Editing Chiropractic

{{Short description|Form of pseudoscientific alternative medicine}}
{{pp-vandalism|small=yes}}
{{Use American English|date=July 2019}}
{{ infobox alternative medicine
| name        = Chiropractic
| image       = File:Kiropraktisk ledd-korreksjon av rygg.jpg
| image_size  =
| alt         = Chiropractor performing adjustment
| caption     = A chiropractor performing a vertebral adjustment
| claims      = [[Vertebral subluxation]], [[spinal adjustment]], [[Innate Intelligence]]
| risks       = [[Vertebral artery dissection]] ([[stroke]]), [[vertebral compression fracture|compression fracture]], [[death]]
| topics      = [[Osteopathy]], [[vitalism]]
| orig-date    = 1895 in [[Davenport, Iowa]], U.S.
| origprop    = [[Daniel David Palmer|D. D. Palmer]]
| laterprop   = [[Bartlett Joshua Palmer|B. J. Palmer]]
| MeshID      = D002684
}}
{{Pseudomedicine sidebar}}
<!-- Conceptual basis and Scope of practice  -->
'''Chiropractic''' ({{IPAc-en|ˌ|k|aɪ|r|oʊ|ˈ|p|r|æ|k|t|ɪ|k}}) is a form of [[alternative medicine]]<ref name=Chapman-Smith>{{cite book|title=Principles and Practice of Chiropractic|vauthors=Chapman-Smith DA, ((Cleveland CS III))|publisher=McGraw-Hill|year=2005|isbn=978-0-07-137534-4|veditors=Haldeman S, Dagenais S, Budgell B|edition=3rd|pages=111–34|chapter=International status, standards, and education of the chiropractic profession|display-editors=etal}}</ref> concerned with the diagnosis, treatment and prevention of [[physical disorder|mechanical disorders]] of the musculoskeletal system, especially of the [[vertebral column|spine]].<ref name=Nelson/> It is based on several [[Pseudoscience|pseudoscientific]] ideas.<ref>For an explanation regarding the description of chiropractic as a pseudoscience, see:

* {{Cite book |last1=Singh |first1=Simon |author-link=Simon Singh |title=Trick or Treatment? Alternative Medicine on Trial |title-link=Trick or Treatment? |last2=Ernst |first2=Edzard |author-link2=Edzard Ernst |date=2008 |publisher=Bantam Press |isbn=978-0-593-06129-9 |location=London |chapter=The Truth About Chiropractic Therapy |oclc=190777228}}
* {{cite book |title=Science & Education |vauthors=Good R, Slezak P |publisher=Springer |year=2011 |pages=401–409 |chapter=Introductory Comments on Pseudoscience in Society and School |doi=10.1007/s11191-010-9331-2 |quote=The uncritical habits of mind that allow pseudosciences like subluxation chiropractic, astrology, intelligent design, and countless 'new age' medical cures to flourish are an important indication that science education needs to be changed.}}
* {{Cite journal |last=Hansson |first=Sven Ove |author-link=Sven Ove Hansson |date=2017-06-01 |title=Science denial as a form of pseudoscience |journal=Studies in History and Philosophy of Science Part A |volume=63 |pages=39–47 |bibcode=2017SHPSA..63...39H |doi=10.1016/j.shpsa.2017.05.002 |issn=0039-3681 |pmid=28629651}}
* {{Cite journal |last=Ernst |first=Edzard |author-link=Edzard Ernst |date=2009-04-01 |title=Complementary/alternative medicine: engulfed by postmodernism, anti-science and regressive thinking |journal=The British Journal of General Practice |volume=59 |issue=561 |pages=298–301 |doi=10.3399/bjgp09X420482 |issn=0960-1643 |pmc=2662117 |pmid=19341568}}
* {{cite journal |last1=Hall |first1=Harriet |author-link=Harriet Hall |date=May 2020 |title=Applied kinesiology and other chiropractic delusions |journal=[[Skeptical Inquirer]] |volume=44 |issue=3 |pages=21–23}}
* {{Cite web |last=Novella |first=Steven |author-link=Steven Novella |date=March 22, 2017 |title=Cracking Down on Chiropractic Pseudoscience |url=https://sciencebasedmedicine.org/cracking-down-on-chiropractic-pseudoscience/ |archive-url=https://web.archive.org/web/20191219214428/https://sciencebasedmedicine.org/cracking-down-on-chiropractic-pseudoscience/ |archive-date=December 19, 2019 |access-date=2019-12-19 |website=sciencebasedmedicine.org |publisher=New England Skeptical Society |language=en-US}}
* Williams, William F. (2000). ''[[Encyclopedia of Pseudoscience: From Alien Abductions to Zone Therapy]]''. Facts on File Inc. p. 51. {{ISBN|1-57958-207-9}}</ref>

Many '''chiropractors''' (often known informally as '''chiros'''), especially those in the field's early history, have proposed that mechanical disorders of the [[joint]]s, especially of the [[vertebral column|spine]], affect general health,<ref name=Nelson>{{cite journal|vauthors=Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T|title=Chiropractic as spine care: a model for the profession|journal=Chiropractic & Osteopathy|volume= 13|issue=1|page=9|year=2005|doi=10.1186/1746-1340-13-9|pmc=1185558|pmid=16000175 |doi-access=free }}</ref> and that regular [[Spinal manipulation|manipulation of the spine]] ([[spinal adjustment]]) improves general health. The main [[chiropractic treatment technique]] involves [[manual therapy]], especially manipulation of the spine, other joints, and [[soft tissue]]s, but may also include exercises and health and lifestyle counseling.<ref name=content-of-practice>{{cite book|chapter-url=http://chiroweb.com/archives/ahcpr/chapter3.htm|chapter=Content of practice|vauthors=Mootz RD, Shekelle PG |year=1997|title=Chiropractic in the United States: Training, Practice, and Research|pages=67–91|veditors=Cherkin DC, Mootz RD |location= Rockville, MD|publisher=Agency for Health Care Policy and Research|oclc=39856366}} AHCPR Pub No. 98-N002.</ref> A chiropractor may have a [[Doctor of Chiropractic|Doctor of Chiropractic (D.C.)]] degree and be referred to as "doctor" but is not a [[Doctor of Medicine|Doctor of Medicine (M.D.)]] or a [[Doctor of Osteopathic Medicine|Doctor of Osteopathic Medicine (D.O.)]].<ref>{{Cite web|url=https://sciencebasedmedicine.org/the-dc-as-pcp-drug-wars-resume/|title=The DC as PCP? Drug Wars Resume – Science-Based Medicine|date=2019-12-18|website=sciencebasedmedicine.org|url-status=live|archive-url=https://web.archive.org/web/20191218003248/https://sciencebasedmedicine.org/the-dc-as-pcp-drug-wars-resume/|archive-date=2019-12-18|access-date=2020-03-27}}</ref><ref>{{Cite web|url=https://sciencebasedmedicine.org/legislative-alchemy-2018-chiropractors-rebranding-as-primary-care-physicians-continues/|title=Legislative Alchemy 2018: Chiropractors rebranding as primary care physicians continues|last=Bellamy|first=Jann|date=December 20, 2018|website=sciencebasedmedicine.org|language=en-US|url-status=live|archive-url=https://web.archive.org/web/20191219062602/https://sciencebasedmedicine.org/legislative-alchemy-2018-chiropractors-rebranding-as-primary-care-physicians-continues/|archive-date=December 19, 2019|access-date=2019-12-18}}</ref> While many chiropractors view themselves as [[primary care]] providers,<ref name="Ernst-eval" /><ref name="CooperMcKee2003" /> chiropractic clinical training does not meet the requirements for that designation.<ref name="Nelson" />

<!-- Efficacy -->
[[Systematic review]]s of controlled clinical studies of treatments used by chiropractors have found no evidence that [[chiropractic manipulation]] is [[Efficacy#Medicine|effective]], with the possible exception of treatment for [[back pain]].<ref name=Ernst-eval>{{cite journal | author = Ernst E | title = Chiropractic: a critical evaluation | journal = Journal of Pain and Symptom Management| volume = 35 | issue = 5 | pages = 544–62 | date = May 2008 | pmid = 18280103 | doi = 10.1016/j.jpainsymman.2007.07.004 | doi-access = free }}</ref> A 2011 critical evaluation of 45 systematic reviews concluded that the data included in the study "fail[ed] to demonstrate convincingly that spinal manipulation is an effective intervention for any condition."<ref name=Posadzki-Ernst>{{cite journal |vauthors=Posadzki P, Ernst E | title = Spinal manipulation: an update of a systematic review of systematic reviews | journal = The New Zealand Medical Journal| volume = 124 | issue = 1340|pages=55–71|year=2011|pmid=21952385}}</ref> Spinal manipulation may be [[cost-effective]] for sub-acute or chronic low back pain, but the results for acute low back pain were insufficient.<ref name=Lin2011/> No compelling evidence exists to indicate that maintenance chiropractic care adequately prevents symptoms or diseases.<ref name="ErnstMaintenance2009"/>

<!-- Safety -->
There is not sufficient data to establish the safety of chiropractic manipulations.<ref name="Gouveia" /> It is frequently associated with mild to moderate [[adverse effects]], with serious or fatal complications in rare cases.<ref name="Ernst-adverse">{{cite journal | author = Ernst E | title = Adverse effects of spinal manipulation: a systematic review | journal = Journal of the Royal Society of Medicine| volume = 100 | issue = 7 | pages = 330–38 | year = 2007 | pmid = 17606755 | pmc = 1905885 | doi = 10.1177/014107680710000716 | url = http://jrsm.rsmjournals.com/cgi/content/full/100/7/330 | archive-url = https://web.archive.org/web/20100516074554/http://jrsm.rsmjournals.com/cgi/content/full/100/7/330 | archive-date = 2010-05-16 }}
*{{cite web |author=Christian Nordqvist |date=2007-07-02 |title=Spinal Manipulation Should Not Be Routinely Used, New Study Warns |website=Med News Today |url=http://www.medicalnewstoday.com/articles/75754.php}}</ref> There is controversy regarding the degree of risk of [[vertebral artery dissection]], which can lead to [[stroke]] and death, from [[cervical manipulation]].<ref name="Haynes" /> Several deaths have been associated with this technique<ref name="Ernst-adverse" /> and it has been suggested that the relationship is [[causative]],<ref name="Ernst-2010" /><ref name="Ernst-death" /> a claim which is disputed by many chiropractors.<ref name="Ernst-death">{{cite journal | author = Ernst E | title = Deaths after chiropractic: a review of published cases | journal = International Journal of Clinical Practice| volume = 64 | issue = 8 | pages = 1162–65 | year = 2010 | pmid = 20642715 | doi = 10.1111/j.1742-1241.2010.02352.x | s2cid = 45225661 | doi-access = free }}</ref>

<!-- Epidemiology -->
Chiropractic is well established in the United States, Canada, and Australia.<ref name="global-strategy" /> It overlaps with other manual-therapy professions such as [[osteopathy]] and [[physical therapy]].<ref name="Norris" /> Most who seek chiropractic care do so for [[low back pain]].<ref name="Hurwitz">{{cite journal |vauthors=Hurwitz EL, Chiang LM | title = A comparative analysis of chiropractic and general practitioner patients in North America: findings from the joint Canada/United States Survey of Health, 2002-03 | journal = BMC Health Services Research| volume = 6 | page = 49 | year = 2006 | pmc = 1458338 | doi = 10.1186/1472-6963-6-49 | pmid = 16600038 | doi-access = free }}</ref> Back and neck pain are considered the specialties of chiropractic, but many chiropractors treat ailments other than musculoskeletal issues.<ref name="Ernst-eval" />  Chiropractic has two main groups: "straights", now the minority, emphasize [[vitalism]], "[[Innate Intelligence]]", and consider vertebral subluxations to be the cause of all disease; and "mixers", the majority, are more open to mainstream views and conventional medical techniques, such as exercise, [[massage]], and [[cryotherapy#Ice pack therapy|ice therapy]].<ref name="Kaptchuk-Eisenberg" />

