Chiropractic

Editor-in-Chief: Dr. Stephen J. Press [mailto:drsjp@drpress.com]



Chiropractic (from Greek chiro- χειρο- "hand-" + praktikós πρακτικός "concerned with action") is a complementary and alternative medicine health care profession that focuses on diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system and the effects of these disorders on the functions of the nervous system and general health. It emphasizes manual therapy including spinal adjustment and other joint and soft-tissue manipulation. Today, according to the mainstream of the profession, it is based on the premise that spinal joint dysfunction can interfere with the nervous system and result in many different conditions of diminished health. The concept of what was called vertebral subluxation is now adhered to by a small minority and generally relegated to history. The term was defined quite differently by the chiropractic vs the medical professions, and thus incited much misunderstanding. Thus, this alternative form of therapy examines the relationship between structure and function and its impact on neurological mechanisms in both health and disease.

Education
(See also Chiropractic - Education) Doctors of Chiropractic usually obtain one of the following equivalent first professional degrees in chiropractic medicine: D.C., D.C.M.,  B.Chiro or M.Chiro. These programs are taken in specialized, accredited Chiropractic Colleges, some of which are in Universities, and in the US, are post-college, 10 semester (5 academic year) courses, including clinical practice (approx. PGY 1 - taken before receipt of the degree).

Treatment
(See also Chiropractic - Treatment Methods) In treating patients, chiropractors may develop a comprehensive treatment plan based on the patient's individual needs. Such a plan may include spinal adjustments, soft tissue therapy, prescription of exercises, and health and lifestyle counseling.

Historical overview
(See also Chiropractic - History) Chiropractic was founded in 1895 by D. D. Palmer in the USA, and is practiced in more than 100 countries. Since its inception, chiropractic has been controversial, both within the profession and in the medical and scientific community, particularly regarding the metaphysical approach espoused by its founders and advocated by the small, but vocal minority which historically were known as "straight" chiropractors. This same criticism may have been the catalyst that allowed some within the profession to emphasize primarily a neuromusculoskeletal approach in their educational curriculum, leading them away from the original metaphysical explanations of their predecessors towards more scientific ones.

Popularity, and utilization
(See also Chiropractic - Economics) The utilization of chiropractic has increased in popularity. The profession has remained unified with a continuous commitment to clinical care. Chiropractic's greatest contribution to health care may be its patient-physician relationship and hands-on treatment. Patients are usually satisfied with the treatment they received.

Research, Evidence Based Practice
(See also Chiropractic - Research) The principles of evidence-based medicine has grown in prominence and have been used to review research studies and generate practice guidelines. The efficacy of chiropractic treatment has not been rigorously proven. Chiropractic care is generally safe when employed skillfully and appropriately. The cost-effectiveness of maintenance chiropractic care is unknown. Vaccination remains controversial within the chiropractic community.

Scope of practice
(See also Chiropractic - Scope) Chiropractors are primary-contact health care practitioners who emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery. Although chiropractors have many attributes of primary care providers, chiropractic has more of the attributes of a medical specialty like dentistry. The practice of chiropractic medicine involves a range of diagnostic methods including skeletal imaging, observational and tactile assessments, orthopedic and neurological evaluation, laboratory tests, and specialized tests. A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider. Common patient management involves:

In Some States, Chiropractic includes:
 * spinal manipulation and other manual therapies to the joints and soft tissues
 * rehabilitative exercises
 * health promotion
 * electrical modalities
 * conservative and complementary procedures
 * lifestyle counseling.
 * Nutritional medicine
 * Naturopathy, and Homeopathy

Since the profession never desired inclusion of legend drugs or surgery, the laws in the various States were not written to allow medical prescriptions for legend drugs; a 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for over-the-counter drugs. A notable exception is the state of Oregon which is considered to have an "expansive" scope of practice of chiropractic, which allows chiropractors to prescribe over-the-counter substances and perform minor surgery. In some locations chiropractors (DCs) and veterinarians (DVMs) with additional training and certification can practice veterinary chiropractic which includes the diagnosis, treatment and rehabilitation of injured animals. However, the official position of the American Chiropractic Association is that applying manipulative techniques to animals does not constitute chiropractic and that veterinary chiropractic is a misnomer.

