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Chiropractic (from Greek chiro- χειρο- "hand-" + praktikós πρακτικός "concerned with action") is a complementary and alternative medicine health care profession that focuses on diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system and the effects of these disorders on the functions of the nervous system and general health. It emphasizes manual therapy including spinal adjustment and other joint and soft-tissue manipulation.^[1] Traditionally, it is based on the premise that a vertebral subluxation or spinal joint dysfunction can interfere with the nervous system and result in many different conditions of diminished health. Today, this alternative form of therapy examines the relationship between structure and function and its impact on neurological mechanisms in both health and disease.^[2]^[3]^[4]

Chiropractors usually obtain one of the following equivalent first professional degrees in chiropractic medicine (D.C. or D.C.M. or B.Chiro or M.Chiro). Chiropractors use a combination of treatments that are predicated on the specific needs of the individual patient. A chiropractor can develop and carry out a comprehensive treatment and management plan that can include spinal adjustments, soft tissue therapy, prescription of exercises, and health and lifestyle counseling.^[5]

Chiropractic was founded in 1895 by D. D. Palmer in the USA, and is practiced in more than 100 countries.^[6] Since its inception, chiropractic has been controversial, both within the profession and in the medical and scientific community, particularly regarding the metaphysical approach espoused by its founders and advocated by "straight" chiropractors.^[7]^[8] This same criticism may have been the catalyst that allowed some within the profession to emphasize primarily a neuromusculoskeletal approach in their educational curriculum, leading them away from the original metaphysical explanations of their predecessors towards more scientific ones.^[9]^[10]

Chiropractors have historically fallen into two main groups, "straights" and "mixers"; both groups contain recent off-shoots.^[11]^[12] Significant differences regarding scope of practice, claims made about spinal manipulation, and beliefs regarding professional integration, differentiate the various schools of thought and practice styles held within the profession.^[13]

Philosophy

**Two chiropractic belief system constructs**
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
taken from Mootz & Phillips 1997^[14]

Traditional and evidence-based chiropractic belief systems vary along a philosophical spectrum ranging from vitalism to materialism. These opposing philosophies have been a source of debate since the time of Aristotle and Plato. Vitalism, the belief that living things contain an element that cannot be explained through matter, was responsible for legally and philosophically differentiating chiropractic from conventional medicine and thereby helping ensure professional autonomy.^[15] Chiropractic also retains elements of materialism, the belief that all things have explanations, which forms the basis of science. Evidence-based chiropractic balances this dualism by emphasizing both the tangible, testable principle that structure affects function, and the untestable, metaphorical recognition that life is self-sustaining.^[14]

The chiropractor's purpose is to foster the establishment and maintenance of an organism-environment dynamic that is the most conducive to functional well-being of the person as a whole.^[14] Principles such as holism, naturalism, therapeutic conservatism, critical rationalism, and thoughts from the phenomenological and humanistic paradigms form an important part of the philosophy of chiropractic."^[16]

Chiropractors can adopt or share vitalist, naturalist, or materialist viewpoints and emphasize a holistic, patient-centered approach that appreciates the multifactorial nature of influences (i.e. structural, chemical, and psychological) on the functioning of the body in health and disease and recognizes the dynamics and interplay between lifestyle, environment, and health. This holistic paradigm is also blended with a biopsychosocial approach, which is also emphasized in chiropractic care. In addition, chiropractors also retain naturopathic and naturalist principles that suggest decreased "host resistance" of the body facilitates the disease process and that natural interventions are preferable towards strengthening the host in its effort to optimize function and return to homeostasis.^[14] Chiropractic care primarily emphasizes manipulation and other manual therapies as an alternative than medications and surgery.^[17]

Chiropractors also commonly use nutrition, exercise, patient education, health promotion and lifestyle counseling as part of their holistic outlook towards preventive health care.^[18] Chiropractic's claim to improve health by improving biomechanical and neural function by the manual correction of joint and soft tissue dysfunctions of the neuromusculoskeletal system differentiates it from mainstream medicine and other complementary and alternative medicine (CAM) disciplines, but is also rooted, in part, in osteopathy and eastern medicine interventions.^[16] All chiropractic paradigms emphasize the spine as their focus, but their rationales for treatment vary depending on their particular belief system.

The philosophy of chiropractic also stresses the importance of prevention and primarily utilizes a pro-active approach and a wellness model to achieve this goal.^[19] For some, prevention includes a concept of "maintenance care" that attempts to "detect and correct" structural imbalances of the neuromusculoskeletal system while in its primary, or functional state.^[20] The objective is early identification of mechanical dysfunctions to prevent or delay permanent pathological changes.^[21]

In summary, the major premises regarding the philosophy of chiropractic include:^[14]

Holism

non-invasive, emphasizes patient's inherent recuperative abilities
recognizes dynamics between lifestyle, environment, and health
spine and health are related in an important and fundamental way, and this relationship is mediated through the nervous system.^[15]
recognizes the centrality of the nervous system and its intimate relationship with both the structural and regulatory capacities of the body
appreciates the multifactorial nature of influences (structural, chemical, and psychological) on the nervous system

Conservatism

balances the benefits against the risks of clinical interventions
emphasizes non-invasive treatments to minimize risk with a preference to avoid surgery and medication
recognizes as imperative the need to monitor progress and effectiveness through appropriate diagnostic procedures
prevents unnecessary barriers in the doctor-patient encounter

Manual and biopsychosocial approaches

strives toward early intervention, emphasizing timely diagnosis and treatment of reversible conditions before loss of functionality
emphasizes a patient-centered model in which the patient is considered to be indispensable in, and ultimately responsible for, the maintenance of health^[15]
approach of improving health through influencing function through structure primarily via manual therapies

Scope of practice

Chiropractors are primary-contact health care practitioners who emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery.^[22] Although chiropractors have many attributes of primary care providers, chiropractic has more of the attributes of a medical specialty like dentistry.^[23] The practice of chiropractic medicine involves a range of diagnostic methods including skeletal imaging, observational and tactile assessments, orthopedic and neurological evaluation, laboratory tests,^[22] and specialized tests.^[1] A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider.^[23] Common patient management involves:

spinal manipulation and other manual therapies to the joints and soft tissues
rehabilitative exercises
health promotion
electrical modalities
conservative and complementary procedures
lifestyle counseling.^[24]

Chiropractors generally cannot write medical prescriptions; a 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for over-the-counter drugs.^[25] A notable exception is the state of Oregon which is considered to have an "expansive" scope of practice of chiropractic, which allows chiropractors to prescribe over-the-counter substances and perform minor surgery.^[26] In some locations chiropractors (DCs) and veterinarians (DVMs) with additional training and certification can practice veterinary chiropractic which includes the diagnosis, treatment and rehabilitation of injured animals.^[27]^[28] However, the official position of the American Chiropractic Association is that applying manipulative techniques to animals does not constitute chiropractic and that veterinary chiropractic is a misnomer.^[29] Chiropractors are also generally permitted to use adjunctive therapeutic modalities such as acupuncture and manipulation under anesthesia with additional training from accredited universities/colleges.^{[citation needed]}

Chiropractic medicine is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries.^[30] Similar to other primary contact health providers, chiropractors can specialize in different areas of chiropractic medicine. The most common post-graduate diplomate programs include neurology, sports sciences, clinical sciences, rehabilitation sciences, orthopedics and radiology which generally require 2–3 additional years of additional post graduate study and passing competency examinations.^[31]

Education, licensing, and regulation

International training guidelines require that persons without relevant prior health care experience must spend at least 4200 student/teacher contact hours in four years of full‐time education; experienced health professionals need only 2200 hours. Both figures include at least 1000 hours of supervised clinical training.^[22] In some countries a license is required in order to practice.^[32]

A Chiropractic Examining Board requires all candidates to complete a twelve-month clinical internship to obtain licensure.^{[citation needed]} Licensure is granted following successful completion of all state/provincial and national board exams so long as the DC maintains malpractice insurance.^[33] Nonetheless, there are still some variations in educational standards internationally depending on admission and graduation requirements.^{[citation needed]} Chiropractic medicine is regulated in Canada by provincial statute. Regulatory colleges are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.^[34] Today, there are 15 accredited Doctor of Chiropractic programs in 18 locations in the USA and 2 in Canada,^[35] and an estimated 70,000 chiropractors in the USA, 6500 in Canada, 2500 in Australia, 2,381 in the UK, and smaller numbers in about 80 other countries.^[36]

Treatment procedures

Procedures received by more than 1/3 of patients of licensed U.S. chiropractors (2003 survey)^[37]
procedure	% of DCs using it	% of patients receiving it
Diversified (full-spine manipulation)	96.2	71.5
Physical fitness/exercise promotion	98.3	64.9
Corrective or therapeutic exercise	98.3	63.2
Ergonomic/postural advice	97.3	61.9
Self-care strategies	96.6	60.6
Activities of daily living	96.6	57.9
Changing risky/unhealthy behaviors	96.6	54.9
Nutritional/dietary recommendations	97.7	51.8
Relaxation/stress reduction recommendations	96.4	50.1
Ice pack/cryotherapy	94.5	48.5
Extremity adjusting	95.4	46.8
Trigger point therapy	91.0	45.3
Disease prevention/early screening advice	90.8	39.7

Spinal manipulation, the most common modality in chiropractic care,^[37] is a passive manual maneuver during which a three-joint complex is taken past the normal physiological range of movement without exceeding the anatomical boundary limit.^[38] The medicinal use of spinal manipulation can be traced back over 3000 years to ancient Chinese writings. Hippocrates, the "father of medicine" used manipulative techniques,^[39] as did the ancient Egyptians and many other cultures. A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of the osteopathic medicine and chiropractic medicine.^[40] Spinal manipulation gained mainstream recognition during the 1980s (see History). In the U.S., chiropractors perform over 90% of all manipulative treatments^[41] and consider themselves to be expertly qualified providers of spinal adjustment, manipulation and other manual treatments.^[42]

Manipulation under anesthesia or MUA is a specialized manipulative procedure that typically occurs in hospitals administered under general anesthesia.^[43] Typically, it is performed on patients who have failed to respond to other forms of treatment.^{[citation needed]}

Schools of thought and practice styles

Common themes to chiropractic care include holistic, conservative and non-medication approaches via manual therapy.^[44] Still, significant differences exist amongst the practice styles, claims and beliefs between various chiropractors.^[13]

Straight

Straight chiropractors are the oldest movement. They adhere to the philosophical principles set forth by D. D. and B. J. Palmer, and retain metaphysical definitions and vitalistic qualities. Straight chiropractors believe that vertebral subluxation leads to interference with an Innate intelligence within the human nervous system and is a primary underlying risk factor for almost any disease. Straights view the medical diagnosis of patient complaints (which they consider to be the "secondary effects" of subluxations) to be unnecessary for treatment. Thus, straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not "mix" other types of therapies. Their philosophy and explanations are metaphysical in nature and prefer to use traditional chiropractic lexicon (i.e. perform spinal analysis, detect subluxation, correct with adjustment, etc.). They prefer to remain separate and distinct from mainstream health care.

