cochrane review". Spine (Systematic Review) 38 (3): E158–77. doi:10.1097/BRS.0b013e31827dd89d. PMID 23169072.
- Lin CW, Haas M, Maher CG, Machado LA, van Tulder MW (2011). "Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review". European Spine Journal 20 (7): 1024–1038. doi:10.1007/s00586-010-1676-3. PMC 3176706. PMID 21229367.
- Leboeuf-Yde C, Hestbaek L (2008). "Maintenance care in chiropractic--what do we know?". Chiropr Osteopat 16: 3. doi:10.1186/1746-1340-16-3. PMC 2396648. PMID 18466623.
- Johnson, Claire; Rubinstein, Sidney M.; Côté, Pierre; Hestbaek, Lise; Injeyan, H. Stephen; Puhl, Aaron; Green, Bart; Napuli, Jason G.; Dunn, Andrew S.; Dougherty, Paul; Killinger, Lisa Zaynab; Page, Stacey A.; Stites, John S.; Ramcharan, Michael; Leach, Robert A.; Byrd, Lori D.; Redwood, Daniel; Kopansky-Giles, Deborah R. (2012). "Chiropractic Care and Public Health: Answering Difficult Questions About Safety, Care Through the Lifespan, and Community Action". Journal of Manipulative and Physiological Therapeutics 35 (7): 493–513. doi:10.1016/j.jmpt.2012.09.001. ISSN 0161-4754. PMID 23069244.
- Ernst E (2007). "Adverse effects of spinal manipulation: a systematic review". J R Soc Med 100 (7): 330–8. doi:10.1258/jrsm.100.7.330. PMC 1905885. PMID 17606755. Lay summary – Med News Today (2007-07-02).
- Ernst E, Posadzki P (2012). "Reporting of adverse effects in randomised clinical trials of chiropractic manipulations: a systematic review". N Z Med J 125 (1353): 87–140. PMID 22522273.
- Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ (2012). "Assessing the risk of stroke from neck manipulation: a systematic review". International Journal of Clinical Practice 66 (10): 940–947. doi:10.1111/j.1742-1241.2012.03004.x. PMC 3506737. PMID 22994328.
- Ernst E (2010). "Vascular accidents after neck manipulation: cause or coincidence?". Int J Clin Pract 64 (6): 673–7. doi:10.1111/j.1742-1241.2009.02237.x. PMID 20518945.
- Ernst E (2010). "Deaths after chiropractic: a review of published cases". Int J Clinical Practice 64 (8): 1162–1165. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715.
- Tetrault M (2004). "Global professional strategy for chiropractic" (PDF). Chiropractic Diplomatic Corps. Retrieved 2008-04-18.
- Norris P (2001). "How 'we' are different from 'them': occupational boundary maintenance in the treatment of musculo-skeletal problems". Sociol Health Illn 23 (1): 24–43. doi:10.1111/1467-9566.00239.
- Hurwitz EL, Chiang LM (2006). "A comparative analysis of chiropractic and general practitioner patients in North America: findings from the joint Canada/United States Survey of Health, 2002-03". BMC Health Serv Res 6: 49. doi:10.1186/1472-6963-6-49. PMC 1458338. PMID 16600038.
- Martin SC (October 1993). "Chiropractic and the social context of medical technology, 1895-1925". Technol Cult 34 (4): 808–34. doi:10.2307/3106416. JSTOR 3106416. PMID 11623404.
- Homola S (2006). "Chiropractic: history and overview of theories and methods". Clin Orthop Relat Res 444: 236–42. doi:10.1097/01.blo.0000200258.95865.87. PMID 16446588.
- Joseph C. Keating, Jr., Cleveland CS III, Menke M (2005). "Chiropractic history: a primer" (PDF). Association for the History of Chiropractic. Retrieved 2008-06-16. "A significant and continuing barrier to scientific progress within chiropractic are the anti-scientific and pseudo-scientific ideas (Keating 1997b) which have sustained the profession throughout a century of intense struggle with political medicine. Chiropractors' tendency to assert the meaningfulness of various theories and methods as a counterpoint to allopathic charges of quackery has created a defensiveness which can make critical examination of chiropractic concepts difficult (Keating and Mootz 1989). One example of this conundrum is the continuing controversy about the presumptive target of DCs' adjustive interventions: subluxation (Gatterman 1995; Leach 1994)."
- Busse JW, Morgan L, Campbell JB (2005). "Chiropractic antivaccination arguments". J Manipulative Physiol Ther 28 (5): 367–73. doi:10.1016/j.jmpt.2005.04.011. PMID 15965414.
- Campbell JB, Busse JW, Injeyan HS (2000). "Chiropractors and vaccination: a historical perspective". Pediatrics 105 (4): e43. doi:10.1542/peds.105.4.e43. PMID 10742364.
- Johnson C, Baird R, Dougherty PE, Globe G, Green BN, Haneline M, Hawk C, Injeyan HS, Killinger L, Kopansky-Giles D, Lisi AJ, Mior SA, Smith M (2008). "Chiropractic and public health: current state and future vision". J Manipulative Physiol Ther 31 (6): 397–410. doi:10.1016/j.jmpt.2008.07.001. PMID 18722194.
- Cooper RA, McKee HJ (2003). "Chiropractic in the United States: trends and issues". Milbank Q 81 (1): 107–38, table of contents. doi:10.1111/1468-0009.00040. PMC 2690192. PMID 12669653.
- Villanueva-Russell Y (2005). "Evidence-based medicine and its implications for the profession of chiropractic". Soc Sci Med 60 (3): 545–61. doi:10.1016/j.socscimed.2004.05.017. PMID 15550303.
