Chiropractic

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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. Chiropractors view subluxations as the first stage of degenerative changes such as arthritis, they believe that these are misaligned, fixated or unusually mobile vertebrae that, by interfering with the nervous system, can affect health adversely in diverse ways. Subluxations are treated with procedures called spinal adjustments that are intended to help improve body posture and joint mobility. Chiropractors also treat some conditions that they believe may originate with a subluxation, but which conventional medical practitioners consider to be wholly unrelated to disorders of the spine.

The word 'subluxation' has a different meaning for biologists, and the special way the term is used by DCs must be understood in order to appreciate their art. The meaning that DCs give the term is unique among health and healing arts professionals, and stems from the historical roots of chiropractic. In conventional medicine, subluxation always means that there is a physical dislocation such that the part is completely out of place. In chiropractic subluxations, this is almost never the case. Unless otherwise specified, the word 'subluxation' in this article uses the chiropractic definition.

Introduction

Chiropractic was founded in 1895 by Daniel David Palmer. He postulated that misalignments of vertebrae compressed spinal nerves and interfered with the transmission of the body's inborn 'healing power' or 'spiritual energy'. He called these misalignments "subluxations" and used the name Innate Intelligence to describe this inborn intelligence that he suspected used the nervous system to transfer information between the body and the mind. He considered that subluxations blocked Innate Intelligence, thereby allowing 'dis-ease' or disharmony. He compared this block to a crimp in a hose that slows the flow of water to a garden: uncrimp the hose, the flow returns, and the garden will flourish.

The practice of chiropractic has made many transformations since its inception. Greater understanding of how the brain makes decisions and communicates through the nervous system, including how it regulates peripheral organs, hormone secretion and the immune system, has led to a progressive replacement of the more 'mystical' explanations used originally with explanations more compatible with contemporary physiology. While the 'pinched garden hose theory' has mostly been abandoned, the metaphor is sometimes still used by DCs to explain the concept of subluxations to patients. Today's chiropractor uses several different types of manual therapies and spinal adjustments mostly for the treatment of conditions such a low back pain, neck pain and headaches for which they have shown efficacy. Some no longer use the word subluxation to describe the spinal conditions that they treat, though most still consider that the spine plays a role in all health and disease.

There is a growing medical literature that shows that chiropractic care can be as effective as physical therapy and conventional non-surgical medical treatment for back pain, even for some severe underlying conditions that most often prompt patients to undergo spinal surgery. Several recent large randomized studies have shown that manual therapy is as good as these conventional medical treatments of back pain, that patients tend to be more satisfied with chiropractic care (even though chiropractic care does not include the use of narcotics and other pain-relieving drugs), and the overall cost is similar. Some DCs use manual therapy to treat systemic diseases (includingallergy and otitis media) in both children and adults. For these other conditions, it is not established that chiropractic is any more efficacious than placebo treatments and this practice has been contentious both within the profession and between chiropractic and conventional medicine.

Currently there are about 70,000 DCs practicing in the USA, 5000 in Canada, 2500 in Australia, 1300 in the UK, with smaller numbers in about 50 other countries. There are 17 chiropractic colleges in the USA, two in Canada and another 13 internationally. Several specialty certifications are awarded. Some DCs specialize in musculoskeletal problems or sports injuries, others combine chiropractic with physiotherapy, nutrition, exercise, or other complementary and alternative methods. However, DCs do not prescribe drugs or perform surgery, and do not recommend 'over-the-counter' medications. They believe that this is the province of conventional medicine, while their role is to pursue drug-free alternative treatments in an effort to avoid the need for surgery.

Chiropractic in practice

Chiropractors consider that disc degeneration is a result of chronic subluxation (in the chiropractic sense). Osteoarthrits is one form of arthritis that DCs work to prevent or improve. The left image shows two normal vertebrae and the disc in between. The right image shows lost disc spacing and degenerative disease of a disc and vertebrae.

By far the vast majority of patients who visit a DC for the first time do so for low back pain, neck pain and headaches. Chiropractors will take note of the patient's chief complaint as well as a comprehensive survey for symptoms arising from other body systems; special attention is paid to symptoms that may require immediate referral or continued follow up. Otherwise, DCs follow similar routines for patient care as their medical counterparts during an office visit, but give less emphasis to laboratory tests and more to spinal testing.

