Critical views of chiropractic: Difference between revisions

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The purpose of this article is to document and explain critical views of chiropractic where they have been expressed by notable sources, whether from within the chiropractic profession or from scientific or medical sources. Criticism from the public, when organized by consumer groups, is also briefly noted. Reporting a criticism here does not imply that that criticism is endorsed by ''Citizendium'' or its editors.  
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[[Chiropractic]] has received its share of criticism from the [[health sciences]], most particularly from physicians in the USA, where the practice of chiropractic has its largest base. Some of these criticisms have also been echoed within the chiropractic profession. This article discusses criticisms that have been expressed by notable sources, and includes the rebuttals of chiropractors to these views. Reporting a criticism, or its rebuttal, here, does not imply that ''either'' is endorsed by Citizendium or its editors.


Chiropractic, like other alternative medical professions, has received its share of criticism from established Health science, and many of these criticisms have also been raised by some within the profession. Criticisms have been directed at the scientific foundations of chiropractic, on some aspects of chiropractic treatments, and on health advice that is often given by chiropractors. Sometimes also, individual behavior regarding advertisement and sensationalism is denounced.  
==Introduction==
Critics from the [[medicine|medical establishment]], especially in the USA, have claimed:
*that an organized subgroup of chiropractors in the USA openly promote "drugless healing" as a business model of total health care, and even advocate expansion of market base into the care of the well child.
*that chiropractic accepts too low a standard of academic and scientific scholarship in its professional journals and schools.
*that chiropractic argues that such coursework in "medical diagnosis" qualifies its practitioners to be fully qualified to make medical evaluations, and to rule out signs of serious disease.
*that the entire basis ([[vertebral subluxation]]) of chiropractic theory is not scientifically sound.
*that some chiropractors advise parents that ''all'' vaccinations have higher risks and less benefit than any organized health science or biological science group accepts, thus exposing children to the risk of preventable illnesses and putting the general population at risk of epidemics. Worryingly, this subgroup is the ''same'' group that advocates chiropractic as comprehensive primary health care for children.
*that, in the USA, chiropractors are not trained in medicine, nursing, or health science, and so are not competent to act as comprehensive primary health care providers, yet some subgroups of chiropractors make that claim, without protest by the larger profession.
*that chiropractic accepts a general level of self-promotion in advertising that is unprofessional and misleading.
*that while chiropractic has ''only'' been shown to be effective for backpain, and some types of headache, chiropractors advertise for and treat patients for non-musculoskeletal conditions like [[infant colic]], none the less.
*that the chiropractic profession promotes the notion that chiropractic is effective in "muscloskeletal conditions", when the evidence for relief of backpain does ''not'' in any way show that chiropractic care helps conditions such as myasthenia gravis, multiple sclerosis, or rheumatoid arthritis, or other serious and common conditions that a reasonably knowledgeable layman would assume to fall into the category of "musculoskeletal conditions"
 
==History of antagonism between the AMA and chiropractic==
In the 1960's, the American Medical Association (AMA) vehemently criticized chiropractic, and discouraged physicians from cooperating with chiropractors in patient treatment, research and educational activities such as sharing clinical research data. Chiropractors were denied access to hospital facilities, and, for instance, medical doctors were discouraged from aiding chiropractors in interpreting electrocardiograms. As a result, four chiropractors brought an antitrust case against the AMA and others, and in 1987 a Federal Judge ruled that the AMA was guilty of an illegal conspiracy to suppress competition. The judge said that the evidence at the trial showed that the AMA had taken “active steps, often covert, to undermine chiropractic educational institutions, conceal evidence of the usefulness of chiropractic care, undercut insurance programs for patients of chiropractic, subvert government inquiries into the efficacy of chiropractic, engage in a massive disinformation campaign to discredit and destabilise the chiropractic profession and engage in numerous other responses to maintain a physician monopoly over health care."<ref>[http://www.chiro.org/abstracts/amavschiro.pdf The Wilk case: text of the Judge's opinion and order]</ref>. Since then, there has been more co-operation between medical physicians and chiropractors in the USA, and many family doctors are willing to refer their patients on to chiropractors for certain conditions. However, there is still little evidence that mainstream medicine in the USA accepts chiropractic as a full partner in health care. Although physicians today acknowlege that business interests can distort their ideals of practice, academic physicians feel that any financial conflict of interest is beside the point. In university-based medicine, decades of effort have been devoted to upgrading medical practice and medical research, and in marshalling the medical profession towards more scientifically based practice. Their criticisms of the chiropractic profession are, they believe, made by the same criteria that have been used to transform American Medicine.
 
Interestingly, the editorial view of chiropractic from the health sciences, even in the USA, has ''also'' been complimentary, at least compared to other forms of alternative medicine. One authoritative medical textbook praises chiropractic (by comparison with other fields of alternative medicine) stating: "unfortunately, most of the other fields have no agreed upon practice standards, credentialing processes, requirements for continuing education, or accountability."<ref> Stephen E. Straus:Chapter 10. Complementary and Alternative Medicine. Harrison's Principles of Internal Medicine, 16th Edition. Copyright © 2005 The McGraw-Hill Companies, Inc.</ref> Chiropractors point to evidence that they have significantly upgraded their standards of education and research independently of Medicine, and without public funding; improvements in chiropractic standards have been acknowledged by the AMA, who indeed claimed that this was a positive outcome of their campaign. Chiropractors say that chiropractic research has been starved of funds, and that they have been prevented from integrating into hospital-based medicine by a medical profession that has been selective in its use of evidence. Chiropractors claim that their training and experience in musculoskeletal conditions exceeds that of conventional physicians, and that, for several conditions, evidence-based methods have shown that chiropractic treatments are at least as effective as conventional treatments and that the risks are fewer.
 
==Chiropractic today: many styles of practice==
The varying schools and philosophies within chiropractic have led to a wide variation in practice patterns&mdash;along with debates over theory, practice, and future directions. Chiropractic was begun by an individual who did not accept the newly-emerging germ theory of disease<ref>Busse JW ''et al.'' (2005) Chiropractic antivaccination arguments. J Manip Physiol Ther 28:367-73</ref>, and who, like most healers of the time, had no formal training in science. He chose a [[Vitalism|vitalistic]] path for his new concept, describing an "Innate Intelligence" as the force behind the body's response to dis-ease. As chiropractic grew, an increasing emphasis on educational standards and on science in professional schools was encouraged by the creation of the CCE, chiropractic's accrediting body. Its purpose was to maintain standards of education while allowing the philosophies of the individual schools to remain intact.<ref>Coulter I ''et al.'' (1998) A comparative study of chiropractic and medical education. Alt Ther Health Med 4:64-75</ref>  Some schools hold to the old tenets of Palmer, while others increasingly use science-based knowledge. At one end of the spectrum, some chiropractors adhere closely to the beliefs expressed by the founders of chiropractic and tend to reject some of the basic tenets of biological medicine, while other end practitioners reject such traditional chiropractic notions as [[Vertebral subluxation|vertebral subluxations]] and '[[Innate Intelligence]]', and focus on the objective benefits of the chiropractic techniques. The vast majority practice somewhere in between these extremes.
 
"Straight" chiropractors limit their practices to analyzing the spine and correcting subluxations; those who retain a literal belief that they are affecting "Innate Intelligence" are often called "superstraights"; chiropractors who mix spinal manipulation with other treatments are called "mixers". These factions have been in disagreement with each other for most of chiropractic's history, disagreements that have been fought out in courts and state legislatures and remain unresolved. Both classes are criticised by Health Sciences, but for partly different reasons: straights for allegedly overusing spinal manipulation and applying it to conditions for which it offers no benefit, mixers for a claimed propensity to promote dubious ‘remedies’, including homeopathic remedies and dietary supplements of no demonstrated benefit. Both classes have, particularly in the past, opposed many scientifically-based public health measures including immunization, fluoridation, pasteurization of milk, prescription drugs and surgery.
 
==The chiropractic perspective==
<blockquote>''Some critics claim that an organized subgoup of chiropractors in the USA openly promote "drugless healing" as a business model of total health care, and even advocate expansion of market base into the care of the well child.''</blockquote>
 
Chiropractors indeed believe that it is important to minimise the use of drugs, and see their role in particular as being to pursue alternatives to drugs. They believe that preventative care is also an important part of health care, one that is particularly important for children.
 
==Drugless stance on healing==
<blockquote>''Some critics are concerned that while chiropractic has been shown to be effective for backpain, headache and certain musculoskeletal conditions, chiropractors treat patients for a much wider range of conditions where there is no strong objective evidence that their interventions are effective. ''</blockquote>
 
Most chiropractors take a drugless approach to healing, considering that the side effects of drugs can complicate the patient's health status. Physicians are concerned that this can mislead some patients into thinking that all drugs are unnecessary or even harmful, and to overestimate the body's intrinsic ability to remain healthy. They fear that some patients with serious conditions that can be treated effectively with medications may be misled into not taking potentially life-saving treatments, such as [[insulin]], [[Hypertension|blood pressure]] regulators, and [[Statin|cholesterol lowering drugs]]. They are also concerned that patients may even forego laboratory tests such as [[colonoscopy|colonoscopies]] and [[physical]]s that can "catch" some cancers while they are still treatable.Because they feel that healing comes from within the body, chiropractors don't talk of 'cure', but of 'helping the body cure itself'. As a result, the chiropractor sees all who suffer as in need of his or her help. The degree to which they claim to be able to help varies, not only from condition to condition but also from case to case. They claim to work to relieve pain using manual methods and expect that this will minimize the need for medications and thus reduce the potential for side effects which carry greater risk than of any of their treatments.


The efficacy of chiropractic for some conditions, including some musculoskeletal problems and migraine is widely accepted. However, many chiropractors believe that chiropractic is effective in treating a very wide range of conditions. Because the views of chiropractors are very diverse, these criticisms are not applicable to all chiropractors. But in principle the following points are debated:
The spinal cord carries a vast amount of information from peripheral organs and tissues to the brain, including sensations of [[pain]], [[touch]], and [[temperature]]. In addition, virtually every organ and its blood supply is regulated both directly by efferent nerves, many of which travel down the spinal cord, and indirectly by [[neuroendocrinology| neuroendocrine]] regulation of [[hormone]] secretion. Accordingly, disruption of spinal information flow might influence virtually any organ system. However it is not clear that ''any'' particular organ dysfunction is caused by a disorder of spinally-mediated information transfer, or whether manipulation by chiropractors could correct such a disorder. Scientists and physicians generally are skeptical about these possibilities, while believing that, in some cases, chiropractic treatment might be efficacious because it exploits the [[placebo effect]] in an efficient way.


'''Theory'''
Some chiropractors nevertheless believe that several conditions ''can'' be resolved by chiropractic interventions. Such beliefs are based on their clinical experience, not on evidence from large controlled trials, and not on any scientific demonstration of a causal mechanism linking the intervention to its claimed effect. It is possible that cases that have not responded to conventional treatment might include some where the underlying cause is indeed a disorder of neural regulation of an organ system, as the failure of conventional treatment might be taken as excluding more common causes of dysfunction, such as infectious disease. It is also possible that what seems to be a symptom of an organ disease is actually the result of a reflex pain generated from the spine. Thus, if an organ-related complaint responds to chiropractic adjustments, it is possible that a spinal condition was the original cause of the problem.<ref>Nansel D, Szlazak M (1995) Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manip Physiol Ther 18:379-97 PMID 7595111</ref>  Regardless, chiropractors feel that their high patient satisfaction rates and low malpractice rates show that their patients are well informed about the limitations, the risks, and the benefits.
:Whether chiropractic's cause-effect claims for health benefits beyond musculoskeletal complaints have been adequately demonstrated by scientific experiment.  
:The notion that the chiropractic philosophy to avoid using drugs can be dangerous to patients if they discontinue to take drugs prescribed for different reasons.  
:The rejection of vaccination by many chiropractors can be dangerous for the populace as a whole if the immunization ratio falls too low.


