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The '''philosophy of Chiropractic''' merges both elements of [[vitalism]] and [[materialism]]. Chiropractic medicine embraces naturalistic principles that suggest decreased "host resistance" of the body facilitates the disease process. Chiropractors propose manual, conservative and natural interventions are preferable towards optimizing health and functional well-being. Chiropractors emphasizes manual and manipulative therapies and as an alternative to [[medications]] and [[surgery]] for neuromusculoskeletal disorders<ref name="Keating05">{{cite book|author= Keating JC Jr|chapter= Philosophy in chiropractic|pages=77–98|title= Principles and Practice of Chiropractic|edition=3rd|editor= Haldeman S, Dagenais S, Budgell B ''et al.'' (eds.)|publisher=[[McGraw-Hill]]|year=2005|isbn=0-07-137534-1}}</ref> The relationship between structure, especially the spine, and function as modulated by the nervous system, is central to chiropractic and its approach to the restoration and preservation of health. Chiropractors examine the [[biomechanics]] of the spine and other joints of the [[musculoskeletal|neuromusculoskeletal]] system and examines its role in health and disease. <ref>{{cite book|last=Bergmann, T.F.|first=Perterson D.H|title=Chiropractic Technique: Principles and Procedures|year=2011|publisher=Elsevier|isbn=9780323049696}}</ref>It is hypothesized that clinically significant neurophysiological consequences may occur as a result of spinal dysfunction/subluxation, described by chiropractors as the vertebral subluxation complex<ref name="Coulter 1999 19–29">{{cite book|last=Coulter|first=ID|title=Chiropractic: A Philosophy for Alternative Health Care|year=1999|publisher=Butterworth-Heinemann|isbn=0750640065|pages=19–29}}</ref>
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#REDIRECT[[Chiropractic]]
Most practitioners currently accept the importance of scientific research into chiropractic.<ref name="Keating05">{{cite book|author= Keating JC Jr|chapter= Philosophy in chiropractic|pages=77–98|title= Principles and Practice of Chiropractic|edition=3rd|editor= Haldeman S, Dagenais S, Budgell B.)|publisher=[[McGraw-Hill]]|year=2005|isbn=0-07-137534-1}}</ref> Foundational concepts of the philosophy of chiropractic includes the following principles:
{{quotation|
* Vitalism accepts that all living organisms are sustained by a vital force that is both different from, and greater than, physical and chemical forces. Contemporary is it is referred to as "vis medicatrix naturae" (the healing power of nature).
*Holism postulates that health is related to the balanced integration of the individual in all aspects and levels of being: body, mind and spirit, including interpersonal relationships and the interplay between lifestyle, environment, and health.
*Naturalism states a preference for natural remedies. This is bound up with a set of philosophical principles which may be expressed as the body is built on nature’s order, it has natural ability to heal itself, that this is reinforced by the use of natural remedies, that it should not be tampered with unnecessarily through the use of drugs or surgery
*Humanism is based on the postulate that individuals have immutable rights, for example the right to dignity. In CAM there is extensive concern about dehumanizing procedures and the dehumanizing institutions that have been created for the ill. Partly it is recognition of the personal, social and spiritual aspects of health and a move away from simply the biology of health.
*Therapeutic Conservatism is the use therapies that have a low level of side effects and it tends to accept that the least care is the best care. This in some ways is derived from earlier principles. if the body is capable of healing itself, the role of the therapy is simply to initiate the process.<ref name="Coulter 1999 19–29"/>}}

==History==
{{main|History of chiropractic}}
Upon its founding 1895, chiropractic's early philosophy was rooted in [[vitalism]], [[magnetism]], [[spiritualism]] and other constructs that were not amenable to the [[scientific method]]. Chiropractic's founder, D.D. Palmer, attempted to merge [[science]] and [[metaphysics]].<ref name="Leach 2004 15">{{cite book|last=Leach|first=Robert|title=The Chiropractic Theories: A Textbook of Scientific Research|year=2004|publisher=Lippincott, Williams and Wilkins|isbn=0683307479|pages=15}}</ref> In 1896, D.D. Palmer's first descriptions and underlying philosophy of chiropractic was strikingly similar to Andrew Still's [[Osteopathic medicine in the United States#Osteopathic Principles|principles of osteopathy]] established a decade earlier.<ref name=Ernst-eval/> Both described the body as a "machine" whose parts could be manipulated to produce a drugless cure. Both professed the use of spinal manipulation on joint dysfunction/subluxation to improve health. Palmer drew further distinctions by noting that he was the first to use short-lever HVLA manipulative techniques using the [[spinous process]] and [[transverse processes]] as mechanical levers. Additionally he described the effects of chiropractic spinal manipulation was mediated by the nervous system in contrast to osteopathy who believed the effects were attributed to the supremacy of the [[circulatory system]]. <ref name="lifeline">{{cite web|url=http://www.chiro.org/Plus/History/Persons/PalmerDD/PalmerDD's-Lifeline-chrono.pdf |title=98_04_13~1.PDF |format=PDF |date= |accessdate=2010-10-14}}</ref> Palmer initially denied being trained by [[osteopathic medicine]] founder [[A.T. Still]]. But Palmer's papers, held at the [[Palmer College of Chiropractic]], indicate that he wrote in 1899:

: ''"Some years ago I took and expensive course in Electropathy, Cranial Diagnosis, Hydrotherapy, Facial Diagnosis. Later I took Osteopathy [which] gave me such a measure of confidence as to almost feel it unnecessary to seek other sciences for the mastery of curable disease. Having been assured that the underlying philosophy of chiropractic is the same as that of osteopathy...Chiropractic is osteopathy gone to seed."''<ref name="Leach 2004 15"/>

By embracing both vitalism and materialism the philosophy of chiropractic has produced a diverse and eclectic mix of chiropractors which despite their emphasis of manual therapy they may vary on their perceived scope of practice, interventions and their role in the health care system.<ref name="Keating05">{{cite book |author= Keating JC Jr |chapter= Philosophy in chiropractic |pages=77–98 |title= Principles and Practice of Chiropractic |edition= 3rd ed. |editor= Haldeman S, Dagenais S, Budgell B ''et al.'' (eds.) |publisher=McGraw-Hill |year=2005 |isbn=0-07-137534-1}}</ref>

