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Chiropractic (from Greek chiro- χειρο- "hand-" + praktikós πρακτικός "concerned with action") is a complementary and alternative medicine health care profession concerned with the 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. There is an emphasis on manual therapy including spinal adjustment and other joint and soft-tissue manipulation. Council on Chiropractic Education (2007). Standards for Doctor of Chiropractic programs and requirements for institutional status (PDF). Retrieved on 2008-02-14. 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, the progressive view examines the relationship between structure and function and its impact on neurological mechanisms in both health and disease.National Center for Complementary and Alternative Medicine (2007). An introduction to chiropractic. Retrieved on 2008-02-14.American Chiropractic Association. A history of chiropractic care. Retrieved on 2008-02-14.Chiropractic Care and Back Pain. WebMD. WebMD LLC (2008-02-24). Retrieved on 2008-02-25.
Chiropractors, known as Doctors of Chiropractic or chiropractic doctors/physicians, in some jurisdictions,[1][2] use a combination of treatments which are predicated on the specific needs of the individual patient. A chiropractor can develop and carry out a comprehensive treatment/management plan which can include spinal adjustments, soft tissue therapy, prescription of exercises, and health and lifestyle counseling.What Is Chiropractic?
Chiropractic was founded in 1895 by D. D. Palmer in the USA, and is now practiced in more than 100 countries.Federation of Chiropractic Licensing Boards, Questions and Answers about Professional Regulation and the Chiropractic Profession, Where are chiropractors regulated?, January 9, 2006.available onlineMichel Tetrault, DC, Country Chiropractic Support, Chiropractic Diplomatic Corps. available online Since its inception, chiropractic has been the subject of controversy within the profession and among the medical and scientific community, particularly regarding the metaphysical approach espoused by its founders and currently maintained by principle-based (straight) chiropractors. "Subluxation: dogma or science?", Chiropractic & Osteopathy, PubMed. Retrieved on 2008-02-10. Jaroff, Leon. "Back Off, Chiropractors!", CNN, Time magazine, February 27, 2002. Retrieved on 2008-02-10. This same criticism may have been the catalyst that allowed some within the profession to take a more neuromusculoskeletal approach in their educational standards (see Council on Chiropractic Education), leading them away from the more metaphysical explanations of their predecessors towards more scientific ones.Wilk vs American Medical Association Summary:Vivo M, Chiropractors as Primary Care Providers, Dynamic Chiropractic, Jun 4, 2007, accessed October 14, 2007
Chiropractors have historically fallen into two main groups, "straights" and "mixers"; both have had splinter groups. 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.
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Contemporary chiropractic belief systems vary along a philosophical spectrum ranging from vitalism to the 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 allopathic medicine and thereby helping ensure professional autonomy.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, 77–98. ISBN 0-07-137534-1. Chiropractic also retains elements of materialism, the belief that all things have explanations, which forms the basis of science. Contemporary chiropractors 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"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, 65–76. ISBN 0-07-137534-1.
Chiropractors can adopt or share vitalist, naturalist, or materialist viewpoints and emphasize a holistic, patient-centered approach which 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.Hansen DT, Mootz RD (1999). "Formal processes in health care technology assessment: a primer for the chiropractic profession", in Mootz RD, Hansen DT: Chiropractic technologies. Jones & Bartlett, 3–17. ISBN 0834213737.
Chiropractors also commonly use nutrition, exercise, patient education, health promotion and lifestyle counseling as part of their holistic outlook towards preventive health care.Rupert RL (2000). "A survey of practice patterns and the health promotion and prevention attitudes of US chiropractors, maintenance care: part I". J Manipulative Physiol Ther 23 (1): 1–9. doi:10.1016/S0161-4754(00)90107-6. PMID 10658870. 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.Rupert RL, Manello D, Sandefur R (2000). "Maintenance care: health promotion services administered to US chiropractic patients aged 65 and older, part II". J Manipulative Physiol Ther 23 (1): 10–9. doi:10.1016/S0161-4754(00)90108-8. PMID 10658871. For some, prevention includes a concept of "maintenance care" which attempts to "detect and correct" structural imbalances of the neuromusculoskeletal system while in its primary, or functional state.Canadian Chiropractic Association (1996). Glenerin guidelines: preventive maintenance care. Retrieved on 2008-02-26. The objective is early identification of mechanical dysfunctions to prevent subsequent deterioration which would result in permanent pathological changes.Strang VV (1984). Essential Principles of Chiropractic. Davenport, IA: Palmer College of Chiropractic, p. 26. OCLC 12102972.