Mixer

Range of belief perspectives in chiropractic
perspective attribute	potential belief endpoints
scope of practice:	narrow ("straight") ←	→ broad ("mixer")
diagnostic approach:	intuitive ←	→ analytical
philosophic orientation:	vitalistic ←	→ materialistic
scientific orientation:	descriptive ←	→ experimental
process orientation:	implicit ←	→ explicit
practice attitude:	doctor/model-centered ←	→ patient/situation-centered
professional integration:	separate and distinct ←	→ integrated into mainstream
taken from Mootz & Phillips 1997^[14]

Mixer chiropractors are an early offshoot of the straight movement. This branch "mixes" diagnostic and treatment approaches from naturopathic, osteopathic, medical, and chiropractic viewpoints. Unlike straight chiropractors, mixers believe subluxation is one of the many causes of disease, and they incorporate mainstream medical diagnostics and employ myriad treatments including joint and soft tissue manipulation, electromodalities, physical therapy, exercise-rehabilitation and other complementary and alternative approaches such as acupuncture.^[11]

Utilization and satisfaction rates

Chiropractic is the largest alternative medical profession in the U.S.^[11] and is the 3rd largest doctored profession behind medicine and dentistry in North America.^[45] The percentage of population that utilize chiropractic care at any given time generally fall into a range from 6% to 12% in the U.S. and Canada,^[46] with a global high of 20% in Alberta.^[47] The vast majority who seek chiropractic care do so for relief from back and neck pain and other neuromusculoskeletal complaints;^[48] most do so specifically for low back pain.^[46] Complementary and alternative medicine (CAM) practitioners such as chiropractors are often used as a complementary form of care to primary medical intervention.^[46] Satisfaction rates are typically higher for chiropractic care compared to medical care, with quality of communication seeming to be a consistent predictor of patient satisfaction with chiropractors.^[49] Despite high patient satisfaction scores, utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient.^[50] The use of chiropractic is growing modestly; CAM as a whole is seeing wholesale increases.^[46] Employment of U.S. chiropractors is expected to increase 14% between 2006 and 2016, faster than the average for all occupations.^[51]

History

File:Ddpalmer3.jpg

D.D. Palmer

Chiropractic (also known as Chiropractic Medicine) was founded in the 1890s by Canadian-American Daniel David Palmer in Davenport, Iowa, USA. Palmer and his son B.J. Palmer later wrote that the elder Palmer gave the first chiropractic adjustment to a deaf man, Harvey Lillard, on September 18, 1895, restoring the man's hearing.^[52] Lillard's daughter disputed the account, saying that Palmer had merely slapped Lillard on the back after hearing a joke.^[53] Investigator Cyrus Lerner found in 1952 that the Lillard story disagreed with other evidence published about the same time, speculated that B.J. concocted the date of the first adjustment in order to establish priority for chiropractic, and compared the Lillard story to the Tales of the Arabian Nights.^[54] Palmer hypothesized that manual manipulation of the spine could result in improved neurological function and health. Friend and Rev. Samuel Weed suggested combining the words cheiros and praktikos (meaning "done by hand") and chiropractic was born.^{[citation needed]}

Vertebral subluxation

Palmer hypothesized that vertebral joint misalignments, which he termed "vertebral subluxations," interfered with the body's function and its inborn (innate) ability to heal itself.^[12] D.D. Palmer 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. D.D. Palmer, using a vitalistic approach, imbued the term subluxation with a metaphysical and philosophical meaning. He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic.^[55] This concept was later expanded upon by his son, B.J. Palmer and was instrumental in providing the legal basis of differentiating chiropractic medicine from conventional medicine. In 1910, D.D. Palmer theorized that the nervous system controlled 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 that 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 functionality—too much or not enough action—which is disease."^[56]

The concept of subluxation remains unsubstantiated and largely untested, and a debate about whether to keep it in the chiropractic paradigm has been ongoing for decades.^[7] In general, critics of traditional subluxation-based chiropractic (including chiropractors) are skeptical of its clinical value, dogmatic beliefs and metaphysical approach. While straight chiropractic still retains the traditional vitalistic construct espoused by the founders, evidence-based chiropractic suggests that a mechanistic view will allow chiropractic care to become integrated into the wider health care community.^[7] This is still a continuing source of debate within the chiropractic profession as well, with some schools of chiropractic (for example, Palmer School of Chiropractic^[57]) still teaching the traditional/straight subluxation-based chiropractic, while others (for example, Canadian Memorial Chiropractic College^[58]) have moved towards an evidence-based chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions but retains a holistic approach and an emphasis on manual therapy.^{[citation needed]} A 2003 survey of North American chiropractors found that 88% wanted to retain the term vertebral subluxation complex, and that when asked to estimate the percent of visceral ailments that subluxation significantly contributes to, the mean response was 62%.^[25] As of 2005, the chiropractic subluxation was defined by the World Health Organization as "A lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. It is essentially a functional entity, which may influence biomechanical and neural integrity."^[22] "This definition is different from the current medical definition, in which subluxation is a significant structural displacement, and therefore visible on static imaging studies."^[22]

Medical opposition

In 1899, a medical doctor in Davenport, USA, named Heinrich Matthey started a campaign against drugless practitioners.^[54]^[59] D.D. Palmer insisted that his techniques did not need the same courses or license as medical doctors, as his graduates did not prescribe drugs, perform surgery or evaluate laboratory diagnostics. However, in 1906, D.D. Palmer was convicted for practicing medicine without a license. In response, B.J. created the Universal Chiropractic Association (UCA) for the purpose of protecting its members by covering their legal expenses should they get arrested for practicing medicine.^[60]

File:BJPalmer2.jpg

BJ Palmer, Developer of Chiropractic, 1882-1961

Its first case came in 1907, when Shegataro Morikubo, DC was charged with unlicensed practice of osteopathic medicine in Wisconsin. Morikubo was freed using the defense that chiropractic philosophy was different from osteopathic philosophy. The victory reshaped the development of the chiropractic profession, which then marketed itself as a science, an art and a philosophy.^[54] This began a longstanding feud between chiropractors and medical doctors that would culminate in the mid 1980's in a landmark case, Wilk et al. vs American Medical Association (AMA). Until 1983, the AMA held that it was unethical for medical doctors to associate with an "unscientific practitioner," and labeled chiropractic "an unscientific cult."^[61] In 1984, Joseph Janse, DC, ND, attempted to describe the divide in chiropractic and medical philosophy regarding prevention and patient care:

"Unless pathology is demonstrable under the microscope, as in the laboratory or by roentgenograms, to them [medical doctors] it does not exist. For years the progressive minds in chiropractic have pointed out this deficiency. With emphasis they [chiropractors] have maintained the fact that prevention is so much more effective than attempts at a cure. They pioneered the all-important principle that effective eradication of disease is accomplished only when it is in its functional (beginning) phase rather than its organic (terminal) stage. It has been their contention that in general the doctor, the therapist and the clinician have failed to realize exactly what is meant by disease processes, and have been satisfied to consider damaged organs as disease, and to think in terms of sick organs and not in terms of sick people. In other words, we have failed to contrast disease with health, and to trace the gradual deteriorization along the downward path, believing almost that mild departures from the physiological normal were of little consequence, until they were replaced by pathological changes…"^[62]

In 1992, the AMA stated "It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient. A physician may refer a patient for diagnostic or therapeutic services to a chiropractor permitted by law to furnish such services whenever the physician believes that this may benefit his or her patient. Physicians may also ethically teach in recognized schools of chiropractic."^[63] In 1997, the following literature was adopted as policy of the AMA after a report on a number of alternative therapies. The report said (about chiropractic care): "Manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints."^[64]

The British Medical Association (BMA) notes that "There is also no problem with GPs 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."^[65]

Internal conflicts

Straights and mixers have had conflicts that continue to this day.^[66] Objective Straight chiropractors, who were an off-shoot of straights, only focused on the correction of chiropractic vertebral subluxations while traditional straights claimed that chiropractic adjustments are a plausible treatment for a wide range of diseases.^[67] Reform chiropractors were a recent evidence-based off-shoot of mixers who rejected traditional Palmer philosophy and tended not to use alternative medicine methods.^[10]

Wilk et al. vs. American Medical Association

Chester A. Wilk, DC from Chicago initiated an antitrust suit against the AMA and other medical associations in 1976 - Wilk et al. vs AMA et al.^[68] The landmark lawsuit ended in 1987 when the US District Court found the AMA guilty of conspiracy and restraint of trade; the Joint Council on Accreditation of Hospitals and the American College of Physicians were exonerated. The court recognized that the AMA had to show its concern for patients, but was not persuaded that this could not have been achieved in a manner less restrictive of competition, for instance by public education campaigns.^[9] A summary of the court's opinion concluded:

"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."^[9]

On February 7, 1990, the AMA lost its appeal,^[69] and could no longer prevent medical physicians from collaborating with chiropractors.^[9]

Movement toward science

In 1975, chiropractors joined medical and scientific attendees in a workshop sponsored by the National Institutes of Health on the research status of spinal manipulation. In 1978, the Journal of Manipulative & Physiological Therapeutics (JMPT) was launched.^[70] In 1983 the JMPT published an article advocating "a scientific institution with some capability for research" and was considered the beginning of the scientific chiropractic movement.^[71] Robert S. Francis, DC, states that "Spinal manipulative therapy gained recognition by mainstream medicine during the 1980s."^[72] Various chiropractic groups distributed patient brochures with unsubstantiated claims.^[73] In the early 1990s there was little scientific research into chiropractic. In 1993, the Manga report funded by the Ministry of Health strongly supported chiropractic care for lower back pain.^[70] At the time, the Manga report "caused ripples throughout the traditional medical community when it concluded that chiropractic management of low-back pain is both more effective and cost-effective than traditional medical treatment."^[74] A 2001 study says "The Manga report was not a controlled clinical trial but a review of the literature that offered an opinion that has not been experimentally established."^[73] In 1998, historian Joseph Keating Jr wrote that "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."^[75] A 2002 study states "Chiropractic theory is still controversial, but recent expansion in federal support of chiropractic research bodes well for further scientific development. The medical establishment has not yet fully accepted chiropractic as a mainstream form of care. The next decade should determine whether chiropractic maintains the trappings of an alternative health care profession or becomes fully integrated into all health care systems."^[23] In 2006, Samuel Homola stated "Although the definition of chiropractic as a method of correcting vertebral subluxations to restore and maintain health is questionable, spinal manipulation is of value in the treatment of some types of back pain."^[76]

