Talk:Chiropractic/Draft

Gareth Leng has nominated this version of this article for approval. Other editors may also sign to support approval. The Healing Arts Workgroup is overseeing this approval. Unless this notice is removed, the article will be approved on 20070326.

The history seems mixed in with the presentation of the theory, which to some extent is unavoidable, but it seems odd to discuss the concept of subluxation _after_ the legal fight with the AMA. DavidGoodman 21:52, 2 November 2006 (CST)

I've re-ordered. I think this is basically a good aricle, and that the historical approach is a good way to explain the subject, I've trimmed it down from the WP original, and thrown some detail into the references. I'm now done with thisGareth Leng 11:06, 7 November 2006 (CST)

lead

I re-wrote some of the lead to bring it into the 21st century. Chiropractic is much bigger and more complicated than just the looking for and treating the mythical subluxation;) We really treat a lot of pain and work with a lot of musculoskeletal problems while asserting that taking care of your spine is a good idea. That is not to say that there weren't all kinds of methods that have been tried and developed over the years, but they can pretty much be boiled down to working toward this end. --D. Matt Innis 20:56, 3 December 2006 (CST)

Thanks Matt. ..."potential nervous system interference"... think we need in the lead to explain things simply, can you have a think about a rewording that might work for say a 14 year old? Gareth Leng 09:07, 4 December 2006 (CST)

I spent all that money to learn how to think like a 14 year old:) There's a joke in there somewhere. You said it best, I just replaced it! --D. Matt Innis 10:33, 4 December 2006 (CST)

Chiropractic vertebral subluxation

I think you're right that the VS should be closer to the top. I also think that we can do a better job explaining it. Lets go for it. I'll try and get it all down and if you would go behind me and clean up that would be fine. --D. Matt Innis 15:15, 5 December 2006 (CST)

Hi Matt. There's one thing I'm very unclear about. DD Palmer clearly saw that promoting chiropractic as a religion might protect it from being taken over by the medical establishment. How much of this was sincere and how much was it just a stategem? In other words, did he deliberately stress the mystical associations of some concepts, in almost a cynical way? Or did he indeed become self deluded and see himself as a prophet?Gareth Leng 05:32, 6 December 2006 (CST)

Gareth, as you know, I have been reading everything I can find to determine this very question for the last 6 months. There are sources that state it both ways. The problem is that there were battles going back and forth from BJ's group vs DD's group and the mixers (John Howard, et al at National, etc.) on the side shaking their heads. Because BJ had taken over the "fountainhead" role, DD was dying to get it back. He tried to open several new schools, even calling one "Fountainhead", but he couldn't pry it loose. Meanwhile, BJ and his group were building a philosophy based profession and finding a way to get the practice of chiropractic legally seperable from medicine. When DD made the "religious" statement, California (the state has was wanting to move to from Oregon) was fighting a fierce battle with medicine to create a law that would protect chiropractors. BJ's straights kept interfering and because chiropractors could not reach a consensus, they were not able to do so. Meanwhile chiropractors were going to jail by the boatloads. Seeing that BJ was becoming the "philosopher" of chiropractic, and seeing how christian scientists had just won the right to practice citing freedom of religion, it does not seem far fetched to see that DD could kill two birds with one stone; become the "leader" of chiropractic again, and free the profession to practice without the threat of jail. From what I can tell, he was rejected, though that could be because he died months later. BJ then covered up his fathers writing until his death in 1963 in the Palmer archives.

So, I think a case can be built either way using resources, but if we put them all together, it looks to me that DD was intially making sound and bold scientific statements about his idea. He was reducing them as he found out new information, even from nerve pinch to no nerve pinch in the intervertebral foramen, etc. But, after going to jail, his attitude changed drastically and the "vital" elements from his past began to show back up. He was really wanting to be a scientist, but because of the political environment, it wasn't going to happen. I really think that the next several generations held these concepts in order to keep medicine from dictating how they could practice until science could catch up, similar to John Howards statement about "DD palcing a veil around chiropractic to protect it until it grew up." --D. Matt Innis 07:07, 6 December 2006 (CST)

On Approval - I think we need to set in place a process for approving this article, and I'd propose that we ask Nancy if she'd take on the role of "objective editorial oversight" to guide and be the ultimate arbitor.Gareth Leng 05:32, 6 December 2006 (CST)

Comments and suggested changes by Nancy

Chiropractic approach to healthcare

current article text : The traditional, 'medical' or 'allopathic' approach to health care regards disease as usually the result of some external influence, such as a toxin, parasite, allergen, or infectious agent: the solution is to counter that influence (e.g. using an antibiotic for a bacterial infection). By contrast, chiropractic involves a naturopathic approach, believing that lowered 'host resistance' is necessary for disease to occur, so the answer is to strengthen the host.[7]

My comment: Allopathy is a historical practice, and does not connotate current medicine. Medicine is simply medicine, the professional current practice of medicine, and not 'medicine ', If you hyperlink medicine to the current CZ article, that might help. I think a line like: "Although host responses and resistance are considered important in medicine, few treatments in mainstream medical practice are actually aimed at fighting disease through augmenting host response alone." In medicine and nursing, host resistance is more often generally approached through nutrition, exercise and physical therapy.

If I wait too long on an editing page, I'll have a problem posting and so my comments are going to be parcelled. more to come. (by the way, I think the writing is very good) Nancy Sculerati MD 07:09, 6 December 2006 (CST)

Allopathy is a historical practice, and does not connotate current medicine.

I am so glad to see you say that. I agree. I have that same problem with chiropractic. The current practice of chiropractic is the whole of what chiropractors do, not just the DD Palmer definition. But when we begin to write that, we realize that when we say chiropractors use physical therapy, we are stepping on the toes of physical therapists who claim it as theirs and nutritionists, etc. But pigeonholing both medicine to "drugs to fight disease" and chiropractic to "free the 'vital spark'" is really innaccurate. We have to differentiate chiropractic from what chiropractors do and medicine from what medical doctors really do. Perhaps we should say 'the allpathic model" or "the historical allopathic model". Or we can return to using this as the quote from Rbert Mootz,D.C as his opinion. What do you think? --D. Matt Innis 08:47, 6 December 2006 (CST)

What about treatment of systemic disease and local infections?

Personally, I would go to a good chiropracter in a minute for a musculo-skeletal problem, and have, in my practice, referred to selected chiropracter's for treatment of back pain. So, I want you to know that I am not an 'enemy physician'. But there is a big issue here that is unsaid. There are many chripracters (at least in NYC) who treat cancer, AIDS, allergy, ear infections in children and basically any illness through adjustments. Some of them tell their patients that antibiotics and other generally accepted medical treatments can interfere with the success of chiropracic therapy. There is nothing at all mentioned in this article about the treatment of specific illnesses, such as breast cancer or gallstones or otitis media in Chiropractic. That is too important to leave unsaid. Matt, could you address it? Do all chiropracters' treat all illnesses? What's the code of ethics for referral? Are there specific schools of chiropractic that have differing outlooks in this regard. I will re-read article, but I don't think this is discussed. Nancy Sculerati MD 07:24, 6 December 2006 (CST)

more specific comments

Here are more comments. I won't make any changes in your article unless explicitly invited for each change I suggest. I view my discussion of your paper as a CZ experiment in alternative editing. Maybe we can develop friendly professional protocols that change the culture without losing the great benefits of open interaction!

You have made a very nice article, that – as far as it goes, is both readable and generally accurate. It’s the best single article I have ever read on the subject. I do think it needs improvement – primarily because it must address the treatment of illnesses other than musculoskeletal pain and conditions by chiropractic to avoid being a misleading introduction of its subject. I cannot begin to address that issue myself. I don’t know the field and I don’t know where to learn about it. I think you (Gareth and Matt) are great resources and I am tremendously interested in reading what you come up with. Except for that, I think this article is ready for approval and should be temporarily frozen in anticipation of the launch. I do think there are minor improvements you might consider, but these, in my mind, (unlike the systemic disease issue) in no way preclude approval.

Since every good article has a voice, and having many writers writing the same piece without orchestration tends to muffle it, instead of accentuating it, I am limiting myself to the discussion page. If there is anything I write here that you’d like to use, take it and cut and paste as you wish. If not, that’s fine too.

1.(present version of article) “In conventional medicine, the term subluxation is usually associated with conditions which are a direct consequence of injury to joints or associated nerves. [1]”

I think that this is much too subtle to be informative. If the reader does not already know both the medical and chiropractic definition of “subluxation” (and few will, I didn’t) they won’t get it. Even if they read the hyperlink, they might not understand. That hyperlink text for subluxation is neither clear nor strictly accurate.

1. (suggested change) The same word, subluxation is routinely used by both physicians and chiropractors, but each of these professions means something entirely different by the term.

The chiropractor uses this term to refer to an invisible phenomenon that involves forces of mental energy that are not described in current biology and not recognized as real by the physician. (full description of just exactly what a chiropracter means by the term in plain language).

A physician, on the other hand, only refers to a body part as” having a subluxation” if it is indisputably out of its functional position. So, when a radiologist reads a spinal x-ray as “showing subluxation of a vertebra”, he or she always means a bone in the spinal column is visibly displaced on the image. A pediatrician calls the elbow joint of a child as subluxed in the condition “nursemaid’s elbow” only if the lower arm bones are pulled out of the joint capsule and the child cannot move the forearm.

The differing use of this term by physicians and chiropractors is one factor that has contributed to the hostility of much of organized medicine against the profession of chiropracter. A patient may feel benefit from a chiropracter's treatment of his back pain, but when he next sees his physician, and announces that the chiropracter "fixed my subluxation", that physician is prone to view the chiropracter as a fraud, rather than a healing arts practitioner who may be on to something useful. After all, she'd reviewed the cat scan of the patients back and knows for a fact that there was no subluxation!

Perhaps the lack of scientific recognition of the chiropracter’s meaning of subluxation is due to lack of a focused study by biologists. Arguments have been made that the theoretical basis of the maneuvers in chiropractic do deserve scientific investigation. However, with few exceptions, chiropractors themselves are not trained in science or in the use of formal research methods. (might fit some of that into the research stuff you already have) Also, I argue that the medical definition is actually a biological definition. It is not just true in medicine, but also would be used by a vetinarian, and by an animal physiologist – by anyone who uses the language of biology.

Anyway, regards to all and I'll stop back again soon. Matt, just write how it really is - but you have to reference it to the national or world state of the profession. It seems that the problem may be that most of the global literature was produced decades ago. Still, the article -though of course should go through the history, best serves the reader by describing the current profession. Best you can, honest and plain language (though also diplomatic, accurate and respectful- of course!!) :) Nancy Sculerati MD 09:24, 6 December 2006 (CST)

Thanks, Nancy, for your very insightful input. I think you have addressed the things that I needed to hear. Sometimes you can't tell if anyone else thinks they are important. I will also have to address them in pieces between other activites. Let me start with giving some input to your conversation to let you know where I'll be trying to go.

Consider for the moment that vertebral subluxation does not involve a "spiritual" component. Consider that there is a functional possibility that a vertebra can be in perfect alignment, but due to adhesions from an old injury, it does not move in the kinetic chain properly, it would not show up on an xray, or for that matter, may not show up if you moved the patient through gross ranges of motion. But if you were able to isolate that one joint and put specific pressures on it and it didn't move or have that "elastic feel" like those above and below it, you would certainly note that it was dysfunctional. We call it subluxated for lack of a better word (from way before our time). We certainly don't expect just anybody to find this, anymore than we expect just anyone to be able to palpate a tumor on the kidney; its a feel that you develop with practice, practice, practice. How many people can palpate an ovarian cyst?

Now, whether there are consequences of this "lack of motion" is also debatable. There is research that shows that if we pin two vertebrae together on a rat, signs of degenerative disc and joint disease begin within months. Is this important? Certainly from an arthritic and pain POV this is reasonably important. Some chiropractors assert that this is important for overall health as well. Certainly from the patient's POV it feels better not to have either of these conditions. There is also some research that may provide a link to th line of thinking about health in general; mostly along the lines of innervation by the recurrent nerve of the spine which exits the intervertebral foreman, innervating the facet and posterior disc before returning to synapse in the lamina levels of spine that coorespond with the gray matter for the autonomic ns. Whether this can explain effects that chiropractors claim by affecting perhaps the vasomotor tone of the blood supply to an organ system or whether the nerve carries some other mechanism of information (neurotransmitters or other end products) that determines the health of the organ is still up for grabs, but I think neuroscientists are getting close to finding that out. OR, are somatic referral systems from "subluxated" facets the explanation for a percentage of right shoulder blade and abdominal pain that is often misdiagnosed as gall bladder pain, accounting for the claims? Again, I think we are close to finding that out. --D. Matt Innis 12:29, 6 December 2006 (CST)

Many efficacious practices in medicine came about before the physiology was understood, often there was a rationale offered that was later changed. But you see Matt, a person such as myself, and practically anybody who is not a chiropracter only knows what's in the books, and that's the hundred plus year old theories. It would be like reading a medical textbook from the civil war and relating it to what goes on today in a hospital. So what I want to know from you is what a chiropracter actually does. I can tell you that all doctors, generally speaking, who see patients go through a ritualistic history, physical exam, review of labs and past history, and depending on specialty might offer treatments. Is there a protocol accepted as proper practice for chiropracters? Do you keep records? What do they look like? Do you take x-rays or perform tests? How is a chiropracter licensed? Certified? Could you write about that here in the discussion? Then, if you like, we could put it together in the article.Nancy Sculerati MD 15:09, 6 December 2006 (CST)

Nancy, I changed the conventional medicine subluxation line to this:

• In conventional medicine, the term subluxation is not be used until these joints show a more obvious pattern of pain and misalignment.

Not sure I've captured the essence, what do you think.

As an extra note, I think most chiropractors see this "imaginary force" as a mental process that has its foundations in an the physical/chemical world, but no-one has been able to reduce it to that yet. Certainly, an emergent process that is explained in concepts that get too complex for the average clinician to relay to his patient is a possibility. So basically, I think it boils down to the subluxation being a milder level of what medicine considers a subluxation with a couple added twists concerning the nervous system's role. Am I making sense? --D. Matt Innis 15:17, 6 December 2006 (CST)

I see you've written more, let me see some patients and I'll get back to you. The answer to all of it is; yes. --D. Matt Innis 15:17, 6 December 2006 (CST)

Chiropractic education etc.

Nancy, this is information that was in the WP chiropractic article at one time but has been split into other articles because the original got much too long. We have apparently imported them into CZ so it may be just a matter of adding the wikilinks, though we might want to paraphrase some in this article to give a short synopsis of each. Just give them a quick look and let me know what you think is the most important.

• Chiropractic education
• Chiropractic school
• Council on Chiropractic Education
• Foundation for chiropractic education and research hmm, this one is missing
• Federation of Chiropractic Licensing Boards
• National Board of Chiropractic Examiners

I think this is all related enough that we can probably write a short section and link all these from there. --D. Matt Innis 22:35, 6 December 2006 (CST)

I've had a go at starting to incorporate Nancy's suggestions, amplified in the light of your comments Matt - see if I've got it about right?Gareth Leng 04:58, 7 December 2006 (CST)

Matt, there is almost nothing in WP that is clearly written and plainly explains. So look through and rewrite or just write it yourself. I'd say. The goal (to me) is not to make a lot of high sounding rhetoric but to actually explain, like you would to a friend who is intelligent but knows nothing about what it takes to be a chiropracter, just how you get to be one, how people generally do, and what the professional and legal regulations are like. Explain it to me, I'd like to know and I am a friend, or at least a penpal. I'm asking you. Don't ask me to read WP for your answer. I don't want to. Nancy Sculerati MD 06:02, 7 December 2006 (CST)

Okay, have done some in VS and Education (tough to make education interesting). Feel free to comment and adjust (pun intended:) --D. Matt Innis 11:11, 7 December 2006 (CST)

Going through again and making comments-Nancy

1 current Chiropractors emphasize their belief that a patient's health is compromised when spinal injuries, which some call vertebral subluxations, interfere with the body's ability to maintain adequate posture and joint function. They assert that, when neglected, these conditions can lead to accelerated degenerative changes such as arthritis and, by interfering with the nervous system, result in many different conditions of poor health. In conventional medicine, the term subluxation is not be used until these joints show a more obvious pattern of pain and misalignment. [1]

Why not say- “Chiropractors believe that…” instead of “Chiropractors emphasize their belief that…” 2. Do you really believe that the problem is spinal injuries? From what I understand from what you have written, chiropractors do a maneuver to ‘crack’ or ‘pop’ the inter-vertebral joints. Even if this has benefits, it does not follow that the joints or spines were originally injured or in any way displaced. When you say “In conventional medicine, the term subluxation is not be used until these joints show a more obvious pattern of pain and misalignment.” It implies that there is a continuum between normal joints and subluxed joints, but that is not really true. It is not a continuous change, in medicine a joint is either dislocated or it’s not, it’s a quantum change. Subluxation specifically means that the joint is dislocated out of the normal position such that it is visible on x-ray and would be visible to the naked eye if you removed the soft tissues covering the joint. Are you arguing that everybody who comes to you has minor subluxations in that sense? If they are so subtle that they cannot be either seen by surgeons or radiologists than they don’t exist. Scientists reject the idea that something exists that cannot be measured. For example, you previously – in the talk section, not in the article, pointed out that many doctors cannot palpate an ovarian cyst that perhaps some doctors do feel. So yes, an ovarian cyst may be there and yet a doctor cannot detect it on physical examination. But even if an ovarian cyst cannot be palpated, if it is there it will show up on ultrasound, or CT scan, or certainly if the ovary was surgically removed and examined by a pathologist. If the ovarian cyst that is said to be there by a doctor cannot be seen on ultrasound, cannot be seen by the surgeon removing the ovary, and cannot by the pathologist sectioning the organ and examining it through a microscope, then it is not there. Nancy Sculerati MD 13:26, 7 December 2006 (CST)

Hi - Matt - we had an edit conflict, so I'll back off a while. The bits below were my edits, keep anything worthwhile

I'm done for awhile! Go ahead and do your thing to clean it up and tie it all together and we'll see what we have. I know I scatter my thoughts all over, that's how I think;) --D. Matt Innis 14:35, 7 December 2006 (CST)

There is ongoing debate within the profession as to whether there might be benefit in changing the terminology of subluxation to satisfy the medical model. Similar to when dentistry abandoned the term 'cavity' for 'carie' to describe a barely visible defect that preceded an actual pitting of the tooth that took the form of a cavity. The alternative term segmental dysfunction is already used for insurance and statistical purposes, so making the transition would be relativley easy, but this terminology does not entail the nerological component of the condition.

