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Throughout its history chiropractic has been the subject of internal and external controversy and criticism.^[1][2] Daniel D. Palmer, the founder of chiropractic, claimed to have manipulated the spine of a man who was nearly deaf, allegedly curing him of deafness. In a critical evaluation of the profession, Professor Edzard Ernst stated: "Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today." Chiropractors, including D.D. Palmer, were jailed for practicing medicine without a license.^[3] For most of its existence, chiropractic has battled with mainstream medicine, sustained by what are characterized as antiscientific and pseudoscientific ideas such as subluxation.^[4] Unsubstantiated claims about the efficacy of chiropractic have continued to be made by individual chiropractors and chiropractic associations. The core concept of chiropractic, vertebral subluxation, is not based on sound science. Research has not demonstrated that spinal manipulation is effective for any medical condition, with the possible exception of treatment for back pain.^[3]

Contents 1 Historical elements that have drawn criticism and created controversy 2 Ethics and claims 3 Efficacy 4 References 5 External links 5.1 Internal criticism 5.2 External criticism

[edit] Historical elements that have drawn criticism and created controversy

The birth of chiropractic was on September 18, 1895. What actually happened, and what has been claimed, are two different things. Daniel D. Palmer later claimed that on that day he manipulated the spine of Harvey Lillard, a man who was nearly deaf, allegedly curing him of deafness. Palmer said "there was nothing accidental about this, as it was accomplished with an object in view, and the expected result was obtained. There was nothing 'crude" about this adjustment; it was specific so much so that no chiropractor has equaled it."^[5]

However, this version was disputed by Lillard's daughter, Valdeenia Lillard Simons. She said that her father told her that he was telling jokes to a friend in the hall outside Palmer's office and Palmer, who had been reading, joined them. When Lillard reached the punch line, Palmer, laughing heartily, slapped Lillard on the back with the hand holding the heavy book he had been reading. A few days later, Lillard told Palmer that his hearing seemed better. Palmer then decided to explore manipulation as an expansion of his magnetic healing practice. Simons said "the compact was that if they can make [something of] it, then they both would share. But, it didn't happen."^[6]

In spite of the fact that Lillard could hear well enough to tell jokes, B.J. Palmer claimed under sworn testimony that Lillard was "thoroughly deaf".^[7] Since 1895, the story of Palmer curing a man of deafness has been a part of chiropractic tradition. Palmer's account differs significantly from what actually happened, in that, according to Lillard's daughter, his improved hearing was likely caused by an accidently fortuitous jarring of Lillard's body and not, as claimed by D.D. Palmer, caused by a "specific" adjustment. It was after this event that Palmer began to experiment with manipulation. He also claimed that his second patient, a man with heart disease, was also cured by spinal manipulation.

He defined chiropractic as "a science of healing without drugs" and considered establishing chiropractic as a religion. Chiropractic included vitalistic ideas of Innate Intelligence with religious attributes of Universal Intelligence to substitute science.^[3] Evidence suggests that D.D. Palmer had acquired knowledge of manipulative techniques from Andrew Taylor Still, the founder of osteopathy.^[3] Although D.D. Palmer combined bonesetting to give chiropractic its method, and "magnetic healing" for the theory, he acknowledged a special relation to magnetic healing when he wrote, "chiropractic was not evolved from medicine or any other method, except that of magnetic."^[1] According to D.D. Palmer, subluxation is the sole cause of disease and manipulation is the cure for all diseases of the human race.^[3]

Chiropractic has a strong salesmanship element since it was started by D.D. Palmer. His son, B.J. Palmer, asserted that their chiropractic school was founded on "…a business, not a professional basis. We manufacture chiropractors. We teach them the idea and then we show them how to sell it".^[8] D.D. Palmer established a magnetic healing facility in Davenport, Iowa, styling himself ‘doctor’. Not everyone was convinced, as a local paper in 1894 wrote about him: "A crank on magnetism has a crazy notion hat he can cure the sick and crippled with his magnetic hands. His victims are the weak-minded, ignorant and superstitious, those foolish people who have been sick for years and have become tired of the regular physician and want health by the short-cut method…he has certainly profited by the ignorance of his victims…His increase in business shows what can be done in Davenport, even by a quack."^[8] D.D. Palmer remarked that "Give me a simple mind that thinks along single tracts, give me 30 days to instruct him, and that individual can go forth on the highways and byways and get more sick people well than the best, most complete, all around, unlimited medical education of any medical man who ever lived."^[3]

