Chiropractic

Template:Alternative medical systems Chiropractic is a complementary and alternative health care profession which focuses on diagnosing, treating, and preventing mechanical disorders of the musculoskeletal system, their effects on the nervous system, and on general health. Chiropractic's premise is that spinal joint misalignments, which chiropractors call vertebral subluxations, can interfere with the nervous system and result in many different conditions of diminished health. In contrast, the term subluxation, as used in conventional medicine, is usually associated with conditions which are a direct consequence of injury to joints or associated nerves.

Manipulation of the spine is the main technique in modern chiropractic adjustment, or treatment. Although its use dates from the time of the ancient Egyptians, spinal manipulation in an attempt to correct the theoretical vertebral subluxation is solely a chiropractic endeavor. Chiropractic's contribution to the field of manipulative therapies is the concept of applying a precise adjustment to a specific affected vertebra, as opposed to the generalized maneuvers of the early osteopaths. Some chiropractors adhere strictly to the use of only spinal manipulation in their adjustment, but others include a broad range of methods directed at correcting the subluxation and/or just relieving musculoskeletal pain.

Some chiropractors specialize in treating specific musculoskeletal problems or sports injuries, or they may combine chiropractic with manipulation of the extremities, physiotherapy, nutrition, or exercises. Some also use other complementary and alternative methods as a part of a holistic treatment approach. However, chiropractors do not prescribe drugs; they believe this to be the province of conventional medicine, and that their role is to pursue drug-free alternative treatments. Depending on the country or state in which the Chiropractic school is located, some train in minor surgery. When indicated, the doctor of chiropractic (DC) consults with, or refers to, other health care providers.

Chiropractic was founded in 1895 by Daniel David Palmer, who proposed that all health problems could be treated using "adjustments" of the spine, and sometimes other joints, to correct what he termed "subluxations." He, and later his son, B.J. Palmer, proposed that subluxations were misaligned vertebrae which caused nerve compression that interfered with the transmission of what he named Innate Intelligence. This interference interrupted the proper flow of Innate Intelligence from "above, down, inside, and out" to the organ to which it traveled. As a result, the human body would experience "dis-ease" or disharmony which would result in loss of health. He compared this process 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 chiropractors to explain vertebral subluxation. However, the concept of the subluxation remains integral to typical chiropractic practice, and in 2003 90% of chiropractors believed the vertebral subluxation complex played a significant role in all or most diseases..

There is evidence that spinal manipulation is effective for the treatment of acute low back pain, tension headaches and some musculoskeletal issues, but not all studies support this conclusion. There are no objective controlled trials with definitive conclusions for or against chiropractic claims concerning other health benefits.

Today, there are 17 accredited chiropractic colleges in the USA and two in Canada, and an estimated 70,000 chiropractors in the USA, 5000 in Canada, 2500 in Australia, 1300 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.

There are four main groups of chiropractors: "traditional straights", "objective straights", "mixers", and "reform". All groups, except reform, treat patients using a subluxation-based system. Differences are based on the philosophy for adjusting, claims made about the effects of those adjustments, and various additional treatments provided along with the adjustment.

Chiropractic’s approach to healthcare

According to Robert Mootz DC and Reed Phillips DC, Phd, although chiropractic has much in common with other health professions, its philosophical approach distinguishes it from modern medicine. Chiropractic philosophy involves what has been described as a "contextual, naturopathic approach" to health care. The traditional, "allopathic" or "medical" model considers disease as generally the result of some external influence, such as a toxin, a parasite, an allergen, or an infectious agent: the solution is to counter the perceived environmental factor (e.g., using an antibiotic for a bacterial infection). By contrast, the naturopathic approach considers that lowered "host resistance" is necessary for disease to occur, so the appropriate solution is to direct treatment to strengthen the host, regardless of the environment. In contemporary clinical practice, one can find elements of both naturopathic and allopathic philosophy among all types of providers. The degree to which a practitioner emphases different tenets of these philosophies is one factor that determines the manner in which they practice.

Chiropractic Perspectives That Reflect a Holistic Approach to Patient Care

• noninvasive, emphasizes patient's inherent recuperative abilities
• recognizes dynamics between lifestyle, environment, and health
• emphasizes understanding the cause of illness in an effort to eradicate, rather than palliate, associated symptoms
• 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
• balances the benefits against the risks of clinical interventions
• recognizes as imperative the need to monitor progress and effectiveness through appropriate diagnostic procedures
• prevents unnecessary barriers in the doctor-patient encounter
• emphasizes a patient-centered, hands-on approach intent on influencing function through structure
• strives toward early intervention, emphasizing timely diagnosis and treatment of functional, reversible conditions

Source:AHCPR Chapter 2 Chiropractic Belief Systems, Robert D. Mootz DC; Reed B. Phillips DC, PhD

Most DCs are self employed or work in small groups, employing chiropractic assistants as office staff and to perform therapeutic activities. They may also employ massage and physiotherapists as adjuncts to chiropractic care.