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 medical physician. Postural and spinal function evaluations are carried out, and laboratory tests to evaluate blood and urine may be requested. DCs may also perform X-ray, order MRI, CT scans, or other imaging studies, or might refer to physicians for tests. After making a chiropractic diagnosis, the DC discusses it with the patient, obtains informed consent, and treats according to guidelines agreed by national and local consensus panels that have been established within the profession, such as the Mercy Guidelines; in accord with these guidelines, no ethical DC will ever 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.

When examining the patient, the DC palpates the spine to feel the contour of deep muscles that run between the vertebrae (the multifidus and erector spinae muscles) and assess their symmetry and flexibility. If an area feels tight, hard or bony, the DC checks to see if the vertebral joint below it moves properly. If it is stiff or unusually mobile, the area is identified as a 'trouble spot' or subluxation, which might reflect a new or an old injury, or a postural abnormality. Often, the patient identifies that same spot by pain felt during the palpation. The DC is likely to suspect that this joint might cause problems if neglected, and will adjust it in an effort to prevent these and alleviate present symptoms.

Manipulation can cause a rapid release of gas from the joint fluid. See animation.

The most common adjustment involves manipulating the spine with a fast but gentle thrust that usually causes a 'popping' sound. The sound is thought to be from a form of cavitation in the fluid-filled diarthrodial joints. During a manipulation, the force applied separates the surfaces of the encapsulated joint cavity, creating a relative vacuum within the joint space. In this environment, gases that are naturally dissolved in all bodily fluids form a bubble (as when gas is released from a carbonated drink when it is opened), creating a rapid vibration, and a sound is heard. The effects of the bubble within the joint continue for hours while it is slowly reabsorbed. During this time, the joint is able to move more freely and stimulates the nerves surrounding the joint capsule.

Many other techniques for analyzing and adjusting subluxations have been developed over the last century, and not all include the cavitation-type spinal manipulation. The 'Activator Technique' uses a hand held percussion instrument, the 'Thompson Technique' uses a special table with sections that drop, and the Cox Flexion Distraction technique uses a table that tractions the lower back and is specifically for treating lumbar disc herniations and facet-related injuries.

Subluxation and Innate Intelligence

With today's advances in scientific understanding, some DCs feel that the 19th century concepts of Innate Intelligence and vertebral subluxation appear to be too vague to have any scientific accuracy. In 1998, Lon Morgan DC wrote that the concept of Innate Intelligence originates in "borrowed mystical and occult practices of a bygone era"; he described it as untestable and unverifiable, and harmful to progress within the profession.

Other DCs argue that these concepts still fulfil a useful role, both as metaphors, standing for physiological processes that are poorly understood, and because they help them to see their patients as more than the 'sum of their parts'. They believe that trying to explain all the complex processes that combine to make a human being function in terms of biology misses things that are important for understanding what makes a human being healthy. Meridel Gatterman DC said of 'subluxation', "To some it has become the holy word; to others, an albatross to be discarded ... Why then do we persist in using the term when ... the concept that once helped to hold a young profession together now divides it? ...The obvious answer is: The concept of subluxation is central to chiropractic." Thus there is ongoing debate as to whether the term subluxation should be abandoned to satisfy science (much as there was when dentists abandoned the term 'cavity' for 'dental caries' to promote the understanding of the tiny defects that precede the formation of a cavity).

Anthony Rosner of the Foundation for Chiropractic Education and Research suggests that perhaps there is no reason to discard the concept of subluxation if it is treated as a 'provisional' concept that will undergo continuous modification.

Chiropractic approach to healthcare

ACC Chiropractic/Medical Management Model

"For every chiropractor, there is an equal and opposite chiropractor" Stanley Martin DC (attrib.)

The chiropractic approach always focuses on direct treatment of the patient in hopes of "strengthening the host", regardless of the nature of any outside or environmental agents that might cause disease. Contemporary DCs can take several different approaches to patient care ranging from a "holistic" and naturopathic approach to being integrated as a musculoskletal specialist in the conventional medical model. These differences are reflected in different professional associations.

