Chiropractic

Page semi-protected
Source: Wikipedia, the free encyclopedia.

Chiropractic
B. J. Palmer
MeSHD002684
This article is part of a series on
Alternative medicine
General information
Fringe medicine and science
Conspiracy theories
Classifications
Traditional medicine
Diagnoses

Chiropractic is a form of

esoteric origins[3] and is based on several pseudoscientific ideas.[4]

Many chiropractors, especially those in the field's early history, have proposed that mechanical disorders of the

Doctor of Chiropractic (D.C.) degree and be referred to as "doctor" but is not a Doctor of Medicine (M.D.) or a Doctor of Osteopathic Medicine (D.O.).[6][7] While many chiropractors view themselves as primary care providers,[8][9] chiropractic clinical training does not meet the requirements for that designation.[2]

cost-effective for sub-acute or chronic low back pain, but the results for acute low back pain were insufficient.[11] No compelling evidence exists to indicate that maintenance chiropractic care adequately prevents symptoms or diseases.[12]

There is not sufficient data to establish the safety of chiropractic manipulations.

cervical manipulation.[15] Several deaths have been associated with this technique[14] and it has been suggested that the relationship is causative,[16][17] a claim which is disputed by many chiropractors.[17]

Chiropractic is well established in the United States, Canada, and Australia.

Innate Intelligence", and consider vertebral subluxations to be the cause of all disease; and "mixers", the majority, are more open to mainstream views and conventional medical techniques, such as exercise, massage, and ice therapy.[21]

WHO, and local health department guidance.[31][32] Despite these recommendations, a small but vocal and influential number of chiropractors spread vaccine misinformation.[33]

Conceptual basis

Philosophy

Chiropractic is generally categorized as

musculoskeletal system, especially the spine.[2] Its founder, D. D. Palmer, called it "a science of healing without drugs".[8]

Chiropractic's origins lie in the

holistic paradigm of wellness.[35] 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.[36]

Two chiropractic belief system constructs
The testable principle The untestable metaphor
Chiropractic adjustment

↓

Restoration of structural integrity

↓

Improvement of health status

Universal intelligence

↓

Innate intelligence

↓

Body physiology

Materialistic: Vitalistic:
  • Operational definitions possible
  • Lends itself to scientific inquiry
  • Origin of holism in chiropractic
  • Cannot be proven or disproven
Taken from Mootz & Phillips 1997[35]

Although a wide diversity of ideas exist among chiropractors,[34] 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.[37] Some chiropractors claim spinal manipulation can have an effect on a variety of ailments such as irritable bowel syndrome and asthma.[38]

Chiropractic philosophy includes the following perspectives:[35]

Holism assumes that health is affected by everything in an individual's environment; some sources also include a spiritual or existential dimension.[39] In contrast, reductionism in chiropractic reduces causes and cures of health problems to a single factor, vertebral subluxation.[36] 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.[34]

A large number of chiropractors fear that if they do not separate themselves from the traditional

vitalistic concept of innate intelligence, chiropractic will continue to be seen as a fringe profession.[21] A variant of chiropractic called naprapathy originated in Chicago in the early twentieth century.[40][41] It holds that manual manipulation of soft tissue can reduce "interference" in the body and thus improve health.[41]

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[35]

Straight chiropractors adhere to the philosophical principles set forth by D. D. and B. J. Palmer, and retain metaphysical definitions and vitalistic qualities.[42] 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.[42] Straights view the medical diagnosis of patient complaints, which they consider to be the "secondary effects" of subluxations, to be unnecessary for chiropractic treatment.[42] 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.[42] Their philosophy and explanations are metaphysical in nature and they prefer to use traditional chiropractic lexicon terminology such as "perform spinal analysis", "detect subluxation", "correct with adjustment".[21] They prefer to remain separate and distinct from mainstream health care.[21] 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."[21]

Mixer chiropractors "mix" diagnostic and treatment approaches from chiropractic, medical or osteopathic viewpoints and make up the majority of chiropractors.

herbal remedies, and biofeedback.[21]

Although mixers are the majority group, many of them retain belief in vertebral subluxation as shown in a 2003 survey of 1,100 North American chiropractors, which found that 88 percent wanted to retain the term "vertebral subluxation complex", and that when asked to estimate the percent of disorders of internal organs that subluxation significantly contributes to, the mean response was 62 percent.

visceral disorders, and greatly favored non-subluxation-based clinical approaches for such conditions.[44] 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.[44] Chiropractors often offer conventional therapies such as physical therapy and lifestyle counseling, and it may for the lay person be difficult to distinguish the unscientific from the scientific.[45]

Vertebral subluxation

Main article: Vertebral subluxation
Not to be confused with subluxation, the medical condition.

In science-based medicine, the term "subluxation" refers to an incomplete or partial

dislocation of a joint, from the Latin luxare for 'dislocate'.[46][47] While medical doctors use the term exclusively to refer to physical dislocations, Chiropractic founder D. D. Palmer imbued the word subluxation with a metaphysical and philosophical meaning drawn from pseudoscientific traditions such as Vitalism.[48]

Palmer claimed that vertebral subluxations interfered with the body's function and its inborn ability to heal itself.[49] 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.[48] He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic.[48] This concept was later expanded upon by his son, B. J. Palmer, and was instrumental in providing the legal basis of differentiating chiropractic 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.[50]

x-ray radiography
to examine the bone structure of a patient.