History

(see also article on Daniel David Palmer)

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DD Palmer

In 1885, the world was well into the second industrial revolution, marked by innovation and creativity. Health care had emerged from the drastic practice of heroic medicine and was into an age of alternatives. All varieties of treatments and cures including scientific medicine, vitalism, herbalism, magnetism and leeches, lances, tinctures and patent medicines were developing and competing to be the new method for the century. Neither consumers nor many practitioners had much knowledge of either the causes of, or cures for, illnesses. Allopathy, fueled by Louis Pasteur's refutal of the centuries old spontaneous generation theory in 1859, was growing rapidly just as Charles Darwin published his book on natural selection. German bacteriologist, Robert Koch formulated his postulates bringing scientific clarity to what was a very confused field. Drugs, medicines and quack cures were becoming more prevalent and were mostly unregulated. Concerned about what he saw as the abusive nature of drugging, MD Andrew Taylor Still , ventured into magnetic healing (meaning hypnotism then) and bonesetting in 1875. He opened the American School of Osteopathy (ASO) in Kirksville, Missouri in 1892. Daniel David Palmer (DD Palmer), a teacher, grocer turned magnetic healer opened his office of magnetic healing in Davenport, Iowa in 1886. After nine successful years, DD Palmer gave the first chiropractic adjustment to a deaf janitor, Harvey Lillard, on September 18, 1895.

The first chiropractic adjustment

Harvey Lillard 1906

Palmer and his patient Harvey Lillard gave 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 man, 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. However, this version was disputed by Lillard's daughter, Valdeenia Lillard Simons. She said 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."

Early growth

Rev. Samual Weed

After the case of Harvey Lillard, Palmer stated: "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 patient and friend, Rev. Samuel Weed, to help him name his discovery. He suggested combining the words cheiros and praktikos (meaning "done by hand") to describe Palmer's treatment method, creating the term "chiropractic." In 1896, DD added a school to his magnetic healing infirmary, and began to teach others his method. It would be become known as Palmer School of Chiropractic (PSC, now Palmer College of Chiropractic). Among the first graduates were Andrew P. Davis MD,DO, William A. Seally,MD, BJ Palmer (DD's son), Solon M. Langworthy, John Howard, and Shegataro Morikubo. Langworthy moved to Cedar Rapids, Iowa and opened the second chiropractic school in 1903, the American School of Chiropractic & Nature Cure (ASC & NC) combining it with what would become naturapathic cures and osteopathy. DD Palmer, who was not interested in mixing chiropractic with other cures, turned down an offer to be a partner.

Changing political and healthcare environment

The early 19th century had seen the rise of patent medicine and the nostrum trade. Although some remedies were sold through doctors of medicine, most were sold directly to consumers by lay people, some of whom used very questionable advertising claims. The addictive, and sometimes toxic, effects of some remedies, especially morphine and mercury-based cures (quicksilver or quacksilber in German), prompted the popular rise of alternative, less dangerous methods of homeopathy and eclectic medicine. In the mid 1800's, as the germ theory struggled to replace the metaphysical causes of disease, the search for invisible microbes required the world to embrace the scientific method as a way to discover the cause of disease.

In the USA, licensing for healthcare professionals had all but vanished around the Civil War, leaving the profession open to anyone who felt inclined to become a physician; the market alone determined who would prove successful and who would not. Medical schools were plentiful, inexpensive and mostly privately owned. With free entry into the profession, and education in medicine cheap and readily available, many men entered practice, leading to an overabundance of practitioners which ultimately drove down the individual physician's income. In 1847, the American Medical Association (AMA) was formed and established higher standards for preliminary medical education and for the degree of MD. At the time, most medical practitioners were unable to meet the stringent standards, so a "grandfather clause" was included. The effect was to limit the number of new practitioners.

In 1849, the AMA established a board to analyze quack remedies and nostrums and to enlighten the public about their nature and their dangers. Relationships were developed with pharmaceutical companies in an effort to curb the patent medicine crisis and consolidate the patient base around the medical doctor. By the turn of the century, the AMA had created a Committee on National Legislation to represent the AMA in Washington and re-organized as the national organization of state and local associations. Intense political pressure by the AMA resulted in unlimited and unrestricted licensing only for medical physicians that were trained in AMA-endorsed colleges. By 1901, state medical boards were created in almost every state requiring licentiates to provide a diploma from an AMA approved medical college. By 1910, the AMA was a powerful force; this was the beginning of organized medicine..

