Chiropractic

Chiropractic (from Greek chiro- χειρο- "hand-" + praktikós πρακτικός "concerned with action") is a complementary and alternative medicine health care profession that focuses on diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system and the effects of these disorders on the functions of the nervous system and general health. It emphasizes manual therapy including spinal adjustment and other joint and soft-tissue manipulation. Traditionally, it is based on the premise that a vertebral subluxation or spinal joint dysfunction can interfere with the nervous system and result in many different conditions of diminished health. Today, this alternative form of therapy examines the relationship between structure and function and its impact on neurological mechanisms in both health and disease.

Chiropractors usually obtain one of the following equivalent first professional degrees in chiropractic medicine (D.C. or D.C.M. or B.Chiro or M.Chiro). Chiropractors use a combination of treatments that are predicated on the specific needs of the individual patient. A chiropractor can develop and carry out a comprehensive treatment and management plan that can include spinal adjustments, soft tissue therapy, prescription of exercises, and health and lifestyle counseling.

Chiropractic was founded in 1895 by D. D. Palmer in the USA, and is practiced in more than 100 countries. Since its inception, chiropractic has been controversial, both within the profession and in the medical and scientific community, particularly regarding the metaphysical approach espoused by its founders and advocated by "straight" chiropractors. This same criticism may have been the catalyst that allowed some within the profession to emphasize primarily a neuromusculoskeletal approach in their educational curriculum, leading them away from the original metaphysical explanations of their predecessors towards more scientific ones.

Chiropractors have historically fallen into two main groups, "straights" and "mixers"; both have had off-shoots. Significant differences regarding scope of practice, claims made about spinal manipulation, and beliefs regarding professional integration, differentiate the various schools of thought and practice styles held within the profession. There has been internal conflicts that exist to this day. Traditional and evidence-based chiropractic beliefs range from vitalism to materialism.

The utilization of chiropractic has increased in popularity. The profession has remained unified with a continuous committment to clinical care. Chiropractic's greatest contribution to health care may be its patient-physician relationship which is done by hand. Patients are usually satisfied with the treatment they received.

The principles of evidence-based medicine has grown in prominence and have been used to review research studies and generate practice guidelines. The efficacy of chiropractic treatment has not been rigorously proven. Chiropractic care is generally safe when employed skillfully and appropriately. The cost-effectiveness of maintenance chiropractic care is unknown. Vaccination remains controversial within the chiropractic community.

Philosophy

Two chiropractic belief system constructs

THE TESTABLE PRINCIPLE		THE UNTESTABLE METAPHOR
Chiropractic Adjustment		Universal Intelligence
↓		↓
Restoration of Structural Integrity		Innate Intelligence
↓		↓
Improvement of Health Status		Body Physiology
MATERIALISTIC:		VITALISTIC:
— operational definitions possible		— origin of holism in chiropractic
— lends itself to scientific inquiry		— cannot be proven or disproven
taken from Mootz & Phillips 1997

Traditional and evidence-based chiropractic belief systems vary along a philosophical spectrum ranging from vitalism to materialism. These opposing philosophies have been a source of debate since the time of Aristotle and Plato. Vitalism, the belief that living things contain an element that cannot be explained through matter, was responsible for legally and philosophically differentiating chiropractic from conventional medicine and thereby helping ensure professional autonomy. Chiropractic also retains elements of materialism, the belief that all things have explanations, which forms the basis of science. Evidence-based chiropractic balances this dualism by emphasizing both the tangible, testable principle that structure affects function, and the untestable, metaphorical recognition that life is self-sustaining.

The chiropractor's purpose is to foster the establishment and maintenance of an organism-environment dynamic that is the most conducive to functional well-being of the person as a whole. Principles such as holism, naturalism, therapeutic conservatism, critical rationalism, and thoughts from the phenomenological and humanistic paradigms form an important part of the philosophy of chiropractic."