==="Straight" chiropractic===
[[Image:Daniel David Palmer.jpg|thumb|upright|alt=Half-length sitting portrait of man in his fifties with large gray beard and moustache, wearing coat and vest|]]
Also known as 'subluxation-based' and 'principled chiropractic', chiropractors educated from this paradigm espouse traditional Palmer principles and philosophy. Historically straight chiropractors regarded spinal joint dsyfunction/subluxation as the primary cause of "dis-ease" and could be corrected via specific chiropractic adjustments. This monocausal view of disease has been abandoned by the profession <ref>{{cite book|last=Bergmann, T.F.|first=Perterson D.H|title=Chiropractic Technique: Principles and Procedures|year=2011|publisher=Elsevier|isbn=9780323049696}}</ref> preferring a holistic view of subluxation that is viewed as theoretical construct in a "web of causation" along with other determinants of health.<ref name="Henderson 2012 632–642"/> Palmerian philosophy focused on metaphysical constructs such as [[Innate Intelligence]] and [[Universal Intelligence]] to explain the effects of the chiropractic adjustment, whose intent was the reduce/correct spinal subluxations and improving the functioning of the nervous system. The subluxation was said to be "the cause of 95 percent of all diseases... the other five percent is caused by displaced joints other than those of the vertebral column."<ref name="textbook">Palmer D.D., The Science, Art and Philosophy of Chiropractic. Portland, Oregon: Portland Printing House Company, 1910.</ref> Misalignment of the vertebrae was believed to be cause impingement of the nerve root, a theory which has long been debunked<ref>{{cite journal|coauthors=Christopher J. Good|title=The great subluxation debate: a centrist's perspective|journal=Journal of Chiropractic Humanities|year=2010|volume=17|issue=1|pages=33–39|pmid=22693474}}</ref> Subluxation-based chiropractors view traditional chiropractic lexicon such as "analysis" and "adjustment" and as a critical distinction of chiropractic despite lack of prevalence of these terms in the chiropractic literature<ref>{{cite journal|coauthors=Millar N, Budgell BS, Kwong A.|title=Quantitative corpus-based analysis of the chiropractic literature - a pilot study.|journal=Journal of the Canadian Chiropractic Association|year=2011|month=March|volume=55|issue=1|pages=56–60|pmid=21403783|accessdate=7 February 2013}}</ref> Subluxation-based chiropractors have been criticized both internally and externally for far-reaching claims of "killer" subluxations, pseudoscientific reasoning,<ref name="Ernst-eval">{{cite journal|journal= [[J Pain Symptom Manage]]|year=2008|volume=35|issue=5|pages=544–62|title= Chiropractic: a critical evaluation|author= Ernst E|doi=10.1016/j.jpainsymman.2007.07.004|pmid=18280103 }}</ref> dogmatic approaches <ref name="Keating-subluxation">{{cite journal|journal=[[Chiropr Osteopat]]|year=2005|volume=13|page=17|title=Subluxation: dogma or science?|author=Keating JC Jr, Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF|doi=10.1186/1746-1340-13-17|pmid=16092955|url=http://chiroandosteo.com/content/13/1/17|pmc=1208927|issue=1}}</ref>
unethical business practices that invoke religious themes and high-volume treatments for a variety of conditions that lack supportive scientific evidence.<ref>{{cite journal|coauthors=Gleberzon BJ, Cooperstein R, Perle SM.|title=Can chiropractic survive its chimerical nature?|journal=J Can Chiropr Assoc.|year=2005|month=June|volume=49|issue=2|pages=69–73|pmid=17549192|accessdate=7 February 2013}}</ref> This metaphysical and dogmatic and singular approach to chiropractic care has been criticized for failing to engage in critical and rational thinking and embracing [[evidence-based medicine]].<ref name=Murphy-pod>{{cite pmid|18759966}}</ref> Straight chiropractors use a subluxation-based model as opposed to the patient-centered model now favored in health care.<ref name="Chiro-Beliefs">{{cite book|chapterurl=http://chiroweb.com/archives/ahcpr/chapter2.htm|chapter= Chiropractic belief systems|author= Mootz RD, Phillips RB|year=1997|title= Chiropractic in the United States: Training, Practice, and Research|pages=9–16|editor= Cherkin DC, Mootz RD (eds.)|accessdate=2008-02-14|location= Rockville, MD|publisher= [[Agency for Health Care Policy and Research]]|oclc=39856366}} AHCPR Pub No. 98-N002.</ref> Although they are the minority within the profession, they are considered to have a disproportionate influence as "purists".<ref name="Kaptchuk-Eisenberg"/>

==="Mixer" chiropractic===
Mixers form the majority of chiropractors and attempt to combine the materialistic reductionism of science with the metaphysics of their predecessors and with the [[Holistic medicine|holistic paradigm of wellness]];<ref name=Chiro-Beliefs/> While D.D. Palmer considered vertebral misalignment to be the hallmark feature of subluxation, mixer pioneer Solon Langworthy asserted that intervertebral hypomobility, not misalignment, was subluxation’s cardinal biomechanical feature. This contrasting mechanistic emphasis, intervertebral misalignment vs. hypomobility, formed one the basis for a heated polemic in the profession. Although both misalignment and hypomobility are currently recognized as biomechanical features of subluxation, hypomobility has garnered much more attention in recent years.<ref name="Henderson 2012 632–642"/><ref>{{cite journal|last=Vernon|first=Howard|title=Historical overview and update on subluxation theories|journal=Journal of Chiropractic Humanities|year=2010|volume=22|issue=1|pages=22–32|doi=10.1016/j.echu.2010.07.001|pmid=22693473|accessdate=28 January 2013}}</ref>
Mixers were disdained by the Palmers who disapproved of their use of instrumentation and mixing chiropractic diagnostic and treatment approaches with osteopathic, naturopathic and allopathic viewpoints.<ref name="Kaptchuk-Eisenberg">{{cite journal|journal=[[Arch Intern Med]]|year=1998|volume=158|issue=20|pages=2215–24|title=Chiropractic: origins, controversies, and contributions|author=Kaptchuk TJ, Eisenberg DM|pmid=9818801|url=http://archinte.ama-assn.org/cgi/content/full/158/20/2215|doi=10.1001/archinte.158.20.2215 }}</ref> By embracing a mechanistic viewpoint, mixers are able balance the vitalistic notions with critical reasoning skills that led to legitimate scientific investigation of chiropractic principles. Mechanistic underpinnings have led to testable hypotheses that structure affects function via the nervous system by the scientific study of joint dysfunction (subluxation) and the biological mechanisms underlying manipulative therapies<ref name="Keating05">{{cite book|author= Keating JC Jr|chapter= Philosophy in chiropractic|pages=77–98|title= Principles and Practice of Chiropractic|edition=3rd|editor= Haldeman S, Dagenais S, Budgell B ''et al.'' (eds.)|publisher=[[McGraw-Hill]]|year=2005|isbn=0-07-137534-1}}</ref> Scientific chiropractors suggests that a mechanistic view will allow chiropractic care to become integrated into the wider health care community.<ref name="Keating-subluxation">{{cite journal|journal=[[Chiropr Osteopat]]|year=2005|volume=13|page=17|title=Subluxation: dogma or science?|author=Keating JC Jr, Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF|doi=10.1186/1746-1340-13-17|pmid=16092955|url=http://chiroandosteo.com/content/13/1/17|pmc=1208927|issue=1}}</ref> In contrast to subluxation-based chiropractors, evidence-based chiropractors favor and incorporate mainstream medical diagnostic and treatment approaches such as [[exercise]], [[nutrition|nutritional supplementation]], [[Rehabilitation]]{{Disambiguation needed|date=February 2013}}, [[self-care]], physiotherapeutic modalities, and other natural approaches. A majority of mixers retain belief that spinal dysfunction/subluxation may be involved in somato-visceral disorders. This group may represent the 'silent majority' of centrists who embrace evidence-based medicine but feel comfortable retaining elements of the subluxation complex that have not been validated through empirical evidence.<ref>{{cite journal|coauthors=Good, CJ|title=The great subluxation debate: a centrist's perspective.|journal=Journal of Chiropractic Humanities|year=2010|volume=17|issue=1|pages=33–39|accessdate=7 February 2013}}</ref>