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.

evidence-based chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions.[52][53]

In 2005, the

Trick or Treatment states "X-rays can reveal neither the subluxations nor the innate intelligence associated with chiropractic philosophy, because they do not exist."[57] 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."[58] 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."[59]

As of 2014, the US National Board of Chiropractic Examiners states "The specific focus of chiropractic practice is known as the chiropractic subluxation or joint dysfunction. A subluxation is a health concern that manifests in the skeletal joints, and, through complex anatomical and physiological relationships, affects the nervous system and may lead to reduced function, disability or illness."[60][27]

Pseudoscience versus spinal manipulation therapy

Main articles: Spinal adjustment and Spinal manipulation

While some chiropractors limit their practice to short-term treatment of musculoskeletal conditions, many falsely claim to be able treat a myriad of other conditions.[61][62] Some dissuade patients from seeking medical care, others have pretended to be qualified to act as a family doctor.[61]

Quackwatch, an alternative medicine watchdog, cautions against seeing chiropractors who:[61][63]

  • Treat young children
  • Discourage immunization
  • Pretend to be a family doctor
  • Take full spine X-rays
  • Promote unproven dietary supplements
  • Are antagonistic to scientific medicine
  • Claim to treat non-musculoskeletal problems

Writing for the Skeptical Inquirer, one physician cautioned against seeing even chiropractors who solely claim to treat musculoskeletal conditions:

I think Spinal Manipulation Therapy (SMT) is a reasonable option for patients to try ... But I could not in good conscience refer a patient to a chiropractor... When chiropractic is effective, what is effective is not 'chiropractic': it is SMT. SMT is also offered by physical therapists, DOs, and others. These are science-based providers ... If I thought a patient might benefit from manipulation, I would rather refer him or her to a science-based provider.[61]

Scope of practice

A treatment table at a chiropractic office

Chiropractors emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery,[54] 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.[8] 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.[64] 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.[64] 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 attributes of a medical specialty like dentistry or podiatry.[65] It has been proposed that chiropractors specialize in nonsurgical spine care, instead of attempting to also treat other problems,[36][65] but the more expansive view of chiropractic is still widespread.[66]

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.[67] Many chiropractors believe they are primary care providers,[8][9] including US[68] and UK chiropractors,[69] but the length, breadth, and depth of chiropractic clinical training do not support the requirements to be considered primary care providers,[2] so their role on primary care is limited and disputed.[2][9]

Chiropractic overlaps with several other forms of manual therapy, including massage therapy,

osteopathic medicine in the U.S. has merged with the medical profession.[71] 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.[19]

Chiropractic diagnosis may involve a range of methods including skeletal imaging, observational and tactile assessments, and orthopedic and neurological evaluation.[54] A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider.[65] 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.[5]

A chiropractic adjustment of a horse

Chiropractors are not normally licensed to write medical prescriptions or perform major surgery in the United States[73] (although New Mexico has become the first US state to allow "advanced practice" trained chiropractors to prescribe certain medications[74][75]). 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.[76] 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.[73] 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 that 72% of Swiss chiropractors considered their ability to prescribe nonprescription medication as an advantage for chiropractic treatment.[77]

A related field, veterinary chiropractic, applies manual therapies to animals and is recognized in many US states,[78] but is not recognized by the American Chiropractic Association as being chiropractic.[79] It remains controversial within certain segments of the veterinary and chiropractic professions.[80]

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.[81] 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.[81] Two US states (Washington and Arkansas) prohibit physical therapists from performing SM,[82] 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.[83]

Treatments

Main articles: Chiropractic treatment techniques and Spinal adjustment
A chiropractor performs an adjustment on a patient.

Spinal manipulation, which chiropractors call "spinal adjustment" or "chiropractic adjustment", is the most common treatment used in chiropractic care.

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.[85]

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 US chiropractors in a 2003 survey:

anesthesiologist; a 2008 systematic review did not find enough evidence to make recommendations about its use for chronic low back pain.[93]

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 US chiropractors in a 2003 survey: Diversified technique (full-spine manipulation; mentioned in previous paragraph),

disease prevention/early screening advice.[84]

A 2010 study describing Belgian chiropractors and their patients found chiropractors in Belgium mostly focus on neuromusculoskeletal complaints in adult patients, with emphasis on the spine.[94] The diversified technique is the most often applied technique at 93%, followed by the Activator mechanical-assisted technique at 41%.[94] A 2009 study assessing chiropractic students giving or receiving spinal manipulations while attending a United States chiropractic college found Diversified, Gonstead, and upper cervical manipulations are frequently used methods.[95]

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

antiscientific reasoning and makes unsubstantiated claims.[2][27][51][96][97] 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".[98] 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.[99] Specific guidelines concerning the treatment of nonspecific (i.e., unknown cause) low back pain are inconsistent between countries.[100]

Effectiveness

Numerous controlled clinical studies of treatments used by chiropractors have been conducted, with varied results.[8] There is no conclusive evidence that chiropractic manipulative treatment is effective for the treatment of any medical condition, except perhaps for certain kinds of back pain.[8][10]

Generally, the research carried out into the effectiveness of chiropractic has been of poor quality.[101][102] Research published by chiropractors is distinctly biased: reviews of SM for back pain tended to find positive conclusions when authored by chiropractors, while reviews by mainstream authors did not.[8]

There is a wide range of ways to measure treatment outcomes.

placebo response,[104] but it is difficult to construct a trustworthy placebo for clinical trials of spinal manipulative therapy (SMT).[105] The efficacy of maintenance care in chiropractic is unknown.[106]

Available evidence covers the following conditions:

Safety

Chiropractic adjustment on children

The World Health Organization found chiropractic care in general is safe when employed skillfully and appropriately.[54] There is not sufficient data to establish the safety of chiropractic manipulations.[13] Manipulation is regarded as relatively safe but complications can arise, and it has known adverse effects, risks and contraindications.[54] 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.[54] 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.[54] 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.[148] Indirect risks of chiropractic involve delayed or missed diagnoses through consulting a chiropractor.[8]

