Chiropractic

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Chiropractic is a health care discipline which emphasizes the inherent recuperative power of the body to heal itself without drugs or surgery.

Chiropractic is a complementary and alternative health care profession that focuses on treating and preventing mechanical disorders of the musculoskeletal system in an effort to improve body posture and motion. Chiropractors ('doctors of chiropractic', DCs) believe that health can be compromised when vertebral subluxations interfere with the body's ability to maintain adequate posture and proper joint function.

Subluxations can occur after a traumatic injury to the ligaments, muscles or joints that support the spine. This might be either an acute injury, accompanied by immediate pain, or a repetitive type injury, resulting for example from prolonged poor posture. DCs believe that, when neglected, these can lead to accelerated degenerative changes such as arthritis and, by interfering with the nervous system, can result in many different conditions of poor health. In conventional medicine, subluxation means that there is a physical dislocation such that the part is completely out of place, while the chiropractic subluxation includes subtle changes in alignment and function.

Chiropractic was founded in 1895 by Daniel David Palmer, who proposed that virtually all health problems could be treated using 'adjustments' to correct 'subluxations'. He proposed that subluxations were misaligned vertebrae which compressed spinal nerves, interfering with the transmission of what he called Innate intelligence. As a result, the human body would experience 'dis-ease' or disharmony. He compared this to stepping on a hose that slowed the flow of water to a garden: if you take your foot off the hose, the flow returns to normal and the garden will flourish. While the 'pinched garden hose theory' has mostly been abandoned, it is still used in a modified form by some DCs to explain vertebral subluxation to their patients. Most DCs still believe that the vertebral subluxation complex plays a role in most, if not all, diseases.. Template:Alternative medical systems

Chiropractic in practice

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

DCs treat patients with manual and mechanical methods called spinal adjustments. The most common adjustment involves manipulating the spine with a fast but gentle thrust that usually causes a 'popping' sound. The sound is thought to be from a form of cavitation within the fluid-filled diarthrodial joints. During a manipulation, the force applied separates the surfaces of the encapsulated joint cavity, creating a relative vacuum within the joint space. In this environment, gases that are naturally dissolved in all bodily fluids turn into a bubble (similar to when gas is released from a carbonated drink when it is opened), creating a rapid vibration, and a sound is heard. The effects of this bubble within the joint continue for hours while it is slowly reabsorbed. During this time, the joint is able to move more freely and stimulates the nerves surrounding the joint's capsule. This procedure is performed by osteopaths and physiotherapists as well as by DCs; despite the different treatment goals, the procedures performed are very similar. DCs aim to apply a precise adjustment to a specific affected vertebra, as distinct from the more generalized maneuvers of the early osteopaths. This technique has been shown to be beneficial for low back pain, neck pain and headaches.

DCs follow similar guidelines for patient care as their medical counterparts, but give less emphasis to laboratory tests and more to spinal testing. They take a thorough patient and family history, review the organ systems and conduct a physical examination. They make postural observations and evaluate spinal function, and they might request laboratory tests to evaluate blood and urine and perform X-ray, order MRI, CT scans, and other imaging techniques, or might refer to general practitioners or specialists for these. After making a diagnosis, the DC discusses the findings with the patient, obtains informed consent, and treats according to guidelines agreed by national and local consensus panels, such as the Mercy guidelines. They do not treat cancer, metabolic disorders such as diabetes, or infectious diseases, although they might treat patients that have these conditions.

Disc degeneration as a result of chronic subluxation is one form of arthritis that DCs work to prevent or improve. This joint will feel tender and stiff.

When a patient first consults a DC, it is usually because of a problem that seems to be directly associated with the spine. When examining the patient, the DC will palpate the spine to feel the contour of deep muscles that run between the vertebrae (the multifidus and erector spinae muscles) and assess their symmetry and flexibility. If an area of muscle feels tight, hard or bony, the DC checks to see if the vertebral joint below it moves properly. If it is stiff or unusually mobile, the area is identified as a 'trouble spot', which might reflect a new or an old injury, or a postural abnormality. Often, the patient identifies that same spot by pain felt during the palpation. It is this joint that the DC asserts is likely to cause problems if neglected and will adjust in an effort to prevent these.

In 2006, about 70,000 DCs were in clinical practice in the USA, 5000 in Canada, 2500 in Australia, 1300 in the UK, with smaller numbers in about 50 other countries. There are 17 chiropractic colleges in the USA and two in Canada. There are several specialty certifications awarded (see Accredited Programs.) Some DCs specialize in musculoskeletal problems or sports injuries, others combine chiropractic with physiotherapy, nutrition, or exercise. Some also use other complementary and alternative methods. However, DCs do not prescribe drugs; they believe that this is the province of conventional medicine, while their role is to pursue drug-free alternative treatments in an effort to prevent the need for surgery.

