In the mid-1990's, the Association of Chiropractic Colleges redefined a subluxation as a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system and general health. In 1997 the Foundation for Chiropractic Education and Research defined a subluxation as a joint problem (whether a problem with the way the joint is functioning, a physical problem with the joint, or a combination of any of these) that affects the function of nerves and therefore affects the body's organs and general health.

In 1998, Lon Morgan DC wrote, in the Journal of the Canadian Chiropractic Association,

"Innate Intelligence clearly has its origins in borrowed mystical and occult practices of a bygone era. It remains untestable and unverifiable and has an unacceptably high penalty/benefit ratio for the chiropractic profession. The chiropractic concept of Innate Intelligence is an anachronistic holdover from a time when insufficient scientific understanding existed to explain human physiological processes. It is clearly religious in nature and must be considered harmful to normal scientific activity." ^*

Today, chiropractors use the concept of Innate Intelligence to describe the body's self-healing physiology; accordingly, they hold that healthcare interventions should consider the person as a whole and that conservative (non-invasive) treatment approaches should be used where possible.

=Philosophy of the subluxation

Scientific investigation of chiropractic

While there is continuing research, and continuing debate about the effectiveness of chiropractic for the many conditions in which it is applied, chiropractic care seems to be most effective in treating acute low back pain and tension headaches.McCrory DC, et al. Evidence Report: Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache. Duke University Evidence-Based Practice Center, Durham, North Carolina, January 2001 available online (PDF format) When testing the efficacy of health treatments, double blind studies are generally considered the highest standards of scientific rigour. These are designed so that neither the patient nor the doctor know whether they are using the actual treatment or a placebo (or "sham") treatment. However, this is not possible in testing chiropractic because chiropractic treatment involves a manipulation; no "sham" procedure can be devised easily for this, and even if the patient is unaware whether the treatment is a real procedure or a sham procedure, the doctor cannot be unaware. Thus there is the potential for "observer bias" - the tendency to see what you expect to see, and also the potential for the patient to wish to report benefits to "please" the doctor. This is a problem not confined to chiropractic - many other medical treatments similarly are not amenable to double-blind placebo-controlled trials, indeed this is true for all surgical procedures. It is also a very real problem in evaluating treatments; even when there are objective outcome measures, the placebo effect can be very substantial indeed.

Thus, chiropractors have historically relied mostly upon their own clinical experience and the shared experience of their colleagues, as reported in case studies, to direct their treatment methods. In this they are not different to the practice in much of conventional medicine. However a bigger difference is that conventional medical treatments, especially new treatments, often have a stronger scientific foundation, in that their rationale is supported by experiments that analyse their mechanisms of action in detail.

University of Saskatchewan sociologist Leslie Biggs interviewed 600 Canadian chiropractors in 1997, and found that, while 86% felt that chiropractic methods needed to be validated, 74% of them did not believe that controlled clinical trials were the best way to evaluate chiropractic. Also noted was 68% believed that most diseases are caused by spinal malalignment, yet only 30% agreed that subluxation was the cause of many diseases.^* With this in mind, critics identify three problem areas with the current status of chiropractic research: a failure to show efficacy for the conditions treated; an implausible mechanisms of action; and the use of invalid biomechanical assessments.

When a valid mechanism of action is not determined, it would be sufficient for a profession to present evidence showing benefit for the claims made. There is scientific agreement that, wherever applicable, an evidence based medicine framework should be used to assess health outcomes, and that systematic reviews with strict protocols are an important part of objectively evaluating the efficacy of treatments. Where evidence from such reviews is lacking, this does not necessarily mean that the treatment is ineffective, only that the case for a benefit of treatment may not have been rigorously established.

The Cochrane Collaboration and Bandolier publish such reviews. A 2005 editorial in The Journal of Manipulative and Physiological Therapeutics, "The Cochrane Collaboration: is it relevant for doctors of chiropractic?"^*, proposed that involvement in Cochrane collaboration would be a way for chiropractic to gain greater acceptance within medicine. The collaboration has 11,500 contributors from more than 90 countries organised in 50 review groups. For chiropractic, relevant review groups include the Back Group; the Bone, Joint, and Muscle Trauma Group; the Musculoskeletal Group; and the Neuromuscular Disease Group. The editorial states:

"For example, a chiropractor may provide conservative care supported by a Cochrane review to a patient with carpal tunnel syndrome. If the patient's symptoms become progressive, the doctor may consider referring the patient for surgery using a recent Cochrane review that examined new surgical techniques compared with traditional open surgery for the said condition.”"