Spinal manipulation is associated with frequent, mild and temporary

adverse effects,[14][148] including new or worsening pain or stiffness in the affected region.[149] 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;[13] adverse reactions appear to be more common following manipulation than mobilization.[150] The most frequently stated adverse effects are mild headache, soreness, and briefly elevated pain fatigue.[151] Chiropractic is correlated with a very high incidence of minor adverse effects.[8] Rarely,[54] 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[14] and children.[152] Estimates vary widely for the incidence of these complications,[13] 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.[14] Adverse effects are poorly reported in recent studies investigating chiropractic manipulations.[153] A 2016 systematic review concludes that the level of reporting is unsuitable and unacceptable.[154] Reports of serious adverse events have occurred, resulting from spinal manipulation therapy of the lumbopelvic region.[155] 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.[13] Several case reports show temporal associations between interventions and potentially serious complications.[156] The published medical literature contains reports of 26 deaths since 1934 following chiropractic manipulations and many more seem to remain unpublished.[17]

disc herniation is very rare following spinal manipulation therapy.[164]

Chiropractors sometimes employ diagnostic imaging techniques such as X-rays and CT scans that rely on ionizing radiation.[165] Although there is no clear evidence to justify the practice, some chiropractors still X-ray a patient several times a year.[57] Practice guidelines aim to reduce unnecessary radiation exposure,[165] which increases cancer risk in proportion to the amount of radiation received.[166] Research suggests that radiology instruction given at chiropractic schools worldwide seem to be evidence-based.[56] 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.[56]

Risk-benefit

A 2012 systematic review concluded that no accurate assessment of risk-benefit exists for cervical manipulation.[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.[17] The same review concluded that the risk of death from manipulations to the neck outweighs the benefits.[17] Chiropractors have criticized this conclusion, claiming that the author did not evaluate the potential benefits of spinal manipulation.[167] 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."[167] A 1999 review of 177 previously reported cases published between 1925 and 1997 in which injuries were attributed to manipulation of the cervical spine (MCS) concluded that "The literature does not demonstrate that the benefits of MCS outweigh the risks." The professions associated with each injury were assessed. Physical therapists (PT) were involved in less than 2% of all cases, with no deaths caused by PTs. Chiropractors were involved in a little more than 60% of all cases, including 32 deaths.[168]

A 2009 review evaluating maintenance chiropractic care found that spinal manipulation is 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.[12]

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.[169] 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.[11]

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 placebo controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain.[170] 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.[171] The cost-effectiveness of maintenance chiropractic care is unknown.[106][non-primary source needed]

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% for in-hospital admissions, 59% for hospital days, 62% for outpatient surgeries and procedures, and 85% for pharmaceutical 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.[172]

Education, licensing, and regulation

Main articles: Chiropractic education and List of chiropractic schools

Requirements vary between countries. In the U.S. chiropractors obtain a non-medical accredited diploma in the field of chiropractic.

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.[176] 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.[177] Graduates of the Canadian Memorial Chiropractic College (CMCC) are formally recognized to have at least 7–8 years of university level education.[178][179] 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.[54]

Upon graduation, there may be a requirement to pass national, state, or provincial board examinations before being

orthopedics and sports chiropractic, and through full-time residency programs such as radiology or orthopedics.[184]

In the U.S., chiropractic schools are accredited through the

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.[178][179]

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.[192][193] There are an estimated 49,000 chiropractors in the U.S. (2008),[194] 6,500 in Canada (2010),[195] 2,500 in Australia (2000),[29] and 1,500 in the UK (2000).[196]

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.[76] The fourth year of chiropractic education persistently showed the highest stress levels.[197] Every student, irrespective of year, experienced different ranges of stress when studying.[197] The chiropractic leaders and colleges have had internal struggles.[198] Rather than cooperation, there has been infighting between different factions.[198] A number of actions were posturing due to the confidential nature of the chiropractic colleges in an attempt to enroll students.[198][clarification needed]

Ethics

Main article: Chiropractic professional ethics

The chiropractic oath is a modern variation of the classical

International Chiropractor's Association (ICA) also has a set of professional canons.[201]

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.[36] According to a 2015 Gallup poll of U.S. adults, the perception of chiropractors is generally favorable; two-thirds of American adults agree that chiropractors have their patient's best interest in mind and more than half also agree that most chiropractors are trustworthy. Less than 10% of US adults disagreed with the statement that chiropractors were trustworthy.[202][203]

The charity Sense about Science launched a campaign to draw attention to the BCA legal case against science writer Simon Singh.[204] In 2009, a number of organizations and public figures signed a statement entitled "The law has no place in scientific disputes".[205]

Chiropractors, especially in America, have a reputation for unnecessarily treating patients.[57] In many circumstances the focus seems to be put on economics instead of health care.[57] Sustained chiropractic care is promoted as a preventive tool, but unnecessary manipulation could possibly present a risk to patients.[8] Some chiropractors are concerned by the routine unjustified claims chiropractors have made.[8] 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.[206]

The US

Medicare Part B, a total of $359 million, did not comply with Medicare requirements.[207] There have been at least 15 OIG reports about chiropractic billing irregularities since 1986.[207]

