Chiropractic

Template:Totally disputed Chiropractic, or chiropractic care, is a Complementary and Alternative Medicine (CAM) health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. There is an emphasis on manual treatments including spinal manipulations termed "adjustments." Evidence for the clinical efficacy of chiropractic does not meet the scientific standards of evidence-based medicine, and thus, has generated significant controversy since its inception.

Introduction

Chiropractic was founded in 1895 by Daniel David Palmer, and was based on the belief that all health problems could be prevented and treated using "adjustments" of the spine, and sometimes other joints, to correct what he termed "subluxations". He postulated that these subluxations occurred from nerve compression or "interference" when two adjacent vertebrae became misaligned causing subsequent problems in more distant body parts or organ systems connected by that particular nerve. For a variety of reasons, this one idea has yet to pass scientific muster and has led to controversy among chiropractors and allopaths as well as parts of the scientific community. Regardless, a majority of chiropractors still believe that subluxations play a significant role in all or most diseases and practice accordingly, while others choose to limit their practices to the care of low back and neck pain. In the U.S. and Canada, chiropractors are also commonly referred to as "doctors of chiropractic" or "chiropractic physicians".

The main chiropractic technique is joint manipulation (called "adjustment"), especially of the spine. Spinal adjustments may provide short-term relief of certain forms of back and neck pain, headaches, and other spine-related conditions, but studies show conflicting results. A recent (2006) systematic review of systematic reviews of spinal manipulation published in The Journal of The Royal Society of Medicine concluded "Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment." [1]

A 2005 study stated that "the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs."

Chiropractic is used by some professional athletes, and, for example, the U.S. Olympic Medical Services Staff includes doctors of chiropractic who work with medical doctors for the benefit of the athletes. [2] Doctors of chiropractic may also employ massage and physiotherapists as adjuncts to chiropractic care.

The U.S. Department of Labor's Occupational Outlook Handbook said:

Because chiropractors emphasize the importance of healthy lifestyles and do not prescribe drugs or perform surgery, chiropractic care is appealing to many health-conscious Americans. Chiropractic treatment of the back, neck, extremities, and joints has become more accepted as a result of research and changing attitudes about alternative, noninvasive health care practices. [3]

According to a 2002 survey released in 2004 by the National Center for Complementary and Alternative Medicine, chiropractic was the fourth most commonly used complementary and alternative medicine therapy among adults in the United States (7.5%). It is now practiced in hundreds of different ways.

Although chiropractic gained more acceptance from the 1960's, its popularity is declining. The U.S. National Center for Education Statistics reports that enrollments for sixteen U.S. chiropractic programs fell by 39.9% from 16,500 in 1996 to 9,921 in 2002, and the number of chiropractic patients fell by 25% from 1997 to 2002.

History

Chiropractic was founded by Daniel David Palmer in Davenport, Iowa. He said he "received chiropractic from the other world", from a deceased physician named Dr. Jim Atkinson. [4] [5] D.D. Palmer regarded chiropractic as partly religious in nature, and in a letter of May 4, 1911 he said: "we must have a religious head, one who is the founder, as did Christ, Mohamed, Jo. Smith, Mrs. Eddy, Martin Luther and other who have founded religions. I am the fountain head. I am the founder of chiropractic in its science, in its art, in its philosophy and in its religious phase." [6]

Keating et al writing for the Association for the History of Chiropractic said D.D. Palmer

"introduced the concept of Innate Intelligence circa 1904. Innate, he believed, was an intelligent entity which directed all the functions of the body, and used the nervous system to exert its influence. (Donahue 1986, 1987)."

Many chiropracters are innatist.

Palmer’s son B. J. Palmer initiated research, development and promotion of chiropractic.

DD Palmer's effort to find a single cause for all disease led him to say:

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. (From: Palmer D.D. The Science, Art and Philosophy of Chiropractic. Portland, Oregon: Portland Printing House Company, 1910.)

The term chiropractic originated when Palmer asked a patient - Rev. Samuel Weed - to come up with a name from the Greek language to describe his practice. Weed suggested combining the words chiros and praktikos (meaning "done by hand") to describe the adjustment of a vertebra in the spinal column.