'''Practice'''
==Evidence standards in chiropractic==
:Whether chiropractic education in childhood diseases is sufficient for treating children for conditions in which chiropractic does not have validated evidence of efficacy.
<blockquote>''Some critics claim that chiropractic accepts too low a standard of academic and scientific scholarship in its professional journals and schools.'' </blockquote>
:Whether treatment development is based on sufficient hard data on the treatment's effectiveness.


==Introduction==
Some critics have warned about the over-willingness of chiropractors to accept anecdotal evidence of efficacy<ref>[http://www.worldchiropracticalliance.org/tcj/1996/may/may1996kent.htm Critical thinking:] Christopher Kent, president of the [http://www.ccp-guidelines.org/ Council on Chiropractic Practice], advises his colleagues of the importance of high standards of evidence </ref>, while conversely, for instance when a patient has a stroke soon after a spinal adjustment, chiropractors are too ready to dismiss the adverse event as “unrelated". In short, the criticism is that many chiropractors are too ready to embrace evidence supportive of chiropractic, however weak it may be, and too quick to denounce evidence of its risks unless the evidence is overwhelming.
As the most popular of the alternative medical professions in the West, chiropractic stands alone as a major profession in the healing arts that is outside the [[Health Sciences]]. Accordingly, in its 100-year history, [[Chiropractic]] has been under frequent attack from [[Osteopathy]], from [[Medicine (United States)|Medicine]], and from scientists critical of its [[Science|scientific foundations]]. Nonetheless, its appeal to patients is such that chiropractic has not only survived, but thrived. At this time, the most profound criticisms of chiropractic probably come from the chiropractic profession itself. As the varying schools and philosophies within chiropractic are less cohesive than those found within other health professions, such as [[Nursing]] or [[Physical Therapy]], a range of practice patterns with the profession are to be expected - along with controversies over theory and practice, and debate about the future direction of the field.  
 
 
Anecdotal evidence is subject to [[recall bias]], which is the human psychological tendency to preferentially recall unusual cases and forget routine cases. Recall bias is the reason why anecdotal evidence of efficacy or safety of a treatment has been discounted by the mainstream medical community. The [[scientific method]] has been embraced by the mainstream medical community as the ideal technique for determining the truth; the [[scientific method]] is simply the testing of hypotheses with experiments. Anecdotal evidence is therefore not scientific evidence of efficacy, and too encumbered by recall bias to garner acceptance as a way of rationally determining the truth. The mainstream medical community views anecdotal evidence as a way of generating new hypotheses for later scientific testing, not as proof of any hypothesis in and of itself.
Why should chiropractic be ''less'' cohesive in underlying views than, for example, Physical Therapy or Nursing? Unlike the founding philosophies of these other relatively recent health professions, chiropractic was originated by an individual who dismissed the newly emerging germ theory of disease <ref>Busse JW (2005) Chiropractic antivaccination arguments. J Manip Physiol Ther 28:367-373 </ref>, and who had no formal training in science. However, like these other professions, as chiropractic developed, there has been an increasing emphasis on educational excellence in professional schools, with a strong focus on science in the classroom. Overall, this has resulted in a wide range of individual practice styles in current chiropractors. At one end of the range, some chiropractors reject some of the basic tenets of biological medicine, while at the other end, some reject such traditional chiropractic notions as [[Vertebral subluxation|vertebral subluxations]] and "innate intelligence" altogether.  


Current criticism from the health sciences has been mainly directed at concerns over the ''extent'' of chiropractic practice (the wide range of conditions that some chiropractors are willing to offer treatment), and at the advice that chiropractors give to their patients against vaccines and standard medical treatments. There is concern that many chiropractors promote popular beliefs that lie outside their scope of practice and professional knowledge, and which are rejected by mainstream science and medicine. For example, some chiropractors promote their belief in a link between autism and additives in vaccines, and promote their opinions as almost certainly true, rather than entirely speculative.
Joseph Keating, professor at the [http://www.scuhs.edu/ Los Angeles College of Chiropractic] and a prominent [http://www.chiro.org/Plus/History/ historian of chiropractic] said in 1997 that "the doubting, skeptical attitudes of science do not predominate in chiropractic education or among practitioners". He stated that there is scientific support for chiropractic's main intervention method (spinal manipulation of patients with lower back pain), but chiropractic's culture has nurtured antiscientific attitudes, and poor science published in poor journals by chiropractors who are not well trained in science has given chiropractors false confidence about the value of various chiropractic techniques.<ref>Keating JC (1997) [http://www.findarticles.com/p/articles/mi_m2843/is_n4_v21/ai_19727577/print]
:Nelson CF (1993) Chiropractic magazines. J Manip Physiol Ther 16:280-281. Letter to the editor
</ref> However, in 1998, Keating published a review about the ''Journal of Manipulative and Physical Therapy'' from 1989-1996. He concluded that scholarly activity within chiropractic had improved significantly, and that "Increases in controlled outcome studies, collaboration among chiropractic institutions, contributions from nonchiropractors, contributions from nonchiropractic institutions and funding for research suggest a degree of professional maturation and growing interest in the content of the discipline."<ref>:{{cite journal | author = Keating JC ''et al.'' | title = A descriptive analysis of the Journal of Manipulative and Physiological Therapeutics, 1989-1996 | journal = J Manip Physiol Ther | volume = 21 |  pages = 539-52 | year = 1998 | id = PMID 9798183}}</ref>


There is also concern about what is seen as a weakness in the scientific quality of the professional literature of chiropractic. For these reasons, a segment of health science professionals have remained very sceptical of or even hostile to chiropractic practice. Such hostility is most common in the USA, where regulation of chiropractic (and the health sciences) is less vigorous than in European and Canadian health care systems, and where the chiropractic profession is much larger than in any other country.
==Scientific foundations of chiropractic==
<blockquote>''Some critics have claimed that the theoretical basis of subluxation is not scientifically sound.''</blockquote>


Interestingly, the editorial view of chiropractic from Medicine and the health sciences, even in the USA has ''also'' been complimentary, at least in comparison to other forms of alternative medicine. One authoritative medical textbook, praises chiropractic by comparison with other fields of alternative medicine, stating: "unfortunately, most of the other fields have no agreed upon practice standards, credentialing processes, requirements for continuing education, or accountability." <ref> Stephen E. Straus:Chapter 10. Complementary and Alternative Medicine. Harrison's Principles of Internal Medicine, 16th Edition. Copyright © 2005 The McGraw-Hill Companies, Inc.</ref>
The founder of chiropractic, D.D. Palmer, thought that most health problems were caused by spinal misalignments ("[[vertebral subluxation]]s") that blocked the flow of "[[Innate Intelligence]]" along spinal nerves. Accordingly, he proposed that chiropractic adjustments might be effective in treating almost any disease. Since then, chiropractors have been alert for evidence that their manipulations might be beneficial in conditions not directly related to the spine. There is some evidence (from [[case studies]]) that in some cases they do have benefits, but this evidence is generally regarded as weak because it may be influenced by the beliefs and expectations of the patient and the practitioner, and improvements after treatment may be coincidental instead of causally related.<ref>Scientifically, evidence is regarded as ''validated'' only if evidence leads to an objective protocol for intervention with objectively verifiable efficacy</ref>.  
===Evidence standards in chiropractic===
Some critics, and indeed some of the leaders of the chiropractic profession, have warned about the over-willingness of chiropractors to accept anecdotal evidence of the efficacy of chiropractic.
<ref>[http://www.worldchiropracticalliance.org/tcj/1996/may/may1996kent.htm Critical thinking]
:Christopher Kent, president of the [http://www.ccp-guidelines.org/ Council on Chiropractic Practice], advises his colleagues of the importance of high standards of evidence </ref>, while on the other hand, when adverse events are associated with chiropractic manipulations (for instance when a patient has a stroke soon after a spinal adjustment) chiropractors are too ready to dismiss the adverse event as “unrelated". In short, the criticism is that many chiropractors are too ready to embrace evidence that is supportive of chiropractic, however weak it may be, and too quick to denounce evidence of its risks unless the evidence is overwhelming. In both cases, the scientific view would advise caution in interpretation and careful further investigation under controlled conditions.


Joseph Keating, professor at the [http://www.scuhs.edu/ Los Angeles College of Chiropractic] and a prominent [http://www.chiro.org/Plus/History/ historian of chiropractic] has written extensively both to criticise weaknesses in the arguments used by chiropractors, and to denounce disreputable practices within the profession. In 1997, he described chiropractic as a 'science, antiscience and pseudoscience', and said "Although available scientific data support chiropractic's principle intervention method (the manipulation of patients with lower back pain), the doubting, skeptical attitudes of science do not predominate in chiropractic education or among practitioners". <ref>Keating JC (1997) [http://www.findarticles.com/p/articles/mi_m2843/is_n4_v21/ai_19727577/print]</ref> He argued that chiropractic's culture has nurtured antiscientific attitudes and activities, and that "a combination of uncritical rationalism and uncritical empiricism has been bolstered by the proliferation of pseudoscience journals of chiropractic wherein poor quality research and exuberant over-interpretation of results masquerade as science and provide false confidence about the value of various chiropractic techniques".  
Several concepts used by chiropractors are not used in the health sciences; in particular, the concepts of 'vertebral subluxation' and 'Innate Intelligence'. Some chiropractors recognise that these concepts are impediments to better integration with the Health Sciences, and for example, Ronald Carter, a former President of the Canadian Chiropractic Association, proposed that the [[Vertebral subluxation| "subluxation story"]] should be abandoned, suggesting that it is time for the 'silent majority' to present a rational model of chiropractic so that it can become an essential member of the health care team.<ref>[http://www.jcca-online.org/client/cca/JCCA.nsf/objects/Commentary:+Subluxation-the+silent+killer/$file/2-commentary.pdf Subluxation - The Silent Killer]  
:Keating JC [http://www.sherman.edu/research/rsch510/FaultyLogic-in-Chiro.pdf Faulty Logic and Non-skeptical Arguments in Chiropractic (pdf)]  
:Keating JC ''et al.'' (2005) Subluxation: dogma or science? Chiropr Osteopat 13:17 PMID 16092955</ref> Other chiropractors have gone further, Samuel Homola, an outspoken dissident within the profession, has argued that evidence-based chiropractic is the only way forward for chiropractors to gain greater acceptance by conventional medicine.<ref>Homola S [http://jmmtonline.com/documents/HomolaV14N2E.pdf Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor]. Homola's book [http://www.chirobase.org/05RB/BCC/00c.html ''Chiropractic, Bonesetting, and Cultism''], published in 1964, contains trenchant criticism of the profession, and the following year Homola's application to renew his membership of the American Chiropractic Association (ACA) was rejected. In 1991, David Redding, chairman of the ACA board of governors, welcomed Homola back to the ACA, and in 1994, 30 years after its publication, the book was reviewed for the first time in a chiropractic journal[http://www.chiroweb.com/archives/08/01/17.html].</ref> Homola's views however represent those of only very few chiropractors.