In 2009, a backlash to the libel suit filed by the British Chiropractic Association (BCA) against Simon Singh inspired the filing of formal complaints of false advertising against more than 500 individual chiropractors within one 24-hour period,[208][209] 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."[208] An editorial in Nature suggested that the BCA may have been trying to suppress debate and that this use of English libel law was a burden on the right to freedom of expression, which is protected by the European Convention on Human Rights.[210] The libel case ended with the BCA withdrawing its suit in 2010.[211][212]

Reception

Chiropractic is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries.

complementary and alternative medicine, which has not integrated into mainstream medicine.[64]

Australia

In Australia, there are approximately 2488 chiropractors, or one chiropractor for every 7980 people.[213] Most private health insurance funds in Australia cover chiropractic care, and the federal government funds chiropractic care when the patient is referred by a medical practitioner.[214] In 2014, the chiropractic profession had a registered workforce of 4,684 practitioners in Australia represented by two major organizations – the Chiropractors' Association of Australia (CAA) and the Chiropractic and Osteopathic College of Australasia (COCA).[215] Annual expenditure on chiropractic care (alone or combined with osteopathy) in Australia is estimated to be between AUD$750–988 million with musculoskeletal complaints such as back and neck pain making up the bulk of consultations; and proportional expenditure is similar to that found in other countries.[215] While Medicare (the Australian publicly funded universal health care system) coverage of chiropractic services is limited to only those directed by a medical referral to assist chronic disease management, most private health insurers in Australia do provide partial reimbursement for a wider range of chiropractic services in addition to limited third party payments for workers compensation and motor vehicle accidents.[215]

Of the 2,005 chiropractors who participated in a 2015 survey, 62.4% were male and the average age was 42.1 (SD = 12.1) years.[215] Nearly all chiropractors (97.1%) had a bachelor's degree or higher, with the majority of chiropractor's highest professional qualification being a bachelor or double bachelor's degree (34.6%), followed by a master's degree (32.7%), Doctor of Chiropractic (28.9%) or PhD (0.9%).[215] Only a small number of chiropractor's highest professional qualification was a diploma (2.1%) or advanced diploma (0.8%).[215]

Germany

In Germany, chiropractic may be offered by medical doctors and alternative practitioners. Chiropractors qualified abroad must obtain a German non-medical practitioner license. Authorities have routinely required a comprehensive knowledge test for this, but in the recent past, some administrative courts have ruled that training abroad should be recognised.[216]

Switzerland

In Switzerland, only trained medical professionals are allowed to offer chiropractic. There are 300 chiropractors in Switzerland.[217]

United Kingdom

In the United Kingdom, there are over 2,000 chiropractors, representing one chiropractor per 29,206 people.[213] 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.[218]

A 2010 study by questionnaire presented to UK chiropractors indicated only 45% of chiropractors disclosed to patients the serious risk associated with manipulation of the cervical spine and that 46% believed there was possibility patients would refuse treatment if the risks were correctly explained. However 80% acknowledged the ethical/moral responsibility to disclose risk to patients.[219]

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,[220] with a global high of 20% in Alberta in 2006.[221] In 2008, chiropractors were reported to be the most common CAM providers for children and adolescents, these patients representing up to 14% of all visits to chiropractors.[222]

There were around 50,330 chiropractors practicing in North America in 2000.[213] In 2008, this has increased by almost 20% to around 60,000 chiropractors.[8] In 2002–03, the majority of those who sought chiropractic did so for relief from back and neck pain and other neuromusculoskeletal complaints;[20] most do so specifically for low back pain.[20][220] The majority of U.S. chiropractors participate in some form of managed care.[9] Although the majority of U.S. chiropractors view themselves as specialists in neuromusculoskeletal conditions, many also consider chiropractic as a type of primary care.[9] In the majority of cases, the care that chiropractors and physicians provide divides the market, however for some, their care is complementary.[9]

In the U.S., chiropractors perform over 90% of all manipulative treatments.[223] 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.[224]

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.[225] As of 2007 7% of the U.S. population is being reached by chiropractic.[226] They were the third largest medical profession in the US in 2002, following physicians and dentists.[227] Employment of U.S. chiropractors was expected to increase 14% between 2006 and 2016, faster than the average for all occupations.[194]

In the U.S., most states require insurers to cover chiropractic care, and most

HMOs cover these services.[222]

History

Main article: History of chiropractic
Daniel David (D. D.) Palmer, founder of chiropractic

Chiropractic's origins lie in the

bonesetting, in which untrained practitioners engaged in joint manipulation or resetting fractured bones.[8]
Chiropractic was founded in 1895 by
esoteric origins.[3]

Chiropractic competed with its predecessor osteopathy, another medical system based on magnetic healing; both systems were founded by charismatic midwesterners in opposition to the conventional medicine of the day, and both postulated that manipulation improved health.

Bartlett Joshua (B. J.) Palmer, became committed to promoting chiropractic, took over the Palmer School in 1906, and rapidly expanded its enrollment.[22]

Early chiropractors believed that all disease was caused by interruptions in the flow of innate intelligence, a

trusts, among which they included the American Medical Association (AMA).[22]

B. J. Palmer, early developer of chiropractic

Chiropractic has seen considerable controversy and criticism.[25][26] 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.[22] 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.[22] The mixer camp grew until by 1924 B. J. estimated that only 3,000 of the United States' 25,000 chiropractors remained straight.[22] 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.[22]

Harvey Lillard, first chiropractic patient

Chiropractors faced heavy opposition from organized medicine.