Chiropractors can adopt or share vitalist, naturalist, or materialist viewpoints and emphasize a holistic, patient-centered approach that appreciates the multifactorial nature of influences (i.e. structural, chemical, and psychological) on the functioning of the body in health and disease and recognizes the dynamics and interplay between lifestyle, environment, and health. This holistic paradigm is also blended with a biopsychosocial approach, which is also emphasized in chiropractic care. In addition, chiropractors also retain naturopathic and naturalist principles that suggest decreased "host resistance" of the body facilitates the disease process and that natural interventions are preferable towards strengthening the host in its effort to optimize function and return to homeostasis. Chiropractic care primarily emphasizes manipulation and other manual therapies as an alternative than medications and surgery.

Chiropractors also commonly use nutrition, exercise, patient education, health promotion and lifestyle counseling as part of their holistic outlook towards preventive health care. Chiropractic's claim to improve health by improving biomechanical and neural function by the manual correction of joint and soft tissue dysfunctions of the neuromusculoskeletal system differentiates it from mainstream medicine and other complementary and alternative medicine (CAM) disciplines, but is also rooted, in part, in osteopathy and eastern medicine interventions. All chiropractic paradigms emphasize the spine as their focus, but their rationales for treatment vary depending on their particular belief system.

The philosophy of chiropractic also stresses the importance of prevention and primarily utilizes a pro-active approach and a wellness model to achieve this goal. For some, prevention includes a concept of "maintenance care" that attempts to "detect and correct" structural imbalances of the neuromusculoskeletal system while in its primary, or functional state. The objective is early identification of mechanical dysfunctions to prevent or delay permanent pathological changes.

In summary, the major premises regarding the philosophy of chiropractic include:

• Holism

• non-invasive, emphasizes patient's inherent recuperative abilities
• recognizes dynamics between lifestyle, environment, and health
• spine and health are related in an important and fundamental way, and this relationship is mediated through the nervous system.
• recognizes the centrality of the nervous system and its intimate relationship with both the structural and regulatory capacities of the body
• appreciates the multifactorial nature of influences (structural, chemical, and psychological) on the nervous system

• Conservatism

• balances the benefits against the risks of clinical interventions
• emphasizes non-invasive treatments to minimize risk with a preference to avoid surgery and medication
• recognizes as imperative the need to monitor progress and effectiveness through appropriate diagnostic procedures
• prevents unnecessary barriers in the doctor-patient encounter

• Manual and biopsychosocial approaches

• strives toward early intervention, emphasizing timely diagnosis and treatment of reversible conditions before loss of functionality
• emphasizes a patient-centered model in which the patient is considered to be indispensable in, and ultimately responsible for, the maintenance of health
• approach of improving health through influencing function through structure primarily via manual therapies

Scope of practice

Chiropractors are primary-contact health care practitioners who emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery. Although chiropractors have many attributes of primary care providers, chiropractic has more of the attributes of a medical specialty like dentistry. The practice of chiropractic medicine involves a range of diagnostic methods including skeletal imaging, observational and tactile assessments, orthopedic and neurological evaluation, laboratory tests, and specialized tests. 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 and other manual therapies to the joints and soft tissues
• rehabilitative exercises
• health promotion
• electrical modalities
• conservative and complementary procedures
• lifestyle counseling.

Chiropractors generally cannot write medical prescriptions; a 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for over-the-counter drugs. A notable exception is the state of Oregon which is considered to have an "expansive" scope of practice of chiropractic, which allows chiropractors to prescribe over-the-counter substances and perform minor surgery. In some locations chiropractors (DCs) and veterinarians (DVMs) with additional training and certification can practice veterinary chiropractic which includes the diagnosis, treatment and rehabilitation of injured animals. However, the official position of the American Chiropractic Association is that applying manipulative techniques to animals does not constitute chiropractic and that veterinary chiropractic is a misnomer. Chiropractors are also generally permitted to use adjunctive therapeutic modalities such as acupuncture and manipulation under anesthesia with additional training from accredited universities/colleges.