• Traditional Straights hold that subluxation is a risk factor for most diseases. They do not try to diagnose complaints, which they consider to be secondary effects; instead, they screen patients for 'red flags' of serious disease. Accreditation standards require that differential diagnosis is taught in all chiropractic programs, and several chiropractic licensing boards require that patient complaints are diagnosed before they receive care. Many traditional straights belong to the International Chiropractors Association and offer general health care to both adults and children. Traditional straights teach their patients that vaccinations in childhood are dangerous, and are sceptical of pharmacology and medicine.
• Mixers use more diverse diagnostic and treatment approaches, including naturopathic remedies and physical therapy devices. Many belong to the American Chiropractic Association, and all the major groups in Europe are part of the European Chiropractors Union.
• Objective Straights focus on correcting subluxations. They typically do not diagnose patient complaints, or refer to other professionals, but they encourage their patients to consult a medical physician "if they indicate that they want to be treated for the symptoms they are experiencing or if they would like a medical diagnosis to determine the cause of their symptoms". Many belong to the Federation of Straight Chiropractic Organizations and the World Chiropractic Alliance.
• Reform chiropractors, also a minority, are mostly mixers who use manipulation to treat osteoarthritis and other musculoskeletal conditions. They prefer to integrate their skills into contemporary medicine and do not subscribe to Palmer philosophy or vertebral subluxation theory, and tend not to use CAM methods.

Chiropractic education, licensing and regulation

Palmer Chiropractic College with a bust of DD Palmer (center)

When chiropractic began, licensing for the health professions was just beginning, and physicians learned their trades 'on the job', much as an apprentice would learn a trade today. DD Palmer began teaching his technique in three-month courses; most of his students had already certified as MDs or osteopaths, and were looking to add a new method to their practices.

After the Flexner report, which enhanced the standards of education for medicine, chiropractic schools were shut out of the new system, and had to develop their own educational standards. Over the years, these have become progressively more stringent. Students today must meet a minimum prerequisite course of study of 90 semester hours from an accredited college or university, including biology, psychology, and physics. Chiropractic programs require at least 4,200 hours of instruction in subjects including physiology and anatomical studies, including 8 months of human dissection, and students must undertake a research project in their third year. The final two years cover manipulation and spinal adjustment and give experience in physical and laboratory diagnosis, orthopedics, neurology, geriatrics, physiotherapy, and nutrition. After this, to qualify for licensure, graduates must pass four examinations from the National Board of Chiropractic Examiners and satisfy State-specific requirements. Chiropractic colleges also offer postdoctoral training with exams leading to 'diplomate' status in particular specialties. In the USA, this training is overseen by the Council on Chiropractic Education. Each state has its own licensing board, overseen by a Federation of Chiropractic Licensing Boards, which handle any necessary disciplinary actions. Unlike medicine, in the USA, laws governing the practice of chiropractic vary from state to state and, as a result, procedures used by DCs vary as well.

In the UK, chiropractic is regulated by the General Chiropractic Council (GCC), a statutory body with regulatory powers established by an Act of Parliament in 1994 . The GCC is charged with maintaining standards and enforcing professional discipline, and it is against the law for anyone to represent themselves as a chiropractor in the UK unless they are registered with the GCC.

History

See Chiropractic History for a more detailed account

The early 19th century saw the rise of patent medicine and the nostrum trade. Some remedies were sold by doctors of medicine, but most were sold by lay people, often using dubious advertising claims. The addictive or toxic effects of many of these remedies, especially morphine and mercury-based cures, and the harsh laxatives and emetics, prompted the rise of the alternative remedies of homeopathy and eclectic medicine. These treatments were better tolerated and were usually at least no more ineffective. In the USA, licensing for medical professionals had all but vanished around the Civil War, leaving the profession open to anyone who declared themselves to be a physician. By 1885, purveyers of scientific medicine, herbalism, magnetism and leeches, lances, tinctures and patent medicines were all in competition, and, with no patent protection for new discoveries, claims for the drugless healing professions proliferated. Neither patients nor many practitioners had much knowledge of either the causes of, or cures for, illnesses, and quack cures were becoming more common and were mostly unregulated.