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.[9]

Serious research to test chiropractic theories did not begin until the 1970s, and is continuing to be hampered by antiscientific and

massage therapists and other health professions.[9] The profession responded by marketing natural products and devices more aggressively, and by reaching deeper into alternative medicine and primary care.[9]

Public health

Further information:
Vaccine controversy § Alternative medicine, and Water fluoridation controversy

Some chiropractors oppose vaccination and water fluoridation, which are common public health practices.[36] Within the chiropractic community there are significant disagreements about vaccination, one of the most cost-effective public health interventions available.[233] Most chiropractic writings on vaccination focus on its negative aspects,[28] claiming that it is hazardous, ineffective, and unnecessary.[29] 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.[29] The extent to which anti-vaccination views perpetuate the current chiropractic profession is uncertain.[28] 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.[29] The Canadian Chiropractic Association supports vaccination;[28] a survey in Alberta in 2002 found that 25% of chiropractors advised patients for, and 27% against, vaccinating themselves or their children.[234]

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.[235] 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.[36]

Controversy

Main article: Chiropractic controversy and criticism

Throughout its history chiropractic has been the subject of internal and external controversy and criticism.

mainstream medicine, sustained by antiscientific and pseudoscientific ideas such as subluxation.[42] Collectively, systematic reviews have 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.[8] Chiropractic remains controversial, though to a lesser extent than in past years.[25]