== Spinal dysfunction/subluxation==
{{Main|spinal dysfunction}}
Spinal dysfunction dubbed ''subluxation'' by chiropractors, is a biomechanical spinal lesion (structure) hypothesized to interfere neurophysiological function. Chiropractic theory suggests spinal dysfunction/subluxation may contribute to neuromusculoskeletal and [[visceral]] disorders via aberrant spinal segmental and suprasegmental reflexes. While spinal manipulation is widely seen as a reasonable treatment option for biomechanical disorders of the spine, such as neck pain and low back pain, the use of spinal manipulation to treat non-musculoskeletal complaints remains controversial.<ref>{{cite journal|coauthors=Bolton PS, Budgell B.|title=Visceral responses to spinal manipulation.|journal=J Electromyogr Kinesiol.|year=2012|month=Oct|volume=22|issue=5|pages=777-784|pmid=22440554|accessdate=9 February 2013}}</ref> Chiropractors suggest spinal manipulation normalizes spine biomechanics, and as a consequence, normalizes afferent input to the central nervous system resulting in optimized neurological function and improved health outcomes.<ref>{{cite journal|coauthors=H. Haavik-Taylor, B. Murphy|title=The effects of spinal manipulation on central integration of dual somatosensory input observed after motor training: a crossover study|journal=JMPT|year=2010|volume=33|issue=4|pages=261–272|accessdate=27 January 2013}}</ref>

Chiropractic philosophy and emphasis on [[joint dysfunction|joint dysfunction/subluxation]] and it's putative role in neuromusculoskeletal and visceral disorders has been a source of controversy since its inception in 1895 due its vitalistic and metaphysical origins which used terminology that was not amenable to scientific investigation. Far reaching claims and lack of scientific evidence supporting traditional Palmer chiropractic philosophy that spinal joint dysfunction /subluxation as the sole cause of disease has led to a critical evaluation of a central tenet of chiropractic medicine and the appropriateness of the professions role in treating a broad spectrum disorders that are not related to the neuromusculoskeletal system.<ref name="How can chiropractic become a respected mainstream profession? The example of podiatry.">Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF.http://www.ncbi.nlm.nih.gov/pubmed/18759966</ref> Today the monocausal view of disease has been abandoned by the profession <ref>{{cite book|last=Bergmann, T.F.|first=Perterson D.H|title=Chiropractic Technique: Principles and Procedures|year=2011|publisher=Elsevier|isbn=9780323049696}}</ref>preferring a holistic view of subluxation that is viewed as theoretical construct in a "web of causation" along with other determinants of health.<ref name="Henderson 2012 632–642"/> Although there is external and internal debate within the chiropractic profession regarding the clinical significance of joint dysfunction/subluxation<ref name="The prevalence of the term subluxation in North American English-Language Doctor of chiropractic programs.">Mirtz TA, Perle SM.http://www.ncbi.nlm.nih.gov/pubmed/21682859</ref> the manipulable lesion remains inextricably linked to the profession as basis for spinal manipulation.<ref name="Henderson 2012 632–642">{{cite journal|last=Henderson|first=C.N.R|journal=Journal of Electromyography and Kinesiology|year=2012|month=October|volume=22|issue=5|pages=632–642|accessdate=27 January 2013}}</ref>