Daniel David Palmer (DD Palmer), a teacher and grocer turned magnetic healer, opened his office of magnetic healing in Davenport, Iowa in 1886. Nine years later, on September 18, 1895, he had the opportunity to treat a deaf janitor, Harvey Lillard. According to Palmer, Lillard had told him that, while working in a cramped area seventeen years earlier, he had felt a 'pop' in his back and had since been virtually deaf. Palmer claimed to have found a sore lump that indicated spinal misalignment, and corrected the misalignment; after which Lillard could then "hear the wheels of the horse-drawn carts" in the street below. Lillard's daughter related the incident somewhat differently. She reported that her father mentioned that he was joking with a friend in the hall outside Palmer's office when Palmer joined them. As Lillard reached the punchline, Palmer, laughing heartily, slapped Lillard on the back with the heavy book he had been reading. A few days later, Lillard's hearing seemed better, and Palmer decided to explore manipulation as a healing practice.

Palmer himself described the next phase: "I had a case of heart trouble which was not improving. I examined the spine and found a displaced vertebra pressing against the nerves which innervate the heart. I adjusted the vertebra and gave immediate relief -- nothing 'accidental' or 'crude' about this. Then I began to reason if two diseases, so dissimilar as deafness and heart trouble, came from impingement, a pressure on nerves, were not other disease due to a similar cause? Thus the science (knowledge) and art (adjusting) of Chiropractic were formed at that time."

DD Palmer asked a friend, the Reverend Samuel Weed, to help him name his discovery; he suggested combining the words cheiros and praktikos (meaning 'done by hand'). In 1896, DD Palmer added a school to his magnetic healing infirmary and began to teach others the new "chiropractic"; it would become the Palmer School (now College) of Chiropractic. DD Palmer's first descriptions for chiropractic were very similar to Andrew Still's earlier principles of osteopathy: both described the body as a 'machine' whose parts could be manipulated to effect a drugless cure. However, Palmer stated that he concentrated on reducing 'heat' from friction of the misaligned parts, while Still claimed to enhance the flow of blood.

Medicine, osteopathy, and chiropractic; the three rivals

In 1899, a Davenport MD, Heinrich Matthey, began a campaign to change the state law in Iowa to prevent "drugless healers" from practicing there. Osteopathic schools responded by developing a program of college inspection and accreditation, but DD Palmer, whose school had just graduated its 7th student, insisted that his graduates did not need the same training as medicine, as they did not prescribe drugs. Nevertheless, in 1906 he was arrested and convicted for claiming that he could cure disease when he had no license to practise either medicine or osteopathy. This prompted the creation of the 'Universal Chiropractic Association' to provide legal defense for its members; its first case (of more than 15000 over 30 years) was in 1907, when Shegataro Morikubo DC of Wisconsin was charged with unlicensed practice of osteopathy. Attorney Tom Morris legally differentiated chiropractic from osteopathy by the differences in the philosophy of chiropractic's 'supremacy of the nerve' and osteopathy's 'supremacy of the artery'. Morikubo was freed, and the victory shaped the development of chiropractic, which then marketed itself as a science, an art and a philosophy.

The American Medical Association plans to eliminate chiropractic

"Medicine, Monopolies, and Malice". (Chester Wilk DC, book title)

The American Medical Association (AMA) had been formed in 1847 to raise standards in medical education. After intense political pressure, medical boards were formed in almost every state, requiring licentiates to have a diploma from an AMA-approved college. By 1906, the AMA had drawn up a list of unacceptable schools, and in 1910, as a result of the Flexner Report, hundreds of private medical and homeopathic schools were closed. The AMA had effectively gained control of federal healthcare research and student aid.

In 1963, the AMA formed a 'Committee on Quackery' to contain and if possible eliminate chiropractic. It sought to ensure that Medicare should not cover chiropractic and that the U.S. Office of Education should not recognize a chiropractic accrediting agency, by encouraging continued separation of the two national associations, and by persuading state medical societies to initiate legislation to control chiropractic. The AMA distributed propaganda to teachers and guidance counselors, eliminated 'Chiropractic' from the U.S Department of Labor's Health Careers Guidebook, and established guidelines for 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." and set out to forbid its members from working with chiropractors; until 1980, the AMA 'Principles of Medical Ethics' 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."

However, the AMA crusade raised suspicions that it was motivated at least in part by narrow professional self-interest, and in 1976, a Chicago DC, Chester Wilk, and three others brought an antitrust suit against the AMA - Wilk et al vs AMA et al. The judge in the ensuing trial 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."