Chiropractic vertebral subluxation

With proper training and posture the spine can withstand extreme pressure...

The human spine is a column of 24 bony vertebrae, each interconnected by an intricate maze of muscles, ligaments and connective tissue to the vertebrae above and below. The result is a remarkably mobile structure that allows for amazing combinations of movement while protecting the spinal cord, a delicate bundle of nerves that is the pathway of communication between brain and body. The strength of the athlete and the agility of the gymnast are testaments of the durability and resilience that is built into its design. Today, all DCs are trained to detect alterations in position and/or function between these segments, aiming to identify areas of the spine that are at risk of injury or degeneration as a result of this abnormal position or motion. They use terms such as subluxation, vertebral subluxation, and vertebral subluxation complex to describe these. Some believe that even tiny changes in position or function can alter the information transmitted between the brain and body, and can result in ill health, and reduced resistance to disease.

...and allow for significant ranges of motion and shock absorbtion

The word subluxation has different meanings for physicians and DCs. The DC uses it to refer to a condition that cannot always be directly observed, but whose existence is inferred from the symptoms. Because DCs prefer to talk to their patients using simple 'holistic' explanations, and refer to vague 'forces' that are not described in current biology, physicians are often skeptical. By contrast, a physician only refers to a body part as 'having a subluxation' if it can be objectively demonstrated that it is out of its functional position. Thus, when a radiologist reads a spinal x-ray as 'showing subluxation of a vertebra', he or she always means that a bone in the spinal column is visibly displaced; for example, a pediatrician calls the elbow joint of a child as subluxed in the condition 'Nursemaid's elbow' only if the lower arm bones are pulled out of the joint capsule and the child cannot move the forearm. A DC on the other hand may diagnose a subluxation by manual palpation - recognising that when specific pressure is applied to one joint in isolation, it didn't move or have an 'elastic feel' like those above and below it. Whether such subtle changes are of any functional significance is at the heart of the scientific controversy, and the differing use of the term subluxation has contributed to the hostility of much of organized medicine. A patient may feel benefit from a DC's treatment of his back pain, but when he tells his physician that the DC 'fixed my subluxation', that physician may view the DC as a fraud - after all, she'd reviewed the scan of the patient's back and knows there was no subluxation!

Subluxation and Innate Intelligence- the controversial concepts

Because half of the nervous system is sensory and the other half is motor, DD Palmer postulated that living things had an Innate intelligence, a 'spiritual energy' or 'life force' that received the sensory information and made a decision as to what the motor nerves should convey. He thought that 'subluxation's interfered with this, and that by fixing them, all diseases could be treated. He qualified this by noting that it was not essential to know exactly what Innate Intelligence was, so long as DCs could locate and adjust subluxations.

For many, these concepts today appear to be too vague to be scientific. However, some DCs argue that their concepts help them to see their patients as more than the 'sum of their parts'. They believe that trying to explain all the complex physiological processes that combine to make a human being function in terms of the basic underlying physical and chemical components, misses things that are important for understanding what makes a human being healthy.

Thus there is ongoing debate within the profession as to whether the term subluxation should be abandoned to satisfy the medical model (much as there was when dentists abandoned the term 'cavity' for 'dental caries' to promote the understanding of the tiny defects that precede the formation of a cavity). The alternative term segmental dysfunction is used for insurance and statistical purposes, but to include neurological components, it has been proposed that the term 'complex joint dysfunction' might be better, using the term 'dysafferentation' specifically for neuropathological symptoms. Meridel Gatterman DC said of 'subluxation', "To some it has become the holy word; to others, an albatross to be discarded ... to add to the confusion, more than 100 synonyms for subluxation have been used. Why then do we persist in using the term when it has become so overburdened with clinical, political,and philosophical ... significance ... that the concept that once helped to hold a young profession together now divides it and keeps it quarrelling over basic semantics? The obvious answer is: The concept of subluxation is central to chiropractic." Anthony Rosner of the Foundation for Chiropractic Education and Research suggests that there is no reason to discard the concept completely, if it is treated as a 'provisional' concept that will undergo continuous and extensive modification over time.

Similarly, in 1998, Lon Morgan, a reform DC, wrote that the concept of 'Innate Intelligence' originates in "borrowed mystical and occult practices of a bygone era"; he described it as untestable and unverifiable, and as a holdover from a time when insufficient scientific understanding existed to explain human physiological processes, clearly religious in nature, and harmful to normal scientific activity.

