Chiropractic is a form of alternative medicine that focuses on diagnosis and treatment of mechanical disorders of the musculoskeletal system, especially the spine, under the belief that these disorders affect general health via the nervous system. It is the largest alternative medical profession, and although chiropractors have many similarities to primary care providers, they are more similar to a medical specialty like dentistry or podiatry. The main chiropractic treatment technique involves manual therapy, especially manipulation of the spine, other joints, and soft tissues, but may also include exercises and health and lifestyle counseling. The "specific focus of chiropractic practice" is chiropractic subluxation. Traditional chiropractic assumes that a vertebral subluxation or spinal joint dysfunction interferes with the body's function and its innate intelligence. A large number of chiropractors want to separate themselves from the traditional vitalistic concept of innate intelligence.
Many studies of treatments used by chiropractors have been conducted, with conflicting results.Systematic reviews of this research have not found evidence that chiropractic manipulation is effective, with the possible exception of treatment for back pain. A critical evaluation found that collectively, spinal manipulation was ineffective at treating any condition. A Cochrane review found very low to moderate evidence that spinal manipulation therapy was any more effective than inert interventions, sham SMT or as an adjunct therapy for acute low back pain. Spinal manipulation may be cost-effective for sub-acute or chronic low back pain but the results for acute low back pain were insufficient. The efficacy and cost-effectiveness of maintenance chiropractic care are unknown. The evidence suggests that spinal manipulation therapy is safe, but the rate of adverse events is unknown as there is under-reporting. It is frequently associated with mild to moderate adverse effects, with serious or fatal complications in rare cases. There is controversy surrounding the level of risk of stroke from cervical manipulation. It has been suggested that the relationship is causative, but this is disputed by many chiropractors who believe it is unproven.
Chiropractic is well established in the United States, Canada, and Australia. It overlaps with other manual-therapy professions, including massage therapy, osteopathy, and physical therapy. Back and neck pain are the specialties of chiropractic but many chiropractors treat ailments other than musculoskeletal issues. Most who seek chiropractic care do so for low back pain.
D.D. Palmer founded chiropractic in the 1890s, and his son B.J. Palmer helped to expand it in the early 20th century. It has two main groups: "straights", now the minority, emphasize vitalism, innate intelligence and spinal adjustments, and consider vertebral subluxations to be the cause of all disease; "mixers", the majority, are more open to mainstream views and conventional medical techniques, such as exercise, massage, and ice therapy. Throughout its history, chiropractic has been controversial. Chiropractic's foundation is at odds with mainstream medicine, and has been sustained by pseudoscientific ideas such as subluxation and innate intelligence that are not based on solid science. Despite the overwhelming evidence that vaccination is an effective public health intervention, among chiropractors there are significant disagreements over the subject, which has led to negative impacts on both public vaccination and mainstream acceptance of chiropractic. The American Medical Association called chiropractic an "unscientific cult" in 1966 and boycotted it until losing an antitrust case in 1987. Chiropractic has had a strong political base and sustained demand for services; in recent decades, it has gained more legitimacy and greater acceptance among medical physicians and health plans in the U.S., and evidence-based medicine has been used to review research studies and generate practice guidelines.
Chiropractic is a form of alternative medicine which focuses on manipulation of the musculoskeletal system, especially the spine. Its founder, D.D. Palmer, called it "a science of healing without drugs".
|The testable principle||The untestable metaphor|
|Chiropractic adjustment||Universal intelligence|
|Restoration of structural integrity||Innate intelligence|
|Improvement of health status||Body physiology|
|Taken from Mootz & Phillips 1997|
Chiropractic's origins lie in the folk medicine of bonesetting, and as it evolved it incorporated vitalism, spiritual inspiration and rationalism. Its early philosophy was based on deduction from irrefutable doctrine helped distinguish chiropractic from medicine, provided it with legal and political defenses against claims of practicing medicine without a license, and allowed chiropractors to establish themselves as an autonomous profession. This "straight" philosophy, taught to generations of chiropractors, rejects the inferential reasoning of the scientific method, and relies on deductions from vitalistic first principles rather than on the materialism of science. However, most practitioners tend to incorporate scientific research into chiropractic, and most practitioners are "mixers" who attempt to combine the materialistic reductionism of science with the metaphysics of their predecessors and with the holistic paradigm of wellness. A 2008 commentary proposed that chiropractic actively divorce itself from the straight philosophy as part of a campaign to eliminate untestable dogma and engage in critical thinking and evidence-based research.
Although a wide diversity of ideas exist among chiropractors, they share the belief that the spine and health are related in a fundamental way, and that this relationship is mediated through the nervous system. Chiropractors examine the biomechanics, structure and function of the spine, along with its effects on the musculoskeletal and nervous systems and what they believe to be its role in health and disease. Some chiropactors say spinal manipulation can have an effect of a variety of ailments such as irritable bowel syndrome and asthma.