- Reggars JW (2011). "Chiropractic at the crossroads or are we just going around in circles?". Chiropr Man Therap 19: 11. doi:10.1186/2045-709X-19-11. PMC 3119029. PMID 21599991.
- Mootz RD, Phillips RB (1997). "Chiropractic belief systems". In Cherkin DC, Mootz RD (eds.). Chiropractic in the United States: Training, Practice, and Research. Rockville, MD: Agency for Health Care Policy and Research. pp. 9–16. OCLC 39856366. Retrieved 2008-02-14. AHCPR Pub No. 98-N002.
- Keating JC Jr (2005). "Philosophy in chiropractic". In Haldeman S, Dagenais S, Budgell B et al. (eds.). Principles and Practice of Chiropractic (3rd ed.). McGraw-Hill. pp. 77–98. ISBN 0-07-137534-1.
- Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF (Aug 2008). "How can chiropractic become a respected mainstream profession? The example of podiatry". Chiropractic & osteopathy 16: 10. doi:10.1186/1746-1340-16-10. PMC 2538524. PMID 18759966.
- Gay RE, Nelson CF (2003). "Chiropractic philosophy". In Wainapel SF, Fast A (eds.). Alternative Medicine and Rehabilitation: a Guide for Practitioners. New York: Demos Medical Publishing. ISBN 1-888799-66-8.
- Physicians Group Management. "History of chiropractic care". Retrieved 2014-03-22.
- "Chiropractic". NHS Choices. 1 May 2012. Retrieved January 2014.
- Freeman J (February 2005). "Towards a definition of holism". Br J Gen Pract 55 (511): 154–5. PMC 1463203. PMID 15720949.
- Keating JC Jr, Cleveland CS III, Menke M (2005). "Chiropractic history: a primer" (PDF). Association for the History of Chiropractic. Retrieved 2008-06-16.
- McDonald WP, Durkin KF, Pfefer M et al. (2003). How Chiropractors Think and Practice: The Survey of North American Chiropractors. Ada, OH: Institute for Social Research, Ohio Northern University. ISBN 0-9728055-5-9.[page needed] Summarized in: McDonald WP, Durkin KF, Pfefer M (2004). "How chiropractors think and practice: the survey of North American chiropractors". Semin Integr Med 2 (3): 92–8. doi:10.1016/j.sigm.2004.07.002. Lay summary – Dyn Chiropr (2003-06-02).
- Smith M, Carber LA (2008). "Survey of US Chiropractor Attitudes and Behaviors about Subluxation". Journal of Chiropractic Humanities 15: 19–26. doi:10.1016/s1556-3499(13)60166-7.
- Keating JC Jr (1995). "D.D. Palmer's forgotten theories of chiropractic" (PDF). Association for the History of Chiropractic. Retrieved 2008-05-14.
- Palmer DD (1910). The Chiropractor's Adjuster: Text-book of the Science, Art and Philosophy of Chiropractic for Students and Practitioners. Portland, OR: Portland Printing House Co. OCLC 17205743. "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."
- Keating JC, Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF (August 2005). "Subluxation: dogma or science?". Chiropr Osteopat 13: 17. doi:10.1186/1746-1340-13-17. PMC 1208927. PMID 16092955.
- Rose KA, Adams A (2000). "A survey of the use of evidence-based health care in chiropractic college clinics" (PDF). J Chiropr Educ 14 (2): 71–7.
- Homola S (2006). "Can chiropractors and evidence-based manual therapists work together? an opinion from a veteran chiropractor" (PDF). J Man Manip Ther 14 (2): E14–8.
- World Health Organization (2005). "WHO guidelines on basic training and safety in chiropractic" (PDF). ISBN 92-4-159371-7. Retrieved 2008-02-29.
- Singh S, Ernst E (2008). "The truth about chiropractic therapy". Trick or Treatment: The Undeniable Facts about Alternative Medicine. W.W. Norton. pp. 145–90. ISBN 978-0-393-06661-6.
- David Chapman-Smith (2000). "Principles and Goals of Chiropractic Care". The Chiropractic Profession: Its Education, Practice, Research and Future Directions. NCMIC Group. p. 160. ISBN 1-892734-02-8.
- "Guidance on claims made for the chiropractic vertebral subluxation complex" (PDF). General Chiropractic Council. Retrieved 2010-09-30.
- Villanueva-Russell Y (June 2011). "Caught in the crosshairs: identity and cultural authority within chiropractic". Soc Sci Med 72 (11): 1826–37. doi:10.1016/j.socscimed.2011.03.038. PMID 21531061.
- Gleberzon BJ, Cooperstein R, Perle SM (2005). "Can chiropractic survive its chimerical nature?". J Can Chiropr Assoc 49 (2): 69–73. PMC 1840015. PMID 17549192.
- Theberge N (January 2008). "The integration of chiropractors into healthcare teams: a case study from sport medicine". Sociol Health Illn 30 (1): 19–34. doi:10.1111/j.1467-9566.2007.01026.x. PMID 18254831.
- Pettman E (2007). "A history of manipulative therapy". J Man Manip Ther 15 (3): 165–74. doi:10.1179/106698107790819873. PMC 2565620. PMID 19066664.
- Baer HA (2006). "The drive for legitimization by osteopathy and chiropractic in Australia: between heterodoxy and orthodoxy". Complement Health Pract Rev 11 (2): 77–94. doi:10.1177/1533210106292467.
- Parkman CA (2004). "Issues in credentialing CAM providers". Case Manager 15 (4): 24–7. doi:10.1016/j.casemgr.2004.05.004. PMID 15247891.
- Occupational And Professional Licensing, Chiropractic Practitioners, Chiropractic Advanced Practice Certification Registry. Retrieved 2010-05-03.