Conflicting accounts of origins of spinal manipulation

Palmer and his patient Harvey Lillard give differing accounts of when and how Palmer began to experiment with spinal manipulation. Palmer recalled an incident in 1895 when he was investigating the medical history of a deaf janitor, Harvey Lillard. Lillard informed Palmer that while working in a cramped area seventeen years earlier, he felt a 'pop' in his back, and had been nearly deaf ever since. Palmer’s examination found a sore lump which indicated spinal misalignment and a possible cause of Lillard's deafness. Palmer corrected the misalignment, and Lillard could then hear the wheels of the horse-drawn carts in the street below. Palmer said there was nothing accidental about this, as it was accomplished with an object in view, and the expected result was obtained. There was nothing 'crude" about this adjustment; it was specific so much so that no chiropractor has equalled it.[7]

Palmer's version was disputed by Lillard's daughter, Valdeenia Lillard Simons. She says that her father told her that he was telling jokes to a friend in the hall outside Palmer's office and, Palmer, who had been reading, joined them. When Lillard reached the punch line, Palmer, laughing heartily, slapped Lillard on the back with the hand holding the heavy book he had been reading. A few days later, Lillard told Palmer that his hearing seemed better. Palmer then decided to explore manipulation as an expansion of his magnetic healing practice. Simons said "the compact was that if they can make [something of] it, then they both would share. But, it didn't happen." Westbrooks B. The troubled legacy of Harvey Lillard: the black experience in chiropractic. Chiropractic History 2(1)46­53, 1982.

Wilk et al. vs The American Medical Association

Before 1980, Principle 3 of the American Medical Association Principles of Medical Ethics stated: "A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily professionally associate with anyone who violates this principle." Until 1983, the AMA held that it was unethical for medical doctors to associate with an "unscientific practitioner," and labeled chiropractic "an unscientific cult."

As a result of this policy, an antitrust suit was brought against the AMA and other medical associations in 1976 - Wilk et al v. American Medical Association et al - by Wilk and other chiropractors. The landmark lawsuit ended in 1987 when the Federal Appeals Court found the AMA guilty of conspiracy and restraint of trade; the Joint Council on Accreditation of Hospitals and the American College of Physicians were exonerated. The court recognized that the AMA had to show its concern for patients, but was not persuaded that this objective could not have been satisfied in a manner less restrictive of competition, for instance by public education campaigns. The AMA then lost its appeal to the Supreme Court and had to allow its members to collaborate with chiropractors. ^{PDF of key transcripts}

The judge in the Wilk case said that the AMA had covered up research on the effectiveness of chiropractic for back pain. She then said that chiropractors clearly wanted "a judicial pronouncement that chiropractic is a valid. efficacious, even scientific health care service." She said no "well designed, controlled, scientific study" had been done, and concluded "I decline to pronounce chiropractic valid or invalid on anecdotal evidence." ^{PDF of key transcripts}

Chiropractic subluxation

Palmer imbued the term "subluxation" with a metaphysical and philosophical meaning. He held that certain dislocations of bones interfered with the "innate intelligence", a kind of spiritual energy or life force dependent upon God that connects the brain to the rest of the body. Palmer claimed that subluxations interfered with the proper communication of this innate intelligence with the rest of the body, and that, by fixing them, 100% of all diseases could be treated.

In 1998, Lon Morgan, D.C., wrote, in the Journal of the Canadian Chiropractic Association,

"Innate Intelligence clearly has its origins in borrowed mystical and occult practices of a bygone era. It remains untestable and unverifiable and has an unacceptably high penalty/benefit ratio for the chiropractic profession. The chiropractic concept of Innate Intelligence is an anachronistic holdover from a time when insufficient scientific understanding existed to explain human physiological processes. It is clearly religious in nature and must be considered harmful to normal scientific activity." [8]

In the mid-1990's, the Association of Chiropractic Colleges redefined a subluxation as a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system and general health. In 1997 the Foundation for Chiropractic Education and Research defined a subluxation as a joint problem (whether a problem with the way the joint is functioning, a physical problem with the joint, or a combination of any of these) that affects the function of nerves and therefore affects the body's organs and general health.

Most chiropractors believe that the body has an intelligent and self-healing physiology, that healthcare interventions should consider the person as a whole and that conservative (non-invasive) treatment approaches should be used where possible.