<!-- History -->
[[Daniel David Palmer|D. D. Palmer]] founded chiropractic in the 1890s,<ref name="Martin" /> claiming that he had received it from "the other world".<ref name="Religion" /> Palmer maintained that the tenets of chiropractic were passed along to him by a doctor who had died 50 years previously.<ref>[[David Lazarus|Lazarus, David]] (June 30, 2017). [https://www.latimes.com/business/lazarus/la-fi-lazarus-chiropractic-quackery-20170630-story.html Column: Chiropractic treatment, a $15-billion industry, has its roots in a ghost story.] {{Webarchive|url=https://web.archive.org/web/20200719094829/https://www.latimes.com/business/lazarus/la-fi-lazarus-chiropractic-quackery-20170630-story.html|date=July 19, 2020}} --- "Daniel David Palmer, the 'father' of chiropractic who performed the first chiropractic adjustment in 1895, was an avid spiritualist. He maintained that the notion and basic principles of chiropractic treatment were passed along to him during a seance by a long-dead doctor. 'The knowledge and philosophy given me by Dr. Jim Atkinson, an intelligent spiritual being ... appealed to my reason,' Palmer wrote in his memoir ''The Chiropractor,'' which was published in 1914 after his death in Los Angeles. Atkinson had died 50 years prior to Palmer's epiphany." ''Los Angeles Times.'' Retrieved: September 25, 2019.</ref> His son [[Bartlett Joshua Palmer|B. J. Palmer]] helped to expand chiropractic in the early 20th century.<ref name="Martin">{{cite journal | author = Martin SC | title = Chiropractic and the social context of medical technology, 1895-1925 | journal = Technology and Culture| volume = 34 | issue = 4 | pages = 808–34 | date = October 1993 | pmid = 11623404 | doi = 10.2307/3106416 | jstor = 3106416 | s2cid = 23423922 }}</ref> Throughout its history, [[Chiropractic controversy and criticism|chiropractic has been controversial]].<ref name="DeVocht">{{cite journal | author = DeVocht JW | s2cid = 35775630 | title = History and overview of theories and methods of chiropractic: a counterpoint | journal = Clinical Orthopaedics and Related Research| volume = 444 | pages = 243–49 | year = 2006 | pmid = 16523145 | doi = 10.1097/01.blo.0000203460.89887.8d }}</ref><ref name="Homola">{{cite journal | author = Homola S | title = Chiropractic: history and overview of theories and methods | journal = Clinical Orthopaedics and Related Research| volume = 444 | pages = 236–42 | year = 2006 | pmid = 16446588 | doi = 10.1097/01.blo.0000200258.95865.87 | url = https://zenodo.org/record/889994 }}</ref> Its foundation is at odds with [[evidence-based medicine]], and is underpinned by [[pseudoscientific]] ideas such as [[vertebral subluxation]] and Innate Intelligence.<ref name="History-Primer2" /> Despite the overwhelming evidence that [[vaccination]] is an effective [[public health]] intervention, there are significant disagreements among chiropractors over the subject,<ref name="Busse">{{cite journal |vauthors=Busse JW, Morgan L, Campbell JB | title = Chiropractic antivaccination arguments | journal = Journal of Manipulative and Physiological Therapeutics| volume = 28 | issue = 5 | pages = 367–73 | year = 2005 | pmid = 15965414 | doi = 10.1016/j.jmpt.2005.04.011 | url = http://jmptonline.org/article/S0161-4754(05)00111-9/fulltext | url-access = subscription }}</ref> which has led to negative impacts on both public vaccination and mainstream acceptance of chiropractic.<ref name="Campbell">{{cite journal |vauthors=Campbell JB, Busse JW, Injeyan HS | title = Chiropractors and vaccination: a historical perspective | journal = Pediatrics| volume = 105 | issue = 4 | page = e43 | year = 2000 | pmid = 10742364 | doi = 10.1542/peds.105.4.e43 | url = http://pediatrics.aappublications.org/cgi/content/full/105/4/e43 | doi-access = free | url-access = subscription }}</ref> The [[American Medical Association]] called chiropractic an "unscientific cult" in 1966<ref name="Chiro-PH" /> and boycotted it until losing an [[Wilk v. American Medical Association|antitrust case in 1987]].<ref name="CooperMcKee2003">{{cite journal |vauthors=Cooper RA, McKee HJ | title = Chiropractic in the United States: trends and issues | journal = Milbank Quarterly| volume = 81 | issue = 1 | pages = 107–38, table of contents | year = 2003 | pmid = 12669653 | pmc = 2690192 | doi = 10.1111/1468-0009.00040 }}</ref> Chiropractic has had a strong political base and sustained demand for services. In the last decades of the twentieth century, it gained more legitimacy and greater acceptance among conventional physicians and [[Health insurance in the United States|health plan]]s in the United States.<ref name="CooperMcKee2003" /> During the [[COVID-19 pandemic]], chiropractic professional associations advised chiropractors to adhere to [[Centers for Disease Control|CDC]], [[WHO]], and local health department guidance.<ref>WFC Public Health Committee and WFC Research Committee (March 17, 2020). [https://www.wfc.org/website/images/wfc/Latest_News_and_Features/Coronavirus_statement_2020_03_17.pdf COVID-19 Advice for Chiropractors] World Federation of Chiropractic.</ref><ref>Robert C. Jones, et al. [https://www.acatoday.org/News-Publications/Coronavirus-COVID-19/Safe-Responsible-Response Not Business as Usual: A Safe, Responsible Response to COVID-19] American Chiropractic Association</ref> Despite these recommendations, a small but vocal and influential number of chiropractors spread [[vaccine misinformation]].<ref>MICHELLE R. SMITH, SCOTT BAUER and MIKE CATALINI (October 8, 2021). [https://apnews.com/article/anti-virus-chiropractors-rising-force-misinformation-02b347767b45cab1d6d532be03c57529 Anti-vaccine chiropractors rising force of misinformation.] Associated Press.</ref>

== Conceptual basis ==

=== Origins in "folk medicine" ===
Chiropractic is generally categorized as [[complementary and alternative medicine]] (CAM),<ref name=Chapman-Smith/> which focuses on manipulation of the [[musculoskeletal system]], especially the [[vertebral column|spine]].<ref name=Nelson /> Its founder, D.{{nbsp}}D. Palmer, called it "a science of healing without drugs".<ref name=Ernst-eval/>

Chiropractic's origins lie in the [[folk medicine]] of [[bonesetter|bonesetting]],<ref name=Ernst-eval /> and as it evolved it incorporated [[vitalism]], [[spirituality|spiritual inspiration]] and [[rationalism]].<ref name=Keating05 /> Its early philosophy was based on [[deductive reasoning|deduction]] from [[dogma|irrefutable doctrine]], which helped distinguish chiropractic from medicine, provided it with legal and political defenses against claims of practicing medicine without a license, and allowed chiropractors to establish themselves as an autonomous profession.<ref name=Keating05 /> This "straight" philosophy, taught to generations of chiropractors, rejects the [[Inference|inferential reasoning]] of the [[scientific method]],<ref name=Keating05 /> and relies on deductions from vitalistic first principles rather than on the [[materialism]] of science.<ref name=Chiro-Beliefs /> However, most practitioners tend to incorporate scientific research into chiropractic,<ref name="Keating05" /> and most practitioners are "mixers" who attempt to combine the materialistic [[reductionism]] of science with the [[metaphysics]] of their predecessors and with the [[Holistic medicine|holistic paradigm of wellness]].<ref name=Chiro-Beliefs /> A 2008 commentary proposed that chiropractic actively divorce itself from the straight philosophy as part of a campaign to eliminate [[Testability|untestable]] dogma and engage in [[critical thinking]] and evidence-based research.<ref name=Murphy-pod>{{cite journal | vauthors = Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF | title = How can chiropractic become a respected mainstream profession? The example of podiatry | journal = Chiropractic & Osteopathy | volume = 16 | page = 10 | date = Aug 2008 | pmid = 18759966 | pmc = 2538524 | doi = 10.1186/1746-1340-16-10 | doi-access = free }}</ref>

Although a wide diversity of ideas exist among chiropractors,<ref name=Keating05 /> they share the belief that the spine and health are related in a fundamental way, and that this relationship is mediated through the [[nervous system]].<ref>{{cite book|vauthors=Gay RE, Nelson CF |chapter= Chiropractic philosophy|chapter-url=https://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=altrehab.section.336|veditors=Wainapel SF, Fast A |title= Alternative Medicine and Rehabilitation: a Guide for Practitioners|year=2003|isbn=978-1-888799-66-8|location= New York|publisher= [[Demos Medical Publishing]]}}</ref> Some chiropractors claim spinal manipulation can have an effect on a variety of ailments such as [[irritable bowel syndrome]] and [[asthma]].<ref name=nhs-choices>{{cite web |url=http://www.nhs.uk/conditions/chiropractic/Pages/Introduction.aspx |title=Chiropractic |publisher=[[NHS Choices]] |date=20 August 2014 |access-date=19 September 2016}}</ref>

Chiropractic philosophy includes the following perspectives:<ref name=Chiro-Beliefs>{{cite book|chapter-url=http://chiroweb.com/archives/ahcpr/chapter2.htm|chapter= Chiropractic belief systems|vauthors=Mootz RD, Phillips RB |year=1997|title= Chiropractic in the United States: Training, Practice, and Research|pages=9–16|veditors=Cherkin DC, Mootz RD |location= Rockville, MD|publisher= [[Agency for Health Care Policy and Research]]|oclc=39856366}} AHCPR Pub No. 98-N002.</ref>

[[Holism]] assumes that health is affected by everything in an individual's environment; some sources also include a spiritual or [[Existentialism|existential]] dimension.<ref>{{cite journal | author = Freeman J | title = Towards a definition of holism | journal = The British Journal of General Practice | volume = 55 | issue = 511 | pages = 154–55 | date = February 2005 | pmid = 15720949 | pmc = 1463203 }}</ref> In contrast, reductionism in chiropractic reduces causes and cures of health problems to a single factor, [[#Vertebral subluxation|vertebral subluxation]].<ref name=Murphy-pod /> [[Homeostasis]] emphasizes the body's inherent self-healing abilities. Chiropractic's early notion of innate intelligence can be thought of as a metaphor for homeostasis.<ref name=Keating05>{{cite book|author= Keating JC Jr|chapter= Philosophy in chiropractic|pages=77–98|title= Principles and Practice of Chiropractic|edition=3rd|veditors=Haldeman S, Dagenais S, Budgell B |publisher=[[McGraw-Hill]]|year=2005|isbn=978-0-07-137534-4|display-editors=etal}}</ref>

A large number of chiropractors fear that if they do not separate themselves from the traditional [[vitalistic]] concept of innate intelligence, chiropractic will continue to be seen as a fringe profession.<ref name=Kaptchuk-Eisenberg>{{cite journal |vauthors=Kaptchuk TJ, Eisenberg DM |title=Chiropractic: origins, controversies, and contributions |journal=Archives of Internal Medicine|volume=158 |issue=20 |pages=2215–24 |date=November 1998 |pmid=9818801 |doi=10.1001/archinte.158.20.2215 |doi-access=free }}</ref> A variant of chiropractic called naprapathy originated in Chicago in the early twentieth century.<ref name="Gardner1957">{{cite book|author=Martin Gardner|author-link=Martin Gardner|title=Fads and Fallacies in the Name of Science|url=https://books.google.com/books?id=TwP3SGAUsnkC&pg=PA227|date=1 June 1957|publisher=Courier Corporation|isbn=978-0-486-20394-2|pages=227–}}</ref><ref name=napra-qa/> It holds that manual manipulation of soft tissue can reduce "interference" in the body and thus improve health.<ref name=napra-qa>{{cite web |url=http://www.quackwatch.com/01QuackeryRelatedTopics/dictionary/mdglos.html |publisher=Quackwatch |title=Dictionary of Metaphysical Healthcare&nbsp;– Glossary |year=1997 |author=Raso J |access-date=12 February 2016}}</ref>

=== "Subluxation" as a Vitalist concept ===
{{Main|Vertebral subluxation}}
{{distinguish|text=[[subluxation]], the medical condition}}

In science-based medicine, the term "subluxation" refers to an incomplete or partial [[dislocation (medicine)|dislocation]] of a [[Joint dislocation|joint]], from the Latin ''luxare'' for 'dislocate'.<ref name="Merriam-Webster">{{cite web | title=Subluxation | website=Merriam-Webster | url=https://www.merriam-webster.com/dictionary/subluxation | access-date=January 4, 2018}}</ref><ref>{{cite web |url=https://www.etymonline.com/word/luxation#:~:text=luxation%20(n.),a%20word%20of%20uncertain%20origin |title=luxation (n.) |work=Online Etymology Dictionary |access-date=July 28, 2021 |url-status=live|archive-url=https://web.archive.org/web/20190501165646/https://www.etymonline.com/word/luxation |archive-date=2019-05-01 }}</ref>  While medical doctors use the term exclusively to refer to physical dislocations, Chiropractic founder D. D. Palmer imbued the word ''subluxation'' with a metaphysical and philosophical meaning drawn from pseudoscientific traditions such as [[Vitalism]].<ref name=Keating1995 />

Palmer claimed that ''vertebral subluxations'' interfered with the body's function and its inborn ability to heal itself.<ref name=History-PPC>{{cite book|vauthors= Keating JC Jr|chapter= A brief history of the chiropractic profession|pages=23–64|title= Principles and Practice of Chiropractic|edition=3rd|veditors = Haldeman S, Dagenais S, Budgell B |publisher=McGraw-Hill|year=2005|isbn=978-0-07-137534-4|display-editors=etal|author-link= Joseph C. Keating, Jr}}</ref> D. D. Palmer repudiated his earlier theory that vertebral subluxations caused pinched nerves in the intervertebral spaces in favor of subluxations causing altered nerve vibration, either too tense or too slack, affecting the tone (health) of the end organ.<ref name=Keating1995 /> He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic.<ref name=Keating1995>{{cite web|url=http://chiro.org/Plus/History/Persons/PalmerDD/PalmerDD's_Forgotten_Theories1995.pdf |archive-url=https://web.archive.org/web/20070710071140/http://www.chiro.org/Plus/History/Persons/PalmerDD/PalmerDD's_Forgotten_Theories1995.pdf |archive-date=2007-07-10 |url-status=live|title= D. D. Palmer's forgotten theories of chiropractic|last=Keating |first=J. C. Jr|publisher= [[Association for the History of Chiropractic]]|year=1995|access-date=2008-05-14}}</ref> This concept was later expanded upon by his son, B. J. Palmer, and was instrumental in providing the legal basis of differentiating chiropractic from conventional medicine. 