However, in 1998, after reviewing the articles published in the ''Journal of Manipulative and Physical Therapy'' (JMPT) from 1989-1996, Keating concluded that "substantial increases in scholarly activities within the chiropractic profession are suggested by the growth in scholarly products published in the discipline's most distinguished periodical (''JMPT''). Increases in controlled outcome studies, collaboration among chiropractic institutions, contributions from nonchiropractors, contributions from nonchiropractic institutions and funding for research suggest a degree of professional maturation and growing interest in the content of the discipline."
For scientifically-minded physicians, the lack of proof that nerve conduction is actually affected by chiropractic manipulation means that D.D. Palmer's theories remain speculative. Chiropractors  believe that their own experience of the efficacy of chiropractic for their patients is sufficient justification for retaining Palmer's explanations. Some chiropractors also believe that retaining these concepts are important for the future of Chiropractic as a viable, independent profession, believing that this will ensure that Medicine will not absorb chiropractic.
<ref>:{{cite journal | author = Keating JC ''et al.'' | title = A descriptive analysis of the Journal of Manipulative and Physiological Therapeutics, 1989-1996 | journal = J Manip Physiol Ther | volume = 21 |  pages = 539-52 | year = 1998 | id = PMID 9798183}}</ref> However the JMPT remains the only chiropractic research journal that is recognized by the NIH Library of Medicine, and the only one indexed in Index Medicus.


===Scientific foundations of chiropractic===
Chiropractors also feel that criticism of the scientific basis of their treatments smacks of 'double standards', and feel that scientific evaluation of treatment interventions are similarly lacking in many areas of care that are fully accepted by Medicine. They believe that family doctors do ''not'' routinely investigate the causal basis of their patients' symptoms, but usually prescribe treatments based on their clinical experience of what has been effective in similar cases in the past - just as chiropractors do.
Several concepts used by chiropractors are not used in the conventional health sciences; in particular, the chiropractic concepts of [[vertebral subluxation]] and [[innate intelligence]]. Some leaders of the chiropractic profession have recognised that these concepts are impediments to greater integration of chiropractic and healthsciences, and have urged the community to abandon them. For example, Ronald Carter, Past President of the Canadian Chiropractic Association, proposed that the [[Vertebral subluxation| "subluxation story"]] should be abandoned rather than simply re-packaged. He suggested that it is time for the 'silent majority' to present a rational model of chiropractic so that it can become an essential member of the health care team.
<ref>[http://www.jcca-online.org/client/cca/JCCA.nsf/objects/Commentary:+Subluxation-the+silent+killer/$file/2-commentary.pdf Subluxation - The Silent Killer]
:Keating JC [http://www.sherman.edu/research/rsch510/FaultyLogic-in-Chiro.pdf Faulty Logic and Non-skeptical Arguments in Chiropractic (pdf)] (Keating distinguishes between sound and unsound arguments in support of chiropractic.)
:Keating JC ''et al.'' (2005) Subluxation: dogma or science? Chiropr Osteopat 13:17 PMID 16092955  ("We lament efforts to generate unity within the profession through consensus statements concerning subluxation dogma, and believe that cultural authority will continue to elude us so long")</ref>


Other chiropractors have gone further, Samuel Homola, a second generation chiropractor who has been an outspoken dissident within the profession, has argued that evidence-based chiropractic is the only way forward for chiropractic to gain greater acceptance by conventional medicine.<ref>Homola S [http://jmmtonline.com/documents/HomolaV14N2E.pdf Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor]. Homola's book [http://www.chirobase.org/05RB/BCC/00c.html ''Chiropractic, Bonesetting, and Cultism''], published in 1964, contains trenchant criticism of the profession, and the following year Homola's application to renew his membership of the American Chiropractic Association (ACA) was rejected. In 1991, David Redding, chairman of the ACA board of governors, welcomed Homola back to the ACA. In 1994, 30 years after its publication, the book was reviewed for the first time in a chiropractic journal[http://www.chiroweb.com/archives/08/01/17.html].</ref> Homola,s views however represent those of only a small minority of chiropractors.
==Vaccination==
<blockquote>''Some critics claim that some chiropractors advise parents that ''all'' vaccinations have higher risks and less benefit than any organized health science or biological science group accepts, thus exposing children to the risk of preventable illnesses and putting the general population at risk of epidemics. ''</blockquote>


===Vaccination===
Efforts by the chiropractic profession to dissuade people from accepting the polio vaccine in the 1950's and 1960's in the USA sparked much of the resentment towards chiropractic that spawned the AMA lawsuit, and which still hinders chiropractic from being accepted as a member of the health sciences. Even today, some chiropractors believe that there is a link between [[autism]] and additives in [[Vaccination|vaccines]] on the basis of early studies that have been extensively criticised, and despite evidence from large well-controlled studies showing no such link.[http://www.cdc.gov/nip/vacsafe/concerns/autism/autism-mmr.htm] A survey in the Canadian Province of [[Alberta]] found that 27% of chiropractors advised their patients against having themselves or their children immunized (about the same proportion as advised in favour of [[Vaccination|immunization]]).<ref>Russell ML ''et al.'' (2004) Beliefs and behaviours: understanding chiropractors and immunization. Vaccine 23:372-9 PMID 15530683 ; figures are for survey respondents only</ref>  
Despite overwhelming evidence that vaccination is a highly effective way of controlling infectious diseases, many chiropractors are opposed to vaccination. For example, a survey in the Canadian Province of Alberta found that 27% of the chiropractors who completed the survey advised their patients against having themselves or their children immunized (about the same proportion as advised in favour of [[immunization]]). <ref>Russell ML ''et al.'' (2004) Beliefs and behaviours: understanding chiropractors and immunization. Vaccine 23:372-9 PMID 15530683 </ref>  


In line with a general philosophy of chiropractic to avoid medicines and drugs, 'traditional straight' chiropractors are opposed to childhood vaccination. Their main association, the International Chiropractors Association (ICA), is "supportive of a conscience clause or waiver in compulsory vaccination laws, providing an elective course of action for all regarding immunization, thereby allowing patients freedom of choice in matters affecting their bodies and health." The American Chiropractic Association (ACA) [http://www.amerchiro.org/level2_css.cfm?T1ID=10&T2ID=117] and the World Chiropractic Alliance (WCA)[http://www.worldchiropracticalliance.org/Positions/vaccines.htm] have adopted very similar positions.  
In line with a general philosophy to avoid medicines and drugs, 'traditional straight' chiropractors are opposed to compulsory childhood vaccination. Their main association, the International Chiropractors Association (ICA), supports a "conscience clause or waiver in compulsory vaccination laws, providing an elective course of action for all regarding immunization, thereby allowing patients freedom of choice in matters affecting their bodies and health." The [[American Chiropractic Association]] (ACA) [http://www.amerchiro.org/level2_css.cfm?T1ID=10&T2ID=117] and the World Chiropractic Alliance (WCA)[http://www.worldchiropracticalliance.org/Positions/vaccines.htm] have adopted very similar positions.  


Although personal choice seems innocuous to those who are not intimately familiar with the biology of vaccination, unless very few people elect out of universal vaccination there are [[Public Health]] consequences. For vaccination to be effective as a way of controlling infectious disease spread between people, there must be at a very high immunity rate in the population (typically 85% or higher). If too many individuals are unvaccinated, then there is a real risk of an outbreak of disease, and because vaccination is never 100% effective, this puts at risk not only those who are unvaccinated, but also those who have already accepted the risk of vaccination for the greater good. <ref>
While 'freedom of choice' seems innocuous to those who are unfamiliar with the biology of vaccination, to scientists and physicians there are [[Public Health|public health]] consequences if more than a very few people opt out of universal vaccination. For vaccination to be effective in controlling infectious diseases that spread from person to person, there must be a very high immunity rate in the population (typically 85% or higher). If too many people are unvaccinated, then there is a real risk of an outbreak of disease, and because vaccination is never 100% effective, this puts at risk not only people who are unvaccinated, but also people who have already accepted the risk of vaccination for the greater good.<ref>
Bradley P (1999) Should childhood immunisation be compulsory? J Med Ethics 25:330-334</ref> Because of this, the policy has to be compulsory to be fair, otherwise a few who avoid vaccination gain benefits at the expense of the majority. Accordingly, many scientific and medical organisations have strongly and publicly supported policies of compulsory vaccination and consider it irresponsible for organisations like the ICA and ACA not to do do likewise.<ref>'''Chiropractic and vaccination'''
Bradley P (1999) Should childhood immunisation be compulsory? J Med Ethics 25:330-334</ref> Because of this, the policy has to be compulsory to be fair, otherwise a few who avoid vaccination gain benefits at the expense of the majority. Accordingly, many scientific and medical organisations have strongly supported policies of compulsory vaccination and consider it irresponsible for organisations like the ICA and ACA not to do likewise.<ref>'''Chiropractic and vaccination'''
:Campbell JB ''et al'' (2000) Chiropractors and vaccination: A historical perspective. Pediatrics [http://pediatrics.aappublications.org/cgi/content/abstract/105/4/e43 105:e43]
:Campbell JB ''et al.'' (2000) Chiropractors and vaccination: A historical perspective. Pediatrics [http://pediatrics.aappublications.org/cgi/content/abstract/105/4/e43 105:e43]
:Busse JW ''et al'' (2002) Attitudes toward vaccination: a survey of Canadian chiropractic students. CMAJ [http://www.cmaj.ca/cgi/content/full/166/12/1531 166:]
:Busse JW ''et al.'' (2002) Attitudes toward vaccination: a survey of Canadian chiropractic students. CMAJ [http://www.cmaj.ca/cgi/content/full/166/12/1531 166:]
:Omer SB ''et al.'' (2006) Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence. JAMA 296:1757-63  PMID 17032989  
:Omer SB ''et al.'' (2006) Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence. JAMA 296:1757-63  PMID 17032989  
:Centers for Disease Control and Prevention (2006). Pertussis outbreak in an Amish community--Kent County, Delaware, September 2004-February 2005. MMWR - Morbidity & Mortality Weekly Report 55:817-21  PMID 16888610  
:Centers for Disease Control and Prevention (2006). Pertussis outbreak in an Amish community--Kent County, Delaware, September 2004-February 2005. MMWR - Morbidity & Mortality Weekly Report 55:817-21  PMID 16888610  
:Leon Jaroff (2005) [http://www.time.com/time/columnist/printout/0,8816,1069538,00.html Chiropractors v. Vaccination] ''Time'' magazine, 7th June  
:Leon Jaroff (2005) [http://www.time.com/time/columnist/printout/0,8816,1069538,00.html Chiropractors v. Vaccination] ''Time'' magazine, 7th June  
:Feikin DR ''et al.'' (2000) Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA 284:3145-50.
:Feikin DR ''et al.'' (2000) Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA 284:3145-50  
:Grod JP, Sikorski D, Keating JC, Jr. (2001) Unsubstantiated claims in patient brochures from the largest state, provincial, and national chiropractic associations and research agencies. J Manip Physiol Ther 24:514-9  PMID 11677551
:Grod JP, Sikorski D, Keating JC, Jr (2001) Unsubstantiated claims in patient brochures from the largest state, provincial, and national chiropractic associations and research agencies. J Manip Physiol Ther 24:514-9  PMID 11677551
:Sikorski D, Grod JP, Keating JC, Jr. (2002) The unsubstantiated website claims of chiropractic colleges in Canada and the United States. J Chiropr Edu 16:95-6.
:Sikorski D ''et al.'' (2002) The unsubstantiated website claims of chiropractic colleges in Canada and the United States. J Chiropr Edu 16:95-6.
:Busse JW ''et al.'' (2005) Chiropractic antivaccination arguments. J Manip Physiol Therap 28:367-73  PMID 1744481  
:Busse JW ''et al.'' (2005) Chiropractic antivaccination arguments. J Manip Physiol Therap 28:367-73  PMID 1744481  
</ref>
</ref>


