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Chiropractic

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Chiropractic, or chiropractic care, is a CAM health care profession with an underlying principle that health problems can be prevented and treated using spinal adjustments in order to correct spinal dysfunction, or subluxations. Chiropractic maintains that the brain and nervous system control and coordinate all the body's functions in part through nerve branches that exit from the spinal cord between the vertebrae. Some chiropractors infer a causal relationship between nerve interference or compression at the spine and subsequent problems in more distant parts or organ systems regulated by the nerve. The methods employed by chiropractors and the efficacy of chiropractic treatments are controversial in many countries.

Practitioners of chiropractic are called chiropractors. In the United States of America they receive the degree Doctor of Chiropractic (D.C.) and are referred to as "doctor". However, they are not medical doctors. Chiropractors are licensed in all jurisdictions of the United States, in addition to many other countries throughout the world.

There is objective clinical data and peer-reviewed research that demonstrates the efficacy of certain therapeutic techniques used by chiropractors. The primary therapeutic technique used by chiropractors is joint manipulation (which they term "adjustments"), especially spinal manipulation (which is also used by some other healthcare professions). Spinal manipulation has been shown to have some value in the short-term relief of certain forms of back and neck pain, headaches, and other spine-related conditions. Studies done to demonstrate the efficacy of chiropractic care have produced conflicting results. For example, a 1979 study showed manipulation of the lumbar spine to have no "superior long-term effect compared to other methods of treatment", [1] while a 2005 study stated that "the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs." [1]

For decades, the American Medical Association (AMA) described chiropractic care as unscientific, and dealt with it in its Committee on Quackery. A lawsuit brought in 1976 (Wilk v. American Medical Association) by the chiropractic industry charged the AMA, as well as the Joint Council on Accreditation of Hospitals and the American College of Physicians, with restraint of trade. The lawsuit was won on appeal by the chiropractors, and the AMA has been more careful in its description of chiropractic care and its restrictions on dealing with chiropractors. Medical associations outside of the United States continue to call chiropractic care unscientific. However, chiropractic's popularity continues to grow; chiropractic offices are often seen in shopping complexes as well as in the lockerrooms of many professional and Olympic athletes.

Because chiropractors emphasize the importance of healthy lifestyles and do not prescribe drugs or perform surgery, chiropractic care is appealing to many health-conscious Americans. Chiropractic treatment of the back, neck, extremities, and joints has become more accepted as a result of research and changing attitudes about alternative, noninvasive health care practices. [2] According to a survey released in 2004 by the National Center for Complementary and Alternative Medicine, chiropractic was the fourth most commonly used complementary and alternative medicine therapy among adults in the United States (7.5%).3,4

Contents

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History

The roots of chiropractic care can be traced all the way back to the beginning of recorded time. [3] Writings from China and Greece written in 2700 B.C. and 1500 B.C. mention spinal manipulation and the maneuvering of the lower extremities to ease lower back pain. As early as 400 BCE the knowledge of a patient's spine was thought to be important in the treatment of many diseases, with Hippocrates, in his work On the Articulations, writing: [4]

…knowledge [of the spine] is requisite in many diseases.

Chiropractic was founded by Daniel David Palmer in Davenport, Iowa, USA. Palmer was born in Pickering, Ontario, and moved to the United States in 1865. Referred to by some historians as a "fish monger" because he sold fish commercially, Palmer practiced magnetic healing beginning in the mid-1880s in Burlington, Iowa. Palmer was well read in medical journals of his time and had great knowledge of the developments that were occurring throughout the world regarding anatomy and physiology.

During this time he tried to find a single cause for 100% of all diseases. He reached a point where he even claimed to have succeeded in this mission:

A subluxated vertebrae . . . is the cause of 95 percent of all diseases. . . . The other five percent is caused by displaced joints other than those of the vertebral column. [5]

In 1895, Palmer was investigating the medical history of a deaf janitor, Harvey Lillard. Lillard informed Palmer that while working in a cramped area seventeen years prior, he felt a pop in his back and had been nearly deaf ever since. Upon examination, Palmer found what he described as a lump that was sore to the touch. He concluded that this lump was a misalignment in the spine and a possible cause of Lillard's deafness. After Palmer supposedly corrected this misalignment, Lillard could reportedly hear the wheels of the horse-drawn carts in the street below.