In summary, the major premises regarding the philosophy of chiropractic include: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, 9–16. OCLC 39856366.
- Holism
- noninvasive, 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 noninvasive 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 whereby 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
| 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 is thousands of years old; it was reemphasized in the late 1800s with the birth of osteopathy and chiropractic, and it gained mainstream recognition during the 1980s (see History). Today manipulative therapy is employed by medical specialists (e.g., physiatrists, orthopedists, sports medicine practitioners), and some osteopathic physicians, physical therapists and athletic trainers. [3] In the U.S., chiropractors perform over 90% of all manipulative treatments[4] and consider themselves to be expertly qualified providers of spinal adjustment, manipulation and other manual treatments.World Federation of Chiropractic (2005). WFC consultation on the identity of the chiropractic profession. Retrieved on 2008-02-14.
Manipulation under anesthesia or MUA is a specialized procedure that requires direct medical supervision and typically occurs in hospitals. MDs administer general anaesthesia and DCs administer spinal manipulation. Typically, it is performed on patients who have failed to respond to other forms of treatment.[citation needed]
Common themes to chiropractic care include holistic, conservative and non-medication approaches via manual therapy. Nevertheless, there are significant differences amongst the practice styles, claims and beliefs between various chiropractors.James W. Healey, DC (1990) It\'s Where You Put the Period. Dynamic Chiropractic, October 10, 1990, Volume 08, Issue 21 Those differences are reflected in the varied viewpoints of multiple national practice associations.[5]
Straight chiropractors are the oldest movement. They adhere to the philosophical principles set forth by D. D. and B. J. Palmer, retaining metaphysical definitions and vitalistic qualities. Straight chiropractors suggest 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. Objective Straight chiropractors, a recent offshoot, is differentiated from traditional straights mainly by the claims made. While traditional straights claimed that chiropractic adjustments are a plausible treatment for a wide range of diseases, objective straights only focus on the correction of chiropractic vertebral subluxations.[citation needed]
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, mixer chiropractors 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.Kaptchuk TJ, Eisenberg DM (1998). "Chiropractic: origins, controversies, and contributions". Arch Intern Med 158 (20): 2215–24. PMID 9818801. They tend to focus more on the neuromusculoskeletal system but also treat non-neuromusculoskeletal conditions as well. Mixers tend to use more mainstream scientific methods and descriptions as opposed to metaphysical ones, but a minority of practitioners still employ questionable techniques and devices regarded as dubious by the scientific and medical communities. Reform chiropractors are a recent evidence-based off-shoot of mixers who use scientifically-oriented methods and protocols and primarily regard themselves as neuromusculoskeletal specialists. Reform minded chiropractors have rejected traditional chiropractic theory, practice a manual medicine[6] and favour limited prescription rights yet retain holistic and naturopathic elements. Reform chiropractors support the scientific validity and cost-effectiveness of vaccination. In contrast to straight chiropractors, mixers and reformers generally want to be integrated into mainstream health care via integrative medicine.[citation needed]
There have been some calls to differentiate reform or \'contemporary\' chiropractors from both straight and mixer chiropractors by establishing a Doctor of Chiropractic Medicine (D.C.M.) degree. It is argued this would distinguish them from previous diplomas, and would allow current DCs to upgrade their education to the DCM degree which would permit DCMs to utilize prescription drugs suitable to the limitations of their practices and have a unified scope of practice across all jurisdictions.[7] "The Skeptical Inquirer magazine blasts chiropractic as unscientific \'societal problem\'", The Chiropractic Journal, January 1988. Retrieved on 2008-02-02.