Scientific investigation

The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under managed care.^[77] Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs pseudoscientific and antiscientific reasoning and makes unsubstantiated claims.^[70]

Effectiveness

The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective.^[78] Chiropractic care, like all medical treatment, benefits from the placebo response.^[79] The efficacy and cost-effectiveness of maintenance care in chiropractic is unknown.^[80]

Research has focused on spinal manipulation therapy (SMT) rather than specifically on chiropractic SMT.^[77] There is little consensus as to who should administer the SMT, raising concerns by chiropractors that orthodox medical physicians could "steal" SMT procedures from chiropractors; the focus on SMT has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.^[77] Many controlled clinical studies of SMT are available, but their results disagree,^[81] and they are typically of low quality.^[82]^[83] It is hard to construct a trustworthy placebo for clinical trials of SMT, as experts often disagree whether a proposed placebo actually has no effect.^[84] Although a 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference,^[85] a 2008 supportive review found serious flaws in the critical approach, and found that SMT and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments.^[86]

Available evidence covers the following conditions:

Low back pain. Opinions differ on the efficacy of SMT for nonspecific or uncomplicated low back pain.^[87] An authoritative 2004 review found that SMT or mobilization is no more or less effective than other interventions.^[88] A 2008 review found strong evidence that SMT is similar in effect to medical care with exercise, and moderate evidence that SMT is similar to physical therapy and other forms of conventional care.^[86] A 2007 literature synthesis found good evidence supporting SMT for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain.^[89]

Whiplash and other neck pain. There is no overall consensus on manual therapies for neck pain.^[90] An authoritative 2004 review found that SMT/mobilization is effective only when combined with other interventions such as exercise.^[91] A 2008 review found that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SMT, mobilization, supervised exercise, low-level laser therapy and perhaps acupuncture are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves prognosis.^[92] A 2007 review found that SMT and mobilization are effective for neck pain.^[90] A 2005 review found little investigative research into chiropractic manipulative therapy for acute neck pain.^[93]

Headache. An authoritative 2004 review found that SMT may be effective for migraine and tension headache, and SMT and neck exercises may be effective for cervicogenic headache.^[94] A 2006 review found no rigorous evidence supporting SMT or other manual therapies for tension headache.^[95] A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.^[96]

Other. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs,^[97] and a lack of higher-quality publications supporting chiropractic management of leg conditions.^[98] A 2007 literature synthesis found fair evidence supporting assurance and advice to stay active for sciatica and radicular pain in the leg.^[89] There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine)^[99] and no scientific data for idiopathic adolescent scoliosis.^[100] A 2007 systematic review found that the entire clinical encounter of chiropractic care (as opposed to just SMT) provides benefit to patients with asthma, cervicogenic dizziness, and baby colic, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizzinesss, and vision conditions.^[82] Other reviews have found no evidence of benefit for baby colic,^[101] bedwetting,^[102] fibromyalgia,^[103] or menstrual cramps.^[104]

Safety

Chiropractic care in general is safe when employed skillfully and appropriately. Its primary therapeutic procedure, spinal manipulation, involves directed thrust to move a joint past its physiological range of motion without exceeding the anatomical limit. Manipulation is regarded as relatively safe, but as with all therapeutic interventions, complications can arise, and it has known adverse effects, risks and contraindications.^[22] Absolute contraindications to spinal manipulation are conditions that should not be manipulated; these contraindications include rheumatoid arthritis and conditions known to result in unstable joints. Relative contraindications are conditions where increased risk is acceptable in some situations and where low-force and soft-tissue techniques are treatments of choice; these contraindications include osteoporosis.^[22] Although most contraindications apply only to manipulation of the affected region, some neurological signs indicate referral to emergency medical services; these include sudden and severe headache or neck pain unlike that previously experienced.^[105]

Spinal manipulation is associated with frequent, mild and temporary adverse effects,^[105]^[106] including new or worsening pain or stiffness in the affected region.^[107] They have been estimated to occur in 34% to 55% of patients, with 80% of them disappearing within 24 hours.^[105] Rarely, spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death; these can occur in adults^[106] and children.^[108] The incidence of these complications is unknown, due to rarity, high levels of underreporting, and difficulty of linking manipulation to adverse effects such as stroke, a particular concern.^[106] Several case reports show temporal associations between interventions and potentially serious complications.^[109] Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.^[109] Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.^[110]

Vaccination

Although vaccination is one of the most cost-effective forms of prevention against infectious disease, it remains controversial within the chiropractic community.^[111] Most chiropractic writings on vaccination focus on its negative aspects,^[111] claiming that it is hazardous or ineffective.^[112] Evidence-based chiropractors have embraced vaccination, but a minority of the profession rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that diseases cannot be affected by vaccines.^[113] The American Chiropractic Association and the International Chiropractic Association support individual exemptions to compulsory vaccination laws, and a 1995 survey of U.S. chiropractors found that about a third believed there was no scientific proof that immunization prevents disease.^[113] The Canadian Chiropractic Association supports vaccination; surveys in Canada in 2000 and 2002 found that 40% of chiropractors supported vaccination, and that over a quarter opposed it and advised patients against vaccinating themselves or their children.^[111]

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^ Vohra S, Johnston BC, Cramer K, Humphreys K (2007). "Adverse events associated with pediatric spinal manipulation: a systematic review". Pediatrics. 119 (1): e275–83. doi:10.1542/peds.2006-1392. PMID 17178922.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ ^a ^b Hurwitz EL, Carragee EJ, van der Velde G (2008). "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders". Spine. 33 (4 Suppl): S123–52. doi:10.1097/BRS.0b013e3181644b1d. PMID 18204386.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM (2008). "Does cervical manipulative therapy cause vertebral artery dissection and stroke?". Neurologist. 14 (1): 66–73. doi:10.1097/NRL.0b013e318164e53d. PMID 18195663.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ ^a ^b ^c Busse JW, Morgan L, Campbell JB (2005). "Chiropractic antivaccination arguments". J Manipulative Physiol Ther. 28 (5): 367–73. doi:10.1016/j.jmpt.2005.04.011. PMID 15965414.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Ernst E (2001). "Rise in popularity of complementary and alternative medicine: reasons and consequences for vaccination". Vaccine. 20 (Suppl 1): S89–93. doi:10.1016/S0264-410X(01)00290-0. PMID 11587822.
^ ^a ^b Campbell JB, Busse JW, Injeyan HS (2000). "Chiropractors and vaccination: a historical perspective". Pediatrics. 105 (4): e43. PMID 10742364.{{cite journal}}: CS1 maint: multiple names: authors list (link)

External links

Template:Dmoz

[ccestandards-1] Council on Chiropractic Education (2007). "Standards for Doctor of Chiropractic programs and requirements for institutional status" (PDF). Retrieved 2008-02-14.

[2] National Center for Complementary and Alternative Medicine (2007). "An introduction to chiropractic". Retrieved 2008-02-14.

[3] American Chiropractic Association. "A history of chiropractic care". Retrieved 2008-02-14.

[4] "Chiropractic Care and Back Pain". WebMD. WebMD LLC. 2008-02-24. Retrieved 2008-02-25.

[What_Is_Chiropractic-5] "What is chiropractic?". Ontario Chiropractic Association. Retrieved 2008-05-12.

[6] Tetrault M (2005). "Country support groups". Chiropractic Diplomatic Corps. Retrieved 2008-05-06.

[Keating-subluxation-7] Keating JC Jr, Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF (2005). "Subluxation: dogma or science?". Chiropr Osteopat. 13: 17. doi:10.1186/1746-1340-13-17.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)

[Leon_Jaroff-8] Jaroff, Leon (February 27, 2002). "Back Off, Chiropractors!". CNN. Time magazine. Retrieved 2008-02-10.

[Wilk-9] "The Wilk case" (PDF). Chiropractic Resource Organization. Retrieved 2008-05-12.

[JCMC-10] Mirtz TA, Long P, Dinehart A; et al. (2002). "NACM and its argument with mainstream chiropractic health care". J Controv Med Claims. 9 (1): 11–18. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link) Article summary.

[Kaptchuk-Eisenberg-11] Kaptchuk TJ, Eisenberg DM (1998). "Chiropractic: origins, controversies, and contributions". Arch Intern Med. 158 (20): 2215–24. PMID 9818801.

[History-PPC-12] Keating JC Jr (2005). "A brief history of the chiropractic profession". In Haldeman S, Dagenais S, Budgell B et al. (eds.) (ed.). Principles and Practice of Chiropractic (3rd ed. ed.). McGraw-Hill. pp. 23–64. ISBN 0-07-137534-1. {{cite book}}: |edition= has extra text (help); |editor= has generic name (help)CS1 maint: multiple names: editors list (link)

[Healey-13] Healey JW (1990). "It's where you put the period". Dyn Chiropr. 8 (21).

[Chiro_Beliefs-14] ^ ^a ^b ^c ^d ^e ^f Mootz RD, Phillips RB (1997). "Chiropractic belief systems". In Cherkin DC, Mootz RD (eds.) (ed.). Chiropractic in the United States: Training, Practice, and Research (PDF). AHCPR Pub No. 98-N002. Rockville, MD: Agency for Health Care Policy and Research. pp. 9–16. OCLC 39856366. Retrieved 2008-05-11. {{cite book}}: |editor= has generic name (help); External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)

[Keating05-15] Keating JC Jr (2005). "Philosophy in chiropractic". In Haldeman S, Dagenais S, Budgell B et al. (eds.) (ed.). Principles and Practice of Chiropractic (3rd ed. ed.). McGraw-Hill. pp. 77–98. ISBN 0-07-137534-1. {{cite book}}: |edition= has extra text (help); |editor= has generic name (help)CS1 maint: multiple names: editors list (link)

[Phillips-PPC-16] Phillips RB (2005). "The evolution of vitalism and materialism and its impact on philosophy". In Haldeman S, Dagenais S, Budgell B et al. (eds.) (ed.). Principles and Practice of Chiropractic (3rd ed. ed.). McGraw-Hill. pp. 65–76. ISBN 0-07-137534-1. {{cite book}}: |edition= has extra text (help); |editor= has generic name (help)CS1 maint: multiple names: editors list (link)

[17] Hansen DT, Mootz RD (1999). "Formal processes in health care technology assessment: a primer for the chiropractic profession". In Mootz RD, Hansen DT (ed.). Chiropractic technologies. Jones & Bartlett. pp. 3–17. ISBN 0834213737.