Those chiropractors who ''do'' advise against vaccination are not convinced that the evidence for its effectiveness outweighs the possible risks to an individual. When new vaccines are introduced to protect against relatively rare conditions, the balance of benefits and risks is much harder to establish, particularly because the risks are uncertain without extensive experience over a prolonged period. Such skepticism is not restricted to chiropractic; what is particular to chiropractic is a belief by some that chiropractic offers a feasible alternative to vaccination. It is not clear how common such beliefs are amongst chiropractors, but they have been expressed (for example) by the WCA. In Canada, chiropractors have been formally prevented from advising against vaccination.
Those chiropractors who advise against certain vaccinations are not convinced that evidence for its benefits always outweighs the risks to an individual. Many chiropractors support immunization for life-threatening diseases such as [[polio]] or [[diphtheria]], but some think that, when new vaccines are introduced to protect against relatively benign conditions such as chicken pox, the balance of benefits and risks is less clear. Because chicken pox carries a relatively small risk of death or disability, the possible risks of vaccination might outweigh the benefits, and they believe that the principle of informed consent should apply, giving the individual the right to make the choice for themselves. Such skepticism is not restricted to chiropractic, but as a healthcare profession, this position has greater implications in the fields of public health.  


Some chiropractors are speaking out against anti-vaccination views. For example, writing in ''Dynamic Chiropractor'', Stephen Perle and Randy Ferrance harshly criticise anti-vaccination chiropractors<ref>Perle S, Ferrence R (2005) [http://www.chiroweb.com/archives/23/04/13.html What's Good for the Goose Is ... Ethics and Vaccinations]. Dynamic Chiropractor, Volume 23, Issue 4</ref>: "We are not aware," they write, "of a single well-controlled study which found that chiropractic care prevented any infectious disease or reduced the severity of such a disease."  They declare that it is dishonest of chiropractors to warn their patients about the danger of vaccinations without advising them of their benefits, and endorse the guidance of the College of Chiropractors of Ontario, which states, in its "Standard of Practice", that "Chiropractors may not, in their professional capacity express views about immunization/vaccination as it is outside their scope of practice."<ref> [http://www.cco.on.ca/standard_of_practice_s-015.htm Immunization/Vaccination Standard of Practice S-015] (2004) by the Executive Committee and Quality Assurance Committee of the College of Chiropractors of Ontario</ref>
Other chiropractors hold views in line with those of physicians and public health officials, and have spoken out against chiropractic policies that they feel don't do enough to oppose anti-vaccination efforts. Writing in ''Dynamic Chiropractor'', Stephen Perle and Randy Ferrance<ref>Perle S, Ferrence R (2005) [http://www.chiroweb.com/archives/23/04/13.html What's Good for the Goose Is ... Ethics and Vaccinations]. Dynamic Chiropractor, Volume 23, Issue 4</ref>: say they are not aware "of a single well-controlled study which found that chiropractic care prevented any infectious disease or reduced the severity of such a disease."  They declare that it is dishonest of chiropractors to warn their patients about the danger of vaccinations without advising them of their benefits, and endorse the guidance of the College of Chiropractors of Ontario, which states that "chiropractors may not, in their professional capacity express views about immunization/vaccination as it is outside their scope of practice."<ref> [http://www.cco.on.ca/standard_of_practice_s-015.htm Immunization/Vaccination Standard of Practice S-015] (2004) by the Executive Committee and Quality Assurance Committee of the College of Chiropractors of Ontario</ref> In Canada, chiropractors have been formally prevented from advising against vaccination.


==Limited v Unlimited Provision of healthcare==
==Limited versus unlimited provision of healthcare==
:''It wasn't so long ago that a college president suggested, "Rigor mortis is the only thing we can't help!"'' Joseph Keating, chiropractic historian.<ref>Joseph Keating Jr (1994) [http://www.chiroweb.com/archives/print_friendly.php?volume=12&amp;issue=06&amp;issue_date=March%2011%2C%201994&amp;pr_file_name=http%3A%2F%2Fwww.chiroweb.com%2Farchives%2F12%2F06%2F16.html Ivory Tower Review: The "20/20" Expose] Dynamic Chiropractic, Volume 12, Issue 6, Hosted by chiroweb.com</ref>
<blockquote>''Some critics argue that chiropractic's claims for health benefits beyond certain musculoskeletal complaints are not warranted.''<ref>''It wasn't so long ago that a college president suggested, "Rigor mortis is the only thing we can't help!"'' Joseph Keating Jr (1994) [http://www.chiroweb.com/archives/print_friendly.php?volume=12&amp;issue=06&amp;issue_date=March%2011%2C%201994&amp;pr_file_name=http%3A%2F%2Fwww.chiroweb.com%2Farchives%2F12%2F06%2F16.html Ivory Tower Review: The "20/20" Expose] Dynamic Chiropractic, Volume 12, Issue 6, Hosted by chiroweb.com </ref></blockquote>  
:''A chiropractor is a cultist -- in the medical sense, a person who assumes all disease stems from one cause or can be cured by a single method. According to the chiropractor, there is one common denominator in all disease-nerve interference; and one panacea for every ailment -- the spinal "adjustment" that removes such interference.'' Kathleen Cassidy Doyle, cited by Samuel Homola<ref>the Public Affairs Pamphlet, "Science vs Chiropractic," by Kathleen Cassidy Doyle, of the Public Affairs Committee of New York, cited by Samuel Homola in [http://www.chirobase.org/05RB/BCC/00c.html Chiropractic, Bonesetting, and Cultism]</ref>


Many physicians are concerned about all treatments that have no established scientific basis or clearly validated evidence of efficacy, feeling there is a risk that ineffective treatments might delay more appropriate medical treatment. In 1998, the American Medical Association (AMA) published a report on "Alternative Medicine".<ref>[http://www.ama-assn.org/ama/pub/category/13638.html Alternative Medicine,] Report 12 of the AMA Council on Scientific Affairs (A-97)</ref> Referring to chiropractic, this stated that manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints, and that some chiropractors limit their practices to these conditions. The report also acknowledged that, in a national survey of referral patterns by board-certified family physicians and internists, 47% said they would refer patients for chiropractic treatment. However, the AMA Report also suggests that most chiropractors continue to claim that chiropractic manipulation cures disease rather than simply relieving symptoms. "They promote manipulation as useful in a host of conditions, ranging from infectious diseases to immune therapy, even claiming to prevent future conditions from occurring (even if years away) including menstrual irregularity, difficulty giving birth, and cancer. Chiropractors commonly provide advice in nutrition and other preventive practices, and maintain that a regular series of "adjustments" is needed by most persons to maintain optimal health." In 1997, the AMA adopted as a statement of Policy that "Patients who choose alternative therapies should be educated as to the hazards that might result from postponing or stopping conventional medical treatment."
The sharpest criticism from the health sciences has been mainly about the ''extent'' of chiropractic practice (the range of conditions for which chiropractors offer treatment), and about advice that chiropractors give against standard medical treatments. These are mainly aimed at those chiropractors who follow the traditional ideas of chiropractic as an unlimited healing art, and who most aggressively market the profession as a general alternative to the health sciences. Currently, that traditional "straight chiropractic" philosophy is best represented in the USA. There is concern that many chiropractors promote popular beliefs that critics claim are outside their scope of practice and professional knowledge, and which are rejected by mainstream science and medicine. Chiropractic is effective in some musculoskeletal conditions, but critics claim that this is unreasonably generalized to "musculoskeletal conditions", a phrase without specific meaning that does not include the conditions, such as myasthenia gravis, multiple sclerosis, or rheumatoid arthritis, that any reasonably knowledgeable layman might assume to be such a condition.  


[[Pediatrician]]s are especially concerned about the use of chiropractic care for infants and children, not only because of the unknown risks associated with the treatments, but they fear parents unknowingly risk their children's lives by not having them evaluated by a physician properly trained in childhood diseases in a timely manner. Chiropractic treatment of [[infantile colic]], [[Otitis Media|otitis media]], "excessive crying" and issues relating to [[vaccination]] are common points of contention.
Many physicians are concerned about ''all'' treatments that have no accepted scientific basis or validated evidence of efficacy, because ineffective treatments might delay more appropriate treatment. In 1998, the AMA published a report on "Alternative Medicine".<ref>[http://www.ama-assn.org/ama/pub/category/13638.html Alternative Medicine,] Report 12 of the AMA Council on Scientific Affairs (A-97)</ref> About chiropractic, it stated that manipulation has reasonably good efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints, that some chiropractors limit their practices to these conditions, and that, in a national survey of family physicians and internists, 47% said they would refer patients for chiropractic treatment. However, the Report also said that most chiropractors "promote manipulation as useful in a host of conditions, ranging from infectious diseases to immune therapy, even claiming to prevent future conditions from occurring (even if years away) including menstrual irregularity, difficulty giving birth, and cancer. A common criticism of chiropractors has been the willingness of some to treat conditions where there is no ''validated basis'' for believing chiropractic to be effective, especially conditions that might be life-altering without concurrent medical care.  Chiropractors commonly provide advice in nutrition and other preventive practices, and maintain that a regular series of 'adjustments' is needed by most persons to maintain optimal health." In 1997, the AMA as a statement of Policy, said that "Patients who choose alternative therapies should be educated as to the hazards that might result from postponing or stopping conventional medical treatment."