==Manual and manipulative therapy==
{{Main|manual therapy|spinal manipulation}}
Chiropractors propose manual, conservative and natural interventions are preferable towards optimizing health and well-being. Chiropractors emphasize manual and manipulative therapies as an alternative to [[medications]] and [[surgery]] for functional neuromusculoskeletal and visceral disorders<ref name="Keating05">{{cite book|author= Keating JC Jr|chapter= Philosophy in chiropractic|pages=77–98|title= Principles and Practice of Chiropractic|edition=3rd|editor= Haldeman S, Dagenais S, Budgell B ''et al.'' (eds.)|publisher=[[McGraw-Hill]]|year=2005|isbn=0-07-137534-1}}</ref> The medicinal use of manual interventions, including spinal manipulation, can be traced back over 3000 years to ancient Chinese writings. [[Hippocrates]], the "Father of medicine" used manipulative techniques<ref name=Swedlo>{{cite conference |url=http://www.hom.ucalgary.ca/Dayspapers2002.pdf |format=PDF |booktitle= Proc 11th Annual History of Medicine Days |editor= Whitelaw WA (ed.) |title= The historical development of chiropractic |publisher= [[Faculty of Medicine, The University of Calgary]] |pages= 55–58 |author= Swedlo DC |date=2002 |accessdate=2008-05-14}}</ref> as did the ancient Egyptians and many other cultures. A modern re-emphasis on [[manipulative therapy]] occurred in the late 19th century in North America with the emergence of the [[osteopathic medicine]] and [[chiropractic medicine]]. The Father of chiropractic posited that spinal manipulation on spinal dysfunctions could improve health and prevent disease. The profession has since abandoned the monocausal view of disease via spinal dysfunction/subluxation<ref>{{cite book|last=Bergmann, T.F.|first=Perterson D.H|title=Chiropractic Technique: Principles and Procedures|year=2011|publisher=Elsevier|isbn=9780323049696}}</ref> Spinal manipulation has gained mainstream recognition during the 1980s.<ref>{{cite web |url=http://muaphysicians.com/historical.html |publisher= International MUA Academy of Physicians |title= Manipulation under anesthesia: historical considerations |author= Francis RS |date=2005 |accessdate=2008-07-06}}</ref> In North America, chiropractors perform over 90% of all manipulative treatments<ref>{{cite web |url=http://nccam.nih.gov/health/chiropractic/chiropractic05.pdf |format=PDF |title= About chiropractic and its use in treating low-back pain |accessdate=2008-03-24 |date=2005 |publisher=[[NCCAM]] |archiveurl = http://web.archive.org/web/20080227113930/http://nccam.nih.gov/health/chiropractic/chiropractic05.pdf <!-- Bot retrieved archive --> |archivedate = 2008-02-27}}</ref> with the balance provided by [[osteopathic medicine]], [[physical therapy]] and [[naturopathic medicine]]. [[Manipulation under anesthesia]] or MUA is a specialized manipulative procedure that typically occurs in hospitals administered under general anesthesia.<ref>{{cite journal |journal= J Manipulative Physiol Ther |date=2005 |volume=28 |issue=7 |pages=526–33 |title= Manipulation under anesthesia: a report of four cases |author= Cremata E, Collins S, Clauson W, Solinger AB, Roberts ES |doi=10.1016/j.jmpt.2005.07.011 |pmid=16182028}}</ref> Typically, it is performed on patients who have failed to respond to other forms of treatment.<ref>{{cite journal |journal=J Manipulative Physiol Ther |date=2000 |volume=23 |issue=2 |pages=127–9 |title=Manipulation under joint anesthesia/analgesia: a proposed interdisciplinary treatment approach for recalcitrant spinal axis pain of synovial joint origin |author=Michaelsen MR |doi=10.1016/S0161-4754(00)90082-4 |pmid=10714542 |url=http://www.jmptonline.org/article/S0161-4754(00)90082-4/abstract}}</ref>There has been considerable debate on the safety of spinal manipulation, in particular with the cervical spine.<ref name=Ernst-adverse>{{cite journal |pmid=17606755 |doi=10.1258/jrsm.100.7.330 |laysummary=http://www.medicalnewstoday.com/articles/75754.php |laysource=Med News Today |laydate=2 July 2007 |year=2007 |month=Jul |last1=Ernst |first1=E |title=Adverse effects of spinal manipulation: a systematic review |volume=100 |issue=7 |pages=330–8 |issn=0141-0768 |journal=Journal of the Royal Society of Medicine |pmc=1905885}}</ref> Although serious injuries and fatal consequences can occur and may be under-reported,<ref name=Ernst-death>{{cite journal |journal= Int J Clinical Practice |year=2010 |volume=64 |issue= 8 |pages=1162–1165 |title= Deaths after chiropractic: a review of published cases |author= E Ernst |pmid=20642715 |doi=10.1111/j.1742-1241.2010.02352.x}}</ref> these are generally considered to be rare when spinal manipulation is employed skillfully and appropriately.<ref name=WHO-guidelines>{{cite journal |author= World Health Organization|year=2005|title= WHO guidelines on basic training and safety in chiropractic|url=http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf|format=PDF|isbn= 92-4-159371-7|accessdate=2008-02-29}}</ref>

Manual and conservative therapies commonly used by chiropractors may be effective for the treatment of [[low back pain]] <ref name=Cochrane-2011>{{cite journal|journal= [[Cochrane Database Syst Rev]]|year=2011|issue=2|pages=CD008112|title= Spinal manipulative therapy for chronic low-back pain|author= Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW|doi=10.1002/14651858.CD008112.pub2|pmid=21328304|volume=|editor1-last= Rubinstein|editor1-first= Sidney M}}</ref><ref name=Dagenais-2010>{{cite journal|journal= [[Spine J]]|year=2010|volume=10|issue=10|pages=918–940|title= NASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back pain|author= Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM|doi=10.1016/j.spinee.2010.07.389|pmid=20869008}}</ref><ref name=Bronfort-Haas>{{cite journal|journal= Chiropractic & Osteopathy|year=2010|volume=18|issue=3|title= Effectiveness of manual therapies: the UK evidence report|author= Bronfort G, Haas M, Evans R, Leininger B, Triano J|doi=10.1186/1746-1340-18-3|pmid=20184717|url=http://chiromt.com/content/18/1/3|pmc=2841070|page= 3}}</ref> as well as [[Lumbar vertebrae|lumbar]] [[spinal disc herniation|disc herniation]] with [[radiculopathy]],<ref name="Leininger B, Bronfort G, Evans R, Reiter T 2011 105–25">{{cite journal|journal= Phys Med Rehabil Clin N Am|year=2011|volume=22|issue=1|pages=105–25|title= Spinal manipulation or mobilization for radiculopathy: a systematic review|author= Leininger B, Bronfort G, Evans R, Reiter T|pmid=21292148|doi=10.1016/j.pmr.2010.11.002}}</ref><ref name="Hahne AJ, Ford JJ, McMeeken JM 2010 E488–504">{{cite journal|journal= Spine|year=2010|volume=35|issue=11|pages=E488–504|title= Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review|author= Hahne AJ, Ford JJ, McMeeken JM|pmid=20421859|doi=10.1097/BRS.0b013e3181cc3f56}}</ref> neck pain,<ref name="Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL 2010 315–333">{{cite journal|journal= Manual Therapy|year= 2010|volume=15|issue=4|pages=315–333|title= Manipulation or mobilisation for neck pain: a Cochrane Review|author= Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL|pmid=20510644|doi= 10.1016/j.math.2010.04.002 }}</ref> some forms of headache,<ref name="Chaibi A, Tuchin PJ, Russell MB 2011">{{cite journal|journal= J Headache Pain|year=2011|volume= 12|issue= 2|pages= 127–33|title= Manual therapies for migraine: a systematic review|author= Chaibi A, Tuchin PJ, Russell MB|pmid=21298314|doi=10.1007/s10194-011-0296-6|pmc=3072494}}</ref><ref name="Bronfort G, Nilsson N, Haas M et al. 2004 CD001878">{{cite journal|journal= Cochrane Database Syst Rev|year=2004|issue=3|pages=CD001878|title= Non-invasive physical treatments for chronic/recurrent headache|author= Bronfort G, Nilsson N, Haas M ''et al.''|doi=10.1002/14651858.CD001878.pub2|pmid=15266458|editor1-last= Brønfort|editor1-first= Gert}}</ref> and some extremity joint conditions.<ref name="Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W 2009 53–71">{{cite journal|author= Brantingham JW, Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W|title= Manipulative therapy for lower extremity conditions: expansion of literature review|journal= J Manipulative Physiol Ther|volume=32|issue=1|pages=53–71|year=2009|pmid=19121464|doi=10.1016/j.jmpt.2008.09.013}}</ref><ref name="pmid21109059">{{Cite pmid|21109059}}</ref> In general, spinal manipulation is equivalent to other conservative measures for musculoskeletal complaints.[http://www.ncbi.nlm.nih.gov/pubmed/21328304][http://www.ncbi.nlm.nih.gov/pubmed/22621391]. There is insufficient evidence regarding the effectiveness of spinal manipulation on non-musculoskeletal conditions.<ref name=Trick-or-Treatment>{{cite book|pages=145–90|chapter=The truth about chiropractic therapy|title=Trick or Treatment: The Undeniable Facts about Alternative Medicine|author=Singh S, Ernst E|year=2008|publisher=W.W. Norton|isbn=978-0-393-06661-6 }}</ref>[http://www.ncbi.nlm.nih.gov/pubmed/18280103]. Spinal manipulation is generally regarded as cost-effective treatment of neuromusculoskeletal disorders when used alone or in combination with other treatment approaches.<ref>{{cite journal|journal= J Electromyogr Kinesiol|year=2012|volume=|issue=|pages=|title=Spinal manipulation epidemiology: Systematic review of cost effectiveness studies|author= Michaleff ZA, Lin CW, Maher CG, van Tulder MW|doi= 10.1016/j.jelekin.2012.02.011|pmid=22429823|pmc= }}</ref> Evidence supports the cost-effectiveness of using spinal manipulation for the treatment of sub-acute or chronic low back pain whereas the results for acute low back pain were inconsistent.<ref>{{cite journal|journal= European Spine Journal|year=2011|volume=20|issue=7|pages=1024–1038|title=Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review|author= Lin CW, Haas M, Maher CG, Machado LA, van Tulder MW|doi=10.1007/s00586-010-1676-3|pmid=21229367|pmc= 3176706 }}</ref> In the 1980s, spinal manipulation gained mainstream acceptance<ref>{{cite web |url=http://muaphysicians.com/historical.html |publisher= International MUA Academy of Physicians |title= Manipulation under anesthesia: historical considerations |author= Francis RS |date=2005 |accessdate=2008-07-06}}</ref>which has led to increased collaboration between chiropractors and medical doctors developing inter-professional pathways of care for manual and conservative treatment of neuromusculoskeletal disorders.<ref name="DeVocht-JW">{{cite journal|journal=Clin Orthop Relat Res|year=2006|volume=444|pages=243–9|title=History and overview of theories and methods of chiropractic: a counterpoint|author=DeVocht JW|doi=10.1097/01.blo.0000203460.89887.8d|pmid=16523145 }}</ref><ref>{{cite journal|coauthors=Mior S, Barnsley J, Boon H, Ashbury FD, Haig R.|title=Designing a framework for the delivery of collaborative musculoskeletal care involving chiropractors and physicians in community-based primary care.|journal=J Interprof Care|year=2010|month=Nov|volume=24|issue=6|pages=678–89|pmid=20441400|accessdate=4 February 2013}}</ref><ref>{{cite journal|coauthors=Mior S, Gamble B, Barnsley J, Côté P, Côté E.|title=Changes in primary care physician's management of low back pain in a model of interprofessional collaborative care: an uncontrolled before-after study.|journal=Chiropr Man Therap|year=2013|month=Feb|volume=21|issue=1|accessdate=4 February 2013}}</ref>