Chiropractic philosophy includes the following perspectives:
Holism assumes that health is affected by everything in an individual's environment; some sources also include a spiritual or existential dimension. In contrast, reductionism in chiropractic reduces causes and cures of health problems to a single factor, vertebral subluxation. Conservatism considers the risks of clinical interventions when balancing them against their benefits. It emphasizes noninvasive treatment to minimize risk, and avoids surgery and medication.Homeostasis emphasizes the body's inherent self-healing abilities. Chiropractic's early notion of innate intelligence can be thought of as a metaphor for homeostasis.
|Perspective attribute||Potential belief endpoints|
|Scope of practice:||narrow ("straight") ←||→ broad ("mixer")|
|Diagnostic approach:||intuitive ←||→ analytical|
|Philosophic orientation:||vitalistic ←||→ materialistic|
|Scientific orientation:||descriptive ←||→ experimental|
|Process orientation:||implicit ←||→ explicit|
|Practice attitude:||doctor/model-centered ←||→ patient/situation-centered|
|Professional integration:||separate and distinct ←||→ integrated into mainstream|
|Taken from Mootz & Phillips 1997|
Straight chiropractors adhere to the philosophical principles set forth by D.D. and B.J. Palmer, and retain metaphysical definitions and vitalistic qualities. Straight chiropractors believe that vertebral subluxation leads to interference with an "innate intelligence" exerted via the human nervous system and is a primary underlying risk factor for many diseases. Straights view the medical diagnosis of patient complaints (which they consider to be the "secondary effects" of subluxations) to be unnecessary for chiropractic treatment. Thus, straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not "mix" other types of therapies into their practice style. Their philosophy and explanations are metaphysical in nature and they prefer to use traditional chiropractic lexicon terminology (e.g., perform spinal analysis, detect subluxation, correct with adjustment). They prefer to remain separate and distinct from mainstream health care. Although considered the minority group, "they have been able to transform their status as purists and heirs of the lineage into influence dramatically out of proportion to their numbers."
Mixer chiropractors "mix" diagnostic and treatment approaches from chiropractic, medical and/or osteopathic viewpoints and make up the majority of chiropractors. Unlike straight chiropractors, mixers believe subluxation is one of many causes of disease, and hence they tend to be open to mainstream medicine. Many of them incorporate mainstream medical diagnostics and employ conventional treatments including techniques of physical therapy such as exercise, stretching, massage, ice packs, electrical muscle stimulation, therapeutic ultrasound, and moist heat. Some mixers also use techniques from alternative medicine, including nutritional supplements, acupuncture, homeopathy, herbal remedies, and biofeedback.
Although mixers are the majority group, many of them retain belief in vertebral subluxation as shown in a 2003 survey of 1100 North American chiropractors, which found that 88% wanted to retain the term "vertebral subluxation complex", and that when asked to estimate the percent of disorders of internal organs (such as the heart, the lungs, or the stomach) that subluxation significantly contributes to, the mean response was 62%. A 2008 survey of 6,000 American chiropractors demonstrated that most chiropractors seem to believe that a subluxation-based clinical approach may be of limited utility for addressing visceral disorders, and greatly favored non-subluxation-based clinical approaches for such conditions. The same survey showed that most chiropractors generally believed that the majority of their clinical approach for addressing musculoskeletal/biomechanical disorders such as back pain was based on subluxation.
Palmer hypothesized that vertebral joint misalignments, which he termed vertebral subluxations, interfered with the body's function and its inborn ability to heal itself. D.D. Palmer repudiated his earlier theory that vertebral subluxations caused pinched nerves in the intervertebral spaces in favor of subluxations causing altered nerve vibration, either too tense or too slack, affecting the tone (health) of the end organ. D.D. Palmer, using a vitalistic approach, imbued the term subluxation with a metaphysical and philosophical meaning. He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic. This concept was later expanded upon by his son, B.J. Palmer, and was instrumental in providing the legal basis of differentiating chiropractic from conventional medicine. In 1910, D.D. Palmer theorized that the nervous system controlled health:
Vertebral subluxation, a core concept of traditional chiropractic, remains unsubstantiated and largely untested, and a debate about whether to keep it in the chiropractic paradigm has been ongoing for decades. In general, critics of traditional subluxation-based chiropractic (including chiropractors) are skeptical of its clinical value, dogmatic beliefs and metaphysical approach. While straight chiropractic still retains the traditional vitalistic construct espoused by the founders, evidence-based chiropractic suggests that a mechanistic view will allow chiropractic care to become integrated into the wider health care community. This is still a continuing source of debate within the chiropractic profession as well, with some schools of chiropractic still teaching the traditional/straight subluxation-based chiropractic, while others have moved towards an evidence-based chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions.