Perhaps the lack of scientific recognition of the chiropractor’s meaning of subluxation is because biologists have not given the concept much serious attention. Arguments have been made that the theoretical basis of the maneuvers in chiropractic deserve more scientific investigation, claiming that, with few exceptions, chiropractors are not trained in science or in formal research methods. But chiropractors argue that their concept allows them to see their patients as more than the 'sum of their parts'. They believe that trying to explain all the complex physiological processes that combine to make a human being function in terms of the basic underlying physical and chemical components, misses things that are important for understanding what makes a human being healthy. Perhaps this is why chiropractors have been so reluctant to join their medical counterparts in their pursuit of the scientific answers to disease. They tend to prefer to interest their patients in taking part themselves in building health and wellness. Some contend that retaining the holistic concept of subluxation is an important element in preserving that principle. Gareth Leng 13:29, 7 December 2006 (CST)

Hi Nancy, I think you're getting to the heart of the divergence of views in your comments. But I'd wonder whether it's really true that 'Scientists reject the idea that something exists that cannot be measured', after all we commonly admit that 'lack of evidence' is not 'evidence of lack'. I think it is true (and rightly true) that scientists are very reluctant to invoke any redundant explanations or introduce unneccessary concepts, but we are often forced to where we encounter things we can't explain; often they are 'holding terms' until an explanation becomes clear, but sometimes they last a long time. I'm thinking especially of mental states - like stress or anger or anxiety, we have a pretty poor understanding of what these are, and essentially they are still high level concepts awaiting mechanistic explanation. Most relevantly, wjhile we know that the mind has an influence on how we recover from illness, we have a very limited grasp of what this involvesGareth Leng 13:39, 7 December 2006 (CST)

I need to clarify my meaning - and, as always, I could just be wrong. But I say that if something by definition cannot be measured or detected in anyway, then it has to be said to have no real existance. Meaning, maybe a sound does not show up on a picture, maybe it is not 'heard' if no one is there to hear it, but there is, at least in theory, a way to measure a sound. And if you claim that there are sounds, but that these are simply are too subtle to be detected by any method, inccluding the most sensitive instrument to detect molecular motion, then I say there are no sounds. Maybe there is something there, but it's not a sound. I had prepared some comments before I came back to the talk page and read your last entry. Take a look below at the ovary business. I'm pasting the comments in just after the period here.

Let's go back to the ovarian cyst. Again, if an ovarian cyst cannot be palpated, if it is there it will show up on ultrasound, or CT scan, or certainly if the ovary was surgically removed and examined by a pathologist. If the ovarian cyst that is said to be there by a doctor cannot be seen on ultrasound, cannot be seen by the surgeon removing the ovary, and cannot be detected by the pathologist sectioning the organ and examining it through a microscope, then it is not there. Either the doctor who palpated it and identified it made a mistake, or there was something there and it went away before the subsequent tests were made, or there was something there (that's probably still there) that was not actually in the ovary. If a doctor says, well - the cyst is there, and it is absolutely in the ovary, but any attempt to detect it will fail - yet not remove it in a curative sense and I'm reluctant to any way try to actually detect it - but I insist that it is a cyst on the ovary- what are we left with?

Unless I've got it wrong ( and I may) a chiropractor is insisting that there is a joint dislocation that is so small that even the most sensitive scan cannot detect it, yet it is a true physical dislocation of the joint. I say, that cannot be so. Perhaps there is a problem with the joint, but it is not a physical dislocation. Perhaps it's something in the way the joint moves, and if that's so there is a way to measure it. Measurements do not have to be invasive. Maybe it is nothing to do with the joint in terms of a problem, but manipulating the joint still provides a health benefit. In other words, perhaps there is a difference in blood flow or neuronal activity or something after the manipulation. The fact that it hasn't been measured does not mean it can never be measured. But if for political correctness within chiropracty we have to insist that there is simply an unmeasurable physical dislocation of the bones in a joint capsule, one that is by definition too subtle to be measured in any way - I say that's religion, not science. And, by the way, I believe that religion works as a cure for some ills in some cases.Nancy Sculerati MD 15:12, 7 December 2006 (CST)

You've got it exactly right! What we're saying is that there is something physical there and we feel it with our fingers and it is slight. We feel it the same way a gynecologist feels the ovarian cyst. I wouldn't expect a gynecologist to feel a subluxation any more than I can feel an ovarian cyst. It takes practice and you have to know what a lot of normals feel like before you can find an abnormal. This part is not the religion. The religion comes when someone believes that when they "pop" the joint, it frees Innate Intelligence to flow to the body. But that is another story. The scientific chiropractor is looking for the neurological or blood supply changes that you suggest. Am I making sense? --D. Matt Innis 16:05, 7 December 2006 (CST)

And, along those lines, I also believe there are real effects of religion and prayer, and plan to use them when the time comes, but not in place of medicine or surgery;)--D. Matt Innis 16:26, 7 December 2006 (CST)

well, not really for the article - but in terms of general discussion, there are reasonable ways to go about testing for objective evidence. For example, if a patient has an ovarian cyst - more than one experienced doctor can feel it. I don't say everu docyor, but among GYN oncologists, who are probably the best at feeling pelvic masses on exam, it won't be that only 1/500 experienced ones feel it. So, one way to approach research in this field might be to select a number of chirppractors who are experienced and well trained. Take 20 patients. On a single day - have all the chiropractors, one by one but not in the presence of each other, feel that patient and list just where adjustments are needed, but do no adjusting. Ideally, when testing examination capabilities there is some gold standard, like surgical examination of the ovary or at least an imaging study, but I accept that here there may not be. On the other hand, if we could be free to imagine any research protocol - I'd say take patients who were already scheduled to get CT scans of their backs. Let the group of chiropractors examine them. Then compare the CT scans, and the chiropractors findings. It should be that several (not all but more than a chance number) of chiropractors agree on certain joints as needing adjustment. If so , then having a radiologist examine the scans and look at those joints as compared to those that no chiropractor thought needed adjustment might reveal some ojective radiological findings (not necesarily dislocation - just something) that correlates. I'll do a search to see if anything lik that has ben done.Nancy Sculerati MD 17:09, 7 December 2006 (CST)

Yes, vertebral subluxation is much less than a dislocation. It may also be aligned correctly but not be moving correctly. This is why we differntiate as "a misaligned or dysfunctional" vertbra. The technology is here and it is starting to show us. MRIs were showing atrophy of the multifidus muscle at the level of the patients pain seen on MRI years ago, but nobody was looking. As you know, these are the small muscles that run only from one lamina of a vertebra to the spinous process of the next vertebra. In other words, these are deepest and most intricate muscles related to the facet joint that gets palpated. If a joint get stuck, it is the one that will atrophy first. They get their nerve supply only from the nerve that exits at that level. When palpating, you attempt to feel the relative symmetry of the muscle bellies of this and the erector spinae. When you find one that is tight or you feel only a hard boney feel that doesn't move properly (sometimes they move too much), you know it is an area that is having trouble, whether it is from an old injury, a new injury, or postural abnormality. The patient knows you found it as well because it will be tender. We would certainly identify that as a subluxation. Depending on the history and what we are considering doing about it, we might xray to see if there were signs of degenerative joint disease so that we could get a feel for how long it has been there. If the xray looks normal that does not mean that no subluxation exists, only that it is pretty safe to assume that it is relatively recent(within the last couple years). There are too many factors for deciding that and it becomes more of an art than a science, but you do similar things in your practice I'm sure. The xray may also helpbmake sure that there are no contraindications to manipulation, i.e. spondylolysis, osteoporosis, osteopenia, unusual anomalies, metastatic cancer(one-eyed pedicles or osteolytic and osteoblastic activity), aneuysmal bone cysts, etc.. There is so much more to it than that, but I hope it helps you understand what and why we do things the way we do. It is no longer a question of "do these exist" it is "are they significant" and if so, significant for what? Do they have any effect on health whatsoever? Most of us really don't expect anyone to find a "spiritlike" creature, but we would like to know whether the nervous system can play the role that DD Palmer originally postulated - adjust vertebra = affect nerve = affect health.

This is just one example of how the information is coming out [1]. No we don't have all the answers, yet, but that it doesn't mean that we are going about it in an unscientific way. There is no-one more anxious to find out these answers than we chiropractors, we just need the resources to conduct the research and it is coming slowly, but surely. --D. Matt Innis 18:53, 7 December 2006 (CST)

So, Matt & Gareth – some specific article comments.

1.If your only evidence that some chiropractors are trained in surgery is that an individual chiropractor claimed he was, then I think – for now- you should take that out. That’s the sort of thing that needs to be firmly proved before stating it in the article, and by documented sources like actual copies of state laws, not by here say.

Done --D. Matt Innis 21:16, 7 December 2006 (CST)

2. In conventional medicine, the term subluxation is not be used until these joints show a more obvious pattern of pain and misalignment. This is not true. There can be a subluxation without pain, a subluxation does not even have to be in a joint – for example, the lens of the eye can be subluxed. Subluxation means( in conventional medicine), that there is a physical dislocation such that the part is completely out of place. Period.

Nancy, would you put that in for me so we get it right this time. --D. Matt Innis 21:16, 7 December 2006 (CST)

3. I was really struck by your descriptions of what you do, and I think you should incorporate them into the article. You wrote” When palpating, you attempt to feel the relative symmetry of the muscle bellies of this and the erector spinae. When you find one that is tight or you feel only a hard boney feel that doesn't move properly (sometimes they move too much), you know it is an area that is having trouble, whether it is from an old injury, a new injury, or postural abnormality. The patient knows you found it as well because it will be tender.” Perhaps you might (for the article) write: The chiropractor palpates the spine to carefully feel for the contour of deep muscles that run from vertebra to vertebra. The relative symmetry and flexibility of the multifidus and erector spinae muscles are clinically assessed during that examination, along with their associated structures. When an area of musculature is feels tight, hard or boney, the chiropractor checks to see if the vertebral joint under it often moves properly. If the joint is either stiff or unusually mobile, such an area is identified as a trouble spot, which may be secondary from an old injury, a new injury, or postural abnormality. Often, the patient also identifies that same spot during the chiropractor’s examination because of pain during palpation. Unless I got the above wrong, of course. Nancy Sculerati MD 21:03, 7 December 2006 (CST)

You got it right! I'll put it in an you are welcome to clean it up. I do get wordy sometimes and I need somebody to keep me on topic:) --D. Matt Innis 21:16, 7 December 2006 (CST)

Did you see the answer to your cavitation question? --D. Matt Innis 21:16, 7 December 2006 (CST)

---

I went to the hyperlink on cavitation and I couldn’t easily understand it. Please fix it. Which kind of cavitation do adjustments depend on, inertial or non-inertial?

Inertial, I describe it to my patients like when you open a pepsi bottle and you release pressure and bubbles form (only in the joint you are creating a relative vacuum). They will stay there until they are resorbed by the fluid again - or in the pepsi example, when it goes flat. During that time, the joint space is widened and results in more motion for the joint. From what we can tell, the reason they feel better is because there is a blast from the mechanoreceptors in the facet capsule that overwhelm the normal proprioceptive feedback loops (gate theory) and decrease pain similar to scratching an itch. NOW - is there a reflex arc that has effects the organs innervated at that level of the spinal cord? This is what chiropractors "believe" and "emphasize" as the reason for their treatment, because we don't "know" that it is there, "yet".--D. Matt Innis 16:47, 7 December 2006 (CST)

The article says "Some also use other complementary and alternative methods. However, chiropractors do not prescribe drugs; they believe that this is the province of conventional medicine, while their role is to pursue drug-free alternative treatments, but some are trained in minor surgery."

Exactly what surgery procedures do chiropractors do? Exactly what is the training? Which are trained? Nancy Sculerati MD 14:55, 7 December 2006 (CST)

A chiropractor stopped by from Portland Oregon who said his school taught minor surgery and it was legal in Oregon and other countries. I would assume they mean things like taking off warts or something along that line, but I really have no idea. I will check into it. --D. Matt Innis 16:22, 7 December 2006 (CST)

Opening too long?

I wonder if the opening paragraphs could be trimmed? Shouldn't it be more like an abstract (~300 words) of the article? The first section could be an overview type section if you think this is still required. Chris Day (Talk) 16:49, 7 December 2006 (CST)

I think Gareth and Nancy would probably be best for this... everything I do adds more words and before we know it we'll have to split the article again! --D. Matt Innis 21:37, 7 December 2006 (CST)

Much better! This is really coming together nicely. You guys are goood! Are we missing anything? --D. Matt Innis 10:54, 9 December 2006 (CST)

Cavitation gif

I added an animated gif for cavitation. Is it helpful or does it take away from the quality of the article? --D. Matt Innis 10:52, 9 December 2006 (CST)

I liked it.

Should I make it so it "cracks" constantly or just when you click on the "see animation". --D. Matt Innis 22:55, 11 December 2006 (CST)

btw, Tom Moore or Tom Morris???

Morris! Tom Moore was a fellow scoutmaster:) --D. Matt Innis 11:23, 10 December 2006 (CST)

Need a para to meet Nancy's major concern (treating other conditions). This will need you and I Matt. I could have a go but won't get it right first off - shall I try and you can put me right?Gareth Leng 10:36, 10 December 2006 (CST).

Yes, maybe it would be better for you to start with what you think is important and I'll clarify. That way I won't go overboard on tangents. For references, dysafferentation gives a great history of research that makes an effort to explain the science behind the concept of subluxation, Sympathetic nervous system response to mechanical stress of the spinal column in rats. shows that there may well be some autonomic response that affects organ systems, and Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease discusses that maybe there is confusion about the etiology of pain - perhaps the reason the patient failed with medical care was misdiagnosis it was somatovisceral in the first place. But I am sure you have a pretty good feel for what is needed for the article on your own.

I can't wait to read it! --D. Matt Innis 12:02, 10 December 2006 (CST)

Non-spinal disorders

OK, first shot - up for brickbats.Gareth Leng 05:13, 13 December 2006 (CST)

Hey, you've been holding out on me;) Now we're talking! Very well put and succinct. You have a very good grasp. Okay, I'll do my thing in short spurts throughout the day. You are welcome to cleanup at any time. I do see some things that I think we can square. --D. Matt Innis 07:55, 13 December 2006 (CST)

OK, took a few shots myself. Yours are pretty solid. I think we have a way to go. Nancy, if your watching, feel free to jump in because I can use your POV otherwise I am just making assumptions. --D. Matt Innis 21:15, 13 December 2006 (CST)

Also, I think we're going to have to trim the history some and create another article for chiropractic history. I don't want to lose the total story because I think it answers a lot of questions that everybody (including chiropractors) ask. What do you guys think? --D. Matt Innis 21:36, 13 December 2006 (CST)

I've removed this sentence as I didn't understand it "BJ Palmer reduced the adjustment to 'Hole In One' - the adjustment of only the atlas, while mixers continued to add and refine techniques to find and reduce subluxations." Maybe this should go in the BJP article?

No big loss, nobody uses that terminology anymore. Apparently it is now Specific Chiropractic (specific to the atlas vertebra). --D. Matt Innis 07:38, 14 December 2006 (CST)

You know I love the history and I really don't want to see it go elsewhere, although it deserves expansion elsewhere. Lets try and tighten a bit and see what Nancy thinks.Gareth Leng 04:27, 14 December 2006 (CST)

OK, sounds good. --D. Matt Innis 07:38, 14 December 2006 (CST)

I've made the article on DD Palmer live and taken the religion quote into it in full; I thought maybe it was tangential here. Think we need to look at the effects of the reordering - I see that the Flexnor report is now mentioned before its described etc., a few things like that.Gareth Leng 05:53, 14 December 2006 (CST)

Yep, it's reshuffle time then we can go another round. --D. Matt Innis 07:38, 14 December 2006 (CST)

Good job guys. I'm liking it more everyday. Nancy, nice touch on the lead.. keep working! --D. Matt Innis 13:51, 14 December 2006 (CST)

Will do. hey, what are brickbats and how come you both understand that word? Nancy Sculerati MD 14:33, 14 December 2006 (CST)

LOL! I didn't say I knew what brickbats were, only that I knew what Gareth meant:) I'll take a jab at it - I picture large flat bats that are used to break ?bricks? or maybe to paddle bad kids! --D. Matt Innis 14:44, 14 December 2006 (CST)

Oh, wait a minute - maybe it has something to do with the all british past-time, Cricket! --D. Matt Innis 14:46, 14 December 2006 (CST)

Heck no! I was WAY OFF! [2]

Lets get the cancer thing right

It is important that we get this right, at least on a rationale basis:

• There are chiropractors who are willing to use adjustments to treat any disease, including AIDS and cancer, in both children and adults.

I shutter to think that there might be someone out there telling their patient that they are treating their cancer or AIDS as a chiropractor. Having said that, I think it is safe to say that all DCs treat patients that have AIDS and some cancers (provided their are no red flags - metastasis to the spine, osteopenia, etc.). I generally tell them that if they think it is helping them in any way, use me as you see fit, but be sure to let their MD know. Those few patients that I have seen are also going through the medical route with chemo, etc. Though I suppose there are those that may choose not to do the chemo and go to the chiropractor instead, hopefully the chiropractor is telling them that it is not a cure for cancer or AIDS! If not, they are certainly at risk of violating most chiropractic legislation that states that a chiropractor may treat what they are taught in school. At Logan, in our jurisprudence class, if we answered any question wrong concerning what we should do with a cancer patient, we immediately flunked the class - NO QUESTIONS ASKED - no passing GO, no second chances. Nobody ever missed those questions. In other words, I don't think this is common acceptible practice in chiropractic. I would really like to know if this was really something you guys hear from reliable sources or is this one of those rumors that goes around? Or is it that the chiropractor is using homeopathy or some other CAM. If that's the case, then how do we handle that? I'll stop now. --D. Matt Innis 16:19, 14 December 2006 (CST)

Matt, I had edited that out even before I read your post. I edited it out when I got to the Mercy guidelines. But then, I came to the talk page to ask you the question I am about to pose, and I came across the above post. Anyway, please know that I lived in Greenwhich Village for about 30 years and I practiced medicine in NYC for about 20 (counting residency). There are people who go to DC for adjustments for treatment of their immune system and cancer, but I'm not claiming on the basis of what I know that this is because the DC misleads them or is specifically treating them for those illnesses. Frankly, in my earlier days AIDS was considered not only incurable but untreatable ( in the early 80's) and so if a DC was offering treatment I wouldn't even consider that unethical. I do know that Otitis media and allergy were specifically treated in the 90's by DC in Manhattan, and that they wrote about it in local neighborhood papers and circulated sort of "info-mercial" papers. Since the original DC did treat everything, I made an asumption and am glad to have you correct it.