- Occupational And Professional Licensing, Chiropractic Practitioners, Chiropractic Advanced Practice Certification Registry (PDF) Retrieved 2010-05-03.
- Morrison P (2009). "Adjusting the role of chiropractors in the United States: why narrowing chiropractor scope of practice statutes will protect patients". Health Matrix Clevel 19 (2): 493–537. PMID 19715143.
- Wangler M, Zaugg B, Faigaux E (2010). "Medication Prescription: A Pilot Survey of Bernese Doctors of Chiropractic Practicing in Switzerland". Journal of Manipulative and Physiological Therapeutics 33 (3): 231–237. doi:10.1016/j.jmpt.2010.01.013. PMID 20350678.
- Ramey DW (June 2003). "Regulatory aspects of complementary and alternative veterinary medicine". J Am Vet Med Assoc 222 (12): 1679–82. doi:10.2460/javma.2003.222.1679. PMID 12830858.
- ACA House of Delegates (1994). "'Veterinary' chiropractic". American Chiropractic Association. Retrieved 2008-07-05.
- Kamen D (2001). "Politics and technique". Dyn Chiropr 19 (13).
- Anderson, Chantal (2009-01-22). "Physical therapists, chiropractors square off over bill". The Seattle Times. Retrieved 2010-09-23.
- Hilliard JW, Johnson ME (2004). "State practice acts of licensed health professions: scope of practice". DePaul J Health Care Law 8 (1): 237–61.
- Christensen MG, Kollasch MW (2005). "Professional functions and treatment procedures" (PDF). Job Analysis of Chiropractic. Greeley, CO: National Board of Chiropractic Examiners. pp. 121–38. ISBN 1-884457-05-3. Retrieved 2008-08-25.[dead link]
- Winkler K, Hegetschweiler-Goertz C, Jackson PS et al. (2003). "Spinal manipulation policy statement" (PDF). American Chiropractic Association. Retrieved 2008-05-24.
- Pickar JG, Sung PS, Kang YM, Ge W (2007). "Response of lumbar paraspinal muscles spindles is greater to spinal manipulative loading compared with slower loading under length control". Spine J 7 (5): 583–95. doi:10.1016/j.spinee.2006.10.006. PMC 2075482. PMID 17905321.
- Cooperstein R, Gleberzon BJ (2004). Technique Systems in Chiropractic. Churchill Livingstone. ISBN 0-443-07413-5.[page needed]
- Dagenais S, Mayer J, Wooley JR, Haldeman S (2008). "Evidence-informed management of chronic low back pain with medicine-assisted manipulation". Spine J 8 (1): 142–9. doi:10.1016/j.spinee.2007.09.010. PMID 18164462.
- Ailliet L, Rubinstein SM, de Vet HC (October 2010). "Characteristics of chiropractors and their patients in Belgium". J Manipulative Physiol Ther 33 (8): 618–25. doi:10.1016/j.jmpt.2010.08.011. PMID 21036284.
- Ndetan HT, Rupert RL, Bae S, Singh KP (February 2009). "Prevalence of musculoskeletal injuries sustained by students while attending a chiropractic college". J Manipulative Physiol Ther 32 (2): 140–8. doi:10.1016/j.jmpt.2008.12.012. PMID 19243726.
- Joseph C. Keating, Jr. (1997). "Chiropractic: science and antiscience and pseudoscience side by side". Skept Inq 21 (4): 37–43.
- Phillips RB (2005). "The evolution of vitalism and materialism and its impact on philosophy". In Haldeman S, Dagenais S, Budgell B et al. (eds.). Principles and Practice of Chiropractic (3rd ed.). McGraw-Hill. pp. 65–76. ISBN 0-07-137534-1.
- Suter E, Vanderheyden LC, Trojan LS, Verhoef MJ, Armitage GD (February 2007). "How important is research-based practice to chiropractors and massage therapists?". J Manipulative Physiol Ther 30 (2): 109–15. doi:10.1016/j.jmpt.2006.12.013. PMID 17320731.
- Ernst E, Canter PH (April 2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med 99 (4): 192–6. doi:10.1258/jrsm.99.4.192. PMC 1420782. PMID 16574972. Lay summary – BBC News (March 22, 2006).
- Fernández-de-las-Peñas C, Alonso-Blanco C, San-Roman J, Miangolarra-Page JC (2006). "Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type headache, migraine, and cervicogenic headache". J Orthop Sports Phys Ther 36 (3): 160–9. doi:10.2519/jospt.2006.36.3.160. PMID 16596892.
- Johnston BC, da Costa BR, Devereaux PJ, Akl EA, Busse JW (April 2008). "The use of expertise-based randomized controlled trials to assess spinal manipulation and acupuncture for low back pain: a systematic review". Spine 33 (8): 914–8. doi:10.1097/BRS.0b013e31816b4be4. PMID 18404113.
- Ernst E, Posadzki P (2011). "An independent review of NCCAM-funded studies of chiropractic". Clinical Rheumatology 30 (5): 593–600. doi:10.1007/s10067-010-1663-4. PMID 21207089.
- Kemper KJ, Vohra S, Walls R (December 2008). "American Academy of Pediatrics. The use of complementary and alternative medicine in pediatrics". Pediatrics 122 (6): 1374–86. doi:10.1542/peds.2008-2173. PMID 19047261.
- Gotlib A, Rupert R (2008). "Chiropractic manipulation in pediatric health conditions--an updated systematic review". Chiropr Osteopat 16: 11. doi:10.1186/1746-1340-16-11. PMC 2553791. PMID 18789139.
- Ernst E (June 2009). "Chiropractic manipulation, with a deliberate 'double entendre'". Arch. Dis. Child. 94 (6): 411. doi:10.1136/adc.2009.158170. PMID 19460920.