Chiropractic medicine is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries. Similar to other primary contact health providers, chiropractors can specialize in different areas of chiropractic medicine. The most common post-graduate diplomate programs include neurology, sports sciences, clinical sciences, rehabilitation sciences, orthopedics and radiology which generally require 2–3 additional years of additional post graduate study and passing competency examinations.

Education, licensing, and regulation

Main articles: Chiropractic education and List of chiropractic schools

International training guidelines require that persons without relevant prior health care experience must spend at least 4200 student/teacher contact hours in four years of full‐time education; experienced health professionals need only 2200 hours. Both figures include at least 1000 hours of supervised clinical training. In some countries a license is required in order to practice. To help standardize and ensure quality of chiropractic education and patient safety, in 2005 the World Health Organization published the official guidelines for basic training and safety in chiropractic. Most commonly, chiropractors obtain a first professional degree in the field of chiropractic medicine. Typically a 3 year university undergraduate education is required to apply for the chiropractic degree.

A Chiropractic Examining Board requires all candidates to complete a twelve-month clinical internship to obtain licensure. Licensure is granted following successful completion of all state/provincial and national board exams so long as the DC maintains malpractice insurance. Nonetheless, there are still some variations in educational standards internationally depending on admission and graduation requirements. Chiropractic medicine is regulated in Canada by provincial statute. Regulatory colleges are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency. Today, there are 15 accredited Doctor of Chiropractic programs in 18 locations in the USA and 2 in Canada, and an estimated 70,000 chiropractors in the USA, 6500 in Canada, 2500 in Australia, 2,381 in the UK, and smaller numbers in about 80 other countries.

Treatment procedures

Main article: Chiropractic treatment techniques

Procedures received by more than 1/3 of patients of licensed U.S. chiropractors (2003 survey)

procedure	% of DCs using it	% of patients receiving it
Diversified (full-spine manipulation)	96.2	71.5
Physical fitness/exercise promotion	98.3	64.9
Corrective or therapeutic exercise	98.3	63.2
Ergonomic/postural advice	97.3	61.9
Self-care strategies	96.6	60.6
Activities of daily living	96.6	57.9
Changing risky/unhealthy behaviors	96.6	54.9
Nutritional/dietary recommendations	97.7	51.8
Relaxation/stress reduction recommendations	96.4	50.1
Ice pack/cryotherapy	94.5	48.5
Extremity adjusting	95.4	46.8
Trigger point therapy	91.0	45.3
Disease prevention/early screening advice	90.8	39.7

Spinal manipulation, the most common modality in chiropractic care, is a passive manual maneuver during which a three-joint complex is taken past the normal physiological range of movement without exceeding the anatomical boundary limit. The medicinal use of spinal manipulation can be traced back over 3000 years to ancient Chinese writings. Hippocrates, the "father of medicine" used manipulative techniques, as did the ancient Egyptians and many other cultures. A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of the osteopathic medicine and chiropractic medicine. Spinal manipulation gained mainstream recognition during the 1980s (see History). In the U.S., chiropractors perform over 90% of all manipulative treatments and consider themselves to be expertly qualified providers of spinal adjustment, manipulation and other manual treatments.

Manipulation under anesthesia or MUA is a specialized manipulative procedure that typically occurs in hospitals administered under general anesthesia. Typically, it is performed on patients who have failed to respond to other forms of treatment.

Schools of thought and practice styles

Common themes to chiropractic care include holistic, conservative and non-medication approaches via manual therapy. Still, significant differences exist amongst the practice styles, claims and beliefs between various chiropractors.

Straight

Straight chiropractors are the oldest movement. They 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 within the human nervous system and is a primary underlying risk factor for almost any disease. Straights view the medical diagnosis of patient complaints (which they consider to be the "secondary effects" of subluxations) to be unnecessary for 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. Their philosophy and explanations are metaphysical in nature and prefer to use traditional chiropractic lexicon (i.e. perform spinal analysis, detect subluxation, correct with adjustment, etc.). They prefer to remain separate and distinct from mainstream health care.