[[File:Xray Machine Champion Chiropractic.jpg|thumb|right|alt=|Chiropractors use [[x-ray radiography]] to examine the bone structure of a patient.]]
Vertebral subluxation, a core concept of traditional chiropractic, remains unsubstantiated and largely untested, and a debate about whether to keep it in the chiropractic paradigm has been ongoing for decades.<ref name=Keating-subluxation /> In general, critics of traditional subluxation-based chiropractic (including chiropractors) are skeptical of its clinical value, [[dogmatic]] beliefs and metaphysical approach. While straight chiropractic still retains the traditional vitalistic construct espoused by the founders, evidence-based chiropractic suggests that a mechanistic view will allow chiropractic care to become integrated into the wider health care community.<ref name=Keating-subluxation>{{cite journal |vauthors=Keating JC, Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF | title = Subluxation: dogma or science? | journal = Chiropractic & Osteopathy| volume = 13 | page = 17 | date = August 2005 | pmid = 16092955 | pmc = 1208927 | doi = 10.1186/1746-1340-13-17 | doi-access = free }}</ref> This is still a continuing source of debate within the chiropractic profession as well, with some schools of chiropractic still teaching the traditional/straight subluxation-based chiropractic, while others have moved towards an [[evidence-based]] chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions.<ref>{{cite journal|journal=Journal of Chiropractic Education|year=2000|volume=14|issue=2|pages=71–77|title=A survey of the use of evidence-based health care in chiropractic college clinics|vauthors=Rose KA, Adams A|doi=10.7899/1042-5055-14.2.71 |url=http://www.journalchiroed.com/2000/JCEFall2000Rose.PDF|archive-url=https://wayback.archive-it.org/all/20081002073736/http://www.journalchiroed.com/2000/JCEFall2000Rose.PDF|archive-date=2008-10-02}}</ref><ref>{{cite journal|journal=Journal of Manual & Manipulative Therapy|year=2006|volume=14|issue=2|pages=E14–18|title=Can chiropractors and evidence-based manual therapists work together? an opinion from a veteran chiropractor|author=Homola S|url=http://jmmtonline.com/documents/HomolaV14N2E.pdf |archive-url=https://web.archive.org/web/20070710071140/http://jmmtonline.com/documents/HomolaV14N2E.pdf |archive-date=2007-07-10 |url-status=live|doi=10.1179/jmt.2006.14.2.14E|citeseerx=10.1.1.366.2817|s2cid=71826135}}</ref>

In 2005, the [[vertebral subluxation|chiropractic subluxation]] was defined by the [[World Health Organization]] as "a lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact.<ref name=WHO-guidelines /> It is essentially a functional entity, which may influence biomechanical and neural integrity."<ref name=WHO-guidelines /> This differs from the medical definition of subluxation as a significant structural displacement, which can be seen with static imaging techniques such as [[Radio diagnostics|X-rays]].<ref name=WHO-guidelines>{{cite book |author= World Health Organization|year=2005|title= WHO guidelines on basic training and safety in chiropractic|publisher=World Health Organization |url=https://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf|isbn= 978-92-4-159371-7|archive-url=https://web.archive.org/web/20220313162309/https://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf |access-date=2008-02-29|archive-date=2022-03-13 }}</ref> The use of X-ray imaging in the case of vertebral subluxation exposes patients to harmful [[ionizing radiation]] for no evidentially supported reason.<ref>{{cite journal|last1=Jenkins|first1=H. J.|title=Awareness of radiographic guidelines for low back pain: a survey of Australian chiropractors.|journal=Chiropractic & Manual Therapies|date=5 October 2016|volume=24|page=39|doi=10.1186/s12998-016-0118-7|pmc=5051064|pmid=27713818 |doi-access=free }}</ref><ref name=Ammendolia /> The 2008 book ''[[Trick or Treatment]]'' states "X-rays can reveal neither the subluxations nor the innate intelligence associated with chiropractic philosophy, because they do not exist."<ref name=Trick-or-Treatment>{{cite book|pages=145–90|chapter=The truth about chiropractic therapy|title=Trick or Treatment: The Undeniable Facts about Alternative Medicine |last1=Singh |first1=S. |last2=Ernst |first2=E. |year=2008|publisher=W. W. Norton|isbn=978-0-393-06661-6}}</ref> [[Attorneys in the United States|Attorney]] David Chapman-Smith, Secretary-General of the [[World Federation of Chiropractic]], has stated that "Medical critics have asked how there can be a subluxation if it cannot be seen on X-ray. The answer is that the chiropractic subluxation is essentially a functional entity, not structural, and is therefore no more visible on static X-ray than a [[limp]] or headache or any other functional problem."<ref>{{cite book|page=160|chapter=Principles and Goals of Chiropractic Care|title=The Chiropractic Profession: Its Education, Practice, Research and Future Directions|author=David Chapman-Smith|year=2000|publisher=NCMIC Group|isbn=978-1-892734-02-0}}</ref> The [[General Chiropractic Council]], the statutory regulatory body for chiropractors in the United Kingdom, states that the chiropractic vertebral subluxation complex "is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease."<ref>{{cite web |url=http://www.gcc-uk.org/files/link_file/Guidance_on_claims_made_for_the_chiropractic_VSC_18August10.pdf |archive-url=https://www.webcitation.org/5xywlByZ0?url=http://www.gcc-uk.org/files/link_file/Guidance_on_claims_made_for_the_chiropractic_VSC_18August10.pdf  |archive-date=2011-04-16 |title=Guidance on claims made for the chiropractic vertebral subluxation complex |publisher=General Chiropractic Council |access-date=2010-09-30 }}</ref>

As of 2014, the US [[National Board of Chiropractic Examiners]] states "The specific focus of chiropractic practice is known as the chiropractic subluxation or joint dysfunction. A subluxation is a health concern that manifests in the skeletal joints, and, through complex anatomical and physiological relationships, affects the nervous system and may lead to reduced function, disability or illness."<ref name="NBCE_about_chiro">{{Citation |last=NBCE |date=2014 |title=About Chiropractic |publisher=[[National Board of Chiropractic Examiners]] |url=http://www.nbce.org/about/about_chiropractic/ |access-date=February 1, 2015 |archive-url=https://web.archive.org/web/20150619234625/http://www.nbce.org/about/about_chiropractic/ |archive-date=June 19, 2015  }}</ref><ref name=History-Primer2 />

=== Straights (Vitalists) versus Mixers (Materialists)===
[[File:1914 advertisement for a Straight Chiropractic as opposed to Mixer Chiropractic.png|thumb|1914 advertisement for a Straight Chiropractic as opposed to a Mixer Chiropractic]]
By 1914,<ref>{{Cite news|url=https://www.newspapers.com/article/wausau-pilot-straight-chiropractic/168799829/|title=Straight Chiropractic |via= Newspapers.com |newspaper=Wausau Pilot |location=Wausau, Wisconsin |date=Jun 23, 1914 |page=5}}</ref> chiropractors had begun to divide into two groups:  "Straights", adherents of the Palmers' supernatural [[Vitalism|vitalist]] beliefs, and "Mixers" who sought to integrate Chiropractic into science-based mainstream medicine.<ref name="Folk"/>{{rp|172}}  
{| class="wikitable floatright" style="margin-left:0.4em;"
|+ Range of belief perspectives in chiropractic
! Perspective attribute
! colspan="2" | Potential belief endpoints
|-
| Scope of practice:
| align=right | narrow ("straight") ←||→ broad ("mixer")
|-
| Philosophic orientation:
| align=right | vitalistic ←||→ materialistic
|-
| Falsifiability:
| align=right | untestable<br/>Cannot be proven or disproven || testable<br/>Lends itself to scientific inquiry
|-
| colspan="3" style="text-align: center;" | ''Taken from Mootz & Phillips 1997''<ref name=Chiro-Beliefs />
|}

Originally, ''Straight'' chiropractors adhered to  pseudoscientific Vitalist ideas set forth by D.{{nbsp}}D. and B.{{nbsp}}J. Palmer, and even modern "straights" often retain metaphysical definitions and vitalistic qualities.<ref name=History-Primer /> Straight chiropractors believed that vertebral subluxation leads to interference with an "innate intelligence" exerted via the human nervous system and is a primary underlying risk factor for many diseases.<ref name=History-Primer /> Straights view the medical diagnosis of patient complaints, which they consider to be the "secondary effects" of subluxations, to be unnecessary for chiropractic treatment.<ref name=History-Primer /> Thus, straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not "mix" other types of therapies into their practice style.<ref name=History-Primer /> Their philosophy and explanations were metaphysical in nature, and they preferred to use traditional chiropractic lexicon terminology such as "perform spinal analysis", "detect subluxation", "correct with adjustment".<ref name=Kaptchuk-Eisenberg /> They preferred to remain separate and distinct from mainstream health care.<ref name=Kaptchuk-Eisenberg /> Modernly, "Straights" are a minority among Chiropractors, though "they have been able to transform their status as purists and heirs of the lineage into influence dramatically out of proportion to their numbers."<ref name=Kaptchuk-Eisenberg />

''Mixers'', who make up the majority of chiropractors,  "mix" chiropractic with diagnostic and treatment approaches from mainstream medical and osteopathic practices.<ref name=Kaptchuk-Eisenberg /> Unlike straight chiropractors, mixers believe subluxation is just one of many causes of disease, and mixers are open to mainstream medicine.<ref name=Kaptchuk-Eisenberg/> Many mixers incorporate mainstream medical diagnostics and employ conventional medical treatments including techniques of [[physical therapy]] such as exercise, [[stretching]], [[massage]], [[ice pack]]s, [[electrical muscle stimulation]], [[therapeutic ultrasound]], and [[moist heat]].<ref name=Kaptchuk-Eisenberg /> But some mixers also use techniques from pseudoscientific alternative medicine, including unnecessary [[Dietary supplement|nutritional supplements]], [[acupuncture]], [[homeopathy]], [[Herbalism|herbal remedies]], and [[biofeedback]].<ref name=Kaptchuk-Eisenberg />  Author Holly Folk writes that "Few Mixer chiropractors use the term anymore. Today, one is more likely to hear this side described as 'holistic,' 'wellness-oriented,' or 'integrative' practitioners."<ref name="Folk">{{Cite web|url=https://books.google.com/books?id=DnlVDgAAQBAJ|title=The Religion of Chiropractic: Populist Healing from the American Heartland|first=Holly|last=Folk|date=March 13, 2017|publisher=UNC Press Books|via=Google Books}}</ref>{{rp|114}}  Folk argues that "osteopathy underwent a 'Straight-Mixer' debate between traditional vitalists and a faction that embraced the new medical science".{{rp|172}}