- Ernst E (October 2002). "Chiropractic". Annals of Internal Medicine 137 (8): 701 author reply 702. doi:10.7326/0003-4819-137-8-200210150-00025. PMID 12379081.
- Khorsan R, Coulter ID, Hawk C, Choate CG (June 2008). "Measures in chiropractic research: choosing patient-based outcome assessments". J Manipulative Physiol Ther 31 (5): 355–75. doi:10.1016/j.jmpt.2008.04.007. PMID 18558278.
- Kaptchuk TJ (June 2002). "The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance?". Annals of Internal Medicine 136 (11): 817–25. doi:10.7326/0003-4819-136-11-200206040-00011. PMID 12044130.
- Hancock MJ, Maher CG, Latimer J, McAuley JH (2006). "Selecting an appropriate placebo for a trial of spinal manipulative therapy". Aust J Physiother 52 (2): 135–8. doi:10.1016/S0004-9514(06)70049-6. PMID 16764551.
- Posadzki P (2012). "Is spinal manipulation effective for pain? An overview of systematic reviews". Pain Med 13 (6): 754–61. doi:10.1111/j.1526-4637.2012.01397.x. PMID 22621391.
- Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW (June 2011). "Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review". Spine (Systematic review) 36 (13): E825–46. doi:10.1097/BRS.0b013e3182197fe1. PMID 21593658.
- Walker BF, French SD, Grant W, Green S (2010). Walker, Bruce F, ed. "Combined chiropractic interventions for low-back pain". Cochrane Database Syst Rev (4): CD005427. doi:10.1002/14651858.CD005427.pub2. PMID 20393942.
- Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM (October 2010). "NASS Contemporary Concepts in Spine Care: spinal manipulation therapy for acute low back pain". Spine J 10 (10): 918–40. doi:10.1016/j.spinee.2010.07.389. PMID 20869008.
- Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S (2008). "Evidence-informed management of chronic low back pain with spinal manipulation and mobilization". Spine J 8 (1): 213–25. doi:10.1016/j.spinee.2007.10.023. PMID 18164469.
- Lawrence DJ, Meeker W, Branson R, Bronfort G, Cates JR, Haas M, Haneline M, Micozzi M, Updyke W, Mootz R, Triano JJ, Hawk C (2008). "Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis". J Manipulative Physiol Ther 31 (9): 659–74. doi:10.1016/j.jmpt.2008.10.007. PMID 19028250. An earlier, freely readable version is in: Meeker W, Branson R, Bronfort G et al. (2007). "Chiropractic management of low back pain and low back related leg complaints" (PDF). Council on Chiropractic Guidelines and Practice Parameters. Retrieved 2008-11-28.
- Murphy AY, van Teijlingen ER, Gobbi MO (September 2006). "Inconsistent grading of evidence across countries: a review of low back pain guidelines". J Manipulative Physiol Ther 29 (7): 576–81, 581.e1–2. doi:10.1016/j.jmpt.2006.07.005. PMID 16949948.
- Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, Hendry M, Phillips CJ, Nafees S, Fitzsimmons D, Rickard I, Wilkinson C (2013). "Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses.". Spine Journal. doi:10.1016/j.spinee.2013.08.049. PMID 24412033.
- Leininger B, Bronfort G, Evans R, Reiter T (February 2011). "Spinal manipulation or mobilization for radiculopathy: a systematic review". Phys Med Rehabil Clin N Am 22 (1): 105–25. doi:10.1016/j.pmr.2010.11.002. PMID 21292148.
- Hahne AJ, Ford JJ, McMeeken JM (May 2010). "Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review". Spine 35 (11): E488–504. doi:10.1097/BRS.0b013e3181cc3f56. PMID 20421859.
- Vernon H, Humphreys BK (2007). "Manual therapy for neck pain: an overview of randomized clinical trials and systematic reviews" (PDF). Eura Medicophys 43 (1): 91–118. PMID 17369783.
- Schroeder J, Kaplan L, Fischer DJ, Skelly AC (2013). "The Outcomes of Manipulation or Mobilization Therapy Compared with Physical Therapy or Exercise for Neck Pain: A Systematic Review". Evidence-Based Spine-Care Journal 4 (1): 30–41. doi:10.1055/s-0033-1341605. PMC 3699243. PMID 24436697.
- Huisman PA, Speksnijder CM, de Wijer A (January 2013). "The effect of thoracic spine manipulation on pain and disability in patients with non-specific neck pain: a systematic review". Disabil Rehabil: 1. doi:10.3109/09638288.2012.750689. PMID 23339721.
- Cross KM, Kuenze C, Grindstaff TL, Hertel J (September 2011). "Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: a systematic review". J Orthop Sports Phys Ther 41 (9): 633–42. doi:10.2519/jospt.2011.3670. PMID 21885904.
- Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL (August 2010). "Manipulation or mobilisation for neck pain: a Cochrane Review". Man Ther 15 (4): 315–33. doi:10.1016/j.math.2010.04.002. PMID 20510644.
- Shaw L, Descarreaux M, Bryans R, Duranleau M, Marcoux H, Potter B, Ruegg R, Watkin R, White E (2010). "A systematic review of chiropractic management of adults with Whiplash-Associated Disorders: recommendations for advancing evidence-based practice and research". Work 35 (3): 369–94. doi:10.3233/WOR-2010-0996. PMID 20364057.
- Ernst E (2009). "Chiropractic spinal manipulation for whiplash injury? A systematic review of controlled clinical trials". Focus Altern Complement Ther 14 (2): 85–6. doi:10.1111/j.2042-7166.2009.tb01939.x.
- Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW, Côté P, Hogg-Johnson S, Cassidy JD, Haldeman S (2008). "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders". Spine 33 (4 Suppl): S123–52. doi:10.1097/BRS.0b013e3181644b1d. PMID 18204386.