Mixer

Range of belief perspectives in chiropractic

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

Mixer chiropractors are an early offshoot of the straight movement. This branch "mixes" diagnostic and treatment approaches from naturopathic, osteopathic, medical, and chiropractic viewpoints. Unlike straight chiropractors, mixers believe subluxation is one of the many causes of disease, and they incorporate mainstream medical diagnostics and employ myriad treatments including joint and soft tissue manipulation, electromodalities, physical therapy, exercise-rehabilitation and other complementary and alternative approaches such as acupuncture. Mixers tend to be open to mainstream medicine. Mixers are the majority group.

Utilization and satisfaction rates

Chiropractic is the largest alternative medical profession in the U.S. and is the 3rd largest doctored profession behind medicine and dentistry in North America. The percentage of population that utilize chiropractic care at any given time generally fall into a range from 6% to 12% in the U.S. and Canada, with a global high of 20% in Alberta. The vast majority who seek chiropractic care do so for relief from back and neck pain and other neuromusculoskeletal complaints; most do so specifically for low back pain. Complementary and alternative medicine (CAM) practitioners such as chiropractors are often used as a complementary form of care to primary medical intervention. Satisfaction rates are typically higher for chiropractic care compared to medical care, with quality of communication seeming to be a consistent predictor of patient satisfaction with chiropractors. Despite high patient satisfaction scores, utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient. The use of chiropractic is growing modestly; CAM as a whole is seeing wholesale increases. Employment of U.S. chiropractors is expected to increase 14% between 2006 and 2016, faster than the average for all occupations.

History

Main articles: Chiropractic history and Vertebral subluxation

File:Ddpalmer3.jpg

D.D. Palmer

Chiropractic (also known as Chiropractic Medicine) was founded in the 1890s by Canadian-American Daniel David Palmer in Davenport, Iowa, USA. Palmer and his son B.J. Palmer later wrote that the elder Palmer gave the first chiropractic adjustment to a deaf man, Harvey Lillard, on September 18, 1895, restoring the man's hearing. Lillard's daughter disputed the account, saying that Palmer had merely slapped Lillard on the back after hearing a joke. Investigator Cyrus Lerner found in 1952 that the Lillard story disagreed with other evidence published about the same time, speculated that B.J. concocted the date of the first adjustment in order to establish priority for chiropractic, and compared the Lillard story to the Tales of the Arabian Nights. Palmer hypothesized that manual manipulation of the spine could result in improved neurological function and health. Friend and Rev. Samuel Weed suggested combining the words cheiros and praktikos (meaning "done by hand") and chiropractic was born.

Vertebral subluxation

Palmer hypothesized that vertebral joint misalignments, which he termed "vertebral subluxations," interfered with the body's function and its inborn (innate) ability to heal itself. 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 medicine from conventional medicine. In 1910, D.D. Palmer theorized that the nervous system controlled health:

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

The concept of subluxation remains unsubstantiated and largely untested, and a debate about whether to keep it in the chiropractic paradigm has been ongoing for decades. 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 (for example, Palmer College of Chiropractic) still teaching the traditional/straight subluxation-based chiropractic, while others (for example, Canadian Memorial Chiropractic College) have moved towards an evidence-based chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions but retains a holistic approach and an emphasis on manual therapy. A 2003 survey of North American chiropractors found that 88% wanted to retain the term vertebral subluxation complex, and that when asked to estimate the percent of visceral ailments that subluxation significantly contributes to, the mean response was 62%. As of 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 definition is different from the current medical definition, in which subluxation is a significant structural displacement, and therefore visible on static imaging studies."

Medical opposition

In 1899, a medical doctor in Davenport, USA, named Heinrich Matthey started a campaign against drugless practitioners. D.D. Palmer insisted that his techniques did not need the same courses or license as medical doctors, as his graduates did not prescribe drugs, perform surgery or evaluate laboratory diagnostics. However, in 1906, D.D. Palmer was convicted for practicing medicine without a license. In response, B.J. created the Universal Chiropractic Association (UCA) for the purpose of protecting its members by covering their legal expenses should they get arrested for practicing medicine.