Although mixers are the majority group, many of them retain belief in vertebral subluxation as shown in a 2003 survey of 1,100 North American chiropractors, which found that 88 percent wanted to retain the term "vertebral subluxation complex", and that when asked to estimate the percent of disorders of internal organs that subluxation significantly contributes to, the mean response was 62 percent.<ref name=McDonald /> A 2008 survey of 6,000 American chiropractors demonstrated that most chiropractors seem to believe that a subluxation-based clinical approach may be of limited utility for addressing [[visceral disorder]]s, and greatly favored non-subluxation-based clinical approaches for such conditions.<ref name=Smith-Carber /> The same survey showed that most chiropractors generally believed that the majority of their clinical approach for addressing musculoskeletal/biomechanical disorders such as back pain was based on subluxation.<ref name=Smith-Carber>{{cite journal|journal=Journal of Chiropractic Humanities|year=2008|volume=15|pages=19–26|title=Survey of US Chiropractor Attitudes and Behaviors about Subluxation|vauthors=Smith M, Carber LA|url=http://archive.journalchirohumanities.com/Vol%2015/JChiroprHumanit2008v15-19-26.pdf|archive-url=https://web.archive.org/web/20120425234244/http://archive.journalchirohumanities.com/Vol%2015/JChiroprHumanit2008v15-19-26.pdf|archive-date=2012-04-25|doi=10.1016/s1556-3499(13)60166-7}}</ref> Chiropractors often offer conventional therapies such as physical therapy and lifestyle counseling, and it may for the lay person be difficult to distinguish the unscientific from the scientific.<ref name=Benedetti2002>{{Cite book|url=https://books.google.com/books?id=zHxockt9CWQC|title=Spin Doctors: The Chiropractic Industry Under Examination|last1=Benedetti|first1=Paul|last2=MacPhail|first2=Wayne|date=2002-01-01|publisher=Dundurn|isbn=978-1-55002-406-7|language=en|page=18}}</ref>

===Pseudoscience versus spinal manipulation therapy===
{{main|Spinal adjustment|Spinal manipulation}}

While some chiropractors limit their practice to short-term treatment of musculoskeletal conditions, many falsely claim to be able treat a myriad of other conditions.<ref name="skepinq"/><ref>{{cite book |url=https://books.google.com/books?id=vagrYOk47VEC&pg=PA198 |title=Spin Doctors: The Chiropractic Industry Under Examination |last1=Benedetti |first1=Paul |last2=MacPhail |first2=Wayne |publisher=Dundurn Group |location=Toronto |date=2002 |isbn=1-55002-406-X |page=198}}</ref> Some dissuade patients from seeking medical care, others have pretended to be qualified to act as a family doctor.<ref name="skepinq">{{cite web |url=https://skepticalinquirer.org/exclusive/chiropractors-pro-and-con/ |title=Chiropractors: Pro and Con |website=Skeptical Inquirer |last=Hall |first=Harriet |date=June 1, 2017 |access-date=July 28, 2021 |url-status=live|archive-url=https://web.archive.org/web/20200823235423/https://skepticalinquirer.org/exclusive/chiropractors-pro-and-con/ |archive-date=2020-08-23 }}</ref>

[[Quackwatch]], an alternative medicine watchdog, cautions against seeing chiropractors who:<ref name="skepinq"/><ref>{{cite web |url=https://quackwatch.org/chiropractic/ |title=Chirobase |website=Quackwatch |date=7 May 2019 |access-date=July 28, 2021 |url-status=live|archive-url=https://web.archive.org/web/20200610204236/https://quackwatch.org/chiropractic/ |archive-date=2020-06-10 }}</ref>
* Treat young children
* Discourage immunization
* Pretend to be a family doctor
* Take full spine X-rays
* Promote unproven dietary supplements
* Are antagonistic to scientific medicine
* Claim to treat non-musculoskeletal problems

Writing for the ''[[Skeptical Inquirer]]'', one physician cautioned against seeing even chiropractors who solely claim to treat musculoskeletal conditions: {{blockquote|I think [[Spinal manipulation|Spinal Manipulation Therapy]] (SMT) is a reasonable option for patients to try ... But I could not in good conscience refer a patient to a chiropractor...  When chiropractic is effective, what is effective is not 'chiropractic': it is SMT. SMT is also offered by physical therapists, DOs, and others. These are science-based providers ...  If I thought a patient might benefit from manipulation, I would rather refer him or her to a science-based provider.<ref name="skepinq"/>}}

== Scope of practice ==
[[File:Treatment Table Chiropractic.jpg|thumb|A treatment table at a chiropractic office]]

Chiropractors emphasize the conservative management of the [[human musculoskeletal system|neuromusculoskeletal system]] without the use of evidence-based medicines or surgery,<ref name=WHO-guidelines /> with special emphasis on the spine.<ref name=Nelson/> Back and neck pain are the specialties of chiropractic but many chiropractors treat ailments other than musculoskeletal issues.<ref name=Ernst-eval /> There is a range of opinions among chiropractors: some believed that treatment should be confined to the spine, or back and neck pain; others disagreed.<ref name=V-H /> For example, while one 2009 survey of American chiropractors had found that 73% classified themselves as "back pain/musculoskeletal specialists", the label "back and neck pain specialists" was regarded by 47% of them as a ''least'' desirable description in a 2005 international survey.<ref name=V-H>{{cite journal | author = Villanueva-Russell Y | title = Caught in the crosshairs: identity and cultural authority within chiropractic | journal = Social Science & Medicine| volume = 72 | issue = 11 | pages = 1826–37 | date = June 2011 | doi = 10.1016/j.socscimed.2011.03.038 | pmid = 21531061}}</ref> It has been proposed that chiropractors specialize in nonsurgical spine care, instead of attempting to also treat other problems,<ref name=Murphy-pod /><ref name="Meeker-Haldeman">{{cite journal |vauthors=Meeker WC, Haldeman S |year=2002 |title=Chiropractic: a profession at the crossroads of mainstream and alternative medicine |journal=Annals of Internal Medicine |volume=136 |issue=3 |pages=216–27 |citeseerx=10.1.1.694.4126 |doi=10.7326/0003-4819-136-3-200202050-00010 |pmid=11827498 |s2cid=16782086}}</ref> but the more expansive view of chiropractic is still widespread.<ref>{{cite journal |vauthors=Gleberzon BJ, Cooperstein R, Perle SM | title = Can chiropractic survive its chimerical nature? | journal = The Journal of the Canadian Chiropractic Association| volume = 49 | issue = 2 | pages = 69–73 | year = 2005 | pmid = 17549192 | pmc = 1840015 }}</ref>

Mainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be complementary and alternative medicine (CAM);<ref name=Chapman-Smith /> and a 2008 study reported that 31% of surveyed chiropractors categorized chiropractic as CAM, 27% as integrated medicine, and 12% as mainstream medicine.<ref name=Redwood-CAM>{{cite journal |vauthors=Redwood D, Hawk C, Cambron J, Vinjamury SP, Bedard J | title = Do chiropractors identify with complementary and alternative medicine? results of a survey | journal = The Journal of Alternative and Complementary Medicine| volume = 14 | issue = 4 | pages = 361–68 | year = 2008 | doi = 10.1089/acm.2007.0766 | pmid = 18435599}}</ref> Many chiropractors believe they are primary care providers,<ref name=Ernst-eval/><ref name=CooperMcKee2003 /> including US<ref name=Bellamy2010>{{cite journal|last1=Bellamy|first1=Jann J|title=Legislative alchemy: the US state chiropractic practice acts|journal=Focus on Alternative and Complementary Therapies|volume=15|issue=3|year=2010|pages=214–22|doi=10.1111/j.2042-7166.2010.01032.x}}</ref> and UK chiropractors,<ref name=Jones-Harris2010>{{cite journal|title=Are chiropractors in the uk primary healthcare or primary contact practitioners?: a mixed methods study|author=Jones-Harris, Amanda R|journal=Chiropractic & Osteopathy|date=October 2010|volume=18|issue=28|page=28|doi=10.1186/1746-1340-18-28| pmc=3161390|pmid=20979615 |doi-access=free }}</ref> but the length, breadth, and depth of chiropractic clinical training do not support the requirements to be considered primary care providers,<ref name=Nelson /> so their role on primary care is limited and disputed.<ref name=Nelson/><ref name=CooperMcKee2003/>

Chiropractic overlaps with several other forms of manual therapy, including massage therapy, [[osteopathy]], physical therapy, and [[sports medicine]].<ref name=Norris /><ref>{{cite journal | author = Theberge N | title = The integration of chiropractors into healthcare teams: a case study from sport medicine | journal = Sociology of Health & Illness| volume = 30 | issue = 1 | pages = 19–34 | date = January 2008 | pmid = 18254831 | doi = 10.1111/j.1467-9566.2007.01026.x | doi-access = free }}</ref> Chiropractic is autonomous from and competitive with mainstream medicine,<ref name=Pettman /> and osteopathy outside the US remains primarily a manual medical system;<ref>{{cite journal|journal= Complementary Health Practice Review|year=2006|volume=11|issue=2|pages=77–94|doi=10.1177/1533210106292467|title= The drive for legitimization by osteopathy and chiropractic in Australia: between heterodoxy and orthodoxy|author= Baer HA|doi-access=free}}</ref> physical therapists work alongside and cooperate with mainstream medicine, and [[osteopathic medicine in the U.S.]] has merged with the medical profession.<ref name=Pettman>{{cite journal | author = Pettman E | title = A history of manipulative therapy | journal = Journal of Manual & Manipulative Therapy| volume = 15 | issue = 3 | pages = 165–74 | year = 2007 | pmid = 19066664 | pmc = 2565620 | doi = 10.1179/106698107790819873 }}</ref> Practitioners may distinguish these competing approaches through claims that, compared to other therapists, chiropractors heavily emphasize spinal manipulation, tend to use firmer manipulative techniques, and promote maintenance care; that osteopaths use a wider variety of treatment procedures; and that physical therapists emphasize machinery and exercise.<ref name=Norris>{{cite journal|author= Norris P|year=2001|title= How 'we' are different from 'them': occupational boundary maintenance in the treatment of musculo-skeletal problems|journal= Sociology of Health and Illness|volume=23|issue=1|pages=24–43|doi=10.1111/1467-9566.00239|doi-access=free}}</ref>

Chiropractic diagnosis may involve a range of methods including skeletal imaging, observational and tactile assessments, and orthopedic and neurological evaluation.<ref name=WHO-guidelines /> A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider.<ref name=Meeker-Haldeman /> Common patient management involves [[spinal manipulation]] (SM) and other manual therapies to the joints and soft tissues, rehabilitative exercises, health promotion, electrical modalities, complementary procedures, and lifestyle advice.<ref name=content-of-practice/>

[[File:Dr. Heidi Bockhold Adjusts Horse.jpg|thumb|left|A chiropractic adjustment of a horse]]

Chiropractors are not normally licensed to write [[medical prescription]]s or perform major surgery in the United States<ref name=Parkman /> (although [[New Mexico]] has become the first US state to allow "advanced practice" trained chiropractors to prescribe certain medications<ref>[http://www.nmcpr.state.nm.us/nmac/parts/title16/16.004.0015.htm "Occupational And Professional Licensing, Chiropractic Practitioners, Chiropractic Advanced Practice Certification Registry"]. State of New Mexico. {{Webarchive|url=https://web.archive.org/web/20100317015229/http://www.nmcpr.state.nm.us/nmac/parts/title16/16.004.0015.htm |date=2010-03-17 }}. Retrieved 2010-05-03.</ref><ref>[http://www.rld.state.nm.us/uploads/files/2010%20APC%20Formulary%281%29.pdf "Occupational And Professional Licensing, Chiropractic Practitioners, Chiropractic Advanced Practice Certification Registry"] (PDF). State of New Mexico. Retrieved 2010-05-03.</ref>). In the US, their scope of practice varies by state, based on inconsistent views of chiropractic care: some states, such as [[Iowa]], broadly allow treatment of "human ailments"; some, such as [[Delaware]], use vague concepts such as "transition of nerve energy" to define scope of practice; others, such as [[New Jersey]], specify a severely narrowed scope.<ref name=Morrison>{{cite journal | author = Morrison P | title = Adjusting the role of chiropractors in the United States: why narrowing chiropractor scope of practice statutes will protect patients | journal = Health Matrix | volume = 19 | issue = 2 | pages = 493–537 | year = 2009 | pmid = 19715143 }}</ref> US states also differ over whether chiropractors may conduct laboratory tests or diagnostic procedures, dispense dietary supplements, or use other therapies such as homeopathy and acupuncture; in [[Oregon]] they can become certified to perform minor surgery and to deliver children via natural childbirth.<ref name=Parkman>{{cite journal | vauthors = Parkman CA | title = Issues in credentialing CAM providers | journal = The Case Manager| volume = 15 | issue = 4 | pages = 24–27 | year = 2004 | doi = 10.1016/j.casemgr.2004.05.004 | pmid = 15247891}}</ref> A 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for [[over-the-counter drug]]s.<ref name=McDonald>{{cite book|vauthors=McDonald WP, Durkin KF, Pfefer M |year=2003|title=How Chiropractors Think and Practice: The Survey of North American Chiropractors|location=Ada, Ohio|publisher=Institute for Social Research, Ohio Northern University|isbn=978-0-9728055-5-1 |display-authors=etal}}{{page needed|date=May 2013}}</ref> A 2010 survey found that 72% of Swiss chiropractors considered their ability to prescribe nonprescription medication as an advantage for chiropractic treatment.<ref>{{cite journal |vauthors=Wangler M, Zaugg B, Faigaux E | title = Medication Prescription: A Pilot Survey of Bernese Doctors of Chiropractic Practicing in Switzerland | journal = Journal of Manipulative and Physiological Therapeutics| volume = 33 | issue = 3 | pages = 231–237 | year = 2010 | pmid = 20350678 | doi = 10.1016/j.jmpt.2010.01.013 }}</ref>