- Conlin A, Bhogal S, Sequeira K, Teasell R (2005). "Treatment of whiplash-associated disorders--part I: Non-invasive interventions". Pain Res Manag 10 (1): 21–32. PMID 15782244.
- Chaibi A, Tuchin PJ, Russell MB (April 2011). "Manual therapies for migraine: a systematic review". J Headache Pain 12 (2): 127–33. doi:10.1007/s10194-011-0296-6. PMC 3072494. PMID 21298314.
- Posadzki P, Ernst E (June 2011). "Spinal manipulations for the treatment of migraine: a systematic review of randomized clinical trials". Cephalalgia 31 (8): 964–70. doi:10.1177/0333102411405226. PMID 21511952.
- 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.
- Biondi DM (June 2005). "Physical treatments for headache: a structured review". Headache 45 (6): 738–46. doi:10.1111/j.1526-4610.2005.05141.x. PMID 15953306.
- Bronfort G, Nilsson N, Haas M, Evans R, Goldsmith CH, Assendelft WJ, Bouter LM (2004). Brønfort, Gert, ed. "Non-invasive physical treatments for chronic/recurrent headache". Cochrane Database Syst Rev (3): CD001878. doi:10.1002/14651858.CD001878.pub2. PMID 15266458.
- Jansen MJ, Viechtbauer W, Lenssen AF, Hendriks EJ, de Bie RA (2011). "Strength training alone, exercise therapy alone, and exercise therapy with passive manual mobilisation each reduce pain and disability in people with knee osteoarthritis: a systematic review". J Physiother 57 (1): 11–20. doi:10.1016/S1836-9553(11)70002-9. PMID 21402325.
- French HP, Brennan A, White B, Cusack T (April 2011). "Manual therapy for osteoarthritis of the hip or knee - a systematic review". Man Ther 16 (2): 109–17. doi:10.1016/j.math.2010.10.011. PMID 21146444.
- Herd CR, Meserve BB (2008). "A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia". J Man Manip Ther 16 (4): 225–37. doi:10.1179/106698108790818288. PMC 2716156. PMID 19771195.
- McHardy A, Hoskins W, Pollard H, Onley R, Windsham R (February 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.
- Pribicevic M, Pollard H, Bonello R, de Luca K (2010). "A systematic review of manipulative therapy for the treatment of shoulder pain". J Manipulative Physiol Ther 33 (9): 679–89. doi:10.1016/j.jmpt.2010.08.019. PMID 21109059.
- Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W (January 2009). "Manipulative therapy for lower extremity conditions: expansion of literature review". J Manipulative Physiol Ther 32 (1): 53–71. doi:10.1016/j.jmpt.2008.09.013. PMID 19121464.
- Mangum K, Partna L, Vavrek D (2012). "Spinal manipulation for the treatment of hypertension: a systematic qualitative literature review". J Manipulative Physiol Ther 35 (3): 235–43. doi:10.1016/j.jmpt.2012.01.005. PMID 22341795.
- Lystad RP, Bell G, Bonnevie-Svendsen M, Carter CV (2011). "Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness: a systematic review". Chiropr Man Therap 19 (1): 21. doi:10.1186/2045-709X-19-21. PMC 3182131. PMID 21923933.
- Everett CR, Patel RK (September 2007). "A systematic literature review of nonsurgical treatment in adult scoliosis". Spine 32 (19 Suppl): S130–4. doi:10.1097/BRS.0b013e318134ea88. PMID 17728680.
- Romano M, Negrini S (2008). "Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review". Scoliosis 3: 2. doi:10.1186/1748-7161-3-2. PMC 2262872. PMID 18211702.
- Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW (June 2007). "Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research". J Altern Complement Med 13 (5): 491–512. doi:10.1089/acm.2007.7088. PMID 17604553.
- Ernst E (December 2009). "Spinal manipulation for asthma: a systematic review of randomised clinical trials". Respir Med 103 (12): 1791–5. doi:10.1016/j.rmed.2009.06.017. PMID 19646855.
- Hondras MA, Linde K, Jones AP (2005). Hondras, Maria A, ed. "Manual therapy for asthma". Cochrane Database Syst Rev (2): CD001002. doi:10.1002/14651858.CD001002.pub2. PMID 15846609.
- Baby colic:
- Ernst E (2009). "Chiropractic spinal manipulation for infant colic: a systematic review of randomised clinical trials". Int J Clin Pract 63 (9): 1351–3. doi:10.1111/j.1742-1241.2009.02133.x. PMID 19691620.
- Husereau D, Clifford T, Aker P, Leduc D, Mensinkai S (2003). Spinal Manipulation for Infantile Colic (PDF). Technology report no. 42. Ottawa: Canadian Coordinating Office for Health Technology Assessment. ISBN 1-894978-11-0. Retrieved 2008-10-06.
- Glazener CM, Evans JH, Cheuk DK (2005). Glazener, Cathryn MA, ed. "Complementary and miscellaneous interventions for nocturnal enuresis in children". Cochrane Database Syst Rev (2): CD005230. doi:10.1002/14651858.CD005230. PMID 15846744.
- O'Connor D, Marshall S, Massy-Westropp N (2003). O'Connor, Denise, ed. "Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome". Cochrane Database Syst Rev (1): CD003219. doi:10.1002/14651858.CD003219. PMID 12535461.
- 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 28 (10): 1175–8. doi:10.1007/s10067-009-1217-9. PMID 19544042.
- Ernst E (2011). "Chiropractic treatment for gastrointestinal problems: A systematic review of clinical trials". Can J Gastroenterol 25 (1): 39–49. PMC 3027333. PMID 21258667.