===Infantile colic===
[[Pediatrician]]s are especially concerned about chiropractic treatment of children, not only because of the unknown risks of treatment,<ref>See Vohra S ''et al.'' (2007) Adverse events associated with pediatric spinal manipulation: a systematic review. Pediatrics. 119:e275-83  PMID 17178922 and see[http://www.icpa4kids.com/research/ICPA_AAP_Article.htm.] for a response from the International Chiropractic Pediatric Association.</ref> but also because they fear that parents may be risking their children's health by not having them seen by a physician who is properly trained in childhood diseases in a timely manner. Chiropractic treatment of [[infantile colic]], [[Otitis Media|otitis media]], "excessive crying", or [[Attention Deficit Hyperactivity Disorder]] are common points of contention.
For example, [[Baby colic|infantile colic]] is a condition characterised by uncontrollable crying in infants with no clear cause: some reports suggest that chiropractic is efficacious, others do not. Chiropractic is also used to treat asthma; and can be efficacious, but probably no more so than placebo treatment. Placebo effects can be very powerful, indicating the important ability of the mind to contribute to healing, and in some cases chiropractic might be efficacious because it exploits the placebo effect in an efficient way. Chiropractors believe that any treatment that results in less dependence on medication has value, even if it might only be effective because of the reassuring and calming effect on the mother and/or child.<ref>'''Infantile colic'''
 
Infantile colic is a condition characterised by uncontrollable crying in infants with no clear cause: some reports suggest that chiropractic is efficacious, others do not. Chiropractors believe that any treatment that results in using less medication has value, even if it might be effective only because of its reassuring and calming effect on the mother and/or child.<ref>'''Infantile colic'''
:Wiberg JMM ''et al.'' (1999) The short-term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled clinical trial with a blinded observer. J Manip Physiol Ther 22:517-22  PMID 10543581
:Wiberg JMM ''et al.'' (1999) The short-term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled clinical trial with a blinded observer. J Manip Physiol Ther 22:517-22  PMID 10543581
:Sampler S, Lucassen P (2003), [http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004796/frame.html Chiropractic for infantile colic. (Protocol)] ''The Cochrane Database of Systematic Reviews'' Issue 4.  Article No. CD004796. DOI: 10.1002/14651858.CD004796.
:Sampler S, Lucassen P (2003), [http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004796/frame.html Chiropractic for infantile colic. (Protocol)] ''The Cochrane Database of Systematic Reviews'' Issue 4.  Article No. CD004796. DOI: 10.1002/14651858.CD004796.
:EBSCO Complementary and Alternative Medicine Review Board [http://healthlibrary.epnet.com/GetContent.aspx?token=2ef1fb8a-dd34-47b2-8333-a311f8b76703...&chunkiid=37431]</ref>
:EBSCO Complementary and Alternative Medicine Review Board [http://healthlibrary.epnet.com/GetContent.aspx?token=2ef1fb8a-dd34-47b2-8333-a311f8b76703...&chunkiid=37431]</ref>
===Otitis media===
 
Otitis media in infants is another condition that some chiropractors claim to manage efficiently.<ref>[http://www.icpa4kids.org/research/chiropractic/ear.htm  Synopsis of research papers] on chiropractic treatment of ear infection (''otitis media''). Hosted by ICPA Research Foundation. The papers include:
Otitis media in infants is another condition that some chiropractors claim to manage efficiently.<ref>[http://www.icpa4kids.org/research/chiropractic/ear.htm  Synopsis of research papers] on chiropractic treatment of ear infection (''otitis media''). Hosted by ICPA Research Foundation. The papers include:
:Froehle RM (1996) Ear infection: a retrospective study examining improvement from chiropractic care and analyzing for influencing factors. J Manip Physiol Ther 19:169-77.  PMID 8728460 (<small>"Although there were several limitations to this study ... this study's data indicate that limitation of medical intervention and the addition of chiropractic care may decrease the symptoms of ear infection in young children."</small>)
:Froehle RM (1996) Ear infection: a retrospective study examining improvement from chiropractic care and analyzing for influencing factors. J Manip Physiol Ther 19:169-77.  PMID 8728460 (<small>"Although there were several limitations to this study ... this study's data indicate that limitation of medical intervention and the addition of chiropractic care may decrease the symptoms of ear infection in young children."</small>)
:Fallon JM (1997) [http://www.chiro.org/pediatrics/ABSTRACTS/Children_with_Otitis.shtml The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media.] J Clin Chiro Pediatrics 2:167-83. (<small>"The results indicate that there is a strong correlation between the chiropractic adjustment and the resolution of otitis media for the children in this study." </small>)</ref> In the past, antibiotics were the treatment of choice, but recent studies suggest that waiting as long as three days before beginning a regimen could save as many as 30% from unnecessary exposure to antibiotics.<ref>American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. (2004) Diagnosis and Management of Acute Otitis Media. Pediatrics,  Available online at [http://aappolicy.aappublications.org/cgi/content/full/pediatrics;113/5/1451 113:1451-65].These guidelines specify that the diagnosis of acute otitis media is accurately and professionally made, pain is adequately treated, and follow-up and further medical or surgical treatment, if needed, can be assured and will be prompt. It is unclear whether chiropractors are qualified to meet these criteria.</ref> Chiropractors, who also have training in physical examination, believe that they have an important 'watchful waiting' role in monitoring otitis media. However, many physicians feel that, even if chiropractic treatment of such conditions has some benefits by exploiting the placebo effect, there is a risk that false reassurance delays more appropriate medical treatment and that chiropractors, unlike pediatricians and primary care physicians, do not have the examining skills required to know when referral to a specialist in Ear, Nose and Throat ([[Otolaryngology]]) is required to prevent permanent hearing loss or complications such as [[brain abscess]].
:Fallon JM (1997) [http://www.chiro.org/pediatrics/ABSTRACTS/Children_with_Otitis.shtml The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media.] J Clin Chiro Pediatrics 2:167-83. (<small>"The results indicate that there is a strong correlation between the chiropractic adjustment and the resolution of otitis media for the children in this study." </small>)</ref> In the past, antibiotics were the treatment of choice, but recent studies suggest that waiting three days before beginning a regimen could save as many as 30% from unnecessary exposure to antibiotics.<ref>American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media (2004) Diagnosis and management of acute otitis media. Pediatrics   [http://aappolicy.aappublications.org/cgi/content/full/pediatrics;113/5/1451 113:1451-65]. The guidelines specify that the diagnosis of acute otitis media is made accurately and professionally, that pain is adequately treated, and that further medical or surgical treatment, if needed, will be prompt. It is unclear whether chiropractors are qualified to meet these criteria.</ref> Chiropractors believe that they have an important 'watchful waiting' role in monitoring otitis media. However, many physicians feel that, even if chiropractic treatment of such conditions has some benefits by exploiting the placebo effect, there is a risk that false reassurance delays more appropriate medical treatment and that chiropractors, unlike pediatricians and primary care physicians, do not have the examining skills to know when referral to a specialist in Ear, Nose and Throat ([[Otolaryngology]]) is required to prevent permanent hearing loss or complications such as [[brain abscess]]. Chiropractors argue that their [[Chiropractic education|education]] in physical examination is equivalent to that in the health sciences, and so consider this concern unwarranted.


===Drugless stance on healing===
==Competence==
Although the practice of chiropractic has changed considerably since its inception, most chiropractors continue to take a drugless approach to healing. Physicians remain concerned that this position can mislead some patients into thinking that all drugs are unnecessary or even harmful, and to overestimate the body's intrinsic ability to remain healthy. They fear that some patients with serious conditions that can be treated effectively with medications may be led to not take potentially life-saving treatments, such as [[insulin]], blood pressure regulators, and cholesterol lowering drugs. They are also concerned that patients may even forego laboratory tests such as colonoscopies and physicals that can "catch" some cancers while they are still treatable.
<blockquote>''Some critics claim that chiropractors are not trained to diagnose medical diseases and so are not competent to act as comprehensive primary care health care providers''</blockquote>


Physicians and health science professionals have also expressed a belief that "drugless healing" is a marketing strategy by chiropractors, that allows a niche in the health care industry to be exploited. These critics point out that many chiropractors sell food and vitamin supplements as an active business arm of practice.
While chiropractors have shown to be as or more competent than their medical counterparts in the musculoskeletal arena, physicians are concerned when claims are made that chiropractors are primary care providers, a term used to describe entry level physicians or general practitioners. Today's chiropractor has completed courses in medical diagnosis and patient management designed to allow them to assess patients at the entry level and make appropriate decisions for treatment or referral. Some chiropractors have hospital privileges, while others are involved in integrated healthcare environments that employ the skills of all branches of healthcare, but most are sole practitioners in the primary care role. With the advent of [[Health Maintenance Organizations]] (HMOs), most third party payors consider chiropractic as a specialty field that may be considered a ''portal of entry'' (not requiring a referral from a physician) for musculoskeletal conditions. Most chiropractors consider themselves well prepared as [[primary care providers]].


==The chiropractic perspective==
==Advertising==
Because they feel that healing comes from within the body, chiropractors don't talk of 'cure', but of 'helping the body cure itself'. As a result, the traditional chiropractor sees all who suffer as in need of his or her help. The degree to which they claim to be able to help varies, not only from condition to condition but also from case to case, and also because different chiropractors use different techniques. The spinal cord does carry a vast amount of information from peripheral organs and tissues to the brain, including sensations of [[nociceptors| pain]], [[mechanoreceptors| touch]], [[thermoreceptors| temperature]]. In addition, virtually every organ and its blood supply is regulated both directly by efferent nerves, many of which travel down the spinal cord, and indirectly by [[neuroendocrinology| neuroendocrine]] regulation of [[hormone]] secretion. Accordingly, disruption of spinal information flow can influence virtually every organ system. However it is not clear that any particular organ dysfunction is caused by a disorder of spinally-mediated information transfer, or whether manipulation by chiropractors could correct such a disorder, and scientists and physicians generally are skeptical about these possibilities.
<blockquote>''Some critics claim that chiropractic accepts a level of self-promotion in advertising that is unprofessional and misleading.''<ref> JC Smith (1999)[http://www.journalchirohumanities.com/volumes/vol_9/pdfs/SmithComtemp.pdf Chiropractic Ethics: An Oxymoron?] (ethical issues are "in dire need of debate" because of "years of intense medical misinformation/slander" and because of well-publicised examples of tacky advertising, outlandish claims, sensationalism and insurance fraud.)
:Joseph Keating Jr (1991) [http://www.chiroweb.com/archives/09/04/35.html Quackery in Chiropractic.] Dynamic Chiropractic, Volume 9, Issue 4 (Keating discusses his concerns for advertising products before they are scientifically evaluated.)</ref> </blockquote>


Since the original observations of DD Palmer, chiropractors have been alert for evidence that their manipulations might have such beneficial effects. There is evidence (from [[case studies]]) that they can, but this evidence is generally regarded as weak because it may be influenced by the prior beliefs and expectations of the patient and the practitioner, and may be coincidental instead of causally related. Only if it leads to an objective protocol for intervention with objectively verifiable efficacy can it be regarded as validated. A common criticism of chiropractors has been the apparent willingness of some to offer treatment for conditions where there is no validated basis, especially those that might be life-altering without concurrent medical care.  
In 1992, attorney George McAndrews, who represented the plaintiffs in the [[Wilk ''et al.'' vs AMA]] court case, wrote an open letter to the chiropractic profession warning that 'scare tactic' advertising damages the newly won respect within the AMA.<ref> [http://www.chiroweb.com/archives/10/07/16.html Open Letter to the Profession] (See [http://www.chiroweb.com/archives/10/20/21.html here] for commentary.)</ref>


Some chiropractors nevertheless believe that several conditions ''can'' indeed be resolved by chiropractic interventions. Such beliefs are based on their clinical experience, not on firm scientific evidence from large controlled trials, and not on any scientific demonstration of a causal mechanism linking the intervention to its claimed effect. It is possible that cases that have not responded to conventional treatment might include some where the underlying cause is indeed a disorder of neural regulation of an organ system, as the failure of conventional treatment might be taken as excluding more common causes of dysfunction, such as infectious disease. It is also possible that a symptom apparently of an organ disease is actually the result of a somatic reflex pain generated from the spine. Thus, if an organ-related complaint responds to chiropractic adjustments, it is possible that a spinal condition was the cause of the problem in the first place. <ref>Nansel D, Szlazak M (1995) Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manip Physiol Ther 18:379-97 PMID 7595111</ref>
For most of the 20th century, physicians in the USA disdained advertising as unethical and unprofessional. Chiropractors, on the other hand, enthusiastically embraced advertising and, being outside the organisational components of referral mechanisms found in medicine, considered this an acceptable option. More recently, the formal sanction against physician advertisements has been lifted, and advertisements for such services as [[Cosmetic surgery]] and drugs are now common in the USA.


