Chiropractic

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Chiropractic is a health care discipline which emphasizes the inherent recuperative power of the body to heal itself without drugs or surgery.

Chiropractic is a complementary and alternative health care profession that uses various manual therapies to alleviate pain and treat musculoskeletal problems. Chiropractors (DCs) aim to improve overall health by optimizing body posture and joint mobility. They speculate that health can be improved by locating and correcting subluxations of the spine that they claim interfere with the nervous system. According to DCs, subluxations occur after even relatively minor injury to the ligaments, muscles or joints that support the spine. Such injuries might be acute, from trauma, and accompanied by immediate pain; or repetitive, resulting from prolonged posture problems and only gradually cause symptoms. They are the first stage of degenerative changes such as arthritis and, by interfering with the nervous system, impair health. They are located by carefully examining the back, and, if identified, subluxations are treated with manual and mechanical methods called spinal adjustments.

This word 'subluxation' is used with a different meaning by biologists, and the special way it is used by DCs must be understood in order to appreciate their art. The way that DCs use 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. While all agree that injuries and postural adaptations do cause local problems, classifying them as subluxations has been controversial and has triggered debate within the profession to remedy this. Suggesting that the nervous system is involved in any way in these maladies is solely a chiropractic speculation and remains their belief. Unless otherwise specified, the word "subluxation" in this article uses the chiropractic definition.

Chiropractic was founded in 1895 by Daniel David Palmer. In his mind, subluxations compressed spinal nerves, interfering with the transmission of Innate intelligence and thereby causing 'dis-ease' or disharmony. He compared this block to stepping on a hose that slowed the flow of water to a garden: take your foot off the hose, the flow returns, and the garden will flourish. While the 'pinched garden hose theory' has mostly been abandoned, the metaphor is sometimes still used by DCs to explain subluxations to patients. The great majority of DCs today continue to assert that subluxations play a role in most, if not all, diseases. Although most chiropractic care is aimed at musculoskeletal pain and related problems, some DCs are willing to use manual therapy to treat systemic diseases (includingallergy and otitis media) in both children and adults. Although there is no present scientific evidence that adjustments help these conditions, there is now a growing medical literature that shows that chiropractic care is as effective as physical therapy and conventional non-surgical medical treatment for back pain, even for the more severe underlying conditions that most often prompt patients to undergo spinal surgery. Several recent large randomized studies have shown 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 less. This was apparent even though chiropractic care of back pain does not include the use of narcotics and other pain relieving drugs.

In 2006, about 70,000 DCs were 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 and two in Canada. There are several specialty certifications awarded (see Accredited Programs.) 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; 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. Template:Alternative medical systems

Chiropractic in practice

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. This procedure is performed by osteopaths and physiotherapists as well as by DCs; despite the different treatment goals, the procedures performed are very similar. DCs aim to apply a precise adjustment to a specific affected vertebra, as distinct from the more generalized maneuvers of the early osteopaths.

DCs follow similar guidelines for patient care as their medical counterparts, but give less emphasis to laboratory tests and more to spinal testing. They take a thorough patient and family history, review the organ systems and conduct a physical examination. They make postural observations and evaluate spinal function, and they might request laboratory tests to evaluate blood and urine and perform X-ray, order MRI, CT scans, and other imaging techniques, or might refer to general practitioners or specialists for these. After making a diagnosis, the DC discusses the findings with the patient, obtains informed consent, and treats according to guidelines agreed by national and local consensus panels, such as the Mercy guidelines. They do not treat cancer, metabolic disorders such as diabetes, or infectious diseases, although they might treat patients that have these conditions.

Disc degeneration as a result of chronic subluxation is one form of arthritis that DCs work to prevent or improve. This joint will feel tender and stiff.

When a patient first consults a DC, it is usually because of a problem that seems to be directly associated with the spine. 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', 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. It is this joint that the DC asserts is likely to cause problems if neglected, and will adjust in an effort to prevent these and alleviate present symptoms.

Subluxation and Innate Intelligence- the controversial concepts

Because half of the nervous system is sensory and half is motor, DD Palmer postulated that living things had an Innate intelligence, a 'spiritual energy' that received the sensory information and, which, according to this information, decided on exactly what commands the motor nerves should convey. He thought that subluxation must interfere with these signals, and that this would be the cause of disease; he concluded that all diseases could be treated by fixing the subluxations. He considered, however, that it was not essential to know exactly what innate intelligence was, so long as DCs could locate and adjust subluxations.

For many, these nineteenth century concepts today 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 normal scientific activity. However, some DCs argue that these concepts help 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. 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 it has become so overburdened with clinical, political,and philosophical ... significance ... that the concept that once helped to hold a young profession together now divides it and keeps it quarrelling over basic semantics? 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 the medical model (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).