A related field, [[veterinary chiropractic]], applies manual therapies to animals and is recognized in many US states,<ref name=AVMAScope>{{cite web|title=Scope of Practice: Complementary and alternative veterinary medicine (CAVM) and other practice act exemptions|url=https://www.avma.org/Advocacy/StateAndLocal/Pages/sr-cavm-exemptions.aspx|website=[[American Veterinary Medical Association]]|access-date=April 1, 2016|date=May 2019|archive-date=April 4, 2016|archive-url=https://web.archive.org/web/20160404015034/https://www.avma.org/Advocacy/StateAndLocal/Pages/sr-cavm-exemptions.aspx}}</ref> but is not recognized by the [[American Chiropractic Association]] as being chiropractic.<ref>{{cite web|url=http://amerchiro.org/level2_css.cfm?T1ID=10&T2ID=117#107 |access-date=2008-07-05 |title='Veterinary' chiropractic |year=1994 |author=ACA House of Delegates |publisher=[[American Chiropractic Association]]  |archive-url=https://web.archive.org/web/20080517055938/http://www.amerchiro.org/level2_css.cfm?T1ID=10&T2ID=117#107 |archive-date=May 17, 2008 }}</ref> It remains controversial within certain segments of the veterinary and chiropractic professions.<ref>{{cite magazine |magazine=[[Dynamic Chiropractic]] |volume=19 |issue=13 |url=https://www.dynamicchiropractic.com/mpacms/dc/article.php?id=18081 |first=Daniel|last=Kamen |title= Politics and technique|date=June 18, 2001}}</ref>

No single profession "owns" spinal manipulation and there is little consensus as to which profession should administer SM, raising concerns by chiropractors that other medical physicians could "steal" SM procedures from chiropractors.<ref name=Villanueva-Russell /> A focus on evidence-based SM research has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.<ref name=Villanueva-Russell>{{cite journal|author=Villanueva-Russell Y|title=Evidence-based medicine and its implications for the profession of chiropractic|journal=Social Science & Medicine|volume=60|issue=3|pages=545–61|year=2005|doi=10.1016/j.socscimed.2004.05.017|pmid=15550303}}</ref> Two US states (Washington and Arkansas) prohibit physical therapists from performing SM,<ref>{{cite news |last=Anderson |first=Chantal |title=Physical therapists, chiropractors square off over bill |url=http://blog.seattletimes.nwsource.com/politicsnorthwest/2009/01/22/the_campus_is_heating_up.html |date=2009-01-22 |work=The Seattle Times |access-date=2010-09-23  |archive-url=https://web.archive.org/web/20100922091855/http://blog.seattletimes.nwsource.com/politicsnorthwest/2009/01/22/the_campus_is_heating_up.html |archive-date=2010-09-22 }}</ref> some states allow them to do it only if they have completed advanced training in SM, and some states allow only chiropractors to perform SM, or only chiropractors and physicians. Bills to further prohibit non-chiropractors from performing SM are regularly introduced into state legislatures and are opposed by physical therapist organizations.<ref>{{cite journal |journal=DePaul Journal of Health Care Law |year=2004 |volume=8 |issue=1 |pages=237–61 |title= State practice acts of licensed health professions: scope of practice |url=https://via.library.depaul.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1155&context=jhcl |vauthors=Hilliard JW, Johnson ME }}</ref>

== Treatments ==
{{Main|Chiropractic treatment techniques|Spinal adjustment}}
[[File:Chiropractic spinal adjustment.jpg|thumb|A chiropractor performs an adjustment on a patient.]]

Spinal manipulation, which chiropractors call "spinal adjustment" or "chiropractic adjustment", is the most common treatment used in chiropractic care.<ref name=NBCE_techniques /> Spinal manipulation is a passive manual maneuver during which a three-joint complex is taken past the normal range of movement, but not so far as to dislocate or damage the joint.<ref name=ACA-SMP /> Its defining factor is a dynamic thrust, which is a sudden force that causes an audible release and attempts to increase a joint's range of motion.<ref name=ACA-SMP /> High-velocity, low-amplitude spinal manipulation (HVLA-SM) thrusts have physiological effects that signal neural discharge from paraspinal muscle tissues, depending on duration and amplitude of the thrust are factors of the degree in paraspinal muscle spindles activation.<ref name=Pickar2007 /> Clinical skill in employing HVLA-SM thrusts depends on the ability of the practitioner to handle the duration and magnitude of the load.<ref name=Pickar2007>{{cite journal |vauthors=Pickar JG, Sung PS, Kang YM, Ge W | title = Response of lumbar paraspinal muscles spindles is greater to spinal manipulative loading compared with slower loading under length control | journal = The Spine Journal| volume = 7 | issue = 5 | pages = 583–95 | year = 2007 | pmid = 17905321 | pmc = 2075482 | doi = 10.1016/j.spinee.2006.10.006 }}</ref> More generally, [[spinal manipulative therapy]] (SMT) describes techniques where the hands are used to manipulate, massage, mobilize, adjust, stimulate, apply traction to, or otherwise influence the spine and related tissues.<ref name=ACA-SMP>{{cite web|url=http://acatoday.org/pdf/spinal_manipulation_policy.pdf|title=Spinal manipulation policy statement|vauthors=Winkler K, Hegetschweiler-Goertz C, Jackson PS|access-date=2008-05-24|year=2003|publisher=American Chiropractic Association|display-authors=etal|archive-url=https://web.archive.org/web/20110720114044/http://www.acatoday.org/pdf/spinal_manipulation_policy.pdf|archive-date=2011-07-20}}</ref>

There are several schools of chiropractic adjustive techniques, although most chiropractors mix techniques from several schools. The following adjustive procedures were received by more than 10% of patients of licensed US chiropractors in a 2003 survey:<ref name=NBCE_techniques /> [[Diversified technique]] (full-spine manipulation, employing various techniques), extremity adjusting, [[Activator technique]] (which uses a spring-loaded tool to deliver precise adjustments to the spine), Thompson Technique (which relies on a drop table and detailed procedural protocols), [[Clarence Gonstead#Gonstead Technique|Gonstead]] (which emphasizes evaluating the spine along with specific adjustment that avoids rotational vectors), Cox/flexion-distraction (a gentle, low-force adjusting procedure which mixes chiropractic with osteopathic principles and utilizes specialized adjusting tables with movable parts), adjustive instrument, Sacro-Occipital Technique (which models the spine as a torsion bar), [[Neuromuscular therapy|Nimmo Receptor-Tonus Technique]], [[applied kinesiology]] (which emphasises "muscle testing" as a diagnostic tool), and cranial.<ref>{{cite book|title=Technique Systems in Chiropractic|vauthors=Cooperstein R, Gleberzon BJ |publisher=Churchill Livingstone|year=2004|isbn=978-0-443-07413-4|ref=TSC }}{{page needed|date=May 2013}}</ref> Chiropractic biophysics technique uses inverse functions of rotations during spinal manipulation.<ref>{{cite journal |vauthors=Harrison DD, Janik TJ, Harrison GR, Troyanovich S, Harrison DE, Harrison SO |title=Chiropractic biophysics technique: a linear algebra approach to posture in chiropractic |journal=Journal of Manipulative and Physiological Therapeutics|volume=19 |issue=8 |pages=525–35 |year=1996 |pmid=8902664}}</ref> [[Chiropractic treatment techniques#Koren Specific Technique|Koren Specific Technique]] (KST) may use their hands, or they may use an electric device known as an "ArthroStim" for assessment and spinal manipulations.<ref name=Aetna/> Insurers in the US and UK that cover other chiropractic techniques exclude KST from coverage because they consider it to be "experimental and investigational".<ref name=Aetna>{{cite web|title=Provider Manual for Chiropractic Services|url=https://www.nd.gov/dhs/services/medicalserv/medicaid/docs/chiropractic-manual.pdf|website=North Dakota Department of Human Services|publisher=State of North Dakota|access-date=2016-04-14|archive-url=https://web.archive.org/web/20160408173429/http://www.nd.gov/dhs/services/medicalserv/medicaid/docs/chiropractic-manual.pdf|archive-date=2016-04-08}}</ref><ref>{{Cite web| title = Complementary and Alternative Therapies Evidence Based Decision Making Framework| author = NHS Leeds West CCG Assurance Committee| work = leedswestccg.nhs.uk| date = 2014-01-02| access-date = 2015-06-30| url = http://www.leedswestccg.nhs.uk/content/uploads/2014/07/Complementary-and-alternative-therapies.pdf| archive-url = https://web.archive.org/web/20160304065519/http://www.leedswestccg.nhs.uk/content/uploads/2014/07/Complementary-and-alternative-therapies.pdf| archive-date = 2016-03-04}}</ref><ref>{{citation|title=Chiropractic Services - Policy|url=http://www.aetna.com/cpb/medical/data/100_199/0107.html|website=Aetna|access-date=29 March 2016|archive-url=https://web.archive.org/web/20160324082643/http://www.aetna.com/cpb/medical/data/100_199/0107.html|archive-date=24 March 2016}}</ref><ref>{{cite web|title=Chiropractic Policy|url=https://osuhealthplan.com/sites/all/themes/osuhealthplan/pdf/policies/Chiropractic%20Policy.pdf|archive-url=https://web.archive.org/web/20170105054235/https://osuhealthplan.com/sites/all/themes/osuhealthplan/pdf/policies/Chiropractic%20Policy.pdf|archive-date=5 January 2017|publisher=Oklahoma State University Health Plan|access-date=14 April 2016|date=1 April 2016}}</ref> Medicine-assisted manipulation, such as [[manipulation under anesthesia]], involves sedation or local anesthetic and is done by a team that includes an [[anesthesiologist]]; a 2008 [[systematic review]] did not find enough evidence to make recommendations about its use for chronic low back pain.<ref>{{cite journal |vauthors=Dagenais S, Mayer J, Wooley JR, Haldeman S | title = Evidence-informed management of chronic low back pain with medicine-assisted manipulation | journal = The Spine Journal| volume = 8 | issue = 1 | pages = 142–49 | year = 2008 | doi = 10.1016/j.spinee.2007.09.010 | pmid = 18164462}}</ref>

[[File:Manuellterapi5.jpg|thumb|450px|[[Lumbar spine|Lumbar]], [[cervical spine|cervical]] and [[thoracic spine|thoracic]] chiropractic spinal manipulation]]

Many other procedures are used by chiropractors for treating the spine, other joints and tissues, and general health issues. The following procedures were received by more than one-third of patients of licensed US chiropractors in a 2003 survey: Diversified technique (full-spine manipulation; mentioned in previous paragraph), [[physical fitness]]/exercise promotion, corrective or therapeutic exercise, [[ergonomic]]/[[Neutral spine|postural]] advice, [[self-care]] strategies, [[activities of daily living]], changing risky/unhealthy behaviors, [[Diet (nutrition)|nutritional/dietary]] recommendations, [[Relaxation technique|relaxation]]/[[stress reduction]] recommendations, [[Cryotherapy|ice pack/cryotherapy]], extremity adjusting (also mentioned in previous paragraph), trigger point therapy, and [[disease prevention]]/early [[Screening (medicine)|screening]] advice.<ref name=NBCE_techniques>{{cite book|title= Job Analysis of Chiropractic|chapter= Professional functions and treatment procedures|year=2005|pages=121–38|vauthors=Christensen MG, Kollasch MW |location= Greeley, CO|publisher= [[National Board of Chiropractic Examiners]]|chapter-url=http://nbce.org/pdfs/job-analysis/chapter_10.pdf|access-date=2008-08-25|isbn=978-1-884457-05-0 |url= http://nbce.org/pdfs/job-analysis/chapter_10.pdf|archive-url= https://wayback.archive-it.org/all/20080910235612/http://nbce.org/pdfs/job-analysis/chapter_10.pdf|archive-date=2008-09-10}}</ref>