File:BJPalmer2.jpg

BJ Palmer, Developer of Chiropractic, 1882-1961

Its first case came in 1907, when Shegataro Morikubo, DC was charged with unlicensed practice of osteopathic medicine in Wisconsin. Morikubo was freed using the defense that chiropractic philosophy was different from osteopathic philosophy. The victory reshaped the development of the chiropractic profession, which then marketed itself as a science, an art and a philosophy. This began a longstanding feud between chiropractors and medical doctors that would culminate in the mid 1980's in a landmark case, Wilk et al. vs American Medical Association (AMA). Until 1983, the AMA held that it was unethical for medical doctors to associate with an "unscientific practitioner," and labeled chiropractic "an unscientific cult." In 1984, Joseph Janse, DC, ND, attempted to describe the divide in chiropractic and medical philosophy regarding prevention and patient care:

"Unless pathology is demonstrable under the microscope, as in the laboratory or by roentgenograms, to them [medical doctors] it does not exist. For years the progressive minds in chiropractic have pointed out this deficiency. With emphasis they [chiropractors] have maintained the fact that prevention is so much more effective than attempts at a cure. They pioneered the all-important principle that effective eradication of disease is accomplished only when it is in its functional (beginning) phase rather than its organic (terminal) stage. It has been their contention that in general the doctor, the therapist and the clinician have failed to realize exactly what is meant by disease processes, and have been satisfied to consider damaged organs as disease, and to think in terms of sick organs and not in terms of sick people. In other words, we have failed to contrast disease with health, and to trace the gradual deteriorization along the downward path, believing almost that mild departures from the physiological normal were of little consequence, until they were replaced by pathological changes…"

In 1992, the AMA stated "It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient. A physician may refer a patient for diagnostic or therapeutic services to a chiropractor permitted by law to furnish such services whenever the physician believes that this may benefit his or her patient. Physicians may also ethically teach in recognized schools of chiropractic." In 1997, the following literature was adopted as policy of the AMA after a report on a number of alternative therapies. The report said (about chiropractic care): "Manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints."

The British Medical Association (BMA) notes that "There is also no problem with GPs referring patients to practitioners in osteopathy and chiropractic who are registered with the relevant statutory regulatory bodies, as a similar means of redress is available to the patient." In 1997, the BMA identified chiropractic health care as having "the potential for greatest use alongside orthodox medical care."

Internal conflicts

Straights and mixers have had conflicts that continue to this day. Objective Straight chiropractors, who were an off-shoot of straights, only focused on the correction of chiropractic vertebral subluxations while traditional straights claimed that chiropractic adjustments are a plausible treatment for a wide range of diseases. Reform chiropractors were an evidence-based off-shoot of mixers who rejected traditional Palmer philosophy and tended not to use alternative medicine methods. There is disagreement over what does innate and subluxation mean to chiropractic. Some chiropractors believe in Innate intelligence, an untestable faith-based belief, not of science, which has been a source of derision for chiropractors. In Wisconsin, US, there was local chiropractic support to offset a chiropractic anti-fluoridation campaign.

Wilk et al. vs. American Medical Association

Chester A. Wilk, DC from Chicago initiated an antitrust suit against the AMA and other medical associations in 1976 - Wilk et al. vs AMA et al. The landmark lawsuit ended in 1987 when the US District Court found the AMA guilty of conspiracy and restraint of trade; the Joint Council on Accreditation of Hospitals and the American College of Physicians were exonerated. The court recognized that the AMA had to show its concern for patients, but was not persuaded that this could not have been achieved in a manner less restrictive of competition, for instance by public education campaigns. A summary of the court's opinion concluded:

"Evidence at the trial showed that the defendants took active steps, often covert, to undermine chiropractic educational institutions, conceal evidence of the usefulness of chiropractic care, undercut insurance programs for patients of chiropractors, subvert government inquiries into the efficacy of chiropractic, engage in a massive disinformation campaign to discredit and destabilize the chiropractic profession and engage in numerous other activities to maintain a medical physician monopoly over health care in this country."