In 2005, the chiropractic subluxation was defined by the World Health Organization as "a lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. It is essentially a functional entity, which may influence biomechanical and neural integrity." This differs from the medical definition of subluxation as a significant structural displacement, which can be seen with static imaging techniques such as X-rays. The 2008 book Trick or Treatment states "X-rays can reveal neither the subluxations nor the innate intelligence associated with chiropractic philosophy, because they do not exist."Attorney David Chapman-Smith, Secretary-General of the World Federation of Chiropractic, has stated that "Medical critics have asked how there can be a subluxation if it cannot be seen on x-ray. The answer is that the chiropractic subluxation is essentially a functional entity, not structural, and is therefore no more visible on static x-ray than a limp or headache or any other functional problem." The General Chiropractic Council, the statutory regulatory body for chiropractors in the United Kingdom, states that the chiropractic vertebral subluxation complex "is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease."
As of 2014, the National Board of Chiropractic Examiners states "The specific focus of chiropractic practice is known as the chiropractic subluxation or joint dysfunction. A subluxation is a health concern that manifests in the skeletal joints, and, through complex anatomical and physiological relationships, affects the nervous system and may lead to reduced function, disability or illness."
Chiropractors emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery, with special emphasis on the spine. Back and neck pain are the specialties of chiropractic but many chiropractors treat ailments other than musculoskeletal issues. There is a range of opinions among chiropractors: some believed that treatment should be confined to the spine, or back and neck pain; others disagreed. For example, while one 2009 survey of American chiropractors had found that 73% classified themselves as "back pain/musculoskeletal specialists", the label "back and neck pain specialists" was regarded by 47% of them as a least desirable description in a 2005 international survey. Chiropractic combines aspects from mainstream and alternative medicine, and there is no agreement about how to define the profession: although chiropractors have many attributes of primary care providers, chiropractic has more of the attributes of a medical specialty like dentistry or podiatry. It has been proposed that chiropractors specialize in nonsurgical spine care, instead of attempting to also treat other problems, but the more expansive view of chiropractic is still widespread. Mainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be complementary and alternative medicine (CAM); and a 2008 study reported that 31% of surveyed chiropractors categorized chiropractic as CAM, 27% as integrated medicine, and 12% as mainstream medicine.
Chiropractic overlaps with several other forms of manual therapy, including massage therapy, osteopathy, physical therapy, and sports medicine. Chiropractic is autonomous from and competitive with mainstream medicine, and osteopathy outside the US remains primarily a manual medical system; physical therapists work alongside and cooperate with mainstream medicine, and osteopathic medicine in the U.S. has merged with the medical profession. Practitioners may distinguish these competing approaches through claims that, compared to other therapists, chiropractors heavily emphasize spinal manipulation, tend to use firmer manipulative techniques, and promote maintenance care; that osteopaths use a wider variety of treatment procedures; and that physical therapists emphasize machinery and exercise.
Chiropractic diagnosis may involve a range of methods including skeletal imaging, observational and tactile assessments, and orthopedic and neurological evaluation. A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider. Common patient management involves spinal manipulation (SM) and other manual therapies to the joints and soft tissues, rehabilitative exercises, health promotion, electrical modalities, complementary procedures, and lifestyle advice.
Chiropractors are not normally licensed to write medical prescriptions or perform major surgery in the United States, (although New Mexico has become the first US state to allow "advanced practice" trained chiropractors to prescribe certain medications.). In the US, their scope of practice varies by state, based on inconsistent views of chiropractic care: some states, such as Iowa, broadly allow treatment of "human ailments"; some, such as Delaware, use vague concepts such as "transition of nerve energy" to define scope of practice; others, such as New Jersey, specify a severely narrowed scope. US states also differ over whether chiropractors may conduct laboratory tests or diagnostic procedures, dispense dietary supplements, or use other therapies such as homeopathy and acupuncture; in Oregon they can become certified to perform minor surgery and to deliver children via natural childbirth. A 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for over-the-counter drugs. A 2010 survey found 72% of Switzerland chiropractors judged the current allowance in Switzerland to prescribing nonprescription medication as an advantage for chiropractic treatment.
A related field, veterinary chiropractic, applies manual therapies to animals and is recognized in a few US states, but is not recognized by the American Chiropractic Association as being chiropractic. It remains controversial within certain segments of the veterinary, and chiropractic profession.
No single profession "owns" spinal manipulation and there is little consensus as to which profession should administer SM, raising concerns by chiropractors that other medical physicians could "steal" SM procedures from chiropractors. A focus on evidence-based SM research has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.
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