A 2010 study describing Belgian chiropractors and their patients found chiropractors in Belgium mostly focus on neuromusculoskeletal complaints in adult patients, with emphasis on the spine.<ref name=Ailliet2010 /> The diversified technique is the most often applied technique at 93%, followed by the Activator mechanical-assisted technique at 41%.<ref name=Ailliet2010>{{cite journal |vauthors=Ailliet L, Rubinstein SM, de Vet HC | title = Characteristics of chiropractors and their patients in Belgium | journal = Journal of Manipulative and Physiological Therapeutics| volume = 33 | issue = 8 | pages = 618–25 | date = October 2010 | pmid = 21036284 | doi = 10.1016/j.jmpt.2010.08.011 }}</ref> A 2009 study assessing chiropractic students giving or receiving spinal manipulations while attending a United States chiropractic college found Diversified, Gonstead, and upper cervical manipulations are frequently used methods.<ref>{{cite journal |vauthors=Ndetan HT, Rupert RL, Bae S, Singh KP | title = Prevalence of musculoskeletal injuries sustained by students while attending a chiropractic college | journal = Journal of Manipulative and Physiological Therapeutics| volume = 32 | issue = 2 | pages = 140–48 | date = February 2009 | pmid = 19243726 | doi = 10.1016/j.jmpt.2008.12.012 }}</ref>

=== Practice guidelines ===

Reviews of research studies within the chiropractic community have been used to generate practice guidelines outlining standards that specify which chiropractic treatments are legitimate (i.e. supported by evidence) and conceivably reimbursable under [[managed care]] health payment systems.<ref name=Villanueva-Russell /> Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs [[antiscientific]] reasoning and makes unsubstantiated claims.<ref name=Nelson /><ref name=History-Primer2>{{cite web|title=Chiropractic history: a primer |author=Joseph C. Keating Jr. |author2=Cleveland CS III |author3=Menke M |url=http://www.historyofchiropractic.org/assets/documents/ChiroHistoryPrimer.pdf |year=2005 |access-date=2008-06-16 |publisher=Association for the History of Chiropractic |archive-date=19 June 2013 |archive-url=https://web.archive.org/web/20130619204140/http://www.historyofchiropractic.org/assets/documents/ChiroHistoryPrimer.pdf |quote=A significant and continuing barrier to scientific progress within chiropractic are the anti-scientific and pseudo-scientific ideas (Keating 1997b) which have sustained the profession throughout a century of intense struggle with political medicine. Chiropractors' tendency to assert the meaningfulness of various theories and methods as a counterpoint to allopathic charges of quackery has created a defensiveness which can make critical examination of chiropractic concepts difficult (Keating and Mootz 1989). One example of this conundrum is the continuing controversy about the presumptive target of DCs' adjustive interventions: subluxation (Gatterman 1995; Leach 1994).  |author-link=Joseph C. Keating, Jr }}</ref><ref name=Keating-subluxation /><ref>{{cite journal |author=Joseph C. Keating Jr. |journal=Skeptical Inquirer |volume=21 |issue=4 |pages=37–43 |title=Chiropractic: science and antiscience and pseudoscience side by side |year=1997|author-link=Joseph C. Keating, Jr }}</ref><ref>{{cite book|author= Phillips RB|chapter= The evolution of vitalism and materialism and its impact on philosophy|pages=65–76|title= Principles and Practice of Chiropractic|edition=3rd|veditors=Haldeman S, Dagenais S, Budgell B |publisher=[[McGraw-Hill]]|year=2005|isbn=978-0-07-137534-4|display-editors=etal}}</ref> Chiropractic remains at a crossroads, and that in order to progress it would need to embrace science; the promotion by some for it to be a cure-all was both "misguided and irrational".<ref name=Reggars2011>{{cite journal | author = Reggars JW | title = Chiropractic at the crossroads or are we just going around in circles? | journal = Chiropractic & Manual Therapies| volume = 19 | page = 11 | year = 2011 | pmid = 21599991 | pmc = 3119029 | doi = 10.1186/2045-709X-19-11 | doi-access = free }}</ref> 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.<ref>{{cite journal |vauthors=Suter E, Vanderheyden LC, Trojan LS, Verhoef MJ, Armitage GD | title = How important is research-based practice to chiropractors and massage therapists? | journal = Journal of Manipulative and Physiological Therapeutics| volume = 30 | issue = 2 | pages = 109–15 | date = February 2007 | pmid = 17320731 | doi = 10.1016/j.jmpt.2006.12.013 }}</ref> Specific guidelines concerning the treatment of nonspecific (i.e., unknown cause) low back pain are inconsistent between countries.<ref name=Murphy>{{cite journal |vauthors=Murphy AY, van Teijlingen ER, Gobbi MO | title = Inconsistent grading of evidence across countries: a review of low back pain guidelines | journal = Journal of Manipulative and Physiological Therapeutics| volume = 29 | issue = 7 | pages = 576–81, 581.e1–2 | date = September 2006 | pmid = 16949948 | doi = 10.1016/j.jmpt.2006.07.005 }}</ref>

=== Effectiveness ===
Numerous controlled clinical studies of treatments used by chiropractors have been conducted, with varied results.<ref name=Ernst-eval/>  There is no conclusive evidence that chiropractic manipulative treatment is effective for the treatment of any medical condition, except perhaps for certain kinds of back pain.<ref name=Ernst-eval /><ref name=Posadzki-Ernst/>

Generally, the research carried out into the effectiveness of chiropractic has been of poor quality.<ref name=Ernst-Canter>{{cite journal |vauthors=Ernst E, Canter PH | title = A systematic review of systematic reviews of spinal manipulation | journal = Journal of the Royal Society of Medicine| volume = 99 | issue = 4 | pages = 192–96 | date = April 2006 | pmid = 16574972 | pmc = 1420782 | doi = 10.1177/014107680609900418}}
*{{cite news |date=March 22, 2006 |title=Back treatment 'has few benefits' |work=BBC News |url=http://news.bbc.co.uk/2/hi/health/4824594.stm}}</ref><ref>{{cite journal |vauthors=Johnston BC, da Costa BR, Devereaux PJ, Akl EA, Busse JW | title = The use of expertise-based randomized controlled trials to assess spinal manipulation and acupuncture for low back pain: a systematic review | journal = Spine| volume = 33 | issue = 8 | pages = 914–18 | date = April 2008 | pmid = 18404113 | doi = 10.1097/BRS.0b013e31816b4be4| s2cid = 28092478 }}</ref>  Research published by chiropractors is distinctly biased: reviews of SM for back pain tended to find positive conclusions when authored by  chiropractors, while reviews by mainstream authors did not.<ref name=Ernst-eval/>

There is a wide range of ways to measure treatment outcomes.<ref>{{cite journal |vauthors=Khorsan R, Coulter ID, Hawk C, Choate CG | title = Measures in chiropractic research: choosing patient-based outcome assessments | journal = Journal of Manipulative and Physiological Therapeutics| volume = 31 | issue = 5 | pages = 355–75 | date = June 2008 | pmid = 18558278 | doi = 10.1016/j.jmpt.2008.04.007 }}</ref> Chiropractic care benefits from the [[placebo response]],<ref>{{cite journal | author = Kaptchuk TJ | title = The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance? | journal = Annals of Internal Medicine| volume = 136 | issue = 11 | pages = 817–25 | date = June 2002 | pmid = 12044130 | doi = 10.7326/0003-4819-136-11-200206040-00011 | citeseerx = 10.1.1.694.4848 | s2cid = 207535762 }}</ref> but it is difficult to construct a trustworthy placebo for clinical trials of spinal manipulative therapy (SMT).<ref>{{cite journal | vauthors = Hancock MJ, Maher CG, Latimer J, McAuley JH | title = Selecting an appropriate placebo for a trial of spinal manipulative therapy | journal = Australian Journal of Physiotherapy| volume = 52 | issue = 2 | pages = 135–38 | year = 2006 | pmid = 16764551 | doi = 10.1016/S0004-9514(06)70049-6 | doi-access = free }}</ref> The efficacy of maintenance care in chiropractic is unknown.<ref name=Leboeuf-Yde-C/>