Global Distribution
Chiropractic medicine is established in the U.S., Canada, Australia, Switzerland, Great Britain, France, and Scandinavia, and is present to a lesser extent in more than 90 other countries. Similar to other primary contact health providers, chiropractors can specialize in different areas of chiropractic medicine. The most common post-graduate diplomate programs include neurology, sports sciences, clinical sciences, rehabilitation sciences, orthopedics and radiology which generally require 2–3 additional years of additional post graduate study and passing competency examinations. Chiropractors may further specialize in fields such as Chiropractic Orthopedics (DABCO), Chiropractic Radiology (DABCR), and Chiropractic Sports Physician (DABCSP) by completing additional study and passing the specified boards that are separate and distinctly different than medical boards.

Chiropractic - Positions
The Chiropractic profession, working through its International and national associations has formulated certain positions statements on various controversial and non-controversial topics. Please see Chiropractic - Positions

Safety
(See also Chiropractic - Safety)

There have been allegations that certain Chiropractic techniques were associated with vertebral artery or carotid dissections / or strokes post-manipulation. Several in depth major meta-surveys have now vindicated Chiropractic from that idea. All evidence now demonstrates clearly that the extremely rare event is statistically the same risk as a patient experiences from seeing a medical general practitioner, suggesting that such patients are seeing primary care providers because of symptoms which present in pre-stroke syndrome and not being damaged in some way by  the ministrations of either kind of physician.

Effectiveness
The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Opinions differ as to the efficacy of chiropractic treatment; many other medical procedures also lack rigorous proof of effectiveness. Chiropractic care, like all medical treatment, benefits from the placebo response. The efficacy of maintenance care in chiropractic is unknown.

Research has focused on spinal manipulation therapy (SMT) in general, rather than specifically on chiropractic SMT. There is little consensus as to who should administer the SMT, raising concerns by chiropractors that orthodox medical physicians could "steal" SMT procedures from chiropractors; the focus on SMT has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks. Many controlled clinical studies of SMT are available, but their results disagree, and they are typically of low quality. It is hard to construct a trustworthy placebo for clinical trials of SMT, as experts often disagree whether a proposed placebo actually has no effect. Although a 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference, a 2008 supportive review found serious flaws in the critical approach, and found that SMT and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments.

Available evidence covers the following conditions:


 * Low back pain. There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain; methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the guidelines' reliability. A 2007 U.S. guideline weakly recommended SMT as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail, whereas the Swedish guideline for low back pain was updated in 2002 to no longer suggest considering SMT for acute low back pain for patients needing additional help, possibly because the guideline's recommendations were based on a high evidence level. A 2008 review found strong evidence that SMT is similar in effect to medical care with exercise, and moderate evidence that SMT is similar to physical therapy and other forms of conventional care. A 2007 literature synthesis found good evidence supporting SMT for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain. Of four systematic reviews published between 2000 and May 2005, only one recommended SMT, and a 2004 Cochrane review stated that SMT or mobilization is no more or less effective than other standard interventions for back pain.


 * Whiplash and other neck pain. There is no overall consensus on manual therapies for neck pain. A 2008 review found evidence that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SMT, mobilization, supervised exercise, low-level laser therapy and perhaps acupuncture are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves prognosis. A 2007 review found that SMT and mobilization are effective for neck pain. Of three systematic reviews of SMT published between 2000 and May 2005, one reached a positive conclusion, and a 2004 Cochrane review found that SMT and mobilization are beneficial only when combined with exercise, the benefits being pain relief, functional improvement, and global perceived effect for subacute/chronic mechanical neck disorder. A 2005 review found limited evidence supporting SMT for whiplash.


 * Headache. A 2006 review found no rigorous evidence supporting SMT or other manual therapies for tension headache. A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine. A 2004 review found that SMT may be effective for migraine and tension headache, and SMT and neck exercises may be effective for cervicogenic headache. Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of SMT.


 * Other. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs, and a lack of higher-quality publications supporting chiropractic management of leg conditions. A 2007 literature synthesis found fair evidence supporting assurance and advice to stay active for sciatica and radicular pain in the leg. There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine) and no scientific data for idiopathic adolescent scoliosis. A 2007 systematic review found that few studies of chiropractic care for nonmusculoskeletal conditions are available, and they are typically not of high quality; it also found that the entire clinical encounter of chiropractic care (as opposed to just SMT) provides benefit to patients with asthma, cervicogenic dizziness, and baby colic, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizzinesss, and vision conditions. Other reviews have found no evidence of benefit for baby colic, bedwetting, fibromyalgia, or menstrual cramps.