Chiropractic approach to healthcare

Click to see ACC Chiropractic/Medical Management Model

"For every chiropractor, there is an equal and opposite chiropractor"

The traditional, 'medical' (sometimes called 'allopathic') approach to health care regards disease as usually the result of some external influence, such as a toxin, parasite, allergen, or infectious agent: the solution is to counter that influence (e.g. using an antibiotic for a bacterial infection). By contrast, chiropractic involves a 'naturopathic' approach, believing that lowered 'host resistance' is necessary for disease to occur, and hence that the answer is to strengthen the host. Contemporary chiropractors take several different approaches to patient care. These differences are reflected in different professional associations, though most DCs do not belong to any association.

• Traditional Straights accept DD Palmer's view that vertebral subluxation is a risk factor for most diseases. They do not try to diagnose complaints, which they consider to be secondary effects; instead, they screen patients for 'red flags' of serious disease. This has been contentious, as accreditation standards require that differential diagnosis is taught in all chiropractic programs, and several chiropractic licensing boards require that patient complaints are diagnosed before they receive care. Many traditional straights belong to the International Chiropractors Association.
• Mixers use more diverse diagnostic and treatment approaches, including naturopathic remedies and physical therapy devices. Many belong to the American Chiropractic Association, and all the major groups in Europe are part of the European Chiropractors Union.
• Objective Straights focus on correcting vertebral subluxations. They typically do not diagnose patient complaints, or refer to other professionals, but they encourage their patients to consult a medical physician "if they indicate that they want to be treated for the symptoms they are experiencing or if they would like a medical diagnosis to determine the cause of their symptoms". Many belong to the Federation of Straight Chiropractic Organizations and the World Chiropractic Alliance.
• Reform chiropractors, also a minority, are mostly mixers who use manipulation to treat osteoarthritis and other musculoskeletal conditions. They do not subscribe to Palmer philosophy or vertebral subluxation theory. They are similar in practice to mixers, although they tend not to use complementary and alternative methods.

Chiropractic education, licensing and regulation

Palmer Chiropractic College with DD Palmers bust (center)

Chiropractic began in America's heartland as the country entered a renaissance of scientific and industrial growth after the civil war; then, licensing for the health professions was just beginning, and physicians learned their trades 'on the job', much as an apprentice would learn a trade today. DD Palmer began teaching his technique in three-month courses; most of his students had already certified as MDs or osteopaths looking to add a new method to their practices. However, after the Flexnor report, which greatly enhanced the standards of education for medicine, chiropractic schools were essentially shut out of the new system, and had to develop their own educational standards.

Over the years, these standards became progressively more stringent. Students today must meet a minimum prerequisite course of study of 90 semester hours from an accredited college or university, including biology, organic and inorganic chemistry, psychology, and physics. Chiropractic programs require at least 4,200 hours of instruction in subjects including physiology, neurology, orthopedics, pathology and anatomical studies including 8 months of human dissection, and students must undertake a research project in their third year. The final two years stress courses in manipulation and spinal adjustment and give clinical experience in physical and laboratory diagnosis, orthopedics, neurology, geriatrics, physiotherapy, and nutrition. After this, to qualify for licensure, graduates must pass four examinations from the National Board of Chiropractic Examiners [11] and satisfy State-specific requirements. Chiropractic colleges also offer postdoctoral training in, for example, sports injuries, rehabilitation, radiology, pediatrics, and applied chiropractic sciences, with exams leading to 'diplomate' status in a given specialty. In the USA, this training is overseen by the Council on Chiropractic Education. Each state has its own licensing board, overseen by a Federation of Chiropractic Licensing Boards.

History

(see also article on Daniel David Palmer)

By 1885, the era of the drastic measures of heroic medicine was gone, and purveyers of scientific medicine, herbalism, magnetism and leeches, lances, tinctures and patent medicines were all in competition. Neither patients nor many practitioners had much knowledge of either the causes of, or cures for, illnesses, and drugs, medicines and quack cures were becoming more common and were mostly unregulated. Concerned about what he saw as the abusive nature of drugging, Andrew Taylor Still ventured into 'magnetic healing' and bonesetting in 1875, and opened the American School of Osteopathy in Missouri in 1892.