Palmer's version of this event has always been disputed by Lillard's daughter, Valdeenia Lillard Simons. She says that her father told her that he was telling jokes to a friend in the hall outside Palmer's office and, Palmer, who had been reading, joined them. When Lillard reached the punch line, Palmer, laughing heartily, slapped Lillard on the back with the hand holding the heavy book he had been reading. A few days later, Lillard told Palmer that his hearing seemed better. Palmer then decided to explore manipulation as an expansion of his magnetic healing practice. Simons said "the compact was that if they can make [something of] it, then they both would share. But, it didn't happen."

The term chiropractic originated when Palmer asked a patient - Rev. Samuel Weed - to come up with a name from the Greek language to describe his practice. Of the several names submitted to him, Palmer accepted one which combined the words chiros and praktikos (meaning "done by hand") to describe his adjustment of a vertebra in the spinal column. Palmer had been a beekeeper, school teacher, and grocery store owner, and had an interest in the various health philosophies of his day such as magnetic healing, osteopathy, and spiritualism.

His interest in spiritualism had a major role in his claims regarding the spiritual origins of chiropractic. He claimed to have received the principles of chiropractic "from the other world" (during spiritistic seances), from a "supernatural source", the long dead medical physician, Dr. Jim Atkinson. [6] [7]

While D. D. Palmer founded chiropractic, it is generally recognized that his dynamic son, B. J. Palmer, bears the major responsibility for the later development and marketing of chiropractic.

Chiropractic has gained general acceptance in the last 40 years as an appropriate treatment for certain back and neck problems. This was partly a result of the prolonged litigation between the powerful American Medical Association (AMA) and various chiropractors over the legitimacy of the field (see Wilk v. American Medical Association). The AMA is politically opposed to chiropractic as a healing discipline and disputes the concept of subluxation.

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Chiropractic subluxation

Palmer imbued the term "subluxation" with a metaphysical and philosophical meaning. He held that certain dislocations of bones interfered with the "innate intelligence", a kind of spiritual energy or life force dependent upon God that connects the brain to the rest of the body. Palmer claimed that subluxations interfered with the proper communication of this innate intelligence with the rest of the body, and that by fixing them 100% of all diseases could be treated.

In the mid-1990s the Association of Chiropractic Colleges redefined a subluxation as follows: "A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system and general health." In 1997 the Foundation for Chiropractic Education and Research defined a subluxation as "a joint problem (whether a problem with the way the joint is functioning, a physical problem with the joint, or a combination of any of these) that affects the function of nerves and therefore affects the body's organs and general health."

Most chiropractors subscribe to the principle that the body has an intelligent and self-healing physiology. One result of this is the general chiropractic belief that healthcare interventions should consider the person as a whole and that conservative (non-invasive) treatment approaches should be used where possible.

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Philosophy of the subluxation

Chiropractic philosophy holds that much of the body is controlled by messages sent to and from the brain along the nervous system. The medical community agrees that all messages - whether it is the brain commanding the foot to move or an organ telling the brain it is in need of repair - pass through the spinal cord; which acts as a kind of cerebral router. An outgoing message from the brain passes down the spinal cord and through the appropriate spinal nerve branch held between the vertebrae on either side of the spinal cord. There are 31 pairs of spinal nerves that emerge from the spinal cord; all of which are housed by vertebrae. If the vertebrae are misaligned (subluxated), chiropractors believe that a spinal nerve can be squeezed or pinched and therefore message flow can be compromised. By aligning the vertebrae and removing restrictions on the spinal nerves, chiropractic claims to allow the spinal cord to more effectively relay messages to and from the brain; thus promoting better health.