But what I want to see are the written guidelines of what to treat and not treat. I can't find them in that Mercy book. It may just be that I'm not looking in the right place. Can you show them to me? [If not there, somewhere else? [User:Nancy Sculerati MD|Nancy Sculerati MD]] 16:43, 14 December 2006 (CST)

What about the length?

I do not want to butcher this article, but we have a real problem with the length. This is what I propose: for now- we have previous versions and can always put it back- lets take out all the "Three Rivals" stuff and put it in a new "History of Medicine" or History of Medicne in the US and link it. I'm going to try. Nancy Sculerati MD

I just looked again, and that's not a good solution. I also looked at the biology article, it's 37 kbytes. I really think we have to aim for under 40. Can we do a History of Chiropractic article and link it? We should keep the first stuff on palmer in there. Matt and Gareth- would you each comment, please? Nancy Sculerati MD 17:21, 14 December 2006 (CST)

We had this same problem on WP and had to cut out a lot of history, all of education and regulation, and most of the heart of the article. It pretty much gutted it. That's why when you asked about adding stuff, I hesitated, but I am okay with it as long as it gets replaced with something better. So far all the changes have been for the better. I'm open to any ideas and know that we can always put things back as long as we end up with an article that accurately, neutrally and sympathetically paints the proper picture. --D. Matt Innis 19:49, 14 December 2006 (CST)

I went ahead and made a new Chiropractic History article and copied it over. We can always delete it if we don't want to use it, but if you guys want to try some things go ahead.

As a note, I do think that having the history helpd to explain why chiropractic and chiropractors say the things they do and act the way they do. It also helps to realize why the research is not where it would have been had things not happened the way they did. It's something that I think neither chiropractors nor MDs knew at the time. They both just believed what was spoon fed them. --D. Matt Innis 20:44, 14 December 2006 (CST)

I'll go look at the article now. I think we have to be able to say just what you said above, Matt, in the text. Nancy Sculerati MD

How about we ditch the Critical section, too. This was a compromise section from WP that can be integrated elsewhere as well. --D. Matt Innis 07:27, 15 December 2006 (CST)

The lead seems to repeat itself. We can probably combine some of it further. --D. Matt Innis 07:52, 15 December 2006 (CST)

I also think that there is too much information about chiropractic to be squeezed into one article. Vertebral subluxation can take up 32Kb all by itself. We'll need articles on VS, spinal manipulation, spinal adjustment, history, science, use of CAMs, and perhaps the controversial issues. So maybe we should consider this the flagship article for chiropractic and link from here. Each section could just be a succinct and interesting narrative tidbit that you guys do so well about each subject and split off into the main article from there. Any comments? --D. Matt Innis 07:59, 15 December 2006 (CST)

Down to 46kB, and I think it's surviving well??? Gareth Leng 08:23, 15 December 2006 (CST)

OK Critical section is delegated, down to 41kBGareth Leng 08:38, 15 December 2006 (CST)

I'm still holding my breath;), but trust you guys implicitly. --D. Matt Innis 08:41, 15 December 2006 (CST)

This sentence:

• Although there has never been any scientific evidence that adjustments help such conditions, there is a growing body of medical literature that proves chiropractic care is as effective as physical therapy and conventional non-surgical medical treatment of back pain, even for the more severe underlying conditions that most often prompt patients to undergo spinal surgery.

There is evidence that professes to be scientific, and even has some peer review, though there is question as to the quality of the methods used and the peer review process. I am not the best to put this into words that can satisfy both POVs and still remain accurate. I would appreciate any input. --D. Matt Innis 10:18, 15 December 2006 (CST)

OK 40kB and I think my knife is now blunt. I've created a new article for critical views. Matt, please look carefully and see where I've cut too deep or if I've changed meaning or balance. I'll look at any specific points later, please don't be shy of saying that anything doesn't look right. I know the history is now simplified, but hope the thread is still OK, and the main article on history will give the embellished story.Gareth Leng 10:45, 15 December 2006 (CST)

Matt, I've been playing with words here and there. I am concerned about the caption for the radiograph. Since readers often look at pictures and read the caption even though they have not read the full text, I do not like the word subluxation under the radiograph of the spine, when any one who can read a radiograph of the spine will immediately object "there is no subluxation!!". So, for that specific caption, could you kindly change the word subluxation to segmental dysfunction or something that will fly without discord? Nancy Sculerati MD

Nancy, since this is the chiropractic page, I think we should probably stick to chiropractic jargon. Though I think chiropractic and medicine are slowly approaching each other in terms of understanding and practice, I'm not sure that we are at the point where we can describe chiropractic in only medical terms, mostly because of the vitalistic approach and lack of a better word for the "theoretical sub-optimal subluxation". As Churchland observed "If a restriction in favor of operational definitions were to be followed ... most of theoretical physics would have to be dismissed as meaningless pseudoscience!" Chiropractic has its own language, just like physics. If we don't use chiropractic language, we won't be able to get other chiropractic editors to back this up? We have to describe things in chiropractic terms, then we can point out similarities and differences if we want. Remember, chiropractors were some of the first to use xrays to evaluate the spine, and this is where the word subluxation degeneration was coined. How can we take that away from them? Make sense?--D. Matt Innis 18:25, 15 December 2006 (CST)

Where do we go from here

I worked mostly with the lead tonight and a little elsewhere. It's looking pretty empty to me. I'll look at it again tomorrow. --D. Matt Innis 22:39, 15 December 2006 (CST)

I think it's accurate, balanced and interesting, and I think I've checked every cited source myself. Personally I liked it better longer, but can see this is very much a subjective assessment and that a more concise article will meet the needs of this better. We can quibble about occasional words, but I honestly think we'd be worrying about things that won't even be noticed by most readers and won't be dwelt on by the few that do, so I'd be more concerned just to get the prose flowing sweetly in the last edit. I think the important question is for Matt - does he (and will his fellow chiropractors) feel that this article is a good and fair account of their profession? You say when you think it's ready to approve.Gareth Leng 05:14, 16 December 2006 (CST)

I agree with you Gareth, but I know that I do because Matt wants to have an article that is fair and neutral. Since we have already explained the word subluxation as used by chiropractors and said that this is our default meaning of the word, it's fine to use it for the caption. I still have one problem in content, Matt. Since extreme Straights are likely to have a position different from yours about treating serious systemic diseases that have a recognized convention medical cure, I just want some official DC source to quote that says this is not ethical (or proper or something). You told me that (more or less) any student in one of the programs would fail if he or she said otherwise, that say manual therapy was the treatment of choice for early breast cancer, but Matt, you only went to one school! There has to be something you can find, and it's best if it come from your own profession. Like I said, I can't find it in the Mercy Guidelines. Is it there? If we can't find it- then I'd like to put a sentence in the article to that effect that we write ourselves. Nancy Sculerati MD 06:17, 16 December 2006 (CST)

Nancy, I see what you mean. I'll look for something. If we find something, it will probably say along the lines that require referral to the appropriate specialist. I'm not absolutely sure, but in Michigan, their law was one of the "model law" straight laws that prohibited a chiropractor from diagnosing anything, therefore recently when a chiropractor was sued for "failure to refer" a breast cancer patient, he was aquitted. I'll see what came of that, too. --D. Matt Innis 07:57, 16 December 2006 (CST)

Found this, this, this, and this. Notice that is talking about using chiropractic for pain in cancer patients, not the cancer itself. This is what your looking for!. I went ahead and looked them up and found this same guy- you goota read this! [3]. Looks like he went overboard:) Though I think it illustrates what I was saying that anyone that says that stuff is risking his license and if someone dies, jail time. At least if he is calling it chiropractic, because chiropractic doesn't cure anything. --D. Matt Innis 08:05, 16 December 2006 (CST)

Otitis media in infants?

Matt, you are adding a lot of speculative things about how DC might turn out to be helpful that I can't live with. That otitis media stuff in infants is one. Colic is another. Generally claiming that "calming a mother" by manipulating the cervical spine of a newborn or infant for a "placebo effect" when for example - most otitis media in infants NEEDS NO TREATMENT and the rare infant that has meningitis almost always ALSO HAS OTITIS MEDIA, and meningitis in its early stages is hard to recognize, and might even begin with the high pitched cry that most people would assume is just colic, especially if the baby has a history of colic - is not something that I can ever approve. This is just the sort of treatment of nonmuskuloskeletal stuff I'm talking about that I consider unethical! We have a problem, Nancy Sculerati MD 10:08, 16 December 2006 (CST)

OK, let's keep cool here. I'm not sure that there is anything much wrong with the text here, except in one small place where there seems to be an inadvertent promotional statement. I think the situation is this, please correct me - patients visit an MD or a DC for otitis media or colic. OK. For an MD this usually needs no treatment. For a DC, maybe some would treat, and the treatment reasures the mother and thereby calms the infant. The DC sees nothing wrong in this, even if the effect is just placebo. Nancy is concerned about DCs missing more serious causes - right? Important, as they're often missed by MDs too.

In the UK at least, MDs do have a problem, in that they know that the placebo effect is powerful, but can't ethically use it (they have to explain the basis of the treatment to their patients). They know also that time spent with patients results in higher cure rates, but don't have the time.

Of course you are right, but keep in mind that it assumes that the doctor sees it as a placebo effect. DCs have an explanation for the effects. It is new research that says the effects of chiropractic on ear infections is about the same as placebo. I'm sure that will eventually play into the overall picture, just as it has for diabetes, cancer, etc. It won't mean that these people can't benefit from care, just that the patients with ear infections are not affected any more than a placebo. --D. Matt Innis 23:30, 16 December 2006 (CST)

So here seems to be the core of the dilemna. Can you encapsulate your concerns about the ethics of DCs treating infantile colic Nancy? Is it (just) concern about diverting from appropriate treatment in rare cases of serious illness? Gareth Leng 10:57, 16 December 2006 (CST)

I can live with text that does not agree with my beliefs - let's establish that at the outset. I do not believe that a chiropractor should ever treat an infant unless there is some extremely special circumstance. Just having an MD does not qualify a person to care for an infant either, and I would be appalled if a sick infant was brought to an adult psychiatrist, or an adult radiologist, or a newly minted MD for treatment also unless there were very special circumstances. I have a question. We have spent some time in the article describing this "popping" of joints, do DC also manipulate infants joints to make that sound? (Matt and Gareth-will you sign your posts with the three tilde so it's clear it's you?) Nancy Sculerati MD I've been thinking more about what I object to, from the first I have reviewed the article, my concern is that chiropractic treats systemic diseases and disorders that are not musculoskeletal disorders of the back. In fact, one of my first edits, when I moved from advice on the talk page to working on the article, was to remove that phrasing of what chiropractors treat (musculoskeltal disorders) from the leading sentences of the introduction. I see that it's now there again. It can't be said that DC's treat musculoskeletal disorders (without any further qualification) and also claim that chiropractic treats colic and otitis media. These are not musculoskeletal disorders. Matt, you told me that actually 90% of what DC do is that, and I found nothing in medline to refute it. There is good evidence that manual therapy helps for back pain. But to use manual therapy to treat other illnesses like allergy symptoms is a stretch. It has no rational basis in biology. You can counter that some medical therapies have no rational basis in biology, but that's no real answer. I have been asking you to find a single statement by any official organization of DC's that says it's unethical to treat conditions like early breast cancer with manual therapy, come on Matt, you can't just use your own impression that this is not done as an answer. We cannot approve an article that implies that chiropractic treatment of nonmusculoskeletal disorders is reasonable and accepted, and imply that manual therapy is an accepted treatment for a sick baby without clearly addressing these issues. Do better.Nancy Sculerati MD

Nancy, I apologize, I thought I was just explaining things among pen pals, but I think I understand, I'll try to back up my edits with verifiable and reliable sources, I certainly shouldn't think that I speak for all chiropractors. It would probably help if we all did that. Maybe the article that discusses chiropractors treating breast cancer has a reference that I can follow through to find out the specifics. I've never heard of it. I did find this, that pretty much says exactly what we have, but if you find something that says chiropractic to treat breast cancer, I would like to see it and the doctor who is doing it. Meanwhile, I'll just do my best to quote the source rather than create original research. --D. Matt Innis 20:19, 16 December 2006 (CST)

This is probably a good synopsis (that is not in my words) of straight chiropractic. I think this is important; I quote, "Although there have been attempts to use the terms 'diagnosis' and 'chiropractic diagnosis' to describe chiropractic analysis, these are indistinct and misleading uses of medical terminology which may create false patient expectations. Diagnosis is universally understood to be a medical procedure concerning disease or morbid processes. Because straight chiropractic is non-therapeutic, the term 'diagnosis' is not germane to the practice of straight chiropractic." and I offer in reference to the use of the word treatment; "Those things done to or for a patient for the alleviation of symptoms and /or disease. Since the straight chiropractic objective does not include the treatment of symptoms and/or disease, the term treatment is not appropriate in straight chiropractic." and lastly "There are two types of primary, portal of entry providers: limited and unlimited. These terms refer to the scope of practice relative to the area of anatomy addressed, conditions addressed, and procedures used. Allopathic and osteopathic physicians are examples of unlimited providers, while dentists and optometrists are examples of limited providers. Virtually all state laws are based upon the concept of the chiropractor as a limited, primary, portal of entry health care provider. Straight chiropractic is a limited health care profession, while mixing chiropractic considers itself an unlimited health care profession." --D. Matt Innis 21:11, 16 December 2006 (CST)

For types of spinal adjustments, please see the spinal adjustment article. There are many many more techniques and some especially for children. I won't say no in answer to your question on manipulation for infants, because on occasion it is used, but infants respond very well to much gentler soft tissue techniques that are a lot like mobilization and massage. If you cradle the infants skull and place your index finger so that the PIP joint is just behind the posterior arch of the atlas you can begin a slight caudally stretching massage while slowly tractioning the skull in the opposite direction. Most of the time, you will begin to feel the soft tissue relaxing and the atlas moves forward in relation to the skull. Yes, occasionally the atlas is so fixated it won't move and a very short and gentle wiggle is all it takes. The lymph nodes are easily palpable from this position as well. I agree that meningitis and mastoiditis and encephalitis are all very important to watch for. I checked a three year old this summer who had fallen from a swing. The child had already had tubes and the mother thought it was okay that the ears continued to drain for months. She was on maintenance dose of antibiotics. The mastoids were assymetrical and lymph nodes were very pronounced. We sent her to the best pediatric EENT in Charlotte and she had an immediate mastoidectomy. She is fine today and we have just begun seeing her again with our emphasis on trying to make sure she heals without too much restriction in the upper cervical region. There is no research to back up our protocol, but I think that was the best way to handle it. --D. Matt Innis 22:16, 16 December 2006 (CST)

Most ear infections that have shown up in my office have already been treated for several infections and are even on "maintenance" doses of antibiotics. When a parent asks if I can help, I check the upper cervical region. If there are signs of assymmetry or "trouble spots", I tell them that we can work with that in the manner that I explained above and see what happens. Do you see something wrong with that? So you have to ask this; IF the research were to show that chiropractic care cut the number of children that required tubes in half, would you tell your patients who had children with otitis media to take them for adjustments? --D. Matt Innis 22:54, 16 December 2006 (CST)

My copy of the Mercy Guidelines are at the office. When I get in on Monday morning, I'll check to see if it says anything about treating specific diseases and guidleines for them. I haven't been able to find anything on the net that I think you are interested in. --D. Matt Innis 02:21, 17 December 2006 (CST)

I have inserted references(it added some Kbs) and tried to clean up as much of my original research as possible, but give it another once over to make sure it is accurate and neutral. Gareth, I probably messed up your references, so go ahead and fix them. I really like the reference section and the more I read the history section, the more I realize how good a cleaning you did without losing too much of the reason chiropractors think the way they do. I think we have a pretty good article here that we can grow with. I'll check in again tomorrow afternoon. --D. Matt Innis 02:21, 17 December 2006 (CST)

OK, I've consolidated the references in sections - removed some of the older ones that are redundant with Nancy's, and tightened up the efficacy section especially. I think I like this article even better now, seems fresher and sharper, the efficacy section was pretty ponderous before. I left the single edit that I thought might be contentious until the end and flagged it. Gareth Leng 07:44, 17 December 2006 (CST)

I'm about to go look at what you and Gareth have done, Matt. Before I do I want o answer your questions posed in your last post. I think that the way we use words is very important, ofeten times we even hide our real meaning from ourselves. This is why, when I go through the article, I am likely going to change some phrases to make things plain. It is one thing to talk of "limited" and "unlimited", it's another thing to make plain what that means. From what you write of the case of the draining ears, you did that child a great service. In terms of how we phrase things, you often talk (as do many people including health science professionals) of "avoiding tubes" or "avoiding exposure to antibiotics", yet that's not what you probably really mean. What you mean (if I may take a stab at it) is "getting the problem fixed in the least invasive and most healthy way". This is why you are not upset, but rather proud, that your referral of that little girl to "the best ENT in Charlotte" ended up in major surgery. The goal is not to avoid surgery, the goal is to do the right thing to get somebody better. It's easy for people to think about that in a backwards direction, and get confused about the real goals. My concern is that there does not seem to be an overall regulation of what chiropractors do- by their own professional organizations. That's why I'm looking for some official statement by even one organization about ethics or proper practice. Can you help me find that? regards, Nancy Sculerati MD

Yes, Nancy, I don't expect my edits to be the last word, only one voice in the woods, hopefully clarifying a very complex and diverse profession into 32Kb. I don't expect it to be easy, but your input is essential because your POV is fresh and helps to make this a better article. ;) --D. Matt Innis 08:53, 17 December 2006 (CST)

And I think you have understood properly about "getting the problem fixed in the least invasive and most healthy way". Please also understand that I do not write that way to intentionally mislead, it is just the way I write, and I am so glad to have you and Gareth to clarify it for me. If we were able to sit down and talk through it with a glass of wine (and scotch for Gareth), I'm sure we would have had this all written in an hour and you would realize that our ideas aren't that far apart on anything. I suppose the laws of physics suggests that when an object appears to be working backward, it is just because it is approaching you from a different direction. --D. Matt Innis 09:34, 17 December 2006 (CST)

Regulation

I will be able to look at my copy of the Mercy guidleines tomorrow to see what pages 215 - 218 are (since they are not online). Hopefully they will clarify some. The state boards are the disciplinary bodies, but I am trying to find some more specific guidelines. North Carolina statute for disciplinary action. --D. Matt Innis 18:28, 17 December 2006 (CST)

North Carolina acceptable care statute. --D. Matt Innis 18:50, 17 December 2006 (CST)

Norht Carolina Unethical Conduct statute --D. Matt Innis 18:54, 17 December 2006 (CST)

NC Practice in hospitals --D. Matt Innis 18:55, 17 December 2006 (CST)

NC definition of chiropractic/scope --D. Matt Innis 18:59, 17 December 2006 (CST)

Wisconsin statute --D. Matt Innis 19:12, 17 December 2006 (CST)

Found this from Cancer Research UK about chiropractic care in cancer, might help? [4] GCC [5] GCC Code of Practice [6]Gareth Leng 09:24, 18 December 2006 (CST)

That's similar to things that I am finding here. I have been able to make some copies of some pages of the Mercy guidelines that I will try to find a way to get online. If nothing else I could fax them somewhere. Now I have to get home where I have a scanner:) --D. Matt Innis 10:31, 18 December 2006 (CST)

Nancy, also note the agendas for the FCLB on their website, [7],[8],[9] Is this the kind of stuff you were looking for? --D. Matt Innis 11:20, 18 December 2006 (CST)

Article is fine by me, I've added some of the links above to the FCLB article, and maybe your agendas should be flagged there.Well done Matt, hope you,re pleasedGareth Leng 14:47, 18 December 2006 (CST)

Approval template?