It is generally not within the scope of practice of chiropractors to write medical prescriptions. A notable exception is the state of Oregon, which allows chiropractors with minor additional qualification to prescribe over-the-counter drugs.[citation needed] Traditionally, chiropractors have opposed prescription drugs, but recently a majority of North American chiropractors have supported limited prescription rights.McDonald WP (2003). How Chiropractors Think and Practice: The Survey of North American Chiropractors. Ada, OH: Institute for Social Research, Ohio Northern University. ISBN 0972805559. Depending on the country or state in which a chiropractic school is located, some chiropractors may obtain additional training to perform minor surgery, obstetrics and proctology.Oregon Chiropractic Licensing Information. When indicated, the doctor of chiropractic consults with, co-manages with, or refers to other health care providers.
Utilization rates for chiropractic vary depending on the study, but generally fall into a range from around 6% to around 12% of the U.S. and Canadian populations, with a global high of 20% in Alberta.[8] The vast majority who seek chiropractic care do so for relief from back and neck pain and other neuromusculoskeletal complaints;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. PMID 16600038. most do so 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.Lawrence DJ, Meeker WC (2007). "Chiropractic and CAM utilization: a descriptive review". Chiropr Osteopat 15 (2). doi:10.1186/1746-1340-15-2. PMID 17241465. Chiropractic care has historically had a high rate of patient satisfaction which helped it survive and eventually grow as profession.[citation needed] A 2006 U.S. survey found that 83% of patients were very satisfied or satisfied with their care. Satisfaction rates are typically higher for chiropractic than for MD care, with quality of communication seeming to be a consistent predictor of patient satisfaction with chiropractors.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. Despite high patient satisfaction scores, utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient.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, 111–34. ISBN 0-07-137534-1. 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.Bureau of Labor Statistics (2007). Occupational outlook handbook. Retrieved on 2008-02-14.
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,Dean C. Swedlo, "The Historical Development of Chiropractic." pp. 55-58, The Proceedings of the 11th Annual History of Medicine Days, Faculty of Medicine, The University of Calgary as did the ancient Egyptians and many other cultures. A modern reemphasis on manipulative therapy occurred near the turn of the 20th century in North America with the emergence of the osteopathy, founded by Andrew Still in 1874; chiropractic, founded by Daniel David Palmer in 1895 in Davenport, Iowa; and naprapathy, founded by Oakley Smith in 1907.Keating JC Jr (2003). "Several pathways in the evolution of chiropractic manipulation". J Manipulative Physiol Ther 26 (5): 300–21. doi:10.1016/S0161-4754(02)54125-7. PMID 12819626.
D.D. Palmer gave the first spinal adjustment to a deaf janitor, Harvey Lillard, on September 18, 1895, reportedly resulting in a restoration of the man\'s hearing.Palmer D.D., The Science, Art and Philosophy of Chiropractic. Portland, Oregon: Portland Printing House Company, 1910. Palmer had discovered that manual manipulation of the spine could result in improved neurological function. Friend and Rev. Samuel Weed suggested combining the words cheiros and praktikos (meaning "done by hand") and chiropractic was born. Palmer claimed that vertebral joint misalignments, which he termed "Subluxations" interfered with the body\'s function and its inborn ability to heal itself.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, 23–64. ISBN 0-07-137534-1. This concept was later expanded upon by his son, B.J. Palmer.
D.D. Palmer, using a vitalistic approach, imbued the term subluxation with a metaphysical and philosophical meaning. He held that a malposition of spinal bones, which protect the spinal cord and nerve roots, interfered with the transmission of nerve impulses. Because half of the nervous system is sensory and the other half motor (control), he postulated that living things had an Innate intelligence, a kind of "spiritual energy" or life force that received the sensory information from the various parts of the body and made a decision as to what the motor nerves should convey. D.D. Palmer claimed that subluxations interfered with this innate intelligence, and that by fixing them, all diseases could be treated.Palmer D.D., The Science, Art and Philosophy of Chiropractic. Portland, Oregon: Portland Printing House Company, 1910.