==Advertising==
==Safety and consent==
Excessive advertising claims for the efficacy of chiropractic have been criticised frequently. <ref> JC Smith (1999)[http://www.journalchirohumanities.com/volumes/vol_9/pdfs/SmithComtemp.pdf Chiropractic Ethics: An Oxymoron?] (ethical issues are "in dire need of debate" because of "years of intense medical misinformation/slander" and because of well-publicised examples of tacky advertising, outlandish claims, sensationalism and insurance fraud.)
Critics of chiropractic have expressed doubt about the safety of chiropractic. This includes doubt over the repeated exposure of chiropractic patients to X-rays based on the scientifically dubious theory of subluxations, the risk of fracture and dislocation, and the risk of vertebral artery dissection. Manipulation of the neck can lead to strain on the vertebral artery, and critics point to people who have had serious injuries and death resulting from chiropractic neck manipulation.<ref>Samuel Homola, [http://www.quackwatch.com/01QuackeryRelatedTopics/chiroeval.html Chriopractic: Does the Bad Outweigh the Good?], Quackwatch</ref>  
:Joseph Keating Jr (1991) [http://www.chiroweb.com/archives/09/04/35.html Quackery in Chiropractic.] Dynamic Chiropractic, Volume 9, Issue 4 (Keating discusses his concerns for advertising products before they are scientifically evaluated.)</ref>


In 1992, attorney George McAndrews, who represented the plainiffs in the [[Wilk ''et al.'' vs AMA]] court case, wrote an open letter to the chiropractic profession warning that 'scare tactic' advertising damages the newly won respect within the AMA. <ref> [http://www.chiroweb.com/archives/10/07/16.html Open Letter to the Profession] (See [http://www.chiroweb.com/archives/10/20/21.html here] for commentary.)</ref>
In ''Trick or Treatment'', a book by [[Simon Singh]] and [[Edzard Ernst]], the case of Laurie Mathiason, a Canadian woman who died following chiropractic neck manipulation, is presented along with legal findings regarding the culpability of the chiropractor involved. A number of other cases are listed from Canada, and Canadian research is presented which the authors claim implies that chiropractic treatment can increase the risk of arterial damage by a factor of five<ref>Edzard Ernst and Simon Singh, ''Trick or Treatment: Alternative Medicine on trial'', Corgi Books, ISBN: 978-0-552-15762-9</ref>. Based on this, Singh and Ernst raise questions about whether or not chiropractors are adequately abiding by the requirements of informed consent that are present in most nation's health regulatory frameworks. They point to a study of British chiropractors published in 2005 on their approach to consent policy which found that only 23% of chiropractors in Britain discuss potential serious side effects of chiropractic treatment - Singh and Ernst conclude that this is not sufficient either to meet the rules regarding consent set by the British government's Department of Health or the rules set out by the General Chiropractic Council in the UK.


However, the history of both professions in the USA is relevant in this regard. For most of the 20th century, physicians disdained advertising as both unethical and unprofessional. Chiropractors, on the other hand, enthusiastically embraced advertising. More recently, the formal sanction against physician advertisements has been lifted, and currently media advertisements for such services as [[Cosmetic surgery]] are common in the USA.
Contextually, the possible safety problems and shortcomings in informed consent procedure are particularly damaging as many chiropractors, as with many alternative medicine practitioners, are frequently critical of the side-effects of "established" or "mainstream" medicine.
<ref>Joseph Keating Jr (1991) [http://www.chiroweb.com/archives/09/04/35.html Quackery in Chiropractic.] Dynamic Chiropractic, Volume 9, Issue 4
::Keating discusses his concerns for advertising products before they are scientifically evaluated.</ref>


==Criticism from other professions, and public groups==
==Criticism from other professions, and public groups==
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Chiropractic has received its share of criticism from the health sciences, most particularly from physicians in the USA, where the practice of chiropractic has its largest base. Some of these criticisms have also been echoed within the chiropractic profession. This article discusses criticisms that have been expressed by notable sources, and includes the rebuttals of chiropractors to these views. Reporting a criticism, or its rebuttal, here, does not imply that either is endorsed by Citizendium or its editors.

Introduction

Critics from the medical establishment, especially in the USA, have claimed:

  • that an organized subgroup of chiropractors in the USA openly promote "drugless healing" as a business model of total health care, and even advocate expansion of market base into the care of the well child.
  • that chiropractic accepts too low a standard of academic and scientific scholarship in its professional journals and schools.
  • that chiropractic argues that such coursework in "medical diagnosis" qualifies its practitioners to be fully qualified to make medical evaluations, and to rule out signs of serious disease.
  • that the entire basis (vertebral subluxation) of chiropractic theory is not scientifically sound.
  • that some chiropractors advise parents that all vaccinations have higher risks and less benefit than any organized health science or biological science group accepts, thus exposing children to the risk of preventable illnesses and putting the general population at risk of epidemics. Worryingly, this subgroup is the same group that advocates chiropractic as comprehensive primary health care for children.
  • that, in the USA, chiropractors are not trained in medicine, nursing, or health science, and so are not competent to act as comprehensive primary health care providers, yet some subgroups of chiropractors make that claim, without protest by the larger profession.
  • that chiropractic accepts a general level of self-promotion in advertising that is unprofessional and misleading.
  • that while chiropractic has only been shown to be effective for backpain, and some types of headache, chiropractors advertise for and treat patients for non-musculoskeletal conditions like infant colic, none the less.
  • that the chiropractic profession promotes the notion that chiropractic is effective in "muscloskeletal conditions", when the evidence for relief of backpain does not in any way show that chiropractic care helps conditions such as myasthenia gravis, multiple sclerosis, or rheumatoid arthritis, or other serious and common conditions that a reasonably knowledgeable layman would assume to fall into the category of "musculoskeletal conditions"

History of antagonism between the AMA and chiropractic

In the 1960's, the American Medical Association (AMA) vehemently criticized chiropractic, and discouraged physicians from cooperating with chiropractors in patient treatment, research and educational activities such as sharing clinical research data. Chiropractors were denied access to hospital facilities, and, for instance, medical doctors were discouraged from aiding chiropractors in interpreting electrocardiograms. As a result, four chiropractors brought an antitrust case against the AMA and others, and in 1987 a Federal Judge ruled that the AMA was guilty of an illegal conspiracy to suppress competition. The judge said that the evidence at the trial showed that the AMA had taken “active steps, often covert, to undermine chiropractic educational institutions, conceal evidence of the usefulness of chiropractic care, undercut insurance programs for patients of chiropractic, subvert government inquiries into the efficacy of chiropractic, engage in a massive disinformation campaign to discredit and destabilise the chiropractic profession and engage in numerous other responses to maintain a physician monopoly over health care."[1]. Since then, there has been more co-operation between medical physicians and chiropractors in the USA, and many family doctors are willing to refer their patients on to chiropractors for certain conditions. However, there is still little evidence that mainstream medicine in the USA accepts chiropractic as a full partner in health care. Although physicians today acknowlege that business interests can distort their ideals of practice, academic physicians feel that any financial conflict of interest is beside the point. In university-based medicine, decades of effort have been devoted to upgrading medical practice and medical research, and in marshalling the medical profession towards more scientifically based practice. Their criticisms of the chiropractic profession are, they believe, made by the same criteria that have been used to transform American Medicine.

Interestingly, the editorial view of chiropractic from the health sciences, even in the USA, has also been complimentary, at least compared to other forms of alternative medicine. One authoritative medical textbook praises chiropractic (by comparison with other fields of alternative medicine) stating: "unfortunately, most of the other fields have no agreed upon practice standards, credentialing processes, requirements for continuing education, or accountability."[2] Chiropractors point to evidence that they have significantly upgraded their standards of education and research independently of Medicine, and without public funding; improvements in chiropractic standards have been acknowledged by the AMA, who indeed claimed that this was a positive outcome of their campaign. Chiropractors say that chiropractic research has been starved of funds, and that they have been prevented from integrating into hospital-based medicine by a medical profession that has been selective in its use of evidence. Chiropractors claim that their training and experience in musculoskeletal conditions exceeds that of conventional physicians, and that, for several conditions, evidence-based methods have shown that chiropractic treatments are at least as effective as conventional treatments and that the risks are fewer.

Chiropractic today: many styles of practice

The varying schools and philosophies within chiropractic have led to a wide variation in practice patterns—along with debates over theory, practice, and future directions. Chiropractic was begun by an individual who did not accept the newly-emerging germ theory of disease[3], and who, like most healers of the time, had no formal training in science. He chose a vitalistic path for his new concept, describing an "Innate Intelligence" as the force behind the body's response to dis-ease. As chiropractic grew, an increasing emphasis on educational standards and on science in professional schools was encouraged by the creation of the CCE, chiropractic's accrediting body. Its purpose was to maintain standards of education while allowing the philosophies of the individual schools to remain intact.[4] Some schools hold to the old tenets of Palmer, while others increasingly use science-based knowledge. At one end of the spectrum, some chiropractors adhere closely to the beliefs expressed by the founders of chiropractic and tend to reject some of the basic tenets of biological medicine, while other end practitioners reject such traditional chiropractic notions as vertebral subluxations and 'Innate Intelligence', and focus on the objective benefits of the chiropractic techniques. The vast majority practice somewhere in between these extremes.

"Straight" chiropractors limit their practices to analyzing the spine and correcting subluxations; those who retain a literal belief that they are affecting "Innate Intelligence" are often called "superstraights"; chiropractors who mix spinal manipulation with other treatments are called "mixers". These factions have been in disagreement with each other for most of chiropractic's history, disagreements that have been fought out in courts and state legislatures and remain unresolved. Both classes are criticised by Health Sciences, but for partly different reasons: straights for allegedly overusing spinal manipulation and applying it to conditions for which it offers no benefit, mixers for a claimed propensity to promote dubious ‘remedies’, including homeopathic remedies and dietary supplements of no demonstrated benefit. Both classes have, particularly in the past, opposed many scientifically-based public health measures including immunization, fluoridation, pasteurization of milk, prescription drugs and surgery.

The chiropractic perspective

Some critics claim that an organized subgoup of chiropractors in the USA openly promote "drugless healing" as a business model of total health care, and even advocate expansion of market base into the care of the well child.

Chiropractors indeed believe that it is important to minimise the use of drugs, and see their role in particular as being to pursue alternatives to drugs. They believe that preventative care is also an important part of health care, one that is particularly important for children.

Drugless stance on healing

Some critics are concerned that while chiropractic has been shown to be effective for backpain, headache and certain musculoskeletal conditions, chiropractors treat patients for a much wider range of conditions where there is no strong objective evidence that their interventions are effective.

Most chiropractors take a drugless approach to healing, considering that the side effects of drugs can complicate the patient's health status. Physicians are concerned that this can mislead some patients into thinking that all drugs are unnecessary or even harmful, and to overestimate the body's intrinsic ability to remain healthy. They fear that some patients with serious conditions that can be treated effectively with medications may be misled into not taking potentially life-saving treatments, such as insulin, blood pressure regulators, and cholesterol lowering drugs. They are also concerned that patients may even forego laboratory tests such as colonoscopies and physicals that can "catch" some cancers while they are still treatable.Because they feel that healing comes from within the body, chiropractors don't talk of 'cure', but of 'helping the body cure itself'. As a result, the chiropractor sees all who suffer as in need of his or her help. The degree to which they claim to be able to help varies, not only from condition to condition but also from case to case. They claim to work to relieve pain using manual methods and expect that this will minimize the need for medications and thus reduce the potential for side effects which carry greater risk than of any of their treatments.

