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 uses manual therapy to alleviate pain and treat musculoskeletal problems. Chiropractors (DCs) aim to improve overall health, and function of the back, by improving body posture and joint mobility. Believing that health is compromised when the vertebral column is not in optimal alignment, they identify theoretically sub-optimal vertebral joint alignments (“vertebral subluxations") as detrimental to the body's ability to heal, and adjust them.

This word "subluxation" is used with a different meaning by biologists, and the special way the word is used by chiropractors must be understood in order to appreciate their art. The way that chiropractors use the term is unique among all other health and healing arts professionals, and stems from the historical roots of chiropractic. In conventional medicine and biology, subluxation always means that there is a physical dislocation such that the part is completely out of place. In chiropractic subluxations, this is almost never the case. Unless otherwise specified, the word "subluxation" in this article refers to the chiropractic definition of the term.

According to chiropractors, subluxations can occur after injury to the ligaments, muscles or joints that support the spine. Such injuries might be acute, from trauma, and accompanied by immediate pain; or repetitive, resulting from prolonged posture problems and only gradually cause symptoms. DCs believe that, unless adjusted with manual therapy, vertebral subluxations accelerate degenerative changes such as arthritis and, by interfering with the nervous system, impair health. The presence of subluxations isdetermined by carefully examining the back, and, if identified, subluxations are treated with manual and mechanical methods called spinal adjustments.

Chiropractic was founded in 1895 by Daniel David Palmer. In his mind, subluxations were misaligned vertebrae which compressed spinal nerves, interfering with the transmission Innate intelligence and thereby causing 'dis-ease' or disharmony. He compared this to stepping on a hose that slowed the flow of water to a garden: 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, the metaphor is sometimes still used by chiropractors to explain vertebral subluxation to patients. Most DCs today continue to assert that the vertebral subluxation complex plays a role in most, if not all, diseases. Although most chiropractic care is aimed at musculoskeletal pain and related problems, there are chiropractors who are willing to use manual therapy to treat systemic disease (includingallergy and specific illnesses that are not in the musculoskeltal system otitis media), in both children and adults. Although there has never been any scientific evidence that adjustments help such conditions, there is a growing body of medical literature that proves chiropractic care is as effective as physical therapy and conventional non-surgical medical treatment of back pain, even for the more severe underlying conditions that most often prompt patients to undergo spinal surgery (need those refernces I sent you Matt, I'll look them up soon). Several recent large randomized studies have shown that not only is manual therapy at least as good as these conventional medical treatments for back pain, but that patients tend to be more satisfied with chiropractic care and that the financial cost is less. This satisfaction was apparent even though chiropractic care of back pain does not include the use of narcotics and other pain relieving drugs.(ref-I have them, will dig them up)

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.Template:Alternative medical systems

Chiropractic in practice

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

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.

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, which, according to this information, decided on exactly what commands the motor nerves should convey. He thought that subluxation must interfere with these signals, and that this would be the cause of disease; he concluded that all diseases could be treated by fixing th subluxations. He considered, however, that it was not essential to know exactly what Innate Intelligence was, so long as DCs could locate and adjust subluxations.

For many, the concepts of innate intelligence and subluxation today appear to be too vague to be scientific. However, some DCs argue that these 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' 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 believes 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)

When chiropractic began, 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 enhanced the standards of education for medicine, chiropractic schools were 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 and anatomical studies, including 8 months of human dissection, and students must undertake a research project in their third year. The final two years cover manipulation and spinal adjustment and give 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 [10] and satisfy State-specific requirements. Chiropractic colleges also offer postdoctoral training with exams leading to 'diplomate' status in particular specialties. 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

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. By 1885, purveyers of scientific medicine, herbalism, magnetism and leeches, lances, tinctures and patent medicines were all in competition, and with no patent protection for new discoveries, claims for the drugless healing professions proliferated. 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.

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. 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 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.

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. 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. However, Palmer stated that he concentrated on reducing 'heat' from friction of the misaligned parts, while Still claimed to enhance the flow of blood.

Medicine, osteopathy, and chiropractic; the three rivals

In 1899, a Davenport MD, Heinrich Matthey, began a campaign to change the state law in Iowa to prevent drugless healers from practicing, 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 graduates did not need the same training as medicine, as they did not prescribe drugs. Nevertheless, in 1901, he was charged with misrepresenting to a student a course in chiropractic which was not a real science. He was arrested twice more by 1906, and was convicted for claiming that he could cure disease when he had no license to practise either medicine or osteopathy.

His conviction prompted the creation of the 'Universal Chiropractic Association'; to provide for legal defense of members; its first case (of more than 15000 prosecutions of DCs fought in the first 30 years) was in 1907, when Shegataro Morikubo DC of Wisconsin was charged with unlicensed practice of osteopathy. 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.

The American Medical Association plans to eliminate chiropractic

"Medicine, Monopolies, and Malice". (Chester Wilk DC, book title[11])

In 1847, the American Medical Association (AMA) had been formed to establish higher standards for medical education. By the turn of the century, 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 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 effectively gained control of federal healthcare research and student aid.

In 1963, the AMA formed a 'Committee on Quackery' to contain and if possible eliminate chiropractic, by seeking to ensure that Medicare should not cover chiropractic and that the U.S. Office of Education should not recognize a chiropractic accrediting agency, by encouraging continued separation of the two national associations, and by persuading 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. 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." [12]

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." [13]

Efficacy

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] By 1997, there were 14 peer-reviewed journals that specifically encourage chiropractic research, but only the JMPT is indexed in Index Medicus[15].

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 appropriate for 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 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)."

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 [16]

Because they feel that healing comes from within the body, DCs don't talk 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 also because different DCs use 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 both directly by efferent nerves, many of which travel down the spinal cord, and indirectly by neuroendocrine regulation of hormone secretion. Accordingly, disruption of spinal information flow can influence the physiological function of virtually every organ system. However it is not clear that it is 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 anecdotal evidence (from case studies) that they can; however this evidence is generally regarded as weak because it may be 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 objectively verifiable efficacy can it be regarded as validated. One common criticism 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 treatment might be taken as excluding more common causes of dysfunction, such as infectious disease. It is also possible that the symptom apparently of an organ disease was actually the result of a somatic reflex pain generated from the spine. Thus, if an organ-related complaint fails to get the expected results from conventional treatment but then responds to chiropractic adjustments, it is possible that a spinal condition was the cause of the symptom in the first place. [17]

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 to treat asthma; here the evidence is that it can be efficacious, but no more than placebo treatment. Placebo effects can be very powerful, which is an indication of the potential importance of the ability of the mind to contribute to healing, and 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.[18] 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 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 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 osteopathy, from 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. [19]

• 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, 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