The Cochrane Collaboration found insufficient evidence to support or refute that manual therapy is beneficial for asthma. Carpal tunnel syndrometrials have not shown benefit from diuretics, non-steroidal anti-inflammatory drugs, magnets, laser acupuncture, exercise or chiropractic and there is not enough evidence to show the effects of spinal manipulation for painful menstrual periods.

Bandolier found limited evidence that spinal manipulative therapy might reduce the frequency and intensity of migraine attacks, but the evidence that spinal manipulation is better than amitriptyline, or adds to the effects of amitriptyline, is insubstantial for the treatment of migraine, though it suggests that "spinal manipulative therapy might be worth trying for some patients with migraine or tension headaches."

Based on a small, poor quality set of trials, there is no convincing evidence for long-term benefits of chiropractic interventions for acute or chronic low back pain. There might be some short-term pain relief, especially in patients with acute pain.Assendelft WJJ, Koes BW, Van der Heijden GJMG, Bouter LM. The effectiveness of chiropractic for treatment of low back pain: An update and attempt at statistical pooling. J Manip Physiol Ther 1996; 19:499-507

There is much conflict in the results of chiropractic research. For instance, many chiropractors claim to treat infantile colic. According to a 1999 survey of the Ontario Chiropractic Association (representing 83% of chiropractors in Ontario), 46% treated children for colic. Verhoef MJ,Costa Papadopoulos C. Survey of Canadian chiropractors’involvement in the treatment of patients under the age of 18. Wiberg JMM, Nordsteen J, Nilsson N. The short-term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled clinical trial with a blinded observer. J Manip Physiol Ther 1999;22:517-22.^*" target="_blank" >However, in 2001, a Norwegian double-blind study said “Chiropractic spinal manipulation is no more effective than placebo in the treatment of infantile colic.” Olafsdottir E, Forshei S, Fluge G, Markestad T. Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Arch Dis Child 2001;84:138-141. [http://adc.bmjjournals.com/cgi/content/abstract/84/2/138

American Medical Association

Specifically about chiropractic, "Manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints",

and on alternative therapies in general, "There is little evidence to confirm the safety or efficacy of most alternative therapies. Much of the information currently known about these therapies makes it clear that many have not been shown to be efficacious. Well-designed, stringently controlled research should be done to evaluate the efficacy of alternative therapies."

Safety

Nothing more than a temporal relationship has ever been established in relation to severe complications and chiropractic intervention. Chiropractic continues to be one of the safest health professionsand chiropractors have some of the lowest malpractice insurance premiums in the health care industry[http://www.idealspine.com/pages/safety_of_chiropractic_care.htm.

Documented serious complications after manipulation of the cervical spine are very rare (1 in 3-4 million manipulations or fewer). This estimate is based on international studies of millions of chiropractic cervical adjustments from 1965 to the present day. The "one in a million" estimate is echoed in an extensive review of spinal manipulation performed by the RAND corporation.However, in another study, Dvorak cites figures of 1 in 400,000, while Jaskoviak reported approximately 5 million cervical manipulations from 1965 to 1980 at The National College of Chiropractic Clinic in Chicago, without a single case of vertebral artery stroke or serious injury [http://www.chiro.org/chimages/chiropage/cva-1.html. Less conservative treatments such as neck surgery are also often used for conditions similar to the conditions chiropractors treat using spinal adjustments. Cervical spine surgery has a 3-4% rate of complication and 4,000-10,000 deaths per million neck surgeries.