The alternative term segmental dysfunction is used for insurance and statistical purposes, but it has been proposed that 'complex joint dysfunction' might better capture the meaning for DCs, using 'dysafferentation' specifically for neuropathological symptoms. Anthony Rosner of the Foundation for Chiropractic Education and Research suggests that 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

Click to see ACC Chiropractic/Medical Management Model

"For every chiropractor, there is an equal and opposite chiropractor"

The traditional, 'medical' approach regards some diseases as the result of an 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). Although host resistance is recognized as a factor in determining the course or susceptibility to these diseases, and to inherited and other conditions, treatment is generally aimed at pharmaceutical or surgical intervention, rather than any non-invasive strengthening of host defenses. By contrast, chiropractic believes that lowered 'host resistance' is always necessary for disease to occur, and hence that the answer is to strengthen the host. Contemporary chiropractors take several different approaches to patient care. These differences are reflected in different professional associations, (although most DCs do not belong to any association).

• Traditional Straights hold that ssubluxation 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. This has been contentious, as 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.
• 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 do not subscribe to Palmer philosophy or vertebral subluxation theory. They are similar in practice to mixers, although they tend not to use complementary and alternative methods.

Chiropractic education, licensing and regulation

Palmer Chiropractic College with DD Palmers bust (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 looking to add a new method to their practices.

After the Flexnor 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 became 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 [10] 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.

History

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 gave the first chiropractic adjustment to 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, Valdeenia , 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[11])

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 fromworking 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." [12]

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." [13]

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. [14] By 1997, there were 14 peer-reviewed journals that specifically encourage chiropractic research, but only the JMPT is indexed in Index Medicus[15].

Where applicable, an evidence based medicine framework should be used to assess the outcomes of medical interventions. Where there isn't enough good evidence, as is often the case, this does not imply that the treatment is ineffective, only that the case for a benefit has not been established.

The first significant recognition that spinal manipulation was appropriate for low back pain was a meta-analysis by the RAND Corporation. RAND's studies were about spinal manipulation, not chiropractic specifically, and dealt with appropriateness, which measures benefit and harm; the efficacy of chiropractic and other treatments were not directly compared, but 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 Manga 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." There are no objective controlled trials with definitive conclusions for or against chiropractic claims of other health benefits. A 2005 editorial in JMPT proposed that involvement in the Cochrane Collaboration would be a way for chiropractic to gain more acceptance within medicine.

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.

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!" Joseph Keating, chiropractic historian [16]

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, and also because different DCs use different techniques. The spinal cord does carry a vast amount of information from peripheral organs and tissues to the brain, including sensations of pain, touch, temperature. In addition, virtually every organ and its blood supply is regulated both directly by efferent nerves, many of which travel down the spinal cord, and indirectly by neuroendocrine regulation of hormone secretion. Accordingly, disruption of spinal information flow can influence virtually every organ system. However it is not clear that it is possible to show whether any particular organ dysfunction is caused by a disorder of spinally-mediated information transfer, or whether manipulation by DCs can correct such a disorder.

Since the original observations of DD Palmer, DCs have been alert for evidence that their manipulations might have such beneficial effects. There is much anecdotal evidence (from case studies) that they can, but this evidence is generally regarded as weak because it may be influenced by the prior beliefs and expectations of the patient and the practitioner; only if it leads to an objective protocol for intervention with objectively verifiable efficacy can it be regarded as validated. A common criticism of DCs has been the apparent willingness of some to offer treatment for conditions where there is no validated basis, especially those that might be life-threatening or life-altering without concurrent medical care.

Some DCs believe however, mainly from their collective clinical experience, that several conditions can be resolved by chiropractic interventions. In particular, cases that have not responded to conventional treatment might include some where the underlying cause is indeed a disorder of neural regulation of an organ system, as the failure of conventional treatment might be taken as excluding more common causes of dysfunction, such as infectious disease. It is also possible that the symptom apparently of an organ disease was actually the result of a somatic reflex pain generated from the spine. Thus, if an organ-related complaint responds to chiropractic adjustments, it is possible that a spinal condition was the cause of the problem in the first place. [17]

One such condition is infantile colic, characterised by uncontrollable crying in infants with no clear cause, where some reports suggest that chiropractic is efficacious, while others do not. Chiropractic is also used to treat asthma; and can be efficacious, but no more so than placebo treatment. Placebo effects can be very powerful, indicating the important ability of the mind to contribute to healing, and in some cases chiropractic might be efficacious because it exploits the placebo effect in an efficient way. Even if chiropractic is just effective because of the reassuring and calming effect on the mother and/or child, DCs agree that anything that results in less dependence on medication has value. Otitis media in infants is another condition that some DCs claim to manage efficiently. In the past, antibiotics were the treatment of choice, but recent studies suggest that waiting as long as three days before beginning a regimen could save as many as 30% from unnecessary exposure to antibiotics.[18] DCs, who also have training in physical examination, might fill an important 'watchful waiting' role in monitoring otitis media.

Safety

As with all interventions, there are risks with spinal manipulation: these 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 are estimated to be 1 in a million manipulations or fewer, but there is uncertainty about how these are recorded. The RAND study assumed that only 1 in 10 cases would have been reported, but a survey of neurologists in the UK for cases of serious neurological complication within 24 hours of cervical spinal manipulation (not specifically by a DC), concluded that underreporting was close to 100%, rendering 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

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 criticisms in a move to reform chiropractic from within. (see Critical views of Chiropractic).

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