Just before 1881, the teaching profession had begun significant changes as well. Advances in chemistry and science in Germany created strong incentives to create markets for their new products. By 1895, the new "Kulturopolitik" ideology of "First teach them; then sell them" had begun creating the political pressure necessary to improve teaching in science and math in schools and colleges in the US. The medical schools were the first to suffer the attack; they were ridiculed as obsolete -- inadequate -- and inefficient. The crisis attracted the attention of some of the world's richest men. In 1901 the "Rockefeller Institute for Medical Research" was started by John D. Rockefeller. By 1906, the AMA’s Council on Medical Education had created a list of unacceptable schools that in 1910, as a result of the Flexner Report financed by the Carnegie Foundation, closed hundreds of private medical and homeopathic schools and named Johns Hopkins as the model school. The AMA had created the nonprofit, federally subsidized university hospital setting as the new teaching facility of the medical profession, effectively gaining control of all federal healthcare research and student aid.

Osteopathy vs chiropractic

As there was no constitutional or patent protection for new discoveries, the claims for the drugless healing professions took on a life of their own. In 1896, DD Palmer's first descriptions for chiropractic were strikingly similar to Andrew Still's principles of osteopathy established a decade earlier. Both described the body as a "machine" whose parts could be manipulated to effect a drugless cure. Both professed to affect the blood and nerves and promote health, though Palmer stated he concentrated on reducing "heat" from friction of the misaligned parts and Still claimed to enhance the flow of blood. As word spread about the new doctor of drugless healing in Iowa, osteopaths began a campaign to protect what they perceived as their rights to their profession, resulted in new laws to protect osteopathy.

Medicine vs chiropractic

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Chiropractic Caduceus

In September 1899, Davenport MD, Heinrich Matthey started a campaign against drugless healers in Iowa. Suddenly, the existing state law, which referred to "the healing arts", was severely denounced. The demand was made for a change in the statute to prevent any drugless healer practicing in the state. Matthey warned that health education could no longer be entrusted to anyone but doctors of medicine. Osteopathic schools across the country responded immediately by developing a program of college inspection and accreditation. DD Palmer, whose school had just graduated its 7th student, insisted that his techniques did not need the same courses or license as medicine, as his graduates did not prescribe drugs or evaluate blood or urine. However, in 1901, DD was charged with misrepresenting to a student a course in chiropractic which was not a real science. He persisted in his strong stance against licensure citing freedom of choice as his cause. He was arrested twice more by 1906, and although he contended that he was not practicing medicine, he was convicted for professing he could cure disease without a license in medicine or osteopathy.

Dr Solon Langworthy, who continued to mix chiropractic at the ASC&NC, took a different route for chiropractic. He improved classrooms and provided a curriculum of study instead of the single course. He narrowed the scope of chiropractic to the treatment of the spine and nerve, leaving blood to the osteopath, 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" (or intervertebral foramina) and interrupted the nerve energy. In 1906, Langworthy published the first book on chiropractic, called "Modernized Chiropractic" -- "Special Philosophy -- A Distinct System". He brought chiropractic into the scientific arena.

DD responded to Langworthy with malice concerning the mixing of chiropractic, and persuaded the Governor of Minnesota to veto legislation that would have allowed ASC&NC students to practice in his state. But he did accept some of the concepts laid out by Langworthy. He introduced the concept of Innate Intelligence in about 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.

After DD's conviction in 1906 and time in jail, he was forced to turn over his interests in the PSC to his son, BJ and wife Mabel. DD relocated first to Oklahoma and then to California, leaving BJ Palmer in charge of the PSC, the "Fountainhead of Chiropractic".

BJ Palmer re-develops chiropractic

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BJ Palmer Developer of Chiropractic 1882-1961

Prosecution of DCs for unlicensed practice after the conviction of DD Palmer and a previous charge against BJ Palmer resulted in BJ and several Palmer graduates creating the Universal Chiropractic Association (UCA). Its initial purpose was to protect its members by covering their legal expenses should they get arrested. Its first case came in 1907, when Shegataro Morikubo DC of Wisconsin was charged with unlicensed practice of osteopathy. It was a test of the new osteopathic law. In an ironic twist, using mixer Langworthy's book Modernized Chiropractic, attorney Tom Moore 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 the chiropractic profession, which then marketed itself as a science, an art and a philosophy, and BJ Palmer became the "Philosopher of Chiropractic".

John F.A. Howard DC, Founder National College of Chiropractic 1906

The next 15 years saw the opening of 30 more chiropractic schools, including John Howard's National School of Chiropractic (now the National University of Health Sciences) that moved to Chicago, Illinois. Each school attempted to develop its own identity, while BJ Palmer continued to develop the philosophy behind his father's discovery. Concerning the more than 15000 prosecutions of chiropractors fought the first 30 years, BJ would later note:

"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."

