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**Chiropractic**
Daniel David Palmer (founder)
Invented in 1895 in Davenport, USA
Chiropractic education
World Federation of Chiropractic
Schools Accreditation

Chiropractic is a form of alternative medicine^[1] that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine, under the belief that these disorders affect general health via the nervous system.^[2] Many chiropractors reject being characterized as complementary and alternative medicine (CAM).^[3] It is a healthcare profession^[4] and although chiropractors have many similarities to primary care providers, they are more similar to a medical specialty like dentistry or podiatry.^[5] The main chiropractic treatment technique involves manual therapy, including manipulation of the spine, other joints, and soft tissues; treatment may also includes exercises and health and lifestyle counseling.^[6] Traditional chiropractic assumes that a vertebral subluxation or spinal joint dysfunction interferes with the body's function and its innate intelligence.^[7] A large number of chiropractors want to separate themselves from the traditional vitalistic concept of innate intelligence.^[8]

Many studies of treatments used by chiropractors have been conducted, with conflicting results.^[9] Systematic reviews of this research have not found evidence that chiropractic manipulation is effective, with the possible exception for the treatment of back pain.^[10] A critical evaluation found that collectively, spinal manipulation was ineffective for any condition.^[11] A Cochrane review found very low to moderate evidence that spinal manipulation therapy was no more effective than inert interventions, sham SMT or as an adjunct therapy for acute low back pain.^[12] Spinal manipulation may be cost-effective for sub-acute or chronic low back pain but the results for acute low back pain were insufficient.^[13] The efficacy and cost-effectiveness of maintenance chiropractic care are unknown.^[14] The evidence suggests that spinal manipulation therapy is safe^[15] but the rate of adverse events is unknown^[16] as there is under-reporting.^[17] It is frequently associated with mild to moderate adverse effects, with serious or fatal complications in rare cases.^[16] There is controversy surrounding the level of risk of stroke from cervical manipulation.^[18] It has been suggested that the relationship is causative,^[19] but this is disputed by many chiropractors, who believe the association between chiropractic therapy and vertebrobasilar artery stroke is unproven.^[20]

Chiropractic is well established in the U.S., Canada and Australia.^[21] It overlaps with other manual-therapy professions, including massage therapy, osteopathy, and physical therapy.^[22] Back and neck pain are the specialties of chiropractic but many chiropractors treat ailments other than musculoskeletal issues.^[10] Most who seek chiropractic care do so for low back pain.^[23]

D.D. Palmer founded chiropractic in the 1890s, and his son B.J. Palmer helped to expand it in the early 20th century.^[24] It has two main groups: "straights", now the minority, emphasize vitalism, innate intelligence and spinal adjustments, and consider vertebral subluxations to be the cause of all disease; "mixers", the majority, are more open to mainstream views and conventional medical techniques, such as exercise, massage, and ice therapy.^[8] Throughout its history, chiropractic has been controversial.^[9]^[25] For most of its existence it has been at odds with mainstream medicine, sustained by pseudoscientific ideas such as subluxation and innate intelligence^[26] that are not based on solid science.^[10] Despite the general consensus of public health professionals regarding the benefits of vaccination, among chiropractors there are significant disagreements over the subject,^[27] which has led to negative impacts on both public vaccination and mainstream acceptance of chiropractic.^[28] The American Medical Association called chiropractic an "unscientific cult" in 1966^[29] and boycotted it until losing an antitrust case in 1987.^[30] Chiropractic has had a strong political base and sustained demand for services; in recent decades, it has gained more legitimacy and greater acceptance among medical physicians and health plans in the U.S.,^[30] and evidence-based medicine has been used to review research studies and generate practice guidelines.^[31] The practice remains at a crossroads between science and ideological dogma.^[32]

Scope of practice

Template:Image Chiropractors emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery,^[33] with special emphasis on the spine.^[2] Back and neck pain are the specialties of chiropractic but many chiropractors treat ailments other than musculoskeletal issues.^[10] There is a range of opinions among chiropractors: some believed that treatment should be confined to the spine, or back and neck pain; others disagreed.^[4] For example, while one 2009 survey of American chiropractors had found that 73% classified themselves as "back pain/musculoskeletal specialists", the label "back and neck pain specialists" was regarded by 47% of them as a least desirable description in a 2005 international survey.^[4] Chiropractic combines aspects from mainstream and alternative medicine, and there is no agreement about how to define the profession: although chiropractors have many attributes of primary care providers, chiropractic has more of the attributes of a medical specialty like dentistry or podiatry.^[5] It has been proposed that chiropractors specialize in nonsurgical spine care, instead of attempting to also treat other problems,^[5]^[34] but the more expansive view of chiropractic is still widespread.^[35] Mainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be complementary and alternative medicine (CAM);^[1] and a 2008 study reported that 31% of surveyed chiropractors categorized chiropractic as CAM, 27% as integrated medicine, and 12% as mainstream medicine.^[3]

Chiropractic overlaps with several other forms of manual therapy, including massage therapy, osteopathy, physical therapy, and sports medicine.^[22]^[36] Chiropractic is autonomous from and competitive with mainstream medicine,^[37] and osteopathy outside the US remains primarily a manual medical system;^[38] physical therapists work alongside and cooperate with mainstream medicine, and osteopathic medicine in the U.S. has merged with the medical profession.^[37] Practitioners may distinguish these competing approaches through claims that, compared to other therapists, chiropractors heavily emphasize spinal manipulation, tend to use firmer manipulative techniques, and promote maintenance care; that osteopaths use a wider variety of treatment procedures; and that physical therapists emphasize machinery and exercise.^[22]

Chiropractic diagnosis may involve a range of methods including skeletal imaging, observational and tactile assessments, and orthopedic and neurological evaluation.^[33] A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider.^[5] Common patient management involves spinal manipulation (SM) and other manual therapies to the joints and soft tissues, rehabilitative exercises, health promotion, electrical modalities, complementary procedures, and lifestyle advice.^[6]

Chiropractors are not normally licensed to write medical prescriptions or perform major surgery in the United States,^[39] (although New Mexico has become the first US state to allow "advanced practice" trained chiropractors to prescribe certain medications.^[40]^[41]). In the US, their scope of practice varies by state, based on inconsistent views of chiropractic care: some states, such as Iowa, broadly allow treatment of "human ailments"; some, such as Delaware, use vague concepts such as "transition of nerve energy" to define scope of practice; others, such as New Jersey, specify a severely narrowed scope.^[42] US states also differ over whether chiropractors may conduct laboratory tests or diagnostic procedures, dispense dietary supplements, or use other therapies such as homeopathy and acupuncture; in Oregon they can become certified to perform minor surgery and to deliver children via natural childbirth.^[39] A 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for over-the-counter drugs.^[43] A 2010 survey found 72% of Switzerland chiropractors judged the current allowance in Switzerland to prescribing nonprescription medication as an advantage for chiropractic treatment.^[44]

A related field, veterinary chiropractic, applies manual therapies to animals and is recognized in a few US states,^[45] but is not recognized by the American Chiropractic Association as being chiropractic.^[46] It remains controversial within certain segments of the veterinary, and chiropractic profession.^[47]

No single profession "owns" spinal manipulation and there is little consensus as to which profession should administer SM, raising concerns by chiropractors that other medical physicians could "steal" SM procedures from chiropractors.^[31] A focus on evidence-based SM research has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.^[31] Two U.S. states (Washington and Arkansas) prohibit physical therapists from performing SM,^[48] some states allow them to do it only if they have completed advanced training in SM, and some states allow only chiropractors to perform SM, or only chiropractors and physicians. Bills to further prohibit non-chiropractors from performing SM are regularly introduced into state legislatures and are opposed by physical therapist organizations.^[49]

History

Chiropractic was founded in 1895 by Daniel David (D.D.) Palmer in Davenport, Iowa. Palmer, a magnetic healer, hypothesized that manual manipulation of the spine could cure disease.^[50] The first chiropractic patient of D.D. Palmer was Harvey Lillard, a worker in the building where Palmer's office was located.^[51] He claimed that he had severely reduced hearing for 17 years, which started soon following a "pop" in his spine.^[51] A few days following his adjustment, Lillard claimed his hearing was almost completely restored.^[51] Chiropractic competed with its predecessor osteopathy, another medical system based on magnetic healing and bonesetting; both systems were founded by charismatic midwesterners in opposition to the conventional medicine of the day, and both postulated that manipulation improved health.^[50] Although initially keeping chiropractic a family secret, in 1898 Palmer began teaching it to a few students at his new Palmer School of Chiropractic.^[24] One student, his son Bartlett Joshua (B.J.) Palmer, became committed to promoting chiropractic, took over the Palmer School in 1906, and rapidly expanded its enrollment.^[24]

Early chiropractors believed that all disease was caused by interruptions in the flow of innate intelligence, a vitalistic nervous energy or life force that represented God's presence in man; chiropractic leaders often invoked religious imagery and moral traditions.^[24] D.D. and B.J. both seriously considered declaring chiropractic a religion, which might have provided legal protection under the U.S. constitution, but decided against it partly to avoid confusion with Christian Science.^[24]^[52] Early chiropractors also tapped into the Populist movement, emphasizing craft, hard work, competition, and advertisement, aligning themselves with the common man against intellectuals and trusts, among which they included the American Medical Association (AMA).^[24]

Chiropractic has seen considerable controversy and criticism.^[9]^[25] Although D.D. and B.J. were "straight" and disdained the use of instruments, some early chiropractors, whom B.J. scornfully called "mixers", advocated the use of instruments.^[24] In 1910 B.J. changed course and endorsed X-rays as necessary for diagnosis; this resulted in a significant exodus from the Palmer School of the more conservative faculty and students.^[24] The mixer camp grew until by 1924 B.J. estimated that only 3,000 of the U.S.'s 25,000 chiropractors remained straight.^[24] That year, B.J.'s invention and promotion of the neurocalometer, a temperature-sensing device, was highly controversial among B.J.'s fellow straights. By the 1930s chiropractic was the largest alternative healing profession in the U.S.^[24]

Chiropractors faced heavy opposition from organized medicine.^[51] Thousands of chiropractors were prosecuted for practicing medicine without a license, and D.D. and many other chiropractors were jailed.^[51] To defend against medical statutes B.J. argued that chiropractic was separate and distinct from medicine, asserting that chiropractors "analyzed" rather than "diagnosed", and "adjusted" subluxations rather than "treated" disease.^[51] B.J. cofounded the Universal Chiropractors' Association (UCA) to provide legal services to arrested chiropractors.^[51] Although the UCA won their first test case in Wisconsin in 1907, prosecutions instigated by state medical boards became increasingly common and in many cases were successful. In response, chiropractors conducted political campaigns to secure separate licensing statutes, eventually succeeding in all fifty states, from Kansas in 1913 through Louisiana in 1974.^[51] The longstanding feud between chiropractors and medical doctors continued for decades. The AMA labeled chiropractic an "unscientific cult" in 1966,^[29] and until 1980 advised its members that it was unethical for medical doctors to associate with "unscientific practitioners".^[53] This culminated in a landmark 1987 decision, Wilk v. AMA, in which the court found that the AMA had engaged in unreasonable restraint of trade and conspiracy, and which ended the AMA's de facto boycott of chiropractic.^[30]

Serious research to test chiropractic theories did not begin until the 1970s, and is continuing to be hampered by antiscientific and pseudoscientific ideas that sustained the profession in its long battle with organized medicine.^[51] By the mid 1990s there was a growing scholarly interest in chiropractic, which helped efforts to improve service quality and establish clinical guidelines that recommended manual therapies for acute low back pain.^[51] In recent decades chiropractic gained legitimacy and greater acceptance by medical physicians and health plans, and enjoyed a strong political base and sustained demand for services.^[30] However, its future seemed uncertain: as the number of practitioners grew, evidence-based medicine insisted on treatments with demonstrated value, managed care restricted payment, and competition grew from massage therapists and other health professions.^[30] The profession responded by marketing natural products and devices more aggressively, and by reaching deeper into alternative medicine and primary care.^[30]

Conceptual basis

Philosophy

Chiropractic is a form of alternative medicine^[1] which focuses on manipulation of the musculoskeletal system, especially the spine.^[2] Its founder, D.D. Palmer, called it "a science of healing without drugs".^[10]

**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^[54]

Chiropractic's origins lie in the folk medicine of bonesetting,^[10] and as it evolved it incorporated vitalism, spiritual inspiration and rationalism.^[55] Its early philosophy was based on deduction from irrefutable doctrine helped distinguish chiropractic from medicine, provided it with legal and political defenses against claims of practicing medicine without a license, and allowed chiropractors to establish themselves as an autonomous profession.^[55] This "straight" philosophy, taught to generations of chiropractors, rejects the inferential reasoning of the scientific method,^[55] and relies on deductions from vitalistic first principles rather than on the materialism of science.^[54] However, most practitioners tend to incorporate scientific research into chiropractic,^[55] and most practitioners are "mixers" who attempt to combine the materialistic reductionism of science with the metaphysics of their predecessors and with the holistic paradigm of wellness.^[54] A 2008 commentary proposed that chiropractic actively divorce itself from the straight philosophy as part of a campaign to eliminate untestable dogma and engage in critical thinking and evidence-based research.^[34]

Although a wide diversity of ideas exist among chiropractors,^[55] they share the belief that the spine and health are related in a fundamental way, and that this relationship is mediated through the nervous system.^[56] Chiropractors examine the biomechanics, structure and function of the spine, along with its effects on the musculoskeletal and nervous systems and what they believe to be its role in health and disease.^[57] Some chiropactors say spinal manipulation can have an effect of a variety of ailments such as irritable bowel syndrome and asthma.^[58]

Chiropractic philosophy includes the following perspectives:^[54]

Holism assumes that health is affected by everything in an individual's environment; some sources also include a spiritual or existential dimension.^[59] In contrast, reductionism in chiropractic reduces causes and cures of health problems to a single factor, vertebral subluxation.^[34] Conservatism considers the risks of clinical interventions when balancing them against their benefits. It emphasizes noninvasive treatment to minimize risk, and avoids surgery and medication.^[57] Homeostasis emphasizes the body's inherent self-healing abilities. Chiropractic's early notion of innate intelligence can be thought of as a metaphor for homeostasis.^[55] Straights tend to use an approach that focuses on the chiropractor's perspective and the treatment model, whereas mixers tend to focus on the patient and the patient's situation.^[54]

Straights and mixers

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^[54]

Straight chiropractors adhere to the philosophical principles set forth by D.D. and B.J. Palmer, and retain metaphysical definitions and vitalistic qualities.^[51] Straight chiropractors believe that vertebral subluxation leads to interference with an "innate intelligence" exerted via the human nervous system and is a primary underlying risk factor for many diseases.^[51] Straights view the medical diagnosis of patient complaints (which they consider to be the "secondary effects" of subluxations) to be unnecessary for chiropractic treatment.^[51] Thus, straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not "mix" other types of therapies into their practice style.^[51] Their philosophy and explanations are metaphysical in nature and they prefer to use traditional chiropractic lexicon terminology (i.e. perform spinal analysis, detect subluxation, correct with adjustment, etc.).^[8] They prefer to remain separate and distinct from mainstream health care.^[8] Although considered the minority group, "they have been able to transform their status as purists and heirs of the lineage into influence dramatically out of proportion to their numbers."^[8]

Mixer chiropractors "mix" diagnostic and treatment approaches from chiropractic, medical and/or osteopathic viewpoints and make up the majority of chiropractors.^[8] Unlike straight chiropractors, mixers believe subluxation is one of many causes of disease, and hence they tend to be open to mainstream medicine.^[8] Many of them incorporate mainstream medical diagnostics and employ conventional treatments including techniques of physical therapy such as exercise, stretching, massage, ice packs, electrical muscle stimulation, therapeutic ultrasound, and moist heat.^[8] Some mixers also use techniques from alternative medicine, including nutritional supplements, acupuncture, homeopathy, herbal remedies, and biofeedback.^[8]

Although mixers are the majority group, many of them retain belief in vertebral subluxation as shown in a 2003 survey of 1100 North American chiropractors, which found that 88% wanted to retain the term "vertebral subluxation complex", and that when asked to estimate the percent of disorders of internal organs (such as the heart, the lungs, or the stomach) that subluxation significantly contributes to, the mean response was 62%.^[43] A 2008 survey of 6000 American chiropractors demonstrated that most chiropractors seem to believe that a subluxation-based clinical approach may be of limited utility for addressing visceral disorders, and greatly favored non-subluxation-based clinical approaches for such conditions.^[60] The same survey showed that most chiropractors generally believed that the majority of their clinical approach for addressing musculoskeletal/biomechanical disorders such as back pain was based on subluxation.^[60]

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.^[7] 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.^[61] D.D. Palmer, using a vitalistic approach, imbued the term subluxation with a metaphysical and philosophical meaning.^[61] He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic.^[61] 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."^[62]

Vertebral subluxation, a core concept of traditional chiropractic, remains unsubstantiated and largely untested, and a debate about whether to keep it in the chiropractic paradigm has been ongoing for decades.^[63] 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.^[63] This is still a continuing source of debate within the chiropractic profession as well, with some schools of chiropractic still teaching the traditional/straight subluxation-based chiropractic, while others have moved towards an evidence-based chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions.^[64]^[65]

In 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.^[33] It is essentially a functional entity, which may influence biomechanical and neural integrity."^[33] This differs from the medical definition of subluxation as a significant structural displacement, which can be seen with static imaging techniques such as X-rays.^[33] The 2008 book Trick or Treatment states "X-rays can reveal neither the subluxations nor the innate intelligence associated with chiropractic philosophy, because they do not exist."^[66] Attorney David Chapman-Smith, Secretary-General of the World Federation of Chiropractic, has stated that "Medical critics have asked how there can be a subluxation if it cannot be seen on x-ray. The answer is that the chiropractic subluxation is essentially a functional entity, not structural, and is therefore no more visible on static x-ray than a limp or headache or any other functional problem."^[67] The General Chiropractic Council, the statutory regulatory body for chiropractors in the United Kingdom, states that the chiropractic vertebral subluxation complex "is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease."^[68]

Treatments

Spinal manipulation, which chiropractors call "spinal adjustment" or "chiropractic adjustment", is the most common treatment used in chiropractic care.^[69] Spinal manipulation is a passive manual maneuver during which a three-joint complex is taken past the normal range of movement, but not so far as to dislocate or damage the joint.^[70] Its defining factor is a dynamic thrust, which is a sudden force that causes an audible release and attempts to increase a joint's range of motion.^[70] High-velocity, low-amplitude spinal manipulation (HVLA-SM) thrusts have physiological effects that signal neural discharge from paraspinal muscle tissues, depending on duration and amplitude of the thrust are factors of the degree in paraspinal muscle spindles activation.^[71] Clinical skill in employing HVLA-SM thrusts depends on the ability of the practitioner to handle the duration and magnitude of the load.^[71] More generally, spinal manipulative therapy (SMT) describes techniques where the hands are used to manipulate, massage, mobilize, adjust, stimulate, apply traction to, or otherwise influence the spine and related tissues.^[70]

There are several schools of chiropractic adjustive techniques, although most chiropractors mix techniques from several schools. The following adjustive procedures were received by more than 10% of patients of licensed U.S. chiropractors in a 2003 survey:^[69] Diversified technique (full-spine manipulation, employing various techniques), extremity adjusting, Activator technique (which uses a spring-loaded tool to deliver precise adjustments to the spine), Thompson Technique (which relies on a drop table and detailed procedural protocols), Gonstead (which emphasizes evaluating the spine along with specific adjustment that avoids rotational vectors), Cox/flexion-distraction (a gentle, low-force adjusting procedure which mixes chiropractic with osteopathic principles and utilizes specialized adjusting tables with movable parts), adjustive instrument, Sacro-Occipital Technique (which models the spine as a torsion bar), Nimmo Receptor-Tonus Technique, Applied Kinesiology (which emphasises "muscle testing" as a diagnostic tool), and cranial.^[72] Medicine-assisted manipulation, such as manipulation under anesthesia, involves sedation or local anesthetic and is done by a team that includes an anesthesiologist; a 2008 systematic review did not find enough evidence to make recommendations about its use for chronic low back pain.^[73]

Lumbar, cervical and thoracic chiropractic spinal manipulation.