On February 7, 1990, the AMA lost its appeal, and could no longer prevent medical physicians from collaborating with chiropractors.

Movement toward science

In the first 50 years of chiropractic, there was a lack of research. The terms science and research were often used as marketing tools. Several decades would pass before research and an interest in science became evident in chiropractic. In 1975, chiropractors joined medical and scientific attendees in a workshop sponsored by the National Institutes of Health on the research status of spinal manipulation. In 1978, the Journal of Manipulative & Physiological Therapeutics (JMPT) was launched. In 1983 the JMPT published an article advocating "a scientific institution with some capability for research" and was considered the beginning of the scientific chiropractic movement. Robert S. Francis, DC, states that "Spinal manipulative therapy gained recognition by mainstream medicine during the 1980s." Various chiropractic groups distributed patient brochures with unsubstantiated claims. In the early 1990s there was little scientific research into chiropractic. In 1993, the Manga report funded by the Ministry of Health strongly supported chiropractic care for lower back pain. At the time, the Manga report "caused ripples throughout the traditional medical community when it concluded that chiropractic management of low-back pain is both more effective and cost-effective than traditional medical treatment." A 2001 study says "The Manga report was not a controlled clinical trial but a review of the literature that offered an opinion that has not been experimentally established." In 1998, historian Joseph Keating Jr wrote that "substantial increases in scholarly activities within the chiropractic profession are suggested by the growth in scholarly products published in the discipline's most distinguished periodical (JMPT). Increases in controlled outcome studies, collaboration among chiropractic institutions, contributions from nonchiropractors, contributions from nonchiropractic institutions and funding for research suggest a degree of professional maturation and growing interest in the content of the discipline." A 2002 study states "Chiropractic theory is still controversial, but recent expansion in federal support of chiropractic research bodes well for further scientific development. The medical establishment has not yet fully accepted chiropractic as a mainstream form of care. The next decade should determine whether chiropractic maintains the trappings of an alternative health care profession or becomes fully integrated into all health care systems." Chiropractic began a century ago in simplistic terms but as the profession developed it is now well established with many chiropractic colleges worldwide. There are barriers between primary care physicians and chiropractors for having positive referral relationships. Despite internal debate and external opposition, its unified profession suggests it will endure as a relevant component of health care.

Scientific research

The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under managed care. Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs pseudoscientific and antiscientific reasoning and makes unsubstantiated claims. 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. Evidence-based chiropractors possess the ability to apply research in practice. Continued education enhances the scientific knowledge of the practitioner.

Effectiveness

The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective. Chiropractic care, like all medical treatment, benefits from the placebo response. The efficacy of maintenance care in chiropractic is unknown.

Research has focused on spinal manipulation therapy (SMT) in general, rather than specifically on chiropractic SMT. Many controlled clinical studies of SMT are available, but their results disagree, and they are typically of low quality. It is hard to construct a trustworthy placebo for clinical trials of SMT, as experts often disagree whether a proposed placebo actually has no effect. Although a 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference, a 2008 supportive review found serious flaws in the critical approach, and found that SMT and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments.

Available evidence covers the following conditions:

• Chiropractic management of Low back pain.

Evidence indicates that spinal manipulation can provide mild-to-moderate relief from low-back pain. It appears to be as effective as conventional treatments, and recent guidelines for health care practitioners include it as a treatment option for pain that does not improve with self-care. Spinal manipulation is generally a safe treatment for low-back pain. The most common side effects (e.g., discomfort in the treated area) are minor and go away within 1 to 2 days. Serious complications are very rare. Patients tend to prefer chiropractic care for management of low back pain compared to standard medical care. Recent research into spinal manipulation for low-back pain has begun to look at the effects of different forms of manipulation, as well as treatment duration and frequency. Grading of the evidence regarding the efficacy of SMT appears to be inconsistent A 2008 review found strong evidence that SMT is similar in effect to medical care with exercise, and moderate evidence that SMT is similar to physical therapy and other forms of conventional care. A 2007 literature synthesis found good evidence supporting SMT for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain. A 2004 Cochrane review () stated that SMT or mobilization is just as effective than other standard interventions for back pain.