His influence over the next several years further divided the mixers, or those who mixed chiropractic with other cures, from the straights who practiced chiropractic by itself..

DD Palmer's last years

While BJ worked to protect and develop chiropractic around the Palmer school, DD Palmer continued to develop his techniques from Oregon. In 1910, he theorised that nerves control health:

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

Before his sudden and controversial death in 1913, DD Palmer often voiced concern for BJ Palmer's management of chiropractic. He challenged BJ's methods and philosophy and made every effort to regain control of chiropractic. He repudiated his earlier theory that vertebral subluxations caused pinched nerves in the intervertebral spaces in favor of subluxations causing altered nerve vibration, either too tense or too slack, affecting the tone(health) of the end organ and noted,

"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."

During the long fought battle for licensure in California, he wrote of his philosophy for chiropractic, and hinted at his plan for the legal defense of chiropractic:

"You ask, what I think will be the final outcome of our law getting. It will be that we will have to build a boat similar to Christian Science and hoist a religious flag. I have received chiropractic from the other world, similar as did Mrs. Eddy. No other one has laid claim to that, NOT EVEN B.J. Exemption clauses instead of chiro laws by all means, and LET THAT EXEMPTION BE THE RIGHT TO PRACTICE OUR RELIGION. But 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. Now, if chiropractors desire to claim me as their head, their leader, the way is clear. My writings have been gradually steering in that direction until now it is time to assume that we have the same right to as has Christian scientists."

Straight vs Mixer

State laws to regulate and protect chiropractic practice were eventually introduced in all fifty states in the US, but it was a hard-fought struggle. Medical Examining Boards worked to keep all healthcare practices under their legal control, but an internal struggle among DC's on how to structure the laws significantly complicated the process. Initially, the UCA, led by BJ Palmer, opposed state licensure altogether. Palmer feared that such regulation would lead to allopathic control of the profession. The UCA eventually caved in, but BJ remained strong in the opinion that examining boards should be composed exclusively of chiropractors (not mixers), and the educational standards to be adhered to were the same as the Palmer School. A "Model Bill" was drafted in 1922 to present to all states that did not yet have a law. They embarked on a method of "cleaning house" of mixers by warning state associations to purge their mixing members or face competition by the formation of a new "straight" association in their state.

Frank Margetts circa 1922

Mixers, disturbed by the edicts of the PSC having so much influence in their daily practice, came together to create the American Chiropractic Association (one of the early precursors to today's ACA). Though born out of necessity to defend against the UCA attacks, the ACA's stated purposes were to advance education and research for chiropractic. Its growth was initially stunted by its resolution to recognize physio-therapy and other modalities as pertaining to chiropractic. What growth did occur was credited to its second president, Frank R.Margetts, DC with support from his alma mater, National Chiropractic College. He insisted that no college administrator could hold an official position in the association, essentially giving doctors in the field a collective voice. But a disagreement within the UCA in 1924 turned the tide for the ACA. BJ was still working to purge mixers from practicing chiropractic, and he saw a new invention by Dossa D. Evans, the "Neurocalometer" (NCM), as the answer to all of straight chiropractic's (and particularly PSC's) legal and financial problems. As the owner of the patent on the NCM, he planned to limit the number of NCMs to 5000 and lease them only to graduates of the Palmer related schools who were members of the UCA. He then claimed that the NCM was the only way to accurately locate subluxations, preventing over 20,000 mixers from being able to defend their method of practice.

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John J. Nugent

There was an immediate uproar among practicing DC's. Even Tom Moore, BJ's long-time ally and president of the UCA, displayed his dismay by resigning (though he was later reinstated). BJ reluctantly resigned as treasurer, ending his relationship with the UCA. BJ moved on to form the Chiropractic Health Bureau (today's ICA), along with his staunchest supporters. Membership in the UCA dropped while the ACA membership rose. In 1930, the ACA and UCA joined to form the National Chiropractic Association (NCA). The NCA developed a Committee on Educational Standards (CES), making John J. Nugent DC responsible for raising educational standards for the profession. The years of consolidation or closing of unacceptable schools while developing the new standards earned Nugent the nickname "Chiropractic's Abraham Flexnor" from his admirers and "Chiropractic's Anti-christ" from his adversaries. The CES evolved into today's Council on Chiropractic Education (CCE), and was granted the status of chiropractic's accrediting body by the US Department of Education. Nugent was also later instrumental in the Chiropractic Research Foundation (CRF), today's Foundation for Chiropractic Education and Research (FCER). The differences in state laws that exist today can be traced back to these early legal struggles.