Many other procedures are used by chiropractors for treating the spine, other joints and tissues, and general health issues. The following procedures were received by more than one-third of patients of licensed U.S. chiropractors in a 2003 survey: Diversified technique (full-spine manipulation; mentioned in previous paragraph), physical fitness/exercise promotion, corrective or therapeutic exercise, ergonomic/postural advice, self-care strategies, activities of daily living, changing risky/unhealthy behaviors, nutritional/dietary recommendations, relaxation/stress reduction recommendations, ice pack/cryotherapy, extremity adjusting (also mentioned in previous paragraph), trigger point therapy, and disease prevention/early screening advice.^[69]

A 2010 study describing Belgium chiropractors and their patients found chiropractors in Belgium mostly focus on neuromusculoskeletal complaints in adult patients, with emphasis on the spine.^[74] The diversified technique is the most often applied technique at 93%, followed by the Activator mechanical-assisted technique at 41%.^[74] A 2009 study assessing chiropractic students giving or receiving spinal manipulations while attending a U.S. chiropractic college found Diversified, Gonstead, and upper cervical manipulations are frequently used methods.^[75]

Practice guidelines

Reviews of research studies within the chiropractic community have been used to generate practice guidelines outlining standards that specify which chiropractic treatments are "legitimate" (i.e., supported by evidence) and conceivably reimbursable under managed care health payment systems.^[31] Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs antiscientific reasoning and makes unsubstantiated claims.^[2]^[26]^[63]^[76]^[77] Chiropractic remains at a crossroads, and that in order to progress it would need to embrace science; the promotion by some for it to be a cure-all was both "misguided and irrational".^[32] A 2007 survey of Alberta chiropractors found that they do not consistently apply research in practice, which may have resulted from a lack of research education and skills.^[78]

Effectiveness

Opinions differ as to the efficacy of chiropractic treatment.^[9] Many controlled clinical studies of spinal manipulation (SM) have been conducted, but their results often disagree^[79] and they are typically of low methodological quality.^[80]^[81] An independent review of National Center for Complementary and Alternative Medicine-funded studies on chiropractic manipulation for musculoskeletal issues found their quality was generally questionable, several randomised clinical trials did not report adverse effects and the majority was not described in enough detail to allow duplication.^[82] A 2011 overview of systematic reviews found that collectively, spinal manipulation failed to show it is effective for any condition.^[11] A 2008 review found that with the possible exception of back pain, chiropractic manipulation has not been shown to be effective for any medical condition.^[10] Health claims made by chiropractors regarding use of manipulation for pediatric health conditions are supported by only low levels of scientific evidence^[83]^[84] that does not demonstrate clinically relevant benefits.^[85] Most research has focused on spinal manipulation in general,^[86] rather than solely on chiropractic manipulation.^[31]

There is a wide range of ways to measure treatment outcomes.^[87] Chiropractic care, like all medical treatment, benefits from the placebo response.^[88] It is difficult to construct a trustworthy placebo for clinical trials of spinal manipulative therapy (SMT), as experts often disagree about whether a proposed placebo actually has no effect.^[89] The efficacy of maintenance care in chiropractic is unknown.^[14]

Available evidence covers the following conditions:

Low back pain. A 2013 Cochrane review found very low to moderate evidence that SMT was no more effective than inert interventions, sham SMT or as an adjunct therapy for acute low back pain.^[12] The same review found that SMT appears to be no better than other recommended therapies.^[12] A 2012 overview of systematic reviews found that collectively, SM failed to show it is an effective intervention for pain.^[90] A 2011 Cochrane review found strong evidence that suggests there is no clinically meaningful difference between SMT and other treatments for reducing pain and improving function for chronic low back pain.^[91] A 2010 Cochrane review found no current evidence to support or refute a clinically significant difference between the effects of combined chiropractic interventions and other interventions for chronic or mixed duration low back pain.^[92] A 2010 systematic review found that most studies suggest SMT achieves equivalent or superior improvement in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up.^[93] A 2008 review found strong evidence that SM is similar in effect to medical care with exercise.^[94] A 2008 literature synthesis found good evidence supporting SM for low back pain regardless of duration.^[95] Specific guidelines concerning the treatment of nonspecific (i.e., unknown cause) low back pain are inconsistent between countries.^[96]

Radiculopathy. A 2013 systematic review and meta-analysis found a statistically significant improvement in overall recovery from sciatica following SM, when compared to usual care, and suggested that SM may be considered.^[97] There is moderate quality evidence to support the use of SM for the treatment of acute lumbar radiculopathy^[98] and acute lumbar disc herniation with associated radiculopathy.^[99] There is low or very low evidence supporting SM for chronic lumbar spine-related extremity symptoms and cervical spine-related extremity symptoms of any duration and no evidence exists for the treatment of thoracic radiculopathy.^[98]

Whiplash and other neck pain. There is no consensus on the effectiveness of manual therapies for neck pain.^[100] A 2013 systematic review found that the data suggests that there are minimal short- and long-term treatment differences when comparing manipulation or mobilization of the cervical spine to physical therapy or exercise for neck pain improvement.^[101] A 2013 systematic review found that although there is insufficient evidence that thoracic SM is more effective than other treatments, it is a suitable intervention to treat some patients with non-specific neck pain.^[102] A 2011 systematic review found that thoracic SM may offer short-term improvement for the treatment of acute or subacute mechanical neck pain; although the body of literature is still weak.^[103] A 2010 Cochrane review found low quality evidence that suggests cervical manipulation may offer better short-term pain relief than a control for neck pain, and moderate evidence that cervical manipulation and mobilization produced similar effects on pain, function and patient satisfaction.^[104] A 2010 systematic review found low level evidence that suggests chiropractic care improves cervical range of motion and pain in the management of whiplash.^[105] A 2009 systematic review of controlled clinical trials found no evidence that chiropractic SM is effective for whiplash injury.^[106] A 2008 review found evidence that suggests that manual therapy and exercise are more effective than alternative strategies for neck pain but none of these treatments is clearly superior.^[107] A 2007 review found that SM and mobilization are effective for neck pain.^[100] A 2005 review found consistent evidence supporting mobilization for acute whiplash, and limited evidence supporting SM for whiplash.^[108]

Headache. A 2011 systematic review found evidence that suggests that chiropractic SMT might be as effective as propranolol or topiramate in the prevention of migraine headaches.^[109] A 2011 systematic review found evidence that does not support the use of SM for the treatment of migraine headaches.^[110] A 2006 review found no rigorous evidence supporting SM or other manual therapies for tension headache.^[111] 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.^[112] A 2004 Cochrane review found evidence that suggests SM may be effective for migraine, tension headache and cervicogenic headache.^[113]

Extremity conditions. A 2011 systematic review and meta-analysis concluded that the addition of manual mobilizations to an exercise program for the treatment of knee osteoarthritis resulted in better pain relief then a supervised exercise program alone and suggested that manual therapists consider adding manual mobilisation to optimise supervised active exercise programs.^[114] There is silver level evidence that manual therapy is more effective than exercise for the treatment of hip osteoarthritis, however this evidence could be considered to be inconclusive.^[115] A 2008 systematic review found that the addition of cervical spine mobilization to a treatment regimen for lateral epicondylosis (tennis elbow) resulted in significantly better pain relief and functional improvements in both the short and long-term.^[116] There is a small amount of research into the efficacy of chiropractic treatment for upper limbs,^[117] limited to low level evidence supporting chiropractic management of shoulder pain^[118] and limited or fair evidence supporting chiropractic management of leg conditions.^[119]

Other. A 2012 systematic review found insufficient low bias evidence to support the use of spinal manipulation as a therapy for the treatment of hypertension.^[120] A 2011 systematic review found moderate evidence to support the use of manual therapy for cervicogenic dizziness.^[121] There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine)^[122] and no scientific data for idiopathic adolescent scoliosis.^[123] A 2007 systematic review found that few studies of chiropractic care for nonmusculoskeletal conditions are available, and they are typically not of high quality; it also found that the entire clinical encounter of chiropractic care (as opposed to just SM) provides benefit to patients with cervicogenic dizziness, 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, high blood pressure, and vision conditions.^[124] Other reviews have found no evidence of significant benefit for asthma,^[125]^[126] baby colic,^[84]^[127] bedwetting,^[128] carpal tunnel syndrome,^[129] fibromyalgia,^[130] gastrointestinal disorders,^[131] kinetic imbalance due to suboccipital strain (KISS) in infants,^[84]^[132] menstrual cramps,^[133] or pelvic and back pain during pregnancy.^[134]

Safety

Chiropractic care in general is safe when employed skillfully and appropriately.^[33] Manipulation is regarded as relatively safe, but as with all therapeutic interventions, complications can arise, and it has known adverse effects, risks and contraindications.^[33] Absolute contraindications to spinal manipulative therapy are conditions that should not be manipulated; these contraindications include rheumatoid arthritis and conditions known to result in unstable joints.^[33] 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.^[33] 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.^[135] Indirect risks of chiropractic involve delayed or missed diagnoses through consulting a chiropractor.^[10]

Spinal manipulation is associated with frequent, mild and temporary adverse effects,^[16]^[135] including new or worsening pain or stiffness in the affected region.^[136] They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours;^[137] adverse reactions appear to be more common following manipulation than mobilization.^[138] Chiropractic is correlated with a very high incidence of minor adverse effects.^[10] Chiropractic are more commonly associated with serious related adverse effects than other professionals following manipulation.^[20] Rarely,^[33] 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^[16] and children.^[139] Estimates vary widely for the incidence of these complications,^[137] and the actual incidence is unknown, due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke, which is a particular concern.^[16] Adverse effects are poorly reported in recent studies investigating chiropractic manipulations.^[17] Reports of serious adverse events have occurred, resulting from spinal manipulation therapy of the lumbopelvic region.^[140] Estimates for serious adverse events vary from 5 strokes per 100,000 manipulations to 1.46 serious adverse events per 10 million manipulations and 2.68 deaths per 10 million manipulations, though it was determined that there was inadequate data to be conclusive.^[137] Several case reports show temporal associations between interventions and potentially serious complications.^[107] The published medical literature contains reports of 26 deaths since 1934 following chiropractic manipulations and many more seem to remain unpublished.^[20] Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age,^[141] but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.^[107]^[142] Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy and vertebrobasilar artery stroke.^[143] There is insufficient evidence to support a strong association or no association between cervical manipulation and stroke.^[18] There is controversy in regard to the level of risk of stroke from cervical manipulation.^[18] Many chiropractors state that, the association between chiropractic therapy and vertebral arterial dissection is not proven.^[20] However, it has been suggested that the causality between chiropractic cervical manipulation beyond the normal range of motion and vascular accidents is probable^[20] or definite.^[19] The incidence of internal carotid artery dissection following cervical spine manipulation is unknown.^[144] The literature infrequently reports helpful data to better understand the association between cervical manipulative therapy, cervical artery dissection and stroke.^[145]

Chiropractors, like other primary care providers, sometimes employ diagnostic imaging techniques such as X-rays and CT scans that rely on ionizing radiation.^[146] Although there is no clear evidence for the practice, some chiropractors may still X-ray a patient several times a year.^[66] Practice guidelines aim to reduce unnecessary radiation exposure,^[146] which increases cancer risk in proportion to the amount of radiation received.^[147] Research suggests that radiology instruction given at chiropractic schools worldwide seem to be evidence-based.^[148] Although, there seems to be a disparity between some schools and available evidence regarding the aspect of radiography for patients with acute low back pain without an indication of a serious disease, which may contribute to chiropractic overuse of radiography for low back pain.^[148]

Risk-benefit

A 2012 systematic review concluded that no accurate assessment of risk-benefit exists for cervical manipulation.^[18] A 2012 summary stated that, "The best evidence suggests that SMT, whether it be for neck or low back pain, is a safe and effective therapy. At a population level, the benefits still outweigh the risks."^[15] A 2010 systematic review stated that there is no good evidence to assume that neck manipulation is an effective treatment for any medical condition and suggested a precautionary principle in healthcare for chiropractic intervention even if a causality with vertebral artery dissection after neck manipulation were merely a remote possibility.^[20] The same review concluded that the risk of death from manipulations to the neck outweighs the benefits.^[20] Chiropractors have criticized this conclusion, claiming that the author did not evaluate the potential benefits of spinal manipulation.^[149] Edzard Ernst stated "This detail was not the subject of my review. I do, however, refer to such evaluations and should add that a report recently commissioned by the General Chiropractic Council did not support many of the outlandish claims made by many chiropractors across the world."^[149]

A 2009 review evaluating maintenance chiropractic care found that spinal manipulation is routinely associated with considerable harm and no compelling evidence exists to indicate that it adequately prevents symptoms or diseases, thus the risk-benefit is not evidently favorable.^[150] A 2008 summary found that the best evidence suggests that chiropractic care is a useful therapy for subjects with neck or low-back pain for which the risks of serious adverse events should be considered negligible.^[151] A 2007 systematic review found that with uncertain efficacy and definite risks, the risk-benefit balance of spinal manipulation can't be positive.^[16] A 2006 overview of systematic reviews found the risk-benefit balance does not favor spinal manipulation over other treatments like physical therapy.^[79]

Cost-effectiveness

A 2012 systematic review suggested that the use of spine manipulation in clinical practice is a cost-effective treatment when used alone or in combination with other treatment approaches.^[152] A 2011 systematic review found evidence supporting the cost-effectiveness of using spinal manipulation for the treatment of sub-acute or chronic low back pain; the results for acute low back pain were insufficient.^[13] A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings.^[153]

A 2006 systematic cost-effectiveness review found that the reported cost-effectiveness of spinal manipulation in the United Kingdom compared favorably with other treatments for back pain, but that reports were based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain.^[154] A 2005 American systematic review of economic evaluations of conservative treatments for low back pain found that significant quality problems in available studies meant that definite conclusions could not be drawn about the most cost-effective intervention.^[155] The cost-effectiveness of maintenance chiropractic care is unknown.^[14]

Analysis of a clinical and cost utilization data from the years 2003 to 2005 by an integrative medicine independent physician association (IPA) which looked the chiropractic services utilization found that the clinical and cost utilization of chiropractic services based on 70,274 member-months over a 7-year period decreased patient costs associate with the following use of services by 60.2% for in-hospital admissions, 59.0% for hospital days, 62.0% for outpatient surgeries and procedures, and 85% forpharmaceutical costs when compared with conventional medicine (visit to a medical doctor primary care provider) IPA performance for the same health maintenance organization product in the same geography and time frame.^[156]

International reception

Chiropractic is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries.^[21] It is viewed as a marginal complementary and alternative medicine health care profession.^[4]

Australia

In Australia, most private health insurance funds cover chiropractic care, and the federal government funds chiropractic care when the patient is referred by a medical practitioner.^[157]

United Kingdom

In the United Kingdom chiropractic is available on the National Health Service in some areas, such as Cornwall where the treatment is only available for neck or back pain.^[158]

A 2010 questionnaire presented to UK chiropractors indicated only 45% of chiropractors disclosed with patients the serious risk associated with manipulation of the cervical spine as a direct consequence of the fear that the patient would refuse treatment despite knowing the moral responsibility.^[159]