The spinal cord carries a vast amount of information from peripheral organs and tissues to the brain, including sensations of pain, touch, and temperature. In addition, virtually every organ and its blood supply is regulated both directly by efferent nerves, many of which travel down the spinal cord, and indirectly by neuroendocrine regulation of hormone secretion. Accordingly, disruption of spinal information flow might influence virtually any organ system. However it is not clear that any particular organ dysfunction is caused by a disorder of spinally-mediated information transfer, or whether manipulation by chiropractors could correct such a disorder. Scientists and physicians generally are skeptical about these possibilities, while believing that, in some cases, chiropractic treatment might be efficacious because it exploits the placebo effect in an efficient way.

Some chiropractors nevertheless believe that several conditions can be resolved by chiropractic interventions. Such beliefs are based on their clinical experience, not on evidence from large controlled trials, and not on any scientific demonstration of a causal mechanism linking the intervention to its claimed effect. It is possible that cases that have not responded to conventional treatment might include some where the underlying cause is indeed a disorder of neural regulation of an organ system, as the failure of conventional treatment might be taken as excluding more common causes of dysfunction, such as infectious disease. It is also possible that what seems to be a symptom of an organ disease is actually the result of a reflex pain generated from the spine. Thus, if an organ-related complaint responds to chiropractic adjustments, it is possible that a spinal condition was the original cause of the problem.[5] Regardless, chiropractors feel that their high patient satisfaction rates and low malpractice rates show that their patients are well informed about the limitations, the risks, and the benefits.

Evidence standards in chiropractic

Some critics claim that chiropractic accepts too low a standard of academic and scientific scholarship in its professional journals and schools.

Some critics have warned about the over-willingness of chiropractors to accept anecdotal evidence of efficacy[6], while conversely, for instance when a patient has a stroke soon after a spinal adjustment, chiropractors are too ready to dismiss the adverse event as “unrelated". In short, the criticism is that many chiropractors are too ready to embrace evidence supportive of chiropractic, however weak it may be, and too quick to denounce evidence of its risks unless the evidence is overwhelming.

Anecdotal evidence is subject to recall bias, which is the human psychological tendency to preferentially recall unusual cases and forget routine cases. Recall bias is the reason why anecdotal evidence of efficacy or safety of a treatment has been discounted by the mainstream medical community. The scientific method has been embraced by the mainstream medical community as the ideal technique for determining the truth; the scientific method is simply the testing of hypotheses with experiments. Anecdotal evidence is therefore not scientific evidence of efficacy, and too encumbered by recall bias to garner acceptance as a way of rationally determining the truth. The mainstream medical community views anecdotal evidence as a way of generating new hypotheses for later scientific testing, not as proof of any hypothesis in and of itself.

Joseph Keating, professor at the Los Angeles College of Chiropractic and a prominent historian of chiropractic said in 1997 that "the doubting, skeptical attitudes of science do not predominate in chiropractic education or among practitioners". He stated that there is scientific support for chiropractic's main intervention method (spinal manipulation of patients with lower back pain), but chiropractic's culture has nurtured antiscientific attitudes, and poor science published in poor journals by chiropractors who are not well trained in science has given chiropractors false confidence about the value of various chiropractic techniques.[7] However, in 1998, Keating published a review about the Journal of Manipulative and Physical Therapy from 1989-1996. He concluded that scholarly activity within chiropractic had improved significantly, and that "Increases in controlled outcome studies, collaboration among chiropractic institutions, contributions from nonchiropractors, contributions from nonchiropractic institutions and funding for research suggest a degree of professional maturation and growing interest in the content of the discipline."[8]

Scientific foundations of chiropractic

Some critics have claimed that the theoretical basis of subluxation is not scientifically sound.

The founder of chiropractic, D.D. Palmer, thought that most health problems were caused by spinal misalignments ("vertebral subluxations") that blocked the flow of "Innate Intelligence" along spinal nerves. Accordingly, he proposed that chiropractic adjustments might be effective in treating almost any disease. Since then, chiropractors have been alert for evidence that their manipulations might be beneficial in conditions not directly related to the spine. There is some evidence (from case studies) that in some cases they do have benefits, but this evidence is generally regarded as weak because it may be influenced by the beliefs and expectations of the patient and the practitioner, and improvements after treatment may be coincidental instead of causally related.[9].

Several concepts used by chiropractors are not used in the health sciences; in particular, the concepts of 'vertebral subluxation' and 'Innate Intelligence'. Some chiropractors recognise that these concepts are impediments to better integration with the Health Sciences, and for example, Ronald Carter, a former President of the Canadian Chiropractic Association, proposed that the "subluxation story" should be abandoned, suggesting that it is time for the 'silent majority' to present a rational model of chiropractic so that it can become an essential member of the health care team.[10] Other chiropractors have gone further, Samuel Homola, an outspoken dissident within the profession, has argued that evidence-based chiropractic is the only way forward for chiropractors to gain greater acceptance by conventional medicine.[11] Homola's views however represent those of only very few chiropractors.

For scientifically-minded physicians, the lack of proof that nerve conduction is actually affected by chiropractic manipulation means that D.D. Palmer's theories remain speculative. Chiropractors believe that their own experience of the efficacy of chiropractic for their patients is sufficient justification for retaining Palmer's explanations. Some chiropractors also believe that retaining these concepts are important for the future of Chiropractic as a viable, independent profession, believing that this will ensure that Medicine will not absorb chiropractic.

Chiropractors also feel that criticism of the scientific basis of their treatments smacks of 'double standards', and feel that scientific evaluation of treatment interventions are similarly lacking in many areas of care that are fully accepted by Medicine. They believe that family doctors do not routinely investigate the causal basis of their patients' symptoms, but usually prescribe treatments based on their clinical experience of what has been effective in similar cases in the past - just as chiropractors do.

Vaccination

Some critics claim that some chiropractors advise parents that all vaccinations have higher risks and less benefit than any organized health science or biological science group accepts, thus exposing children to the risk of preventable illnesses and putting the general population at risk of epidemics.

Efforts by the chiropractic profession to dissuade people from accepting the polio vaccine in the 1950's and 1960's in the USA sparked much of the resentment towards chiropractic that spawned the AMA lawsuit, and which still hinders chiropractic from being accepted as a member of the health sciences. Even today, some chiropractors believe that there is a link between autism and additives in vaccines on the basis of early studies that have been extensively criticised, and despite evidence from large well-controlled studies showing no such link.[5] A survey in the Canadian Province of Alberta found that 27% of chiropractors advised their patients against having themselves or their children immunized (about the same proportion as advised in favour of immunization).[12]

In line with a general philosophy to avoid medicines and drugs, 'traditional straight' chiropractors are opposed to compulsory childhood vaccination. Their main association, the International Chiropractors Association (ICA), supports a "conscience clause or waiver in compulsory vaccination laws, providing an elective course of action for all regarding immunization, thereby allowing patients freedom of choice in matters affecting their bodies and health." The American Chiropractic Association (ACA) [6] and the World Chiropractic Alliance (WCA)[7] have adopted very similar positions.

While 'freedom of choice' seems innocuous to those who are unfamiliar with the biology of vaccination, to scientists and physicians there are public health consequences if more than a very few people opt out of universal vaccination. For vaccination to be effective in controlling infectious diseases that spread from person to person, there must be a very high immunity rate in the population (typically 85% or higher). If too many people are unvaccinated, then there is a real risk of an outbreak of disease, and because vaccination is never 100% effective, this puts at risk not only people who are unvaccinated, but also people who have already accepted the risk of vaccination for the greater good.[13] Because of this, the policy has to be compulsory to be fair, otherwise a few who avoid vaccination gain benefits at the expense of the majority. Accordingly, many scientific and medical organisations have strongly supported policies of compulsory vaccination and consider it irresponsible for organisations like the ICA and ACA not to do likewise.[14]

Those chiropractors who advise against certain vaccinations are not convinced that evidence for its benefits always outweighs the risks to an individual. Many chiropractors support immunization for life-threatening diseases such as polio or diphtheria, but some think that, when new vaccines are introduced to protect against relatively benign conditions such as chicken pox, the balance of benefits and risks is less clear. Because chicken pox carries a relatively small risk of death or disability, the possible risks of vaccination might outweigh the benefits, and they believe that the principle of informed consent should apply, giving the individual the right to make the choice for themselves. Such skepticism is not restricted to chiropractic, but as a healthcare profession, this position has greater implications in the fields of public health.

Other chiropractors hold views in line with those of physicians and public health officials, and have spoken out against chiropractic policies that they feel don't do enough to oppose anti-vaccination efforts. Writing in Dynamic Chiropractor, Stephen Perle and Randy Ferrance[15]: say they are not aware "of a single well-controlled study which found that chiropractic care prevented any infectious disease or reduced the severity of such a disease." They declare that it is dishonest of chiropractors to warn their patients about the danger of vaccinations without advising them of their benefits, and endorse the guidance of the College of Chiropractors of Ontario, which states that "chiropractors may not, in their professional capacity express views about immunization/vaccination as it is outside their scope of practice."[16] In Canada, chiropractors have been formally prevented from advising against vaccination.

Limited versus unlimited provision of healthcare

Some critics argue that chiropractic's claims for health benefits beyond certain musculoskeletal complaints are not warranted.[17]

The sharpest criticism from the health sciences has been mainly about the extent of chiropractic practice (the range of conditions for which chiropractors offer treatment), and about advice that chiropractors give against standard medical treatments. These are mainly aimed at those chiropractors who follow the traditional ideas of chiropractic as an unlimited healing art, and who most aggressively market the profession as a general alternative to the health sciences. Currently, that traditional "straight chiropractic" philosophy is best represented in the USA. There is concern that many chiropractors promote popular beliefs that critics claim are outside their scope of practice and professional knowledge, and which are rejected by mainstream science and medicine. Chiropractic is effective in some musculoskeletal conditions, but critics claim that this is unreasonably generalized to "musculoskeletal conditions", a phrase without specific meaning that does not include the conditions, such as myasthenia gravis, multiple sclerosis, or rheumatoid arthritis, that any reasonably knowledgeable layman might assume to be such a condition.

Many physicians are concerned about all treatments that have no accepted scientific basis or validated evidence of efficacy, because ineffective treatments might delay more appropriate treatment. In 1998, the AMA published a report on "Alternative Medicine".[18] About chiropractic, it stated that manipulation has reasonably good efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints, that some chiropractors limit their practices to these conditions, and that, in a national survey of family physicians and internists, 47% said they would refer patients for chiropractic treatment. However, the Report also said that most chiropractors "promote manipulation as useful in a host of conditions, ranging from infectious diseases to immune therapy, even claiming to prevent future conditions from occurring (even if years away) including menstrual irregularity, difficulty giving birth, and cancer. A common criticism of chiropractors has been the willingness of some to treat conditions where there is no validated basis for believing chiropractic to be effective, especially conditions that might be life-altering without concurrent medical care. Chiropractors commonly provide advice in nutrition and other preventive practices, and maintain that a regular series of 'adjustments' is needed by most persons to maintain optimal health." In 1997, the AMA as a statement of Policy, said that "Patients who choose alternative therapies should be educated as to the hazards that might result from postponing or stopping conventional medical treatment."