All, shouldn't there be a {{ToApprove}} template here, pointing to the version in the history up for approval?

I note that someone put it up for approval on the main article page, and used a different template. Do please use the above template on the talk page. Let's keep the main page as free of administrivia as possible.

I also note that there are fewer than the stated quorum for approval, but I think in this case--given the people involved--we can fudge a bit. --Larry Sanger 16:05, 18 December 2006 (CST)

Yes, Larry! I saw that, but wasn't sure.. thanks for clearing that up. I'm looking to see whether Nancy needs to make some last minute changes before we all agree to it, so stay close! --D. Matt Innis 16:33, 18 December 2006 (CST)

Matt, I'd like to go through it now. Nancy Sculerati MD

Notes for discussion: 1.pain and other symptoms for repetitive injuries - is this correct? 2. drug part in introduction. Is change acceptable? 3. took out "normal scientific activity" as this does not make sense to me. Put in "progress within the profession". Is this ok?

1. pain and other symptoms from repetative injuries - is this correct?

Very close, but not quite...

the point should be that some subluxations result from one-time traumatic injuries such as lifting or whiplash and some are the result of prolonged postural/repetitive/ergonomic i.e. biomechanical stresses. Also, subluxations are not necessarily painful(especially the latter), but when there is pain, that is definitely part of the subluxation. --D. Matt Innis 23:23, 18 December 2006 (CST)

3. progress within the profession

yes!--D. Matt Innis 23:31, 18 December 2006 (CST)

4. Put in that straights teach against vaccinations - because they do. 5. took out nearly all of the nonspinal stuff because it's not appropriate, too long, and it's said in other parts of the article 6) where's the refernce for the 1996 study in 'Safety'? Need footnote. 7. went back over - studies that show DC efficacy for Rx backpain need references/footnotes. I see that the references are all there, even if the foot notes are not. In it's exact form at this time, it has my approval. Matt- if there is something you can't live with - tell me. Gareth same to you.Nancy Sculerati MD

Well done Nancy, it works for me. I've made some minor formatting adjustments, added a few links. The section on non-spinal treatments that you rightly removed I've transferred pro tem to Critical Views of Chiropractic, and added a stub section on vaccination to that.Gareth Leng 04:33, 19 December 2006 (CST) Looked up ICA (traditional straights) and vaccination - they state that their advice is that vaccination is "not without risk and that therefore "The International Chiropractors Association is supportive of a conscience clause or waiver in compulsory vaccination laws, providing an elective course of action for all regarding immunization, thereby allowing patients freedom of choice in matters affecting their bodies and health." Personally I disagree with this advice, but I am not sure that saying its not without risk is the same as saying it is dangerous? Think this might be an overstatementGareth Leng 04:49, 19 December 2006 (CST)

trouble spots

My list to work with 1. A thorough patient and family history, review of organ systems and a physical examination are all part of a complete evaluation by a DC, however these are all done in a chiropractic manner and are not equivalent to a medical history and physical as done by a physician. --D. Matt Innis 07:43, 19 December 2006 (CST)

Matt, it's different in priniciple and therefore "not equivalent". Find another word or phrase for different besides "not equivalent" that you can agree with, and let's discuss it. Nancy Sculerati MD

Okay, i just took off the italics so it doesn't look like its POV and I can live with it. There are all kinds of levels of physicals and examinations and I'm sure they are all "not equivalent" even among physicians in the same field. --D. Matt Innis 10:03, 19 December 2006 (CST)

Gareth, straights warn against vaccination because they believe it causes problems. Look at the external links Matt provided. There is no reason not to say this plainly. It is true. Nancy Sculerati MD

Yes you are right Nancy, I've added some refs to the critical views articleGareth Leng 10:28, 19 December 2006 (CST)

2. Ethical DCs do not claim to be able to cure cancer, metabolic disorders such as diabetes, or infectious diseases, although they might treat patients who have these conditions, to relieve pain or provide a feeling of well-being.

This statement seems to give me the feeling that there must be unethical DCs as well. Can we find a little better way of saying it without losing the meaning? --D. Matt Innis 10:03, 19 December 2006 (CST)

Agree with Matt here; there are unethical DCs and there are unethical MDs (Harold Shipman was a mass murderer after all) and hopefully theuy get struck off. The codes of ethics appear to make it clear that even if individual DCS have suvch beliefs they are forbidden to advertise them and must advise patiets (informed consent) accurately of risks and benefits according to current knowledge. I've seen lots of contemporary chiro literature stating very clearly that chiro is not a cure for these and none, from credible sources, that claims it is.Gareth Leng 10:28, 19 December 2006 (CST)

3. Nancy, not sure about the references you are talking about in 6 and 7, hopefully those were fixed and that is why i can't find them. --D. Matt Innis 10:15, 19 December 2006 (CST)

4. Traditional straights are skeptical of biology. - Hopefully you guys realize that they really aren't skeptical of the study of 'Life' or 'living matter' (biology), they love to study it as well. They are skeptical of Big Phamaceutical Companie's science. --D. Matt Innis 10:15, 19 December 2006 (CST)

5. Gareth, maybe you can do something neat with the [10],[11],[12] that are in the lead like you've done with the rest. We worked so hard, they make it look trashy. --D. Matt Innis 10:23, 19 December 2006 (CST)OKGareth Leng 10:28, 19 December 2006 (CST)

OK, I'm very happy. Am off to Berlin now, back SaturdayGareth Leng 11:25, 19 December 2006 (CST)

Oh what a life! Have a great time! --D. Matt Innis 11:29, 19 December 2006 (CST)

I want to discuss point 2 above- ethical DCs don npot claim to be able to cure cancer, metabolic disorders... I was so happy when I hit upon that sentence because I thought it briefly encapsulated the whole point about what is acceptable practice in the chiropractic profession for a potential patient to know, without going on and on. Well, maybe I have to do better. Here's what I'm trying to say: Just as no ethical plastic surgeon will promise that they can "make you look just like XXX, the movie star...," There are doctors who practice cosmetic surgery who are not ethical and do make such claims. If I was writing about cosmetic plastic surgery (and I will be) I would be careful to put that in (worded differently) because it is important "consumer knowledge" and it also would accurately fit in to the whole spiel about how a plastic surgeon approaches patient care. I might also say something like "No ethical anesthesiologist will ever promis that there is no risk to anesthesia", or "No ethical surgeon will ever promise that there is no risk to surgery". Now, in the case of chiropractic, there is that fringe of the profession - whether for profit or because of sincere belief, or a combination of the two, imply or outright state their treatment provides fabulous no-risk cures. Just like the cosmetic surgeon who claims that they can promise you the nose of XXX, this is something that goes on but is not easy to prove. And there is no reason to prove it, anyway - that's not the point. The point is to make it clear that such a practice is not acceptable to the ethical majority of the profession, and if you hear that coming out of your cosmetic surgeon's mouth...run! And so that's how I put it. "No ethical...." That particular phrase is typically the way we physicians talk about boundries in our own professional specialties, both about actual procedures and treatments we offer, and about advertising claims, etc. So, here in the talk page, let's figure out a better way to say it. Gareth will just have to log in from Berlin while we languish here at home! Nancy Sculerati MD

Hi guys, I've gone over it again after your adjustments, took out a few things I didn't understand, and adjusted the first para and the second para of the into especially - the lead to tidy up and keep neutral, and the intro because, well, see if it works for you anyway. I think we need to approve this now, basically because every little change from here can essentially trigger a problem inadvertently, it's so easy to introduce a potentially misleading slant without intending to, especially now that the article is trimmed right down.Gareth Leng 15:26, 22 December 2006 (CST)

I'd be willing to accept this version. Anything else is not an emergency and can be worked when other authors and editors arrive, but mostly I think we can offshoot into different articles from here like the biology page, some articles will be more supportive while others might be critical such as we've started. That is the only way we can beat the 32Kb limit for such a large field. --Matt Innis (Talk) 16:31, 22 December 2006 (CST)

I am not against your approving it. However, I do not think that the opening makes much sense. Matt, I don't think we can emphasize subluxations so much without pointing out that only chiropracters know what they are and can identify them, and I don't want to hurt you , but that's the way it is. Also, we are back to claiming that chiropracters treat musculoskeletal disorders, which is very vague and not true. Again, there are chiropracters who treat children (and not for back pain) and assert that they offer total care for men, women, including pregnant women, and children. However we had the wording back when we three agreed, it didn't strike me as so jarring - but here we have an introduction that hides more than it reveals. There is no longer a 32 kb limit- if you look at the forums you will see that Larry Sanger says he favors 40-50 kb as an upper limit. Perhaps we can put back the critical view section, and manage the first paragraph so that it is truly clear and accurate. sigh. Nancy Sculerati MD

Nancy, that was an off-hand remark of mine. If the article seems too long to you or other editors now, that is a much better reason for us not to lengthen it, right now, than any off-hand generalization I might make. As you can see from that forum message, I'm not sure what to think, and we could use some serious thinking on the general question of article length. --Larry Sanger 18:18, 22 December 2006 (CST)

Quote related question

Matt, how does the quote here:

It wasn't so long ago that a college president suggested, "Rigor mortis is the only thing we can't help!"

relate to the rest of the Chiropractic treatment of non-spinal disorders section? The connection is not obvious to me. Sorry if i am missing the context here. Chris Day (Talk) 17:47, 22 December 2006 (CST)

Chris, this is a very good question. This really goes to the heart of the medical/chiropractic debate. The person that made that statement was Sid Williams, president and founder of Life Chiropractic College in Atlanta Georgia which grew to become the largest chiropractic college in the 1980s. He was known for his enthusiasm and gospell-like speaches and was a strong advocate for tradtional straight chiropractic. He is a contorversial figure even within chiropractic. The short version is that he made this statement during a series of seminars and it raised the ire of chiropractors and medical doctors who would have liked to see chiropractic limited to just musculoskeletal and spine pain. But, as with any statement that causes controversy, there is an element of truth that chiropractic care might well have value for anyone who is still alive, whether they have spine pain or not. As a side note, Life chiropractic soon lost its accreditation status and is still embroiled in a political controversy to restore its status.

The statement that we make strikes me as being accurate, though perhaps the title of the section could reflect what we say a little better. Perhaps you or Gareth can take a look at that. Hope that hepls. --Matt Innis (Talk) 08:33, 24 December 2006 (CST)

Intro again-

Sorry to keep coming back to this but it is probably the most important part of the text with respect to 'catching' the reader. At present Subluxation seems to dominate the section to a disproportinate degree. How about something alomng the lines of:

Chiropractic is a complementary and alternative health care profession that uses manual therapies on the spine and extremities with the aim of improving health. While chiropractors treat all types of musculoskeletal problems, their defining theory is that they can affect body function by locating and correcting what they call subluxations of the spine. These are distinct from medical subluxations. Chiropractors view subluxations as the first stage of degenerative changes, such as arthritis, and believe that these are misaligned, fixated or unusually mobile vertebrae. Subluxations are treated with procedures called spinal adjustments that are intended to help improve body posture and joint mobility.

I moved a few things around and deleted the bits below.

that, by interfering with the nervous system, can affect health adversely in diverse ways.

This seems too detailed.

They locate these subluxations by carefully examining the back. When they believe that they have located a subluxation, they

Again, this is too detailed for the intro.

Also there should be a link to medical subluxations so readers can contrast them, if they chooose, i hope these comments are useful to you. Chris Day (Talk) 17:58, 22 December 2006 (CST)

That is certainly more succinct and says the same thing. We could use this subluxation for now until we get something together. --Matt Innis (Talk) 00:08, 23 December 2006 (CST)

There is a problem here that we keep getting stuck on. Your intro seems clear and succinct and is technically accurate as Matt says, but it appears as Nancy might say, to elide over the issue that divides MDs and DCs - i e that DCs think that subluxations are the cause of some ailments that MDs regard as unrelated to the spine. Hence the two sentences that you suggest deleting (stressing the indirect effects of nervous system interference). I think the emphasis is on subluxation because this is the critical source of the disagreements between DCs and MDs. However for a lay reader this will all possibly pass by them anyway.Gareth Leng 07:41, 23 December 2006 (CST)

Let's try this

Okay, after reading all of the above that was posted today, and since I rearranged the article and made some changes, how about Nancy you take a shot at it to get your POV back that I may have watered down. Then I will make some comments here on the talk page. Then, Gareth, if you can take Nancy's stuff and my comments and Chris's concerns and put them together from a scientists POV and lets see what we end up with. --Matt Innis (Talk) 00:03, 23 December 2006 (CST)

Looking at the content and the content of the version we were all happy with, it's hard to see much difference except in subtle things, like the order of things. I've shifted the definition of subluxation bit back to the front. I have the feeling now that we're reading the same things but reading different things into them, so I was a bit confused by Nancy's comments at first, as I couldn't see what was different, but I do see some places that can be read in ways that are wrong.Gareth Leng 04:36, 23 December 2006 (CST)

Sorry guys, I saw I messed up the Talk page inadvertently before skipping off to Berlin - sigh Gareth Leng 04:56, 23 December 2006 (CST)

yes, on reading over, the article looks ok. Nancy Sculerati MD

Looks good to me, moving that section back to the intro did make a difference. I think it works for me, too! Nancy, please take one more look, it needs to satisfy your concerns, too, otherwise when this goes live, no-one is going to give credibility to CZ. Just keep in mind that most of my problems will come from chiropractors themselves, so most of the edits I make are really trying to accomodate as many of them as possible in a respectful manner, otherwise they, too, will think this process is biased. I'm going to go ahead and stick the tag back on and we can fine tune from here. Sound good!!!! Meanwhile I've got some shopping to do if I am going to live past christmas;) --Matt Innis (Talk) 08:41, 23 December 2006 (CST)

Moved approval template to make it more visible (was originally here)--ZachPruckowski 01:30, 26 December 2006 (CST)

Can someone put the right version in the description? :) --Matt Innis (Talk) 08:49, 26 December 2006 (CST) I found it! --Matt Innis (Talk)

I also changed the date to the 26th to give everyone a chance to look at it again. --Matt Innis (Talk) 07:45, 24 December 2006 (CST)

Folks, please rely on another sysop to do the work of approving this article. Any constable should be able to help. Needless to say, I trust you. --Larry Sanger 23:12, 25 December 2006 (CST)

Ok, I'm working on making this approved. Give me a bit, I'm new to this :) It looks great, everyone. -- Sarah Tuttle 13:40, 28 December 2006 (CST)

Tada. Consider yourselves approved. Hurrah. Someone want to make a shoutout to CZ-L about the new approved article? :) -- Sarah Tuttle 14:02, 28 December 2006 (CST)

Ah, beat me to it, Sarah. :) Looks like a great article. --Mike Johnson 18:08, 28 December 2006 (CST)

APPROVED Version 1.0

Discussion for Version 1.0 stopped here. Please continue further discussion under this break.

Image is a copyright violation

That image was lifted from this website. The summary of the photo prettymuch freely admits it was just lifted from a Google Image search. This is a huge no-no, no? Benjamin Lowe 16:40, 14 February 2007 (CST)

Agreed, it has to go. Chris Day (Talk) 16:50, 14 February 2007 (CST)

I'll check into getting it removed properly. Matt Innis (Talk) 22:05, 14 February 2007 (CST)

Rationale for replacement of acronyms and informal abbreviations.