United States and Canada

The percentage of the population that utilizes chiropractic care at any given time generally falls into a range from 6% to 12% in the U.S. and Canada,^[160] with a global high of 20% in Alberta in 2006.^[161] In 2008, chiropractors were reported to be the most common CAM providers for children and adolescents, consuming up to 14% of all visits to chiropractors.^[83] In 2002-3, the majority of those who sought chiropractic did so for relief from back and neck pain and other neuromusculoskeletal complaints;^[23] most do so specifically for low back pain.^[23]^[160] The majority of U.S. chiropractors partake in some form of managed care.^[30] Although the majority of U.S. chiropractors view themselves as specialists in neuroleptic malignant syndrome conditions, many also consider chiropractic as a type of primary care.^[30] In the majority of cases, the care that chiropractors and physicians provide divides the market, however for some, their care is complementary.^[30]

In the U.S., chiropractors perform over 90% of all manipulative treatments.^[162] Satisfaction rates are typically higher for chiropractic care compared to medical care, with a 1998 U.S. survey reporting 83% of respondents satisfied or very satisfied with their care; quality of communication seems to be a consistent predictor of patient satisfaction with chiropractors.^[163]

Utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient.^[1] The use of chiropractic declined from 9.9% of U.S. adults in 1997 to 7.4% in 2002; this was the largest relative decrease among CAM professions, which overall had a stable use rate.^[164] As of 2007 7% of the U.S. population is being reached by chiropractic.^[165] Employment of U.S. chiropractors is expected to increase 14% between 2006 and 2016, faster than the average for all occupations.^[166]

In the U.S., most states require insurers to cover chiropractic care, and most HMOs cover these services.^[83] In Canada, there is lack of coverage under the universal public health insurance system.^[167]

Training

Requirements vary between countries. In the U.S. chiropractors obtain a first professional degree in the field of chiropractic.^[168] Chiropractors often argue that this education is as good as or better than medical physicians', but most chiropractic training is confined to classrooms with much time spent learning theory, adjustment, and marketing.^[42] Chiropractic curricula in the U.S. have been criticized for failing to meet generally accepted standards of evidence-based medicine.^[169] The curriculum content of North American chiropractic and medical colleges with regard to basic and clinical sciences has been more similar than not, both in the kinds of subjects offered and in the time assigned to each subject.^[170] Accredited chiropractic programs in the U.S. require that applicants have 90 semester hours of undergraduate education with a grade point average of at least 3.0 on a 4.0 scale. Many programs require at least three years of undergraduate education, and more are requiring a bachelor's degree.^[171] Canada requires a minimum three years of undergraduate education for applicants, and at least 4200 instructional hours (or the equivalent) of full‐time chiropractic education for matriculation through an accredited chiropractic program.^[172] Graduates of the Canadian Memorial Chiropractic College (CMCC) are formally recognized to have at least 7–8 years of university level education.^[173]^[174] The World Health Organization (WHO) guidelines suggest three major full-time educational paths culminating in either a DC, DCM, BSc, or MSc degree. Besides the full-time paths, they also suggest a conversion program for people with other health care education and limited training programs for regions where no legislation governs chiropractic.^[33]

Upon graduation, there may be a requirement to pass national, state, or provincial board examinations before being licensed to practice in a particular jurisdiction.^[175]^[176] Depending on the location, continuing education may be required to renew these licenses.^[177]^[178] Specialty training is available through part-time postgraduate education programs such as chiropractic orthopedics and sports chiropractic, and through full-time residency programs such as radiology or orthopedics.^[179]

In the U.S., chiropractic schools are accredited through the Council on Chiropractic Education (CCE) while the General Chiropractic Council (GCC) is the statutory governmental body responsible for the regulation of chiropractic in the UK.^[180]^[181] The U.S. CCE requires a mixing curriculum, which means a straight-educated chiropractor may not be eligible for licensing in states requiring CCE accreditation.^[42] CCEs in the U.S., Canada, Australia and Europe have joined to form CCE-International (CCE-I) as a model of accreditation standards with the goal of having credentials portable internationally.^[182] Today, there are 18 accredited Doctor of Chiropractic programs in the U.S.,^[183] 2 in Canada,^[184] 6 in Australasia,^[185] and 5 in Europe.^[186] All but one of the chiropractic colleges in the U.S. are privately funded, but in several other countries they are in government-sponsored universities and colleges.^[9] Of the two chiropractic colleges in Canada, one is publicly funded (UQTR) and one is privately funded (CMCC). In 2005, CMCC was granted the privilege of offering a professional health care degree under the Post-secondary Education Choice and Excellence Act, which sets the program within the hierarchy of education in Canada as comparable to that of other primary contact health care professions such as medicine, dentistry and optometry.^[173]^[174]

Regulatory colleges and chiropractic boards in the U.S., Canada, Mexico, and Australia are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.^[187]^[188] There are an estimated 49,000 chiropractors in the U.S. (2008),^[166] 6,500 in Canada (2010),^[189] 2,500 in Australia (2000),^[28] and 1,500 in the UK (2000).^[190]

A 2008 commentary proposed that the chiropractic profession actively regulate itself to combat abuse, fraud, and quackery, which are more prevalent in chiropractic than in other health care professions, violating the social contract between patients and physicians.^[34]

The fourth year of chiropractic education persistently showed the highest stress levels.^[191] Every student, irrespective of year, experienced different ranges of stress when studying.^[191] The chiropractic leaders and colleges have had internal struggles.^[192] Rather than cooperation, there has been infighting between different factions.^[192] A number of actions were posturing due to the confidential nature of the chiropractic colleges in an attempt to enroll students.^[192]

Ethical and medicolegal issues

The chiropractic oath is a modern variation of the classical Hippocratic Oath historically taken by physicians and other healthcare professionals swearing to practice their professions ethically.^[193] The American Chiropractic Association (ACA) has an ethical code "based upon the acknowledgement that the social contract dictates the profession’s responsibilities to the patient, the public, and the profession; and upholds the fundamental principle that the paramount purpose of the chiropractic doctor's professional services shall be to benefit the patient."^[194] The International Chiropractor's Association (ICA) also has a set of professional canons.^[195]

According to a 2006 Gallup poll of U.S. adults, when asked how they would "rate the honesty and ethical standards of people in these different fields", chiropractic compared unfavorably with mainstream medicine. When chiropractic was rated, it "rated dead last amongst healthcare professions". While 84% of respondents considered nurses' ethics "very high" or "high," only 36% felt that way about chiropractors. Other healthcare professions ranged from 38% for psychiatrists, to 62% for dentists, 69% for medical doctors, 71% for veterinarians, and 73% for druggists or pharmacists.^[34]^[196]^[197]^[198]

Chiropractors, especially in America, have a reputation for unnecessarily treating patients.^[66] In many circumstances the focus seems to be put on economics instead of health care.^[66] Sustained chiropractic care is promoted as a preventative tool, but unnecessary manipulation could possibly present a risk to patients.^[10] Some chiropractors are concerned by the routine unjustified claims chiropractors have made.^[10] A 2010 analysis of chiropractic websites found the majority of chiropractors and their associations made claims of effectiveness not supported by scientific evidence, while 28% of chiropractor websites advocate lower back pain care, which has some sound evidence.^[199]

In 2009, a backlash to the libel suit filed by the British Chiropractic Association (BCA) against Simon Singh, has inspired the filing of formal complaints of false advertising against more than 500 individual chiropractors within one 24 hour period,^[200]^[201] prompting the McTimoney Chiropractic Association to write to its members advising them to remove leaflets that make claims about whiplash and colic from their practice, to be wary of new patients and telephone inquiries, and telling their members: "If you have a website, take it down NOW." and "Finally, we strongly suggest you do NOT discuss this with others, especially patients."^[200] An editorial in Nature has suggested that the BCA may be trying to suppress debate and that this use of British libel law is a burden on the right to freedom of expression, which is protected by the European Convention on Human Rights.^[202] The libel case ended with the BCA withdrawing its suit in 2010.^[203]^[204]

Criticism

Throughout its history chiropractic has been the subject of internal and external controversy and criticism.^[8]^[205] According to Daniel D. Palmer, the founder of chiropractic, subluxation is the sole cause of disease and manipulation is the cure for all diseases of the human race.^[10]^[206] A critical evaluation stated "Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today."^[10] Chiropractors, including D.D. Palmer, were jailed for practicing medicine without a license.^[10] For most of its existence, chiropractic has battled with mainstream medicine, sustained by antiscientific and pseudoscientific ideas such as subluxation.^[51] Collectively, systematic reviews has not demonstrated that spinal manipulation, the main treatment method employed by chiropractors, is effective for any medical condition, with the possible exception of treatment for back pain.^[10] Chiropractic has been controversial, though to a lesser extent than in past years.^[9]

Public health

Some chiropractors oppose vaccination and water fluoridation, which are common public health practices.^[34] Within the chiropractic community there are significant disagreements about vaccination,^[27]^[28] one of the most cost-effective public health interventions available.^[207] Most chiropractic writings on vaccination focus on its negative aspects,^[27] claiming that it is hazardous, ineffective, and unnecessary.^[28] Some chiropractors have embraced vaccination, but a significant portion of the profession rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that vaccines interfere with healing.^[28] The extent to which anti-vaccination views perpetuate the current chiropractic profession is uncertain.^[27] The American Chiropractic Association and the International Chiropractors 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.^[28] The Canadian Chiropractic Association supports vaccination;^[27] a survey in Alberta in 2002 found that 25% of chiropractors advised patients for, and 27% against, vaccinating themselves or their children.^[208]

Early opposition to water fluoridation included chiropractors, some of whom continue to oppose it as being incompatible with chiropractic philosophy and an infringement of personal freedom. Other chiropractors have actively promoted fluoridation, and several chiropractic organizations have endorsed scientific principles of public health.^[209] In addition to traditional chiropractic opposition to water fluoridation and vaccination, chiropractors' attempts to establish a positive reputation for their public health role are also compromised by their reputation for recommending repetitive lifelong chiropractic treatment.^[34]

References

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^ ^a ^b Tetrault M (2004). "Global professional strategy for chiropractic" (PDF). Chiropractic Diplomatic Corps. Retrieved 2008-04-18.
^ ^a ^b ^c Norris P (2001). "How 'we' are different from 'them': occupational boundary maintenance in the treatment of musculo-skeletal problems". Sociol Health Illn. 23 (1): 24–43. doi:10.1111/1467-9566.00239.
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^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j Martin SC (October 1993). "Chiropractic and the social context of medical technology, 1895-1925". Technol Cult. 34 (4): 808–34. doi:10.2307/3106416. JSTOR 3106416. PMID 11623404.
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^ Suter E, Vanderheyden LC, Trojan LS, Verhoef MJ, Armitage GD (February 2007). "How important is research-based practice to chiropractors and massage therapists?". J Manipulative Physiol Ther. 30 (2): 109–15. doi:10.1016/j.jmpt.2006.12.013. PMID 17320731.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ ^a ^b Ernst E, Canter PH (April 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. PMC 1420782. PMID 16574972. {{cite journal}}: Unknown parameter |laydate= ignored (help); Unknown parameter |laysource= ignored (help); Unknown parameter |laysummary= ignored (help)
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External links

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[Chapman-Smith-1] 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.). McGraw-Hill. pp. 111–34. ISBN 0-07-137534-1. {{cite book}}: |editor= has generic name (help)CS1 maint: multiple names: editors list (link)

[Nelson-2] Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T (2005). "Chiropractic as spine care: a model for the profession". Chiropr Osteopat. 13 (1): 9. doi:10.1186/1746-1340-13-9. PMC 1185558. PMID 16000175.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)

[Redwood-CAM-3] Redwood D, Hawk C, Cambron J, Vinjamury SP, Bedard J (2008). "Do chiropractors identify with complementary and alternative medicine? results of a survey". J Altern Complement Med. 14 (4): 361–8. doi:10.1089/acm.2007.0766. PMID 18435599.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[V-H-4] Villanueva-Russell Y (June 2011). "Caught in the crosshairs: identity and cultural authority within chiropractic". Soc Sci Med. 72 (11): 1826–37. doi:10.1016/j.socscimed.2011.03.038. PMID 21531061.

[Meeker-Haldeman-5] Meeker WC, Haldeman S (2002). "Chiropractic: a profession at the crossroads of mainstream and alternative medicine" (PDF). Ann Intern Med. 136 (3): 216–27. doi:10.7326/0003-4819-136-3-200202050-00010. PMID 11827498.

[content-of-practice-6] Mootz RD, Shekelle PG (1997). "Content of practice". In Cherkin DC, Mootz RD (eds.) (ed.). Chiropractic in the United States: Training, Practice, and Research. Rockville, MD: Agency for Health Care Policy and Research. pp. 67–91. OCLC 39856366. {{cite book}}: |access-date= requires |url= (help); |editor= has generic name (help); External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help) AHCPR Pub No. 98-N002.

[History-PPC-7] 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.). McGraw-Hill. pp. 23–64. ISBN 0-07-137534-1. {{cite book}}: |editor= has generic name (help)CS1 maint: multiple names: editors list (link)

[Kaptchuk-Eisenberg-8] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j Kaptchuk TJ, Eisenberg DM (November 1998). "Chiropractic: origins, controversies, and contributions". Arch. Intern. Med. 158 (20): 2215–24. doi:10.1001/archinte.158.20.2215. PMID 9818801. Cite error: The named reference "Kaptchuk-Eisenberg" was defined multiple times with different content (see the help page).

[DeVocht-9] ^ ^a ^b ^c ^d ^e ^f 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.

[Ernst-eval-10] ^ ^a ^b ^c ^d ^e ^f ^g ^h ⁱ ^j ^k ^l ^m ⁿ ^o 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. Cite error: The named reference "Ernst-eval" was defined multiple times with different content (see the help page).

[Posadzki-Ernst-11] Posadzki P, Ernst E (2011). "Spinal manipulation: an update of a systematic review of systematic reviews". N Z Med J. 124 (1340): 55–71. PMID 21952385.

[Cochrane-2013-12] Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW (February 2013). "Spinal manipulative therapy for acute low back pain: an update of the cochrane review". Spine (Systematic Review). 38 (3): E158–77. doi:10.1097/BRS.0b013e31827dd89d. PMID 23169072.{{cite journal}}: CS1 maint: multiple names: authors list (link)