However, it is difficult to be sure what percentage of incidents are reported; the RAND study, for example, assumed that only 1 in 10 cases would have been reported. Dr Edzard Ernst surveyed neurologists in Britain for cases of serious neurological complication occurring within 24 hours of cervical spinal manipulation during the past year; 35 cases had been seen by the 24 who responded, but none had been reported. His survey led him to conclude that underreporting was closer to 100%, rendering estimates "nonsensical." ^*

A 2001 study in the medical journal Stroke found that vertebrobasilar accidents (VBAs) are five times more likely in those aged <45 years who had visited a chiropractor in the week before the VBA, compared to controls who had not visited a chiropractor. ^*

A New Zealand Commission report in 1979 supported the safety of chiropractic; the report said "We are satisfied that chiropractic treatment in New Zealand is remarkably safe." (Report of the Commission of Inquiry Into Chiropractic 1979:p 77). However, the judge in the Wilk v. American Medical Association case; described this report as "unsatisfactory", and a review of the report by the United States Congress' Office of Technology Assessment found 'serious problems' in its treatment of safety and efficacy issues. ^*

Few studies that deal with the stroke issue and cervical manipulation take into account the difference between "manipulation" and the "chiropractic adjustment". According to "a research report in the Journal of Manipulative and Physiological Therapeutics, "manipulations" administered by a Kung Fu practitioner, GPs, osteopaths, physiotherapists, a wife, a blind masseur, and an Indian barber had been incorrectly attributed to chiropractors." The report goes on to say, "The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a non-chiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader's opinion of chiropractic and chiropractors." (Terrett AGJ: Misuse of the literature by medical authors in discussing spinal manipulative therapy injury. JMPT 1995;18:203) Chiropractic adjustments are set apart from manipulation due to their precision and specificity ^*. While there are nearly 200 different chiropractic techniques, which vary considerably in their application, and such differences have never been taken into account in relation to safety issues.

Chiropractic education, licensing, and regulation

United States

Students often enter chiropractic school with a Bachelor's degree, or with three years of post-secondary education in the sciences and other appropriate coursework. However, in 2005 only one chiropractic college required a baccalaureate degree as an admission requirement. ^* The minimum prerequisite for enrollment in a chiropractic college set forth by the CCE is 90 semester hours, and the minimum cumulative GPA for a student entering is 2.50. Commonly required classes include: psychology, biology, organic and inorganic chemistry, and physics. Other common medical classes are: anatomy or embryology, physiology, microbiology, diagnosis, neurology, x-ray, orthopedics, obstetrics/gynecology, histology, and pathology.

Chiropractic programs require at least 4,200 hours of combined classroom, laboratory, and clinical experience. The last 2 years stress courses in manipulation and spinal adjustment and provide clinical experience in physical and laboratory diagnosis, orthopedics, neurology, geriatrics, physiotherapy, and nutrition. Graduates must complete 5 years of schooling and pass 4 national board exams to complete their education. To qualify for licensure, graduates must sit State examinations; most State boards require at least 2 years of undergraduate education, and an increasing number require a 4-year bachelor’s degree. All boards require the completion of a 4-year program at an accredited college leading to the DC degree. Once licensed, most States require chiropractors to attend 12-48 hours of continuing education annually. Chiropractic colleges also offer postdoctoral training in neurology, orthopedics, sports injuries, nutrition, rehabilitation, industrial consulting, radiology, family practice, pediatrics, and applied chiropractic sciences. After such training, chiropractors may take exams leading to "diplomate" status in a given specialty including orthopedics, neurology and radiology.

