Chiropractic
Chiropractic is a form of alternative medicine concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially of the spine. The main chiropractic treatment technique involves manual therapy but may also include exercises and health and lifestyle counseling. Most who seek chiropractic care do so for low back pain. Chiropractic is well established in the United States, Canada, and Australia, along with other manual-therapy professions such as osteopathy and physical therapy.
Many chiropractors, especially those in the field's early history, have proposed that mechanical disorders affect general health, and that regular manipulation of the spine improves general health. A chiropractor may have a Doctor of Chiropractic degree and be referred to as "doctor" but is not a Doctor of Medicine or a Doctor of Osteopathic Medicine. While many chiropractors view themselves as primary care providers, chiropractic clinical training does not meet the requirements for that designation. A small but significant number of chiropractors spread vaccine misinformation, promote unproven dietary supplements, or administer full-spine x-rays.
There is no good evidence that chiropractic manipulation is effective in helping manage lower back pain. A 2011 critical evaluation of 45 systematic reviews concluded that the data included in the study "fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition." Spinal manipulation may be cost-effective for sub-acute or chronic low back pain, but the results for acute low back pain were insufficient. No compelling evidence exists to indicate that maintenance chiropractic care adequately prevents symptoms or diseases.
There is not sufficient data to establish the safety of chiropractic manipulations. It is frequently associated with mild to moderate adverse effects, with serious or fatal complications in rare cases. There is controversy regarding the degree of risk of vertebral artery dissection, which can lead to stroke and death, from cervical manipulation. Several deaths have been associated with this technique and it has been suggested that the relationship is causative, a claim which is disputed by many chiropractors.
Chiropractic is based on several pseudoscientific ideas. Spiritualist D. D. Palmer founded chiropractic in the 1890s, claiming that he had received it from "the other world", from a doctor who had died 50 years previously. Throughout its history, chiropractic has been controversial. Its foundation is at odds with evidence-based medicine, and is underpinned by pseudoscientific ideas such as vertebral subluxation and Innate Intelligence. Despite the overwhelming evidence that vaccination is an effective public health intervention, there are significant disagreements among chiropractors 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 the last decades of the twentieth century, it gained more legitimacy and greater acceptance among conventional physicians and health plans in the United States. During the COVID-19 pandemic, chiropractic professional associations advised chiropractors to adhere to CDC, WHO, and local health department guidance. Despite these recommendations, a small but vocal and influential number of chiropractors spread vaccine misinformation.
Status as fringe healing
Chiropractic is not regarded as a mainstream branch of medicine.Origins in "folk medicine"
Chiropractic's origins lie in the folk medicine of bonesetting, and as it evolved it incorporated vitalism, spiritual inspiration and rationalism. Its founder, D.D. Palmer, called it "a science of healing without drugs". Its early philosophy was based on deduction from irrefutable doctrine, which 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. Some chiropractors claim spinal manipulation can have an effect on a variety of ailments such as irritable bowel syndrome and asthma.
"Subluxation" as a Vitalist concept
In science-based medicine, the term "subluxation" refers to an incomplete or partial dislocation of a joint, from the Latin luxare for "dislocate". Whereas medical doctors use the term exclusively to refer to physical dislocations, Chiropractic founder D. D. Palmer imbued the word subluxation with a metaphysical and philosophical meaning drawn from pseudoscientific traditions such as Vitalism.Palmer claimed that 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 of the end organ. 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.
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 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.
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 US 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."
Pseudoscience versus spinal manipulation therapy
While some chiropractors limit their practice to short-term treatment of musculoskeletal conditions, many falsely claim to be able treat myriad other conditions. Some dissuade patients from seeking medical care, others have pretended to be qualified to act as a family doctor.Quackwatch, an alternative medicine watchdog, cautions against seeing chiropractors who:
- Treat young children
- Discourage immunization
- Pretend to be a family doctor
- Take full spine X-rays
- Promote unproven dietary supplements
- Are antagonistic to scientific medicine
- Claim to treat non-musculoskeletal problems
Scope of practice
Chiropractors emphasize the conservative management of the neuromusculoskeletal system without the use of evidence-based 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. 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 ; and a 2008 study reported that 31% of surveyed chiropractors categorized chiropractic as CAM, 27% as integrated medicine, and 12% as mainstream medicine. Many chiropractors believe they are primary care providers, including US and UK chiropractors, but the length, breadth, and depth of chiropractic clinical training do not support the requirements to be considered primary care providers, so their role on primary care is limited and disputed.
Chiropractic overlaps with several other forms of manual therapy, including massage therapy, osteopathy, physical therapy, and sports medicine. In a 2010 article on the history of manipulative therapy, the author opined that "physical therapy emerged and grew alongside osteopathy, chiropractic, and the evolving "scientific" medical profession. However, over the next 100 years, physical therapy, osteopathy, and chiropractic were destined to travel very different paths. In its country of origin, osteopathy would coalesce with the medical profession. Chiropractic would remain autonomous from, and highly competitive with, medicine. Physical therapy, whose roots lay in working alongside and cooperating with medical physicians, continues to do so.". 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 and other manual therapies to the joints and soft tissues, rehabilitative exercises, health promotion, electrical modalities, complementary procedures, and lifestyle advice.
A related field, veterinary chiropractic, applies manual therapies to animals and is recognized in many 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 professions.
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. Two US states prohibit physical therapists from performing SM, some states allow them to do it only if they have completed advanced training in SM, and some states allow only chiropractors to perform SM, or only chiropractors and physicians. Bills to further prohibit non-chiropractors from performing SM are regularly introduced into state legislatures and are opposed by physical therapist organizations.