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 <!-- History -->
 [[Daniel David Palmer|D.D. Palmer]] founded chiropractic in the 1890s, and his son [[Bartlett Joshua Palmer|B.J. Palmer]] helped to expand it in the early [[20th century]].<ref name=Martin/> It has two main groups: "straights", now the minority, emphasize vitalism, innate intelligence and [[spinal adjustment]]s, and consider vertebral subluxations to be the cause of all disease; "mixers", the majority, are more open to mainstream views and conventional medical techniques, such as [[exercise]], [[massage]], and [[ice pack|ice therapy]].<ref name=Kaptchuk-Eisenberg/> Throughout its history, chiropractic has been [[Chiropractic controversy and criticism|controversial]].<ref name=DeVocht/><ref name=Homola/> For most of its existence it has been at odds with [[mainstream medicine]], sustained by [[pseudoscientific]] ideas such as subluxation and innate intelligence<ref name=History-Primer2/> that are not based on solid science.<ref name=Ernst-eval/> Despite the general consensus of [[public health]] professionals regarding the benefits of [[vaccination]], among chiropractors there are significant disagreements over the subject,<ref name=Busse/> which has led to negative impacts on both public vaccination and mainstream acceptance of chiropractic.<ref name=Campbell/> The [[American Medical Association]] called chiropractic an "unscientific cult" in 1966<ref name=Chiro-PH/> and boycotted it until losing an [[Wilk v. American Medical Association|antitrust case in 1987]].<ref name=Cooper/> Chiropractic has had a strong political base and sustained demand for services; in recent decades, it has gained more legitimacy and greater acceptance among medical [[physician]]s and [[health plan]]s in the U.S.,<ref name=Cooper/> and [[evidence-based medicine]] has been used to review research studies and generate [[Medical guideline|practice guidelines]].<ref name=Villanueva-Russell/> The practice remains at a crossroads between science and ideological [[dogma]].<ref name="Reggars2011"/>
+== Scope of practice ==
+{{Image|Treatment Table Chiropractic.jpg|thumb|right|alt=|A treatment table at a chiropractic office.}}
+Chiropractors emphasize the conservative management of the [[human musculoskeletal system|neuromusculoskeletal system]] without the use of medicines or surgery,<ref name=WHO-guidelines/> with special emphasis on the spine.<ref name=Nelson>{{cite journal | author = Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T | title = Chiropractic as spine care: a model for the profession | journal = Chiropr Osteopat | volume = 13 | issue = 1 | pages = 9 | year = 2005 | pmid = 16000175 | pmc = 1185558 | doi = 10.1186/1746-1340-13-9 | url = http://chiroandosteo.com/content/13/1/9 }}</ref> Back and neck pain are the specialties of chiropractic but many chiropractors treat ailments other than musculoskeletal issues.<ref name=Ernst-eval/> There is a range of opinions among chiropractors: some believed that treatment should be confined to the spine, or back and neck pain; others disagreed.<ref name="V-H"/> For example, while one 2009 survey of American chiropractors had found that 73% classified themselves as "back pain/musculoskeletal specialists", the label "back and neck pain specialists" was regarded by 47% of them as a ''least'' desirable description in a 2005 international survey.<ref name="V-H">{{cite journal | author = Villanueva-Russell Y | title = Caught in the crosshairs: identity and cultural authority within chiropractic | journal = Soc Sci Med | volume = 72 | issue = 11 | pages = 1826–37 | date = June 2011 | pmid = 21531061 | doi = 10.1016/j.socscimed.2011.03.038 }}</ref> Chiropractic combines aspects from mainstream and alternative medicine, and there is no agreement about how to define the profession: although chiropractors have many attributes of [[primary care]] providers, chiropractic has more of the attributes of a medical specialty like [[dentistry]] or [[podiatry]].<ref name=Meeker-Haldeman>{{cite journal | author = Meeker WC, Haldeman S | title = Chiropractic: a profession at the crossroads of mainstream and alternative medicine | journal = [[Ann Intern Med]] | volume = 136 | issue = 3 | pages = 216–27 | year = 2002 | pmid = 11827498 | doi = 10.7326/0003-4819-136-3-200202050-00010 | url = http://www.annals.org/cgi/reprint/136/3/216.pdf | format = PDF }}</ref> It has been proposed that chiropractors specialize in nonsurgical spine care, instead of attempting to also treat other problems,<ref name=Meeker-Haldeman/><ref name=Murphy-pod/> but the more expansive view of chiropractic is still widespread.<ref>{{cite journal | author = Gleberzon BJ, Cooperstein R, Perle SM | title = Can chiropractic survive its chimerical nature? | journal = J Can Chiropr Assoc | volume = 49 | issue = 2 | pages = 69–73 | year = 2005 | pmid = 17549192 | pmc = 1840015 }}</ref> Mainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be [[Alternative medicine|complementary and alternative medicine]] (CAM);<ref name=Chapman-Smith/> and a 2008 study reported that 31% of surveyed chiropractors categorized chiropractic as CAM, 27% as integrated medicine, and 12% as mainstream medicine.<ref name=Redwood-CAM>{{cite journal | author = Redwood D, Hawk C, Cambron J, Vinjamury SP, Bedard J | title = Do chiropractors identify with complementary and alternative medicine? results of a survey | journal = [[J Altern Complement Med]] | volume = 14 | issue = 4 | pages = 361–8 | year = 2008 | pmid = 18435599 | doi = 10.1089/acm.2007.0766 }}</ref>
+Chiropractic overlaps with several other forms of manual therapy, including [[massage therapy]], [[osteopathy]], physical therapy, and [[sports medicine]].<ref name=Norris/><ref>{{cite journal | author = Theberge N | title = The integration of chiropractors into healthcare teams: a case study from sport medicine | journal = Sociol Health Illn | volume = 30 | issue = 1 | pages = 19–34 | date = January 2008 | pmid = 18254831 | doi = 10.1111/j.1467-9566.2007.01026.x }}</ref> Chiropractic is autonomous from and competitive with mainstream medicine,<ref name=Pettman/> and osteopathy outside the US remains primarily a manual medical system;<ref>{{cite journal|journal= Complement Health Pract Rev|year=2006|volume=11|issue=2|pages=77–94|doi=10.1177/1533210106292467|title= The drive for legitimization by osteopathy and chiropractic in Australia: between heterodoxy and orthodoxy|author= Baer HA}}</ref> physical therapists work alongside and cooperate with mainstream medicine, and [[osteopathic medicine in the U.S.]] has merged with the medical profession.<ref name=Pettman>{{cite journal | author = Pettman E | title = A history of manipulative therapy | journal = J Man Manip Ther | volume = 15 | issue = 3 | pages = 165–74 | year = 2007 | pmid = 19066664 | pmc = 2565620 | doi = 10.1179/106698107790819873 }}</ref> Practitioners may distinguish these competing approaches through claims that, compared to other therapists, chiropractors heavily emphasize spinal manipulation, tend to use firmer manipulative techniques, and promote maintenance care; that osteopaths use a wider variety of treatment procedures; and that physical therapists emphasize machinery and exercise.<ref name=Norris>{{cite journal|author= Norris P|year=2001|title= How 'we' are different from 'them': occupational boundary maintenance in the treatment of musculo-skeletal problems|journal= Sociol Health Illn|volume=23|issue=1|pages=24–43|doi=10.1111/1467-9566.00239}}</ref>
+Chiropractic diagnosis may involve a range of methods including skeletal imaging, observational and tactile assessments, and orthopedic and neurological evaluation.<ref name=WHO-guidelines/> A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider.<ref name=Meeker-Haldeman/> Common patient management involves [[spinal manipulation]] (SM) and other manual therapies to the joints and soft tissues, rehabilitative exercises, health promotion, electrical modalities, complementary procedures, and lifestyle advice.<ref name=content-of-practice>{{cite book|chapterurl=http://chiroweb.com/archives/ahcpr/chapter3.htm|chapter= Content of practice|author= Mootz RD, Shekelle PG|year=1997|title= Chiropractic in the United States: Training, Practice, and Research|pages=67–91|editor= Cherkin DC, Mootz RD (eds.)|accessdate=2008-10-10|location= Rockville, MD|publisher= Agency for Health Care Policy and Research|oclc=39856366}} AHCPR Pub No. 98-N002.</ref>
+[[File:Dr. Heidi Bockhold Adjusts Horse.jpg|thumb|left|A chiropractic adjustment of a horse.]]
+Chiropractors are not normally licensed to write [[medical prescription]]s or perform major surgery in the United States,<ref name=Parkman/> (although [[New Mexico]] has become the first US state to allow "advanced practice" trained chiropractors  to prescribe certain medications.<ref>[http://www.nmcpr.state.nm.us/nmac/parts/title16/16.004.0015.htm Occupational And Professional Licensing, Chiropractic Practitioners, Chiropractic Advanced Practice Certification Registry]. Retrieved 2010-05-03.</ref><ref>[http://www.rld.state.nm.us/uploads/files/2010%20APC%20Formulary%281%29.pdf Occupational And Professional Licensing, Chiropractic Practitioners, Chiropractic Advanced Practice Certification Registry (PDF)] Retrieved 2010-05-03.</ref>). In the US, their scope of practice varies by state, based on inconsistent views of chiropractic care: some states, such as [[Iowa]], broadly allow treatment of "human ailments"; some, such as [[Delaware]], use vague concepts such as "transition of nerve energy" to define scope of practice; others, such as [[New Jersey]], specify a severely narrowed scope.<ref name=Morrison>{{cite journal | author = Morrison P | title = Adjusting the role of chiropractors in the United States: why narrowing chiropractor scope of practice statutes will protect patients | journal = Health Matrix Clevel | volume = 19 | issue = 2 | pages = 493–537 | year = 2009 | pmid = 19715143 }}</ref> US states also differ over whether chiropractors may conduct laboratory tests or diagnostic procedures, dispense [[dietary supplement]]s, or use other therapies such as homeopathy and acupuncture; in [[Oregon]] they can become certified to perform minor surgery and to deliver children via natural childbirth.<ref name=Parkman>{{cite journal | author = Parkman CA | title = Issues in credentialing CAM providers | journal = Case Manager | volume = 15 | issue = 4 | pages = 24–7 | year = 2004 | pmid = 15247891 | doi = 10.1016/j.casemgr.2004.05.004 }}</ref> A 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for [[over-the-counter drug]]s.<ref name=McDonald>{{cite book|author=McDonald WP, Durkin KF, Pfefer M et al.|year=2003|title=How Chiropractors Think and Practice: The Survey of North American Chiropractors|location=Ada, OH|publisher=Institute for Social Research, Ohio Northern University|isbn=0-9728055-5-9 }}{{page needed|date=May 2013}} Summarized in: {{cite journal|journal=Semin Integr Med|year=2004|volume=2|issue=3|pages=92–8|title=How chiropractors think and practice: the survey of North American chiropractors|author=McDonald WP, Durkin KF, Pfefer M|doi=10.1016/j.sigm.2004.07.002|laydate=2003-06-02|laysummary=http://chiroweb.com/archives/21/12/19.html|laysource= Dyn Chiropr }}</ref> A 2010 survey found 72% of Switzerland chiropractors judged the current allowance in Switzerland to prescribing nonprescription medication as an advantage for chiropractic treatment.<ref>{{cite journal | author = Wangler M, Zaugg B, Faigaux E | title = Medication Prescription: A Pilot Survey of Bernese Doctors of Chiropractic Practicing in Switzerland | journal = Journal of Manipulative and Physiological Therapeutics | volume = 33 | issue = 3 | pages = 231–237 | year = 2010 | pmid = 20350678 | doi = 10.1016/j.jmpt.2010.01.013 }}</ref>
+A related field, [[veterinary chiropractic]], applies manual therapies to animals and is recognized in a few US states,<ref>{{cite journal | author = Ramey DW | title = Regulatory aspects of complementary and alternative veterinary medicine | journal = J Am Vet Med Assoc | volume = 222 | issue = 12 | pages = 1679–82 | date = June 2003 | pmid = 12830858 | doi = 10.2460/javma.2003.222.1679 }}</ref> but is not recognized by the [[American Chiropractic Association]] as being chiropractic.<ref>{{cite web|url=http://amerchiro.org/level2_css.cfm?T1ID=10&T2ID=117#107|accessdate=2008-07-05|title='Veterinary' chiropractic|year=1994|author=ACA House of Delegates|publisher=American Chiropractic Association }}</ref> It remains controversial within certain segments of the veterinary, and chiropractic profession.<ref>{{cite journal |journal= Dyn Chiropr |year=2001 |volume=19 |issue=13 |url=http://www.chiroweb.com/archives/19/13/07.html |author= Kamen D |title= Politics and technique}}</ref>
+No single profession "owns" spinal manipulation and there is little consensus as to which profession should administer SM, raising concerns by chiropractors that other medical physicians could "steal" SM procedures from chiropractors.<ref name=Villanueva-Russell/> A focus on evidence-based SM research 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 | author = Villanueva-Russell Y | title = Evidence-based medicine and its implications for the profession of chiropractic | journal = [[Soc Sci Med]] | volume = 60 | issue = 3 | pages = 545–61 | year = 2005 | pmid = 15550303 | doi = 10.1016/j.socscimed.2004.05.017 }}</ref> Two U.S. states (Washington and Arkansas) prohibit physical therapists from performing SM,<ref>{{cite news |last=Anderson |first=Chantal |title=Physical therapists, chiropractors square off over bill |url=http://blog.seattletimes.nwsource.com/politicsnorthwest/2009/01/22/the_campus_is_heating_up.html |date=2009-01-22 |work=The Seattle Times |accessdate=2010-09-23}}</ref> some states allow them to do it only if they have completed advanced training in SM, and some states allow only chiropractors to perform SM, or only chiropractors and physicians. Bills to further prohibit non-chiropractors from performing SM are regularly introduced into state legislatures and are opposed by physical therapist organizations.<ref>{{cite journal |journal= DePaul J Health Care Law |year=2004 |volume=8 |issue=1 |pages=237–61 |title= State practice acts of licensed health professions: scope of practice |author= Hilliard JW, Johnson ME}}</ref>
+== History ==
+{{Main|Chiropractic history}}
+[[File:Harvey Lillard.jpg|thumb|left|169px|[[William Harvey Lillard|Harvey Lillard]], first chiropractic patient]]
+[[Image:Daniel David Palmer.jpg|thumb|upright|alt=Half-length sitting portrait of man in his fifties with large gray beard and moustache, wearing coat and vest|[[Daniel David Palmer|D.D. Palmer]], founder of chiropractic]]
+Chiropractic was founded in 1895 by [[Daniel David Palmer|Daniel David (D.D.) Palmer]] in [[Davenport, Iowa]]. Palmer, a [[Magnetic healing|magnetic healer]], hypothesized that manual manipulation of the spine could cure disease.<ref name=Baer/> The first chiropractic patient of D.D. Palmer was [[Harvey Lillard]], a worker in the building where Palmer's office was located.<ref name=History-Primer/> He claimed that he had severely reduced hearing for 17 years, which started soon following a "pop" in his spine.<ref name=History-Primer/> A few days following his adjustment, Lillard claimed his hearing was almost completely restored.<ref name=History-Primer/> Chiropractic competed with its predecessor [[osteopathy]], another medical system based on magnetic healing and [[bonesetting]]; both systems were founded by charismatic midwesterners in opposition to the conventional medicine of the day, and both postulated that manipulation improved health.<ref name=Baer>{{cite journal |journal=Med Anthropol Q |year=1987 |volume=1 |issue=2 |pages=176–93 |title=Divergence and convergence in two systems of manual medicine: osteopathy and chiropractic in the United States |author=Baer HA |doi=10.1525/maq.1987.1.2.02a00030 }}</ref> Although initially keeping chiropractic a family secret, in 1898 Palmer began teaching it to a few students at his new [[Palmer School of Chiropractic]].<ref name=Martin/> One student, his son [[Bartlett Joshua Palmer|Bartlett Joshua (B.J.) Palmer]], became committed to promoting chiropractic, took over the Palmer School in 1906, and rapidly expanded its enrollment.<ref name=Martin>{{cite journal | author = Martin SC | title = Chiropractic and the social context of medical technology, 1895-1925 | journal = Technol Cult | volume = 34 | issue = 4 | pages = 808–34 | date = October 1993 | pmid = 11623404 | doi = 10.2307/3106416 | jstor = 3106416 }}</ref>
+Early chiropractors believed that all disease was caused by interruptions in the flow of [[innate intelligence]], a vitalistic nervous energy or life force that represented God's presence in man; chiropractic leaders often invoked religious imagery and moral traditions.<ref name=Martin/> D.D. and B.J. both seriously considered declaring chiropractic a religion, which might have provided [[Free Exercise Clause of the First Amendment|legal protection under the U.S. constitution]], but decided against it partly to avoid confusion with [[Christian Science]].<ref name=Martin/><ref>{{cite web|url=http://chiro.org/Plus/History/Persons/PalmerDD/PalmerDD's_Religion-of-Chiro.pdf|format=PDF|author= Palmer DD|title= D.D. Palmer's Religion of Chiropractic: Letter to P.W. Johnson, D.C|date=1911-05-04|accessdate=2008-06-29}}</ref> Early chiropractors also tapped into the [[Populism|Populist]] movement, emphasizing craft, hard work, competition, and advertisement, aligning themselves with the common man against intellectuals and [[Trust (19th century)|trusts]], among which they included the [[American Medical Association]] (AMA).<ref name=Martin/>
+[[File:Bartlett joshua palmer.JPG|thumb|right|169px|[[B. J. Palmer]], early developer of chiropractic]]
+Chiropractic has seen considerable [[Chiropractic controversy and criticism|controversy and criticism]].<ref name=DeVocht/><ref name=Homola>{{cite journal | author = Homola S | title = Chiropractic: history and overview of theories and methods | journal = Clin Orthop Relat Res | volume = 444 | pages = 236–42 | year = 2006 | pmid = 16446588 | doi = 10.1097/01.blo.0000200258.95865.87 }}</ref> Although D.D. and B.J. were "straight" and disdained the use of instruments, some early chiropractors, whom B.J. scornfully called "mixers", advocated the use of instruments.<ref name=Martin/> In 1910 B.J. changed course and endorsed [[X-rays]] as necessary for diagnosis; this resulted in a significant exodus from the Palmer School of the more conservative faculty and students.<ref name=Martin/> The mixer camp grew until by 1924 B.J. estimated that only 3,000 of the U.S.'s 25,000 chiropractors remained straight.<ref name=Martin/> That year, B.J.'s invention and promotion of the neurocalometer, a temperature-sensing device, was highly controversial among B.J.'s fellow straights. By the 1930s chiropractic was the largest alternative healing profession in the U.S.<ref name=Martin/>