Philosophy of the subluxation

Both chiropractic and mainstream medicine hold that much of the body is controlled by nerve impulses sent to and from the brain along the spinal cord. Whether the brain commanding the foot to move, the foot signaling the brain that it is in pain, or even a simple patellar reflex, the spinal cord is involved. Outgoing impulses from the brain pass down the spinal cord and exit through the appropriate spinal nerve branch held between the vertebrae on either side of the spinal cord. There are 31 pairs of spinal nerves that emerge from the spinal cord; all of which are housed by vertebrae. If the vertebrae are misaligned (subluxated), chiropractic doctors believe that a spinal nerve can be squeezed or pinched and therefore message flow can be compromised. By aligning the vertebrae and removing restrictions on the spinal nerves, chiropractic claims to allow the spinal cord to more effectively relay messages to and from the brain; thus promoting better health.

Science and chiropractic

Chiropractic is controversial because of the lack of scientific evidence for some of the claims made by chiropractors (see [9]). There is scientific agreement that, wherever applicable, an evidence based medicine framework should be used to assess health outcomes, and that systematic reviews with strict protocols are an important part of objectively evaluating the efficacy of treatments. Where evidence from such reviews is lacking, this does not necessarily mean that the treatment is ineffective, only that the case for a benefit of treatment may not have been rigorously established. Organisations such as the Cochrane Collaboration and Bandolier publish such reviews. An editorial in The Journal of Manipulative and Physiological Therapeutics in 2005, The Cochrane Collaboration: is it relevant for doctors of chiropractic?, proposed that involvement in Cochrane collaboration would be a way for chiropractic to gain greater acceptance within medicine. The collaboration has 11,500 contributors from more than 90 countries organised in 50 review groups. For chiropractic, relevant review groups include the Back Group; the Bone, Joint, and Muscle Trauma Group; the Musculoskeletal Group; and the Neuromuscular Disease Group. The editorial states:

"For example, a chiropractor may provide conservative care supported by a Cochrane review to a patient with carpal tunnel syndrome. If the patient's symptoms become progressive, the doctor may consider referring the patient for surgery using a recent Cochrane review that examined new surgical techniques compared with traditional open surgery for the said condition.”"

The Cochrane Collaboration found insufficient evidence that chiropractic is beneficial for asthma, carpal tunnel syndrome, and painful menstrual periods. Bandolier found insufficient evidence that chiropractic is beneficial for migraine, chronic low back pain and menopausal symptoms .

University of Saskatchewan sociologist Leslie Biggs interviewed 600 Canadian chiropractors in 1997, and found that 74.3% of them did not believe that controlled clinical trials were the best way to evaluate chiropractic, and 68.1% believed that most diseases are caused by spinal malalignment. [10]

Many chiropractors [11] claim to treat infantile colic. According to a 1999 survey of the Ontario Chiropractic Association (representing 83% of chiropractors in Ontario), 46% treated children for colic. [12]. In 2001, a Norwegian double-blind study showed that Chiropractic manipulation for infantile colic proved slightly better (10%) than placebo. [13].

Safety

As with all interventions, risks may be associated with spinal manipulation. These risks, although rare, include vertebrobasilar accidents, strokes, disc herniations, vertebral fracture, and cauda equina syndrome, according to Harrison's. Most serious complications occur after cervical (neck) manipulation. The practice of greatest concern is the rotary neck movement, sometimes called "master cervical" or "rotary break", which has led to trauma, paralysis, strokes, and death.

Documented serious complications due to manipulation of the cervical spine are very rare (1 in 3-4 million manipulations or fewer). This estimate is based on many international studies of millions of chiropractic cervical adjustments, spanning from 1965 to the present day. The "one in a million" estimate is echoed in an extensive review of spinal manipulation performed by the RAND corporation. However, in another study, Dvorak cites figures of 1 in 400,000, while Jaskoviak reported approximately 5 million cervical manipulations from 1965 to 1980 at The National College of Chiropractic Clinic in Chicago, without a single case of vertebral artery stroke or serious injury [14]. Less conservative treatments such as neck surgery are also often used for conditions similar to the conditions chiropractors treat using spinal adjustments. Cervical spine surgery has a 3-4% rate of complication and 4,000-10,000 deaths per million neck surgeries.