[18] Rupert RL (2000). "A survey of practice patterns and the health promotion and prevention attitudes of US chiropractors, maintenance care: part I". J Manipulative Physiol Ther. 23 (1): 1–9. doi:10.1016/S0161-4754(00)90107-6. PMID 10658870.

[19] Rupert RL, Manello D, Sandefur R (2000). "Maintenance care: health promotion services administered to US chiropractic patients aged 65 and older, part II". J Manipulative Physiol Ther. 23 (1): 10–9. doi:10.1016/S0161-4754(00)90108-8. PMID 10658871.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[20] Canadian Chiropractic Association (1996). "Glenerin guidelines: preventive maintenance care". Retrieved 2008-02-26.

[21] Vear HJ (1992). "Scope of chiropractic practice". In Vear HJ (ed.) (ed.). Chiropractic Standards of Practice and Quality of Care. Gaithersburg, MD: Aspen. pp. 49–68. OCLC 23972994. {{cite book}}: |editor= has generic name (help)

[WHO-guidelines-22] ^ ^a ^b ^c ^d ^e ^f ^g World Health Organization (2005). "WHO guidelines on basic training and safety in chiropractic" (PDF). Retrieved 2008-02-29. {{cite journal}}: Cite journal requires |journal= (help)

[Meeker-Haldeman-23] Meeker WC, Haldeman S (2002). "Chiropractic: a profession at the crossroads of mainstream and alternative medicine" (PDF). Ann Intern Med. 136 (3): 216–27. PMID 11827498.

[24] Haldeman, Scott. Guidelines for Chiropractic Quality and Practice Parameters. Sudbury, MA: Jones and Bartlett. pp. 111–113. ISBN 0-7437-2921-3. {{cite book}}: Check |isbn= value: checksum (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

[McDonald-25] McDonald WP, Durkin KF, Pfefer M; et al. (2003). How Chiropractors Think and Practice: The Survey of North American Chiropractors. Ada, OH: Institute for Social Research, Ohio Northern University. ISBN 0972805559. {{cite book}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link) Summarized in: McDonald WP, Durkin KF, Pfefer M (2004). "How chiropractors think and practice: the survey of North American chiropractors". Semin Integr Med. 2 (3): 92–8. doi:10.1016/j.sigm.2004.07.002. {{cite journal}}: Unknown parameter |laydate= ignored (help); Unknown parameter |laysource= ignored (help); Unknown parameter |laysummary= ignored (help)CS1 maint: multiple names: authors list (link)

[LegOR-26] "Chapter 684 — Chiropractors". Oregon State Legislature. Retrieved 2008-05-08.

[VetChiro1-27] "Canadian Animal Chiropractic Certification Program frequently asked questions". Retrieved 2008-05-08.

[RMIT1-28] "RMIT - Animal Chiropractic – Master of Chiropractic Science incorporating Graduate Diploma". www.rmit.edu.au. Retrieved 2008-05-09.

[29] ACA House of Delegates (1994). "'Veterinary' chiropractic". American Chiropractic Association.

[30] Tetrault M (2004). "Global professional strategy for chiropractic" (PDF). Chiropractic Diplomatic Corps. Retrieved 2008-04-18.

[31] Chiropractic training:
Pybus, Beverly, E. A Guide to AHP Credentialing. C. hcPro. pp. 241–243. ISBN 1-57839-478-3. {{cite book}}: |access-date= requires |url= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: multiple names: authors list (link)

Coulter ID, Adams AH, Sandefur R (1997). "Chiropractic training". In Cherkin DC, Mootz RD (eds.) (ed.). Chiropractic in the United States: Training, Practice, and Research (PDF). AHCPR Pub No. 98-N002. Rockville, MD: Agency for Health Care Policy and Research. pp. 9–16. OCLC 39856366. Retrieved 2008-05-11. {{cite book}}: |editor= has generic name (help); External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)CS1 maint: multiple names: authors list (link)

Mestan MA, Taylor JA, Blackshaw GL, McDonald JC (2006). "Commentary: establishing an accredited Master of Science in Diagnostic Imaging degree at a chiropractic college". J Manipulative Physiol Ther. 29 (5): 410–3.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[32] Pybus, Beverly, E. A Guide to AHP Credentialing. C. hcPro. pp. 241–243. ISBN 1-57839-478-3. {{cite book}}: |access-date= requires |url= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: multiple names: authors list (link)

[33] Coulter ID, Adams AH, Sandefur R (1997). "Chiropractic training". In Cherkin DC, Mootz RD (eds.) (ed.). Chiropractic in the United States: Training, Practice, and Research (PDF). AHCPR Pub No. 98-N002. Rockville, MD: Agency for Health Care Policy and Research. pp. 9–16. OCLC 39856366. Retrieved 2008-05-11. {{cite book}}: |editor= has generic name (help); External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)CS1 maint: multiple names: authors list (link)

[34] Mestan MA, Taylor JA, Blackshaw GL, McDonald JC (2006). "Commentary: establishing an accredited Master of Science in Diagnostic Imaging degree at a chiropractic college". J Manipulative Physiol Ther. 29 (5): 410–3.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[CCEB1-32] "Canadian Chiropractic Examining Board". www.cceb.ca. Retrieved 2008-05-09. {{cite web}}: Text "Conseil des examens chiropratique canadien » Becoming a Chiropractor" ignored (help)

[CFCRB-33] "CFCREAB - Becoming a Chiropractor". www.cfcrb.org. Retrieved 2008-05-09.

[34] "Facts & FAQs". Canadian Chiropractic Association. Retrieved 2008-05-08.

[Accredited_Doctor_of_Chiropractic_Programs-35] "Accredited Doctor of Chiropractic Programs". The Council on Chiropractic Education. Retrieved 2008-02-22.

[36] "Introduction". www.wfc.org. Retrieved 2008-05-09.

[NBCE_techniques-37] Christensen MG, Kollasch MW (2005). "Professional functions and treatment procedures". Job Analysis of Chiropractic. Greeley, CO: National Board of Chiropractic Examiners. pp. 121–38. ISBN 1-884457-05-3. {{cite book}}: |access-date= requires |url= (help); |format= requires |url= (help); External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)

[38] Ernst E (2002). "Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995–2001". Med J Aust. 176 (8): 376–80. PMID 12041633.

[Swedlo-39] Swedlo DC (2002). "The historical development of chiropractic" (PDF). In Whitelaw WA (ed.) (ed.). Proc 11th Annual History of Medicine Days. Faculty of Medicine, The University of Calgary. pp. 55–58. Retrieved 2008-05-14. {{cite conference}}: |editor= has generic name (help); Unknown parameter |booktitle= ignored (|book-title= suggested) (help)

[Keating-pathways-40] Keating JC Jr (2003). "Several pathways in the evolution of chiropractic manipulation". J Manipulative Physiol Ther. 26 (5): 300–21. doi:10.1016/S0161-4754(02)54125-7. PMID 12819626.

[41] "About chiropractic and its use in treating low-back pain" (PDF). NCCAM. 2005. Retrieved 2008-03-24.

[wfc-identity-42] World Federation of Chiropractic (2005). "WFC consultation on the identity of the chiropractic profession". Retrieved 2008-02-14.

[43] Cremata E, Collins S, Clauson W, Solinger AB, Roberts ES (2005). "Manipulation under anesthesia: a report of four cases". J Manipulative Physiol Ther. 28 (7): 526–33. doi:10.1016/j.jmpt.2005.07.011. PMID 16182028.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[Surveys_now_and_then-44] "Surveys now and then". Retrieved 2008-03-24. {{cite web}}: Text "Dynamic Chiropractic" ignored (help); Text "Find Articles at BNET.com" ignored (help)

[45] "Establishing a database of U.S. chiropractic health manpower data: furthering the development of research infrastructure". National Library of Medicine. Retrieved 2008-05-06. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

[Lawrence-Meeker-46] Lawrence DJ, Meeker WC (2007). "Chiropractic and CAM utilization: a descriptive review". Chiropr Osteopat. 15 (2). doi:10.1186/1746-1340-15-2. PMID 17241465.{{cite journal}}: CS1 maint: unflagged free DOI (link)

[Crownfield-47] Crownfield PW (2007). "Chiropractic in Alberta: a model of consumer utilization and satisfaction". Dyn Chiropr. 25 (6).

[48] Hurwitz EL, Chiang LM (2006). "A comparative analysis of chiropractic and general practitioner patients in North America: findings from the joint Canada/United States Survey of Health, 2002–03". BMC Health Serv Res. 6 (49). doi:10.1186/1472-6963-6-49. PMID 16600038.{{cite journal}}: CS1 maint: unflagged free DOI (link)

[49] Gaumer G (2006). "Factors associated with patient satisfaction with chiropractic care: survey and review of the literature". J Manipulative Physiol Ther. 29 (6): 455–62. doi:10.1016/j.jmpt.2006.06.013. PMID 16904491.

[50] Chapman-Smith DA, Cleveland CS III (2005). "International status, standards, and education of the chiropractic profession". In Haldeman S, Dagenais S, Budgell B et al. (eds.) (ed.). Principles and Practice of Chiropractic (3rd ed. ed.). McGraw-Hill. pp. 111–34. ISBN 0-07-137534-1. {{cite book}}: |edition= has extra text (help); |editor= has generic name (help)CS1 maint: multiple names: editors list (link)

[BLS-51] Bureau of Labor Statistics (2007). "Occupational outlook handbook". Retrieved 2008-02-14.

[Palmer1906-52] Palmer DD , Palmer BJ (1906). The science of chiropractic: its principles and adjustments. Davenport, IA: Palmer School of Chiropractic. OCLC 36930079.

[53] Westbrooks B (1982). "The troubled legacy of Harvey Lillard: the black experience in chiropractic". Chiropr Hist. 2 (1): 47–53. PMID 11611211.

[Lerner-54] Lerner C (1952). "Unpublished manuscript submitted to the Foundation for Health Research" (PDF). Retrieved 2008-05-12. {{cite journal}}: Cite journal requires |journal= (help)

[55] Keating JC Jr (1995). "D.D. Palmer's forgotten theories of chiropractic" (PDF). Association for the History of Chiropractic. Retrieved 2008-05-14.