Chiropractic has seen considerable controversy within the profession over its philosophy.^[9]

Chiropractic is rooted in mystical concepts, leading to internal conflicts between straights and mixers which continue to this day.^[3] It has two main groups: "straights", now the minority, emphasize vitalism, innate intelligence and spinal adjustments, and consider subluxations to be the leading cause of all disease; "mixers" are more open to mainstream and alternative medical techniques such as exercise, massage, nutritional supplements, and acupuncture.^[1] The straights adhere religiously to the gospel of its founders while mixers are more open.^[3] There is a lack of uniformity and consensus among chiropractors in regard to their role. Depending upon whose point of view; chiropractors are, for example, subluxation-correctors, primary care physicians, neuromusculoskeletal specialists, or holistic health specialists.^[10] Straights have claimed mixers are not real chiropractors because they do not acknowledge Palmer's foundation of chiropractic therapy.^[11]

In 1906, D.D. Palmer was the first of hundreds of chiropractors who went to jail.^[12] Chiropractors were jailed for practicing medicine without a license.^[3] In the 1920s hundreds of unlicensed chiropractors chose jail rather than fines.^[13] Herbert Reaver was the most jailed chiropractor in the U.S.^[14] Chiropractors were charged with not complying with the medical practice act. California chiropractors adopted the motto, "Go to jail for chiropractic." 450 chiropractors were jailed in a single year at the peak of the controversy. Many chiropractors treated fellow prisoners and visiting patients while in jail.^[1]

For much of the history of the chiropractic profession chiropractors have shown little interest in scientific research and have regarded their principles and practices as valid.^[15] Despite heavy opposition by mainstream medicine, by the 1930s chiropractic was the largest alternative healing profession in the U.S.^[16] The lack of acceptance with mainstream public health was contributed to by the long standing American Medical Association (AMA) policies against chiropractic.^[17] The AMA created the Committee on Quackery "to contain and eliminate chiropractic." Using the Committee on Quackery, efforts were made to prevent the participation of chiropractic in organized health care. In 1966 a policy passed by the AMA House of Delegates stating: "It is the position of the medical profession that chiropractic is an unscientific cult whose practitioners lack the necessary training and background to diagnose and treat human disease. Chiropractic constitutes a hazard to rational health care in the United States because of its substandard and unscientific education of its practitioners and their rigid adherence to an irrational, unscientific approach to disease causation."^[17] The longstanding feud between chiropractors and medical doctors continued for decades. The AMA labeled chiropractic an "unscientific cult" in 1966,^[17] and until 1980 held that it was unethical for medical doctors to associate with "unscientific practitioners".^[18] This culminated in a landmark 1987 decision, Wilk v. AMA, in which the court found that the AMA had engaged in unreasonable restraint of trade and conspiracy, and which ended the AMA's de facto boycott of chiropractic.^[19] The rivalry was not solely with conventional medicine; many osteopaths proclaimed that chiropractic was a bastardized form of osteopathy.^[3]

Serious research to test chiropractic theories did not begin until the 1970s, and is continuing to be hampered by what are characterized as antiscientific and pseudoscientific ideas that sustained the profession in its long battle with organized medicine. By the mid 1990s there was a growing scholarly interest in chiropractic, which helped efforts to improve service quality and establish clinical guidelines that recommended manual therapies for acute low back pain.^[4] There are several barriers between primary care physicians and chiropractors for having positive referral relationships which includes a lack of good communication.^[20] The medical establishment has not entirely accepted chiropractic care as mainstream.^[21] After 100 years, the chiropractic profession has failed to define a message that is understandable, credible, and scientifically valid.^[10] The future of chiropractic is uncertain due to the economic struggles and restrictions of the science and methods in chiropractic.^[22]

[edit] Ethics and claims

A Gallup Poll and various research studies and commentaries, some by chiropractors, have pointed out unfavorable facts related to the ethical standards,^[23] rampant fraud, abuse and quackery,^[24] and unsubstantiated claims^[25] made by chiropractors.