With studies of this nature it is difficult to determine what percentage of incidents are reported. The RAND study, for example, assumed that only 1 in 10 cases would have been reported. Dr Edzard Ernst surveyed neurologists in Britain for cases of serious neurological complication occurring within 24 hours of cervical spinal manipulation during the past year. 35 cases had been seen by the 24 who responded, and none of those had been reported. His survey led him to conclude that underreporting was closer to 100%, rendering estimates "nonsensical." [15]

A 2001 study in the medical journal Stroke found that vertebrobasilar accidents (VBAs) are five times more likely in those aged <45 years who had visited a chiropractor in the week before the VBA, compared to controls who had not visited a chiropractor. [16]

Chiropractors cite a New Zealand Commission report as supporting the safety of chiropractic. The report said "We are satisfied that chiropractic treatment in New Zealand is remarkably safe." (Report of the Commission of Inquiry Into Chiropractic 1979:p 77). But this was disputed by the judge in the Wilk v. American Medical Association case; on safety, this report was found to be "unsatisfactory", and a review of the New Zealand report by the United States Congress' Office of Technology Assessment found 'serious problems' in the report's treatment of safety and efficacy issues. It concluded that the New Zealand report's review of the safety issue was 'unsatisfactory.' [17]

Chiropractic education, licensing, and regulation

United States

In the United States, graduates of chiropractic school receive the degree Doctor of Chiropractic (D.C.), are referred to as "doctor", and are eligible to seek licensure in all jurisdictions. The Council on Chiropractic Education [18] (CCE) sets minimum guidelines for chiropractic colleges, but additional requirements may be needed for a license depending on the jurisdiction where a chiropractor chooses to practice. Currently all 19 chiropractic institutions in the USA are accredited by the CCE.

Students often enter chiropractic school with a Bachelor's degree, or with three years of post-secondary education in the sciences and other appropriate coursework. However, in 2005 only one chiropractic college required a baccalaureate degree as an admission requirement. [19] The minimum prerequisite for enrollment in a chiropractic college set forth by the CCE is 90 semester hours, and the minimum cumulative GPA for a student entering is 2.50. Commonly required classes include: psychology, biology, organic and inorganic chemistry, and physics. Other common medical classes are: anatomy or embryology, physiology, microbiology, diagnosis, neurology, x-ray, orthopedics, obstetrics/gynecology, histology, and pathology.

In the U.S., chiropractic programs require at least 4,200 hours of combined classroom, laboratory, and clinical experience. The last 2 years stress courses in manipulation and spinal adjustment and provide clinical experience in physical and laboratory diagnosis, orthopedics, neurology, geriatrics, physiotherapy, and nutrition. Graduates must complete 5 years of schooling and pass 4 national board exams to complete their education. To qualify for licensure, graduates must sit for State examination; most State boards require at least 2 years of undergraduate education, and an increasing number require a 4-year bachelor’s degree. All boards require the completion of a 4-year program at an accredited college leading to the Doctor of Chiropractic degree. Once licensed, most States require chiropractors to attend 12-48 hours of continuing education annually.

Chiropractic colleges also offer Postdoctoral training in neurology, orthopedics, sports injuries, nutrition, rehabilitation, industrial consulting, radiology, family practice, pediatrics, and applied chiropractic sciences. After such training, chiropractors may take exams leading to "diplomate" status in a given specialty including orthopedics, neurology and radiology.

Australia

In Australia, chiropractic is taught at three universities: RMIT in Melbourne, Murdoch University in Perth and Macquarie University in Sydney. To be registered by various state Chiropractic Registration Boards, a Bachelor of Chiropractic Science, a Bachelor of Science or health-related degree, plus the successful completion of a full-fee paying postgraduate qualifying program for the Master of Chiropractic is required.

Practice styles and schools of thought

Contemporary chiropractic is divided into three schools of thought - straight, mixer, and reform - which differ in their approaches to patient care. All chiropractic approaches are based on non-invasive, non-medication approaches, with many based on the use of manipulation as a treatment for mechanical musculoskeletal dysfunction of the spine and extremities. The three schools of thought do not correspond exactly to existing membership organizations, but adherents tend to favor certain organizations.