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Usage

The use of manipulative therapy — especially as practiced by chiropractors — is regarded with controversy by medical authorities in many nations. Of interest is that Hippocrates, considered to be the Father of Medicine, describes manipulative therapy utilizing various methods of spinal realignment in his writings. Its use throughout history is well-documented. [8] It is covered by many health plans such as Medicare in the United States. Although some medical doctors (MDs), many doctors of osteopathy (DOs), as well as some Physical Therapists do perform manipulative therapy, more than 90 percent of the treatment of back pain by manipulative therapy is performed by DCs (Doctors of Chiropractic).1

Joint Manipulation itself creates "cavitation" within the joint. This "popping" sound is the release of tiny carbon dioxide gas bubbles from the synovial fluid which lines the joint. These bubbles are released due to the sudden pressure change within the joint during the manipulation. The most recent scientific research from the traditional medical community suggests that this "cavitation" creates a barrage of sensory information within the joint, which travels to the brain. This change in the sensory information received from the joint creates a change in the motor nerve output from the brain to the muscles acting on the manipulated joint. This can create an immediate reduction in muscle spasm. This is the most recent traditional medical model for the effects of Joint Manipulation, and is not accepted widely within the Chiropractic community.

Other technique models rely on little or no joint cavitation, and thus can not be defined as manipulation. Chiropractors within a great many instrument-assisted and upper cervical specific techniques do not perform adjustments with cavitations. A sound may, or may not be produced.

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Scientific support for chiropractic

According to Harrison's Principles of Internal Medicine, a meta-analysis of nine studies found spinal manipulation to be effective in improving uncomplicated, acute back pain. The studies found no benefit to treating chronic pain or sciatic nerve irritation. However, more recent studies have found chiropractic to be cost effective in the treatment of chronic back pain.

A study in the October 2005 issue of the Journal of Manipulative and Physiological Therapeutics (JMPT)[9] found that chiropractic and medical care have comparable costs for treating chronic low-back pain, with chiropractic care producing significantly better outcomes. A group of chronic low-back patients who underwent chiropractic treatment showed higher pain relief and satisfaction with the care and lower disability scores than a group that underwent medical care.

A 2002 investigation supports that spinal manipulation may benefit patients afflicted with asthma [10]. A 2004 study showed that spinal manipulation may benefit ADHD patients [11].Other recent case studies and research support chiropractic's claim to be effective with a range of conditions including Autism, Irritable Bowel Syndrome, Bell's Palsy, Glaucoma, Crohn's Disease, Colic, Ulcers and Parkinson's Disease.[12][13][14][15][16][17][18][19]

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Chiropractic education, licensure, and regulation

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United States

In the United States, the Council on Chiropractic Education[20] (CCE) is in charge of setting minimum guidelines for chiropractic colleges; however, additional requirements may be needed for a license depending on the jurisdiction where a chiropractor chooses to practice. In 2005, 15 chiropractic programs and 2 chiropractic institutions in the United States were accredited by the CCE. The process of credentialing varies widely by country.

Students often enter chiropractic school with a Bachelor's degree, or with three years of post-secondary education in the sciences and other appropriate coursework. However, in 2005 "only one chiropractic college required a baccalaureate degree as an admission requirement."[21] The minimum prerequisite for enrollment in a chiropractic college set forth by the CCE is 90 semester hours. The minimum cumulative GPA for a student entering a chiropractic college is 2.50. Commonly required classes include: communication or language skills, psychology, social science or humanities, biology, organic and inorganic chemistry, and physics. Other common medical classes are: anatomy or embryology, physiology, microbiology, diagnosis, neurology, x-ray, orthopedics, obstetrics, and gynecology.

In the United States, chiropractic programs require a minimum of 4,200 hours of combined classroom, laboratory, and clinical experience. The last 2 years stress courses in manipulation and spinal adjustment and provide clinical experience in physical and laboratory diagnosis, orthopedics, neurology, geriatrics, physiotherapy, and nutrition. Coursework in Chiropractic school may also include study in gross anatomy, biochemistry, embryology, microbiology, anatomy and physiology in the first half of formal schooling.

Graduates of chiropractic schools have to complete 5 years of schooling and pass 4 national board exams in order to complete their education. To qualify for licensure, graduates of chiropractic schools must sit for State examination. Most State boards require at least 2 years of undergraduate education; an increasing number are requiring a 4-year bachelor’s degree. All boards require the completion of a 4-year program at an accredited chiropractic college leading to the Doctor of Chiropractic degree. Once licensed, most States require chiropractors to annually attend 12 to 48 hours of continuing education courses.