This references recent changes to whole article, where acronyms and abbreviations (DC, MD, GP) were replaced. As I see it, the use of these detracts from the literary quality of the article. These are informal and colloquial terms. They are used, as far as I know, only in North America, and to an outsider seems inappropriate to formal, quality writing which is intended for all of the English speaking world. Do the European and British chiropractors have the degree DC? In South Africa they are awarded a Master in Chiropractic degree, after a tough and long course, and are quite entitled to be called "Dr", but I am not aware of them calling themselves "Dee-sees":) In the UK and Commonwealth countries, Doctors definitely are not MDs (that, over here, is a far higher degree in medicine). After the changes, one has to check that the writing still flows properly, since changing the length of words may make parts "sound odd". I have not noticed any such. --Christo Muller (Talk) 09:01, 20 February 2007 (CST)

Hey Christo. I think we go back and forth on this one. See Chiropractic education for the education questions. I think the problem comes more with what to call MD's and that causes us to use DC's to qualify the difference. I haven't seen your solution yet, but let me check. Matt Innis (Talk) 09:31, 20 February 2007 (CST)

Ah, yes, I see you used physician for MD. I know in some US states, chiropractors are also be called physicians (mine included). The distinction there is medical physician vs chiropractic physician. I'm okay with it. For accuracy sake, I don't think either is a problem (Dc vs chiropractor) so if you think it flows better, that is fine with me. Matt Innis (Talk) 09:41, 20 February 2007 (CST)

Hi Christo, personally I'd always prefer to avoid abbreviations as I think they often get in the way of understanding, so I'm with you 100% on this issue alone, and of course you're also right about MDs. Gareth Leng 11:23, 20 February 2007 (CST)

AMA section

As per a request by Larry for us to review and rethink the section on the AMA plans], I think we have the choice of either totally eliminating the section or editing it to a more neutral tone. How about everyone take a shot at it and lets see if we can get something that we can all re-approve. Thanks, Matt Innis (Talk) 19:13, 4 March 2007 (CST)

I think that it should be rewritten from a neutral perspective. The way it is now, it's from a "neutral" chiropractic prespective. I don't know the history well enough, I have to do some research, but I think, overall-that the facts that are important to present are that the AMA, and Medicne, generally, after being reformed (at least in America) by the Flexnor report, zealously attempted to eradicate association with [practices outside the health sciences,that during that period (up to 19XX), there was an understanding within the medical profession that referral to chiropracters or willingness to teach in schools of chiropractic was unprofessional (I'm writing this off the top of my head and that might not be the right word) for an MD (this is the US so I think MD is ok) and that there was a lawsuit that forced acceptance of chiropractic as a legitimate healing art. Meanwhile, the culture within Medicine changed over the last decades of the 20th Century such that, with a recognition of increasing public interest and satisfaction in alternative medicine (or whatever we call it-CAM) that a more open minded evaluation of these practices by physicians was in the best interest of patients. At the same time, with he advent of evidence -based medicine, it became more clear that "scientific efficacy" (again, the words here are preliminary) was not evident for many practices that were basic within the health sciences, and younger generations of physicians were more tolerant towards practitioners of healing arts that lay outside the health sciences, at least to the point of being willing to discuss patient care, and be interested in evidence based evaluations of CAM. The way that this history is presented in the article is very much from the restriction of trade/battle over patient fees perspective. I think that view is the problem, as well as some of the words-like propaganda. This may come from the focus on the lawsuit- but the lawsuit, although important to include, is really not the main story. I think the changing view of CAM and the direct basis of Science in Medicine is the bigger part. Further, I don't know anything about the relationship of Medicine and Chiropractic in the rest of the world. That seems to be important to art least mention.Perhaps we can just delete the section for now-do a quick approval without it- and then over the next few days write a balanced less polemical view, and stick it in a third approved edition.Nancy Sculerati MD 21:36, 4 March 2007 (CST)

Webster Merriam defines propaganda as: 2 : the spreading of ideas, information, or rumor for the purpose of helping or injuring an institution, a cause, or a person 3 : ideas, facts, or allegations spread deliberately to further one's cause or to damage an opposing cause; also : a public action having such an effect

The judge's opinion in the Wilk case makes it clear that the antichiropractic literature circulated by the AMA was exactly this. I don't really see the problem? The section, on my reading at least, was wholly neutral. I've reworded it, but I don't really see how it can be expressed very differently and still be in accord with the facts of the judicial opinion.

The Wilk case was a very clear turning point, and I don't know how any encyclopedic article can avoid this. It is true that the public interest defence offered by the AMA isn't described here, it was rejected by the judge and was apparently conceded by the AMA during the trial as no longer valid as a justification for continuing the boycott, so it's hard to see how to introduce this.

The AMA during the trial accepted that there had been considerable improvement in chiropractic, and they claimed that this was a positive outcome of the boycott.

It is tricky. The AMA's actions were clearly regarded as thoroughly reprehensible by the judge in this case. Both the chiropractic profession and the AMA itself regard the activities that were identified as unlawful restraint of trade as of central importance to the evolution of chiropractic. How can any balanced article neglect this?

Gareth Leng 07:06, 5 March 2007 (CST)

I agree with both of you. I think the ages old turf battle in the early 1900s was a contentious battle, but with the advent of evidence based medicine concepts, the efficacy of chiropractic and at least spinal manipulation was becoming evident as being at least as efficacious in some cases as some other medical interventions, but there were those on both sides that were just unwilling to give up the fight. At the same time as "younger" and "less committed" doctors were beginning to see that there may be some value here, AMA ethics guidelines still made it unethical to associate, refer to, accept referrals from, or teach in chiropractic colleges - not to mention research anything related to chiropractic. The Wilk suit broke this barrier and allowed more corroberative efforts to emerge. I'm not sure this would have happened had the case not broken through this barrier so that people like Nancy and I could now even consider talking to each other about these issues. If we could write a subsection explaining this evolution such as Nancy suggests, maybe that could solve our problem. What do you think? -Matt Innis (Talk) 07:33, 5 March 2007 (CST)

What Nancy proposes is fine by me, but I'm not sure that it really fixes the problem, if indeed there really is a problem. In the UK, medical students are now taught of the overriding importance of the patient-doctor relationship, to recognise and appreciate that this an area in which the traditional practise of conventional medicine has much to learn from some CAMs. However it seems to me that Nancy's suggestion fits better into a lead overview of the Healing Arts rather than specifically chiropractic.

What the AMA and the NHS say now is very different from what it is sometimes presumed that they "really think". I don't think that we can address the latter. I think we must respect what is said publicly. To undermine the written word by insinuation is just wrong in my view. If it is the case that the AMA still thinks that chiropractic is reprehensible but say differently for legal or political reasons, then I'm afraid they must be hung by their words; it's not up to us to damn them for spinelessness, nor is it ours to see the feelings behind the words. I don't think we've tempered in the article what the AMA said about chiropractic in 1966, nor should we; nor should we temper what the courts said about the AMA, nor should we disguise the fact that the AMA retracted from their position - and indeed had done so before the end of the court case. The judge issued an injunction against the AMA, because she did not believe that the AMA were sincere in what they said... so where is neutrality here? We report, we don't comment; we do not attribute motives to what is said or done, but surely we must report the judicial opinion accurately. Gareth Leng 08:26, 5 March 2007 (CST)

Are we satisfied that we have stated the facts neutrally? I agree with all the changes made so far. It may also be apparent that the views of the AMA (or ACA for that matter) are not always the views of its members as well as the fact that not all MDs in the US are members of the AMA. I would even go as far as to say that the hard line held by the AMA in the 1960s may well have led to a loss of membership during those years. Membership has improved, whether the result of softening on these issues is debatable. --Matt Innis (Talk) 10:04, 5 March 2007 (CST)

Have we staed facts and reported opinions objectively? I really can't see that there is anything in the AMA section that is objectively problematical. Reading the judge's opinion, it's hard to see how we could report the case any differently and still be objective.Clearly we need to cite that opinion in full, the link I found is to chiro.org; there may be a direct link which would be better.Gareth Leng 10:24, 5 March 2007 (CST)

I don't think the link makes that big a difference. I will put the re-approve tag on it and give it a day to think about it. -Matt Innis (Talk) 10:31, 5 March 2007 (CST)

I made changes in severaql places-please go over todays "recent changes" to see and check. Nancy Sculerati MD 12:10, 5 March 2007 (CST)

Thank you Nancy! Well done as usual. I think we could tighten all of the AMA stuff a little, just to keep it from overwhelming the rest of the article. I would add more to the rest, but we are once again going over. -Matt Innis (Talk) 13:43, 5 March 2007 (CST)

Nancy, the section on 19th century standards that you added was there before, but we took it out when we moved the history section. Obviously, I too, think it is important, as did Gareth when I first wrote it, but we took it out due to length. Perhaps we need to go ahead and put it back in. Again, though, we seem to be delving off on a tangent that could lead us away from the purpose of this particular article. Maybe we should shorten it all and build the Chiropractic History article instead. - Matt Innis (Talk) 15:11, 5 March 2007 (CST)

I really think we should keep it in, here why: when a user, at least from the States, who has heard about chiropractic but doesn't know much about it reads this article it is important that they understand the relationship between Medicine and Chiropractic. Like that kooky e-mail Larry got, many people have some notion that "doctors are against chiropractic", and further-without explaining some of the background of educational systems for 19th/20th Century health profesionals, which leads into how DD Palmer ran his school (it was really, in length and breadth not much different than the bulk of the proprietary medical schools), which leads into how, after the Flexner report, in one sense the schools of chiropractic were a recidivist branch that the AMA couldn't touch, with gives a balanced view of why professors of medicine might have spurned chiropractic, as well as the financial aspect, and finally-mentioning the lawsuit shows how there was a seachange in relations between medicine and chiropractic that was legally mandated. Without that the reader is left without any good understanding of these major points. I think this is more important than many other sections of the article. Nancy Sculerati MD 15:41, 5 March 2007 (CST)

I agree with your outline and purpose, so I think we are on the same page. I think we can do it, but we may have to re-arrange somewhat because I think we are repeating ourselves some. So maybe if we get it into chronological order, we can simplify it some. I am a believer in context. If we put everything into context, suddenly the picture is much clearer and the reader can understand not only what it is, but why it is as well. I also changed the date to the 14th on the ToApprove template. Lets do this right;) --Matt Innis (Talk) 15:51, 5 March 2007 (CST)

Flexner Report

Hey All, one thing I have been noticing is the tendency for this article to drift to into a postion that the Flexner report directly influenced chiropractic. My research does not support this contention. At the turn of the century, a large percentage of physicians were still using homeopathic type remedies but the schools were so disorganized that these were the direct target of the Flexnor report. At the time of the report there were only 3 or 4 chiorpractic schools (at te most). And remember, the list was made at least 6 years before, when the only "drugless" schools would have been Palmer's and Still's osteopathic schools. Palmer had about 21 graduates before he was arrested in 1904. Several of those were MDs (they are not sure of how many). My point being that the Flexnor report was directed mostly at the homeopathic schools. The significance of the flexnor report is that once the homeopathic schools were closed, where did those physicians go? But I am only guessing on that:) Matt Innis (Talk) 19:14, 5 March 2007 (CST)

The Flexner report was directed at all schools, including many that were allopathic. It was directed at any school that allowed students to study without strict academic prerequisites, that did not offer laboratory training in science, and that did not require students to show proficiency on tests on evaluations on at least a university level before graduation. It had nothing much to do with anything else. I think that the Flexnor report really did influence chiropractic, because after that time there was a much more complrte schism between college educated people entering medical schools and then having formal postgraduate clinical training (eventually- those changes took decades), based on the John Hopkins model, and chiropracter schools being in a whole different category. I have begun to read the history of those times as far as the history of health care in the United States and the Flexner report-which was the culmination of several decades of a movement that was involved within Medicine and civil-minded people of increasing regulation of public health with creation of oversight boards, and setting standards for certification of health professionals as well as medical education, marked. in 1910, a change. Most of the many schools of medicine closed, all of the small proprietary schools closed, including, arguably, some that actually offerred good education. That included at least one of the black medical schools in Kentucky (look at the stub just started Flexner Report discussion for reference. Again, the purpose of an encyclopedia article on chiropractic is to give a complete view of the field, especially since it was invented in the US, and the schism between MDs and Dcs was so pronounced, all of this is important. How many chiropractic schools existed before the Flexnor report came out is not the point, the point is that before the Flexner report reforms, the average chiropracter, from whatever school, was not so different in backgound and education as the average MD- at least in most rural communities in the US. After the Flexner reforms, only the better educated MDs came to be eventually regarded as legitimate physicians. Of course, there was a transition period when physicians from the old proprietary schools were still practicing and grandfathered in, but the academic university trained MD of the 1930's etc saw them as "quacks" and prejudice was not confined to homeopathy or chiropracty. Some of it may have been professional jealusy over patient fees, but plenty of it was well educated physicians who were appalled at the fact that some practitioners had no understanding of te germ theory of disease, vaccinations, public health measures, and encouraged their patients in traditional health beliefs that predated modern medicine. The way the article read in its first approved version, it presented the AMA strictly as a business organization bent on stamping out a commercial rival.The AMA does have an element of being a business organization, and that is certainly why Chiropractic won the law suit. But the AMA, especially in 1910, is and was far more than a trade organization, it has always had a major purpose in improving medical care in the United States and in promoting a high standard of education and quality within Medicine. That absolutely must be made clear, because that's the fair view.Nancy Sculerati MD 09:45, 6 March 2007 (CST)

empiric medicine

Nancy made a sentence that needs more explanation:

• Although many clinical practices in medicine were based on empiric teaching rather than science, other empiric sorts of practices, like chiropractic, were disdained as meritless by the majority of MDs.

This is very true and begs a "why?" Why would there be a double standard? I'm thinking this is because of the attitude of the Palmers toward medicine and the environment of paranoia or mistrust. Any other ideas that we might be able to verify as good reasons. I think DCs would like to think it was all political, but I doubt it was. --Matt Innis (Talk) 20:09, 5 March 2007 (CST)

I don't know; I think that although medicine was very extensively (mainly) based on empirical practice, it aspired to develop in a way that was led by basic biological understanding. BJ Palmer also aspired to make chiropractic scientific, but his concept was subtly different, he saw science as a way of providing a rational basis for given chiropractic practics. In other words, I think the difference is that in conventional medicine, there wasn't an overt "attachment" to any particular form of treatment. So I think the disdain came because conventional medics thought that the scientific basis for chiropractic as advanced by Palmer was tainted by the intention that it should justify the particular practices of chiropractic. I don't know if I've explained this well, and don't know if I've got it right. So on Nancy's sentence, I don't know if it was the practice of chiropractic that was regarded as meritless or the scientific foundations that were disdained, and suspect that the disdain was because the explanations were seen as justifications, rather than as objective accounts based on science as it was understood. Gareth Leng 03:48, 6 March 2007 (CST)

At present, the article describes the AMA position on the merits of chiropractic before the Wilk case, and reports the case as an antitrust case won by Wilk et al. This makes a very serious omission of balancing fact, that the judge declared in very clear terms that the campaign against chiropractic was dishonest as well as unlawful, and indeed this was the basis on which she issued an injunction against the AMA. Presenting the AMA case against chiropractic but not stating that the judge found this case to have been dishonestly presented is just wrong in my view.Gareth Leng 10:29, 6 March 2007 (CST)

The AMA

Hi, Nancy. The role of the AMA in furthering medical eduction has always led this section, so I didn't read it as being as negative as you did.

However I think that your changes have removed part of the record that is necessary to understand the hostility between Chiropractic and the AMA. The following sections are directly in the court record; they are not our opinion or interpretation, but the judge's summary. Certainly it casts the AMA's actions in this case in a bad light, and this is properly tempered by explaining the remedial actions of the AMA since. But the record does appear to show that the AMA's actions went far beyond what is fair and reasonable; I think looking at the record, the excesses are those of the Committee and that by the time of the trial the AMA leadership was desperately distancing itself from them. Below is the section that was removed:

"Judge Susan Getzendanner said that, according to the evidence:

"the defendants took active steps, often covert, to undermine chiropractic educational institutions, conceal evidence of the usefulness of chiropractic care, undercut insurance programs for patients of chiropractors, subvert government inquiries into the efficacy of chiropractic, engage in a massive disinformation campaign to discredit and destabilize the chiropractic profession and engage in numerous other activities to maintain a medical physician monopoly over health care in this country." [13] The judge reported that the Committee on Quackery essentially consisted of doctors who had volunteered for service on the Committee because of their firm belief that chiropractic had to be stopped or eliminated. Evidence had been given to the Committee that chiropractic was effective - more effective than the medical profession in treating certain kinds of problems, and that some medical physicians believed chiropractic to be effective, and that chiropractors were better trained to deal with musculoskeletal problems than most medical physicians. However, the Committee did not follow up any of these studies or opinions. At the trial however, most of the witnesses who appeared on behalf of the AMA agreed that some chiropractic treatment is efficacious. "

The reference gives the complete published judgement, and all of the details in the above are in that judgement.Gareth Leng 10:21, 6 March 2007 (CST)

I only removed it- as I wrote (I hope) in that Summary section that you make notes in when you make changes, because I though it could go into the History of Chiropractic. I'm happy to leave it- but I think that we should agree (probably one way or another) to up our limit to 40 kB for this article. At the time I culled that quote, I was looking for stuff to move or drop, and I really think that the long section on what goes on in a "typical" chiropractic office should stay. I deleted some of the subluxation stuff because now there is another article, but -although this article might be improved with some rewriting, I think that dropping it down to 32 kb will ruin it. Nancy Sculerati MD 10:41, 6 March 2007 (CST)

Thanks, I agree on the limit; think it could be copy edited to tighten, let's see after that.Gareth Leng 12:01, 6 March 2007 (CST)

What most MDs think or thought... I always have problems with such statements mainly because when I try to find evidence it is often ambiguous or contradictory. I came across this for example, from 1989 (the Wilk era), and it doesn't really support a general negative view of chiropractic Cherkin D et al (1989) Family physicians' views of chiropractors: hostile or hospitable? Am J Public Health. 79:636–7 [10]. Similarly survays of collaboration generally show a degree of openness from MDs that is just not consistent with a general negative view. Is there a difference between family practitioners, who might be sympathetic to empirical practise, and academic or hospital based medicine I wonder?Gareth Leng 12:37, 6 March 2007 (CST)

OK, 40kB and I don't think I've lost anything...Gareth Leng 12:50, 6 March 2007 (CST)

There certainly was in the US. There is a book (I think from the 30's) called Arrowsmith by Sinclair Lewis that is fiction, but a classic of medical fiction. It tells the story of a University trained young doctor setting up practice in the midwest and having to struggle to accept that the established MD's in town are nearly totally ignorant of science and yet nearly worshippped by their patients, who flock to treatments like electrical and magnetic fields, while he is held in ridicule. He knows how to give diptheria toxin, unlike them, but the child dies anyway and it is them that know the "art" of medicine, how to smooth things over with the parents. He ends up working on medical research, goes back to the lab.However, I think that as time went on, although people trusted their local doctors, regardless of education, all practicing MDs from the US were products of the reformed medical schools, and more and more credence was given to the standards set by academic medicine. Remember, in the US, by the 1970's there were few "family physicians", there were so-called GPs who were on the low end of the staus hierarchy, and lots of specialists. That began to turn around in the late 80's and 90's with formal residency traing -for the first time-in family medicine. When I was in medical school in NYC (class 1981) referring doctors from outside of academia were called LMD's (an abbreviation for local medical doctor) and it was generaly understood among the residents and attendings that you never trusted a LMD, a few of them might be good, clinically, but they were out of date and their tests and work-ups had to be repeated for the sake of the patient. "Most MDs" is no fabulous way of putting this, but in America, especially durring those years, there great public respect for the "top doctors" and the top doctors were at the big medical centers, and the big medical centers were directly affiliated with Medical Schools, that were mostly affiliated with Universities. In the 1970's-90's there was a movement in the US against Medicine, the health care system was bankrupting families while the salries of physicians skyrocketted, and -although science brought many good things, still the art of healing, which actually comforts patients, was notably lacking in most if not all of the big academic centers. Also- as actual trials and tests of long held medical practices came to pass, many things that were taken for granted as "scientific" and "correct", like shaving pubic air and painting the birth canal area with antiseptics in women for birth, turned out to either make no difference or to be actually harmful. Then managed care came in to reduce costs and the academic medical centers began giving courses on bedside manner -for lack of a better word. As in the US physicians have to cover their own malpractice costs and many other expenses, like rent,-which all continued to rise as managed care continually reduced fees, many physicians began to look at cosmetic procedures and products, and alternative therapies as a way to survive financially because these products and services (I'm not saying chiropractic, but many of them) are not regulated to a few dollars a visit. Additionally, most of the alternative medicine practices were performed in ways that were fairly uniformly high in the "bedside manner" department, since much depended on placebo effect and that is quite dependent on presentation to the patient. So, suddenly, between everything, alternative medicine got some respect. That's very abbreviated, but I think -overall-true. Nancy Sculerati MD 14:49, 6 March 2007 (CST)

A little JAMA research

I'm going through the full text articles that I can access online from JAMA (the Journal of the American Medical Association) that come up with a search for keyword: Chiropractic. As is my usual wont, I'll stick the references below with my own one or two line summary.