Australia

United Kingdom

Modern chiropractic groups

1. Traditional Straight chiropractors are the oldest movement, operating half of the accredited schools and graduating 75% of practicing chiropractors. This group adheres to the tenents set forth by DD and BJ Palmer, but expanded the earlier theories of vertebral subluxation by suggesting alternative mechanisms. Traditional straight chiropractors accept Palmer's hypothesis that spinal adjustments remove interference to the human nervous system and improve communication between the brain and target tissues. Treatments are assumed to remove a primary underlying risk factor for disease rather than treat a patient's disease. They use differential diagnosis to rule out serious disease, but most straight chiropractors limit treatment to spinal adjustments. They tend to be members of the International Chiropractors Association (ICA).
2. Mixing chiropractors are an early offshoot of the straight movement; their schools comprise 50% of the ones in operation, but produce only 25% of graduating chiropractors. This branch originated from naturopathic, osteopathic, medical, and even chiropractic doctors who attended the Palmer College of Chiropractic and then re-organized the treatment system to include more diagnostic and treatment approaches. They eventually split from the traditional straight group and formed various other chiropractic schools including the National College of Chiropractic. Their treatments may include naturopathic remedies, physical therapy devices, or other CAMs. While still subluxation based, mixer chiropractors also treat problems associated with both the spine and extremities, including musculoskeletal issues such as pain and decreased range of motion. Mixer chiropractors describe vertebral subluxations as a form of joint dysfunction or osteoarthritis. Diagnosis is made after ruling out other known disorders and noting general signs of mechanical dysfunction in the spine. They tend to be members of the American Chiropractors Association, and all the major groups in Europe are also in membership of the European Chiropractors Union.Souza T (2005) Differential Diagnosis and Management for the Chiropractor, Third Edition : Protocols and Algorithms Jones and Bartlett Publishers Inc. 3rd edition
3. Objective Straight chiropractors are a recent off-shoot of the traditional straights and are a minority group. They differentiated themselves because the traditional straights make getting sick people well their objective, while objective straight chiropractors make the correction of vertebral subluxation their sole objective. Objective straights view the diagnosis of patient complaints as unnecessary, and avoid it if possible. They feel that a medical diagnosis is best perfomed by a medical doctor. This stance against diagnosing patient complaints has been a source of contention within the profession because accreditation standards mandate that differential diagnosis be taught in all chiropractic programs, so that the care provided to patients is safe and relevant to their complaints. Moreover, several state chiropractic licensing boards mandate that patient complaints be diagnosed before receiving care. Objective Straights do not refer to other professionals, but they do encourage their patients "to see a medical physician if they indicate that they want to be treated for the symptoms they are experiencing or if they would like a medical diagnosis to determine the cause of their symptoms. This is as close to making a referral as the objective straight chiropractor comes. The straight chiropractor never refers to a specific provider or to a specific specialty." [http://www.f-a-c-e.com/positionpaper5.htm Most straight chiropractors limit treatment to spinal adjustments. Objective Straight chiropractors tend to be members of the Federation of Straight Chiropractic Organization (FSCO) and the World Chiropractic Alliance (WCA).
4. Reform chiropractors are a small group of mixers who advocate a limited use of chiropractic primarily for treatment of osteoarthritis and musculoskeletal conditions. They reject the Palmer philosophy as well as the vertebral subluxation.

References

See also

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

External links

Advocacy

Chiropractic organizations

• American Chiropractic Association (ACA)
• British Chiropractic Association (BCA)
• Canadian Chiropractic Association (CCA)
• Japanese Association of Chiropractors (JAC)
• International Chiropractors Association (ICA)
• National Association for Chiropractic Medicine
• World Chiropractic Alliance (WCA)
• World Federation of Chiropractic (WFC)
• Foundation for Chiropractic Education and Research (FCER)

Descriptions of chiropractic procedures

• Chiropractic treatments for back pain by Spine-health.com
• Glossary of Chiropractic Terms

Other resources

• Chiropractic Resource Organization
• Dynamic Chiropractic Online (ChiroWeb)
• Directory of Chiropractors in the United States
• The Chiropractic Profession and Its Research and Education Programs
• The Future of Chiropractic Revisited: 2005 to 2015

Other

• Cherkin, Daniel C.; Mootz, Robert D. (1997) Chiropractic in the United States: Training, Practice, and Research, available online
• Healey, James W. (1990) "It's Where You Put the Period", Dynamic Chiropractic, Volume 08, Issue 21 (October 10, 1990) available online

Critiques

• A Different Way To Heal? -- PBS - Scientific American Frontiers, Web Feature
• Chiropractic: science and antiscience and pseudoscience side by side -- Joseph C. Keating, Jr, PhD
• Commentary: The Specter of Dogma -- Joseph C. Keating, Jr., PhD
• Faulty Logic and Non-skeptical Arguments in Chiropractic -- Joseph C. Keating Jr, PhD
• NCAHF on Chiropractic (2001)

Alternative medical systems | Alternative medicine | Chiropractic | Manipulative therapy

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