Chiropractic colleges also offer Postdoctoral training in neurology, orthopedics, sports injuries, nutrition, rehabilitation, industrial consulting, radiology, family practice, pediatrics, and applied chiropractic sciences. Once such training is complete, chiropractors may take specialty exams leading to “diplomate” status in a given specialty. Exams are administered by specialty chiropractic associations.

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Philosophical schools of chiropractic

Contemporary chiropractic is generally divided into three basic schools - straight, mixer, and reform - which differ in their approaches to patient care. However, all chiropractic approaches are, at a minimum, heavily based on the use of manipulation as a treatment for mechanical musculoskeletal dysfunction of the spine and extremities.

  1. Straight chiropractors only concern themselves with vertebral subluxation correction. Practitioners often use varying vertebral manipulation techniques known as "adjustments" for the purpose of preventive medicine and pain relief. Straight chiropractors hold that only the body can cure the body. By aligning the vertebrae, straight chiropractors believe that they are clearing nerve impulse restrictions and therefore providing a more efficient dialogue between the brain and the rest of the body's systems, thus putting the body in a better position to cure (or heal) itself.
  2. Mixing chiropractors combine contemporary medical diagnosis and treatment with chiropractic adjustments. Mixing style practitioners utilize adjustments to treat chiropractic subluxations, as well as naturopathic style remedies for other disorders. Methods used might include ultrasound, TENS, rehabilitation or the use of other diagnostic methods such as Applied Kinesiology (AK). Mixing chiropractic is itself divided into conservative and liberal groups2.
  3. Reform chiropractors are a minority group oriented at mainstream science. The National Association for Chiropractic Medicine (NACM) represents a small group of chiropractors which advocates a highly limited use of chiropractic medicine. By openly rejecting some of the more controversial aspects of chiropractic, including the original chiropractic hypothesis that subluxations are the cause of 100% of all [22]diseases, NACM members claim to receive mainstream approval5 more so than practitioners of straight or mixing chiropractic. The NACM is a private organization that does not release membership data of its members, however, one outside estimate reported membership to be in the "low hundreds" [23].

In Australia, one of the first countries to widely accept chiropractic (since 1905), the deliniation into Straight vs Mixer chiropractor is all but relegated to history. The above categories are not commonly cited by the profession or the public. Most universities teaching chiropractic in Australia, including Palmer in Davenport Iowa, USA, are utilizing rehab methods, exercise and physiological therapeutics and nutrition. The National College (now University) incorporated physical therapy as early as 1912, even before there was a profession bearing its name. The profession here continues to be divided only into specialities. Some do spine-only. Others prefer to do sports and rehabilitation. There are musculoskeletal foci and those who co-manage people with organic problems, MS or cancer along with their regular medical approaches. Philosophically, spinal and musculoskeletal approaches to health can benefit the WHOLE person, and the general public accepts this. At any rate, straight chiropractors, who do nothing but adjust spinal subluxations, diligently work with other professionals such that they are needed to benefit the patients overall well being.

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Criticism of chiropractic

Critics, including many mainstream medical doctors and scientists, often reject the claims of some chiropractic associations and schools as pseudoscience, quackery, or fraud.

Advocates believe at least some of this criticism was encouraged by the American Medical Association during the 1970s and early 1980s in what they have labeled "anti-chiropractic prejudice". In a carefully worded statement, the judge in a trial against the AMA recognized that this skepticism was also the inspiration for the AMA's actions in instituting an illegal boycott of chiropractic:

In 1987, federal court judge Susan Getzendanner concluded that during the 1960s "there was a lot of material available to the AMA Committee on Quackery that supported its belief that all chiropractic was unscientific and deleterious." The judge also noted that chiropractors still took too many x-rays. However, she ruled that the AMA had engaged in an illegal boycott. She concluded that the dominant reason for the AMA's antichiropractic campaign was the belief that chiropractic was not in the best interest of patients. But she ruled that this did not justify attempting to contain and eliminate an entire licensed profession without first demonstrating that a less restrictive campaign could not succeed in protecting the public. Although chiropractors trumpet the antitrust ruling as an endorsement of their effectiveness, the case was decided on narrow legal grounds (restraint of trade) and was not an evaluation of chiropractic methods. [24]

It is, however, factual that this policy of containment was also dispersed within the Australian Medical Association as late as 2001. Nowadays medical physicians and chiropractors look back at their animosity toward each other as a historical process. More and more, the public is demanding that professions work together for the patient's benefit. Many GPs work with chiropractors.