Chiropractic CONDEMNED JAMA, Apr 1969; 208: 352. This rapidly got out of hand, lots of articles and I found myself reading additional journal article linked to full text in reference section. Suffice to say- the late 60's and 70's were full of articles like the one referenced before this statement. Then there began to be articles that looked at controlled trials of chiropractic therapies, then some articles on the inclusion of alternative medicine courses in medical schools. Those articles were the subject of many letters, ranging from a co-plaitiff of Wilks applauding the JAMA for recognizing the worth of chiropractic, to articles from physicians condemning quackery. Many letters pointed out that just because medical schools had courses on CAM, that did not mean they were "how to do it" courses, but likely informational courses. The authors of one paper on courses replied, condemning the letter writer who used the word quackery. There was a link to a New England Jounal of Medicine article that surveyed patients and found 42% used alternative therapy and did not tell their physicians. All in all, the tone definately changes - from let's condemn the quacks to this is something our patients use, let's know more about it. If you like, I can send you some notes I made in a word document. Nancy Sculerati MD 16:59, 6 March 2007 (CST)

That is my understanding as well. That pretty much mirrors our article in the sequence of the scientific reform of chiropractic in the Chiropractic History article. We are not far apart. --Matt Innis (Talk) 19:04, 6 March 2007 (CST)

Overall changes

I don't see that we are changing the article in any significant way that I would consider an improvement worth approving over the original one. It seems that the more we rewrite the more we go in circles. I am concerned that what started as changing the word "propaganda" to make the AMA look better has lost its neutrality. -Matt Innis (Talk) 12:01, 7 March 2007 (CST)

Yes, comparing the present version with the approved, it looks as if the present draft has gone walkabout (we trust it comes back more clear-headed:)). The original idea was to reduce the section on the AMA. (Incidentally, the Am Coll of Surgeons had in 1987 already said that it approved of cooperation between surgeons and chiropractors, so the AMA was not the only player).

I've reduced the original AMA section as :

<Book reference>

In 1963 the American Medical Association formed a Committee on Quackery, which campaigned actively against the practice of Chiropractic. Efforts were made to ensure that Medicare should not cover chiropractic, that the U.S. Office of Education should not recognize a chiropractic accrediting agency, that the two national associations (AMA and ACA) should remain separate, and that state medical societies should initiate legislation to control chiropractic. The AMA distributed anti-chiropractic literature to teachers and guidance counsellors, caused 'Chiropractic' to be removed from the Health Careers Guidebook of the U.S Department of Labor, and established guidelines for training in medical schools about the hazards of chiropractic. In 1966 the AMA declared that "chiropractic is an unscientific cult whose practitioners... constitute a hazard to healthcare in the United States."

As a result of these measures, Chicago chiropractor Chester Wilk and three others brought an antitrust suit against the AMA (Wilk et al vs AMA et al) in 1976. They claimed that the AMA was in violation of the Sherman Antitrust Act by engaging in a conspiracy to restraint of trade. In 1987 the Federal Appeals Court in found that, while accepting that the AMA had a duty to show its concern for patients, it was not persuaded that this duty could not have been done in a way that was less restrictive of competition, for instance by public education campaigns. Since the case was not about the scientific basis of chiropractic treatment, the court declined make any decision on that issue.

Subsequently (1992ref) the AMA has declared that "It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient.” It is acceptable to the AMA that physicians teach in recognized schools of chiropractic. This has opened the doors for AMA members to collaborate more openly with chiropractors in patient care, teaching and research.

Some additional ideas / random thoughts: More important to me is: This is a summary of chiropractic, and the history can be expanded a History of Chiropractic. The Wilk/AMA case deserves its own article. We are not told here what happened to chiropractic between 1910 and 1960. It may be easier to balance the history by splitting the history of chiropractic into decades, and state what ever was of note, then decide how to balance the time line. How was chiropractic developed, taught, promoted? what are the main negative/positive points per decade (there are 11 to cover)? I can't see how a discussion of the 19th century could fit in with the history of chiropractic, except for DD. I ask myself: Where did the recognition of chiropractic come from, if there was all this opposition all the time? Is there place for some more international perspective?

--Christo Muller (Talk) 15:33, 7 March 2007 (CST)

Hey Christo! That works, too. But, if we are going to add the sentence on the judge not ruling on the scientific validity above, we probably should mention that the judge said that the AMA suppressed research. Also, did you see Chiropractic History. This was originally in this article, but gets cut out and then it seems to grow again:) Like a salamander;) -Matt Innis (Talk) 17:27, 7 March 2007 (CST)

I agree that the Wilk case needs its own article. Assuming that we agree to take the long version and swiftly approve it as a short article in its own right, we'd have to consider what aspects are essential for this article, and this goes to the key issue of why the case was so important. I think it is an essential part of understanding the antipathy between conventional medicine in the USA and the chiropractic profession. I think the essential elements are these

• 1) the AMA had actively tried to suppress chiropractic, arguing that its basis was unscientific, and that it deflected its patients from seeking what it saw as more appropriate care.
• 2) the chiropractic profession interpreted the AMA campaign as an unscrupulous attempt by one business competitor to unfairly suppress a rival
• 3) four chiropractors took the AMA and others to court on this basis, even though by this time the AMA had lifted its boycott on members working with chiropractors
• 4) after a long series of court cases, the judge agreed with the chiropractors that a) the AMA had indeed been unlawfully suppressing a rival, b) the AMA had suppressed evidence for the efficacy of chiropractic and c) most of the witnesses at the trial that were called by the AMA had agreed that chiropractic was efficacious in some circumstances
• 5) the judge also agreed that some (but not all) aspects of chiropractic had no firm scientific basis and that the AMA were entitled to be concerned about patient safety, but stated that this could and should have been done in ways that were not unlawful or unfair
• 6) the judge was not persuaded that the AMA was sincere in declaring that it had already changed its policy on chiropractic before the trial, so issued an injunction against the AMA and obliged the AMA to publish her judgement in full in American Medical News

I believe these to be the facts, and that they are essential to understanding a) the depth of antipathy between the AMA and chiropractic and b) the continuing distrust of the AMA by many in the chiropractic profession. I believe also that there are some very common misconceptions that should be corrected:

• a) that the AMA "backed down" - no, it did not back down, it fought to the very end and lost.
• b) that the case was purely about trust law - no, the injunction was placed because of the dishonest nature of the AMA campaign,
• c) that efficacy was not an issue - no, efficacy was central to the evidence in the case; the judge declined to declare chiropractic efficacious or not, but reported that the evidence given at the trial favoured a conclusion that it was efficacious;
• d) that scientific basis was not an issue - no, this was the central tenet of the AMA defence. The judge concluded that the AMA case had some merit in that some aspects of chiropractic had a weak scientific basis, but said that this was not true of all aspects, and so dismissed the AMA defence.

I have to agree with Matt that if the allegations by the AMA about chiropractic are reported, then so must be the judge's dismissal of those allegations as coming from a Committee comprised of doctors who had volunteered for the Committee because of their preformed disapproval of chiropractic, and who ignored all evidence and opinions given to them that favoured chiropractic, including evidence and opinions of other physicians.Gareth Leng 08:39, 8 March 2007 (CST)

I'd suggest the following abbreviated account for the present article:

In 1963, the AMA formed a 'Committee on Quackery' that began a campaign to eliminate chiropractic, and the AMA set out to forbid its members from working with chiropractors on the basis of the AMA 'Principles of Medical Ethics'. Until 1980, these stated that "A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily professionally associate with anyone who violates this principle." As a result, in 1976, a Chicago chiropractor, Chester Wilk, and three others brought an antitrust suit against the AMA (see Wilk et al vs AMA et al.). In 1987, the Federal Appeals Court found the AMA guilty of conspiracy and restraint of trade. The AMA lost its appeal to the Supreme Court.

In her judgement, (ref) Judge Susan Getzendanner strongly criticised the AMA campaign, saying that the AMA had taken: "active steps, often covert, to undermine chiropractic educational institutions, conceal evidence of the usefulness of chiropractic care, undercut insurance programs for patients of chiropractors, subvert government inquiries into the efficacy of chiropractic, engage in a massive disinformation campaign to discredit and destabilize the chiropractic profession and engage in numerous other activities to maintain a medical physician monopoly over health care in this country." [13] She described the Committee on Quackery as essentially comprising doctors who had volunteered to serve because of their belief that chiropractic should be eliminated. Evidence was given to the Committee that chiropractic was more effective than the medical profession for certain problems, and that some medical physicians believed that chiropractors were better trained to deal with musculoskeletal problems than most medical physicians. However, the Committee did not follow up any of these studies or opinions. At the trial, most witnesses who appeared on behalf of the AMA agreed that some chiropractic treatment is efficacious. The court recognized that some chiropractic practices lacked a scientific basis, and that the AMA had a duty to show its concern for patients, but was not persuaded that this could not have been achieved in a way that was less restrictive of competition, for instance by public education campaigns.

In 1992.... Gareth Leng 09:07, 8 March 2007 (CST)

To see the difference

This is the difference between Christo's version and Gareth's version [11]

Folks, take a good look at them both and surely this is an editorial decision as to the direction we want to go. This being an article on my profession, I don't feel comfortable making this call, but trust your combined integrities to make a call that is best for the project. -Matt Innis (Talk) 11:14, 8 March 2007 (CST)

Minor query - Nancy, your edit summarised as "this is just true- it's the health sciences not just "conventional physicians" - were you thinking of osteopaths here?Gareth Leng 11:16, 9 March 2007 (CST)

No, I mean the allied health sciences: nurses, physical therapists, physician's assistants, radiology technologists, medical technologists. I love Matt, and I don't want to personally offend him, but it is important that it is clear that chiropracters are not just a sort of unconventional doctor. The chiropractic understanding of disease is completely apart from the common biological understanding of disease that all the allied health sciences are taught. In the US, there are a few OD's, and I don't know that much about them, but basically, ,any take residency training like MDs and their practice is indistinguishable for those in the mainstream. One thing we are really lacking here is on the practice of chiropractic in the rest of the world. What are the educational requirements? What is the profession like elsewhere? It may be more integrated in with the health scieces, here it is really completely separate. Nancy Sculerati MD 11:45, 9 March 2007 (CST)

The chiropractic understanding of disease is completely apart from the common biological understanding of disease that all the allied health sciences are taught.

I took my undergraduate courses at Indiana University majoring in biology alongside all the premed students. The course completed as a BS in human biology through Logan College of Chiropractic. The Chiropractic program at Logan included Organic Chemistry and Biochemistry taught by a PhD in Biochemistry, Microbiology by a PhD in Microbiology, Dermatology by a Phd in Dermatology. Human anatomy included 8 months of human dissection. And others.. though we did not have any instruction in pharmacology. I have no doubt the residency programs for medicine are quite extensive as they need be in order treat the many life saving illnesses that you treat, as our internship spends most of it's time treating more of the chronic degenerative type conditions, but I am quite sure we have pretty much the same understanding of disease that all allied health sciences are taught. I think we might be taught things from a more vitalistic approach, with the understanding that we aren't so much supposed to change the bodies response to disease as much as assist it in responding to disease. Obviously, there are disease conditions that are more viral than the human organism and for those we need to be constantly vigilant so we can get them to those equipped to battle them. But that is not any different than any other allied health care field's understanding, I don't think for sure, but obviously you don't know what you don't know. --Matt Innis (Talk) 13:57, 9 March 2007 (CST)

This is an interesting thread, though I'm not sure where it's going. obviously I teach in a Medical School. In the UK generally the medical curriculum has evolved to become very vocationally oriented and practically based, so on the face of it Matt's education appears to have a much stronger basic science component than current UK medical training. Indeed medical students are "taught" very little basic science of any sort, depending on what you mean by taught. A medical degree here is a primary degree, not a postgraduate degree, and students enter at 18. Their education (5 years) is based around problem-based learning or case-based learning supplemented by skills training from the very beginning. Problem-based learning is student led in small groups working around a theme (a hypothetical scenario) with a facilitator to ensure that the students keep roughly to learning objectives. Basic science therforeis not taught in a structured way at all, but arises incidentally. This system of teaching has its fans and its critics, and I am a bit of both. Many of my colleagues feel strongly that current medical training does not impart a coherent understanding of scientific foundations of medicine. However the emphasis on skills, independent continuing learning, and on the patient-doctor relationship, are clear benefits. Chiropractic is small here, but there are undergraduate and postgraduate degree courses in colleges that are associated institutions of some of the new Universities; these Institutions are often "looked down on" by Institutions such as mine as they are generally mainly teaching Institutions with little academic research delivering mainly vocational rather than academic courses, but they often have a good (sometimes better) reputation for teaching quality. I,ll try to find about the curriclum. Gareth Leng 05:24, 10 March 2007 (CST)

Briefly, in the UK there are four accredited Colleges, two University based and two asociated with Universities. Accreditation by the GCC requires a 4-year approved degree programme leading to a BSc in Chiropractic. I've looked at the University of Glamorgan site, and the academic side is much stronger than I'd expected it to be (just showing my ignorance and prejudice here). About its training, it states "The profession enjoys independent practising status and emphasises that it is not an alternative to conventional medicine. This course is designed to train chiropractors with an advanced knowledge of human structure and its relationship to general health, plus the ability to diagnose and treat those conditions considered likely to respond to chiropractic management." Students for this degree are taught spinal mechanics by a PhD physiologist actively researching spinal mechanics (in animal experiments, trained in Calgary) whose modules are available to students from several other degree programmes; i.e. the underlying science in the initial years at least seems to be taught from a conventional basic science perspective, and is integrated with the education of other health professionals (not medics, their education here is not integrated with anything else generally). See [12]Gareth Leng 06:02, 10 March 2007 (CST)

Well, I think that we have to reflect the seperation of chiropractic and the health sciences in the USA here, and include a couple of lines in that in "critical views". I'd like to talk this out here on the talk page, because I want Matt's view and very much want him onboard. Let me back up for a minute and suggest, barring the better solution of having chiropracters from other countries collaborate, that we should investigate with due diligence and find out if chiropracters not only share their education with other health professionals in the UK (and we need to look at other countries one by one) but also share practice facilities- do they roiutinely go to hospitals and government financed clinics, for example? In the USA-and this goes also to te discussion we are having Gareth in the History of Medicine (United States), underegraduates that are "pre-med" take the same courses in college as sceince majors who will go on to get Ph Ds in research science. That is also true of the undergarduates who will go on to Dental School. Most colleges have less research oriented courses for Nurses and physical therapists, although the title of the course may be the same- the difficulty and hours in the lab are not. Here comes the critical part-in the USA, to the very best of my knowledge, DCs are educated entirely separately and have their own schools-not the common universities attended by the others, and are, perhaps with rare exception, never integrated into the common health system of Dentists, Doctors (MD), nurses, (RN) etc. This may be an unfair artifact of past exclusion- but there is another side that is important. It is an entirely different system of care. There are chiropracters, like Matt, who refer to hospitals and health science physicians and programs, but that is an individual choice on his part that does not reflect any integration of care for the typical patient of a chiropracter into the health system. In fact, some chiropracters offer full primary care to patients, men, women, and children, (I guess these are "the straights") and there is no general formal or informal system in place to see that such patients also received attention by the Health Sciences. Like with extreme Christian Scientists, patients who under the care of these heaqlers, unless they themselves independantly seek out health care from the generally recognized central health care system, will not receive it. So, for example-there are articles in the US medical literature that analyze why it is that the death rate of breast cancer is higher among black women than white women-even though the rate of the disease is much higher in whites. I'll get that reference when I finish this post. There are many reasons given in this article, basically having to do with late presentation, but one of the reasons for late presentation to MDs that treat cancer is because, in the area of the US where this study was done- black women were disproportionately undereducated, less affluent, and underinsured, as compared to white women, and, like others of that demographic, more likely to seek chiropractic care when they finally did seek attention, and then less likely to get attention from the health system, because it is separate. Now, some of the concern that exits about chiropractic in the US is that those who seek chiropractic care are not getting attention within the broader health system, but outside of it. That was my point about the straights and vaccination, though I didn't make it very well, you see if a parent brings their infant and young child to one of the straights that do noty believe in vaccination (and my understanding from their own lieterature is that none, or almost none, do) that child may well be entirely outside of the health system- never being examined by a nurse or doctor. In other countries, this may not be the case- but it is not reasonable to present Chiropractic as incorporated into the health system in the USA just because it may be elsewhere. I strongly believe that the efficacy of chiropractic care be properly supported, but I also strongly believe that these risks of lack of standard medical care by explicitly addressed. Nancy Sculerati MD 09:27, 10 March 2007 (CST)

late diagnosis reference

Lannin DR. Mathews HF. Mitchell J. Swanson MS. Swanson FH. Edwards MS. Influence of socioeconomic and cultural factors on racial differences in late-stage presentation of breast cancer. [Journal Article. Research Support, Non-U.S. Gov't. Research Support, U.S. Gov't, Non-P.H.S.] JAMA. 279(22):1801-7, 1998 Jun 10. UI: 9628711