The movement toward scientific reform

By the late 1950s, healthcare in the US 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 antiquackery efforts of the medical trust and leadership efforts of the AMA. BJ reduced the adjustment to HIO (Hole In One - the adjustment of only the atlas), while mixers continued to add and refine new proprietary techniques to find and reduce subluxations and improve health. Osteopathy in the USA developed in parallel to medicine and dropped its reliance on spinal manipulation to treat illness. A similar reform movement began within chiropractic: shortly after the death of BJ in 1961, a second generation chiropractor, Samuel Homola, wrote extensively on the subject of limiting the use of spinal manipulation, proposing that chiropractic as a medical specialty should focus on conservative care of musculoskeletal conditions. His sentiments echoed those of the NCA Chairman of the Board (C.O. Watkins DC) twenty years earlier: "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 in the newly formed ACA was not renewed, and his position was rejected by both straight and mixer associations.

In 1975, the National Institutes of Health brought chiropractors, osteopaths, medical doctors and PhD 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, and in 1981 it was included in the National Library of Medicine's Index Medicus. Joseph Keating dates the birth of chiropractic as a science to a 1983 commentary in the 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.

AMA plans to eliminate chiropractic

On November 2, 1963, the AMA Board of Reagents created the "Committee on Quackery" with the goals of first containing, and then eliminating chiropractic. Doyl Taylor, the Director of the AMA Department of Investigation and Secretary of the Committee on Quackery, outlined the steps needed:

1. to ensure that Medicare should not cover chiropractic
2. to ensure that the U.S. Office of Education should not recognize or list a chiropractic accrediting agency
3. to encourage continued separation of the two national associations
4. to encourage state medical societies to take the initiative in their state legislatures in regard to legislation that might affect the practice of 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 specific educational guidelines for medical schools regarding the "hazards to individuals from the unscientific cult of chiropractic."

Wilk et al. vs the American Medical Association (AMA)

Main article: Wilk v. American Medical Association

Before 1980, Principle 3 of the AMA 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, an antitrust suit was brought against the AMA and other medical associations in 1976 - Wilk et al. vs AMA et al.. 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 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 had to allow its members to collaborate with DCs.

The judge in the Wilk case said:

"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."

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, even though "the anecdotal evidence in the record favors chiropractors".

Chiropractic vertebral subluxation

DD Palmer's early reduction of his chiropractic theories. Note that the 1914 remarks came from his book, The Chiropractic Adjuster, released after his death in 1913. Chart reprinted from Keating J (1995), D.D. Palmer's Forgotten Theories of Chiropractic"

Main article: Vertebral subluxation

DD 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, interferred 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. DD Palmer claimed that subluxations interfered with this innate intelligence, and that by fixing them, all diseases could be treated. He qualified this by noting that knowledge of Innate Intelligence was not essential to the competent practice of chiropractic. The idea that all diseases were the result of a subluxation was in line with the common thinking of the day; that there was one cause for disease.

Chiropractors used these metaphorical concepts to rationalize their thinking about the body’s self-healing capacity. In 1998, Lon Morgan DC, a reform chiropractor, wrote that:"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."

Meridel I. Gatterman DC, educator and writer observed:

"The word subluxation has been ... embodied with a multitude of meaning by chiropractors during the past one hundred years. 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."

Debate about the need to remove the concept of subluxation from the chiropractic paradigm has been ongoing since the mid 1960's. While straights still use the term, reformers suggest that a more mechanistic model will allow chiropractic to better integrate into mainstream medicine. 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 "there is no obvious reason to discard the concept of subluxation, while at the same time maintaining that it is not a rigid entity, but rather an important model and concept; a work in progress that undoubtedly will undergo extensive modification as our concepts of light or psychoanalysis have evolved over half a century."

Scientific investigation of chiropractic

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
Table 1. Two chiropractic system constructs. Source: Phillips RB, Mootz RD. Contemporary chiropractic philosophy. In Haldeman S (ed). Principles and Practice of Chiropractic, 2nd Ed. Norwalk, CT: Appleton & Lange, 1992. Chart reprinted from Keating J (1995), D.D. Palmer's Forgotten Theories of Chiropractic[11]

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 (Table 1).

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 totalling $2.3 million). The Foundation for Chiropractic Education and Research and the Consortium for Chiropractic Research 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 included in Index Medicus. Research into chiropractic, whether from Universities or chiropractic colleges, is however often published in many other scientific journals.

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. When testing the efficacy of health treatments, double blind studies are generally considered the highest standards of scientific rigour. These are designed so that neither the patient nor the doctor know whether they are using the actual treatment or a placebo (or "sham") treatment. However, chiropractic treatment involves a manipulation; no "sham" procedure can be devised easily 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. This problem is not confined to chiropractic - many medical treatments are not amenable to double-blind placebo-controlled trials, indeed this is true for all surgical procedures. 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. In this, they are not different to the practice in much of conventional medicine.