A study of California disciplinary statistics during 1997–2000 reported 4.5 disciplinary actions per 1000 chiropractors per year, compared to 2.27 for MDs, and the incident rate for fraud was 9 times greater among chiropractors (1.99 per 1000 chiropractors per year) than among MDs (0.20).^[24] According to a 2006 Gallup Poll of U.S. adults, when asked how they would "rate the honesty and ethical standards of people in these different fields", chiropractic compared unfavorably with mainstream medicine. When chiropractic was rated, it "rated dead last amongst healthcare professions". While 84% of respondents considered nurses' ethics "very high" or "high," only 36% felt that way about chiropractors. Other healthcare professions ranged from 38% for psychiatrists, to 62% for dentists, 69% for medical doctors, 71% for veterinarians, and 73% for druggists or pharmacists.^{[23][26][27][28]} Similar results were found in the 2003 Gallup Poll.^[29] Chiropractic authors have placed these results in perspective in articles, with one writing that "we were the least trusted and least believed health care discipline",^[30] and another writing that chiropractors who use unethical marketing methods "poison the well" for others in the profession, and that they "might be responsible for the negative opinion people have about the ethics of the chiropractic profession."^[31]

Historically the profession has often been accused of quackery, with the profession often responding negatively to such accusations. In its early days, the accusation of quackery was voiced in a 1913 editorial in the Journal of the American Medical Association:

"Chiropractic is a freak offshoot from osteopathy. Disease, say the chiropractors, is due to pressure on the spinal nerves; ergo it can be cured by "adjusting" the spinal column. It is the sheerest quackery, and those who profess to teach it make their appeal to the cupidity of the ignorant. Its practice is in no sense a profession but a trade - and a trade that is potent for great harm. It is carried on almost exclusively by those of no education, ignorant of anatomy, ignorant even of the fundamental sciences on which the treatment of disease depends." (p. 29)^[32]

The view that chiropractic was a trade, rather than a profession, was stated clearly by B.J. Palmer, who asserted that chiropractic was founded on "…a business, not a professional basis. We manufacture chiropractors. We teach them the idea and then we show them how to sell it".^[8]

In more modern times (1991), when the president of the ACA called accusations of quackery a "myth", chiropractic historian, Joseph C. Keating, Jr. responded by calling his comments "absurd" and stated:

"The so-called 'quackery myth about chiropractic' is no myth.....the kernels of quackery (i.e., unsubstantiated and untested health remedies offered as "proven") are ubiquitous in this profession. I dare say that health misinformation (if not quackery) can be found in just about any issue of any chiropractic trade publication (and some of our research journals) and much of the promotional materials chiropractors disseminate to patients. The recent unsubstantiated claims of the ACA are exemplary [examples provided]...It escapes me entirely how Dr. Downing, the ACA, MPI, and Dynamic Chiropractic can suggest that there is no quackery in chiropractic. Either these groups and individuals do not read the chiropractic literature or have no crap-detectors. I urge a reconsideration of advertising and promotion policies in chiropractic."^[33]

In an article on quackery, W.T. Jarvis has stated that "Non-scientific health care (e.g., acupuncture, ayurvedic medicine, chiropractic, homeopathy, naturopathy) is licensed by individual states. Practitioners use unscientific practices and deception on a public who, lacking complex health-care knowledge, must rely upon the trustworthiness of providers. Quackery not only harms people, it undermines the scientific enterprise and should be actively opposed by every scientist."^[34]