• Whiplash and other neck pain. There is no overall consensus on manual therapies for neck pain. A 2008 review found evidence that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SMT, mobilization, supervised exercise, low-level laser therapy and perhaps acupuncture are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves prognosis. A 2007 review found that SMT and mobilization are effective for neck pain. Of three systematic reviews of SMT published between 2000 and May 2005, one reached a positive conclusion, and a 2004 Cochrane review () found that SMT and mobilization are beneficial only when combined with exercise, the benefits being pain relief, functional improvement, and global perceived effect for subacute/chronic mechanical neck disorder. A 2005 review found limited evidence supporting SMT for whiplash.

• Headache. A 2006 review found no rigorous evidence supporting SMT 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 review found that SMT may be effective for migraine and tension headache, and SMT and neck exercises may be effective for cervicogenic headache.

• Other. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs, and a lack of higher-quality publications supporting chiropractic management of leg conditions. A 2007 literature synthesis found fair evidence supporting assurance and advice to stay active for sciatica and radicular pain in the leg. 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 SMT) provides benefit to patients with asthma, cervicogenic dizziness, and baby colic, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizzinesss, and vision conditions. Other reviews have found no evidence of benefit for baby colic, bedwetting, fibromyalgia, or menstrual cramps.

Safety

Chiropractic care in general is safe when employed skillfully and appropriately. Its primary therapeutic procedure, spinal manipulation, involves directed thrust to move a joint past its physiological range of motion without exceeding the anatomical limit. 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 manipulation 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.

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 34% to 55% of patients, with 80% of them disappearing within 24 hours. 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. The incidence of these complications is unknown, due to rarity, high levels of underreporting, and difficulty of linking manipulation to adverse effects such as stroke, a particular concern. Several case reports show temporal associations between interventions and potentially serious complications. Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions. Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.

Cost-benefit

The cost-effectiveness of maintenance chiropractic care is unknown and not well researched. Of the limited quantity of studies found, there is diversity in the findings. Of the various interventions available, the most cost-effective treatment for lower back pain could not be determined because of the lack of more higher quality evaluations. Spinal manipulation appears to be relatively cost-effective for chronic lower back pain. The cost-effectiveness of spinal manipulation therapy has not been demonstrated beyond a reasonable doubt. The data indicates that SMT typically represents an additional cost to conventional treatment. After initial therapy, preliminary evidence suggests that massage but not spinal manipulation may reduce the costs of care. Chiropractic managed care may reduce overall health care costs.

The benefits of chiropractic care for neck pain seems to outweigh the possible risk. When comparing primary care physicians (PCPs) medical management to nonsurgical nonpharmaceutical chiropractic management approaches (CAM-oriented PCPs), a followup study demonstrated with some reservations both a reduction in clinical and cost utilization of in-hospital admissions, hospital days, outpatient surgeries and procedures, and pharmaceutical costs when compared with using conventional medicine IPA performance alone. When compared with treatment options such as physiotherapeutic exercise (also performed by a chiropractor), the risk-benefit balance does not favor SMT. In occupational low back pain, the research found that shorter chiropractor care had a benefit for reducing work-disability recurrence and a longer chiropractic care did not show a benefit for preventing work-disability recurrence. SMT helps to reduce time lost due to workplace back pain, and thus employer savings.

Vaccination

Although vaccination is one of the most cost-effective forms of prevention against infectious disease, it remains controversial within the chiropractic community. Most chiropractic writings on vaccination focus on its negative aspects, claiming that it is hazardous or ineffective. Evidence-based chiropractors have embraced vaccination, but a minority of the profession rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that diseases cannot be affected by vaccines. The American Chiropractic Association and the International Chiropractic 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; surveys in Canada in 2000 and 2002 found that 40% of chiropractors supported vaccination, and that over a quarter opposed it and advised patients against vaccinating themselves or their children.

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