==Ethics and medicolegal issues==
Chiropractors, like other health care professionals, are self-regulated and have a [[fiduciary]] responsibility to protect the public and ensure competent, professional and ethical behaviour. Chiropractors have been noted to have increased instances of fraud, abuse and quackery compared to other health professions.<ref name=Murphy-pod>{{cite journal|pmid=18759966|doi=10.1186/1746-1340-16-10|url=http://chiroandosteo.com/content/pdf/1746-1340-16-10.pdf|year=2008|month=Aug|last1=Murphy|first1=DR|last2=Schneider|last3=Seaman|last4=Perle|last5=Nelson|title=How can chiropractic become a respected mainstream profession? The example of podiatry|volume=16|page=10|journal=Chiropractic & osteopathy|first2=MJ|first3=DR|first4=SM|first5=CF|pmc=2538524}}</ref> Internal criticism identified dubious practice techniques that promote high-volume treatments (which can increase dependency) and far-reaching and outlandish claims regarding the clinical significance of joint dysfunction/subluxation and its role in health and disease<ref name="Gleberzon2005">{{cite journal
|first1=Brian J.
|last1=Gleberzon
|first2=Robert
|last2=Cooperstein
|first3=Stephen M.
|last3=Perle
|journal=Journal of the Canadian Chiropractic Association
|title=Can chiropractic survive its chimerical nature?
|medline=8009545
|year=2005
|volume=49
|issue=2
}}</ref>