In 1985, The National Council Against Health Fraud (NCAHF), a non-profit healthcare watch-dog group, issued a Position Paper critical of chiropractic. A newer Fact Sheet has since been issued in 2001.

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Safety concerns

Critics cite major medical risks associated with spinal manipulation in their opposition to the practice of chiropractic. These risks include vertebrobasilar accidents, disc herniations, vertebral fracture, and cauda equina syndrome, according to Harrison's. Most serious complications occur after cervical (neck) manipulation. The practice of greatest concern is the rotary neck movement, sometimes called "Master cervical" or "rotary break", which has led to trauma, paralysis, strokes, and death among patients.

Serious complications due to manipulation of the cervical spine remain rare, having been documented at 1 in 3 or 4 million manipulations or fewer [25]. Such estimates are believed by skeptics to be unreliable based on the possibility of underreporting. [26] However, the current esitmate is based on multiple international studies of millions of chiropractic cervical adjustments spanning from present day back to at least 1965. The "one in a million" estimate is echoed in an extensive review of spinal manipulation performed by the RAND corporation. Less conservative treatments such as neck surgery are also commonly used for conditions very similar to the conditions chiropractors treat using spinal adjustments. In comparison, cervical spine surgery has a 3-4% rate of complication and 4,000-10,000 deaths per million neck surgeries.

Highly specific spinal adjusting procedures have been developed to address vertebral subluxation of the high neck region (upper cervical) using x-ray imaging. A controlled, linear, low force adjustment is slowly applied to the top vertebra (Atlas), removing the need for more forceful, rapid adjustive procedures. Development of this upper cervical technique technology by the National Upper Cervical Chiropractic Association in the U.S.A. first started in the 1960's in Monroe, Michigan by Dr. Ralph Gregory DC. This work is being carried further today, with the establishment of Atlas Orthogonal Technique (AOT) in 1981, by Dr Roy Sweat of Atlanta, USA. Both AOT and NUCCA have advanced Gregory's work to develop programs endorsed by some chiropractors, dentists, and medical doctors in psychiatry, orthopaedics and neurology, who consider it to be a safe and effective way of dealing with kinematic disorders of the upper cervical joint complex. All upper cervical work is a legacy of the dedication and nurturing by Dr. B.J. Palmer of Davenport, Iowa, USA, in the early 1900s. He advocated the HIO (Hole In One) concept, where he claimed that it was only necessary to adjust the top vertebrae in the spine, making it unnecessary to adjust any of the other vertebrae. He later modified this position.

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Misuse of a science report

Some doctors who have submitted research backing up the medical benefits of limited forms of spinal manipulation have found their claims incorrectly applied to the entire field of chiropractic manipulation. Perhaps the best-known case of this occurred in response to The RAND report on The Appropriateness of Spinal Manipulation for Lower-Back Pain. This study was a meta-analysis of 22 controlled experiments; the conclusion was that certain forms of spinal manipulation were successful in treating certain types of lower back pain. Many chiropractors seized upon these results as proof that chiropractic hypotheses was sound and that chiropractic had reliable results; in fact, the authors of the report said no such thing. Misuse of this report reached such an extent that the RAND report authors were forced to issue a public statement. In 1993 Dr. Paul Shekelle rebuked the chiropractic industry for making false claims about RAND's research:

...we have become aware of numerous instances where our results have been seriously misrepresented by chiropractors writing for their local paper or writing letters to the editor....RAND's studies were about spinal manipulation, not chiropractic, and dealt with appropriateness, which is a measure of net benefit and harms. Comparative efficacy of chiropractic and other treatments was not explicitly dealt with.
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See also

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References

  • Note 5: National Association for Chiropractic Medicine (NACM) [27]
  • a Moritz U (1979). Evaluation of manipulation and other manual therapy. Criteria for measuring the effect of treatment.. Scand J Rehabil Med. 11 (4): 173-9.
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External links

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Advocacy

Chiropractic organizations
Chiropractic colleges
Descriptions of chiropractic procedures
Other resources
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Critiques

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