Daniel David Palmer (DD Palmer), a teacher and grocer turned magnetic healer, opened his office of magnetic healing in Davenport, Iowa in 1886. Nine years later, on September 18, 1895, he gave the first chiropractic adjustment to a deaf janitor, Harvey Lillard. Palmer and Lillard subsequently gave different accounts of this first experiment with spinal manipulation. According to Palmer, Lillard had told him that, while working in a cramped area seventeen years earlier, he had felt a 'pop' in his back and had since been virtually deaf. Palmer found a sore lump that indicated spinal misalignment, he corrected the misalignment, after which Lillard could then "hear the wheels of the horse-drawn carts" in the street below. However, Lillard's daughter, Valdeenia Lillard Simons, said that her father told her that he was joking with a friend in the hall outside Palmer's office when Palmer joined them. As Lillard reached the punchline, Palmer, laughing heartily, slapped Lillard on the back with the heavy book he had been reading. A few days later, Lillard's hearing seemed better, and Palmer decided to explore manipulation as 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."

After the event, Palmer said: "I had a case of heart trouble which was not improving. I examined the spine and found a displaced vertebra pressing against the nerves which innervate the heart. I adjusted the vertebra and gave immediate relief -- nothing 'accidental' or 'crude' about this. Then I began to reason if two diseases, so dissimilar as deafness and heart trouble, came from impingement, a pressure on nerves, were not other disease due to a similar cause? Thus the science (knowledge) and art (adjusting) of Chiropractic were formed at that time."

DD Palmer asked a friend, the Reverend Samuel Weed, to help him name his discovery; he suggested combining the words cheiros and praktikos (meaning 'done by hand'). In 1896, DD Palmer added a school to his magnetic healing infirmary and began to teach others the new "chiropractic"; it would become the Palmer School (now College) of Chiropractic. Among the first graduates were his son, BJ Palmer, Solon Langworthy, John Howard, and Shegataro Morikubo. Langworthy moved to Cedar Rapids, Iowa and opened in 1903, the 'American School of Chiropractic & Nature Cure', combining chiropractic with osteopathy and other natural cures from the newly developing field of naturapathy. DD Palmer, who was not interested in mixing chiropractic with other cures, refused the offer of a partnership.

Changing political and healthcare environment

The country needs fewer and better doctors; ...the way to get them better is to produce fewer. Abraham Flexner[12]

The early 19th century saw the rise of patent medicine and the nostrum trade. Some remedies were sold by doctors of medicine, but most were sold by lay people, often using very dubious advertising claims. The addictive or toxic effects of some remedies, especially morphine and mercury-based cures prompted the rise of the alternative remedies of homeopathy and eclectic medicine, that were less dangerous and probably no more ineffective in most cases. In the USA, licensing for healthcare professionals had all but vanished around the Civil War, leaving the profession open to anyone who declared themselves to be a physician; the market alone determined who would succeed and who would fail. Medical schools were plentiful, inexpensive and mostly privately owned, leading to an overabundance of practitioners. In 1847, the American Medical Association (AMA) was formed and established higher standards for medical education, restricting the number of new practitioners.

In 1849, the AMA formed a board to analyze quack remedies and to educate the public about their dangers. By the turn of the century, the AMA were represented in Washington by a Committee on National Legislation, and after intense political pressure, medical boards were formed in almost every state, requiring licentiates to have a diploma from an AMA-approved college. By 1906, the AMA’s Council on Medical Education had drawn up a list of unacceptable schools, and in 1910, as a result of the Flexner Report, hundreds of private medical and homeopathic schools were closed. The AMA had created the nonprofit, federally subsidized university hospital setting as the new teaching facility of the medical profession, with Johns Hopkins as the model school, effectively gaining control of federal healthcare research and student aid.

Medicine, osteopathy, and chiropractic; the three rivals

With no patent protection for new discoveries, claims for the drugless healing professions proliferated. In 1896, DD Palmer's first descriptions for chiropractic were very similar to Andrew Still's earlier principles of osteopathy: both described the body as a 'machine' whose parts could be manipulated to effect a drugless cure, and both claimed to affect the blood and nerves and promote health. However, Palmer stated that he concentrated on reducing 'heat' from friction of the misaligned parts, while Still claimed to enhance the flow of blood. As news spread about the new doctor of drugless healing in Iowa, osteopaths began to campaign to protect osteopathy.

In September 1899, a Davenport MD, Heinrich Matthey, began a campaign against drugless healers in Iowa. He sought to change the state law (which referred to 'the healing arts') to prevent drugless healers from practicing in the state, arguing that health education could not be entrusted to anyone but doctors of medicine. Osteopathic schools responded by developing a program of college inspection and accreditation, but DD Palmer, whose school had just graduated its 7th student, insisted that his techniques did not need the same training or licensing as medicine, as his graduates did not prescribe drugs or evaluate blood or urine. Nevertheless, in 1901, he was charged with misrepresenting to a student a course in chiropractic which was not a real science. He persisted in his opposition to licensing, arguing for freedom of choice, and was arrested twice more by 1906. Although he denied that what he practiced was medicine, he was convicted for claiming that he could cure disease when he had no license to practise either medicine or osteopathy.