[Palmer1910-56] Palmer DD (1910). The Chiropractor's Adjuster: Text-book of the Science, Art and Philosophy of Chiropractic for Students and Practitioners. Portland, OR: Portland Printing House Co. OCLC 17205743.

[titlePalmer_College_of_Chiropractic,_General_Information-57] "Palmer College of Chiropractic, General Information". Retrieved 2008-03-24.

[58] "Undergraduate and graduate programs 2006–2007" (PDF). Canadian Memorial Chiropractic College. 2006.

[59] Keating J Jr (2001). "Chiropractic at the turn of the century". Dyn Chiropr.

[60] Keating JC Jr (1999). "Tom Moore, defender of chiropractic, part 1". Dyn Chiropr. 17 (25).

[61] Cherkin D (1989). "AMA policy on chiropractic". Am J Public Health. 79 (11): 1569–70. PMID 2817179.

[62] Janse J, quoted in: Strang VV (1984). Essential Principles of Chiropractic. Davenport, IA: Palmer College of Chiropractic. pp. p. 26. OCLC 12102972. {{cite book}}: |pages= has extra text (help)

[E-3.041_Chiropractic-63] "E-3.041 Chiropractic". American Medical Association. Retrieved 2008-03-24.

[AMA_Report_12-64] "Report 12 of the Council on Scientific Affairs (A-97) Full Text". American Medical Association. Retrieved 2008-03-24.

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[Ernst-2008-66] Cite error: The named reference Ernst-2008 was invoked but never defined (see the help page).

[F.A.C.E.-position-paper1-67] "Position Paper One — What is Objective Straight Chiropractic?". Foundation for the Advancement of Chiropractic Education (F.A.C.E.). Retrieved 2008-03-24.

[Sore_Throat-68] Robbins, John (1996). "Medical monopoly: the game nobody wins - excerpt from 'Reclaiming Our Health: Exploding the Medical Myth and Embracing the Source of True Healing'". CNET Networks. Vegetarian Times. {{cite web}}: Cite has empty unknown parameter: |coauthors= (help)

[69] Wilk v. AMA, 895 F.2d 352 (7th Cir. 1990).

[Keating-1997-70] Keating JC Jr (1997). "Chiropractic: science and antiscience and pseudoscience side by side". Skept Inq. 21 (4): 37–43. Retrieved 2008-05-10.

[71] DeBoer KF (1983). "Notes from the (chiropractic college's) underground". J Manipulative Physiol Ther. 6 (3): 147–50. PMID 6655376.

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[Grod-73] Grod JP, Sikorski D, Keating JC Jr (2001). "Unsubstantiated claims in patient brochures from the largest state, provincial, and national chiropractic associations and research agencies". J Manipulative Physiol Ther. 24 (8): 514–9. doi:10.1067/mmt.2001.118205. PMID 11677551.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[74] "Canada Celebrates 100 Years of Chiropractic". Dynamic Chiropractic. July 17, 1995. Retrieved 2008-05-01. {{cite web}}: Cite has empty unknown parameter: |coauthors= (help)

[75] Keating J; et al. (1998). "A descriptive analysis of the Journal of Manipulative and Physiological Therapeutics, 1989-1996". J Manip Physiol Ther. 21: 539–52. PMID 9798183 PMID 9798183. {{cite journal}}: Check |pmid= value (help); Explicit use of et al. in: |author= (help)

[76] Homola S (2006). "Chiropractic: history and overview of theories and methods". Clin Orthop Relat Res. 444: 236–42. doi:10.1097/01.blo.0000200258.95865.87. PMID 16446588.

[Villanueva-Russell-77] Villanueva-Russell Y (2005). "Evidence-based medicine and its implications for the profession of chiropractic". Soc Sci Med. 60 (3): 545–61. doi:10.1016/j.socscimed.2004.05.017. PMID 15550303.

[78] DeVocht JW (2006). "History and overview of theories and methods of chiropractic: a counterpoint". Clin Orthop Relat Res. 444: 243–9. doi:10.1097/01.blo.0000203460.89887.8d. PMID 16523145.

[79] Kaptchuk TJ (2002). "The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance?" (PDF). Ann Intern Med. 136 (11): 817–25. PMID 12044130.

[80] Leboeuf-Yde C, Hestbaek L (2008). "Maintenance care in chiropractic - what do we know?" (PDF). Chiropr Osteopat. 16 (1): 3. doi:10.1186/1746-1340-16-3. PMID 18466623.{{cite journal}}: CS1 maint: unflagged free DOI (link)

[Ernst-Canter-81] Ernst E, Canter PH (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med. 99 (4): 192–6. doi:10.1258/jrsm.99.4.192. PMID 16574972.

[Hawk-82] Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW (2007). "Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research". J Altern Complement Med. 13 (5): 491–512. doi:10.1089/acm.2007.7088. PMID 17604553.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[83] Quality of SMT studies:
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Johnston BC, da Costa BR, Devereaux PJ, Akl EA, Busse JW; Expertise-Based RCT Working Group (2008). "The use of expertise-based randomized controlled trials to assess spinal manipulation and acupuncture for low back pain: a systematic review". Spine. 33 (8): 914–8. doi:10.1097/BRS.0b013e31816b4be4. PMID 18404113.{{cite journal}}: CS1 maint: multiple names: authors list (link)

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[88] Johnston BC, da Costa BR, Devereaux PJ, Akl EA, Busse JW; Expertise-Based RCT Working Group (2008). "The use of expertise-based randomized controlled trials to assess spinal manipulation and acupuncture for low back pain: a systematic review". Spine. 33 (8): 914–8. doi:10.1097/BRS.0b013e31816b4be4. PMID 18404113.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[84] Hancock MJ, Maher CG, Latimer J, McAuley JH (2006). "Selecting an appropriate placebo for a trial of spinal manipulative therapy" (PDF). Aust J Physiother. 52 (2): 135–8. PMID 16764551.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[85] Ernst E (2008). "Chiropractic: a critical evaluation". J Pain Symptom Manage. 35 (5): 544–62. doi:10.1016/j.jpainsymman.2007.07.004. PMID 18280103.

[Bronfort-2008-86] Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S (2008). "Evidence-informed management of chronic low back pain with spinal manipulation and mobilization". Spine J. 8 (1): 213–25. doi:10.1016/j.spinee.2007.10.023. PMID 18164469.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[87] Murphy AY, van Teijlingen ER, Gobbi MO (2006). "Inconsistent grading of evidence across countries: a review of low back pain guidelines". J Manipulative Physiol Ther. 29 (7): 576–81, 581.e1–2. doi:10.1016/j.jmpt.2006.07.005. PMID 16949948.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[88] Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004). "Spinal manipulative therapy for low back pain". Cochrane Database Syst Rev (1): CD000447. doi:10.1002/14651858.CD000447.pub2. PMID 14973958.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[Meeker-2007-89] Meeker W, Branson R, Bronfort G; et al. (2007). "Chiropractic management of low back pain and low back related leg complaints" (PDF). Council on Chiropractic Guidelines and Practice Parameters. Retrieved 2008-03-13. {{cite web}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)

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[93] Haneline MT (2005). "Chiropractic manipulation and acute neck pain: a review of the evidence". J Manipulative Physiol Ther. 28 (7): 520–5. doi:10.1016/j.jmpt.2005.07.010. PMID 16182027.

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[95] Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA (2006). "Are manual therapies effective in reducing pain from tension-type headache?: a systematic review". Clin J Pain. 22 (3): 278–85. doi:10.1097/01.ajp.0000173017.64741.86. PMID 16514329.{{cite journal}}: CS1 maint: multiple names: authors list (link)