OK to summarise in the UK, medical student training is not generally integrated with that of science students. It is skill based not theory based. Training of chiropractors is well integrated with that of science students and other health professionals (ie they taught a high proportion of modules) in 2 of the 4 accrediting institutions. In the UK chiropractic seems to be moving towards fll integration. However, chiropractic is tiny in the UK; theres no doubt in my mindthat this article should reflect the US reality whatever that is.Gareth Leng 12:32, 10 March 2007 (CST)

I think you have to investigate that on your own Gareth, because you are acting as an editor here and I think Matt's view is extremely sympathetic towards Chiropractic and not a neutral mainstream US view. My view is sceptic but not condemning-but there are no chiropracters in any academic or major medical center that I know of, and certainly not that I have ever had contact with, and so I only know what I read and what Matt says. There have been times that you have intervened as editor here when I assumed that your perspective came from knowledge of the field. Some of the nutty comments we have had about quacks and such are nutty, but may have been provoked by the unusually sympathetic view of chiropractic presented here. Again, although there may be some regional variations, in the US chiropractic is alternative medicine in the sense that it lies entirely outside the established network of dental, medical, nursing and physical therapy health network, is not included in hospitals and is not integrated into the health sciences. Whereas a nurse or physician's assistant or physical therapist is required by law to refer to a Physician if certain health conditions occur- and is also required to do that by professional ethics, a chiropracter is not- in the US. If I am wrong, it is from ignorance-but that is what I think and I can find nothing in writing to refute it. Nancy Sculerati MD 13:06, 10 March 2007 (CST)

None of us knows it all which is why we need to work together. In the UK it's clear thatwhat you suggest is not true, in that the chiropractic is regulated very tightly by the GCC, which is a government established body with very similar role and ower as the General Medical Council. In the USA, I see that most medical schools in 1988 offered electives in CAMs and that chiropractic was one of the most common of these (JAMA 1998 280:784-778 [PMID 9729989]); there have been surveys of referrals and willingness to refer to chiropractors in the US, I recall finding one of these if that's relevant. I think there is the expectation here that all subjects be treated sympathetically. To my honest best knowledge the article as it stands is accurate and makes no major negative omissions of verifiable fact which I'm aware, except those covered in the Criticism article. The Wilk case report is verifiably accurate from the published judgement. I'll keep lookingGareth Leng 16:51, 10 March 2007 (CST)

I think the Wilk case is accurate, and the elecetives now offered in medical schools exist, but rarely if ever as the kind of apprenticeships that medical subspecialty electives exist as- instead as "informational electives". Aromatherapy and prayer healing are also covered, that is not to say that these are incorporated into the curriculum as standard therapies. I'm not saying that chiropractic should be presented without sympathy, I am saying that in the US it is misleading to present the chiropracter as just one more kind of doctor or health professional that is in the system, because chiropractic is not within the system and some chiropracters actively encourage their patients to avoid the system because they believe that drugs, vaccinations and standard medical care is a poor choice. That side of it has to be made clear- as well as the fact that chiropractic care for back pain is at least as good as non-surgical medical care and physical therapy. But I would like to see what Matt has to say, and how this can be worded in an agreeable manner.Nancy Sculerati MD 17:35, 10 March 2007 (CST)

in the US it is misleading to present the chiropracter as just one more kind of doctor or health professional that is in the system, because chiropractic is not within the system and some chiropracters actively encourage their patients to avoid the system because they believe that drugs, vaccinations and standard medical care is a poor choice.

I think this is the only sentence that I can respond to, as I don't have access to the breast cancer source. The clarifying issue is the word "system". Chiropractic is within the "healthcare system". I agree that it is not within the "medicol system". Though Wilk broke down some barriers that allow doctors to develop personal and individual relationships, there is still a wall of distrust. I have my doctors that I refer to as well as those that I wouldn't. I think politically, the government would like to see it better integrated, but professionally the two fields are still separated by animosities (real or imagined) as witnessed by the Florida debacle a couple of years back where Jeb Bush (Governor of Florida) requested that chiropractic be integrated into the university of Florida, but was refused because professors threatened to resign because they thought it was a pseudoscience (real or imagined). The second part of the sentence (real or imagined) is probably the reason they are not allowed into the "medical system". I did find some examples of the type of thing that chiropractors read [13],[14](notice who wrote this one-we already cite Lon Morgan once - again this is the internal dialogue within the profession read the last paragraph - makes Nancy's argument). Maybe we can integrate it somehow. Though this is probably more appropriate for the antibiotic and vaccination articles. That is a whole new bag of worms and obviously this is not what defines chiropractic because I think all the schools take a neutral stance on vaccination (I'll check though). I think our section on Chiropractic approaches does as good a job illustrating the different outlooks on these, but maybe we can clarify them more. We should be able to find some sources on this.

While we are on the subject, I don't think starting the introduction with a "slap on the back" is appropriate without a reference. I have never seen it, but I left it in from the WP article. If it is going up front, let's see it. --Matt Innis (Talk) 20:01, 10 March 2007 (CST)

Matt. what I was thinking in the "couple of lines" in the Critical view section was something like this (this is unpolished-just writing it as I think it:): 'One result of the long history of distrust between the system of hospitals and health science professionals on the one side and chiropractic on the other has been the exclusion, until recent years, of chiropractic from the general health care institutions of the United States. When patients are cared for by those chiropracters who do not accept health science, then these patients may, sometimes without realizing it, enter a truly alternative system of care, where the standard diagnostic and therapeutic methods for disease are not used. In some cases, this has been cited as a reason for the late diagnosis of serious diseases.' Whether or not most Schools for DCs try to take a neutral view, there are more than a tiny number of practicing DCs (I guess straights?) who do not. Just as, I'd say, most schools of medicine take an officially neutral view towards alternative medicine and chiropractic, might even offer courses on the topic (though-as you point out about Florida- it is not as though Chiropractors are on the faculty)-again, I am sure that you have a network of physicians that you refer to, and that there are those that refer to you, but that is an individual private practice arrangement. There are chiropractors who never refer to physicians and physicians who never refer to chiropractors. There are chiropractors who never refer to physicians even if a patient is ill. I don't say they do this without good intentions, but breast cancer diagnosis and heart disease diagnosis as performed by health science is not chiropractic. Nancy Sculerati MD 05:38, 11 March 2007 (CDT) Also Matt, when you say "health care system", yes- the Government and private health insurers will pay chiropractic fees, and so in that sense Chiropractic is part of the health care system as recognized by insurers and the Government, but I am talking about a patient's access to standard medical care, a patient being "in" the standard health care system. When a patient ivisits a Chiroptactor, in general, it is not in a medical center or hospital but a private office or a strictly chiropractic group that is OUTSIDE the heath sciences. There is more to vaccination, for example, than just the vaccination- apparently well children are seen by doctors, nurses, and physician's asistants when they get vaccinated and conditions unsuspected by parents are sometimes picked up. The fact that children get a series of vaccination early on is a kind of a fail-safe in having medical attention. If children get their primary care from chiropractors- as offered by some chiropractors who advertise that the offer full care including primary care for children and prenatal care for women-and are not vaccinated they also are not seen by the standard medical people, I don't want to get lost in semantics here, and in that sense they are outsde the health care system. I feel obligated to make this clear because in other countries it sounds like this is not the case. Here, chiropractors- even those who do refer to MDs and DOs (both of whom are within the greater health care system with admitting privileges to hospitals etc), are not themselves able to admit patients to hospitals. There may be some hospitals where chiropractors can consult on patients, but I do not know of any. In the US, chiropractic is not integrated into the standard hospital/health care system. They are separate, and there can be consequences for patients if the patients don't know enough to seek help at the hospital and the chiropractor is distrustful of the medical system. My concern is that this article makes it sound as if it is not that way-like this is Scotland, say, where that does not appear to be true. Matt- you phrase it so that it is not offensive to you, but please-tell it like it is. NancyNancy Sculerati MD 05:50, 11 March 2007 (CDT)

Good to talk

I think we are covering some very important issues relating to neutrality here, and it's good to talk over them professionally. I see Nancy's concern, I just am not sure how to accommodate it properly. A man may swear to tell the truth, but it is not in his power to tell the whole truth and nothing but. “Truth is so subtle a point that our instruments are too blunt to touch it exactly. When they do reach it, they crush the point and bear down around it, more on the false than on the true” (Pascal) The important issue is that we must trust each other's integrity, we are all trying to tell it like it is; we need each other because we have to tell it like it is in a way that we all understand to be true

If we take statements from the AMA, NIH, NHS etc at face value, then I think the article has a tone that is less “sympathetic” to chiropractic than these. So the issue is this: Regardless of what the AMA says officially, and regardless of what is in the peer reviewed literature, many hospital-based physicians in the US are disdainful of chiropractic, and at present this is not adequately reported in the article. As I understand, these physicians work in an environment from which chiropractors are excluded, so the basis for that disdain isn't an obvious matter of direct experience or of verifiable record. My inclination has been that we do not report them, any more than we would report what we think our colleagues really think for example about the standards of medical education in other countries, such as the Indian subcontinent from where many of our health professionals come. Yet as Nancy says, not to report them invites the appearance of bias, ....and yet to report them and not counter them would involve the reality of bias.

Perhaps we might acknowledge the concerns by saying that.

“At present, although many family physicians are willing to refer their patients to chiropractors, chiropractic is not integrated into hospital-based medicine. Many hospital based physicians and academic scientists remain skeptical about the scientific foundations of chiropractic as well as its efficacy for conditions other than some directly associated with the spine, and so remain concerned that some patients who choose to be treated by chiropractors may in some cases be denying themselves the benefits of more efficacious treatment by conventional medicine. They are also concerned at occasional examples of abuses by individual chiropractors. Chiropractors on the other hand believe that these attitudes reflect a lack of understanding of the true nature of chiropractic today, that reflects in part the very separation of chiropractic from hospital based medicine.”

I wrote the above before reading Nancy,s message above so please dont see this as an alternative suggestion; just as a suggestion.Gareth Leng 15:39, 11 March 2007 (CDT)

Thanks, Gareth, for your elegance. Certainly truth is not within my grasp. I'm still waiting to find out if Jesus was real:) Seriously though, all I can do is try to enunciate the truth according to myself, as I assume we all are doing here. I don't have too much trouble with what either you or Nancy are saying here. Certainly both statements are true for somebody. I would really like to see references to support the statement that chiropractic patients are at a higher risk of mortality or morbidity before I would give credence to the assumption. If this were the American Opticians Society making this statement, that would carry a certain amount of weight, but when you place the weight of the AMA behind a statement like that, you expect some scientific analysis and give it more weight. So even if you call it a "maybe" or "possible", when it is attributed to the AMA, it means something more, so lets get this right. We talk about Evidence Based Medicine as a means to determine efficacy regardless of theoretical mechanisms of effect, certainly science can give some idea of whether the assertion is accurate that an alternative education results in a higher risk. Otherwise, this is just someones nightmare that has been marketed well. So, before we make this statement, lets at least verify it or attribute it to the correct group of people so that the proper weight can be applied. I see no problem with highlighting that the two are separate, but to make value judgements based on that separation is a different discussion altogether. Thoughts? -Matt Innis (Talk) 07:44, 12 March 2007 (CDT)

OK maybe my head is hurting here Matt. Did I assign any statement to the AMA? I haven't seen any statement from anywhere attributing higher mortality or morbidity to chiropractic and didn't think I'd said that anyway. What I have been doing is trying to hunt down documentation of the kinds of reservations that Nancy is describing. The best I have found is here [15] where the AMA do say a number of interesting and relevant things about chiropractic. I'll pick out highlights.

1)Manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints, and some chiropractors limit their practices to these conditions. While precise statistics are not available, a majority of chiropractors adhere to the method’s original theories, and continue to claim that chiropractic manipulation cures disease rather than simply relieving symptoms. (Personal communication, Denny Futch DC, Vice President, National Association of Chiropractic Medicine). They promote manipulation as useful in a host of conditions, ranging from infectious diseases to immune therapy, even claiming to prevent future conditions from occurring (even if years away) including menstrual irregularity, difficulty giving birth, and cancer. Chiropractors commonly provide advice in nutrition and other preventive practices, and maintain that a regular series of "adjustments" is needed by most persons to maintain optimal health. 2.In a national survey of referral patterns by board-certified family physicians and internists, ... 47% said they would refer for chiropractic 3.AMA Policy 1997 "Patients who choose alternative therapies should be educated as to the hazards that might result from postponing or stopping conventional medical treatment." (not specifically chiro) 4. Of 125 US medical schools, just over 50 schools offer elective, for-credit courses on alternative therapy, and 18 others offer lecture series or seminars on the subject. Most are being given by "supporters or proponents of alternative methods," and that the "scientific view" is offered in only 7 courses.(not specifically chiro) 5. In their advice to members the AMA says "Avoid hubristic and arrogant attitudes toward alternative medical practices because one might be embarrassed by the subsequent demonstrations of their clinical efficacy." (not specifically chiro)

Suggest that these be the basis of any inserts about attitudes of the medical profession in the US? Its nearly 10 years old but....Gareth Leng 10:28, 12 March 2007 (CDT)

We are dancing around terms here. First, when NIH or other authorities make statements about the "dangers of chiropractic", it is the specific risks of chiropractic therapies that are being discussed- stroke with cervical manipulation, etc. Not the risks of regarding a chiropracter as a comprehensive primary care physician, when, in America, chiropractors are not legally allowed to practice Medicine. In the United States (we don't say "of America here unless we are forced to by Brits :-) (and others)) the term physician means a person who has an unlimited license to practice medicine, and although osteopaths are eligble for that, as well as MD, chiropracters are not, and that is simply true. A hundred years ago, especially in the frontier west and in rural areas, that was not true, and chiropracters were one 'sect' (to use Abraham Flexner's term in the Flexner Report) of physicians. Presently, chiropracters are licensed health care professionals, but not to practice medicine- to practice chiropractic. For whatever reason, and the Wilks case makes a strong argument these reasons were unfair, not only have chiropracters not been physicians for a century, but for a good part of that time physicians in good standing had nothing to do with them. I'm trying to figure out how oseteopathy came to have such a different outcome, and so far it seems to be that their organization insisted on meeting Flexner's standards for education, where as Chiropractic has never been organized in the same sense as the AMA or the Council on Osteopathy. It seems that in the interval, school of chiropractic have raised their standrads, but these schools have remained separate from the Medical (including Osteopathic) Dental and Nursing Schools, which-despite being separate, have frequently been on joint campuses, and shared laboratory and clinical facilities. But I digress- all this time there has remained a 'sect' of Chiropractors, mixers? straights? maybe some of both, who still see themselves as practicing medicine-what Matt calls chiropractic as an 'unlimited profession'. Matt, with al due respect- I do not base my understanding of medicine strictly on my own experience and it is unreasonable for us to produce a document with (hopefully) global impact that is based on one chiropractor's experience, especially one who is not involved nationally in Chiropractic, even if that person is as nice and smart as you. A purusal of the very external references that you have given us back in the section on different types of Chiropractic shows ads-not even by individual chiropractors but by organizations, that present the chiropracter as able to offer a full comprehensive primary health care.Since drugs and surgery are not involved, I guess technically it's not "Medicine", but since drugs and surgery are seen as harmful to patients, the effect is a true alternative medicine where patients who follow these teachings are treated in a comprehensive fashion away from the larger health science system. I can e-mail you the text oof the reference on late diagnosis on breast cancer, which is nothing more than a compilation of what held up diagnosis in a series of patients, and one reason was that these mostly poor and rural woen sought health care from their local chiropracter rather than physician. It's not that anyone is accusing the chiropractors of knowing the women had tumors, the point is that they had their backs adjusted and not their breast cancer diagnosed. In rural areas of tour country even now, and in poor areas, there is still a tradition of DCs acting as physicians and -since they are not "plugged in" to the larger health service network as a group, in fact the very chiropractors who see chiropractic as being unlimited, who teach that vaccinations weaken the immune system, and that medications given by MDs and DOs cause at least as much harm as good, are the very chiropracters who are, logically, least likely to interact with physicians. It is possible to read the article we have written and not realize that chiropractors are not physicians or that the "unlimited" care some offer is -in the Unites States of America not a recognized form of Medicine, and not necesarily a portal to standard medical care, either.m It doesn't matter that that may not be true of "most" chirpractors-it is true of certain sects. Nancy Sculerati MD 10:54, 12 March 2007 (CDT)

??

OK. think I'm starting to see things more clearly from both perspectives, sorry if I've been slow. First, we have to report significant opinions, and I accept Nancy's case that a significant opinion was not adequately reflected, specifically the opinion that chiropractic deflects some patients from effective medical care. This is expressed in the AMA report so I am certain that we should report it. I don't think we should state it as fact but as notable opinion, and I think we should just report it straight. (chiropractors might argue the converse, that if only 47% of family practitioners are willing to chiropractors then they might equally be denying some patients more effective care :) let's not go there.)

However in all honesty Nancy, as I read and re-read the article I don't know how anyone could have been misled into thinking that chiropractors were anything other than clearly distinct from physicians and separate from organised medicine. From the very outset, what chiropractors do and think is constantly contrasted with views of conventional medicine. However, does the revised Criticism section meet your concerns? I've also trimmed the Wilk section down according to my suggestion above. I am not trying here to make a unilateral decision, just inviting you both to look at the overall balance now, afresh.