Early on, the Palmers described this concept as similar to applying pressure to a water hose that supplies a garden: relieve the pressure and the garden flourishes. It was later theorized that a vertebral subluxation was a misaligned vertebra that pinched a nerve. They thought that this interfered with the information the nerve was transmitting between the central nervous system and the structures of the body. He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic.Keating J (1995), D.D. Palmer\'s Forgotten Theories of Chiropractic, A Presentation to the Canadian Memorial Chiropractic College
In 1996, the vertebral subluxation was defined as "a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health", though this definition has come under critique both internally and externally for its ambiguity.Association of Chiropractic Colleges, Chiropractic Paradigm More recently, in 2005, the World Health Organization defined the vertebral subluxation 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."World Health Organization (2005). "WHO guidelines on basic training and safety in chiropractic" (PDF). Retrieved on 2008-02-29.
Nevertheless, the debate about the need to remove the concept of subluxation from the chiropractic paradigm has been ongoing since the mid 1960s. While straights hold firmly to the term and its vitalistic construct, reformers suggest that the mechanistic model will allow chiropractic to better integrate into mainstream medicine without making claims inherent in the term. Anthony Rosner PhD, director of education and research at the Foundation for Chiropractic Education and Research (FCER) considered subluxation and the concept of Occam\'s razor. He suggests
In general, critics of chiropractic subluxation are skeptical on its clinical value and philosophical merits. This is still a continuing source of contention within the chiropractic profession as well, with certain chiropractic schools still teaching the straight/traditional metaphysical model of subluxation while others have moved towards a scientific and evidence-based model.Undergraduate and Graduate Programs, Canadian Memorial Chiropractic CollegePDF online
Note the difference between a chiropractic subluxation and its use in Medicine and Ophthalmology. See subluxation.
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.Keating J. (1999), Tom Moore Defender of Chiropractic Part 1, Dynamic Chiropractic
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".[cite this quote] 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 [allopaths] 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…"Strang VV (1984). Essential Principles of Chiropractic. Davenport, IA: Palmer College of Chiropractic, p. 26. OCLC 12102972.
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..Robbins J (1996),Medical monopoly: the game nobody wins - excerpt from \'Reclaiming Our Health: Exploding the Medical Myth and Embracing the Source of True Healing\', Vegetarian Times available online 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. The AMA lost its appeal to the Supreme Court, and could no longer prevent medical physicians from collaborating with chiropractors.Wilk vs American Medical Association Summary Judge Susan Getzendanner, who presided over the Wilk case, opined:
:"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".[citation needed]
In 1975, the National Institutes of Health brought chiropractors, osteopaths, medical doctors and Ph.D. scientists together in a conference on spinal manipulation to develop strategies to study the effects of spinal manipulation. In 1978, the Journal of Manipulative & Physiological Therapeutics (JMPT) was launched.Keating J Faulty Logic & Non-skeptical Arguments in Chiropractic Joseph Keating dates the birth of chiropractic as a science to a 1983 commentary in JMPT entitled "Notes from the (chiropractic college) underground" in which Kenneth F. DeBoer, then an instructor in basic science at Palmer College in Iowa, revealed the power of a scholarly journal (JMPT) to empower faculty at the chiropractic schools. DeBoer\'s opinion piece demonstrated the faculty\'s authority to challenge the status quo, to publicly address relevant, albeit sensitive, issues related to research, training and skepticism at chiropractic colleges, and to produce "cultural change" within the chiropractic schools so as to increase research and professional standards. It was a rallying call for chiropractic scientists and scholars. Spinal manipulative therapy gained recognition by mainstream medicine during the 1980s.[9]
| 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 |
Chiropractic researchers Robert Mootz and Reed Phillips suggest that, in chiropractic\'s early years, influences from both straight and mixer concepts were incorporated into its construct. They conclude that chiropractic has both materialistic qualities that lend themselves to scientific investigation and vitalistic qualities that do not.