1. Straight chiropractors primarily concern themselves with vertebral subluxation correction. Practitioners often use varying vertebral manipulation techniques known as "adjustments" for the purpose of preventive medicine and pain relief. Straight chiropractors hold that only the body can cure the body. By aligning the vertebrae, straight chiropractors believe that they are clearing nerve impulse restrictions and therefore providing a more efficient dialogue between the brain and the rest of the body's systems, thus putting the body in a better position to cure (or heal) itself. Straight chiropractors are a minority, and tend to be members of the International Chiropractors Association (ICA), and the World Chiropractic Alliance (WCA).
2. Mixing chiropractors combine contemporary medical diagnosis and treatment with chiropractic adjustments. Mixing style practitioners use adjustments to treat chiropractic subluxations, as well as nutrition and naturopathic style remedies for other disorders. Methods used include ultrasound, TENS, rehabilitation or the use of other diagnostic methods such as Applied Kinesiology (AK). Mixing chiropractic is itself divided into conservative and liberal groupsTemplate:Fn. Many mixers are members of the American Chiropractic Association (ACA), but there are also many exceptions.
3. Reform chiropractors are oriented at mainstream medicine, advocating a very limited use of chiropractic primarily for treatment of musculoskeletal conditions.

Most universities teaching chiropractic, including Palmer in Davenport Iowa, use rehabilitation methods, exercise, physiological therapeutics and nutrition. The National College (now University) incorporated physical therapy in 1912, even before there was a profession bearing its name. The profession in the U.S. continues to be divided only into specialities. Some do spine-only, others prefer to do sports and rehabilitation. There are musculoskeletal foci and those who co-manage people with organic problems, MS or cancer along with their regular medical approaches.

See also

• Applied kinesiology
• Manipulative therapy
• Naprapathy
• Osteopathy
• Physical therapy
• Reflexology

External links

Advocacy

Chiropractic organizations

• American Chiropractic Association (ACA)
• British Chiropractic Association (BCA)
• Canadian Chiropractic Association (CCA)
• Japanese Association of Chiropractors (JAC)
• International Chiropractors Association (ICA)
• National Association for Chiropractic Medicine
• World Chiropractic Alliance (WCA)
• World Federation of Chiropractic (WFC)

Chiropractic colleges

• Anglo-European College of Chiropractic
• Association of Chiropractic Colleges
• Canadian Memorial Chiropractic College
• Southern California University of Health Sciences (Los Angeles College of Chiropractic)
• Cleveland Chiropractic College
• Life Chiropractic College West
• Life University School of Chiropractic
• Logan College of Chiropractic
• McTimoney Chiropractic College (UK)
• New York Chiropractic College
• New Zealand College of Chiropractic
• Palmer Chiropractic College
• Parker College of Chiropractic (Dallas, TX)
• Sherman College of Straight Chiropractic (Spartanburg, SC)
• Texas Chiropractic College
• University of Bridgeport College of Chiropractic
• Western States Chiropractic College

Descriptions of chiropractic procedures

• Chiropractic treatments for back pain by Spine-health.com
• Glossary of Chiropractic Terms
• Lower Back Pain Answers

Other resources

• 3D Spine Simulator -- Interactive nerve chart, body posture and subluxation / degeneration models
• Mercola -- alternative health website with many articles about chiropractic treatment
• Chiropractic Resource Organization
• Dynamic Chiropractic Online (ChiroWeb)
• Planet Chiropractic -- More than 1000 Chiropractic related articles
• Today's Chiropractic magazine
• National Upper Cervical Chiropractic Association
• Directory of Chiropractors in the United States
• The Chiropractic Profession and Its Research and Education Programs
• The Future of Chiropractic Revisited: 2005 to 2015

Other

• Cherkin, Daniel C.; Mootz, Robert D. (1997) Chiropractic in the United States: Training, Practice, and Research, available online
• Healey, James W. (1990) "It's Where You Put the Period", Dynamic Chiropractic, Volume 08, Issue 21 (October 10, 1990) available online

Critiques

• Chirobase -- A Skeptical Guide to Chiropractic History, Theories, and Practices, Stephen Barrett
• A Different Way To Heal? -- PBS - Scientific American Frontiers, Web Feature
• Chiropractic, Bonesetting, and Cultism -- Samuel Homola, DC (entire book on-line)
• Chiropractic: science and antiscience and pseudoscience side by side -- Joseph C. Keating, Jr, PhD
• Commentary: The Specter of Dogma -- Joseph C. Keating, Jr., PhD
• Faulty Logic and Non-skeptical Arguments in Chiropractic -- Joseph C. Keating Jr, PhD