===Regulation===
Since its inception, chiropractic was controversial amongst the established medical orthodoxy. Chiropractors were jailed for "practicing medicine without a license" which the profession designed a legal and political defence against prosecution arguing that chiropractic was "separate and distinct from medicine", asserting that chiropractors "analyzed" rather than "diagnosed", and "adjusted" subluxations rather than "treated" disease.<ref name=History-Primer/> In 1963 the American Medical Association formed a "Committee on Quackery" designed to "contain and eliminate" the chiropractic profession. In 1966, the AMA referred to chiropractic an "unscientific cult" and until 1980 and held that it was unethical for medical doctors to associate themselves with "unscientific practitioners".<ref name=Chiro-PH>{{cite journal |journal= J Manipulative Physiol Ther |year=2008 |volume=31 |issue=6 |pages=397–410 |title= Chiropractic and public health: current state and future vision |author= Johnson C, Baird R, Dougherty PE ''et al.'' |doi=10.1016/j.jmpt.2008.07.001 |pmid=18722194 |url=http://jmptonline.org/article/PIIS0161475408001784/fulltext}}</ref> The 1987, the AMA was found guilty of being engaged in an unlawful conspiracy in restraint of trade "to contain and eliminate the chiropractic profession." <ref name=History-Primer/> In the 1980s, spinal manipulation gained mainstream recognition<ref>{{cite web |url=http://muaphysicians.com/historical.html |publisher= International MUA Academy of Physicians |title= Manipulation under anesthesia: historical considerations |author= Francis RS |year=2005 |accessdate=2008-07-06}}</ref> and has spurred ongoing collaboration into research of manipulative therapies and models of delivery of chiropractic care for musculoskeletal conditions in the mainstream healthcare sector.<ref name="DeVocht-JW">{{cite journal|journal=Clin Orthop Relat Res|year=2006|volume=444|pages=243–9|title=History and overview of theories and methods of chiropractic: a counterpoint|author=DeVocht JW|doi=10.1097/01.blo.0000203460.89887.8d|pmid=16523145 }}</ref><ref>{{cite journal|coauthors=Mior S, Barnsley J, Boon H, Ashbury FD, Haig R.|title=Designing a framework for the delivery of collaborative musculoskeletal care involving chiropractors and physicians in community-based primary care.|journal=J Interprof Care|year=2010|month=Nov|volume=24|issue=6|pages=678–89|pmid=20441400|accessdate=4 February 2013}}</ref><ref>{{cite journal|coauthors=Mior S, Gamble B, Barnsley J, Côté P, Côté E.|title=Changes in primary care physician's management of low back pain in a model of interprofessional collaborative care: an uncontrolled before-after study.|journal=Chiropr Man Therap|year=2013|month=Feb|volume=21|issue=1|accessdate=4 February 2013}}</ref>
===Public health===
Public health is becoming an increasingly important topic for chiropractors and what role they may play in the public health arena with recommendations suggesting the natural focus for the chiropractic profession is maintaining spinal and musculoskeletal health, good nutrition and an active lifestyle from childhood and throughout life, thereby promoting general health and freedom from chronic pain, disease and disability.<ref>{{cite journal|last=Johnson|first=C|coauthors=Rubinstein Sm, Cote P, et al. (2012) Chiropractic Care and Public Health: Answering Difficult Questions About Safety, Care Through|title=Chiropractic Care and Public Health: Answering Difficult Questions About Safety, Care Through the Lifespan, and Community Action.|journal=JMPT|year=2012|volume=35|pages=494–513|doi=10.1016/j.jmpt.2012.09.001.|pmid=23069244|accessdate=26 January 2013}}</ref> However, traditionally chiropractic has not endorsed mainstream public health measures such as mandatory [[vaccination]] and [[water fluoridation]] stating the patient should be able to freely choose for themselves.<ref name=Campbell/><ref name=Campbell>{{cite journal|journal=Pediatrics|year=2000|volume=105|issue=4|pages=e43|title= Chiropractors and vaccination: a historical perspective|author= Campbell JB, Busse JW, Injeyan HS|pmid=10742364|url=http://pediatrics.aappublications.org/cgi/content/full/105/4/e43|doi= 10.1542/peds.105.4.e43}}</ref><ref name=Busse>{{cite journal|journal= J Manipulative Physiol Ther|year=2005|volume=28|issue=5|pages=367–73|title= Chiropractic antivaccination arguments|author= Busse JW, Morgan L, Campbell JB|doi=10.1016/j.jmpt.2005.04.011|pmid=15965414|url= http://jmptonline.org/article/S0161-4754(05)00111-9/fulltext}}</ref>
<ref>{{cite journal|journal= Am J Public Health|year=1989|volume=79|issue=10|pages=1405–8|title= Fluoridation referendum in La Crosse, Wisconsin: contributing factors to success|author= Jones RB, Mormann DN, Durtsche TB|pmid=2782512|pmc=1350185|url=http://www.ajph.org/cgi/reprint/79/10/1405.pdf|format=PDF|doi= 10.2105/AJPH.79.10.1405}}</ref>

===Diagnostic imaging===
Chiropractors employ diagnostic imaging techniques such as [[Radio diagnostics|X-rays]] and [[CT scan]]s to assist in the management of patient care. External and internal criticism regarding the frequency and inappropriate use of X-Rays, such as full spine radiographs, resulted in the development of evidence-based general practice guidelines in 2007 to improve patient safety by eliminating unnecessary exposure to radiation.<ref name=Bussieres>{{cite journal|author=Bussières AE, Taylor JAM, Peterson C|title=Diagnostic imaging practice guidelines for musculoskeletal complaints in adults—an evidence-based approach—part 3: spinal disorders|journal=J Manipulative Physiol Ther|volume=31|issue=1|pages=33–88|year=2008|pmid=18308153|doi=10.1016/j.jmpt.2007.11.003|url=http://jmptonline.org/article/S0161-4754(07)00314-4/fulltext }}</ref><ref>{{cite journal|journal=Spine|year=2007|volume=32|issue=22|pages=2509–2514|title=Do chiropractors adhere to guidelines for back radiographs? A study of chiropractic teaching clinics in Canada|author= Ammendolia C, Côté P, Hogg-Johnson S, Bombardier C|doi= 10.1097/BRS.0b013e3181578dee|pmid=18090093}}</ref>

===Safety===
There has been considerable debate on the safety of spinal manipulation, the core clinical act of chiropractors, in particular with the cervical spine.<ref name=Ernst-adverse/> Adverse events in SM studies are believed to be under-reported <ref name=Ernst-2012>{{cite journal|journal=N Z Med J|year=2012|volume=125|issue=1353|pages=87–140|title= Reporting of adverse effects in randomised clinical trials of chiropractic manipulations: a systematic review|author= Ernst E, Posadzki P|pmid=22522273|url=|pmc=}}</ref> and appear to be more common following HVLA manipulation than mobilization.<ref name="Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM 2005 1477–84">{{cite journal|author=Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM|title=Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study|journal=[[Spine (journal)|Spine]]|volume=30|issue=13|pages=1477–84|year=2005|month=July|pmid=15990659|doi= 10.1097/01.brs.0000167821.39373.c1|url=}}</ref>
Although serious injuries and fatal consequences can occur and may be under-reported,<ref name=Ernst-death/> these are generally considered to be rare when spinal manipulation is employed skillfully and appropriately.<ref name=WHO-guidelines/> There is ongoing research investigating upper cervical manipulation and incidence of stroke.<ref name=Haynes>{{cite journal|journal=International Journal of Clinical Practice|year=2012|volume=66|issue=10|pages=940–947|title= Assessing the risk of stroke from neck manipulation: a systematic review|author= Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ.|doi=10.1111/j.1742-1241.2012.03004.x|pmid=22994328|url=http://onlinelibrary.wiley.com/doi/10.1111/j.1742-1241.2012.03004.x/full}}</ref>

==References==
{{reflist}}

⚫
[[Category:Chiropractic]]
[[Category:Musculoskeletal disorders]]
[[Category:Manipulative therapy]]
[[Category:Vitalism]]
[[Category:Holism]]
[[Category:Materialism]]

Revision as of 19:11, 1 April 2013

The philosophy of Chiropractic merges both elements of vitalism and materialism. Chiropractic medicine embraces naturalistic principles that suggest decreased "host resistance" of the body facilitates the disease process. Chiropractors propose manual, conservative and natural interventions are preferable towards optimizing health and functional well-being. Chiropractors emphasizes manual and manipulative therapies and as an alternative to medications and surgery for neuromusculoskeletal disorders[1] The relationship between structure, especially the spine, and function as modulated by the nervous system, is central to chiropractic and its approach to the restoration and preservation of health. Chiropractors examine the biomechanics of the spine and other joints of the neuromusculoskeletal system and examines its role in health and disease. [2]It is hypothesized that clinically significant neurophysiological consequences may occur as a result of spinal dysfunction/subluxation, described by chiropractors as the vertebral subluxation complex[3] Most practitioners currently accept the importance of scientific research into chiropractic.[1] Foundational concepts of the philosophy of chiropractic includes the following principles:

  • Vitalism accepts that all living organisms are sustained by a vital force that is both different from, and greater than, physical and chemical forces. Contemporary is it is referred to as "vis medicatrix naturae" (the healing power of nature).
  • Holism postulates that health is related to the balanced integration of the individual in all aspects and levels of being: body, mind and spirit, including interpersonal relationships and the interplay between lifestyle, environment, and health.
  • Naturalism states a preference for natural remedies. This is bound up with a set of philosophical principles which may be expressed as the body is built on nature’s order, it has natural ability to heal itself, that this is reinforced by the use of natural remedies, that it should not be tampered with unnecessarily through the use of drugs or surgery
  • Humanism is based on the postulate that individuals have immutable rights, for example the right to dignity. In CAM there is extensive concern about dehumanizing procedures and the dehumanizing institutions that have been created for the ill. Partly it is recognition of the personal, social and spiritual aspects of health and a move away from simply the biology of health.
  • Therapeutic Conservatism is the use therapies that have a low level of side effects and it tends to accept that the least care is the best care. This in some ways is derived from earlier principles. if the body is capable of healing itself, the role of the therapy is simply to initiate the process.[3]

History

Main article: History of chiropractic

Upon its founding 1895, chiropractic's early philosophy was rooted in vitalism, magnetism, spiritualism and other constructs that were not amenable to the scientific method. Chiropractic's founder, D.D. Palmer, attempted to merge science and metaphysics.[4] In 1896, D.D. Palmer's first descriptions and underlying philosophy of chiropractic was strikingly similar to Andrew Still's principles of osteopathy established a decade earlier.[5] Both described the body as a "machine" whose parts could be manipulated to produce a drugless cure. Both professed the use of spinal manipulation on joint dysfunction/subluxation to improve health. Palmer drew further distinctions by noting that he was the first to use short-lever HVLA manipulative techniques using the spinous process and transverse processes as mechanical levers. Additionally he described the effects of chiropractic spinal manipulation was mediated by the nervous system in contrast to osteopathy who believed the effects were attributed to the supremacy of the circulatory system. [6] Palmer initially denied being trained by osteopathic medicine founder A.T. Still. But Palmer's papers, held at the Palmer College of Chiropractic, indicate that he wrote in 1899:

"Some years ago I took and expensive course in Electropathy, Cranial Diagnosis, Hydrotherapy, Facial Diagnosis. Later I took Osteopathy [which] gave me such a measure of confidence as to almost feel it unnecessary to seek other sciences for the mastery of curable disease. Having been assured that the underlying philosophy of chiropractic is the same as that of osteopathy...Chiropractic is osteopathy gone to seed."[4]

By embracing both vitalism and materialism the philosophy of chiropractic has produced a diverse and eclectic mix of chiropractors which despite their emphasis of manual therapy they may vary on their perceived scope of practice, interventions and their role in the health care system.[1]

"Straight" chiropractic

Half-length sitting portrait of man in his fifties with large gray beard and moustache, wearing coat and vest

Also known as 'subluxation-based' and 'principled chiropractic', chiropractors educated from this paradigm espouse traditional Palmer principles and philosophy. Historically straight chiropractors regarded spinal joint dsyfunction/subluxation as the primary cause of "dis-ease" and could be corrected via specific chiropractic adjustments. This monocausal view of disease has been abandoned by the profession [7] preferring a holistic view of subluxation that is viewed as theoretical construct in a "web of causation" along with other determinants of health.[8] Palmerian philosophy focused on metaphysical constructs such as Innate Intelligence and Universal Intelligence to explain the effects of the chiropractic adjustment, whose intent was the reduce/correct spinal subluxations and improving the functioning of the nervous system. The subluxation was said to be "the cause of 95 percent of all diseases... the other five percent is caused by displaced joints other than those of the vertebral column."[9] Misalignment of the vertebrae was believed to be cause impingement of the nerve root, a theory which has long been debunked[10] Subluxation-based chiropractors view traditional chiropractic lexicon such as "analysis" and "adjustment" and as a critical distinction of chiropractic despite lack of prevalence of these terms in the chiropractic literature[11] Subluxation-based chiropractors have been criticized both internally and externally for far-reaching claims of "killer" subluxations, pseudoscientific reasoning,[5] dogmatic approaches [12] unethical business practices that invoke religious themes and high-volume treatments for a variety of conditions that lack supportive scientific evidence.[13] This metaphysical and dogmatic and singular approach to chiropractic care has been criticized for failing to engage in critical and rational thinking and embracing evidence-based medicine.[14] Straight chiropractors use a subluxation-based model as opposed to the patient-centered model now favored in health care.[15] Although they are the minority within the profession, they are considered to have a disproportionate influence as "purists".[16]

"Mixer" chiropractic

Mixers form the majority of chiropractors and attempt to combine the materialistic reductionism of science with the metaphysics of their predecessors and with the holistic paradigm of wellness;[15] While D.D. Palmer considered vertebral misalignment to be the hallmark feature of subluxation, mixer pioneer Solon Langworthy asserted that intervertebral hypomobility, not misalignment, was subluxation’s cardinal biomechanical feature. This contrasting mechanistic emphasis, intervertebral misalignment vs. hypomobility, formed one the basis for a heated polemic in the profession. Although both misalignment and hypomobility are currently recognized as biomechanical features of subluxation, hypomobility has garnered much more attention in recent years.[8][17] Mixers were disdained by the Palmers who disapproved of their use of instrumentation and mixing chiropractic diagnostic and treatment approaches with osteopathic, naturopathic and allopathic viewpoints.[16] By embracing a mechanistic viewpoint, mixers are able balance the vitalistic notions with critical reasoning skills that led to legitimate scientific investigation of chiropractic principles. Mechanistic underpinnings have led to testable hypotheses that structure affects function via the nervous system by the scientific study of joint dysfunction (subluxation) and the biological mechanisms underlying manipulative therapies[1] Scientific chiropractors suggests that a mechanistic view will allow chiropractic care to become integrated into the wider health care community.[12] In contrast to subluxation-based chiropractors, evidence-based chiropractors favor and incorporate mainstream medical diagnostic and treatment approaches such as exercise, nutritional supplementation, Rehabilitation[disambiguation needed], self-care, physiotherapeutic modalities, and other natural approaches. A majority of mixers retain belief that spinal dysfunction/subluxation may be involved in somato-visceral disorders. This group may represent the 'silent majority' of centrists who embrace evidence-based medicine but feel comfortable retaining elements of the subluxation complex that have not been validated through empirical evidence.[18]