Sociologist Leslie Biggs interviewed 600 Canadian DCs in 1997: while 86% felt that chiropractic methods needed to be validated, 74% did not believe that controlled clinical trials were the best way to evaluate chiropractic. Moreover, 68% believed that "most diseases are caused by spinal malalignment", although only 30% agreed that "subluxation was the cause of many diseases".

Even when a valid mechanism of action is not determined, it is generally thought sufficient to present evidence showing benefit for the claims made. There is wide agreement that, where applicable, an evidence based medicine framework should be used to assess health outcomes, and that systematic reviews with strict protocols are important for objectively evaluating 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.

A 2005 editorial in JMPT, "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 that, 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..."

The Cochrane Collaboration did not find enough evidence to support or refute the claim that manual therapy (including, but not limited to, chiropractic) is beneficial for asthma. Carpal tunnel syndrome trials have not shown benefit from diuretics, non-steroidal anti-inflammatory drugs, magnets, laser acupuncture, exercise or chiropractic and there is not enough evidence to show the effects of spinal manipulation (including, but not limited to, chiropractic) for painful menstrual periods. Bandolier found limited evidence that spinal manipulative therapy (including, but not limited to, chiropractic) might reduce the frequency and intensity of migraine attacks, but the evidence that spinal manipulation is better than amitriptyline, or adds to the effects of amitriptyline, is insubstantial for the treatment of migraine, although "spinal manipulative therapy might be worth trying for some patients with migraine or tension headaches." According to Bandolier, a systematic review of a small, poor quality set of trials, provided no convincing evidence for long-term benefits of chiropractic interventions for acute or chronic low back pain, despite some positive overall findings [12] but there might be some short-term pain relief, especially in patients with acute pain. However, the BMJ noted in a study on long-term low-back problems "...improvement in all patients at three years was about 29% more in those treated by chiropractors than in those treated by the hospitals. The beneficial effect of chiropractic on pain was particularly clear." A 1994 study by the U.S. Agency for Health Care Policy and Research (AHCPR) and the U.S. Department of Health and Human Services endorses spinal manipulation for acute low back pain in adults in its Clinical Practice Guideline.

The first significant recognition of the appropriateness of spinal manipulation for low back pain was performed by the RAND Corporation. This meta-analysis concluded that some forms of spinal manipulation were successful in treating certain types of lower back pain. Some chiropractors claimed these results as proof of chiropractic hypotheses, but RAND's studies were about spinal manipulation, not chiropractic specifically, and dealt with appropriateness, which is a measure of net benefit and harms; the efficacy of chiropractic and other treatments were not explicitly compared. In 1993, Dr Shekelle rebuked some DCs for their exaggerated claims: :...we have become aware of numerous instances where our results have been seriously misrepresented by chiropractors writing for their local paper or writing letters to the editor....

There is conflict in the results of chiropractic research. For instance, many DCs claim to treat infantile colic. According to a 1999 survey, 46% of chiropractors in Ontario treated children for colic. In 1999 a Danish randomized controlled clinical trial with a blinded observer suggested that there is evidence that spinal manipulation might help infantile colic. However, in 2001, a Norwegian blinded study concluded that chiropractic spinal manipulation was no more effective than placebo for treating infantile colic.

In 1997, historian Joseph Keating Jr described chiropractic as a "science, antiscience and pseudoscience", and said "Although available scientific data support chiropractic's principle intervention method (the manipulation of patients with lower back pain), the doubting, skeptical attitudes of science do not predominate in chiropractic education or among practitioners". He argued that chiropractic's culture has nurtured antiscientific attitudes and activities, and 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, after reviewing the articles published in the JMPT from 1989-1996, he concluded,

"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."

The Manga Report

The Manga Report was an outcomes-study funded by the Ontario Ministry of Health and conducted by three health economists led by Pran Manga. The Report supported the 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."

Workers' Compensation studies

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." 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.

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.

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.

American Medical Association (AMA)

In 1997, the following statement was adopted as policy of the AMA after a report on a number of alternative therapies:[13]

Specifically about chiropractic 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 issued this statement:

"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)"[14]

British Medical Association

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."

Safety

The International Chiropractic Association (ICA) suggests that chiropractic is one of the safest health professions and chiropractors have some of the lowest malpractice insurance premiums in the health care industry. As with all interventions, there are risks associated with spinal manipulation. According to Harrison's, these include vertebrobasilar accidents (VBA), strokes, spinal disc herniation, vertebral fracture, and cauda equina syndrome. A 1996 Danish study determined that the greatest risk is with manipulation of the first two vertebra of the cervical spine, particularly passive rotation of the neck, known as the "master cervical" or "rotary break." However, serious complications after manipulation of the cervical spine are estimated to be just 1 in 3-4 million manipulations or fewer, based on international studies of millions of chiropractic cervical adjustments from 1965 to the present. The RAND corporation's extensive review estimated "one in a million." Dvorak cites figures of 1 in 400,000, while Jaskoviak reported no vertebral artery strokes or serious injury in approximately 5 million cervical manipulations from 1965 to 1980 at The National College of Chiropractic Clinic in Chicago. By contrast, cervical spine surgery, an alternative to spinal manipulation for neck pain and radiating arm pain, has a 3-4% complication rate and 4,000-10,000 deaths per million neck surgeries.