The fact that chiropractors are licensed and most chiropractic schools have achieved accreditation has been discussed and criticized. In an August 1983 interview of Stephen Barrett by the ACA Journal of Chiropractic, Barrett responded to questions by stating that the licensing "law has nothing to do with science. If enough people are interested in getting a law passed, and do it cleverly, they can get a lot accomplished. Other forms of health quackery have been legalized in a number of states. The state legislatures simply say if you can make it and sell it in the state, then it's legal." As to accreditation, he responded that accreditation "has nothing to do with what's taught. You can get accreditation if you develop the correct form and structure in your school. And that has nothing to do with what you teach. Actually, chiropractic is proof that the accreditation system has a hole in it. The accreditation system worked until chiropractic got accredited."^[35]

J.C. Smith, a chiropractor in private practice, wrote in a 1999 article that 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: "Why do we tolerate the charlatans, hucksters, profiteers, and wild-eyed 'philosophers’ who taint our profession's image, who obstruct political unity and espouse untrue science that cannot withstand the test of research; who recruit patients with gimmicks, and who mislead naive students and young practitioners with dogma and promises of great wealth? Is it because profession ethics is mostly lacking in chiropractic? Is it due to a laissez faire attitude within chiropractic where anyone can say anything under the guise of “philosophy”? Or is mainstream chiropractic simply scared to confront these fringe elements, fearful of litigation or argument?"^[36]

In a 2008 commentary,^[23] the chiropractic authors proposed that "the chiropractic profession has an obligation to actively divorce itself from metaphysical explanations of health and disease as well as to actively regulate itself in refusing to tolerate fraud, abuse and quackery, which are more rampant^[24] in our profession than in other healthcare professions," a situation which violates the social contract between patients and physicians. Such self-regulation "will dramatically increase the level of trust in and respect for the profession from society at large."^[23] Another chiropractic study documented that the largest chiropractic associations in the U.S. and Canada distributed patient brochures which contained unsubstantiated claims.^[25] Chiropractors, especially in America, have a reputation for unnecessarily treating patients.^[11] Sustained chiropractic care is promoted as a preventative tool but unnecessary manipulation could possibly present a risk to patients. Some chiropractors are concerned by the routine unjustified claims chiropractors have made.^[3]

Some New Zealand chiropractors appeared to have used the title 'Doctor' in a New Zealand Yellow pages telephone directory in a way that implied they are registered medical practitioners, when no evidence was presented it was true.^[37] In New Zealand, chiropractors are allowed to use the title 'doctor' when it is qualified to show that the title refers to their chiropractic role. A representative from the NZ Chiropractic Board states that entries in the Yellow Pages under the heading of 'Chiropractors' fulfills this obligation when suitably qualified.^[38] If a chiropractor is not a registered medical practitioner, then the misuse of the title 'Doctor' while working in healthcare will not comply with the Health Practitioners Competence Assurance Act 2003.^[37]

UK chiropractic organizations and their members make numerous claims which are not supported by scientific evidence. Many chiropractors adhere to ideas which are against science and most seemingly violate important principles of ethical behaviour on a regular basis. The advice chiropractors gave to their patients is often misleading and dangerous.^[39] This situation, coupled with a backlash to the libel suit filed against Simon Singh, has inspired the filing of formal complaints of false advertising against more than 500 individual chiropractors within one 24 hour period,^[40][41] prompting the McTimoney Chiropractic Association to write to its members advising them to remove leaflets that make claims about whiplash and colic from their practice, to be wary of new patients and telephone inquiries, and telling their members: "If you have a website, take it down NOW." and "Finally, we strongly suggest you do NOT discuss this with others, especially patients."^[40]