See also

References

  1. ^
    ISBN 978-0-07-137534-4
    .
  2. ^
    PMID 16000175
    .
  3. ^
    ISBN 978-3-319-21987-5
    .
  4. ^ For an explanation regarding the description of chiropractic as a pseudoscience, see:
  5. ^
    OCLC 39856366
    . AHCPR Pub No. 98-N002.
  6. ^ "The DC as PCP? Drug Wars Resume – Science-Based Medicine". sciencebasedmedicine.org. 2019-12-18. Archived from the original on 2019-12-18. Retrieved 2020-03-27.
  7. ^ Bellamy, Jann (December 20, 2018). "Legislative Alchemy 2018: Chiropractors rebranding as primary care physicians continues". sciencebasedmedicine.org. Archived from the original on December 19, 2019. Retrieved 2019-12-18.
  8. ^
    PMID 18280103
    .
  9. ^
    PMID 12669653
    .
  10. ^
    PMID 21952385
    .
  11. ^
    PMID 21229367
    .
  12. ^
    PMID 19465044
    .
  13. ^
    S2CID 21279308. Archived
    (PDF) from the original on 2016-09-19.
  14. ^
    PMID 17606755. Archived from the original
    on 2010-05-16.
  15. ^
    PMID 22994328
    .
  16. ^
    S2CID 38571730
    .
  17. ^
    S2CID 45225661
    .
  18. ^ a b Tetrault M (2004). "Global professional strategy for chiropractic" (PDF). Chiropractic Diplomatic Corps. Archived from the original (PDF) on 2008-06-25. Retrieved 2008-04-18.
  19. ^
    doi:10.1111/1467-9566.00239
    .
  20. ^
    PMID 16600038
    .
  21. ^
    PMID 9818801
    .
  22. ^
    S2CID 23423922
    .
  23. ^ a b c "D. D. Palmer's Religion of Chiropractic" – Letter from D. D. Palmer to P. W. Johnson, D.C., May 4, 1911. In the letter, he often refers to himself with royal third person terminology and also as "Old Dad".
  24. ^ Lazarus, David (June 30, 2017). Column: Chiropractic treatment, a $15-billion industry, has its roots in a ghost story. Archived July 19, 2020, at the Wayback Machine --- "Daniel David Palmer, the 'father' of chiropractic who performed the first chiropractic adjustment in 1895, was an avid spiritualist. He maintained that the notion and basic principles of chiropractic treatment were passed along to him during a seance by a long-dead doctor. 'The knowledge and philosophy given me by Dr. Jim Atkinson, an intelligent spiritual being ... appealed to my reason,' Palmer wrote in his memoir The Chiropractor, which was published in 1914 after his death in Los Angeles. Atkinson had died 50 years prior to Palmer's epiphany." Los Angeles Times. Retrieved: September 25, 2019.
  25. ^
    S2CID 35775630
    .
  26. ^
    PMID 16446588
    .
  27. ^ a b c Joseph C. Keating Jr.; Cleveland CS III; Menke M (2005). "Chiropractic history: a primer" (PDF). Association for the History of Chiropractic. Archived from the original (PDF) on 19 June 2013. Retrieved 2008-06-16. A significant and continuing barrier to scientific progress within chiropractic are the anti-scientific and pseudo-scientific ideas (Keating 1997b) which have sustained the profession throughout a century of intense struggle with political medicine. Chiropractors' tendency to assert the meaningfulness of various theories and methods as a counterpoint to allopathic charges of quackery has created a defensiveness which can make critical examination of chiropractic concepts difficult (Keating and Mootz 1989). One example of this conundrum is the continuing controversy about the presumptive target of DCs' adjustive interventions: subluxation (Gatterman 1995; Leach 1994).
  28. ^
    PMID 15965414
    .
  29. ^
    PMID 10742364
    .
  30. ^
    PMID 18722194
    .
  31. ^ WFC Public Health Committee and WFC Research Committee (March 17, 2020). COVID-19 Advice for Chiropractors World Federation of Chiropractic.
  32. ^ Robert C. Jones, et al. Not Business as Usual: A Safe, Responsible Response to COVID-19 American Chiropractic Association
  33. ^ MICHELLE R. SMITH, SCOTT BAUER and MIKE CATALINI (October 8, 2021). Anti-vaccine chiropractors rising force of misinformation. Associated Press.
  34. ^
    ISBN 978-0-07-137534-4
    .
  35. ^
    OCLC 39856366
    . AHCPR Pub No. 98-N002.
  36. ^
    PMID 18759966
    .
  37. ISBN 978-1-888799-66-8
    .
  38. NHS Choices
    . 20 August 2014. Retrieved 19 September 2016.
  39. PMID 15720949
    .
  40. ISBN 978-0-486-20394-2
    .
  41. ^ a b Raso J (1997). "Dictionary of Metaphysical Healthcare – Glossary". Quackwatch. Retrieved 12 February 2016.
  42. ^ a b c d e f g h i j k l m n o Keating, J. C. Jr; Cleveland, C. S. III; Menke, M. (2005). "Chiropractic history: a primer" (PDF). Association for the History of Chiropractic. Archived from the original (PDF) on 2014-04-24. Retrieved 2008-06-16.
  43. ^
    ISBN 978-0-9728055-5-1.[page needed
    ]
  44. ^
    doi:10.1016/s1556-3499(13)60166-7. Archived from the original
    (PDF) on 2012-04-25.
  45. ISBN 978-1-55002-406-7
    .
  46. ^ "Subluxation". Merriam-Webster. Retrieved January 4, 2018.
  47. ^ "luxation (n.)". Online Etymology Dictionary. Archived from the original on 2019-05-01. Retrieved July 28, 2021.
  48. ^ a b c Keating, J. C. Jr (1995). "D. D. Palmer's forgotten theories of chiropractic" (PDF). Association for the History of Chiropractic. Archived (PDF) from the original on 2007-07-10. Retrieved 2008-05-14.
  49. ISBN 978-0-07-137534-4
    .
  50. ^
    OCLC 17205743
    . A subluxated vertebra ... is the cause of 95 percent of all diseases ... The other five percent is caused by displaced joints other than those of the vertebral column.
  51. ^
    PMID 16092955
    .
  52. ^ Rose KA, Adams A (2000). "A survey of the use of evidence-based health care in chiropractic college clinics" (PDF). Journal of Chiropractic Education. 14 (2): 71–77. Archived from the original (PDF) on 2008-10-02.
  53. S2CID 71826135. Archived
    (PDF) from the original on 2007-07-10.
  54. ^
    ISBN 978-92-4-159371-7. Archived from the original
    (PDF) on 2022-03-13. Retrieved 2008-02-29.
  55. PMID 27713818
    .
  56. ^
    PMID 18722195
    .
  57. ^
    ISBN 978-0-393-06661-6
    .
  58. ISBN 978-1-892734-02-0
    .
  59. ^ "Guidance on claims made for the chiropractic vertebral subluxation complex" (PDF). General Chiropractic Council. Archived from the original (PDF) on 2011-04-16. Retrieved 2010-09-30.