Statistics on the reliability of incident reporting for spinal manipulation vary; the RAND study assumed that only 1 in 10 cases would have been reported. However, Dr Ernst surveyed neurologists in Britain for cases of serious neurological complication occurring within 24 hours of cervical spinal manipulation (not specifically by a chiropractor); 35 cases had been seen by the 24 who responded, but none had been reported. He concluded that underreporting was close to 100%, rendering estimates "nonsensical." The NHS Centre for Reviews and Dissemination agreed that the survey had methodological problems with data collection. Both NHS and Ernst noted that bias is a problem with the survey method of data collection.

A 2001 study in the journal Stroke found that vertebrobasilar accidents (VBAs) were five times more likely in those aged <45 years who had visited a chiropractor in the preceding week, compared to controls who had not visited a chiropractor. No significant associations were found for those aged >45 years. The authors concluded; "While our analysis is consistent with a positive association in young adults... The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment." The NHS notes that this study collected data objectively by using administrative data, involving less recall bias than survey studies, but the data were collected retrospectively and probably contained inaccuracies.

There are also concerns about using cervical manipulation for conditions for which it is not indicated. In 1996, Coulter et al. surveyed 4 MDs, 4DCs and 1 MD/DC to evaluate the risks and benefits of manipulation or mobilization of the cervical spine (not necessarily performed by a chiropractor). After looking at more than 700 conditions, there was consensus in only 11% of those conditions that cervical manipulation or mobilization was appropriate.

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 chiropractors. The report goes on to say:

"The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. .... Such reporting adversely affects the reader's opinion of chiropractic and chiropractors."

Chiropractic adjustments are set apart from manipulation due to their precision and specificity . While there are nearly 200 different chiropractic techniques, which vary considerably, such differences have never been taken into account in relation to safety.

A New Zealand Commission report in 1979 said "We are satisfied that chiropractic treatment in New Zealand is remarkably safe... By the end of the inquiry we found ourselves irresistibly and with complete unanimity drawn to the conclusion that modern chiropractic is a soundly based and valuable branch of the health care in a specialized area." (Report of the Commission of Inquiry Into Chiropractic 1979:p 77). However, the judge in the Wilk vs AMA case described this report as "unsatisfactory", and a review by the US Congress' Office of Technology Assessment found 'serious problems' in its treatment of safety and efficacy issues.

In a 1993 study, J.D. Cassidy DC and co-workers concluded that the treatment of lumbar intervertebral disk herniation by side posture manipulation is "both safe and effective."

Chiropractic education, licensing, and regulation

See main articles:

• Chiropractic education
• Chiropractic schools
• Council on Chiropractic Education
• Federation of Chiropractic Licensing Boards

Practice styles and schools of thought

Contemporary chiropractic can be divided into several approaches to patient care: all are 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. Most chiropractors advertise themselves as primary care doctors, and consider themselves part of "alternative health care", but there can be large differences between practitioners. The differences between straights and mixers are reflected in multiple national practice associations, but most chiropractors are not members of any national organization.

1. Traditional Straight chiropractors are the oldest movement; they adhere to the tenets, set forth by DD and BJ Palmer, that vertebral subluxation leads to interference of the human nervous system and is a primary underlying risk factor for almost any disease. Straights view the diagnosis of patient complaints, which they consider to be "secondary effects", to be unnecessary for treatment. Instead, patients are typically screened for "red flags" of serious disease, and treated based on a practitioner's preferred chiropractic technique. This stance against diagnosing has been a source of contention between mixers and straights, because accreditation standards mandate that differential diagnosis be taught in all chiropractic programs so that patient care is safe and relevant to their complaints. Additionally, several state chiropractic licensing boards mandate that patient complaints be diagnosed before receiving care. The most popular national association for traditional straights is the International Chiropractors Association (ICA).
2. Mixing chiropractors are an early offshoot of the straight movement. This branch originated from naturopathic, osteopathic, medical, and even chiropractic doctors who attended the Palmer College of Chiropractic and then re-organized the treatment system to include more diagnostic and treatment approaches. They eventually split from the traditional straight group and formed various other chiropractic schools including the National College of Chiropractic. Their treatments may include naturopathic remedies, physical therapy devices, or other CAM methods. While still subluxation based, mixers also treat problems associated with both the spine and extremities, including musculoskeletal issues such as pain and decreased range of motion. Mixers describe vertebral subluxations as a form of joint dysfunction or osteoarthritis. Diagnosis is made after ruling out other known disorders and noting general signs of mechanical dysfunction in the spine. They tend to be members of the American Chiropractic Association, and all the major groups in Europe are also in membership of the European Chiropractors Union.
3. Objective Straight chiropractors [15] are a recent off-shoot of the traditional straights and are a minority. This group 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. Like traditional straights, objective straights typically do not diagnose patient complaints. They also don't refer to other professionals, but do encourage their patients "to see 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". [16] Most objective straights limit treatment to spinal adjustments; they tend to be members of the Federation of Straight Chiropractic Organization (FSCO) and the World Chiropractic Alliance (WCA).
4. Reform chiropractors, also a minority group, are primarily mixers who advocate the use of manipulation as a treatment for osteoarthritis and other musculoskeletal conditions. They do not subscribe to Palmer philosophy or the vertebral subluxation theory. Instead they recommend the use of palpation and manipulation to identify and treat painful joints which may contain adhesions. This group is very similar in practice to mixer chiropractors, though they tend not to use CAMs.