Spinal dysfunction/subluxation

Main article: spinal dysfunction

Spinal dysfunction dubbed subluxation by chiropractors, is a biomechanical spinal lesion (structure) hypothesized to interfere neurophysiological function. Chiropractic theory suggests spinal dysfunction/subluxation may contribute to neuromusculoskeletal and visceral disorders via aberrant spinal segmental and suprasegmental reflexes. While spinal manipulation is widely seen as a reasonable treatment option for biomechanical disorders of the spine, such as neck pain and low back pain, the use of spinal manipulation to treat non-musculoskeletal complaints remains controversial.[19] Chiropractors suggest spinal manipulation normalizes spine biomechanics, and as a consequence, normalizes afferent input to the central nervous system resulting in optimized neurological function and improved health outcomes.[20]

Chiropractic philosophy and emphasis on joint dysfunction/subluxation and it's putative role in neuromusculoskeletal and visceral disorders has been a source of controversy since its inception in 1895 due its vitalistic and metaphysical origins which used terminology that was not amenable to scientific investigation. Far reaching claims and lack of scientific evidence supporting traditional Palmer chiropractic philosophy that spinal joint dysfunction /subluxation as the sole cause of disease has led to a critical evaluation of a central tenet of chiropractic medicine and the appropriateness of the professions role in treating a broad spectrum disorders that are not related to the neuromusculoskeletal system.[21] Today the monocausal view of disease has been abandoned by the profession [22]preferring a holistic view of subluxation that is viewed as theoretical construct in a "web of causation" along with other determinants of health.[8] Although there is external and internal debate within the chiropractic profession regarding the clinical significance of joint dysfunction/subluxation[23] the manipulable lesion remains inextricably linked to the profession as basis for spinal manipulation.[8]

Manual and manipulative therapy

Main articles: manual therapy and spinal manipulation

Chiropractors propose manual, conservative and natural interventions are preferable towards optimizing health and well-being. Chiropractors emphasize manual and manipulative therapies as an alternative to medications and surgery for functional neuromusculoskeletal and visceral disorders[1] The medicinal use of manual interventions, including spinal manipulation, can be traced back over 3000 years to ancient Chinese writings. Hippocrates, the "Father of medicine" used manipulative techniques[24] as did the ancient Egyptians and many other cultures. A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of the osteopathic medicine and chiropractic medicine. The Father of chiropractic posited that spinal manipulation on spinal dysfunctions could improve health and prevent disease. The profession has since abandoned the monocausal view of disease via spinal dysfunction/subluxation[25] Spinal manipulation has gained mainstream recognition during the 1980s.[26] In North America, chiropractors perform over 90% of all manipulative treatments[27] with the balance provided by osteopathic medicine, physical therapy and naturopathic medicine. Manipulation under anesthesia or MUA is a specialized manipulative procedure that typically occurs in hospitals administered under general anesthesia.[28] Typically, it is performed on patients who have failed to respond to other forms of treatment.[29]There has been considerable debate on the safety of spinal manipulation, in particular with the cervical spine.[30] Although serious injuries and fatal consequences can occur and may be under-reported,[31] these are generally considered to be rare when spinal manipulation is employed skillfully and appropriately.[32]

Manual and conservative therapies commonly used by chiropractors may be effective for the treatment of low back pain [33][34][35] as well as lumbar disc herniation with radiculopathy,[36][37] neck pain,[38] some forms of headache,[39][40] and some extremity joint conditions.[41][42] In general, spinal manipulation is equivalent to other conservative measures for musculoskeletal complaints.[1][2]. There is insufficient evidence regarding the effectiveness of spinal manipulation on non-musculoskeletal conditions.[43][3]. Spinal manipulation is generally regarded as cost-effective treatment of neuromusculoskeletal disorders when used alone or in combination with other treatment approaches.[44] Evidence supports the cost-effectiveness of using spinal manipulation for the treatment of sub-acute or chronic low back pain whereas the results for acute low back pain were inconsistent.[45] In the 1980s, spinal manipulation gained mainstream acceptance[46]which has led to increased collaboration between chiropractors and medical doctors developing inter-professional pathways of care for manual and conservative treatment of neuromusculoskeletal disorders.[47][48][49]

Ethics and medicolegal issues

Chiropractors, like other health care professionals, are self-regulated and have a fiduciary responsibility to protect the public and ensure competent, professional and ethical behaviour. Chiropractors have been noted to have increased instances of fraud, abuse and quackery compared to other health professions.[14] Internal criticism identified dubious practice techniques that promote high-volume treatments (which can increase dependency) and far-reaching and outlandish claims regarding the clinical significance of joint dysfunction/subluxation and its role in health and disease[50]

Regulation

Since its inception, chiropractic was controversial amongst the established medical orthodoxy. Chiropractors were jailed for "practicing medicine without a license" which the profession designed a legal and political defence against prosecution arguing that chiropractic was "separate and distinct from medicine", asserting that chiropractors "analyzed" rather than "diagnosed", and "adjusted" subluxations rather than "treated" disease.[51] In 1963 the American Medical Association formed a "Committee on Quackery" designed to "contain and eliminate" the chiropractic profession. In 1966, the AMA referred to chiropractic an "unscientific cult" and until 1980 and held that it was unethical for medical doctors to associate themselves with "unscientific practitioners".[52] The 1987, the AMA was found guilty of being engaged in an unlawful conspiracy in restraint of trade "to contain and eliminate the chiropractic profession." [51] In the 1980s, spinal manipulation gained mainstream recognition[53] and has spurred ongoing collaboration into research of manipulative therapies and models of delivery of chiropractic care for musculoskeletal conditions in the mainstream healthcare sector.[47][54][55]

Public health

Public health is becoming an increasingly important topic for chiropractors and what role they may play in the public health arena with recommendations suggesting the natural focus for the chiropractic profession is maintaining spinal and musculoskeletal health, good nutrition and an active lifestyle from childhood and throughout life, thereby promoting general health and freedom from chronic pain, disease and disability.[56] However, traditionally chiropractic has not endorsed mainstream public health measures such as mandatory vaccination and water fluoridation stating the patient should be able to freely choose for themselves.[57][57][58] [59]

Diagnostic imaging

Chiropractors employ diagnostic imaging techniques such as X-rays and CT scans to assist in the management of patient care. External and internal criticism regarding the frequency and inappropriate use of X-Rays, such as full spine radiographs, resulted in the development of evidence-based general practice guidelines in 2007 to improve patient safety by eliminating unnecessary exposure to radiation.[60][61]

Safety

There has been considerable debate on the safety of spinal manipulation, the core clinical act of chiropractors, in particular with the cervical spine.[30] Adverse events in SM studies are believed to be under-reported [62] and appear to be more common following HVLA manipulation than mobilization.[63] Although serious injuries and fatal consequences can occur and may be under-reported,[31] these are generally considered to be rare when spinal manipulation is employed skillfully and appropriately.[32] There is ongoing research investigating upper cervical manipulation and incidence of stroke.[64]

References

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