She said that DCs clearly wanted "a judicial pronouncement that chiropractic is a valid, efficacious, even scientific health care service". However, she said that no well-designed, controlled, scientific studies had been done, and concluded "I decline to pronounce chiropractic valid or invalid on anecdotal evidence", even though "the anecdotal evidence in the record favors chiropractors".

In 1987, the Federal Appeals Court found the AMA guilty of conspiracy and restraint of trade. The court recognized 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. The AMA lost its appeal to the Supreme Court, and had to allow its members to collaborate with DCs. After the court victory, Wilk said (of the AMA)

"They don't have to love us, but they'll have to respect us and respect the law."

In 1992, the AMA declared "It is ethical for a physician to associate professionally with chiropractors provided that the physician believes that such association is in the best interests of his or her patient. A physician may refer a patient for diagnostic or therapeutic services to a chiropractor permitted by law to furnish such services whenever the physician believes that this may benefit his or her patient. Physicians may also ethically teach in recognized schools of chiropractic."

Efficacy

In 1978, the Journal of Manipulative & Physiological Therapeutics (JMPT) was launched. Keating dates the birth of chiropractic as a science to a 1983 commentary in the Journal in which Kenneth DeBoer, an instructor at Palmer College, revealed the power of this journal to empower faculty at chiropractic schools, enabling them to challenge the status quo, to publicly address issues related to research, training and skepticism, and to raise professional standards. By 1997, there were 14 peer-reviewed journals that specifically encourage chiropractic research, with the JMPT indexed in Index Medicus. With some federal funding, the claims of chiropractic began to be tested by large, objective clinical trials, providing a stronger evidence base for assessing these claims.

In 1997, an AMA report discussing chiropractic, acknowledged that "manipulation has ... a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints." In 1998, The Mange Report, funded by the Ontario Ministry of Health, accepted the efficacy and cost-effectiveness of chiropractic for low-back pain, found that it had higher patient satisfaction levels, and stated that "major savings from chiropractic management come from fewer and lower costs of auxiliary services, fewer hospitalizations, and a highly significant reduction in chronic problems, as well as in levels and duration of disability." Since then, several large randomized studies have confirmed that not only is manual therapy at least as good as these conventional medical treatments of back pain, but that patients tend to be more satisfied with chiropractic care and that the overall cost is similar. Evidence of efficacy also comes from studies of patient satisfaction and workers' compensation cases; these suggest that most patients are very satisfied with chiropractic treatment, and for example, patients who consult a DC for back-related problems are likely to lose fewer days at work than patients with similar complaints who consult MDs.

There have been trials of chiropractic claims for other health benefits, but mostly these have been small and potentially flawed in various ways, and so it is not possible to draw any definitive conclusions for or against the efficacy of chiropractic in many cases. A 2005 editorial in the JMPT proposed that more involvement in the Cochrane Collaboration, which co-ordinates evidence-based analysis of health interventions, would be a way for chiropractic to gain better acceptance within medicine.

Chiropractic treatment of non-spinal disorders

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

Because they feel that healing comes from within the body, DCs don't talk of 'cure', but of 'helping the body cure itself'. As a result, the traditional DC sees all who suffer as in need of his or her help. The degree to which they claim to be able to help varies, not only from condition to condition but also from case to case.

Safety

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 estimated 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'.

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, GPs, osteopaths, physiotherapists, a wife, a blind masseur, and an Indian barber had all been incorrectly attributed to DCs.

Critical views of Chiropractic

(see Critical views of Chiropractic for a detailed account).

In its 100-year history, chiropractic has been under frequent attack from osteopathy, from conventional medicine, from scientists critical of its scientific foundations, and recently from web-based critics of its advertising tactics and of the extravagent claims and dubious practices of some DCs. Although the profession has survived, and indeed thrived, the profession itself has voiced many of these same criticisms in a move to reform chiropractic from within.

See also

• Chiropractic History
• Spinal adjustment
• Spinal manipulation
• Vertebral subluxation
• Chiropractic education
• Chiropractic schools
• Council on Chiropractic Education
• Federation of Chiropractic Licensing Boards
• Critical views of Chiropractic

References

External links

• Chiropractic Resource Organization
• Dynamic Chiropractic Online - ChiroWeb, Chiropractic news source
• National Center for Complementary and Alternative Medicine - NIH - Manipulative and Body-Based Practices