  60. ^ NBCE (2014), About Chiropractic, National Board of Chiropractic Examiners, archived from the original on June 19, 2015, retrieved February 1, 2015
  61. ^ a b c d Hall, Harriet (June 1, 2017). "Chiropractors: Pro and Con". Skeptical Inquirer. Archived from the original on 2020-08-23. Retrieved July 28, 2021.
  62. ISBN 1-55002-406-X
    .
  63. ^ "Chirobase". Quackwatch. 7 May 2019. Archived from the original on 2020-06-10. Retrieved July 28, 2021.
  64. ^
    PMID 21531061
    .
  65. ^
    S2CID 16782086
    .
  66. PMID 17549192
    .
  67. PMID 18435599
    .
  68. doi:10.1111/j.2042-7166.2010.01032.x
    .
  69. PMID 20979615
    .
  70. PMID 18254831
    .
  71. ^
    PMID 19066664
    .
  72. doi:10.1177/1533210106292467
    .
  73. ^
    PMID 15247891
    .
  74. ^ "Occupational And Professional Licensing, Chiropractic Practitioners, Chiropractic Advanced Practice Certification Registry". State of New Mexico. Archived 2010-03-17 at the Wayback Machine. Retrieved 2010-05-03.
  75. ^ "Occupational And Professional Licensing, Chiropractic Practitioners, Chiropractic Advanced Practice Certification Registry" (PDF). State of New Mexico. Retrieved 2010-05-03.
  76. ^
    PMID 19715143
    .
  77. PMID 20350678
    .
  78. ^ "Scope of Practice: Complementary and alternative veterinary medicine (CAVM) and other practice act exemptions". American Veterinary Medical Association. May 2019. Archived from the original on April 4, 2016. Retrieved April 1, 2016.
  79. ^ ACA House of Delegates (1994). "'Veterinary' chiropractic". American Chiropractic Association. Archived from the original on May 17, 2008. Retrieved 2008-07-05.
  80. ^ Kamen, Daniel (June 18, 2001). "Politics and technique". Dynamic Chiropractic. Vol. 19, no. 13.
  81. ^
    PMID 15550303
    .
  82. ^ Anderson, Chantal (2009-01-22). "Physical therapists, chiropractors square off over bill". The Seattle Times. Archived from the original on 2010-09-22. Retrieved 2010-09-23.
  83. ^ Hilliard JW, Johnson ME (2004). "State practice acts of licensed health professions: scope of practice". DePaul Journal of Health Care Law. 8 (1): 237–61.
  84. ^
    ISBN 978-1-884457-05-0. Archived from the original
    (PDF) on 2008-09-10. Retrieved 2008-08-25.
  85. ^ a b c Winkler K, Hegetschweiler-Goertz C, Jackson PS, et al. (2003). "Spinal manipulation policy statement" (PDF). American Chiropractic Association. Archived from the original (PDF) on 2011-07-20. Retrieved 2008-05-24.
  86. ^
    PMID 17905321
    .
  87. ISBN 978-0-443-07413-4.[page needed
    ]
  88. PMID 8902664
    .
  89. ^ a b "Provider Manual for Chiropractic Services" (PDF). North Dakota Department of Human Services. State of North Dakota. Archived from the original (PDF) on 2016-04-08. Retrieved 2016-04-14.
  90. ^ NHS Leeds West CCG Assurance Committee (2014-01-02). "Complementary and Alternative Therapies Evidence Based Decision Making Framework" (PDF). leedswestccg.nhs.uk. Archived from the original (PDF) on 2016-03-04. Retrieved 2015-06-30.
  91. ^ "Chiropractic Services - Policy", Aetna, archived from the original on 24 March 2016, retrieved 29 March 2016
  92. ^ "Chiropractic Policy" (PDF). Oklahoma State University Health Plan. 1 April 2016. Archived from the original (PDF) on 5 January 2017. Retrieved 14 April 2016.
  93. PMID 18164462
    .
  94. ^
    PMID 21036284
    .
  95. PMID 19243726
    .
  96. ^ Joseph C. Keating Jr. (1997). "Chiropractic: science and antiscience and pseudoscience side by side". Skeptical Inquirer. 21 (4): 37–43.
  97. ISBN 978-0-07-137534-4
    .
  98. PMID 21599991
    .
  99. PMID 17320731
    .
  100. PMID 16949948
    .
  101. PMID 16574972
    .
  102. S2CID 28092478
    .
  103. PMID 18558278
    .
  104. S2CID 207535762
    .
  105. PMID 16764551
    .
  106. ^
    PMID 18466623
    .
  107. ^
    S2CID 28795577
    .
  108. PMID 22621391
    .
  109. S2CID 5061433
    .
  110. PMID 20393942
    .
  111. PMID 20869008
    .
  112. PMID 24412033
    .
  113. ^
    PMID 21292148
    .
  114. S2CID 19121111
    .
  115. PMID 17369783
    .
  116. PMID 24436697
    .
  117. S2CID 12159586
    .
  118. PMID 21885904
    .
  119. PMID 20510644
    .
  120. PMID 20364057
    .
  121. PMID 21298314
    .
  122. S2CID 31205541
    .
  123. S2CID 23367185
    .
  124. S2CID 42640492
    .
  125. PMID 21402325
    .
  126. PMID 21146444
    .
  127. PMID 18328941
    .
  128. PMID 21109059
    .
  129. PMID 22325966
    .
  130. PMID 22341795
    .
  131. PMID 21923933
    .
  132. S2CID 9339782
    .
  133. PMID 18211702
    .
  134. PMID 17604553
    .
  135. PMID 19646855
    .
  136. PMID 15846609
    .
  137. ^
    PMID 18789139
    .
  138. ^ Baby colic:
  139. PMID 22161390
    .
  140. PMID 12535461
    .
  141. ^ Fibromyalgia:
  142. PMID 21258667
    .
  143. PMID 15819137
    .
  144. PMID 16855988
    .
  145. ^
    PMID 24656717
    .
  146. PMID 26422811
    .
  147. PMID 27647578
    .
  148. ^
    PMID 18327295. Archived from the original
    (PDF) on 2010-09-05.
  149. S2CID 42353750
    .
  150. S2CID 45678522
    .
  151. NHS Choices
    . 20 August 2014. Retrieved 22 September 2016.
  152. S2CID 43683198
    .
  153. PMID 22522273
    .
  154. PMID 27241208
    .
  155. PMID 23787298
    .
  156. ^
    S2CID 27261997
    .
  157. PMID 19065058
    .
  158. S2CID 18062970
    .
  159. ^
    PMID 25104849
    .
  160. PMID 27014532
    .
  161. PMID 24387889
    .
  162. PMID 23527121
    .
  163. S2CID 5315779
    .
  164. PMID 26871842
    .
  165. ^
    PMID 18308153
    .
  166. ISBN 978-0-309-09156-5
    .
  167. ^
    S2CID 72845939
    .
  168. Physical Therapy
    . Retrieved November 1, 2021. Although the risk of injury associated with MCS appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (nonthrust passive movements). The literature does not demonstrate that the benefits of MCS outweigh the risks. Several recommendations for future studies and for the practice of MCS are discussed.
  169. PMID 22429823
    .
  170. PMID 17173105. Archived from the original