I seem to be in the middle; actually I feel myself to be off on some third dimension, two thousand miles away. I have to admit I see several sides here. I do find it uncomfortable that the AMA attacks chiropractic for not having an integrated training yet seems to actively prevent such integretaion (in Florida etc.), and can certainly see, in the wake of Wilk, how this might be seen as active suppression of a competitor. I'm glad I'm a long way away sometimes....Gareth Leng 12:21, 12 March 2007 (CDT)

Gareth! You are in the middle! You didn't realize that:) And you are doing a wonderful job of it, too. I'm sure I speak for Nancy when I say we both apprecite your helping us through all this. I haven't had a chance to read through all the changes, yet, but will later this evening.

Nancy, thanks for the breast cancer research. It was indeed enlightening and illustrates your point well. This strikes close to home for me here in North Carolina and I will certainly look into this to see what kind of follow up has occurred.

By the way, while I agree that I am a nice and smart chiropractor:), hopefully I am also a good resource for this article. In the last year I have spent literally thousands of hours researching. Please feel free to look through my notes. [16],[17],[18]. I would also suggest the Lerner report that was used in the state of New York. There is so much more that I haven't even touched on. If you find something like this that contradicts what I have been trying to convey, please feel free to bring to my attention and I will integrate it into the rest of my knowledgebase. Thanks! --Matt Innis (Talk) 16:25, 12 March 2007 (CDT)

Well, that breast cancer article really just emphasizes beliefs, but it's worth including,I think. I just read through a good deal of the Flexner report and am fairly stunned by the racist and sexist assumptions, not to mention the overwhelming arrogance that permeates the thing. It's shocking to me because I approached it with a feeling that Flexner was a hero, not only beccause of medicine but also because of the Institute for Advanced Study. His idealism was not quite the brand that I imagined. Of course, I must remember the times. I put a link to it at the Flexner Report and I swear, if you read it you'll find yourself looking to call the constables every other sentence -for inflammatory language and needless insult. After reading what he said about the schools of osteopathy, I am even more intruiged that they survived. I suspect that they were well financed after the report - they were certainly doing well on a business basis. Thanks, Matt for your Still autobiography link! And Gareth you are nort in some 3rd dimension, we are all in that one-I'd say 5th or 6th! I think that both Matt and I see things from a patient point of view, and in that way we understand each other, and I'm happy with the changes made. Nancy Sculerati MD 17:42, 12 March 2007 (CDT)

No problem with the Still link, Nancy. If you want to get a really thorough understanding from a unique point of view about chiropractic, read the Lerner Report above. It will change you whole outlook. This guys did his own research, going and talking to key people and digging up all kinds of stuff and put it together. It is so thorough but it reads like a mystery novel. He talks about many people addicted to the common treatments laced with alcohol, heroin, and mercury, all killing more than they were saving. If we were living back then, we would have been glad to see Still and Palmer come along. It is guilded with intrigue and cloaked with deceit and mysticism that boggles the mind. He links Rockefeller (horizontal economics buying up all his competition), Carnegie (vertical economics buying into the raw products and sending them through his production line to marketing until he had the consumers dollar), presidents in the pocktets of big money and the pinnacle of social and scientific revolution. It notes that Germany was the center of modern chemistry and patent medicines. Britain was the center of homeopathy and natural remedies. The Americas were young and immigrants were unloading in New York by the thousands. It was exciting and new markets for British and German products were opening everywhere. Competition was tight. Flexner worked for Rockefeller who was German with financing from the Carnegie foundation? Guess what schools they closed, uh huh, homeopathic. Don't forget, we're talking about 1910! Britain was the most powerful nation in the world depending on its trade with other nations, but Germany was becoming the industrialized power of the world, ... guess who have the two biggest navies... yep, Germany and Britain... and the rest is history... 1917 WWI. It's the stuff novels are written about. We were nothing but pawns being played by a giant European chess game. Fun, but nothing that we can use here (maybe on the workgroup page), but it sure is a mind opener. I better see what changes were on this article before I ramble too much. -Matt Innis (Talk) 22:05, 12 March 2007 (CDT)

Well, there are always conspiracy theories. I see it differently so far- Halsted and Osler were at Johns Hopkins, not to mention Cushing and they were putting things together- histology and chemistry and surgery and going lightening fast. The cocaine and morphine helped things along, but nobody was better at adjusting doses than them, I'm sure. They had their own labs, their own operating rooms, their own wards and their own pathology labs. They examined patients, biopsied tumors, looked at them under the microscope, operated on the living flesh and autopsied the dead. They described whole fields of medicine and were able to do things nobody had ever done before. They were brilliant intellectuals and wealthy and cultured men, and Flexner, snob that he was, LOVED them. He -Flexner-saw patients as "clinical material", strictly the raw material for a type of education. He saw the future of scientific medicine as rapidly unlimited and despised the unlettered non-intellectual booster businessman of the midwest and south. He founded the Institute for Advanced Study, and I grew up in that culture- by accident- where I lived, the families of my friends when I was a kid. Like I say- I see it differently. Nancy Sculerati MD 22:29, 12 March 2007 (CDT)

Wow, you did have a unique perspective! No wonder you feel so strongly about it. Don't get me wrong, scientific medicine was the way to go and Flexnor did what had to be done, but to deny that there was a financial incentive would be naive, especially in America, land of capitalism. I'm not saying it is a bad thing, but we can't assume that all of healthcare is about the altruistic endeavor to help patients. If that were the case, we would still be collecting chickens for our pay. You have to ask yourself why countries that have social systems don't seem to have the same problems with chiropractic that the US has. --Matt Innis (Talk) 22:59, 12 March 2007 (CDT)

They don't have thousands and thousands of chiropractors "in business". Nancy Sculerati MD 23:37, 12 March 2007 (CDT)

still needs work

Made a quick read through and saw several edit problems, but didn't change anything as it is getting late here. I still am not satisfied that the introduction fairly portrays Palmers discovery, but will work on it later as well. I miss the prose from the old article that seems to have been lost in our newer version. Maybe if we take a little break and come back, we will see it in a whole new light and we can make it flow better. I'll take another look tomorrow. Overall I don't see any problems with the AMA and critique sections. -Matt Innis (Talk) 22:23, 12 March 2007 (CDT)

Did a quick clean up, just smoothing some of the prose. I've adjusted the account of the hearty slap; both versions are given later, so up front I left it open "(by accident or design)". All the references are now linked for online verification.Gareth Leng 04:45, 13 March 2007 (CDT)

Gave my once or twice over, added some wikilinks (more red links to click on!), and made some minor changes to the intro that I think I can live with. Otherwise a good nights sleep seems to have made everything look better:) -Matt Innis (Talk) 08:52, 13 March 2007 (CDT)

Matt - can you archive most of this? I know I'm an incompetent. I think the article is missing an illustration, I know it will take the limit over but I think it would be in a good cause. I suggest this [19]

Regardless of this, looking to the launch are we ready to reapprove? I am. I'd also like to approve Critical views of chiropractic before the launch to show balance. Gareth Leng 08:58, 14 March 2007 (CDT)

Safety

Mackay B. April the cruellest month for Canada's chiropractors. [News] CMAJ Canadian Medical Association Journal. 166(12):1576, 2002 Jun 11. UI: 12074130 discusses some law suits, and the fact that the Canadian Nation Health service stopped paying for pediatric chiropractic care.

Jones J. Neurologists warn about link between chiropractic, stroke. [News] CMAJ Canadian Medical Association Journal. 166(6):794, 2002 Mar 19. UI: 11944773"More than 60 Canadian neurologists have issued a statement warning that chiropractic neck manipulation can cause stroke and death. The neurologists and the Canadian Stroke Consortium caution that chiropractic manipulation involving the neck can cause arterial dissection. They make 6 recommendations and call for a ban on manipulations involving infants and children. “If there are no clear benefits, any risk is unacceptable,” says Calgary neurologist Brad Stewart."

Meeker WC. Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine.[see comment]. [Review] [164 refs] [Historical Article. Journal Article. Research Support, Non-U.S. Gov't. Research Support, U.S. Gov't, P.H.S.. Review] Annals of Internal Medicine. 136(3):216-27, 2002 Feb 5. UI: 11827498

"The evidence to date indicates that the risk associated with chiropractic manipulation of the neck is both small and inaccurately estimated. The estimated level of risk is smaller than that associated with many commonly used diagnostic tests or prescription drugs. On the other hand, the expected benefit from the manoeuvre is also difficult to quantify. Systematic reviews of the literature and ratings of appropriateness by an expert panel 5,6 suggest that cervical manipulation or mobilization, or both, provide short-term pain relief and range-of-motion enhancement for the subgroup of individuals with subacute or chronic neck pain. The evidence to support the benefit of cervical manipulation for other indications, including acute neck pain, migraine and other miscellaneous conditions, is far less compelling."..."What are the practical implications for patient care? Chiropractic care is common, and the vast majority of patients experience no adverse effects; however, the potential risk of stroke is not zero. Given the potentially devastating consequences of arterial dissection, physicians and chiropractors should discuss this risk, however small it may be, with patients contemplating neck manipulation. As with all clinical interventions, the expected benefits of cervical manipulation should not be overstated. Whether the potential risk of stroke is acceptable is a matter for the patient to decide, and the decision will probably, and legitimately, be informed by the patient's subjective assessment of the severity of his or her symptoms and the desirability of this form of intervention."

several case reports [20]

Rubinstein SM. Peerdeman SM. van Tulder MW. Riphagen I. Haldeman S. A systematic review of the risk factors for cervical artery dissection.[see comment]. [Review] [66 refs] [Journal Article. Review] Stroke. 36(7):1575-80, 2005 Jul. UI: 15933263 note:Haldeman is a DC and an MD and has written pretty extensively on the subject.

Thanks Nancy. Does this mean that you think the safety section needs expanding?

My view here is that we should not go much beyond reporting official advice to patients from e.g. NHS, AMA, NIH. The Canadian neurologists "warning" was given at a press conference announcing the ourset of a study to investigate these very risks, and on the basis of preliminary data. As I understand it, the full study did not support these risks, and the early warning was based on data affected by reporting bias. Ay least that's my memory, which may be unreliable, but I think that's how it appeared when I tried to chase up the outcome of the full study.

I think we need some policy guidelines on such issues in all medicine and health sciences. In my view in general and not just here, articles on Citizendium should avoid appearing to draw its own overall conclusions about either risks or benefits, but may report conclusions drawn by others (attributed, notable sources, major publications), and should report advice to patients as given (for instance) by the AMA or NHS. Articles should not cite case reports (anecdotal evidence, selection bias), but may cite large studies published in major journals, and should give links to evidence-based medicine resources, (systematic reviews, Cochrane etc.).

As always, the issue is how to discuss risks neutrally. It seems to me that reporting official advice and information is straightforward, as this is us reporting advice not giving advice. Where there is dispute about possible risk then both sides must be presented in a balanced way, and I’m not sure that this will lead to clarity. This is why my preference is simply to allude in an uncontroversial way to the possibility that there may be such risks, and refer the reader to reviews and major studies.Gareth Leng 06:20, 15 March 2007 (CDT)

I don't thibk that the evidence argues that spinal adjustments are unsafe, but, at the moment-the entire safety section says :As with all interventions, there are risks. In spinal manipulation risks include: vertebrobasilar accidents, strokes, spinal disc herniation, vertebral fracture, and cauda equina syndrome. A 1996 study showed that the greatest risk is from manipulation of the first two vertebra of the spine, particularly passive rotation of the neck. Serious complications have been reported to be 1 in a million manipulations or fewer, but there is uncertainty about how these are recorded; a survey in 2002 of neurologists in the UK concluded that underreporting rendered estimates 'nonsensical'.[18] Few studies of stroke and cervical manipulation take account of the differences between 'manipulation' and the 'chiropractic adjustment'. According to a report in the JMPT, manipulations administered by a Kung Fu practitioner, general practitioners, osteopaths, physiotherapists, a wife, a blind masseur, and an Indian barber had all been incorrectly attributed to chiropractors.[19] I had thought that this article was going to be very sympathetic to Chiropractic and that Critical Views of Chiropractic would balance that. I now have a different understanding. I think the safety section here should actually be scholarly and include everything, as it is, it 's written to be reassuring and includes no review of the actual literature. I also -now that I have been reading, have a problem with the section on "The 3 rivals of the 19th Century". Chiropractic was not one of 3 rivals in the USA- there was modern medicine, based on science whose practitioers scorned the term allopathy as they consider that a medical "sect" not based on rational understanding, allopathy, homeopathy, eclectic medicine, osteopathy and chiropractic was not even in most of the USA, except for the rural areas and the midwest. in the 1910 Flexner report, chiropractic wasn't even included. Nancy Sculerati MD 07:18, 15 March 2007 (CDT)

Exactly, Nancy, that was my earlier point that we were putting in to much about the Flexnor report. At that point in history chiropractic was a spec in the dust compared to homeopathy that was bigger than scientific medicine. The real battle for Flexnor was homeopathy - these schools did not even have labs to evaluate their own products. Anyway, Andrew Still's osteopathy was taking off as it was 10 years older than chiropractic and had been developing a large following, Palmer just started his clinic and only had 7 graduates by the end of the 19th century (and yes, several were MDs), but he was very vocal with his advertising cures. But Flexnor was after homeopathy initially. Still, being an MD, understood the implications and immediately began to upgrade his quality - including developing accreditation standards and laws to protect his schools. Both Osteo and chiro did not go east - they went to california. Flexnor didn't care about them and by the time he did osteopathy had already developed their program and political base. Initially, it was osteopathy that went after chiropractic, not medicine. I tried to keep it as succinct as possible using the information at our disposal. Let me know if you think something is not correct. I agree the title change to "of the 19th century" is misleading. --Matt Innis (Talk) 08:47, 15 March 2007 (CDT)

Matt, I am getting frustrated altogeher with Chiropractic. I regret giving my approval to the first article. I assumed that both you and Gareth had extensive knowledge, and I added my part. Now I see that I myself have written things here that are just plain wrong, and that they were not removed or corrected. I suggest that we remove the approval template from Chiropractic and work on the draft to make it accurate. And you are wrong about Flexner-he went to California, he reviewed every school considered a "Medical School". It's a long report-but I put the link to it at the bottom of Flexner Report and it's all there. It's hard to do real scholarship, but that's what this article needs. Unless we can recruit individuals who are experts on the subject, the history and practice of Chiropractic as a global profession, I think we have to accept that it will take us a matter of at least weeks to come up with an article that is accurate. Nancy Sculerati MD 09:31, 15 March 2007 (CDT) Well, I've settled down. I may be wrong, you may be wrong, but we are only human and we are trying very hard to get it right. I have reflected that, of all I've read, this has got to be the best single article on Chiropractic I've come across yet and so forget about redacting approval. Please take a look at what I wrote about an integrative view in the talk page for Critical views of chiropractic, and I think we can re-approve this very shortly. Yeah, it would be great to have the World Expert on board, but I'm not so sure there even is a world expert that's also in tune with mainstream medicine and science, and that's, of course, who we actually need. Nancy Sculerati MD 15:56, 15 March 2007 (CDT)

Polio

I've expanded a bit on the polio vaccine just to try to illustrate a bit better why the AMA embraced science and where the division with chiropractic lay. Please checkGareth Leng 05:51, 16 March 2007 (CDT)

revised 19th century section

I am working on a word document to try to get narrative down that explains the background of Medicine and Chiropractic began the AMA suit that I think is important. It's not, I see, that the Chiropractors were so influenced by Flexner and his ilk- it's that the American Medical Profession was. Osler, Cushing and that whole movement of like minded physicians that revolutionized modern medicine in the USA despised allopaths and MDs who adhered to folk remedies and who were not learned or expert in science. By changing the requirements for medical schools that could give the MD and OD- I include both because over the 20th century the actual practice of the OD became pretty indistinguishable from the MD, the nature of American medicine was changed, in its ideal. Even now there are plenty of physicians who scoff as science, see themselves as bussiness men etc- but the Osler/Flexner Contigent (my name for a school of thought) put a stamp on American Medicine as a profession that drove out the heroic healers and sects in Medicine from the 19th Century. I think that an article on Medicine has to show how this movement ended up having a down side with depersonalization of patients, reliance on the trappings of science without demanding true scientific thinking, and other things- including over-prescription (BTW Gareth :-) ) but if I can paint tis picture correctly, it will increase an understanding of why idealistic people in the AMA may have pursued chiropractic. I have no doubt that the Judge was correct, and that there was a business issue here. My point is that I want to show how the idealistic paradigm of modern scientific medicine had reason to abhor the culture of chiropractic. I other words, the kind of ancedotal evidence and willingness to accept temporal association as causality that are still evidenced by the Chiropractic journals are found in Medical Journals of an earlier era - and it was that idealistic scientific academic leadership in medicine that crushed it, at least confined it to private converstaions among physicians and drove it out of being acceptable in journals. So, I'm trying to rewrite this to include that view. Nancy Sculerati MD 09:00, 16 March 2007 (CDT)

I think you are talking about some interseting stuff that needs to be written. It sounds like it needs to have an article all to itself. Keep in mind that MDs and DOs education is very similar now, but that is only since the mid 20th century. Still was anti drug all along until he died. Some of the best research on spinal manipulation came out during this time and was performed at DO schools. One of the reasons that chirorpactic cites as not to join medicine is how DOs lost the art of manipulation when they began to use medications. This is why all but a small reform group (NACM) do not want to see chiropractic prescribe. It would be too easy. Chiropractors identify themselves as manipulation using in an effort to avoid surgery. --Matt Innis (Talk) 09:44, 16 March 2007 (CDT)

Matt, when you say surgery-you mean back surgery? Nancy Sculerati MD 12:27, 16 March 2007 (CDT)

That is a good question. Yes, certainly back surgery, but a subluxation based chiropractor would look at it as if he/she prevented a health problem, he/she may have prevented a "future" surgery.

disambiguation fine print

I added that top line because it struck me, that Veterinary is a whole different deal that we do not have room for here. I'll make a stub for it. It is very big among the sport horse people- around here, anyway. Nancy Sculerati MD 19:50, 16 March 2007 (CDT)