Pediatricians are especially concerned about chiropractic treatment of children, not only because of the unknown risks of treatment,[19] but also because they fear that parents may be risking their children's health by not having them seen by a physician who is properly trained in childhood diseases in a timely manner. Chiropractic treatment of infantile colic, otitis media, "excessive crying", or Attention Deficit Hyperactivity Disorder are common points of contention.

Infantile colic is a condition characterised by uncontrollable crying in infants with no clear cause: some reports suggest that chiropractic is efficacious, others do not. Chiropractors believe that any treatment that results in using less medication has value, even if it might be effective only because of its reassuring and calming effect on the mother and/or child.[20]

Otitis media in infants is another condition that some chiropractors claim to manage efficiently.[21] In the past, antibiotics were the treatment of choice, but recent studies suggest that waiting three days before beginning a regimen could save as many as 30% from unnecessary exposure to antibiotics.[22] Chiropractors believe that they have an important 'watchful waiting' role in monitoring otitis media. However, many physicians feel that, even if chiropractic treatment of such conditions has some benefits by exploiting the placebo effect, there is a risk that false reassurance delays more appropriate medical treatment and that chiropractors, unlike pediatricians and primary care physicians, do not have the examining skills to know when referral to a specialist in Ear, Nose and Throat (Otolaryngology) is required to prevent permanent hearing loss or complications such as brain abscess. Chiropractors argue that their education in physical examination is equivalent to that in the health sciences, and so consider this concern unwarranted.

Competence

Some critics claim that chiropractors are not trained to diagnose medical diseases and so are not competent to act as comprehensive primary care health care providers

While chiropractors have shown to be as or more competent than their medical counterparts in the musculoskeletal arena, physicians are concerned when claims are made that chiropractors are primary care providers, a term used to describe entry level physicians or general practitioners. Today's chiropractor has completed courses in medical diagnosis and patient management designed to allow them to assess patients at the entry level and make appropriate decisions for treatment or referral. Some chiropractors have hospital privileges, while others are involved in integrated healthcare environments that employ the skills of all branches of healthcare, but most are sole practitioners in the primary care role. With the advent of Health Maintenance Organizations (HMOs), most third party payors consider chiropractic as a specialty field that may be considered a portal of entry (not requiring a referral from a physician) for musculoskeletal conditions. Most chiropractors consider themselves well prepared as primary care providers.

Advertising

Some critics claim that chiropractic accepts a level of self-promotion in advertising that is unprofessional and misleading.[23]

In 1992, attorney George McAndrews, who represented the plaintiffs in the Wilk ''et al.'' vs AMA court case, wrote an open letter to the chiropractic profession warning that 'scare tactic' advertising damages the newly won respect within the AMA.[24]

For most of the 20th century, physicians in the USA disdained advertising as unethical and unprofessional. Chiropractors, on the other hand, enthusiastically embraced advertising and, being outside the organisational components of referral mechanisms found in medicine, considered this an acceptable option. More recently, the formal sanction against physician advertisements has been lifted, and advertisements for such services as Cosmetic surgery and drugs are now common in the USA.

Safety and consent

Critics of chiropractic have expressed doubt about the safety of chiropractic. This includes doubt over the repeated exposure of chiropractic patients to X-rays based on the scientifically dubious theory of subluxations, the risk of fracture and dislocation, and the risk of vertebral artery dissection. Manipulation of the neck can lead to strain on the vertebral artery, and critics point to people who have had serious injuries and death resulting from chiropractic neck manipulation.[25]

In Trick or Treatment, a book by Simon Singh and Edzard Ernst, the case of Laurie Mathiason, a Canadian woman who died following chiropractic neck manipulation, is presented along with legal findings regarding the culpability of the chiropractor involved. A number of other cases are listed from Canada, and Canadian research is presented which the authors claim implies that chiropractic treatment can increase the risk of arterial damage by a factor of five[26]. Based on this, Singh and Ernst raise questions about whether or not chiropractors are adequately abiding by the requirements of informed consent that are present in most nation's health regulatory frameworks. They point to a study of British chiropractors published in 2005 on their approach to consent policy which found that only 23% of chiropractors in Britain discuss potential serious side effects of chiropractic treatment - Singh and Ernst conclude that this is not sufficient either to meet the rules regarding consent set by the British government's Department of Health or the rules set out by the General Chiropractic Council in the UK.

Contextually, the possible safety problems and shortcomings in informed consent procedure are particularly damaging as many chiropractors, as with many alternative medicine practitioners, are frequently critical of the side-effects of "established" or "mainstream" medicine.

Criticism from other professions, and public groups

References

  1. ↑ The Wilk case: text of the Judge's opinion and order
  2. ↑ Stephen E. Straus:Chapter 10. Complementary and Alternative Medicine. Harrison's Principles of Internal Medicine, 16th Edition. Copyright © 2005 The McGraw-Hill Companies, Inc.
  3. ↑ Busse JW et al. (2005) Chiropractic antivaccination arguments. J Manip Physiol Ther 28:367-73
  4. ↑ Coulter I et al. (1998) A comparative study of chiropractic and medical education. Alt Ther Health Med 4:64-75
  5. ↑ Nansel D, Szlazak M (1995) Somatic dysfunction and the phenomenon of visceral disease simulation: a probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. J Manip Physiol Ther 18:379-97 PMID 7595111
  6. ↑ Critical thinking: Christopher Kent, president of the Council on Chiropractic Practice, advises his colleagues of the importance of high standards of evidence
  7. ↑ Keating JC (1997) [1]
    Nelson CF (1993) Chiropractic magazines. J Manip Physiol Ther 16:280-281. Letter to the editor
  8. ↑ :Keating JC et al. (1998). "A descriptive analysis of the Journal of Manipulative and Physiological Therapeutics, 1989-1996". J Manip Physiol Ther 21: 539-52. PMID 9798183.
  9. ↑ Scientifically, evidence is regarded as validated only if evidence leads to an objective protocol for intervention with objectively verifiable efficacy
  10. ↑ Subluxation - The Silent Killer
    Keating JC Faulty Logic and Non-skeptical Arguments in Chiropractic (pdf)
    Keating JC et al. (2005) Subluxation: dogma or science? Chiropr Osteopat 13:17 PMID 16092955
  11. ↑ Homola S Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor. Homola's book Chiropractic, Bonesetting, and Cultism, published in 1964, contains trenchant criticism of the profession, and the following year Homola's application to renew his membership of the American Chiropractic Association (ACA) was rejected. In 1991, David Redding, chairman of the ACA board of governors, welcomed Homola back to the ACA, and in 1994, 30 years after its publication, the book was reviewed for the first time in a chiropractic journal[2].
  12. ↑ Russell ML et al. (2004) Beliefs and behaviours: understanding chiropractors and immunization. Vaccine 23:372-9 PMID 15530683 ; figures are for survey respondents only
  13. ↑ Bradley P (1999) Should childhood immunisation be compulsory? J Med Ethics 25:330-334
  14. ↑ Chiropractic and vaccination
    Campbell JB et al. (2000) Chiropractors and vaccination: A historical perspective. Pediatrics 105:e43
    Busse JW et al. (2002) Attitudes toward vaccination: a survey of Canadian chiropractic students. CMAJ 166:
    Omer SB et al. (2006) Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence. JAMA 296:1757-63 PMID 17032989
    Centers for Disease Control and Prevention (2006). Pertussis outbreak in an Amish community--Kent County, Delaware, September 2004-February 2005. MMWR - Morbidity & Mortality Weekly Report 55:817-21 PMID 16888610
    Leon Jaroff (2005) Chiropractors v. Vaccination Time magazine, 7th June
    Feikin DR et al. (2000) Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA 284:3145-50
    Grod JP, Sikorski D, Keating JC, Jr (2001) Unsubstantiated claims in patient brochures from the largest state, provincial, and national chiropractic associations and research agencies. J Manip Physiol Ther 24:514-9 PMID 11677551
    Sikorski D et al. (2002) The unsubstantiated website claims of chiropractic colleges in Canada and the United States. J Chiropr Edu 16:95-6.
    Busse JW et al. (2005) Chiropractic antivaccination arguments. J Manip Physiol Therap 28:367-73 PMID 1744481
  15. ↑ Perle S, Ferrence R (2005) What's Good for the Goose Is ... Ethics and Vaccinations. Dynamic Chiropractor, Volume 23, Issue 4
  16. ↑ Immunization/Vaccination Standard of Practice S-015 (2004) by the Executive Committee and Quality Assurance Committee of the College of Chiropractors of Ontario
  17. ↑ It wasn't so long ago that a college president suggested, "Rigor mortis is the only thing we can't help!" Joseph Keating Jr (1994) Ivory Tower Review: The "20/20" Expose Dynamic Chiropractic, Volume 12, Issue 6, Hosted by chiroweb.com
  18. ↑ Alternative Medicine, Report 12 of the AMA Council on Scientific Affairs (A-97)
  19. ↑ See Vohra S et al. (2007) Adverse events associated with pediatric spinal manipulation: a systematic review. Pediatrics. 119:e275-83 PMID 17178922 and see[3] for a response from the International Chiropractic Pediatric Association.
  20. ↑ Infantile colic
    Wiberg JMM et al. (1999) The short-term effect of spinal manipulation in the treatment of infantile colic: A randomized controlled clinical trial with a blinded observer. J Manip Physiol Ther 22:517-22 PMID 10543581
    Sampler S, Lucassen P (2003), Chiropractic for infantile colic. (Protocol) The Cochrane Database of Systematic Reviews Issue 4. Article No. CD004796. DOI: 10.1002/14651858.CD004796.
    EBSCO Complementary and Alternative Medicine Review Board [4]
  21. ↑ Synopsis of research papers on chiropractic treatment of ear infection (otitis media). Hosted by ICPA Research Foundation. The papers include:
    Froehle RM (1996) Ear infection: a retrospective study examining improvement from chiropractic care and analyzing for influencing factors. J Manip Physiol Ther 19:169-77. PMID 8728460 ("Although there were several limitations to this study ... this study's data indicate that limitation of medical intervention and the addition of chiropractic care may decrease the symptoms of ear infection in young children.")
    Fallon JM (1997) The role of the chiropractic adjustment in the care and treatment of 332 children with otitis media. J Clin Chiro Pediatrics 2:167-83. ("The results indicate that there is a strong correlation between the chiropractic adjustment and the resolution of otitis media for the children in this study." )
  22. ↑ American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media (2004) Diagnosis and management of acute otitis media. Pediatrics 113:1451-65. The guidelines specify that the diagnosis of acute otitis media is made accurately and professionally, that pain is adequately treated, and that further medical or surgical treatment, if needed, will be prompt. It is unclear whether chiropractors are qualified to meet these criteria.
  23. ↑ JC Smith (1999)Chiropractic Ethics: An Oxymoron? (ethical issues are "in dire need of debate" because of "years of intense medical misinformation/slander" and because of well-publicised examples of tacky advertising, outlandish claims, sensationalism and insurance fraud.)
    Joseph Keating Jr (1991) Quackery in Chiropractic. Dynamic Chiropractic, Volume 9, Issue 4 (Keating discusses his concerns for advertising products before they are scientifically evaluated.)
  24. ↑ Open Letter to the Profession (See here for commentary.)
  25. ↑ Samuel Homola, Chriopractic: Does the Bad Outweigh the Good?, Quackwatch
  26. ↑ Edzard Ernst and Simon Singh, Trick or Treatment: Alternative Medicine on trial, Corgi Books, ISBN: 978-0-552-15762-9
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