Available evidence covers the following conditions:
* '''[[Low back pain]]'''. A 2013 [[Cochrane review]] found very low to moderate evidence that SMT was no more effective than inert interventions, sham SMT or as an adjunct therapy for acute low back pain.<ref name=Cochrane-2013>{{cite journal |vauthors=Rubinstein SM, Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW | title = Spinal manipulative therapy for acute low back pain: an update of the cochrane review | journal = Spine| volume = 38 | issue = 3 | pages = E158–77 | date = February 2013 | pmid = 23169072 | doi = 10.1097/BRS.0b013e31827dd89d | type = Systematic Review | hdl = 2066/109576 | s2cid = 28795577 | hdl-access = free }}</ref> The same review found that SMT appears to be no better than other recommended therapies.<ref name=Cochrane-2013/> A 2012 overview of systematic reviews found that collectively, SM failed to show it is an effective intervention for pain.<ref>{{cite journal | author = Posadzki P | title = Is spinal manipulation effective for pain? An overview of systematic reviews | journal = Pain Medicine| volume = 13 | issue = 6 | pages = 754–61 | year = 2012 | pmid = 22621391 | doi = 10.1111/j.1526-4637.2012.01397.x | doi-access = free }}</ref> A 2011 Cochrane review found strong evidence that suggests there is no clinically meaningful difference between SMT and other treatments for reducing pain and improving function for chronic low back pain.<ref>{{cite journal |vauthors=Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW | title = Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review | journal = Spine| volume = 36 | issue = 13 | pages = E825–46 | date = June 2011 | pmid = 21593658 | doi = 10.1097/BRS.0b013e3182197fe1 | type = Systematic review | hdl = 1887/117578 | s2cid = 5061433 | hdl-access = free }}</ref> A 2010 Cochrane review found no difference between the effects of combined chiropractic treatments and other treatments for chronic or mixed duration low back pain.<ref>{{cite journal |vauthors=Walker BF, French SD, Grant W, Green S | title = Combined chiropractic interventions for low-back pain | journal = Cochrane Database of Systematic Reviews| issue = 4 | page = CD005427 | year = 2010 | volume = 2010 | pmid = 20393942 | doi = 10.1002/14651858.CD005427.pub2 | pmc = 6984631 | editor1-last = Walker | editor1-first = Bruce F }}</ref> A 2010 systematic review found that most studies suggest SMT achieves equivalent or superior improvement in pain and function when compared with other commonly used interventions for short, intermediate, and long-term follow-up.<ref name=Dagenais-2010>{{cite journal |vauthors=Dagenais S, Gay RE, Tricco AC, Freeman MD, Mayer JM | title = NASS Contemporary Concepts in Spine Care: spinal manipulation therapy for acute low back pain | journal = The Spine Journal| volume = 10 | issue = 10 | pages = 918–40 | date = October 2010 | pmid = 20869008 | doi = 10.1016/j.spinee.2010.07.389 }}</ref> 
* '''[[Radiculopathy]]'''. A 2013 systematic review and meta-analysis found a statistically significant improvement in overall recovery from sciatica following SM, when compared to usual care, and suggested that SM may be considered.<ref>{{cite journal |vauthors=Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, Hendry M, Phillips CJ, Nafees S, Fitzsimmons D, Rickard I, Wilkinson C | title = Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses | journal = The Spine Journal| volume =15  | issue =   6|pages=1461–77| year = 2013 | doi = 10.1016/j.spinee.2013.08.049| pmid = 24412033| url = http://eprints.hud.ac.uk/id/eprint/19023/3/Manuscript_-_sciatica_MTC_paper_%252820130628%2529.pdf }}</ref> There is moderate quality evidence to support the use of SM for the treatment of acute [[Sciatica|lumbar radiculopathy]]<ref name=Leininger2011>{{cite journal |vauthors=Leininger B, Bronfort G, Evans R, Reiter T | title = Spinal manipulation or mobilization for radiculopathy: a systematic review | journal = Physical Medicine and Rehabilitation Clinics of North America| volume = 22 | issue = 1 | pages = 105–25 | date = February 2011 | pmid = 21292148 | doi = 10.1016/j.pmr.2010.11.002 }}</ref> and acute lumbar [[disc herniation]] with associated radiculopathy.<ref>{{cite journal |vauthors=Hahne AJ, Ford JJ, McMeeken JM | title = Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review | journal = Spine| volume = 35 | issue = 11 | pages = E488–504 | date = May 2010 | pmid = 20421859 | doi = 10.1097/BRS.0b013e3181cc3f56 | s2cid = 19121111 | url = https://figshare.com/articles/thesis/Conservative_management_of_lumbar_disc_herniation_with_associated_radiculopathy/21857094 }}</ref> There is low or very low evidence supporting SM for chronic lumbar spine-related extremity symptoms and cervical spine-related extremity symptoms of any duration and no evidence exists for the treatment of thoracic radiculopathy.<ref name=Leininger2011 />
* '''[[Whiplash (medicine)|Whiplash]] and other [[neck pain]]'''. There is no consensus on the effectiveness of manual therapies for [[neck pain]].<ref name=Vernon>{{cite journal |vauthors=Vernon H, Humphreys BK | title = Manual therapy for neck pain: an overview of randomized clinical trials and systematic reviews | journal = Europa Medicophysica| volume = 43 | issue = 1 | pages = 91–118 | year = 2007 | pmid = 17369783 | url = http://www.minervamedica.it/en/getfreepdf.php?cod=R33Y2007N01A0091 | format = PDF }}</ref> A 2013 systematic review found that the data suggests that there are minimal short- and long-term treatment differences when comparing manipulation or mobilization of the cervical spine to physical therapy or exercise for neck pain improvement.<ref>{{cite journal |vauthors=Schroeder J, Kaplan L, Fischer DJ, Skelly AC | title = The Outcomes of Manipulation or Mobilization Therapy Compared with Physical Therapy or Exercise for Neck Pain: A Systematic Review | journal = Evidence-Based Spine-Care Journal| volume = 4 | issue = 1 | pages = 30–41 | year = 2013 | pmid = 24436697 | pmc = 3699243 | doi = 10.1055/s-0033-1341605 }}</ref> A 2013 systematic review found that although there is insufficient evidence that thoracic SM is more effective than other treatments, it is a suitable intervention to treat some patients with non-specific neck pain.<ref>{{cite journal |vauthors=Huisman PA, Speksnijder CM, de Wijer A | title = The effect of thoracic spine manipulation on pain and disability in patients with non-specific neck pain: a systematic review | journal = Disability and Rehabilitation| volume = 35| issue = 20| pages = 1677–85 | date = January 2013 | pmid = 23339721 | doi = 10.3109/09638288.2012.750689 | s2cid = 12159586 }}</ref> A 2011 systematic review found that thoracic SM may offer short-term improvement for the treatment of acute or subacute mechanical neck pain; although the body of literature is still weak.<ref>{{cite journal |vauthors=Cross KM, Kuenze C, Grindstaff TL, Hertel J | title = Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: a systematic review | journal = Journal of Orthopaedic & Sports Physical Therapy| volume = 41 | issue = 9 | pages = 633–42 | date = September 2011 | pmid = 21885904 | doi = 10.2519/jospt.2011.3670 | doi-access = free }}</ref> A 2010 Cochrane review found low quality evidence that suggests cervical manipulation may offer better short-term pain relief than a control for neck pain, and moderate evidence that cervical manipulation and mobilization produced similar effects on pain, function and patient satisfaction.<ref>{{cite journal |vauthors=Gross A, Miller J, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL | title = Manipulation or mobilisation for neck pain: a Cochrane Review | journal = Manual Therapy| volume = 15 | issue = 4 | pages = 315–33 | date = August 2010 | pmid = 20510644 | doi = 10.1016/j.math.2010.04.002 }}</ref> A 2010 systematic review found low level evidence that suggests chiropractic care improves cervical range of motion and pain in the management of whiplash.<ref>{{cite journal |vauthors=Shaw L, Descarreaux M, Bryans R, Duranleau M, Marcoux H, Potter B, Ruegg R, Watkin R, White E | title = A systematic review of chiropractic management of adults with Whiplash-Associated Disorders: recommendations for advancing evidence-based practice and research | journal = Work| volume = 35 | issue = 3 | pages = 369–94 | year = 2010 | pmid = 20364057 | doi = 10.3233/WOR-2010-0996 }}</ref>
* '''Headache'''. There is conflicting evidence surrounding the use of chiropractic SMT for the treatment and prevention of [[migraine headache]]s.<ref>{{cite journal |vauthors=Chaibi A, Tuchin PJ, Russell MB | title = Manual therapies for migraine: a systematic review | journal = [[The Journal of Headache and Pain]]| volume = 12 | issue = 2 | pages = 127–33 | date = April 2011 | pmid = 21298314 | pmc = 3072494 | doi = 10.1007/s10194-011-0296-6 }}</ref><ref>{{cite journal |vauthors=Posadzki P, Ernst E | title = Spinal manipulations for the treatment of migraine: a systematic review of randomized clinical trials | journal = Cephalalgia| volume = 31 | issue = 8 | pages = 964–70 | date = June 2011 | pmid = 21511952 | doi = 10.1177/0333102411405226 | s2cid = 31205541 | doi-access = free }}</ref> A 2006 review found no rigorous evidence supporting SM or other manual therapies for [[tension headache]].<ref>{{cite journal |vauthors=Fernández-de-Las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA | title = Are manual therapies effective in reducing pain from tension-type headache?: a systematic review | journal = The Clinical Journal of Pain| volume = 22 | issue = 3 | pages = 278–85 | year = 2006 | pmid = 16514329 | doi = 10.1097/01.ajp.0000173017.64741.86 | s2cid = 23367185 }}</ref> A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for [[migraine]].<ref>{{cite journal | author = Biondi DM | title = Physical treatments for headache: a structured review | journal = Headache| volume = 45 | issue = 6 | pages = 738–46 | date = June 2005 | pmid = 15953306 | doi = 10.1111/j.1526-4610.2005.05141.x | s2cid = 42640492 }}</ref>
* '''Extremity conditions'''. A 2011 systematic review and meta-analysis concluded that the addition of manual mobilizations to an exercise program for the treatment of knee osteoarthritis resulted in better pain relief than a supervised exercise program alone and suggested that manual therapists consider adding manual mobilization to optimize supervised active exercise programs.<ref>{{cite journal |vauthors=Jansen MJ, Viechtbauer W, Lenssen AF, Hendriks EJ, de Bie RA | title = Strength training alone, exercise therapy alone, and exercise therapy with passive manual mobilisation each reduce pain and disability in people with knee osteoarthritis: a systematic review | journal = Journal of Physiotherapy| volume = 57 | issue = 1 | pages = 11–20 | year = 2011 | pmid = 21402325 | doi = 10.1016/S1836-9553(11)70002-9 | doi-access = free }}</ref> There is silver level evidence that manual therapy is more effective than exercise for the treatment of hip osteoarthritis, however this evidence could be considered to be inconclusive.<ref>{{cite journal |vauthors=French HP, Brennan A, White B, Cusack T | title = Manual therapy for osteoarthritis of the hip or knee - a systematic review | journal = Manual Therapy| volume = 16 | issue = 2 | pages = 109–17 | date = April 2011 | pmid = 21146444 | doi = 10.1016/j.math.2010.10.011 }}</ref> There is a small amount of research into the efficacy of chiropractic treatment for [[upper limb]]s,<ref>{{cite journal |vauthors=McHardy A, Hoskins W, Pollard H, Onley R, Windsham R | title = Chiropractic treatment of upper extremity conditions: a systematic review | journal = Journal of Manipulative and Physiological Therapeutics| volume = 31 | issue = 2 | pages = 146–59 | date = February 2008 | pmid = 18328941 | doi = 10.1016/j.jmpt.2007.12.004 }}</ref> limited to low level evidence supporting chiropractic management of [[shoulder pain]]<ref>{{cite journal |vauthors=Pribicevic M, Pollard H, Bonello R, de Luca K | title = A systematic review of manipulative therapy for the treatment of shoulder pain | journal = Journal of Manipulative and Physiological Therapeutics| volume = 33 | issue = 9 | pages = 679–89 | year = 2010 | pmid = 21109059 | doi = 10.1016/j.jmpt.2010.08.019 }}</ref> and limited or fair evidence supporting chiropractic management of leg conditions.<ref name=BrantinghamBonnefin2012>{{cite journal|last1=Brantingham|first1=James W.|last2=Bonnefin|first2=Debra|last3=Perle|first3=Stephen M.|last4=Cassa|first4=Tammy Kay|last5=Globe|first5=Gary|last6=Pribicevic|first6=Mario|last7=Hicks|first7=Marian|last8=Korporaal|first8=Charmaine|title=Manipulative Therapy for Lower Extremity Conditions: Update of a Literature Review|journal=Journal of Manipulative and Physiological Therapeutics|volume=35|issue=2|year=2012|pages=127–66|doi=10.1016/j.jmpt.2012.01.001|pmid=22325966}}</ref>
* '''Other'''. A 2012 systematic review found insufficient low bias evidence to support the use of spinal manipulation as a therapy for the treatment of hypertension.<ref>{{cite journal |vauthors=Mangum K, Partna L, Vavrek D | title = Spinal manipulation for the treatment of hypertension: a systematic qualitative literature review | journal = Journal of Manipulative and Physiological Therapeutics| volume = 35 | issue = 3 | pages = 235–43 | year = 2012 | pmid = 22341795 | doi = 10.1016/j.jmpt.2012.01.005 }}</ref> A 2011 systematic review found moderate evidence to support the use of manual therapy for cervicogenic dizziness.<ref>{{cite journal |vauthors=Lystad RP, Bell G, Bonnevie-Svendsen M, Carter CV | title = Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness: a systematic review | journal = Chiropractic & Manual Therapies| volume = 19 | issue = 1 | page = 21 | year = 2011 | pmid = 21923933 | pmc = 3182131 | doi = 10.1186/2045-709X-19-21 | doi-access = free }}</ref> There is very weak evidence for chiropractic care for adult [[scoliosis]] (curved or rotated spine)<ref>{{cite journal |vauthors=Everett CR, Patel RK | title = A systematic literature review of nonsurgical treatment in adult scoliosis | journal = Spine| volume = 32 | issue = 19 Suppl | pages = S130–34 | date = September 2007 | pmid = 17728680 | doi = 10.1097/BRS.0b013e318134ea88 | s2cid = 9339782 | doi-access = free }}</ref> and no scientific data for [[idiopathic]] adolescent scoliosis.<ref>{{cite journal |vauthors=Romano M, Negrini S | title = Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review | journal = Scoliosis| volume = 3 | page = 2 | year = 2008 | pmid = 18211702 | pmc = 2262872 | doi = 10.1186/1748-7161-3-2 | doi-access = free }}</ref> A 2007 systematic review found that few studies of chiropractic care for nonmusculoskeletal conditions are available, and they are typically not of high quality; it also found that the entire clinical encounter of chiropractic care (as opposed to just SM) provides benefit to patients with cervicogenic dizziness, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including [[ADHD]]/[[learning disabilities]], [[dizziness]], [[high blood pressure]], and [[Visual perception|vision]] conditions.<ref>{{cite journal |vauthors=Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW | title = Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research | journal = The Journal of Alternative and Complementary Medicine| volume = 13 | issue = 5 | pages = 491–512 | date = June 2007 | pmid = 17604553 | doi = 10.1089/acm.2007.7088 }}</ref> Other reviews have found no evidence of significant benefit for [[asthma]],<ref>{{cite journal | author = Ernst E | title = Spinal manipulation for asthma: a systematic review of randomised clinical trials | journal = Respiratory Medicine| volume = 103 | issue = 12 | pages = 1791–95 | date = December 2009 | pmid = 19646855 | doi = 10.1016/j.rmed.2009.06.017 | doi-access = free }}</ref><ref>{{cite journal |vauthors=Hondras MA, Linde K, Jones AP | title = Manual therapy for asthma | journal=Cochrane Database of Systematic Reviews| issue = 2 | page = CD001002 | year = 2005 | pmid = 15846609 | doi = 10.1002/14651858.CD001002.pub2}}</ref> [[baby colic]],<ref name=Gotlib>{{cite journal |vauthors=Gotlib A, Rupert R | title = Chiropractic manipulation in pediatric health conditions--an updated systematic review | journal = Chiropractic & Osteopathy| volume = 16 | page = 11 | year = 2008 | pmid = 18789139 | pmc = 2553791 | doi = 10.1186/1746-1340-16-11 | doi-access = free }}</ref><ref>Baby colic:
* {{cite journal | author = Ernst E | title = Chiropractic spinal manipulation for infant colic: a systematic review of randomised clinical trials | journal = International Journal of Clinical Practice| volume = 63 | issue = 9 | pages = 1351–53 | year = 2009 | pmid = 19691620 | doi = 10.1111/j.1742-1241.2009.02133.x | s2cid = 36131261 | doi-access = free }}
* {{cite book|vauthors=Husereau D, Clifford T, Aker P, Leduc D, Mensinkai S|title=Spinal Manipulation for Infantile Colic|isbn=978-1-894978-11-8|url=http://cadth.ca/media/pdf/177_spinal_manipulation_tr_e.pdf|access-date=2008-10-06|location=Ottawa|publisher=Canadian Coordinating Office for Health Technology Assessment|year=2003|series=Technology report no. 42|archive-url=https://web.archive.org/web/20081217004845/http://cadth.ca/media/pdf/177_spinal_manipulation_tr_e.pdf|archive-date=2008-12-17}}</ref> [[bedwetting]],<ref name=HuangShu2011>{{cite journal |last1=Huang |first1=Tao |last2=Shu |first2=Xu |last3=Huang |first3=Yu Shan |last4=Cheuk |first4=Daniel KL |last5=Huang |first5=Tao |title=Complementary and miscellaneous interventions for nocturnal enuresis in children | journal=Cochrane Database of Systematic Reviews|year=2011 |issue=12 |page=CD005230 |doi=10.1002/14651858.CD005230.pub2 |pmid=22161390}}</ref> [[carpal tunnel syndrome]],<ref>{{cite journal |vauthors=O'Connor D, Marshall S, Massy-Westropp N, Pitt V | title = Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome | journal = Cochrane Database of Systematic Reviews| issue = 1 | page = CD003219 | year = 2003 | volume = 2003 | pmid = 12535461 | pmc = 6486195 | doi = 10.1002/14651858.CD003219}}</ref> [[fibromyalgia]],<ref>Fibromyalgia:
* {{cite journal |vauthors=Sarac AJ, Gur A | title = Complementary and alternative medical therapies in fibromyalgia | journal = Current Pharmaceutical Design| volume = 12 | issue = 1 | pages = 47–57 | year = 2006 | pmid = 16454724 | doi = 10.2174/138161206775193262 }}
* {{cite journal |vauthors=Schneider M, Vernon H, Ko G, Lawson G, Perera J | title = Chiropractic management of fibromyalgia syndrome: a systematic review of the literature | journal = Journal of Manipulative and Physiological Therapeutics| volume = 32 | issue = 1 | pages = 25–40 | year = 2009 | pmid = 19121462 | doi = 10.1016/j.jmpt.2008.08.012 | doi-access = free }}
* {{cite journal | author = Ernst E | title = Chiropractic treatment for fibromyalgia: a systematic review | journal = Clinical Rheumatology| volume = 28 | issue = 10 | pages = 1175–78 | year = 2009 | pmid = 19544042 | doi = 10.1007/s10067-009-1217-9 | s2cid = 25339207 }}
</ref> [[gastrointestinal disorders]],<ref>{{cite journal | author = Ernst E | title = Chiropractic treatment for gastrointestinal problems: A systematic review of clinical trials | journal = Canadian Journal of Gastroenterology| volume = 25 | issue = 1 | pages = 39–49 | year = 2011 | pmc = 3027333 | pmid = 21258667| doi = 10.1155/2011/910469 | doi-access = free }}</ref> kinetic imbalance due to [[Suboccipital muscles|suboccipital]] strain (KISS) in infants,<ref name=Gotlib /><ref>{{cite journal |vauthors=Brand PL, Engelbert RH, Helders PJ, Offringa M | title = [Systematic review of the effects of therapy in infants with the KISS-syndrome (kinetic imbalance due to suboccipital strain)] | language = nl | journal = Nederlands Tijdschrift voor Geneeskunde| volume = 149 | issue = 13 | pages = 703–07 | year = 2005 | pmid = 15819137 }}</ref> [[menstrual cramps]],<ref>{{cite journal |vauthors=Proctor ML, Hing W, Johnson TC, Murphy PA, Brown J | title = Spinal manipulation for primary and secondary dysmenorrhoea | journal=The Cochrane Database of Systematic Reviews| volume = 3 | issue = 3 | page = CD002119 | year = 2006 | pmid = 16855988 | pmc = 6718213 | doi = 10.1002/14651858.CD002119.pub3}}</ref> [[insomnia]],<ref name=goto>{{Cite journal |last1=Goto |first1=Viviane |last2=Frange |first2=Cristina |last3=Andersen |first3=Monica L. |last4=Júnior |first4=José M. S. |last5=Tufik |first5=Sergio |last6=Hachul |first6=Helena |date=May 2014 |title=Chiropractic intervention in the treatment of postmenopausal climacteric symptoms and insomnia: A review  |journal=Maturitas|volume=78 |issue=1 |pages=3–7 |doi=10.1016/j.maturitas.2014.02.004 |pmid=24656717}}</ref> [[postmenopausal]] symptoms,<ref name=goto/> or [[pelvic girdle pain|pelvic and back pain during pregnancy]].<ref>{{Cite journal|last1=Liddle|first1=Sarah D.|last2=Pennick|first2=Victoria|date=2015-09-30|title=Interventions for preventing and treating low-back and pelvic pain during pregnancy|journal=Cochrane Database of Systematic Reviews|volume=2015|issue=9|pages=CD001139|doi=10.1002/14651858.CD001139.pub4|pmid=26422811|pmc=7053516}}</ref> As there is no evidence of effectiveness or safety for cervical manipulation for baby colic, it is not endorsed.<ref name=CamilleriPark2017>{{cite journal |vauthors=Camilleri M, Park SY, Scarpato E, Staiano A | title=Exploring hypotheses and rationale for causes of infantile colic | journal=Neurogastroenterology & Motility| year= 2017 | volume= 29 | issue= 2 | pages= e12943| doi=10.1111/nmo.12943 | pmc=5276723 | pmid=27647578 | type=Review }}</ref>