+Chiropractors faced heavy opposition from organized medicine.<ref name=History-Primer/> Thousands of chiropractors were prosecuted for [[Health care provider#Practicing without a license|practicing medicine without a license]], and D.D. and many other chiropractors were jailed.<ref name=History-Primer/> To defend against medical statutes B.J. argued that chiropractic was separate and distinct from medicine, asserting that chiropractors "analyzed" rather than "diagnosed", and "adjusted" subluxations rather than "treated" disease.<ref name=History-Primer/> B.J. cofounded the Universal Chiropractors' Association (UCA) to provide legal services to arrested chiropractors.<ref name=History-Primer/> Although the UCA won their first test case in Wisconsin in 1907, prosecutions instigated by state medical boards became increasingly common and in many cases were successful. In response, chiropractors conducted political campaigns to secure separate licensing statutes, eventually succeeding in all fifty states, from Kansas in 1913 through Louisiana in 1974.<ref name=History-Primer/> The longstanding feud between chiropractors and [[medical doctor]]s continued for decades. The AMA labeled chiropractic an "unscientific [[cult]]" in 1966,<ref name=Chiro-PH>{{cite journal | author = Johnson C, Baird R, Dougherty PE, Globe G, Green BN, Haneline M, Hawk C, Injeyan HS, Killinger L, Kopansky-Giles D, Lisi AJ, Mior SA, Smith M | title = Chiropractic and public health: current state and future vision | journal = J Manipulative Physiol Ther | volume = 31 | issue = 6 | pages = 397–410 | year = 2008 | pmid = 18722194 | doi = 10.1016/j.jmpt.2008.07.001 }}</ref> and until 1980 advised its members that it was unethical for medical doctors to associate with "unscientific practitioners".<ref>{{cite journal | author = Cherkin D | title = AMA policy on chiropractic | journal = Am J Public Health | volume = 79 | issue = 11 | pages = 1569–70 | date = November 1989 | pmid = 2817179 | pmc = 1349822 | doi = 10.2105/AJPH.79.11.1569-a }}</ref> This culminated in a landmark 1987 decision, ''[[Wilk v. American Medical Association|Wilk v. AMA]]'', in which the court found that the AMA had engaged in unreasonable restraint of trade and conspiracy, and which ended the AMA's de facto boycott of chiropractic.<ref name=Cooper/>
+Serious research to test chiropractic theories did not begin until the 1970s, and is continuing to be hampered by [[antiscientific]] and [[pseudoscientific]] ideas that sustained the profession in its long battle with organized medicine.<ref name=History-Primer/> By the mid 1990s there was a growing scholarly interest in chiropractic, which helped efforts to improve service quality and establish clinical guidelines that recommended manual therapies for acute low back pain.<ref name=History-Primer>{{cite web |title= Chiropractic history: a primer |author= Keating JC Jr, Cleveland CS III, Menke M |url=http://ahc.memberclicks.net/assets/documents/ChiroHistoryPrimer.pdf |format=PDF |year=2005 |accessdate=2008-06-16 |publisher= Association for the History of Chiropractic}}</ref> In recent decades chiropractic gained legitimacy and greater acceptance by medical physicians and [[health plan]]s, and enjoyed a strong political base and sustained demand for services.<ref name=Cooper/> However, its future seemed uncertain: as the number of practitioners grew, [[evidence-based medicine]] insisted on treatments with demonstrated value, [[managed care]] restricted payment, and competition grew from [[massage therapist]]s and other health professions.<ref name=Cooper/> The profession responded by marketing natural products and devices more aggressively, and by reaching deeper into [[alternative medicine]] and [[primary care]].<ref name=Cooper>{{cite journal | author = Cooper RA, McKee HJ | title = Chiropractic in the United States: trends and issues | journal = Milbank Q | volume = 81 | issue = 1 | pages = 107–38, table of contents | year = 2003 | pmid = 12669653 | pmc = 2690192 | doi = 10.1111/1468-0009.00040 }}</ref>
 == Conceptual basis ==
@@ Line 135: / Line 164: @@
 In 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.<ref name=WHO-guidelines/> It is essentially a functional entity, which may influence biomechanical and neural integrity."<ref name=WHO-guidelines/> This differs from the medical definition of subluxation as a significant structural displacement, which can be seen with static imaging techniques such as [[Radio diagnostics|X-rays]].<ref name=WHO-guidelines>{{cite journal |author= World Health Organization|year=2005|title= WHO guidelines on basic training and safety in chiropractic|url=http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf|format=PDF|isbn= 92-4-159371-7|accessdate=2008-02-29}}</ref> The 2008 book ''[[Trick or Treatment]]'' states "X-rays can reveal neither the subluxations nor the innate intelligence associated with chiropractic philosophy, because they do not exist."<ref name=Trick-or-Treatment/> [[Attorneys in the United States|Attorney]] David Chapman-Smith, Secretary-General of the [[World Federation of Chiropractic]], has stated that "Medical critics have asked how there can be a subluxation if it cannot be seen on x-ray. The answer is that the chiropractic subluxation is essentially a functional entity, not structural, and is therefore no more visible on static x-ray than a [[limp]] or headache or any other functional problem."<ref>{{cite book|page=160|chapter=Principles and Goals of Chiropractic Care|title=The Chiropractic Profession: Its Education, Practice, Research and Future Directions|author=David Chapman-Smith|year=2000|publisher=NCMIC Group|isbn=1-892734-02-8}}</ref> The [[General Chiropractic Council]], the statutory regulatory body for chiropractors in the United Kingdom, states that the chiropractic vertebral subluxation complex "is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease."<ref>{{cite web| url=http://www.gcc-uk.org/files/link_file/Guidance_on_claims_made_for_the_chiropractic_VSC_18August10.pdf| format=PDF|title=Guidance on claims made for the chiropractic vertebral subluxation complex| publisher=General Chiropractic Council|accessdate=2010-09-30}}</ref>
-== Scope of practice ==
-{{Image|Treatment Table Chiropractic.jpg|thumb|right|alt=|A treatment table at a chiropractic office.}}
-Chiropractors emphasize the conservative management of the [[human musculoskeletal system|neuromusculoskeletal system]] without the use of medicines or surgery,<ref name=WHO-guidelines/> with special emphasis on the spine.<ref name=Nelson>{{cite journal | author = Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T | title = Chiropractic as spine care: a model for the profession | journal = Chiropr Osteopat | volume = 13 | issue = 1 | pages = 9 | year = 2005 | pmid = 16000175 | pmc = 1185558 | doi = 10.1186/1746-1340-13-9 | url = http://chiroandosteo.com/content/13/1/9 }}</ref> Back and neck pain are the specialties of chiropractic but many chiropractors treat ailments other than musculoskeletal issues.<ref name=Ernst-eval/> There is a range of opinions among chiropractors: some believed that treatment should be confined to the spine, or back and neck pain; others disagreed.<ref name="V-H"/> For example, while one 2009 survey of American chiropractors had found that 73% classified themselves as "back pain/musculoskeletal specialists", the label "back and neck pain specialists" was regarded by 47% of them as a ''least'' desirable description in a 2005 international survey.<ref name="V-H">{{cite journal | author = Villanueva-Russell Y | title = Caught in the crosshairs: identity and cultural authority within chiropractic | journal = Soc Sci Med | volume = 72 | issue = 11 | pages = 1826–37 | date = June 2011 | pmid = 21531061 | doi = 10.1016/j.socscimed.2011.03.038 }}</ref> Chiropractic combines aspects from mainstream and alternative medicine, and there is no agreement about how to define the profession: although chiropractors have many attributes of [[primary care]] providers, chiropractic has more of the attributes of a medical specialty like [[dentistry]] or [[podiatry]].<ref name=Meeker-Haldeman>{{cite journal | author = Meeker WC, Haldeman S | title = Chiropractic: a profession at the crossroads of mainstream and alternative medicine | journal = [[Ann Intern Med]] | volume = 136 | issue = 3 | pages = 216–27 | year = 2002 | pmid = 11827498 | doi = 10.7326/0003-4819-136-3-200202050-00010 | url = http://www.annals.org/cgi/reprint/136/3/216.pdf | format = PDF }}</ref> It has been proposed that chiropractors specialize in nonsurgical spine care, instead of attempting to also treat other problems,<ref name=Meeker-Haldeman/><ref name=Murphy-pod/> but the more expansive view of chiropractic is still widespread.<ref>{{cite journal | author = Gleberzon BJ, Cooperstein R, Perle SM | title = Can chiropractic survive its chimerical nature? | journal = J Can Chiropr Assoc | volume = 49 | issue = 2 | pages = 69–73 | year = 2005 | pmid = 17549192 | pmc = 1840015 }}</ref> Mainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be [[Alternative medicine|complementary and alternative medicine]] (CAM);<ref name=Chapman-Smith/> and a 2008 study reported that 31% of surveyed chiropractors categorized chiropractic as CAM, 27% as integrated medicine, and 12% as mainstream medicine.<ref name=Redwood-CAM>{{cite journal | author = Redwood D, Hawk C, Cambron J, Vinjamury SP, Bedard J | title = Do chiropractors identify with complementary and alternative medicine? results of a survey | journal = [[J Altern Complement Med]] | volume = 14 | issue = 4 | pages = 361–8 | year = 2008 | pmid = 18435599 | doi = 10.1089/acm.2007.0766 }}</ref>
-Chiropractic overlaps with several other forms of manual therapy, including [[massage therapy]], [[osteopathy]], physical therapy, and [[sports medicine]].<ref name=Norris/><ref>{{cite journal | author = Theberge N | title = The integration of chiropractors into healthcare teams: a case study from sport medicine | journal = Sociol Health Illn | volume = 30 | issue = 1 | pages = 19–34 | date = January 2008 | pmid = 18254831 | doi = 10.1111/j.1467-9566.2007.01026.x }}</ref> Chiropractic is autonomous from and competitive with mainstream medicine,<ref name=Pettman/> and osteopathy outside the US remains primarily a manual medical system;<ref>{{cite journal|journal= Complement Health Pract Rev|year=2006|volume=11|issue=2|pages=77–94|doi=10.1177/1533210106292467|title= The drive for legitimization by osteopathy and chiropractic in Australia: between heterodoxy and orthodoxy|author= Baer HA}}</ref> physical therapists work alongside and cooperate with mainstream medicine, and [[osteopathic medicine in the U.S.]] has merged with the medical profession.<ref name=Pettman>{{cite journal | author = Pettman E | title = A history of manipulative therapy | journal = J Man Manip Ther | volume = 15 | issue = 3 | pages = 165–74 | year = 2007 | pmid = 19066664 | pmc = 2565620 | doi = 10.1179/106698107790819873 }}</ref> Practitioners may distinguish these competing approaches through claims that, compared to other therapists, chiropractors heavily emphasize spinal manipulation, tend to use firmer manipulative techniques, and promote maintenance care; that osteopaths use a wider variety of treatment procedures; and that physical therapists emphasize machinery and exercise.<ref name=Norris>{{cite journal|author= Norris P|year=2001|title= How 'we' are different from 'them': occupational boundary maintenance in the treatment of musculo-skeletal problems|journal= Sociol Health Illn|volume=23|issue=1|pages=24–43|doi=10.1111/1467-9566.00239}}</ref>
-Chiropractic diagnosis may involve a range of methods including skeletal imaging, observational and tactile assessments, and orthopedic and neurological evaluation.<ref name=WHO-guidelines/> A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider.<ref name=Meeker-Haldeman/> Common patient management involves [[spinal manipulation]] (SM) and other manual therapies to the joints and soft tissues, rehabilitative exercises, health promotion, electrical modalities, complementary procedures, and lifestyle advice.<ref name=content-of-practice>{{cite book|chapterurl=http://chiroweb.com/archives/ahcpr/chapter3.htm|chapter= Content of practice|author= Mootz RD, Shekelle PG|year=1997|title= Chiropractic in the United States: Training, Practice, and Research|pages=67–91|editor= Cherkin DC, Mootz RD (eds.)|accessdate=2008-10-10|location= Rockville, MD|publisher= Agency for Health Care Policy and Research|oclc=39856366}} AHCPR Pub No. 98-N002.</ref>
-[[File:Dr. Heidi Bockhold Adjusts Horse.jpg|thumb|left|A chiropractic adjustment of a horse.]]
-Chiropractors are not normally licensed to write [[medical prescription]]s or perform major surgery in the United States,<ref name=Parkman/> (although [[New Mexico]] has become the first US state to allow "advanced practice" trained chiropractors  to prescribe certain medications.<ref>[http://www.nmcpr.state.nm.us/nmac/parts/title16/16.004.0015.htm Occupational And Professional Licensing, Chiropractic Practitioners, Chiropractic Advanced Practice Certification Registry]. Retrieved 2010-05-03.</ref><ref>[http://www.rld.state.nm.us/uploads/files/2010%20APC%20Formulary%281%29.pdf Occupational And Professional Licensing, Chiropractic Practitioners, Chiropractic Advanced Practice Certification Registry (PDF)] Retrieved 2010-05-03.</ref>). In the US, their scope of practice varies by state, based on inconsistent views of chiropractic care: some states, such as [[Iowa]], broadly allow treatment of "human ailments"; some, such as [[Delaware]], use vague concepts such as "transition of nerve energy" to define scope of practice; others, such as [[New Jersey]], specify a severely narrowed scope.<ref name=Morrison>{{cite journal | author = Morrison P | title = Adjusting the role of chiropractors in the United States: why narrowing chiropractor scope of practice statutes will protect patients | journal = Health Matrix Clevel | volume = 19 | issue = 2 | pages = 493–537 | year = 2009 | pmid = 19715143 }}</ref> US states also differ over whether chiropractors may conduct laboratory tests or diagnostic procedures, dispense [[dietary supplement]]s, or use other therapies such as homeopathy and acupuncture; in [[Oregon]] they can become certified to perform minor surgery and to deliver children via natural childbirth.<ref name=Parkman>{{cite journal | author = Parkman CA | title = Issues in credentialing CAM providers | journal = Case Manager | volume = 15 | issue = 4 | pages = 24–7 | year = 2004 | pmid = 15247891 | doi = 10.1016/j.casemgr.2004.05.004 }}</ref> A 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for [[over-the-counter drug]]s.<ref name=McDonald>{{cite book|author=McDonald WP, Durkin KF, Pfefer M et al.|year=2003|title=How Chiropractors Think and Practice: The Survey of North American Chiropractors|location=Ada, OH|publisher=Institute for Social Research, Ohio Northern University|isbn=0-9728055-5-9 }}{{page needed|date=May 2013}} Summarized in: {{cite journal|journal=Semin Integr Med|year=2004|volume=2|issue=3|pages=92–8|title=How chiropractors think and practice: the survey of North American chiropractors|author=McDonald WP, Durkin KF, Pfefer M|doi=10.1016/j.sigm.2004.07.002|laydate=2003-06-02|laysummary=http://chiroweb.com/archives/21/12/19.html|laysource= Dyn Chiropr }}</ref> A 2010 survey found 72% of Switzerland chiropractors judged the current allowance in Switzerland to prescribing nonprescription medication as an advantage for chiropractic treatment.<ref>{{cite journal | author = Wangler M, Zaugg B, Faigaux E | title = Medication Prescription: A Pilot Survey of Bernese Doctors of Chiropractic Practicing in Switzerland | journal = Journal of Manipulative and Physiological Therapeutics | volume = 33 | issue = 3 | pages = 231–237 | year = 2010 | pmid = 20350678 | doi = 10.1016/j.jmpt.2010.01.013 }}</ref>
-A related field, [[veterinary chiropractic]], applies manual therapies to animals and is recognized in a few US states,<ref>{{cite journal | author = Ramey DW | title = Regulatory aspects of complementary and alternative veterinary medicine | journal = J Am Vet Med Assoc | volume = 222 | issue = 12 | pages = 1679–82 | date = June 2003 | pmid = 12830858 | doi = 10.2460/javma.2003.222.1679 }}</ref> but is not recognized by the [[American Chiropractic Association]] as being chiropractic.<ref>{{cite web|url=http://amerchiro.org/level2_css.cfm?T1ID=10&T2ID=117#107|accessdate=2008-07-05|title='Veterinary' chiropractic|year=1994|author=ACA House of Delegates|publisher=American Chiropractic Association }}</ref> It remains controversial within certain segments of the veterinary, and chiropractic profession.<ref>{{cite journal |journal= Dyn Chiropr |year=2001 |volume=19 |issue=13 |url=http://www.chiroweb.com/archives/19/13/07.html |author= Kamen D |title= Politics and technique}}</ref>
-No single profession "owns" spinal manipulation and there is little consensus as to which profession should administer SM, raising concerns by chiropractors that other medical physicians could "steal" SM procedures from chiropractors.<ref name=Villanueva-Russell/> A focus on evidence-based SM research 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 | author = Villanueva-Russell Y | title = Evidence-based medicine and its implications for the profession of chiropractic | journal = [[Soc Sci Med]] | volume = 60 | issue = 3 | pages = 545–61 | year = 2005 | pmid = 15550303 | doi = 10.1016/j.socscimed.2004.05.017 }}</ref> Two U.S. states (Washington and Arkansas) prohibit physical therapists from performing SM,<ref>{{cite news |last=Anderson |first=Chantal |title=Physical therapists, chiropractors square off over bill |url=http://blog.seattletimes.nwsource.com/politicsnorthwest/2009/01/22/the_campus_is_heating_up.html |date=2009-01-22 |work=The Seattle Times |accessdate=2010-09-23}}</ref> some states allow them to do it only if they have completed advanced training in SM, and some states allow only chiropractors to perform SM, or only chiropractors and physicians. Bills to further prohibit non-chiropractors from performing SM are regularly introduced into state legislatures and are opposed by physical therapist organizations.<ref>{{cite journal |journal= DePaul J Health Care Law |year=2004 |volume=8 |issue=1 |pages=237–61 |title= State practice acts of licensed health professions: scope of practice |author= Hilliard JW, Johnson ME}}</ref>
 == Treatments ==
@@ Line 213: / Line 229: @@