On 19 April 2008, Simon Singh wrote an article in the The Guardian^[42][43] which resulted in him being sued for libel by the British Chiropractic Association. Singh wrote in The Guardian criticising the claims made by chiropractors about the efficacy of spinal manipulation in treating childhood ailments, among other things. He suggested there was "not a jot" of evidence to support such interventions for these ailments, and argued that the British Chiropractic Association "happily promotes bogus treatments".^[44] The suit is ongoing, with Singh stating that he will "contest the action vigorously… There is an important issue of freedom of speech at stake."^[45] The article developed the theme of Singh's recently published book Trick or Treatment? Alternative Medicine on Trial, making various claims about the usefulness of chiropractic.^[42] Commentators suggest this ruling could set a precedent to restrict freedom of speech to criticise alternative medicine.^[46][47] The charity Sense About Science has launched a campaign^[48] to draw attention to this particular case. They have issued a statement entitled "The law has no place in scientific disputes",^[49] which has been signed by myriad signers representing science, journalism, publishing, arts, humanities, entertainment, skeptics, campaign groups and law. As of November 29, 2009 (2009 -11-29)^[update], over 20,000 have signed.^[48]

[edit] Efficacy

Not all criticism originated from critics in the medical profession. Some chiropractors are cautiously calling for reform.^[2] Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs what is considered by many chiropractic researchers to be antiscientific reasoning and unsubstantiated claims,^{[4][50][51][52]} that are ethically suspect when they let practitioners maintain their beliefs to patients' detriment.^[50] Samuel Homola writes that the bottom line is "A good chiropractor can do a lot to help you when you have mechanical-type back pain and other musculoskeletal problems. But until the chiropractic profession cleans up its act, and its colleges uniformly graduate properly limited chiropractors who specialize in neuromusculoskeletal problems, you'll have to exercise caution and informed judgment when seeking chiropractic care."^[53] Alan Breen writes there is consistent evidence that manual therapies such as chiropractic adjustments are "helpful and generally produce moderate but significant and sustained improvement for back pain in populations".^[54]

Vertebral subluxation, the core concept of chiropractic, is not based on solid science. Collectively, systematic reviews of this research have not demonstrated that spinal manipulation is effective, with the possible exception of treatment of back pain.^[3] The concept of subluxation remains unsubstantiated and largely untested, and has been debated about whether to keep it in the chiropractic paradigm for decades.^[51] The dogma of subluxation is the biggest single barrier to professional development for chiropractors.^[51] Vertebral subluxation skews the practice of legitimacy in ways that bring ridicule from the scientific community and uncertainty among the general public.^[51] Commitment to the subluxation dogma undermines the desire for scientific investigation of subluxation as hypothesis, and further perpetuates a cycle of a marketing tradition, inevitably bringing charges of quackery.^[51] The cost, effectiveness, and safety, of spinal manipulation are uncertain.^[3] Edzard Ernst stated "the best evidence available to date fails to demonstrate clinically relevant benefits of chiropractic for paediatric patients, and some evidence even suggests that chiropractors can cause serious harm to children".^[55] Alan Breen has described commentaries suggesting that chiropractic does more harm than good as "specious".^[54] A 2007 survey of Alberta chiropractors found that they do not consistently apply research in practice, which may have resulted from a lack of research education and skills though the chiropractic profession has research-focused professional training encouraged by professional association incentives which provide time and support for research.^[56] According to David Colquhoun, chiropractic is no more effective than conventional treatment at its best, and has a disadvantage of being "surrounded by gobbledygook about 'subluxations'", and, more seriously, it does kill patients occasionally. He states that chiropractic manipulation is the number one cause of stroke under the age of 45.^[57] Neck spinal manipulation has a risk of stroke or death.^[58] Although rare,^[59] spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death; these can occur in adults^[60] and children.^[61] Most of the adverse events were benign, however, there are complications that were life threatening.^[62]

Quackwatch is critical of chiropractic; its founder, Stephen Barrett, has written that it is "absurd" to think that chiropractors are qualified to be primary care providers^[63] and considers applied kinesiology to be a "term most commonly used to identify a pseudoscientific system of muscle-testing and therapy".^[64] Breen responds to such characterizations as being incomplete and only based on part of the relevant information stating that such critiques are themselves pseudoscientific.^[54]