See also

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

External links

Professional organizations

• American Chiropractic Association (ACA)
• Association of Chiropractic Colleges (ACC)
• British Chiropractic Association (BCA)
• Canadian Chiropractic Association (CCA)
• Chiropractic Association of South Africa (CASF)
• Chiropractic Doctors' Association of Hong Kong (CDAHK)
• Council on Chiropractic Education - USA (CCE-USA)
• European Chiropractors' Union (ECU)
• Federation of Chiropractic Licensing Boards (FCLB)
• Federation of Straight Chiropractors and Organizations (FSCO)
• Foundation for the Advancement of Chiropractic Education (F.A.C.E.)
• Foundation for Chiropractic Education and Research (FCER)
• Hong Kong Chiropractors' Association (HKCA)
• International Chiropractic Pediatric Association (ICPA)
• International Chiropractors Association (ICA)
• Japanese Association of Chiropractors (JAC)
• National Association for Chiropractic Medicine (NACM)
• National Board of Chiropractic Examiners (NBCE)
• World Chiropractic Alliance (WCA)
• World Federation of Chiropractic (WFC)

Chiropractic schools

• See article: Chiropractic schools

Other resources

• Chiropractic History Archive - Joseph C. Keating Jr, PhD
• The Chiropractic Profession and Its Research and Education Programs
• Chiropractic in the United States: Training, Practice, and Research (1997) - Cherkin, Daniel C.; Mootz, Robert D.
• Chiropractic Resource Organization
• Chiropractic treatments for back pain - Steven G. Yeomans, DC. A Spine-health.com feature (use menu points on left side)
• Dynamic Chiropractic Online - ChiroWeb, Chiropractic news source
• National Directory of Chiropractic - Listing of Chiropractors and information on education and the profession.
• National Center for Complementary and Alternative Medicine - National Institute of Health - Manipulative and Body-Based Practices
• The Future of Chiropractic Revisited: 2005 to 2015
• Olympic Games Inspire Optimal Athletic Care

Internal criticism

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

Samuel Homola DC, a notable and 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 J. Redding, chairman of the ACA board of governors, welcomed Homola back to membership of the ACA, and in 1994, 30 years after its publication, the book was reviewed for the first time by a chiropractic journal. [17]

• Chiropractic Ethics: An Oxymoron?

JC Smith, a chiropractor in private practice, 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 C. Keating, Jr, PhD, professor at the Los Angeles College of Chiropractic and notable historian of chiropractic, warns of pseudoscientific notions that still persist in the mindsets of some chiropractors

• 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, DC 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 P. McAndrews, warns the chiropractic profession that advertising of scare tactic subluxation philosophy damages the newly won respect within the AMA.

• Quackery in Chiropractic -

A 1991 editorial from chiropractic trade magazine, Dynamic Chiropractic, where Joseph C. Keating Jr discusses his concerns for advertising products before they are scientifically evaluated.

• Subluxation - The Silent Killer

A 2000 commentary by Ronald Carter, DC, MA, Past President, Canadian Chiropractic Association in the Journal 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 now time for the silent majority to make their voices heard and come together to present a rational and defensible model of chiropractic so that is not just included in the health care system, but an essential member of the health care team.

External criticism

• A Different Way To Heal? - PBS, Scientific American Frontiers, Web Feature
• Chirobase: Skeptical guide to chiropractic history, theories, and current practices - Stephen Barrett, MD, and Samuel Homola, DC (combines internal and external criticism)
• Chiropractic: Flagship of the Alternative Medicine Fleet, Part One and Part Two - Steven Novella, MD 1997