- 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)]". Ned Tijdschr Geneeskd (in Dutch) 149 (13): 703–7. PMID 15819137.
- Proctor ML, Hing W, Johnson TC, Murphy PA (2006). Proctor, Michelle, ed. "Spinal manipulation for primary and secondary dysmenorrhoea". Cochrane Database Syst Rev 3 (3): CD002119. doi:10.1002/14651858.CD002119.pub3. PMID 16855988.
- Pennick VE, Young G (2007). Pennick, Victoria, ed. "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.
- Anderson-Peacock E, Blouin JS, Bryans R, Danis N, Furlan A, Marcoux H, Potter B, Ruegg R, Stein JG, White E (2005). "Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash" (PDF). J Can Chiropr Assoc 49 (3): 158–209. PMC 1839918. PMID 17549134.
• Anderson-Peacock E, Bryans R, Descarreaux M, Marcoux H, Potter B, Ruegg R, Shaw L, Watkin R, White E (2008). "A Clinical Practice Guideline Update from The CCA•CFCREAB-CPG" (PDF). J Can Chiropr Assoc 52 (1): 7–8. PMC 2258235. PMID 18327295.
- 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. PMID 17906581.
- Gouveia LO, Castanho P, Ferreira JJ (2009). "Safety of chiropractic interventions: a systematic review". Spine 34 (11): E405–13. doi:10.1097/BRS.0b013e3181a16d63. PMID 19444054.
- Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM (July 2005). "Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study". Spine 30 (13): 1477–84. doi:10.1097/01.brs.0000167821.39373.c1. PMID 15990659.
- Vohra S, Johnston BC, Cramer K, Humphreys K (2007). "Adverse events associated with pediatric spinal manipulation: a systematic review". Pediatrics 119 (1): e275–83. doi:10.1542/peds.2006-1392. PMID 17178922.
- Hebert JJ, Stomski NJ, French SD, Rubinstein SM (2013). "Serious Adverse Events and Spinal Manipulative Therapy of the Low Back Region: A Systematic Review of Cases". Journal of Manipulative and Physiological Therapeutics. doi:10.1016/j.jmpt.2013.05.009. PMID 23787298.
- Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ (15 Feb 2008). "Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study". Spine 33 (4 Suppl): S176–83. doi:10.1097/BRS.0b013e3181644600. PMID 18204390.
- Paciaroni M, Bogousslavsky J (2009). "Cerebrovascular complications of neck manipulation". Eur Neurol 61 (2): 112–8. doi:10.1159/000180314. PMID 19065058.
- Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM (2008). "Does cervical manipulative therapy cause vertebral artery dissection and stroke?". Neurologist 14 (1): 66–73. doi:10.1097/NRL.0b013e318164e53d. PMID 18195663.
- Biller, J.; Sacco, R. L.; Albuquerque, F. C.; Demaerschalk, B. M.; Fayad, P.; Long, P. H.; Noorollah, L. D.; Panagos, P. D.; Schievink, W. I.; Schwartz, N. E.; Shuaib, A.; Thaler, D. E.; Tirschwell, D. L. (2014). "Cervical Arterial Dissections and Association With Cervical Manipulative Therapy: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association". Stroke 45 (10): 3155–74. doi:10.1161/STR.0000000000000016. ISSN 0039-2499. PMID 25104849.
- Chung CL, Côté P, Stern P, L'espérance G (2014). "The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature". Journal of Manipulative and Physiological Therapeutics. doi:10.1016/j.jmpt.2013.09.005. PMID 24387889.
- Wynd S, Westaway M, Vohra S, Kawchuk G (2013). "The quality of reports on cervical arterial dissection following cervical spinal manipulation". PLoS ONE 8 (3): e59170. doi:10.1371/journal.pone.0059170. PMC 3604043. PMID 23527121.
- Tuchin, P. (2014). "A systematic literature review of intracranial hypotension following chiropractic". International Journal of Clinical Practice 68 (3): 396–402. doi:10.1111/ijcp.12247. ISSN 1368-5031. PMID 24372942.
- Bussières AE, Taylor JA, Peterson C (2008). "Diagnostic imaging practice guidelines for musculoskeletal complaints in adults—an evidence-based approach—part 3: spinal disorders". J Manipulative Physiol Ther 31 (1): 33–88. doi:10.1016/j.jmpt.2007.11.003. PMID 18308153.
- Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation, Board on Radiation Effects Research, U.S. National Research Council (2006). Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2. Washington, DC: The National Academies Press. ISBN 0-309-09156-X.
- Ammendolia C, Taylor JA, Pennick V, Côté P, Hogg-Johnson S, Bombardier C (2008). "Adherence to radiography guidelines for low back pain: A survey of chiropractic schools worldwide". Journal of Manipulative and Physiological Therapeutics 31 (6): 412–8. doi:10.1016/j.jmpt.2008.06.010. PMID 18722195.
- E Ernst (2011). "Response to critiques of deaths after chiropractic". Int J Clin Pract 65 (1): 106. doi:10.1111/j.1742-1241.2010.02568.x. PMID 21155949.
- Ernst E (2009). "Chiropractic maintenance treatment, a useful preventative approach?". Prev Med 49 (2–3): 99–100. doi:10.1016/j.ypmed.2009.05.004. PMID 19465044.
- Rubinstein SM (2008). "Adverse events following chiropractic care for subjects with neck or low-back pain: do the benefits outweigh the risks?". J Manipulative Physiol Ther 31 (6): 461–464. doi:10.1016/j.jmpt.2008.06.001. PMID 18722202.
- Michaleff ZA, Lin CW, Maher CG, van Tulder MW (2012). "Spinal manipulation epidemiology: Systematic review of cost effectiveness studies". J Electromyogr Kinesiol 22 (5): 655–62. doi:10.1016/j.jelekin.2012.02.011. PMID 22429823.