Lon Morgan, DC, a reform chiropractor, expressed his view of Innate Intelligence this way: "Innate Intelligence clearly has its origins in borrowed mystical and occult practices of a bygone era. It remains untestable and unverifiable and has an unacceptably high penalty/benefit ratio for the chiropractic profession. The chiropractic concept of Innate Intelligence is an anachronistic holdover from a time when insufficient scientific understanding existed to explain human physiological processes. It is clearly religious in nature and must be considered harmful to normal scientific activity."^[65]

Chiropractic historian, Joseph C. Keating, Jr., articulated that "So long as we propound the "One cause, one cure" rhetoric of Innate, we should expect to be met by ridicule from the wider health science community. Chiropractors can’t have it both ways. Our theories cannot be both dogmatically held vitalistic constructs and be scientific at the same time. The purposiveness, consciousness and rigidity of the Palmers' Innate should be rejected."^[66]

William T. Jarvis, Ph.D. has stated: "Chiropractic is a controversial health-care system that has been legalized throughout the United States and in several other countries. In the United States in 1984, roughly 10.7 million people made 163 million office visits to 30,000 chiropractors. More than three fourths of the states require insurance companies to include chiropractic services in health and accident policies. The federal government pays for limited chiropractic services under Medicare, Medicaid, and its vocational rehabilitation program, and the Internal Revenue Service allows a medical deduction for chiropractic services. Chiropractors cite such facts as evidence of "recognition." However, these are merely business statistics and legal arrangements that have nothing to do with chiropractic's scientific validity."^[67]

Chiropractors historically were strongly opposed to vaccination based on their belief that all diseases were traceable to causes in the spine, and therefore could not be affected by vaccines; D.D. Palmer wrote, "It is the very height of absurdity to strive to 'protect' any person from smallpox or any other malady by inoculating them with a filthy animal poison."^[68] Some chiropractors continue to be opposed to vaccination, one of the most effective public health measures in history.^[15] Early opposition to water fluoridation included chiropractors in the U.S. Some chiropractors oppose water fluoridation as being incompatible with chiropractic philosophy and an infringement of personal freedom. Recently, other chiropractors have actively promoted fluoridation, and several chiropractic organizations have endorsed scientific principles of public health.^[69]

[edit] References

[edit] External links

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[edit] Internal criticism

• Chiropractic, Bonesetting, and Cultism. Samuel Homola (entire book on-line). This book, published in 1964, contains trenchant criticism of the profession, and the following year Homola's application to renew his membership of the ACA was rejected. In 1991, David J. Redding, chairman of the ACA board of governors, welcomed Homola back to membership of the ACA, and in 1994, 30 years after its publication, the book was reviewed for the first time by a chiropractic journal.

• Faulty Logic and Non-skeptical Arguments in Chiropractic. Joseph C. Keating, Jr. critically distinguishes between sound and unsound arguments in support of chiropractic.

• Critical thinking. Christopher Kent, DC president of the Council on Chiropractic Practice, advises his colleagues of the importance of high standards of evidence, noting that in the past chiropractors were too ready to accept anecdotal evidence.

• Open Letter to the Profession (See Chiroweb for commentary.) A 1992 letter from ACA attorney, George P. McAndrews, warns the chiropractic profession that advertising of scare tactic subluxation philosophy damages the newly won respect within the AMA.

[edit] External criticism

• Keeping Your Spine In Line, Adjusting the Joints, and Video - Alan Alda, PBS, Scientific American Frontiers, Web Feature (combines internal and external criticism)

• Chirobase: Skeptical guide to chiropractic history, theories, and current practices - Stephen Barrett, MD, and Samuel Homola, DC (combines internal and external criticism)

• Chiropractic, Skeptic’s Dictionary

• Spin Doctors: The Chiropractic Industry Under Examination - Paul Benedetti, Wayne MacPhail

• Chiropractic - H. L. Mencken, Baltimore Evening Sun, December 1924

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