At the 'American School of Chiropractic & Nature Cure', Solon Langworthy narrowed the scope of chiropractic to the treatment of the spine and nerve, and began to refer to the brain as the 'life force'. He was the first to use the word 'subluxation' to describe the misalignment that narrowed the 'spinal windows' (intervertebral foramina). In 1906, he published the first book on chiropractic, Modernized Chiropractic - Special Philosophy; A Distinct System. DD Palmer objected vigorously to the mixing of chiropractic, and persuaded the Governor of Minnesota to veto legislation that would have allowed Langworthy's students to practice there. However, he did accept some of Langworthy's concepts, introducing the concept of Innate Intelligencein about 1904.

BJ Palmer re-develops chiropractic

After DD Palmer's conviction, he turned his interests in the 'Palmer School of Chiropractic' over to his son, BJ Palmer. The conviction of DD Palmer prompted the creation of the 'Universal Chiropractic Association'; its initial purpose was to provide for legal defense of members should they get arrested, and its first case was in 1907, when Shegataro Morikubo DC of Wisconsin was charged with unlicensed practice of osteopathy. In an ironic twist, using mixer Langworthy's book Modernized Chiropractic, attorney Tom Morris legally differentiated chiropractic from osteopathy by the differences in the philosophy of chiropractic's 'supremacy of the nerve' and osteopathy's 'supremacy of the artery'. Morikubo was freed, and the victory reshaped the development of chiropractic, which then marketed itself as a science, an art and a philosophy. In the next 15 years, 30 more chiropractic schools opened, including John Howard's National School of Chiropractic (now the National University of Health Sciences).

Of the more than 15000 prosecutions of DCs that were fought in the first 30 years, BJ Palmer the 'Philosopher of Chiropractic', later said,

"We are always mindful of those early days when UCA...used various expedients to defeat medical court prosecutions. We legally squirmed this way and that, here and there. We did not diagnose, treat, or cure disease. We analyzed, adjusted cause, and Innate in patient cured. All were professional matters of fact in science, therefore justifiable in legal use to defeat medical trials and convictions."

BJ Palmer's influence over the next few years further divided mixers (who mixed chiropractic with other cures) from straights (who practiced chiropractic alone). While he continued at the Palmer school, his father developed his ideas in Oregon, challenging his son's methods and philosophy, and trying to regain control of chiropractic. In 1910, DD Palmer proposed that: "The activity of these nerves, or rather their fibers, may become excited or allayed by impingement, the result being a modification of functionating—too much or not enough action—which is disease." Before his sudden death in 1913 (allegedly run over by an automobile driven by his son) he repudiated his earlier theory that vertebral subluxations caused pinched nerves in favor of subluxations causing altered 'nerve vibration', and declared that "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."

Straight vs Mixer

Laws to regulate and protect chiropractic were eventually introduced in all states in the USA, but it was a hard-fought struggle. Medical Examining Boards tried to keep all healthcare under their control, and disagreement between DCs complicated the process. Initially, the UCA opposed state regulation, fearing that it would lead to allopathic control of the profession. The UCA eventually conceded, but BJ Palmer continued to argue that examining boards should be composed exclusively of chiropractors (not mixers), and that the educational standards to be adhered should be the same as those of the Palmer School. In 1922, a 'model bill' was presented to states that did not yet have a law. They began a process of 'cleaning house' of mixers, warning state associations to purge their mixing members or face competition from a new 'straight' association.

In response, mixers founded the American Chiropractic Association. Its growth was initially stunted by its decision to recognize physiotherapy and other modalities as related to chiropractic, but in 1924, a disagreement within the UCA turned the tide. BJ Palmer was still trying to purge mixers from chiropractic, and he saw a new invention by Dossa D. Evans, the Neurocalometer, as the answer to straight chiropractic's legal and financial problems. As the owner of the patent on the Neurocalometer, he planned to limit it to 5000, and lease them only to members of the UCA. He then claimed that the Neurocalometer was the only way to accurately locate subluxations, preventing over 20,000 mixers from being able to defend their method of practice.