With relatively little federal funding, academic research in chiropractic has only recently become established in the USA. In 1994 and 1995, half of all grant funding to chiropractic researchers was from the US Health Resources and Services Administration (7 grants totaling $2.3 million). The Foundation for Chiropractic Education and Research (11 grants, $881,000) and the Consortium for Chiropractic Research (4 grants, $519,000) accounted for most of the rest. By 1997, there were 14 peer-reviewed chiropractic journals in English that encouraged the publication of chiropractic research, including The Journal of Manipulative and Physiological Therapeutics (JMPT), Topics in Clinical Chiropractic, and the Journal of Chiropractic Humanities. However, of these, only JMPT is indexed in MEDLINE. Research into chiropractic, whether from Universities or chiropractic colleges, is however often published in many other scientific journals.Chirofind.com Chiropractic Research
While there is still debate about the effectiveness of chiropractic for the many conditions in which it is applied, chiropractic seems to be most effective for acute low back pain and tension headaches.McCrory DC, et al. (2001) Evidence Report: Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache. Duke University Evidence-Based Practice Center, Durham, North Carolina available online (PDF format) One small pilot study has shown that upper cervical spinal manipulation may be beneficial for certain types of hypertension.Bakris, G "Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study" Journal of Human Hypertension (2007) 21, 347–352. doi:10.1038/sj.jhh.1002133; published online 2 March 2007 Complete article
When testing the efficacy of health treatments, double blind studies are considered acceptable scientific rigor. These are designed so that neither the patient nor the doctor knows whether they are using the actual treatment or a placebo (or "sham") treatment. However, chiropractic treatment involves a manipulation; "sham" procedures cannot be easily devised for this, and even if the patient is unaware whether the treatment is a real or sham procedure, the doctor cannot be unaware. Thus there may be "observer bias" - the tendency to see what you expect to see, and the potential for the patient to wish to report benefits to "please" the doctor. Similarly, it is often difficult to devise a sham procedure for surgical procedures, but it is not impossible. It is also a problem in evaluating treatments; even when there are objective outcome measures, the placebo effect can be very substantial. Thus, DCs have historically relied mostly on their own clinical experience and the shared experience of their colleagues, as reported in case studies, to direct their treatment methods. Consequently there has been a call to increase qualitative research studies which can better examine the whole chiropractic clinical encounter.
The Manga Report was an outcomes-study funded by the Ontario Ministry of Health and conducted by three health economists led by Professor Pran Manga. The Report supported the scientific validity, safety, efficacy, and cost-effectiveness of chiropractic for low-back pain, and found that chiropractic care had higher patient satisfaction levels than conventional alternatives. The report states that "The literature clearly and consistently shows that the major savings from chiropractic management come from fewer and lower costs of auxiliary services, fewer hospitalizations, and a highly significant reduction in chronic problems, as well as in levels and duration of disability."Manga P, Angus D. (1998) Enhanced Chiropractic Coverage Under OHIP as a Means of Reducing Health Care Costs, Attaining Better Health Outcomes and Achieving Equitable Access to Health Services. Retrieved 08 29 2006, from OCA
In 1998, a study of 10,652 Florida workers\' compensation cases was conducted by Steve Wolk. He concluded that "a claimant with a back-related injury, when initially treated by a chiropractor versus a medical doctor, is less likely to become temporarily disabled, or if disabled, remains disabled for a shorter period of time; and claimants treated by medical doctors were hospitalized at a much higher rate than claimants treated by chiropractors."Wolk S. (1988) An analysis of Florida workers\' compensation medical claims for back-related injuries. J Amer Chir Ass 27:50-59 Similarly, a 1991 study of Oregon Workers\' Compensation Claims examined 201 randomly selected workers\' compensation cases that involved disabling low-back injuries: when individuals with similar injuries were compared, those who visited DCs generally missed fewer days of work than those who visited MDs.Nyiendo J. (1991) Disability low back Oregon workers\' compensation claims. Part II: Time loss. J Manip Physiol Ther 14:231-239