 Analysis of a clinical and cost utilization data from the years 2003 to 2005 by an integrative medicine independent physician association (IPA) which looked the chiropractic services utilization found that the clinical and cost utilization of chiropractic services based on 70,274 member-months over a 7-year period decreased patient costs associate with the following use of services by 60.2% for in-hospital admissions, 59.0% for hospital days, 62.0% for outpatient surgeries and procedures, and 85% forpharmaceutical costs when compared with conventional medicine (visit to a medical doctor primary care provider) IPA performance for the same health maintenance organization product in the same geography and time frame.<ref>{{cite journal | author = Sarnat RL, Winterstein J, Cambron JA | title = Clinical Utilization and Cost Outcomes From an Integrative Medicine Independent Physician Association: An Additional 3-Year Update | journal = Journal of Manipulative and Physiological Therapeutics | volume = 30 | issue = 4 | pages = 263–269 | date = May 2007 | pmid = 17509435 | doi = 10.1016/j.jmpt.2007.03.004 | url = http://www.jmptonline.org/article/S0161-4754(07)00076-0/abstract }}</ref>
-== Education, licensing, and regulation ==
-{{Main|Chiropractic education|List of chiropractic schools}}
-Requirements vary between countries. In the U.S. chiropractors obtain a [[first professional degree]] in the field of chiropractic.<ref>{{cite web|url=http://nces.ed.gov/ipeds/glossary/?charindex=F|title= Glossary|publisher= National Center for Education Statistics, [[U.S. Dept. of Education]]|accessdate=2009-06-05}}</ref> Chiropractors often argue that this education is as good as or better than medical physicians', but most chiropractic training is confined to classrooms with much time spent learning theory, adjustment, and [[marketing]].<ref name=Morrison>{{cite journal | author = Morrison P | title = Adjusting the role of chiropractors in the United States: why narrowing chiropractor scope of practice statutes will protect patients | journal = Health Matrix Clevel | volume = 19 | issue = 2 | pages = 493–537 | year = 2009 | pmid = 19715143 }}</ref> Chiropractic curricula in the U.S. have been criticized for failing to meet generally accepted standards of evidence-based medicine.<ref>{{cite journal | author = Marcus DM, McCullough L | title = An evaluation of the evidence in "evidence-based" integrative medicine programs | journal = Acad Med | volume = 84 | issue = 9 | pages = 1229–34 | year = 2009 | pmid = 19707062 | doi = 10.1097/ACM.0b013e3181b185f4 }}</ref> The curriculum content of North American chiropractic and medical colleges with regard to basic and clinical sciences has been more similar than not, both in the kinds of subjects offered and in the time assigned to each subject.<ref>{{cite journal | author = Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M | title = A comparative study of chiropractic and medical education | journal = Altern Ther Health Med | volume = 4 | issue = 5 | pages = 64–75 | date = September 1998 | pmid = 9737032 }}</ref> Accredited chiropractic programs in the U.S. require that applicants have 90 semester hours of undergraduate education with a [[grade point average]] of at least 3.0 on a 4.0 scale. Many programs require at least three years of undergraduate education, and more are requiring a bachelor's degree.<ref>{{cite web|url=http://www.chirocolleges.org/prospective_students.html|title=Prospective students|publisher=Association of Chiropractic Colleges|accessdate=2009-07-23}}</ref> Canada requires a minimum three years of undergraduate education for applicants, and at least 4200 instructional hours (or the equivalent) of full‐time chiropractic education for matriculation through an accredited chiropractic program.<ref>{{cite web|url=http://chirofed.ca/english/pdf/Standards_for_Doctor_of_Chiropractic_Programmes.pdf|format=PDF|title=Standards for Doctor of Chiropractic Programmes|date=2008-04-05|publisher=[[Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards]]|accessdate=2009-04-23}}{{dead link|date=June 2012}}</ref> Graduates of the [[Canadian Memorial Chiropractic College]] (CMCC) are formally recognized to have at least 7–8 years of university level education.<ref name=CMCCMediaRelations>{{cite web |url=http://www.cmcc.ca/Media_Relations.html |title= Media Relations |publisher= [[Canadian Memorial Chiropractic College]] |accessdate=2010-12-14}}</ref><ref name=GovOntario>{{cite web |url=http://www.edu.gov.on.ca/eng/general/postsec/degreegr.html |title=Degree Authority in Ontario |publisher=Ontario Ministry of Training, Colleges and Universities |accessdate=2010-12-14}}</ref> The [[World Health Organization]] (WHO) guidelines suggest three major full-time educational paths culminating in either a [[Doctor of Chiropractic|DC, DCM, BSc, or MSc]] degree. Besides the full-time paths, they also suggest a conversion program for people with other health care education and limited training programs for regions where no legislation governs chiropractic.<ref name=WHO-guidelines/>
+=== International reception ===
-Upon graduation, there may be a requirement to pass national, state, or provincial board examinations before being [[licensed]] to practice in a particular jurisdiction.<ref>{{cite web |url=http://life.edu/node/94 |title= State chiropractic licensure |accessdate=2009-06-05 |year=2008 |publisher= [[Life University]]}}</ref><ref>{{cite web |url=http://chirofed.ca/english/becoming.html |title= Becoming a chiropractor |publisher=Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards |accessdate=2009-06-05}}</ref> Depending on the location, [[Continuing education#Continuing education for professionals|continuing education]] may be required to renew these licenses.<ref>{{cite journal | author = Grod JP | title = Continuing health education in Canada | journal = [[J Can Chiropr Assoc]] | volume = 50 | issue = 1 | pages = 14–7 | year = 2006 | pmid = 17549163 | pmc = 1839972 }}</ref><ref>{{cite journal | author = Stuber KJ, Grod JP, Smith DL, Powers P | title = An online survey of chiropractors' opinions of Continuing Education | journal = Chiropr Osteopat | volume = 13 | issue = 1 | pages = 22 | year = 2005 | pmid = 16242035 | pmc = 1282582 | doi = 10.1186/1746-1340-13-22 | url = http://chiroandosteo.com/content/13/1/22 }}</ref> Specialty training is available through part-time postgraduate education programs such as chiropractic [[orthopedics]] and sports chiropractic, and through full-time residency programs such as [[radiology]] or [[orthopedics]].<ref>{{cite book |chapterurl=http://chiroweb.com/archives/ahcpr/chapter3.htm |chapter= Chiropractic training |author= Coulter ID, Adams AH, Sandefur R |year=1997 |title= Chiropractic in the United States: Training, Practice, and Research |pages=17–28 |editor= Cherkin DC, Mootz RD (eds.) |url=http://curziechiropractic.com/forms/ahcpr/uschiros.pdf |accessdate=2008-05-11 |location= Rockville, MD |publisher= Agency for Health Care Policy and Research |oclc=39856366}} AHCPR Pub No. 98-N002.</ref>
-In the U.S., chiropractic schools are accredited through the [[Council on Chiropractic Education]] (CCE) while the General Chiropractic Council (GCC) is the statutory governmental body responsible for the regulation of chiropractic in the UK.<ref>{{cite web |title=The Council on Chiropractic Education (CCE) |url=http://cce-usa.org/ |publisher= The Council on Chiropractic Education |accessdate=2008-07-05 }}</ref><ref>{{cite web |url=http://www.gcc-uk.org/page.cfm |title=The General Chiropractic Council |format= |work= |accessdate=2008-07-26 }}</ref> The U.S. CCE requires a mixing curriculum, which means a straight-educated chiropractor may not be eligible for licensing in states requiring CCE accreditation.<ref name=Morrison/> CCEs in the U.S., Canada, Australia and Europe have joined to form CCE-International (CCE-I) as a model of accreditation standards with the goal of having credentials portable internationally.<ref name=CCEI>{{cite web| url = http://www.cceintl.org/About_Us.html| title = About Us| accessdate = 2010-09-30| publisher = [[Councils on Chiropractic Education International]]}}</ref> Today, there are 18 accredited Doctor of Chiropractic programs in the U.S.,<ref>{{cite web|title=Accredited Doctor of Chiropractic programs|url=http://cce-usa.org/adcp.php|publisher=The Council on Chiropractic Education|accessdate=2008-02-22|archiveurl = http://web.archive.org/web/20080214031937/http://www.cce-usa.org/adcp.php|archivedate = 2008-02-14}}</ref> 2 in Canada,<ref>{{cite web|url=http://chirofed.ca/english/accreditation.html|title=Accreditation of educational programmes|publisher=Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards|accessdate=2009-06-05 }}</ref> 6 in Australasia,<ref name=CCEA>{{cite web| url = http://www.ccea.com.au/Accreditation/Program%20Accreditation%20Status.htm| title = Program Accreditation Status| accessdate = 2010-09-30| publisher = Council on Chiropractic Education Australasia}}</ref> and 5 in Europe.<ref>{{cite web|url=http://cce-europe.org/institutions.php|title=Institutions holding ''Accredited Status'' with the ECCE|publisher=[[European Council On Chiropractic Education]]|date=2009-07-23|accessdate=2009-07-25 }}{{dead link|date=June 2012}}</ref> All but one of the chiropractic colleges in the U.S. are privately funded, but in several other countries they are in government-sponsored universities and colleges.<ref name=DeVocht/> Of the two chiropractic colleges in Canada, one is publicly funded ([[UQTR]]) and one is privately funded ([[CMCC]]). In 2005, CMCC was granted the privilege of offering a professional health care degree under the Post-secondary Education Choice and Excellence Act, which sets the program within the hierarchy of education in Canada as comparable to that of other primary contact health care professions such as medicine, dentistry and optometry.<ref name=CMCCMediaRelations/><ref name=GovOntario/>
-Regulatory colleges and chiropractic boards in the U.S., Canada, Mexico, and Australia are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.<ref>{{cite web| url = http://www.chiropracticcanada.ca/en-us/FactsFAQs.aspx| title = Canadian Chiropractic Association FAQs| accessdate = 2010-10-02| publisher = [[Canadian Chiropractic Association]]}}{{dead link|date=January 2013}}</ref><ref>{{cite web| url = http://pacex.fclb.org/Information/FAQ/tabid/364/Default.aspx| title = Federation of Chiropractic Licensing Boards FAQ| accessdate = 2010-10-02| publisher = [[Federation of Chiropractic Licensing Boards]]}}</ref> There are an estimated 49,000 chiropractors in the U.S. (2008),<ref name=BLS>{{cite web|url=http://www.bls.gov/oco/ocos071.htm|title=Chiropractors|publisher= [[U.S. Bureau of Labor Statistics]]|accessdate=2008-07-05|year=2007}}</ref> 6,500 in Canada (2010),<ref>{{cite web| url = http://www.chiropracticcanada.ca/en-us/AboutUs/ChiropracticInCanada.aspx| title = Canadian Chiropractic Association: Chiropractic in Canada| accessdate = 2010-10-02| publisher = [[Canadian Chiropractic Association]]}}</ref> 2,500 in Australia (2000),<ref name=Campbell/> and 1,500 in the UK (2000).<ref>{{cite book|title= The Chiropractic Profession: Its Education, Practice, Research and Future Directions|author= Chapman-Smith D|year=2000|chapter= Current status of the profession|isbn=1-892734-02-8|publisher=[[NCMIC]]|location= West Des Moines, IA}}</ref>
-A 2008 commentary proposed that the chiropractic profession actively regulate itself to combat abuse, fraud, and [[quackery]], which are more prevalent in chiropractic than in other health care professions, violating the [[social contract]] between patients and physicians.<ref name=Murphy-pod/>
-The fourth year of chiropractic education persistently showed the highest stress levels.<ref name=Hester2013/> Every student, irrespective of year, experienced different ranges of stress when studying.<ref name=Hester2013>{{cite journal | author = Hester H, Cunliffe C, Hunnisett A | title = Stress in chiropractic education: a student survey of a five-year course | journal = J Chiropr Educ | volume = 27 | issue = 2 | pages = 147–51 | year = 2013 | pmid = 23957319 | pmc = 3791907 | doi = 10.7899/JCE-13-4 }}</ref> The chiropractic leaders and colleges have had internal struggles.<ref name=Johnson2010/> Rather than cooperation, there has been infighting between different factions.<ref name=Johnson2010/> A number of actions were posturing due to the confidential nature of the chiropractic colleges in an attempt to enroll students.<ref name=Johnson2010>{{cite journal | author = Johnson C | title = Reflecting on 115 years: the chiropractic profession's philosophical path | journal = J Chiropr Humanit | volume = 17 | issue = 1 | pages = 1–5 | year = 2010 | month = December | pmid = 22693471 | pmc = 3342796 | doi = 10.1016/j.echu.2010.11.001 }}</ref>
-=== Ethics ===
-{{Main|Chiropractic professional ethics}}
-The chiropractic oath is a modern variation of the classical [[Hippocratic Oath]] historically taken by [[physician]]s and other healthcare professionals swearing to practice their professions ethically.<ref>{{cite journal | author = Simpson JK, Losco B, Young KJ | title = Development of the murdoch chiropractic graduate pledge | journal = The Journal of chiropractic education | volume = 24 | issue = 2 | pages = 175-86 | year = 2010 | pmid = 21048880 | pmc = 2967342 | doi=10.7899/1042-5055-24.2.175}}</ref> The [[American Chiropractic Association]] (ACA) has an ethical code "based upon the acknowledgement that the social contract dictates the profession’s responsibilities to the patient, the public, and the profession; and upholds the fundamental principle that the paramount purpose of the chiropractic doctor's professional services shall be to benefit the patient."<ref>{{Cite web|author=Staff|title=Code of Ethics|publisher=[[American Chiropractic Association]]|url=http://www.acatoday.org/content_css.cfm?CID=719}}</ref> The [[International Chiropractor's Association]] (ICA) also has a set of professional canons.<ref>{{Cite web|author=Staff|title=ICA code of Ethics|publisher=[[International Chiropractor's Association]]|url=http://www.chiropractic.org/ica/ethics.htm}}</ref>
-According to a 2006 Gallup poll of U.S. adults, when asked how they would "rate the honesty and ethical standards of people in these different fields", chiropractic compared unfavorably with mainstream medicine. When chiropractic was rated, it "rated dead last amongst healthcare professions". While 84% of respondents considered nurses' ethics "very high" or "high," only 36% felt that way about chiropractors. Other healthcare professions ranged from 38% for psychiatrists, to 62% for dentists, 69% for medical doctors, 71% for veterinarians, and 73% for druggists or pharmacists.<ref name=Murphy-pod/><ref>{{cite journal |journal=Dynamic Chiropractic |volume=25 |issue=3 |date=29 January 2007 |title=Gallup Poll: Americans have low opinion of chiropractors' honesty and ethics |url=http://dynamicchiropractic.com/mpacms/dc/article.php?id=52038}}</ref><ref>{{cite news |title=USA TODAY/Gallup poll |url=http://usatoday.com/news/polls/tables/live/2006-12-11-ethics.htm |work=[[USA Today]] |date=11 December 2006}}</ref><ref name=Gallup_chart>[http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx Gallup chart]</ref>
-Chiropractors, especially in America, have a reputation for unnecessarily treating patients.<ref name=Trick-or-Treatment/> In many circumstances the focus seems to be put on economics instead of health care.<ref name=Trick-or-Treatment/> Sustained chiropractic care is promoted as a preventative tool, but unnecessary manipulation could possibly present a risk to patients.<ref name=Ernst-eval/> Some chiropractors are concerned by the routine unjustified claims chiropractors have made.<ref name=Ernst-eval/> A 2010 analysis of chiropractic websites found the majority of chiropractors and their associations made claims of effectiveness not supported by scientific evidence, while 28% of chiropractor websites advocate lower back pain care, which has some sound evidence.<ref>{{cite journal | author = Ernst E, Gilbey A | title = Chiropractic claims in the English-speaking world | journal = The New Zealand medical journal | volume = 123 | issue = 1312 | pages = 36–44 | year = 2010 | pmid = 20389316 }}</ref>
-In 2009, a [[backlash (sociology)|backlash]] to the [[Simon Singh#Chiropractic lawsuit|libel suit filed by the British Chiropractic Association (BCA) against Simon Singh]], has inspired the filing of formal complaints of false advertising against more than 500 individual chiropractors within one 24 hour period,<ref name=withdraw>{{cite web |url=http://blogs.nature.com/news/thegreatbeyond/2009/06/chiropractic_group_advises_mem_1.html |title=The Great Beyond: Chiropractic group advises members to 'withdraw from the battleground' |publisher=Nature.com |author=Lucas Laursen |accessdate=20 June 2009}}</ref><ref>{{cite web |url=http://blogs.nature.com/news/thegreatbeyond/2009/06/chiropractic_complainers_ident.html |title=The Great Beyond: Complaints converge on chiropractors |publisher=Nature.com |author=Lucas Laursen |accessdate=20 June 2009}}</ref> prompting the McTimoney Chiropractic Association to write to its members advising them to remove leaflets that make claims about whiplash and colic from their practice, to be wary of new patients and telephone inquiries, and telling their members: "If you have a website, take it down NOW." and "Finally, we strongly suggest you do NOT discuss this with others, especially patients."<ref name=withdraw/> An editorial in ''Nature'' has suggested that the BCA may be trying to suppress debate and that this use of British libel law is a burden on the right to freedom of expression, which is protected by the [[European Convention on Human Rights]].<ref>{{cite journal | author =  | title = Unjust burdens of proof | journal = Nature | volume = 459 | issue = 7248 | page = 751 | date = June 2009 | pmid = 19516290 | doi = 10.1038/459751a }}</ref> The libel case ended with the BCA withdrawing its suit in 2010.<ref name="news">{{cite news|title=Case dropped against Simon Singh|author=Pallab Ghosh|url=http://news.bbc.co.uk/1/hi/sci/tech/8621880.stm|publisher=BBC News|date=2010-04-15}}</ref><ref name="Mark Henderson">{{cite news|publisher=Times Online|url=http://business.timesonline.co.uk/tol/business/law/article7098157.ece|title=Science writer Simon Singh wins bitter libel battle|author=Mark Henderson|location=London|date=2010-04-16}}</ref>
-== International reception ==
 Chiropractic is established in the [[United States|U.S.]], [[Canada]], and [[Australia]], and is present to a lesser extent in many other countries.<ref name=global-strategy>{{cite web |url=http://chiropracticdiplomatic.com/strategies/global_strategy.pdf |format=PDF |title=Global professional strategy for chiropractic |author=Tetrault M |publisher=Chiropractic Diplomatic Corps |year=2004 |accessdate=2008-04-18 }}</ref> It is viewed as a marginal [[complementary and alternative medicine]] [[health care profession]].<ref name="V-H"/>