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@@ Line 252: / Line 252: @@
 In 1992, the AMA stated "It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient. A physician may refer a patient for diagnostic or therapeutic services to a chiropractor permitted by law to furnish such services whenever the physician believes that this may benefit his or her patient. Physicians may also ethically teach in recognized schools of chiropractic."<ref name="E-3.041 Chiropractic">{{cite web |url=http://www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/E-3.041.HTM |title= E-3.041 Chiropractic |accessdate=2008-03-24 |publisher=American Medical Association}}</ref> In 1997, the following literature was adopted as policy of the AMA after a report on a number of alternative therapies. The report said (about chiropractic care): "[[joint manipulation|Manipulation]] has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints."<ref name="AMA Report 12">{{cite web |url=http://www.ama-assn.org/ama/pub/category/13638.html |title=Report 12 of the Council on Scientific Affairs (A-97) Full Text |accessdate=2008-03-24 |publisher=American Medical Association}}</ref>
-The British Medical Association (BMA) notes that "There is also no problem with GPs 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."<ref name=BMA-referrals>{{cite web |url=http://www.bma.org.uk/ap.nsf/Content/refcomtherap0406?OpenDocument&Highlight=2 |title=Referrals to complementary therapists |accessdate= |last= |first= |coauthors= |date= |work= |publisher=British Medical Association}}</ref> In 1997, the BMA has identified chiropractic health care that can be regarded as "discrete clinical disciplines" because it has "established foundations of training and have the potential for greatest use alongside orthodox medical care."<ref>{{cite journal |journal= Med Law |date=1997 |volume= 16 |issue=3 |pages=437-49 |title= Legislative approaches to the regulation of the chiropractic profession |author=Chapman-Smith DA |url= |pmid=9409129}}</ref>
+The British Medical Association (BMA) notes that "There is also no problem with GPs 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."<ref name=BMA-referrals>{{cite web |url=http://www.bma.org.uk/ap.nsf/Content/refcomtherap0406?OpenDocument&Highlight=2 |title=Referrals to complementary therapists |accessdate= |last= |first= |coauthors= |date= |work= |publisher=British Medical Association}}</ref>
 === Internal conflicts ===
@@ Line 270: / Line 270: @@
 In 1975, chiropractors joined medical and scientific attendees in a workshop sponsored by the [[National Institutes of Health]] on the research status of spinal manipulation. In 1978, the ''Journal of Manipulative & Physiological Therapeutics'' (''JMPT'') was launched.<ref name=Keating-1997>{{cite journal |author= Keating JC Jr |journal= Skept Inq |volume=21 |issue=4 |pages=37–43 |url=http://www.encyclopedia.com/doc/1G1-19727577.html |title= Chiropractic: science and antiscience and pseudoscience side by side |date=1997 |accessdate=2008-05-10}}</ref> In 1983 the ''JMPT'' published an article advocating "a scientific institution with some capability for research" and was considered the beginning of the scientific chiropractic movement.<ref>{{cite journal |journal=J Manipulative Physiol Ther |date=1983 |volume=6 |issue=3 |pages=147–50 |title= Notes from the (chiropractic college's) underground |author= DeBoer KF |pmid=6655376}}</ref> Robert S. Francis, DC, states that "Spinal manipulative therapy gained recognition by mainstream medicine during the 1980s."<ref name="titleInternational MUA Academy of Physicians - Historical Considerations">{{cite web |url=http://www.muaphysicians.com/historical.html |title=International MUA Academy of Physicians - Historical Considerations |accessdate=2008-03-24}}</ref> Various chiropractic groups distributed patient brochures with unsubstantiated claims.<ref name=Grod>{{cite journal |journal= J Manipulative Physiol Ther |date=2001 |volume=24|issue=8|pages=514-9|title= Unsubstantiated claims in patient brochures from the largest state, provincial, and national chiropractic associations and research agencies |author= Grod JP, Sikorski D, Keating JC Jr |doi= 10.1067/mmt.2001.118205|pmid=11677551}}</ref> In the early 1990s there was little scientific research into chiropractic. In 1993, the Manga report funded by the Ministry of Health strongly supported chiropractic care for lower back pain.<ref name=Keating-1997/> At the time, the Manga report "caused ripples throughout the traditional medical community when it concluded that chiropractic management of low-back pain is both more effective and cost-effective than traditional medical treatment."<ref>{{cite web |url=http://www.chiroweb.com/archives/13/15/06.html|title=Canada Celebrates 100 Years of Chiropractic|accessdate=2008-05-01 |last= |first= |coauthors= |date=July 17, 1995 |volume=13|issue=15|publisher=Dynamic Chiropractic}}</ref> A 2001 study says "The Manga report was not a controlled clinical trial but a review of the literature that offered an opinion that has not been experimentally established."<ref name=Grod/> In 1998, historian Joseph Keating Jr wrote that "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."<ref>{{cite journal |author= Keating J ''et al.'' |title= A descriptive analysis of the Journal of Manipulative and Physiological Therapeutics, 1989-1996 |journal= J Manip Physiol Ther |volume= 21 |pages= 539-52 |year= 1998 |pmid= PMID 9798183}}</ref> A 2002 study states "Chiropractic theory is still controversial, but recent expansion in federal support of chiropractic research bodes well for further scientific development. The medical establishment has not yet fully accepted chiropractic as a mainstream form of care. The next decade should determine whether chiropractic maintains the trappings of an alternative health care profession or becomes fully integrated into all health care systems."<ref name=Meeker-Haldeman/> In 2006, Samuel Homola stated "Although the definition of chiropractic as a method of correcting vertebral subluxations to restore and maintain health is questionable, spinal manipulation is of value in the treatment of some types of back pain."<ref>{{cite journal |journal= Clin Orthop Relat Res |date=2006 |volume=444 |pages=236–42 |title= Chiropractic: history and overview of theories and methods |author= Homola S |doi=10.1097/01.blo.0000200258.95865.87 |pmid=16446588}}</ref>
-== Scientific research ==
+== Scientific investigation ==
-The principles of [[evidence-based medicine]] have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under [[managed care]].<ref name=Villanueva-Russell/> Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs pseudoscientific and antiscientific reasoning and makes unsubstantiated claims.<ref name=Keating-1997/> In Canada, it appears that chiropractors do not consistantly apply research in practice which may have resulted from a lack of educational research.<ref>{{cite journal |journal=J Manipulative Physiol Ther |year=2007 |volume=30 |issue=2 |pages=109-15 |title=How important is research-based practice to chiropractors and massage therapists? |author= Suter E, Vanderheyden LC, Trojan LS, Verhoef MJ, Armitage GD |pmid=17320731 |url=http://www.jmptonline.org/article/S0161-4754(06)00337-X/abstract}}</ref> Evidence-based chiropractors possess the ability to apply research in practice. Continued education enhances the scientific knowledge of the practitioner.<ref>{{cite journal |journal=Chiropr Osteopat |year=2006 |volume=24 |issue=14 |pages=14:18 |title=Effectiveness of an evidence-based chiropractic continuing education workshop on participant knowledge of evidence-based health care |author=Feise RJ, Grod JP, Taylor-Vaisey A |pmid=16930482 |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16930482}}</ref> There are barriers between primary care physicians and chiropractors for having positive referral relationships.<ref>{{cite journal |journal=J Ambul Care Manage |year=2007 |volume=30 |issue=4 |pages=347-54 |title=Facilitators and barriers to improving interprofessional referral relationships between primary care physicians and chiropractors |author=Allareddy V, Greene BR, Smith M, Haas M, Liao J |pmid=17873667 |url=http://www.ambulatorycaremanagement.com/pt/re/jacm/abstract.00004479-200710000-00011.htm;jsessionid=LhKG7YVGK1DSXG4mpPCYKJ8JyLvGhztJWsXG2VyQXmFdHt3ZhSmr!1167962659!181195628!8091!-1}}</ref> Despite internal debate and external opposition, its unified profession suggests it will endure as a relevant component of health care.<ref name=Kaptchuk-Eisenberg/>
+The principles of [[evidence-based medicine]] have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under [[managed care]].<ref name=Villanueva-Russell/> Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs pseudoscientific and antiscientific reasoning and makes unsubstantiated claims.<ref name=Keating-1997/>
 === Effectiveness ===
@@ Line 278: / Line 278: @@
 The [[Efficacy#Medical|effectiveness]] of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective.<ref>{{cite journal |journal= Clin Orthop Relat Res |date=2006 |volume=444 |pages=243–9 |title= History and overview of theories and methods of chiropractic: a counterpoint |author= DeVocht JW |doi=10.1097/01.blo.0000203460.89887.8d |pmid=16523145}}</ref> Chiropractic care, like all medical treatment, benefits from the [[placebo response]].<ref>{{cite journal |journal= Ann Intern Med |date=2002 |volume=136 |issue=11 |pages=817–25 |title= The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance? |author= Kaptchuk TJ |pmid=12044130 |url=http://annals.org/cgi/reprint/136/11/817.pdf |format=PDF}}</ref> The efficacy and cost-effectiveness of maintenance care in chiropractic is unknown.<ref>{{cite journal |journal= Chiropr Osteopat |date=2008 |volume=16 |issue=1 |pages=3 |title= Maintenance care in chiropractic - what do we know? |author= Leboeuf-Yde C, Hestbaek L |doi=10.1186/1746-1340-16-3 |pmid=18466623 |url=http://chiroandosteo.com/content/pdf/1746-1340-16-3.pdf |format=PDF}}</ref>
-Research has focused on [[spinal manipulation]] therapy (SMT) in general,<ref>{{cite journal |journal= Ann Intern Med |date=2002 |volume=137 |issue=8 |pages=702 |title= Chiropractic: in response |author= Meeker WC, Haldeman S |url=http://annals.org/cgi/reprint/137/8/701.pdf |format=PDF}}</ref> rather than specifically on chiropractic SMT.<ref name=Villanueva-Russell/> There is little consensus as to who should administer the SMT, raising concerns by chiropractors that orthodox medical physicians could "steal" SMT procedures from chiropractors; the focus on SMT has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.<ref name=Villanueva-Russell>{{cite journal |journal= Soc Sci Med |date=2005 |volume=60 |issue=3 |pages=545–61 |title= Evidence-based medicine and its implications for the profession of chiropractic |author= Villanueva-Russell Y |doi=10.1016/j.socscimed.2004.05.017 |pmid=15550303}}</ref> Many controlled clinical studies of SMT are available, but their results disagree,<ref name=Ernst-Canter>{{cite journal |journal= J R Soc Med |date=2006 |volume=99 |issue=4 |pages=192–6 |title= A systematic review of systematic reviews of spinal manipulation |author= Ernst E, Canter PH |doi=10.1258/jrsm.99.4.192 |pmid=16574972 |url=http://www.jrsm.org/cgi/content/full/99/4/192}}</ref> and they are typically of low quality.<ref name=Hawk/><ref>