There was uproar among DC's, and even Tom Morris, BJ Palmer's old ally and president of the UCA, displayed his dismay by resigning. BJ Palmer resigned as treasurer, ending his relationship with the UCA, and moved on to form the 'Chiropractic Health Bureau' (today's ICA) along with his staunchest supporters. In 1930, the ACA and UCA combined to form the 'National Chiropractic Association' and made John J Nugent responsible for raising educational standards; his zeal earned him the nickname 'Chiropractic's Abraham Flexnor' from admirers and 'Chiropractic's Anti-christ' from adversaries. The CES became today's Council on Chiropractic Education, chiropractic's accrediting body. [13]

The movement toward scientific reform

By the late 1950s, healthcare in the USA had been transformed: the discovery of penicillin and development of the polio vaccine was restoring hope to millions, and the homeopathic physician had all but vanished as a result of the antiquackery efforts of the AMA. Osteopathy developed in parallel to medicine and stopped relying on spinal manipulation to treat illness, and a similar reform movement began within chiropractic: shortly after the death of BJ Palmer in 1961, a second generation chiropractor, Samuel Homola, proposed that chiropractic should focus on conservative care of musculoskeletal conditions. "If we will not develop a scientific organization to test our own methods, organized medicine will usurp our privilege. When it discovers a method of value, medical science will adopt it and incorporate it into scientific medical practice." Homola's membership of the ACA was not renewed, and his views were rejected by both straight and mixer associations.

In 1978, the Journal of Manipulative & Physiological Therapeutics (JMPT) was launched. Keating dates the birth of chiropractic as a science to a 1983 commentary in the Journal in which Kenneth DeBoer, an instructor at Palmer College, revealed the power of this journal to empower faculty at chiropractic schools, enabling them to challenge the status quo, to publicly address issues related to research, training and skepticism, and to raise professional standards. [14]

The American Medical Association plans to eliminate chiropractic

Medicine, Monopolies, and Malice (Chester Wilk, book title[15])

In November 1963, the American Medical Association (AMA) formed a 'Committee on Quackery' to first contain, and then eliminate chiropractic. Doyl Taylor, Secretary of the Committee, outlined steps needed to ensure that Medicare should not cover chiropractic; to ensure that the U.S. Office of Education should not recognize a chiropractic accrediting agency; to encourage continued separation of the two national associations; and to get state medical societies to initiate legislation to control chiropractic. The AMA distributed propaganda to teachers and guidance counselors, eliminated 'Chiropractic' from the U.S Department of Labor's Health Careers Guidebook, and established guidelines for medical schools about the 'hazards' of chiropractic. In 1966 the AMA declared that "chiropractic is an unscientific cult whose practitioners... constitute a hazard to healthcare in the United States." and set out to forbid its members fromworking with chiropractors; until 1980, Principle 3 of the AMA 'Principles of Medical Ethics' stated that "A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily professionally associate with anyone who violates this principle." However, the AMA crusade against chiropractic raised suspicions that it was motivated at least in part by narrow professional self-interest, and in 1975, an anonymous informant leaked internal documents about the crusade. To challenge the AMA, in 1976, a Chicago DC, Chester Wilk, and three other DCs brought an antitrust suit against the AMA and two other medical associations - Wilk et al vs AMA et al.

The judge in the ensuing landmark trial said that, according to the evidence given:

"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."

She said that DCs clearly wanted "a judicial pronouncement that chiropractic is a valid, efficacious, even scientific health care service". However, she said that no well-designed, controlled, scientific studies had been done, and concluded "I decline to pronounce chiropractic valid or invalid on anecdotal evidence", even though "the anecdotal evidence in the record favors chiropractors".

In 1987, the Federal Appeals Court found the AMA guilty of conspiracy and restraint of trade (two co-defendants, the Joint Council on Accreditation of Hospitals and the American College of Physicians were exonerated). The court recognized that the AMA had a duty to show its concern for patients, but was not persuaded that this could not have been achieved in a way that was less restrictive of competition, for instance by public education campaigns. The AMA lost its appeal to the Supreme Court, and had to allow its members to collaborate with chiropractors.

After the court victory, Wilk said (of the AMA)

"They don't have to love us, but they'll have to respect us and respect the law." [16]

In 1992, the AMA declared "It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient. A physician may refer a patient for diagnostic or therapeutic services to a chiropractor permitted by law to furnish such services whenever the physician believes that this may benefit his or her patient. Physicians may also ethically teach in recognized schools of chiropractic." [17]

Efficacy

With little federal funding, academic research in chiropractic has only recently become established in the USA. By 1997, there were 14 peer-reviewed journals that specifically encourage chiropractic research, but only one, The Journal of Manipulative and Physiological Therapeutics (JMPT), is indexed in Index Medicus[18]. There is wide agreement that, where applicable, an evidence based medicine framework should be used to assess the outcomes of medical interventions. Where there isn't enough good evidence, as is often the case, this does not imply that the treatment is ineffective, only that the case for a benefit of treatment has not been established. A 2005 editorial in JMPT proposed that involvement in the Cochrane Collaboration would be a way for chiropractic to gain more acceptance within medicine.