@@ Line 262: / Line 254: @@
 In the U.S., most states require insurers to cover chiropractic care, and most [[HMO]]s cover these services.<ref name=Kemper>{{cite journal | author = Kemper KJ, Vohra S, Walls R | title = American Academy of Pediatrics. The use of complementary and alternative medicine in pediatrics | journal = Pediatrics | volume = 122 | issue = 6 | pages = 1374–86 | date = December 2008 | pmid = 19047261 | doi = 10.1542/peds.2008-2173 | last5 = Provisional Section On Complementary }}</ref> In Canada, there is lack of coverage under the universal public health insurance system.<ref>{{cite journal | author = Garner MJ, Birmingham M, Aker P, Moher D, Balon J, Keenan D, Manga P | title = Developing integrative primary healthcare delivery: adding a chiropractor to the team | journal = Explore (NY) | volume = 4 | issue = 1 | pages = 18–24 | year = 2008 | pmid = 18194787 | doi = 10.1016/j.explore.2007.10.003 }}</ref>
-== History ==
-{{Main|Chiropractic history}}
-[[File:Harvey Lillard.jpg|thumb|left|169px|[[William Harvey Lillard|Harvey Lillard]], first chiropractic patient]]
-[[Image:Daniel David Palmer.jpg|thumb|upright|alt=Half-length sitting portrait of man in his fifties with large gray beard and moustache, wearing coat and vest|[[Daniel David Palmer|D.D. Palmer]], founder of chiropractic]]
-Chiropractic was founded in 1895 by [[Daniel David Palmer|Daniel David (D.D.) Palmer]] in [[Davenport, Iowa]]. Palmer, a [[Magnetic healing|magnetic healer]], hypothesized that manual manipulation of the spine could cure disease.<ref name=Baer/> The first chiropractic patient of D.D. Palmer was [[Harvey Lillard]], a worker in the building where Palmer's office was located.<ref name=History-Primer/> He claimed that he had severely reduced hearing for 17 years, which started soon following a "pop" in his spine.<ref name=History-Primer/> A few days following his adjustment, Lillard claimed his hearing was almost completely restored.<ref name=History-Primer/> Chiropractic competed with its predecessor [[osteopathy]], another medical system based on magnetic healing and [[bonesetting]]; both systems were founded by charismatic midwesterners in opposition to the conventional medicine of the day, and both postulated that manipulation improved health.<ref name=Baer>{{cite journal |journal=Med Anthropol Q |year=1987 |volume=1 |issue=2 |pages=176–93 |title=Divergence and convergence in two systems of manual medicine: osteopathy and chiropractic in the United States |author=Baer HA |doi=10.1525/maq.1987.1.2.02a00030 }}</ref> Although initially keeping chiropractic a family secret, in 1898 Palmer began teaching it to a few students at his new [[Palmer School of Chiropractic]].<ref name=Martin/> One student, his son [[Bartlett Joshua Palmer|Bartlett Joshua (B.J.) Palmer]], became committed to promoting chiropractic, took over the Palmer School in 1906, and rapidly expanded its enrollment.<ref name=Martin>{{cite journal | author = Martin SC | title = Chiropractic and the social context of medical technology, 1895-1925 | journal = Technol Cult | volume = 34 | issue = 4 | pages = 808–34 | date = October 1993 | pmid = 11623404 | doi = 10.2307/3106416 | jstor = 3106416 }}</ref>
+==Training ==
-Early chiropractors believed that all disease was caused by interruptions in the flow of [[innate intelligence]], a vitalistic nervous energy or life force that represented God's presence in man; chiropractic leaders often invoked religious imagery and moral traditions.<ref name=Martin/> D.D. and B.J. both seriously considered declaring chiropractic a religion, which might have provided [[Free Exercise Clause of the First Amendment|legal protection under the U.S. constitution]], but decided against it partly to avoid confusion with [[Christian Science]].<ref name=Martin/><ref>{{cite web|url=http://chiro.org/Plus/History/Persons/PalmerDD/PalmerDD's_Religion-of-Chiro.pdf|format=PDF|author= Palmer DD|title= D.D. Palmer's Religion of Chiropractic: Letter to P.W. Johnson, D.C|date=1911-05-04|accessdate=2008-06-29}}</ref> Early chiropractors also tapped into the [[Populism|Populist]] movement, emphasizing craft, hard work, competition, and advertisement, aligning themselves with the common man against intellectuals and [[Trust (19th century)|trusts]], among which they included the [[American Medical Association]] (AMA).<ref name=Martin/>
+{{Main|Chiropractic education|List of chiropractic schools}}
-[[File:Bartlett joshua palmer.JPG|thumb|right|169px|[[B. J. Palmer]], early developer of chiropractic]]
+Requirements vary between countries. In the U.S. chiropractors obtain a [[first professional degree]] in the field of chiropractic.<ref>{{cite web|url=http://nces.ed.gov/ipeds/glossary/?charindex=F|title= Glossary|publisher= National Center for Education Statistics, [[U.S. Dept. of Education]]|accessdate=2009-06-05}}</ref> Chiropractors often argue that this education is as good as or better than medical physicians', but most chiropractic training is confined to classrooms with much time spent learning theory, adjustment, and [[marketing]].<ref name=Morrison>{{cite journal | author = Morrison P | title = Adjusting the role of chiropractors in the United States: why narrowing chiropractor scope of practice statutes will protect patients | journal = Health Matrix Clevel | volume = 19 | issue = 2 | pages = 493–537 | year = 2009 | pmid = 19715143 }}</ref> Chiropractic curricula in the U.S. have been criticized for failing to meet generally accepted standards of evidence-based medicine.<ref>{{cite journal | author = Marcus DM, McCullough L | title = An evaluation of the evidence in "evidence-based" integrative medicine programs | journal = Acad Med | volume = 84 | issue = 9 | pages = 1229–34 | year = 2009 | pmid = 19707062 | doi = 10.1097/ACM.0b013e3181b185f4 }}</ref> The curriculum content of North American chiropractic and medical colleges with regard to basic and clinical sciences has been more similar than not, both in the kinds of subjects offered and in the time assigned to each subject.<ref>{{cite journal | author = Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M | title = A comparative study of chiropractic and medical education | journal = Altern Ther Health Med | volume = 4 | issue = 5 | pages = 64–75 | date = September 1998 | pmid = 9737032 }}</ref> Accredited chiropractic programs in the U.S. require that applicants have 90 semester hours of undergraduate education with a [[grade point average]] of at least 3.0 on a 4.0 scale. Many programs require at least three years of undergraduate education, and more are requiring a bachelor's degree.<ref>{{cite web|url=http://www.chirocolleges.org/prospective_students.html|title=Prospective students|publisher=Association of Chiropractic Colleges|accessdate=2009-07-23}}</ref> Canada requires a minimum three years of undergraduate education for applicants, and at least 4200 instructional hours (or the equivalent) of full‐time chiropractic education for matriculation through an accredited chiropractic program.<ref>{{cite web|url=http://chirofed.ca/english/pdf/Standards_for_Doctor_of_Chiropractic_Programmes.pdf|format=PDF|title=Standards for Doctor of Chiropractic Programmes|date=2008-04-05|publisher=[[Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards]]|accessdate=2009-04-23}}{{dead link|date=June 2012}}</ref> Graduates of the [[Canadian Memorial Chiropractic College]] (CMCC) are formally recognized to have at least 7–8 years of university level education.<ref name=CMCCMediaRelations>{{cite web |url=http://www.cmcc.ca/Media_Relations.html |title= Media Relations |publisher= [[Canadian Memorial Chiropractic College]] |accessdate=2010-12-14}}</ref><ref name=GovOntario>{{cite web |url=http://www.edu.gov.on.ca/eng/general/postsec/degreegr.html |title=Degree Authority in Ontario |publisher=Ontario Ministry of Training, Colleges and Universities |accessdate=2010-12-14}}</ref> The [[World Health Organization]] (WHO) guidelines suggest three major full-time educational paths culminating in either a [[Doctor of Chiropractic|DC, DCM, BSc, or MSc]] degree. Besides the full-time paths, they also suggest a conversion program for people with other health care education and limited training programs for regions where no legislation governs chiropractic.<ref name=WHO-guidelines/>
-Chiropractic has seen considerable [[Chiropractic controversy and criticism|controversy and criticism]].<ref name=DeVocht/><ref name=Homola>{{cite journal | author = Homola S | title = Chiropractic: history and overview of theories and methods | journal = Clin Orthop Relat Res | volume = 444 | pages = 236–42 | year = 2006 | pmid = 16446588 | doi = 10.1097/01.blo.0000200258.95865.87 }}</ref> Although D.D. and B.J. were "straight" and disdained the use of instruments, some early chiropractors, whom B.J. scornfully called "mixers", advocated the use of instruments.<ref name=Martin/> In 1910 B.J. changed course and endorsed [[X-rays]] as necessary for diagnosis; this resulted in a significant exodus from the Palmer School of the more conservative faculty and students.<ref name=Martin/> The mixer camp grew until by 1924 B.J. estimated that only 3,000 of the U.S.'s 25,000 chiropractors remained straight.<ref name=Martin/> That year, B.J.'s invention and promotion of the neurocalometer, a temperature-sensing device, was highly controversial among B.J.'s fellow straights. By the 1930s chiropractic was the largest alternative healing profession in the U.S.<ref name=Martin/>
+Upon graduation, there may be a requirement to pass national, state, or provincial board examinations before being [[licensed]] to practice in a particular jurisdiction.<ref>{{cite web |url=http://life.edu/node/94 |title= State chiropractic licensure |accessdate=2009-06-05 |year=2008 |publisher= [[Life University]]}}</ref><ref>{{cite web |url=http://chirofed.ca/english/becoming.html |title= Becoming a chiropractor |publisher=Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards |accessdate=2009-06-05}}</ref> Depending on the location, [[Continuing education#Continuing education for professionals|continuing education]] may be required to renew these licenses.<ref>{{cite journal | author = Grod JP | title = Continuing health education in Canada | journal = [[J Can Chiropr Assoc]] | volume = 50 | issue = 1 | pages = 14–7 | year = 2006 | pmid = 17549163 | pmc = 1839972 }}</ref><ref>{{cite journal | author = Stuber KJ, Grod JP, Smith DL, Powers P | title = An online survey of chiropractors' opinions of Continuing Education | journal = Chiropr Osteopat | volume = 13 | issue = 1 | pages = 22 | year = 2005 | pmid = 16242035 | pmc = 1282582 | doi = 10.1186/1746-1340-13-22 | url = http://chiroandosteo.com/content/13/1/22 }}</ref> Specialty training is available through part-time postgraduate education programs such as chiropractic [[orthopedics]] and sports chiropractic, and through full-time residency programs such as [[radiology]] or [[orthopedics]].<ref>{{cite book |chapterurl=http://chiroweb.com/archives/ahcpr/chapter3.htm |chapter= Chiropractic training |author= Coulter ID, Adams AH, Sandefur R |year=1997 |title= Chiropractic in the United States: Training, Practice, and Research |pages=17–28 |editor= Cherkin DC, Mootz RD (eds.) |url=http://curziechiropractic.com/forms/ahcpr/uschiros.pdf |accessdate=2008-05-11 |location= Rockville, MD |publisher= Agency for Health Care Policy and Research |oclc=39856366}} AHCPR Pub No. 98-N002.</ref>
-Chiropractors faced heavy opposition from organized medicine.<ref name=History-Primer/> Thousands of chiropractors were prosecuted for [[Health care provider#Practicing without a license|practicing medicine without a license]], and D.D. and many other chiropractors were jailed.<ref name=History-Primer/> To defend against medical statutes B.J. argued that chiropractic was separate and distinct from medicine, asserting that chiropractors "analyzed" rather than "diagnosed", and "adjusted" subluxations rather than "treated" disease.<ref name=History-Primer/> B.J. cofounded the Universal Chiropractors' Association (UCA) to provide legal services to arrested chiropractors.<ref name=History-Primer/> Although the UCA won their first test case in Wisconsin in 1907, prosecutions instigated by state medical boards became increasingly common and in many cases were successful. In response, chiropractors conducted political campaigns to secure separate licensing statutes, eventually succeeding in all fifty states, from Kansas in 1913 through Louisiana in 1974.<ref name=History-Primer/> The longstanding feud between chiropractors and [[medical doctor]]s continued for decades. The AMA labeled chiropractic an "unscientific [[cult]]" in 1966,<ref name=Chiro-PH>{{cite journal | author = Johnson C, Baird R, Dougherty PE, Globe G, Green BN, Haneline M, Hawk C, Injeyan HS, Killinger L, Kopansky-Giles D, Lisi AJ, Mior SA, Smith M | title = Chiropractic and public health: current state and future vision | journal = J Manipulative Physiol Ther | volume = 31 | issue = 6 | pages = 397–410 | year = 2008 | pmid = 18722194 | doi = 10.1016/j.jmpt.2008.07.001 }}</ref> and until 1980 advised its members that it was unethical for medical doctors to associate with "unscientific practitioners".<ref>{{cite journal | author = Cherkin D | title = AMA policy on chiropractic | journal = Am J Public Health | volume = 79 | issue = 11 | pages = 1569–70 | date = November 1989 | pmid = 2817179 | pmc = 1349822 | doi = 10.2105/AJPH.79.11.1569-a }}</ref> This culminated in a landmark 1987 decision, ''[[Wilk v. American Medical Association|Wilk v. AMA]]'', in which the court found that the AMA had engaged in unreasonable restraint of trade and conspiracy, and which ended the AMA's de facto boycott of chiropractic.<ref name=Cooper/>
+In the U.S., chiropractic schools are accredited through the [[Council on Chiropractic Education]] (CCE) while the General Chiropractic Council (GCC) is the statutory governmental body responsible for the regulation of chiropractic in the UK.<ref>{{cite web |title=The Council on Chiropractic Education (CCE) |url=http://cce-usa.org/ |publisher= The Council on Chiropractic Education |accessdate=2008-07-05 }}</ref><ref>{{cite web |url=http://www.gcc-uk.org/page.cfm |title=The General Chiropractic Council |format= |work= |accessdate=2008-07-26 }}</ref> The U.S. CCE requires a mixing curriculum, which means a straight-educated chiropractor may not be eligible for licensing in states requiring CCE accreditation.<ref name=Morrison/> CCEs in the U.S., Canada, Australia and Europe have joined to form CCE-International (CCE-I) as a model of accreditation standards with the goal of having credentials portable internationally.<ref name=CCEI>{{cite web| url = http://www.cceintl.org/About_Us.html| title = About Us| accessdate = 2010-09-30| publisher = [[Councils on Chiropractic Education International]]}}</ref> Today, there are 18 accredited Doctor of Chiropractic programs in the U.S.,<ref>{{cite web|title=Accredited Doctor of Chiropractic programs|url=http://cce-usa.org/adcp.php|publisher=The Council on Chiropractic Education|accessdate=2008-02-22|archiveurl = http://web.archive.org/web/20080214031937/http://www.cce-usa.org/adcp.php|archivedate = 2008-02-14}}</ref> 2 in Canada,<ref>{{cite web|url=http://chirofed.ca/english/accreditation.html|title=Accreditation of educational programmes|publisher=Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards|accessdate=2009-06-05 }}</ref> 6 in Australasia,<ref name=CCEA>{{cite web| url = http://www.ccea.com.au/Accreditation/Program%20Accreditation%20Status.htm| title = Program Accreditation Status| accessdate = 2010-09-30| publisher = Council on Chiropractic Education Australasia}}</ref> and 5 in Europe.<ref>{{cite web|url=http://cce-europe.org/institutions.php|title=Institutions holding ''Accredited Status'' with the ECCE|publisher=[[European Council On Chiropractic Education]]|date=2009-07-23|accessdate=2009-07-25 }}{{dead link|date=June 2012}}</ref> All but one of the chiropractic colleges in the U.S. are privately funded, but in several other countries they are in government-sponsored universities and colleges.<ref name=DeVocht/> Of the two chiropractic colleges in Canada, one is publicly funded ([[UQTR]]) and one is privately funded ([[CMCC]]). In 2005, CMCC was granted the privilege of offering a professional health care degree under the Post-secondary Education Choice and Excellence Act, which sets the program within the hierarchy of education in Canada as comparable to that of other primary contact health care professions such as medicine, dentistry and optometry.<ref name=CMCCMediaRelations/><ref name=GovOntario/>
-Serious research to test chiropractic theories did not begin until the 1970s, and is continuing to be hampered by [[antiscientific]] and [[pseudoscientific]] ideas that sustained the profession in its long battle with organized medicine.<ref name=History-Primer/> By the mid 1990s there was a growing scholarly interest in chiropractic, which helped efforts to improve service quality and establish clinical guidelines that recommended manual therapies for acute low back pain.<ref name=History-Primer>{{cite web |title= Chiropractic history: a primer |author= Keating JC Jr, Cleveland CS III, Menke M |url=http://ahc.memberclicks.net/assets/documents/ChiroHistoryPrimer.pdf |format=PDF |year=2005 |accessdate=2008-06-16 |publisher= Association for the History of Chiropractic}}</ref> In recent decades chiropractic gained legitimacy and greater acceptance by medical physicians and [[health plan]]s, and enjoyed a strong political base and sustained demand for services.<ref name=Cooper/> However, its future seemed uncertain: as the number of practitioners grew, [[evidence-based medicine]] insisted on treatments with demonstrated value, [[managed care]] restricted payment, and competition grew from [[massage therapist]]s and other health professions.<ref name=Cooper/> The profession responded by marketing natural products and devices more aggressively, and by reaching deeper into [[alternative medicine]] and [[primary care]].<ref name=Cooper>{{cite journal | author = Cooper RA, McKee HJ | title = Chiropractic in the United States: trends and issues | journal = Milbank Q | volume = 81 | issue = 1 | pages = 107–38, table of contents | year = 2003 | pmid = 12669653 | pmc = 2690192 | doi = 10.1111/1468-0009.00040 }}</ref>