- Mootz RD, Hansen DT, Breen A, Killinger LZ, Nelson C (2006). "Health services research related to chiropractic: review and recommendations for research prioritization by the chiropractic profession". J Manipulative Physiol Ther 29 (9): 707–25. doi:10.1016/j.jmpt.2006.09.001. PMID 17142165.
- Canter PH, Coon JT, Ernst E (2006). "Cost-Effectiveness of Complementary Therapies in the United Kingdom—A Systematic Review†". Evid Based Complement Alternat Med 3 (4): 425–32. doi:10.1093/ecam/nel044. PMC 1697737. PMID 17173105.
- van der Roer N, Goossens ME, Evers SM, van Tulder MW (2005). "What is the most cost-effective treatment for patients with low back pain? a systematic review". Best Pract Res Clin Rheumatol 19 (4): 671–84. doi:10.1016/j.berh.2005.03.007. PMID 15949783.
- Sarnat RL, Winterstein J, Cambron JA (May 2007). "Clinical Utilization and Cost Outcomes From an Integrative Medicine Independent Physician Association: An Additional 3-Year Update". Journal of Manipulative and Physiological Therapeutics 30 (4): 263–269. doi:10.1016/j.jmpt.2007.03.004. PMID 17509435.
- "Glossary". National Center for Education Statistics, U.S. Dept. of Education. Retrieved 2009-06-05.
- Marcus DM, McCullough L (2009). "An evaluation of the evidence in "evidence-based" integrative medicine programs". Acad Med 84 (9): 1229–34. doi:10.1097/ACM.0b013e3181b185f4. PMID 19707062.
- Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M (September 1998). "A comparative study of chiropractic and medical education". Altern Ther Health Med 4 (5): 64–75. PMID 9737032.
- "Prospective students". Association of Chiropractic Colleges. Retrieved 2009-07-23.
- "Standards for Accreditation of Doctor of Chiropractic Programmes" (PDF). Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards. 2011-11-26. Retrieved 2014-08-02.
- "Media Relations". Canadian Memorial Chiropractic College. Retrieved 2010-12-14.
- "Degree Authority in Ontario". Ontario Ministry of Training, Colleges and Universities. Retrieved 2010-12-14.
- "State chiropractic licensure". Life University. 2008. Retrieved 2009-06-05.
- "Becoming a chiropractor". Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards. Retrieved 2009-06-05.
- Grod JP (2006). "Continuing health education in Canada". J Can Chiropr Assoc 50 (1): 14–7. PMC 1839972. PMID 17549163.
- Stuber KJ, Grod JP, Smith DL, Powers P (2005). "An online survey of chiropractors' opinions of Continuing Education". Chiropr Osteopat 13 (1): 22. doi:10.1186/1746-1340-13-22. PMC 1282582. PMID 16242035.
- Coulter ID, Adams AH, Sandefur R (1997). "Chiropractic training". In Cherkin DC, Mootz RD (eds.). Chiropractic in the United States: Training, Practice, and Research. Rockville, MD: Agency for Health Care Policy and Research. pp. 17–28. OCLC 39856366. Retrieved 2008-05-11. AHCPR Pub No. 98-N002.
- "The Council on Chiropractic Education (CCE)". The Council on Chiropractic Education. Retrieved 2008-07-05.
- "The General Chiropractic Council". Retrieved 2008-07-26.
- "About Us". Councils on Chiropractic Education International. Retrieved 2010-09-30.
- "Accredited Doctor of Chiropractic programs". The Council on Chiropractic Education. Archived from the original on 2008-02-14. Retrieved 2008-02-22.
- "Accreditation of educational programmes". Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards. Retrieved 2009-06-05.
- "Program Accreditation Status". Council on Chiropractic Education Australasia. Retrieved 2010-09-30.
- "Institutions holding Accredited Status with the ECCE". European Council On Chiropractic Education. 2010-11-01. Retrieved 2014-08-02.
- "Canadian Chiropractic Association FAQs". Canadian Chiropractic Association. Retrieved 2010-10-02.[dead link]
- "Federation of Chiropractic Licensing Boards FAQ". Federation of Chiropractic Licensing Boards. Retrieved 2010-10-02.
- "Chiropractors". U.S. Bureau of Labor Statistics. 2007. Retrieved 2008-07-05.
- "Canadian Chiropractic Association: Chiropractic in Canada". Canadian Chiropractic Association. Retrieved 2010-10-02.
- Chapman-Smith D (2000). "Current status of the profession". The Chiropractic Profession: Its Education, Practice, Research and Future Directions. West Des Moines, IA: NCMIC. ISBN 1-892734-02-8.
- Hester H, Cunliffe C, Hunnisett A (2013). "Stress in chiropractic education: a student survey of a five-year course". J Chiropr Educ 27 (2): 147–51. doi:10.7899/JCE-13-4. PMC 3791907. PMID 23957319.
- Johnson C (December 2010). "Reflecting on 115 years: the chiropractic profession's philosophical path". J Chiropr Humanit 17 (1): 1–5. doi:10.1016/j.echu.2010.11.001. PMC 3342796. PMID 22693471.
- Simpson JK, Losco B, Young KJ (2010). "Development of the murdoch chiropractic graduate pledge". The Journal of chiropractic education 24 (2): 175–86. doi:10.7899/1042-5055-24.2.175. PMC 2967342. PMID 21048880.
- Staff. "Code of Ethics". American Chiropractic Association.
- Staff. "ICA code of Ethics". International Chiropractor's Association.
- "Gallup Poll: Americans have low opinion of chiropractors' honesty and ethics". Dynamic Chiropractic 25 (3). 29 January 2007.