The first significant recognition that spinal manipulation was an appropriate treatment for some types of low back pain was a meta-analysis by the RAND Corporation. RAND's studies were about spinal manipulation, not chiropractic specifically, and dealt with appropriateness, which measures benefit and harm; the efficacy of chiropractic and other treatments were not directly compared, but in 1997, an AMA report, discussing chiropractic, acknowledged that "Manipulation has ... a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints." In 1998, The Manga Report, funded by the Ontario Ministry of Health, accepted the efficacy and cost-effectiveness of chiropractic for low-back pain, found that chiropractic care had higher patient satisfaction levels, and stated that "major savings from chiropractic management come from fewer and lower costs of auxiliary services, fewer hospitalizations, and a highly significant reduction in chronic problems, as well as in levels and duration of disability." There are no objective controlled trials with definitive conclusions for or against chiropractic claims of other health benefits.

Evidence of efficacy also comes from studies of patient satisfaction and from studies of workers' compensation cases; these suggest that most patients are very satisfied with chiropractic treatment, and for example, patients who consult a DC for back-related problems are likely to lose fewer days at work than patients with similar complaints who consult MDs.

In 1997, the historian Joseph Keating said that, despite evidence of the efficacy of manipulation for lower back pain, "the doubting, skeptical attitudes of science do not predominate in chiropractic education or among practitioners". He argued that "a combination of uncritical rationalism and uncritical empiricism has been bolstered by the proliferation of pseudoscience journals of chiropractic wherein poor quality research and exuberant over-interpretation of results masquerade as science and provide false confidence about the value of various chiropractic techniques". However, in 1998, he wrote "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."

Chiropractic treatment of non-spinal disorders

It wasn't so long ago that a college president suggested, "Rigor mortis is the only thing we can't help!" Joseph Keating, chiropractic historian [19]

Because they feel that all healing comes from within the body, DCs don't talk in terms of 'cure', but of 'helping the body cure itself'. As a result, the traditional DC sees all who suffer as in need of his or her help. The degree to which they claim to be able to help varies, not only from condition to condition but also from case to case, and because DCs tend to specialize in different techniques; accordingly, it is not clear that the benefits that some DCs and their patients claim to see with chiropractic treatment of visceral or organ-related disorders can be objectively confirmed.

The spinal cord does carry a vast amount of afferent sensory information from peripheral organs and tissues to the brain, including sensations of pain, touch, temperature, and information for instance about the positions of joints. In addition, virtually every organ and its blood supply is regulated by the central nervous system, both directly by efferent nerves, many of which travel down the spinal cord, and indirectly by neuroendocrine regulation of hormone secretion in response to the afferent information. Accordingly, disruption of spinal information flow can influence the physiological function of virtually every organ system in the body. However it is not clear that it is yet possible to show whether any particular organ dysfunction is in fact caused by a disorder of spinally-mediated information transfer, and whether the type of manipulation performed by DCs can correct such a disorder.

Since the original observations of DD Palmer, DCs have been alert for any evidence that their manipulations might have such beneficial effects. There is a great deal of mainly anecdotal evidence (from case studies) that they can; however anecdotal evidence, though suggestive, is generally recognised as weak evidence because of the likelihood that it is influenced by the prior beliefs and expectations of both the patient and the practitioner; only if it leads to an objective protocol for intervention with reproducible and objectively verifiable efficacy can it be regarded as validated. One of the most common criticisms of chiropractic has been the apparent willingness of some DCs to offer treatment for conditions where there is no validated basis, especially those that might be life-threatening or life-altering without concurrent medical care.

Some DCs believe however, mainly on the strength of their collective clinical experience, that several conditions can sometimes be resolved by chiropractic interventions. In particular, cases that have failed to be resolved by conventional medical treatment might include some where the underlying cause is indeed a disorder of neural regulation of an organ system, as the failure of conventional medical treatment might be taken as evidence excluding more common causes of dysfunction, such as infectious disease. It is also possible that the symptom that doctor and patient thought was the result of an organ disease was actually the result of a somatic reflex pain generated from the spine that mimics an organ-related condition. Thus, if an organ-related complaint fails to get the expected results from conventional medical treatment but then responds to chiropractic adjustments, it is possible that a spinal condition was the cause of the symptom in the first place. [20]