+Regulatory colleges and chiropractic boards in the U.S., Canada, Mexico, and Australia are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.<ref>{{cite web| url = http://www.chiropracticcanada.ca/en-us/FactsFAQs.aspx| title = Canadian Chiropractic Association FAQs| accessdate = 2010-10-02| publisher = [[Canadian Chiropractic Association]]}}{{dead link|date=January 2013}}</ref><ref>{{cite web| url = http://pacex.fclb.org/Information/FAQ/tabid/364/Default.aspx| title = Federation of Chiropractic Licensing Boards FAQ| accessdate = 2010-10-02| publisher = [[Federation of Chiropractic Licensing Boards]]}}</ref> There are an estimated 49,000 chiropractors in the U.S. (2008),<ref name=BLS>{{cite web|url=http://www.bls.gov/oco/ocos071.htm|title=Chiropractors|publisher= [[U.S. Bureau of Labor Statistics]]|accessdate=2008-07-05|year=2007}}</ref> 6,500 in Canada (2010),<ref>{{cite web| url = http://www.chiropracticcanada.ca/en-us/AboutUs/ChiropracticInCanada.aspx| title = Canadian Chiropractic Association: Chiropractic in Canada| accessdate = 2010-10-02| publisher = [[Canadian Chiropractic Association]]}}</ref> 2,500 in Australia (2000),<ref name=Campbell/> and 1,500 in the UK (2000).<ref>{{cite book|title= The Chiropractic Profession: Its Education, Practice, Research and Future Directions|author= Chapman-Smith D|year=2000|chapter= Current status of the profession|isbn=1-892734-02-8|publisher=[[NCMIC]]|location= West Des Moines, IA}}</ref>
-== Public health ==
+A 2008 commentary proposed that the chiropractic profession actively regulate itself to combat abuse, fraud, and [[quackery]], which are more prevalent in chiropractic than in other health care professions, violating the [[social contract]] between patients and physicians.<ref name=Murphy-pod/>
+The fourth year of chiropractic education persistently showed the highest stress levels.<ref name=Hester2013/> Every student, irrespective of year, experienced different ranges of stress when studying.<ref name=Hester2013>{{cite journal | author = Hester H, Cunliffe C, Hunnisett A | title = Stress in chiropractic education: a student survey of a five-year course | journal = J Chiropr Educ | volume = 27 | issue = 2 | pages = 147–51 | year = 2013 | pmid = 23957319 | pmc = 3791907 | doi = 10.7899/JCE-13-4 }}</ref> The chiropractic leaders and colleges have had internal struggles.<ref name=Johnson2010/> Rather than cooperation, there has been infighting between different factions.<ref name=Johnson2010/> A number of actions were posturing due to the confidential nature of the chiropractic colleges in an attempt to enroll students.<ref name=Johnson2010>{{cite journal | author = Johnson C | title = Reflecting on 115 years: the chiropractic profession's philosophical path | journal = J Chiropr Humanit | volume = 17 | issue = 1 | pages = 1–5 | year = 2010 | month = December | pmid = 22693471 | pmc = 3342796 | doi = 10.1016/j.echu.2010.11.001 }}</ref>
+== Ethical and medicolegal issues ==
+{{Main|Chiropractic professional ethics}}
+The chiropractic oath is a modern variation of the classical [[Hippocratic Oath]] historically taken by [[physician]]s and other healthcare professionals swearing to practice their professions ethically.<ref>{{cite journal | author = Simpson JK, Losco B, Young KJ | title = Development of the murdoch chiropractic graduate pledge | journal = The Journal of chiropractic education | volume = 24 | issue = 2 | pages = 175-86 | year = 2010 | pmid = 21048880 | pmc = 2967342 | doi=10.7899/1042-5055-24.2.175}}</ref> The [[American Chiropractic Association]] (ACA) has an ethical code "based upon the acknowledgement that the social contract dictates the profession’s responsibilities to the patient, the public, and the profession; and upholds the fundamental principle that the paramount purpose of the chiropractic doctor's professional services shall be to benefit the patient."<ref>{{Cite web|author=Staff|title=Code of Ethics|publisher=[[American Chiropractic Association]]|url=http://www.acatoday.org/content_css.cfm?CID=719}}</ref> The [[International Chiropractor's Association]] (ICA) also has a set of professional canons.<ref>{{Cite web|author=Staff|title=ICA code of Ethics|publisher=[[International Chiropractor's Association]]|url=http://www.chiropractic.org/ica/ethics.htm}}</ref>
+According to a 2006 Gallup poll of U.S. adults, when asked how they would "rate the honesty and ethical standards of people in these different fields", chiropractic compared unfavorably with mainstream medicine. When chiropractic was rated, it "rated dead last amongst healthcare professions". While 84% of respondents considered nurses' ethics "very high" or "high," only 36% felt that way about chiropractors. Other healthcare professions ranged from 38% for psychiatrists, to 62% for dentists, 69% for medical doctors, 71% for veterinarians, and 73% for druggists or pharmacists.<ref name=Murphy-pod/><ref>{{cite journal |journal=Dynamic Chiropractic |volume=25 |issue=3 |date=29 January 2007 |title=Gallup Poll: Americans have low opinion of chiropractors' honesty and ethics |url=http://dynamicchiropractic.com/mpacms/dc/article.php?id=52038}}</ref><ref>{{cite news |title=USA TODAY/Gallup poll |url=http://usatoday.com/news/polls/tables/live/2006-12-11-ethics.htm |work=[[USA Today]] |date=11 December 2006}}</ref><ref name=Gallup_chart>[http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx Gallup chart]</ref>
+Chiropractors, especially in America, have a reputation for unnecessarily treating patients.<ref name=Trick-or-Treatment/> In many circumstances the focus seems to be put on economics instead of health care.<ref name=Trick-or-Treatment/> Sustained chiropractic care is promoted as a preventative tool, but unnecessary manipulation could possibly present a risk to patients.<ref name=Ernst-eval/> Some chiropractors are concerned by the routine unjustified claims chiropractors have made.<ref name=Ernst-eval/> A 2010 analysis of chiropractic websites found the majority of chiropractors and their associations made claims of effectiveness not supported by scientific evidence, while 28% of chiropractor websites advocate lower back pain care, which has some sound evidence.<ref>{{cite journal | author = Ernst E, Gilbey A | title = Chiropractic claims in the English-speaking world | journal = The New Zealand medical journal | volume = 123 | issue = 1312 | pages = 36–44 | year = 2010 | pmid = 20389316 }}</ref>
+In 2009, a [[backlash (sociology)|backlash]] to the [[Simon Singh#Chiropractic lawsuit|libel suit filed by the British Chiropractic Association (BCA) against Simon Singh]], has inspired the filing of formal complaints of false advertising against more than 500 individual chiropractors within one 24 hour period,<ref name=withdraw>{{cite web |url=http://blogs.nature.com/news/thegreatbeyond/2009/06/chiropractic_group_advises_mem_1.html |title=The Great Beyond: Chiropractic group advises members to 'withdraw from the battleground' |publisher=Nature.com |author=Lucas Laursen |accessdate=20 June 2009}}</ref><ref>{{cite web |url=http://blogs.nature.com/news/thegreatbeyond/2009/06/chiropractic_complainers_ident.html |title=The Great Beyond: Complaints converge on chiropractors |publisher=Nature.com |author=Lucas Laursen |accessdate=20 June 2009}}</ref> prompting the McTimoney Chiropractic Association to write to its members advising them to remove leaflets that make claims about whiplash and colic from their practice, to be wary of new patients and telephone inquiries, and telling their members: "If you have a website, take it down NOW." and "Finally, we strongly suggest you do NOT discuss this with others, especially patients."<ref name=withdraw/> An editorial in ''Nature'' has suggested that the BCA may be trying to suppress debate and that this use of British libel law is a burden on the right to freedom of expression, which is protected by the [[European Convention on Human Rights]].<ref>{{cite journal | author =  | title = Unjust burdens of proof | journal = Nature | volume = 459 | issue = 7248 | page = 751 | date = June 2009 | pmid = 19516290 | doi = 10.1038/459751a }}</ref> The libel case ended with the BCA withdrawing its suit in 2010.<ref name="news">{{cite news|title=Case dropped against Simon Singh|author=Pallab Ghosh|url=http://news.bbc.co.uk/1/hi/sci/tech/8621880.stm|publisher=BBC News|date=2010-04-15}}</ref><ref name="Mark Henderson">{{cite news|publisher=Times Online|url=http://business.timesonline.co.uk/tol/business/law/article7098157.ece|title=Science writer Simon Singh wins bitter libel battle|author=Mark Henderson|location=London|date=2010-04-16}}</ref>
+=== Criticism ===
+{{main|Chiropractic controversy and criticism}}
+Throughout its history chiropractic has been the subject of internal and external controversy and criticism.<ref name=Kaptchuk-Eisenberg>{{cite journal | author = Kaptchuk TJ, Eisenberg DM | title = Chiropractic: origins, controversies, and contributions | journal = Archives of Internal Medicine | volume = 158 | issue = 20 | pages = 2215–24 | date = Nov 1998 | pmid = 9818801 | doi = 10.1001/archinte.158.20.2215 | url = http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=9818801 | issn = 0003-9926 }}</ref><ref name=Jaroff>{{cite news|last=Jaroff|first=Leon|title=Back Off, Chiropractors!|url=http://content.time.com/time/health/article/0,8599,213482,00.html|date=27 February 2002|work=[[Time (magazine)|Time]]|accessdate=7 June 2009}}</ref> According to [[Daniel D. Palmer]], the founder of chiropractic, [[vertebral subluxation|subluxation]] is the sole cause of disease and manipulation is the cure for all diseases of the human race.<ref name=Ernst-eval>{{cite journal | author = Ernst E | title = Chiropractic: a critical evaluation | journal = Journal of pain and symptom management | volume = 35 | issue = 5 | pages = 544–62 | date = May 2008 | pmid = 18280103 | doi = 10.1016/j.jpainsymman.2007.07.004 | issn = 0885-3924 }}</ref><ref>{{cite book|author= Palmer DD|title= The Chiropractor's Adjuster: Text-book of the Science, Art and Philosophy of Chiropractic for Students and Practitioners|url=http://www.scribd.com/doc/45233534/s-Adjuster-1910|location=Portland, OR|publisher= Portland Printing House Co|year=1910|oclc=17205743|quote=A subluxated vertebra&nbsp;... is the cause of 95 percent of all diseases&nbsp;... The other five percent is caused by displaced joints other than those of the vertebral column.}}</ref> A critical evaluation stated "Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today."<ref name=Ernst-eval/> Chiropractors, including D.D. Palmer, were [[jail]]ed for [[Practicing medicine without license|practicing medicine without a license]].<ref name=Ernst-eval/> For most of its existence, chiropractic has battled with [[mainstream medicine]], sustained by [[antiscientific]] and [[pseudoscientific]] ideas such as subluxation.<ref name=History-Primer>{{cite web|title= Chiropractic history: a primer|author= [[Joseph C. Keating, Jr.]], Cleveland CS III, Menke M|url=http://data.memberclicks.com/site/ahc/ChiroHistoryPrimer.pdf|format=PDF|year=2005|accessdate=2008-06-16|publisher= Association for the History of Chiropractic}}</ref> Collectively, [[systematic reviews]] has not demonstrated that [[spinal manipulation]], the main treatment method employed by chiropractors, is [[Efficacy#Healthcare|effective]] for any medical condition, with the possible exception of treatment for [[back pain]].<ref name=Ernst-eval/> Chiropractic has been controversial, though to a lesser extent than in past years.<ref name=DeVocht>{{cite journal | author = DeVocht JW | title = History and overview of theories and methods of chiropractic: a counterpoint | journal = Clin Orthop Relat Res | volume = 444 | pages = 243–9 | year = 2006 | pmid = 16523145 | doi = 10.1097/01.blo.0000203460.89887.8d }}</ref>
+===Public health ===
 {{further2|[[Vaccine controversy#Alternative medicine|Vaccine controversy and alternative medicine]]|[[Water fluoridation controversy]]}}
 Some chiropractors oppose [[vaccination]] and [[water fluoridation]], which are common [[public health]] practices.<ref name=Murphy-pod/> Within the chiropractic community there are significant disagreements about vaccination,<ref name=Busse/><ref name=Campbell/> one of the most cost-effective public health interventions available.<ref>{{cite journal | author = Ehreth J | title = The global value of vaccination | journal = Vaccine | volume = 21 | issue = 7–8 | pages = 596–600 | year = 2003 | pmid = 12531324 | doi = 10.1016/S0264-410X(02)00623-0 }}</ref> Most chiropractic writings on vaccination focus on its negative aspects,<ref name=Busse/> claiming that it is hazardous, ineffective, and unnecessary.<ref name=Campbell/> Some chiropractors have embraced vaccination, but a significant portion of the profession rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that vaccines interfere with healing.<ref name=Campbell/> The extent to which anti-vaccination views perpetuate the current chiropractic profession is uncertain.<ref name=Busse/> The [[American Chiropractic Association]] and the International Chiropractors 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.<ref name=Campbell>{{cite journal | author = Campbell JB, Busse JW, Injeyan HS | title = Chiropractors and vaccination: a historical perspective | journal = Pediatrics | volume = 105 | issue = 4 | pages = e43 | year = 2000 | pmid = 10742364 | doi = 10.1542/peds.105.4.e43 | url = http://pediatrics.aappublications.org/cgi/content/full/105/4/e43 }}</ref> The [[Canadian Chiropractic Association]] supports vaccination;<ref name=Busse>{{cite journal | author = Busse JW, Morgan L, Campbell JB | title = Chiropractic antivaccination arguments | journal = J Manipulative Physiol Ther | volume = 28 | issue = 5 | pages = 367–73 | year = 2005 | pmid = 15965414 | doi = 10.1016/j.jmpt.2005.04.011 | url = http://jmptonline.org/article/S0161-4754(05)00111-9/fulltext }}</ref> a survey in Alberta in 2002 found that 25% of chiropractors advised patients for, and 27% against, vaccinating themselves or their children.<ref>{{cite journal | author = Russell ML, Injeyan HS, Verhoef MJ, Eliasziw M | title = Beliefs and behaviours: understanding chiropractors and immunization | journal = Vaccine | volume = 23 | issue = 3 | pages = 372–9 | year = 2004 | pmid = 15530683 | doi = 10.1016/j.vaccine.2004.05.027 }}</ref>
@@ Line 282: / Line 290: @@
 Early opposition to water fluoridation included chiropractors, some of whom continue to oppose it as being incompatible with chiropractic philosophy and an infringement of personal freedom. Other chiropractors have actively promoted fluoridation, and several chiropractic organizations have endorsed scientific principles of public health.<ref>{{cite journal | author = Jones RB, Mormann DN, Durtsche TB | title = Fluoridation referendum in La Crosse, Wisconsin: contributing factors to success | journal = Am J Public Health | volume = 79 | issue = 10 | pages = 1405–8 | year = 1989 | pmid = 2782512 | pmc = 1350185 | doi = 10.2105/AJPH.79.10.1405 | url = http://www.ajph.org/cgi/reprint/79/10/1405.pdf | format = PDF }}</ref> In addition to traditional chiropractic opposition to water fluoridation and vaccination, chiropractors' attempts to establish a positive reputation for their public health role are also compromised by their reputation for recommending repetitive lifelong chiropractic treatment.<ref name=Murphy-pod/>
-== Controversy ==
-{{main|Chiropractic controversy and criticism}}
-Throughout its history chiropractic has been the subject of internal and external controversy and criticism.<ref name=Kaptchuk-Eisenberg>{{cite journal | author = Kaptchuk TJ, Eisenberg DM | title = Chiropractic: origins, controversies, and contributions | journal = Archives of Internal Medicine | volume = 158 | issue = 20 | pages = 2215–24 | date = Nov 1998 | pmid = 9818801 | doi = 10.1001/archinte.158.20.2215 | url = http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=9818801 | issn = 0003-9926 }}</ref><ref name=Jaroff>{{cite news|last=Jaroff|first=Leon|title=Back Off, Chiropractors!|url=http://content.time.com/time/health/article/0,8599,213482,00.html|date=27 February 2002|work=[[Time (magazine)|Time]]|accessdate=7 June 2009}}</ref> According to [[Daniel D. Palmer]], the founder of chiropractic, [[vertebral subluxation|subluxation]] is the sole cause of disease and manipulation is the cure for all diseases of the human race.<ref name=Ernst-eval>{{cite journal | author = Ernst E | title = Chiropractic: a critical evaluation | journal = Journal of pain and symptom management | volume = 35 | issue = 5 | pages = 544–62 | date = May 2008 | pmid = 18280103 | doi = 10.1016/j.jpainsymman.2007.07.004 | issn = 0885-3924 }}</ref><ref>{{cite book|author= Palmer DD|title= The Chiropractor's Adjuster: Text-book of the Science, Art and Philosophy of Chiropractic for Students and Practitioners|url=http://www.scribd.com/doc/45233534/s-Adjuster-1910|location=Portland, OR|publisher= Portland Printing House Co|year=1910|oclc=17205743|quote=A subluxated vertebra&nbsp;... is the cause of 95 percent of all diseases&nbsp;... The other five percent is caused by displaced joints other than those of the vertebral column.}}</ref> A critical evaluation stated "Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today."<ref name=Ernst-eval/> Chiropractors, including D.D. Palmer, were [[jail]]ed for [[Practicing medicine without license|practicing medicine without a license]].<ref name=Ernst-eval/> For most of its existence, chiropractic has battled with [[mainstream medicine]], sustained by [[antiscientific]] and [[pseudoscientific]] ideas such as subluxation.<ref name=History-Primer>{{cite web|title= Chiropractic history: a primer|author= [[Joseph C. Keating, Jr.]], Cleveland CS III, Menke M|url=http://data.memberclicks.com/site/ahc/ChiroHistoryPrimer.pdf|format=PDF|year=2005|accessdate=2008-06-16|publisher= Association for the History of Chiropractic}}</ref> Collectively, [[systematic reviews]] has not demonstrated that [[spinal manipulation]], the main treatment method employed by chiropractors, is [[Efficacy#Healthcare|effective]] for any medical condition, with the possible exception of treatment for [[back pain]].<ref name=Ernst-eval/> Chiropractic has been controversial, though to a lesser extent than in past years.<ref name=DeVocht>{{cite journal | author = DeVocht JW | title = History and overview of theories and methods of chiropractic: a counterpoint | journal = Clin Orthop Relat Res | volume = 444 | pages = 243–9 | year = 2006 | pmid = 16523145 | doi = 10.1097/01.blo.0000203460.89887.8d }}</ref>
 == References ==

v t e Chiropractic
Chiropractic	History Sports chiropractic Veterinary chiropractic Controversy and criticism
Techniques	Cervical manipulation Activator technique Gonstead technique Koren Specific Technique Manual therapy Myofascial release Spinal adjustment Torque release technique
Education	Schools Credentials
Accrediting bodies	CCEI CCE-USA
International organizations	WFC FICS
People	D.D. Palmer B.J. Palmer Joseph C. Keating Jr. Joseph Janse Clarence Gonstead Tedd Koren
Category