+Research has focused on [[spinal manipulation]] therapy (SMT) rather than specifically on chiropractic SMT.<ref name=Villanueva-Russell/> There is little consensus as to who should administer the SMT, raising concerns by chiropractors that orthodox medical physicians could "steal" SMT procedures from chiropractors; the focus on SMT has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.<ref name=Villanueva-Russell>{{cite journal |journal= Soc Sci Med |date=2005 |volume=60 |issue=3 |pages=545–61 |title= Evidence-based medicine and its implications for the profession of chiropractic |author= Villanueva-Russell Y |doi=10.1016/j.socscimed.2004.05.017 |pmid=15550303}}</ref> Many controlled clinical studies of SMT are available, but their results disagree,<ref name=Ernst-Canter>{{cite journal |journal= J R Soc Med |date=2006 |volume=99 |issue=4 |pages=192–6 |title= A systematic review of systematic reviews of spinal manipulation |author= Ernst E, Canter PH |doi=10.1258/jrsm.99.4.192 |pmid=16574972 |url=http://www.jrsm.org/cgi/content/full/99/4/192}}</ref> and they are typically of low quality.<ref name=Hawk/><ref>
 Quality of SMT studies:
 *{{cite journal |journal= J Orthop Sports Phys Ther |date=2006 |volume=36 |issue=3 |pages=160–9 |title= Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type headache, migraine, and cervicogenic headache |author= Fernández-de-las-Peñas C, Alonso-Blanco C, San-Roman J, Miangolarra-Page JC |pmid=16596892}}
 *{{cite journal |journal=Spine |date=2008 |volume=33 |issue=8 |pages=914–8 |title= The use of expertise-based randomized controlled trials to assess spinal manipulation and acupuncture for low back pain: a systematic review |author= Johnston BC, da Costa BR, Devereaux PJ, Akl EA, Busse JW; Expertise-Based RCT Working Group |doi=10.1097/BRS.0b013e31816b4be4 |pmid=18404113}}
-</ref> It is hard to construct a trustworthy placebo for clinical trials of SMT, as experts often disagree whether a proposed placebo actually has no effect.<ref>{{cite journal |journal= Aust J Physiother |date=2006 |volume=52 |issue=2 |pages=135–8 |title= Selecting an appropriate placebo for a trial of spinal manipulative therapy |author= Hancock MJ, Maher CG, Latimer J, McAuley JH |pmid=16764551 |url=http://www.physiotherapy.asn.au/AJP/52-2/AustJPhysiotherv52i2Hancock.pdf |format=PDF}}</ref> Although a 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference,<ref name=Ernst-2008>{{cite journal |journal= J Pain Symptom Manage |date=2008 |title= Chiropractic: a critical evaluation |author= Ernst E |doi=10.1016/j.jpainsymman.2007.07.004 |pmid=18280103}}</ref> a 2008 supportive review found serious flaws in the critical approach, and found that SMT and [[Spinal mobilization|mobilization]] are at least as effective for chronic low back pain as other efficacious and commonly used treatments.<ref name=Bronfort-2008/>
+</ref> It is hard to construct a trustworthy placebo for clinical trials of SMT, as experts often disagree whether a proposed placebo actually has no effect.<ref>{{cite journal |journal= Aust J Physiother |date=2006 |volume=52 |issue=2 |pages=135–8 |title= Selecting an appropriate placebo for a trial of spinal manipulative therapy |author= Hancock MJ, Maher CG, Latimer J, McAuley JH |pmid=16764551 |url=http://www.physiotherapy.asn.au/AJP/52-2/AustJPhysiotherv52i2Hancock.pdf |format=PDF}}</ref> Although a 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference,<ref>{{cite journal |journal= J Pain Symptom Manage |date=2008 |volume=35 |issue=5 |pages=544–62 |title= Chiropractic: a critical evaluation |author= Ernst E |doi=10.1016/j.jpainsymman.2007.07.004 |pmid=18280103}}</ref> a 2008 supportive review found serious flaws in the critical approach, and found that SMT and [[Spinal mobilization|mobilization]] are at least as effective for chronic low back pain as other efficacious and commonly used treatments.<ref name=Bronfort-2008/>
 Available evidence covers the following conditions:
-* '''[[Low back pain]]'''. Opinions differ on the efficacy of SMT for nonspecific or uncomplicated low back pain.<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=7 |pages=576–81, 581.e1–2 |title= Inconsistent grading of evidence across countries: a review of low back pain guidelines |author= Murphy AY, van Teijlingen ER, Gobbi MO |doi=10.1016/j.jmpt.2006.07.005 |pmid=16949948}}</ref> A 2008 review found strong evidence that SMT is similar in effect to medical care with exercise, and moderate evidence that SMT is similar to [[physical therapy]] and other forms of conventional care.<ref name=Bronfort-2008>{{cite journal |journal= Spine J |date=2008 |volume=8 |issue=1 |pages=213–25 |title= Evidence-informed management of chronic low back pain with spinal manipulation and mobilization |author= Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S |doi=10.1016/j.spinee.2007.10.023 |pmid=18164469}}</ref> A 2007 literature synthesis found good evidence supporting SMT for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain.<ref name=Meeker-2007>{{cite web |title= Chiropractic management of low back pain and low back related leg complaints |author= Meeker W, Branson R, Bronfort G ''et al.'' |url=http://ccgpp.org/lowbackliterature.pdf |format=PDF |date=2007 |accessdate=2008-03-13 |publisher= Council on Chiropractic Guidelines and Practice Parameters}}</ref> Of four systematic reviews published between 2000 and May 2005, only one recommended SMT, and an authoritative 2004 review (<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2004 |issue=1 |pages=CD000447 |title= Spinal manipulative therapy for low back pain |author= Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG |doi=10.1002/14651858.CD000447.pub2 |pmid=14973958}}</ref>) stated that SMT or mobilization is no more or less effective than other interventions for back pain.<ref name=Ernst-Canter/>
+* '''[[Low back pain]]'''. Opinions differ on the efficacy of SMT for nonspecific or uncomplicated low back pain.<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=7 |pages=576–81, 581.e1–2 |title= Inconsistent grading of evidence across countries: a review of low back pain guidelines |author= Murphy AY, van Teijlingen ER, Gobbi MO |doi=10.1016/j.jmpt.2006.07.005 |pmid=16949948}}</ref> An authoritative 2004 review found that SMT or mobilization is no more or less effective than other interventions.<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2004 |issue=1 |pages=CD000447 |title= Spinal manipulative therapy for low back pain |author= Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG |doi=10.1002/14651858.CD000447.pub2 |pmid=14973958}}</ref> A 2008 review found strong evidence that SMT is similar in effect to medical care with exercise, and moderate evidence that SMT is similar to [[physical therapy]] and other forms of conventional care.<ref name=Bronfort-2008>{{cite journal |journal= Spine J |date=2008 |volume=8 |issue=1 |pages=213–25 |title= Evidence-informed management of chronic low back pain with spinal manipulation and mobilization |author= Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S |doi=10.1016/j.spinee.2007.10.023 |pmid=18164469}}</ref> A 2007 literature synthesis found good evidence supporting SMT for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain.<ref name=Meeker-2007>{{cite web |title= Chiropractic management of low back pain and low back related leg complaints |author= Meeker W, Branson R, Bronfort G ''et al.'' |url=http://ccgpp.org/lowbackliterature.pdf |format=PDF |date=2007 |accessdate=2008-03-13 |publisher= Council on Chiropractic Guidelines and Practice Parameters}}</ref>
-* '''[[Whiplash (medicine)|Whiplash]] and other [[neck pain]]'''. There is no overall consensus on manual therapies for neck pain.<ref name=Vernon>{{cite journal |journal= Eura Medicophys |date=2007 |volume=43 |issue=1 |pages=91–118 |title= Manual therapy for neck pain: an overview of randomized clinical trials and systematic reviews |author= Vernon H, Humphreys BK |pmid=17369783 |url=http://www.minervamedica.it/pdf/R33Y2007/R33Y2007N01A0091.pdf |format=PDF}}</ref> A 2008 review found that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SMT, mobilization, supervised exercise, [[low-level laser therapy]] and perhaps [[acupuncture]] are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves [[prognosis]].<ref>{{cite journal |journal=Spine |date=2008 |volume=33 |issue= 4 Suppl |pages=S123–52 |title= Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders |author= Hurwitz EL, Carragee EJ, van der Velde G |doi=10.1097/BRS.0b013e3181644b1d |pmid=18204386}}</ref> A 2007 review found that SMT and mobilization are effective for neck pain.<ref name=Vernon/> Of three systematic reviews of SMT published between 2000 and May 2005, one reached a positive conclusion, and an authoritative 2004 review (<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2004 |issue=1 |pages=CD004249 |title= Manipulation and mobilisation for mechanical neck disorders |author= Gross AR, Hoving JL, Haines TA ''et al.'' |doi=10.1002/14651858.CD004249.pub2 |pmid=14974063}}</ref>) stated that SMT/mobilization is effective only when combined with other interventions such as exercise.<ref name=Ernst-Canter/> A 2005 review found limited evidence supporting SMT for whiplash.<ref>{{cite journal |journal= Pain Res Manag |date=2005 |volume=10 |issue=1 |pages=21–32 |title= Treatment of whiplash-associated disorders—part I: non-invasive interventions |author= Conlin A, Bhogal S, Sequeira K, Teasell R |pmid=15782244}}</ref>
+* '''[[Whiplash (medicine)|Whiplash]] and other [[neck pain]]'''. There is no overall consensus on manual therapies for neck pain.<ref name=Vernon>{{cite journal |journal= Eura Medicophys |date=2007 |volume=43 |issue=1 |pages=91–118 |title= Manual therapy for neck pain: an overview of randomized clinical trials and systematic reviews |author= Vernon H, Humphreys BK |pmid=17369783 |url=http://www.minervamedica.it/pdf/R33Y2007/R33Y2007N01A0091.pdf |format=PDF}}</ref> An authoritative 2004 review found that SMT/mobilization is effective only when combined with other interventions such as exercise.<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2004 |issue=1 |pages=CD004249 |title= Manipulation and mobilisation for mechanical neck disorders |author= Gross AR, Hoving JL, Haines TA ''et al.'' |doi=10.1002/14651858.CD004249.pub2 |pmid=14974063}}</ref> A 2008 review found that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SMT, mobilization, supervised exercise, [[low-level laser therapy]] and perhaps [[acupuncture]] are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves [[prognosis]].<ref>{{cite journal |journal=Spine |date=2008 |volume=33 |issue= 4 Suppl |pages=S123–52 |title= Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders |author= Hurwitz EL, Carragee EJ, van der Velde G |doi=10.1097/BRS.0b013e3181644b1d |pmid=18204386}}</ref> A 2007 review found that SMT and mobilization are effective for neck pain.<ref name=Vernon/> A 2005 review found little investigative research into chiropractic manipulative therapy for acute neck pain.<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2005 |volume=28 |issue=7 |pages=520–5 |title= Chiropractic manipulation and acute neck pain: a review of the evidence |author= Haneline MT |doi=10.1016/j.jmpt.2005.07.010 |pmid=16182027}}</ref>
-* '''[[Headache]]'''. A 2006 review found no rigorous evidence supporting SMT or other manual therapies for [[tension headache]].<ref>{{cite journal |journal= Clin J Pain |date=2006 |volume=22 |issue=3 |pages=278–85 |title= Are manual therapies effective in reducing pain from tension-type headache?: a systematic review |author= Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA |doi=10.1097/01.ajp.0000173017.64741.86 |pmid=16514329}}</ref> A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for [[migraine]].<ref>{{cite journal |journal=Headache |date=2005 |volume=45 |issue=6 |pages=738–46 |title= Physical treatments for headache: a structured review |doi=10.1111/j.1526-4610.2005.05141.x |author= Biondi DM |pmid=15953306}}</ref> A 2004 review found that SMT may be effective for migraine and tension headache, and SMT and neck exercises may be effective for cervicogenic headache.<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2004 |issue=3 |pages=CD001878 |title= Non-invasive physical treatments for chronic/recurrent headache |author= Bronfort G, Nilsson N, Haas M ''et al.'' |doi=10.1002/14651858.CD001878.pub2 |pmid=15266458}}</ref> Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of SMT.<ref name=Ernst-Canter/>