    on 2008-05-11.
  171. PMID 15949783
    .
  172. S2CID 613004
    .
  173. U.S. Dept. of Education. Archived from the original
    on 2009-06-04. Retrieved 2009-06-05.
  174. PMID 19707062
    .
  175. PMID 9737032
    .
  176. ^ "Prospective students". Association of Chiropractic Colleges. Archived from the original on 2009-08-14. Retrieved 2009-07-23.
  177. ^ "Standards for Accreditation of Doctor of Chiropractic Programmes" (PDF). Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards. 2011-11-26. Archived from the original (PDF) on 2015-09-23. Retrieved 2014-08-02.
  178. ^ a b "CMCC Backgrounder 2015" (PDF). Canadian Memorial Chiropractic College. Archived (PDF) from the original on 2019-02-26. Retrieved 26 February 2019.
  179. ^ a b "Degree Authority in Ontario". Ontario Ministry of Training, Colleges and Universities. Retrieved 2010-12-14.
  180. ^ "State chiropractic licensure". Life University. 2008. Archived from the original on 2009-08-01. Retrieved 2009-06-05.
  181. ^ "Becoming a chiropractor". Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards. Archived from the original on 2009-06-15. Retrieved 2009-06-05.
  182. PMID 17549163
    .
  183. PMID 16242035
    .
  184. OCLC 39856366. Archived from the original
    on 2008-06-25. Retrieved 2008-05-11. AHCPR Pub No. 98-N002.
  185. ^ "The Council on Chiropractic Education (CCE)". The Council on Chiropractic Education. Retrieved 2008-07-05.
  186. ^ "The General Chiropractic Council". Retrieved 2020-05-02.
  187. ^ "About Us". Councils on Chiropractic Education International. Archived from the original on 2010-11-18. Retrieved 2010-09-30.
  188. ^ "Accredited Doctor of Chiropractic programs". The Council on Chiropractic Education. Archived from the original on 2008-02-14. Retrieved 2008-02-22.
  189. ^ "Accreditation of educational programmes". Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards. Archived from the original on 2009-05-18. Retrieved 2009-06-05.
  190. ^ "Program Accreditation Status". Council on Chiropractic Education Australasia. Archived from the original on 2011-02-17. Retrieved 2010-09-30.
  191. European Council On Chiropractic Education. 2010-11-01. Archived from the original
    on 2014-07-22. Retrieved 2014-08-02.
  192. ^ "Canadian Chiropractic Association FAQs". Canadian Chiropractic Association. Archived from the original on 2009-08-17. Retrieved 2010-10-02.
  193. ^ "Federation of Chiropractic Licensing Boards FAQ". Federation of Chiropractic Licensing Boards. Retrieved 2010-10-02.
  194. ^
    U.S. Bureau of Labor Statistics
    . 2007. Retrieved 2008-07-05.
  195. ^ "Canadian Chiropractic Association: Chiropractic in Canada". Canadian Chiropractic Association. Archived from the original on 2010-05-27. Retrieved 2010-10-02.
  196. ISBN 978-1-892734-02-0
    .
  197. ^
    PMID 23957319
    .
  198. ^
    PMID 22693471
    .
  199. PMID 21048880
    .
  200. ^ Staff. "Code of Ethics". American Chiropractic Association. Archived from the original on 2014-02-22. Retrieved 2014-02-11.
  201. International Chiropractor's Association. Archived from the original
    on 2014-04-05.
  202. ^ "Majority in U.S. Say Chiropractic Works for Neck, Back Pain". Gallup Inc. 8 September 2015. Retrieved 2015-09-13.
  203. PMID 26362263
    .
  204. ^ "A pivotal moment for free speech in Britain". The Guardian. April 15, 2010.
  205. British Humanist Association
    . July 29, 2009.
  206. PMID 20389316
    .
  207. ^ a b Stephen Barrett (2017-01-02). "Medicare Overpayments to Chiropractors Are Widespread". American Council on Science and Health.
  208. ^ a b Lucas Laursen. "The Great Beyond: Chiropractic group advises members to 'withdraw from the battleground'". Nature.com. Retrieved 20 June 2009.
  209. ^ Lucas Laursen. "The Great Beyond: Complaints converge on chiropractors". Nature.com. Retrieved 20 June 2009.
  210. PMID 19516290
    .
  211. ^ Pallab Ghosh (2010-04-15). "Case dropped against Simon Singh". BBC News.
  212. ^ Mark Henderson (2010-04-16). "Science writer Simon Singh wins bitter libel battle". Times Online. London.
  213. ^
    PMID 23876568
    .
  214. PMID 18377663
    .
  215. ^
    PMID 28056964. This article incorporates text by Jon Adams, Romy Lauche, Wenbo Peng, Amie Steel, Craig Moore, Lyndon G. Amorin-Woods, and David Sibbritt available under the CC BY 4.0
    license.
  216. ^ "Freedom of Profession for Chiropractors in Germany". ACLANZ. aclanz Rechtsanwälte. Retrieved 16 June 2023.
  217. ^ "ChiroSuisse - Organisation". www.chirosuisse.ch (in German). Schweizerische Gesellschaft für Chiropraktik. Retrieved 16 June 2023.
  218. ^ "Chiropractic treatment available on NHS in Cornwall". BBC News. August 13, 2013. Retrieved August 18, 2013.
  219. PMID 20977721
    .
  220. ^
    PMID 17241465
    .
  221. ^ Crownfield PW (2007). "Chiropractic in Alberta: a model of consumer utilization and satisfaction". Dynamic Chiropractic. Vol. 25, no. 6.
  222. ^
    PMID 19047261
    .
  223. ^ Cherkin, Daniel C.; Mootz, Robert D. (2010). "Chiropractic in the United States:Training, Practice, and Research". Chirobase. Retrieved 2010-10-01.
  224. PMID 16904491
    .
  225. PMID 15712765
    .
  226. ^ Stanley, G. (2007). "The Sustainability of Chiropractic". Dynamic Chiropractic. Vol. 25, no. 19.
  227. ISBN 978-0-89789-747-1
    .
  228. ^
    doi:10.1525/maq.1987.1.2.02a00030
    .
  229. ^ "chiropractic". Oxford English Dictionary. Oxford University Press. 2014. Archived from the original on May 3, 2013.
  230. ^ "chiro-". Oxford English Dictionary. Oxford University Press. 2014. Archived from the original on August 12, 2014.
  231. ^ [1] — Chiro.org
  232. PMID 2817179
    .
  233. PMID 27475472
    .
  234. PMID 15530683
    .
  235. PMID 2782512
    .
  236. ^ Jaroff, Leon (27 February 2002). "Back Off, Chiropractors!". Time. Retrieved 7 June 2009.
  237. ^ Gunther Brown, Candy (July 7, 2014). "Chiropractic: Is it Nature, Medicine or Religion?". HuffPost.

Further reading

External links
Retrieved from "https://en.wikipedia.org/w/index.php?title=Chiropractic&oldid=1194023566"