A 1989 study analyzed data on Iowa state records from individuals who filed claims for back or neck injuries. The study compared benefits and the cost of care from MDs, DCs and DOs, focusing on individuals who had missed days of work and who had received compensation for their injuries. Individuals who visited DCs missed on average 2.3 fewer days than those who visited MDs, and 3.8 fewer days than those who saw DOs, and accordingly, less money was dispersed as employment compensation on average for individuals who visited DCs.Johnson M. (1989) A comparison of chiropractic, medical and osteopathic care for work-related sprains/strains. J Manip Physiol Ther 12:335-344
In 1989, a survey by Cherkin et al. concluded that patients receiving care from health maintenance organizations in the state of Washington were three times as likely to report satisfaction with care from DCs as they were with care from other physicians. The patients were also more likely to believe that their chiropractor was concerned about them.Cherkin CD, MacCornack FA, Berg AO (1988) Managing low back pain. A comparison of the beliefs and behaviours of family physicians and chiropractors.West J Med 149:475–480
In 1997, the following statement was adopted as policy of the AMA after a report on a number of alternative therapies.AMA (CSAPH) Report 12 of the Council on Scientific Affairs (A-97) Full Text Specifically about chiropractic care it said,"Manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints." 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. (V, VI)"AMA (Professionalism) E-3.041 Chiropractic
The British Medical Association notes that "There is also no problem with GPs [doctors] 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."British Medical Association, "Referrals to complementary therapists"
Chiropractic care in general, and chiropractic manipulation in particular, are safe when employed skilfully and appropriately. As with all treatments, complications can arise and there are known contraindications and risks.
Absolute contraindications, such as rheumatoid arthritis, prohibit employing manipulation. Relative complications, such as osteoporosis, mean the increased risk is acceptable under some conditions. Although most contraindications apply only to manipulation of the affected region, a few emergency conditions, such as visual field defects, absolutely contraindicate all chiropractic treatment.Anderson-Peacock E, Blouin JS, Bryans R et al. (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. Anderson-Peacock E, Bryans B, Descarreaux M et al. (2008). "A clinical practice guideline update from The CCA•CFCREAB-CPG" (PDF). J Can Chiropr Assoc 52 (1): 7–8.
Risks can reasonably be considered slight when compared to all forms of medical treatment.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. Spinal manipulation is statistically associated with frequent, mild and temporary adverse effects; they have been estimated to occur in 34% to 55% of patients, with 80% of them disappearing within 24 hours. The most common minor side effects reported in a 2007 study of cervical spine manipulation were new or worsening pain in the head, neck, arm or upper back; and stiffness of the neck, shoulder or arm.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. PMID 17906581. Spinal manipulation, particularly on the upper spine, can also result in rare complications that can lead to permanent disability or death; these can occur in adultsErnst E (2007). "Adverse effects of spinal manipulation: a systematic review". J R Soc Med 100 (7): 330–8. PMID 17606755. and children.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. The incidence of these complications is unknown, due to rarity, high levels of underreporting, and difficulty of linking manipulation to adverse effects. Vertebrobasilar artery stroke, the most commonly reported serious complication, is 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.Haldeman S, Carroll L, Cassidy JD, Schubert J, Nygren Å (2008). "The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders: executive summary". Spine 33 (4 Suppl): S5–7. doi:10.1097/BRS.0b013e3181643f40. PMID 18204400.
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. Evidence-based chiropractors have embraced vaccination, but a minority of the profession rejects it, as traditional chiropractic philosophy traces diseases to causes in the spine and states that diseases cannot be affected by vaccines.Campbell JB, Busse JW, Injeyan HS (2000). "Chiropractors and vaccination: a historical perspective". Pediatrics 105 (4): e43. PMID 10742364. 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.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.
Today, there are 15 accredited Doctor of Chiropractic programs in 18 locations in the USA and two 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 50 other countries. In the USA and Canada, licensed individuals who practice chiropractic are commonly referred to as chiropractors, doctors of chiropractic (DC), or chiropractic physicians.[citation needed]