- "USA TODAY/Gallup poll". USA Today. 11 December 2006.
- Gallup chart
- "A pivotal moment for free speech in Britain". The Guardian. April 15, 2010.
- "The BHA re-publishes Simon Singh’s article on chiropractic therapy". British Humanist Association. July 29, 2009.
- Ernst E, Gilbey A (2010). "Chiropractic claims in the English-speaking world". The New Zealand medical journal 123 (1312): 36–44. PMID 20389316.
- Lucas Laursen. "The Great Beyond: Chiropractic group advises members to 'withdraw from the battleground'". Nature.com. Retrieved 20 June 2009.
- Lucas Laursen. "The Great Beyond: Complaints converge on chiropractors". Nature.com. Retrieved 20 June 2009.
- "Unjust burdens of proof". Nature 459 (7248): 751. June 2009. doi:10.1038/459751a. PMID 19516290.
- Pallab Ghosh (2010-04-15). "Case dropped against Simon Singh". BBC News.
- Mark Henderson (2010-04-16). "Science writer Simon Singh wins bitter libel battle". London: Times Online.
- Xue CC, Zhang AL, Lin V, Myers R, Polus B, Story DF (2008). "Acupuncture, chiropractic and osteopathy use in Australia: a national population survey". BMC Public Health 8: 105. doi:10.1186/1471-2458-8-105. PMC 2322980. PMID 18377663.
- "Chiropractic treatment available on NHS in Cornwall". BBC. August 13, 2013. Retrieved August 18, 2013.
- Langworthy JM, Forrest L (2010). "Withdrawal rates as a consequence of disclosure of risk associated with manipulation of the cervical spine". Chiropr Osteopat 18: 27. doi:10.1186/1746-1340-18-27. PMC 3161389. PMID 20977721.
- Lawrence DJ, Meeker WC (2007). "Chiropractic and CAM utilization: a descriptive review". Chiropr Osteopat 15: 2. doi:10.1186/1746-1340-15-2. PMC 1784103. PMID 17241465.
- Crownfield PW (2007). "Chiropractic in Alberta: a model of consumer utilization and satisfaction". Dyn Chiropr 25 (6).
- Daniel C. Cherkin, Robert D. Mootz (2010). "Chiropractic in the United States:Training, Practice, and Research". Chirobase. Retrieved 2010-10-01.
- Gaumer G (2006). "Factors associated with patient satisfaction with chiropractic care: survey and review of the literature". J Manipulative Physiol Ther 29 (6): 455–62. doi:10.1016/j.jmpt.2006.06.013. PMID 16904491.
- Tindle HA, Davis RB, Phillips RS, Eisenberg DM (2005). "Trends in use of complementary and alternative medicine by US adults: 1997-2002". Altern Ther Health Med 11 (1): 42–9. PMID 15712765.
- Stanley, G. (2007). "The Sustainability of Chiropractic". Dyn Chiropr 25 (19).
- Garner MJ, Birmingham M, Aker P, Moher D, Balon J, Keenan D, Manga P (2008). "Developing integrative primary healthcare delivery: adding a chiropractor to the team". Explore (NY) 4 (1): 18–24. doi:10.1016/j.explore.2007.10.003. PMID 18194787.
- Baer HA (1987). "Divergence and convergence in two systems of manual medicine: osteopathy and chiropractic in the United States". Med Anthropol Q 1 (2): 176–93. doi:10.1525/maq.1987.1.2.02a00030.
- Palmer DD (1911-05-04). "D.D. Palmer's Religion of Chiropractic: Letter to P.W. Johnson, D.C" (PDF). Retrieved 2008-06-29.
- Cherkin D (November 1989). "AMA policy on chiropractic". Am J Public Health 79 (11): 1569–70. doi:10.2105/AJPH.79.11.1569-a. PMC 1349822. PMID 2817179.
- "Definition of chiropractic in English". Oxford English Dictionary. Oxford University Press. 2014.
- "Definition of chiro- in English". Oxford English Dictionary. Oxford University Press. 2014.
- Ehreth J (2003). "The global value of vaccination". Vaccine 21 (7–8): 596–600. doi:10.1016/S0264-410X(02)00623-0. PMID 12531324.
- Russell ML, Injeyan HS, Verhoef MJ, Eliasziw M (2004). "Beliefs and behaviours: understanding chiropractors and immunization". Vaccine 23 (3): 372–9. doi:10.1016/j.vaccine.2004.05.027. PMID 15530683.
- Jones RB, Mormann DN, Durtsche TB (1989). "Fluoridation referendum in La Crosse, Wisconsin: contributing factors to success" (PDF). Am J Public Health 79 (10): 1405–8. doi:10.2105/AJPH.79.10.1405. PMC 1350185. PMID 2782512.
- Jaroff, Leon (27 February 2002). "Back Off, Chiropractors!". Time. Retrieved 7 June 2009.
- Gunther Brown, Candy (July 7, 2014). "Chiropractic: Is it Nature, Medicine or Religion?". The Huffington Post.
- Long PH (2013). Barrett S, ed. Chiropractic Abuse: An Insider's Lament. American Council on Science & Health. ISBN 978-0-9727094-9-1.
- Homola S (2002). Shermer M, ed. Chiropractic: Conventional or Alternative Healing?. The Skeptic Encyclopedia of Pseudoscience 1 (ABC-CLIO). pp. 308–. ISBN 978-1-57607-653-8.
- Menke JM (January 2014). "Do Manual Therapies Help Low Back Pain?: A Comparative Effectiveness Meta-Analysis". Spine (Meta-analysis) 39 (7): E463–72. doi:10.1097/BRS.0000000000000230. PMID 24480940.
|Wikisource has the text of the 1922 Encyclopædia Britannica article Chiropractic.|