One such condition is infantile colic, characterised by uncontrollable crying in infants with no clear cause. Some reports suggest that chiropractic is efficacious, but others do not. Chiropractic is also used by some DCs to treat asthma; here the evidence is that it can be efficacious, but no more than placebo treatment. Placebo effects for some conditions can be very powerful, which is an indication of the potential importance of the ability of the mind to contribute to healing. It is possible that chiropractic is efficacious in some cases because it exploits the power of the placebo effect in an efficient way. Regardless of the mechanism of effect, even if it is just their sympathetic tone and calming effect on the mother and/or child, DCs agree that anything that results in less dependence on medication decreases the likelihood of side effects and therefore has value. Otitis media in infants is another condition that some DCs claim to manage efficiently. In the past, antibiotics were the treatment of choice, but recent studies suggest that waiting as long as three days before beginning a regimen could save as many as 30% from unnecessary exposure to antibiotics.[21] DCs, who also have training in physical examination, might therefore fill an important 'watchful waiting' role in evaluating and monitoring otitis media for their patients. Again, evidence as to the effectiveness of chiropractic, and whether it alters the natural course of otitis media, is anecdotal at this point.

Safety

As with all interventions, there are risks with spinal manipulation: these include vertebrobasilar accidents, strokes, spinal disc herniation, vertebral fracture, and cauda equina syndrome. A 1996 Danish study showed that the greatest risk is from manipulation of the first two vertebra of the cervical spine, particularly passive rotation of the neck. Serious complications are estimated to be just 1 in a million manipulations or fewer, but there is uncertainty about how these are recorded. The RAND study assumed that only 1 in 10 cases would have been reported, but a survey of neurologists in the UK for cases of serious neurological complication occurring within 24 hours of cervical spinal manipulation (not specifically by a DC), concluded that underreporting was close to 100%, rendering estimates 'nonsensical'.

Few studies of stroke and cervical manipulation take account of the differences between 'manipulation' and the 'chiropractic adjustment'. According to a report in the JMPT, manipulations administered by a Kung Fu practitioner, GPs, osteopaths, physiotherapists, a wife, a blind masseur, and an Indian barber had all been incorrectly attributed to DCs.

Critical views of Chiropractic

In its 100-year history chiropractic has been under frequent attack from its rival, osteopathy, from organised conventional medicine, from scientists critical of its scientific foundations, and recently from web-based critics of its advertising tactics and of the extravagent claims and dubious practices of some DCs. Although the profession has survived, and indeed thrived, the profession itself has voiced many of these criticisms in a move to reform chiropractic from within. Examples include:

• Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor

Samuel Homola DC, an outspoken dissident within the profession, expresses his opinion that evidence-based chiropractic is the only way forward.

• Chiropractic, Bonesetting, and Cultism - Samuel Homola (entire book on-line).

This book, published in 1964, contains trenchant criticism of the profession, and the following year Homola's application to renew his membership of the ACA was rejected. In 1991, David Redding, chairman of the ACA board of governors, welcomed Homola back to the ACA. In 1994, 30 years after its publication, the book was reviewed for the first time by a chiropractic journal. [22]

• Chiropractic Ethics: An Oxymoron?

JC Smith DC writes in 1999 that ethical issues are "in dire need of debate" because of "years of intense medical misinformation/slander" and because of well-publicised examples of tacky advertising, outlandish claims, sensationalism and insurance fraud.

• Chiropractic: Science and Antiscience and Pseudoscience Side by Side

Joseph Keating Jr, professor at the Los Angeles College of Chiropractic and historian of chiropractic, warns of pseudoscientific notions still held by some DCs

• Faulty Logic and Non-skeptical Arguments in Chiropractic

Dr Keating critically distinguishes between sound and unsound arguments in support of chiropractic

• Critical thinking

Christopher Kent, president of the Council on Chiropractic Practice, advises his colleagues of the importance of high standards of evidence, noting that in the past chiropractors were too ready to accept anecdotal evidence

• Open Letter to the Profession (See Chiroweb for commentary.)

A 1992 letter from ACA attorney George McAndrews warns the chiropractic profession that 'scare tactic' advertising damages the newly won respect within the AMA.

• Quackery in Chiropractic -

A 1991 editorial from Dynamic Chiropractic where Joseph Keating discusses his concerns for advertising products before they are scientifically evaluated.

• Subluxation - The Silent Killer

A 2000 commentary by Ronald Carter, Past President of the Canadian Chiropractic Association discussing his opinion that the subluxation story, regardless of how it is packaged, is not the answer. He suggests it is time for the 'silent majority' to present a rational model of chiropractic so that it can become an essential member of the health care team.

External links

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