+* '''[[Headache]]'''. An authoritative 2004 review found that SMT may be effective for migraine and tension headache, and SMT and neck exercises may be effective for cervicogenic headache.<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2004 |issue=3 |pages=CD001878 |title= Non-invasive physical treatments for chronic/recurrent headache |author= Bronfort G, Nilsson N, Haas M ''et al.'' |doi=10.1002/14651858.CD001878.pub2 |pmid=15266458}}</ref> A 2006 review found no rigorous evidence supporting SMT or other manual therapies for [[tension headache]].<ref>{{cite journal |journal= Clin J Pain |date=2006 |volume=22 |issue=3 |pages=278–85 |title= Are manual therapies effective in reducing pain from tension-type headache?: a systematic review |author= Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA |doi=10.1097/01.ajp.0000173017.64741.86 |pmid=16514329}}</ref> A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for [[migraine]].<ref>{{cite journal |journal=Headache |date=2005 |volume=45 |issue=6 |pages=738–46 |title= Physical treatments for headache: a structured review |doi=10.1111/j.1526-4610.2005.05141.x |author= Biondi DM |pmid=15953306}}</ref>
 * '''Other'''. There is a small amount of research into the efficacy of chiropractic treatment for [[upper limb]]s,<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2008 |volume=31 |issue=2 |pages=146–59 |title= Chiropractic treatment of upper extremity conditions: a systematic review |author= McHardy A, Hoskins W, Pollard H, Onley R, Windsham R |doi=10.1016/j.jmpt.2007.12.004 |pmid=18328941}}</ref> and a lack of higher-quality publications supporting chiropractic management of [[Human leg|leg]] conditions.<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=8 |pages=658–71 |title= Chiropractic treatment of lower extremity conditions: a literature review |author= Hoskins W, McHardy A, Pollard H, Windsham R, Onley R |doi=10.1016/j.jmpt.2006.08.004 |pmid=17045100}}</ref> A 2007 literature synthesis found fair evidence supporting assurance and advice to stay active for [[sciatica]] and [[radicular pain]] in the leg.<ref name=Meeker-2007/> There is very weak evidence for chiropractic care for adult [[scoliosis]] (curved or rotated spine)<ref>{{cite journal |journal=Spine |date=2007 |volume=32 |issue= 19 Suppl |pages=S130–4 |title= A systematic literature review of nonsurgical treatment in adult scoliosis |author= Everett CR, Patel RK |doi=10.1097/BRS.0b013e318134ea88 |pmid=17728680}}</ref> and no scientific data for [[idiopathic]] adolescent scoliosis.<ref>{{cite journal |journal=Scoliosis |date=2008 |volume=3 |pages=2 |title= Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review |author= Romano M, Negrini S |doi=10.1186/1748-7161-3-2 |pmid=18211702 |url=http://scoliosisjournal.com/content/3/1/2}}</ref> A 2007 systematic review found that the entire clinical encounter of chiropractic care (as opposed to just SMT) provides benefit to patients with [[asthma]], cervicogenic dizziness, and [[baby colic]], and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including [[ADHD]]/[[learning disabilities]], [[dizziness]]s, and [[Visual perception|vision]] conditions.<ref name=Hawk>{{cite journal |journal= J Altern Complement Med |date=2007 |volume=13 |issue=5 |pages=491–512 |title= Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research |author= Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW |doi=10.1089/acm.2007.7088 |pmid=17604553}}</ref> Other reviews have found no evidence of benefit for baby colic,<ref>{{cite journal |journal= Paediatr Nurs |date=2007 |volume=19 |issue=8 |pages=26 |title= Effectiveness of chiropractic treatment for infantile colic |author= Kingston H |pmid=17970361}}</ref> [[bedwetting]],<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2005 |issue=2 |pages=CD005230 |title= Complementary and miscellaneous interventions for nocturnal enuresis in children |author= Glazener CM, Evans JH, Cheuk DK |doi=10.1002/14651858.CD005230 |pmid=15846744}}</ref> [[fibromyalgia]],<ref>{{cite journal |journal= Curr Pharm Des |date=2006 |volume=12 |issue=1 |pages=47–57 |title= Complementary and alternative medical therapies in fibromyalgia |author= Sarac AJ, Gur A |pmid=16454724}}</ref> or [[menstrual cramps]].<ref>{{cite journal |journal= Cochrane Database Syst Rev |date=2006 |issue=3 |pages=CD002119 |title= Spinal manipulation for primary and secondary dysmenorrhoea |author= Proctor ML, Hing W, Johnson TC, Murphy PA |doi=10.1002/14651858.CD002119.pub3 |pmid=16855988}}</ref>
@@ Line 299: / Line 299: @@
 Spinal manipulation is associated with frequent, mild and temporary [[Adverse effect (medicine)|adverse effects]],<ref name=CCA-CFCREAB-CPG/><ref name=Ernst-adverse/> including new or worsening pain or stiffness in the affected region.<ref name=Thiel>{{cite journal |journal=Spine |date=2007 |volume=32 |issue=21 |pages=2375–8 |title= Safety of chiropractic manipulation of the cervical spine: a prospective national survey |author= Thiel HW, Bolton JE, Docherty S, Portlock JC |pmid=17906581}}</ref> They have been estimated to occur in 34% to 55% of patients, with 80% of them disappearing within 24 hours.<ref name=CCA-CFCREAB-CPG/> Rarely, spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death; these can occur in adults<ref name=Ernst-adverse>{{cite journal |journal= J R Soc Med |date=2007 |volume=100 |issue=7 |pages=330–8 |title= Adverse effects of spinal manipulation: a systematic review |author= Ernst E |pmid=17606755 |url=http://www.jrsm.org/cgi/content/full/100/7/330}}</ref> and children.<ref name=Vohra>{{cite journal |journal=Pediatrics |date=2007 |volume=119 |issue=1 |pages=e275–83 |title= Adverse events associated with pediatric spinal manipulation: a systematic review |author= Vohra S, Johnston BC, Cramer K, Humphreys K |doi=10.1542/peds.2006-1392 |pmid=17178922 |url=http://pediatrics.aappublications.org/cgi/content/full/119/1/e275}}</ref> The [[Incidence (epidemiology)|incidence]] of these complications is unknown, due to rarity, high levels of underreporting, and difficulty of linking manipulation to adverse effects such as stroke, a particular concern.<ref name=Ernst-adverse/> Several case reports show temporal associations between interventions and potentially serious complications.<ref name=Hurwitz-2008/> [[Vertebrobasilar artery stroke]] is [[Association (statistics)|statistically associated]] with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.<ref name=Hurwitz-2008>{{cite journal |journal=Spine |date=2008 |volume=33 |issue= 4 Suppl |pages=S123–52 |title= Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders |author= Hurwitz EL, Carragee EJ, van der Velde G |doi=10.1097/BRS.0b013e3181644b1d |pmid=18204386}}</ref> Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.<ref>{{cite journal |journal=Neurologist |date=2008 |volume=14 |issue=1 |pages=66–73 |title= Does cervical manipulative therapy cause vertebral artery dissection and stroke? |author= Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM |doi=10.1097/NRL.0b013e318164e53d |pmid=18195663}}</ref>
-=== Cost-benefit ===
-The benefits of chiropractic care seems to outweigh the involved risk.<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2007 |volume=30 |issue=6 |pages=408–18 |title= The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study |author= Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW |doi=10.1016/j.jmpt.2007.04.013 |pmid=17693331}}</ref> Spinal manipulation for the lower back appears to be relatively cost-effective.<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2005 |volume=28 |issue=8 |pages=555-63 |title= Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain |author= Haas M, Sharma R, Stano M |doi=10.1016/j.jmpt.2005.08.006 |pmid=16226622}}</ref> The cost-effectiveness of SM has not been demonstrated beyond a reasonable doubt.<ref name=Ernst-2008/> Of the various interventions available, the most cost-effectiveness treatment for lower back pain could not be determined from the limited research available.<ref>{{cite journal |journal= Best Pract Res Clin Rheumatol |date=2005 |volume=19 |issue=4 |pages=671–84 |title= What is the most cost-effective treatment for patients with low back pain? A systematic review |author= van der Roer N, Goossens ME, Evers SM, van Tulder MW |doi=10.1016/j.berh.2005.03.007 |pmid=15949783}}</ref> The data indicates that SM therapy typically represents an additional cost to conventional treatment.<ref>{{cite journal |journal= Evid Based Complement Alternat Med |date=2006 |volume=3 |issue=4 |pages=425–32 |title= Cost-effectiveness of complementary therapies in the United kingdom—a systematic review |author= Canter PH, Coon JT, Ernst E |doi=10.1093/ecam/nel044 |pmid=17173105 |url=http://ecam.oxfordjournals.org/cgi/content/full/3/4/425}}</ref> Due to SM's popularity, higher quality research into the risk-benefit is recommended.<ref>{{cite journal |journal=Stroke |year=2001 |volume=32 |issue=5 |pages=1054–60 |title= Chiropractic manipulation and stroke: a population-based case-control study |author= Rothwell DM, Bondy SJ, Williams JI |pmid=11340209 |url=http://stroke.ahajournals.org/cgi/content/full/32/5/1054}}</ref> Preliminary evidence suggests that massage but not spinal manipulation may reduce the costs of care after an initial therapy.<ref>{{cite journal |journal= Ann Intern Med |date=June 3, 2003 |volume= 138 |issue= 11 |pages= 898-906 |title= A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain |author= Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. |pmid= 12779300 |url= http://www.annals.org/cgi/reprint/138/11/898.pdf |format=PDF}}</ref> When compared with treatment options such as physiotherapeutic exercise, the risk-benefit balance does not favor SM.<ref name=Ernst-Canter/> The small risk associated with manipulation of the cervical spine could be avoided with the use of nonthrust passive mobilization movements.<ref>{{cite journal |journal=Phys Ther |year=1999 |volume=79 |issue=1 |pages=50-65 |title= Manipulation of the Cervical Spine Risks and Benefits |author= Di Fabio RP |pmid=9920191 |url=http://www.ptjournal.org/cgi/content/full/79/1/50}}</ref> There is no evidence that SM is superior to other treatment options available for patients with low back pain.<ref>{{cite journal |journal= Ann Intern Med |date=2003 |volume=138 |issue=11 |pages=871–81 |title= Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies |author= Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG |pmid=12779297 |url=http://annals.org/cgi/content/full/138/11/871}}</ref> In occupational low back pain, shorter chiropractor care had a benefit for reducing work-disability recurrence and a longer chiropractic care did not show a benefit for preventing work-disability recurrence when analyzing tha data from workers' compensation claims data.<ref>{{cite journal |journal= J Occup Environ Med |date=2007 |volume=49|issue=10|pages=1124-34|title=The association between timing and duration of chiropractic care in work-related low back pain and work-disability outcomes |author= Wasiak R, Kim J, Pransky GS |doi= |pmid=18000417 |url=http://www.joem.org/pt/re/joem/abstract.00043764-200710000-00013.htm;jsessionid=LX7JcGYHTnKLptdqnyJT6qQ5TNFcvDLHhpT9nnVVj2cjHgWtBLVh!1379360954!181195629!8091!-1}}</ref> SM helps to reduce time lost due to workplace back pain, and thus employer savings.<ref>{{cite journal |journal=CMAJ |date=1998 |volume=158 |issue=12 |pages=1625-31 |title=Preventing disability from work-related low-back pain. New evidence gives new hope--if we can just get all the players onside |author=Frank J, Sinclair S, Hogg-Johnson S, Shannon H, Bombardier C, Beaton D, Cole D |pmid=9645178 |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=9645178}}</ref>
 == Vaccination ==