=== Safety ===
[[File:Chiropractic adjustment on child.jpg|thumb|Chiropractic adjustment on children]]

The [[World Health Organization]] found chiropractic care in general is safe when employed skillfully and appropriately.<ref name=WHO-guidelines /> There is not sufficient data to establish the safety of chiropractic manipulations.<ref name=Gouveia /> Manipulation is regarded as relatively safe but complications can arise, and it has known adverse effects, risks and contraindications.<ref name=WHO-guidelines /> Absolute [[contraindication]]s to spinal manipulative therapy are conditions that should not be manipulated; these contraindications include [[rheumatoid arthritis]] and conditions known to result in unstable joints.<ref name=WHO-guidelines /> Relative contraindications are conditions where increased risk is acceptable in some situations and where low-force and soft-tissue techniques are treatments of choice; these contraindications include [[osteoporosis]].<ref name=WHO-guidelines /> Although most contraindications apply only to manipulation of the affected region, some neurological signs indicate referral to [[emergency medical services]]; these include sudden and severe headache or [[neck pain]] unlike that previously experienced.<ref name=CCA-CFCREAB-CPG>{{cite journal | vauthors = Anderson-Peacock E, Blouin JS, Bryans R, Danis N, Furlan A, Marcoux H, Potter B, Ruegg R, Stein JG, White E | title = Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash | journal = The Journal of the Canadian Chiropractic Association| volume = 49 | issue = 3 | pages = 158–209 | year = 2005 | pmid = 17549134 | pmc = 1839918 }}<br />• {{cite journal | vauthors = Anderson-Peacock E, Bryans R, Descarreaux M, Marcoux H, Potter B, Ruegg R, Shaw L, Watkin R, White E | title = A Clinical Practice Guideline Update from The CCA•CFCREAB-CPG | journal = The Journal of the Canadian Chiropractic Association| volume = 52 | issue = 1 | pages = 7–8 | year = 2008 | pmid = 18327295 | pmc = 2258235 | url = http://jcca-online.org/ecms.ashx/PDF/2008/2008-1/ClinicalPracticeGuidelineUpdatefromTheCCACFCREABCPG.pdf  | archive-url = https://www.webcitation.org/5sVyyGVET?url=http://jcca-online.org/ecms.ashx/PDF/2008/2008-1/ClinicalPracticeGuidelineUpdatefromTheCCACFCREABCPG.pdf | archive-date = 2010-09-05 }}</ref> Indirect risks of chiropractic involve delayed or missed diagnoses through consulting a chiropractor.<ref name=Ernst-eval />

Spinal manipulation is associated with frequent, mild and temporary [[Adverse effect (medicine)|adverse effects]],<ref name=Ernst-adverse /><ref name=CCA-CFCREAB-CPG /> including new or worsening pain or stiffness in the affected region.<ref>{{cite journal |vauthors=Thiel HW, Bolton JE, Docherty S, Portlock JC | title = Safety of chiropractic manipulation of the cervical spine: a prospective national survey | journal = Spine| volume = 32 | issue = 21 | pages = 2375–78 | year = 2007 | pmid = 17906581 | doi = 10.1097/BRS.0b013e3181557bb1 | s2cid = 42353750 }}</ref> They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours;<ref name=Gouveia>{{cite journal |vauthors=Gouveia LO, Castanho P, Ferreira JJ | title = Safety of chiropractic interventions: a systematic review | journal = Spine| volume = 34 | issue = 11 | pages = E405–13 | year = 2009 | pmid = 19444054 | doi = 10.1097/BRS.0b013e3181a16d63 | s2cid = 21279308 | url= http://www.chiropratiquelasource.com/recherches/safety.pdf |archive-url=https://web.archive.org/web/20160919152855/http://www.chiropratiquelasource.com/recherches/safety.pdf |archive-date=2016-09-19 |url-status=live}}</ref> adverse reactions appear to be more common following manipulation than mobilization.<ref>{{cite journal |vauthors=Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM | title = Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study | journal = Spine | volume = 30 | issue = 13 | pages = 1477–84 | date = July 2005 | pmid = 15990659 | doi = 10.1097/01.brs.0000167821.39373.c1 | s2cid = 45678522 }}</ref> The most frequently stated adverse effects are mild headache, soreness, and briefly elevated pain fatigue.<ref name=NHSChoicesChiropracticSafety>{{cite web |url=http://www.nhs.uk/Conditions/chiropractic/Pages/Safetyandregulation.aspx |title=Safety and regulation of chiropractic |publisher=[[NHS Choices]] |date=20 August 2014 |access-date=22 September 2016}}</ref> Chiropractic is correlated with a very high [[Incidence (epidemiology)|incidence]] of minor adverse effects.<ref name=Ernst-eval /> Rarely,<ref name=WHO-guidelines /> 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<ref name=Ernst-adverse/> and children.<ref name=Vohra>{{cite journal |vauthors=Vohra S, Johnston BC, Cramer K, Humphreys K | title = Adverse events associated with pediatric spinal manipulation: a systematic review | journal = Pediatrics | volume = 119 | issue = 1 | pages = e275–83 | year = 2007 | pmid = 17178922 | doi = 10.1542/peds.2006-1392 | s2cid = 43683198 | url = http://pediatrics.aappublications.org/cgi/content/full/119/1/e275 | url-access = subscription }}</ref> Estimates vary widely for the incidence of these complications,<ref name=Gouveia /> and the actual incidence is unknown, due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke, which is a particular concern.<ref name=Ernst-adverse /> Adverse effects are poorly reported in recent studies investigating chiropractic manipulations.<ref name=Ernst-2012>{{cite journal |vauthors=Ernst E, Posadzki P | title = Reporting of adverse effects in randomised clinical trials of chiropractic manipulations: a systematic review | journal = The New Zealand Medical Journal| volume = 125 | issue = 1353 | pages = 87–140 | year = 2012 | pmid = 22522273 }}</ref> A 2016 systematic review concludes that the level of reporting is unsuitable and unacceptable.<ref name=GorrellEngel2016>{{cite journal| vauthors=Gorrell LM, Engel RM, Brown B, Lystad RP| title=The reporting of adverse events following spinal manipulation in randomized clinical trials-a systematic review | journal=The Spine Journal| year= 2016 | volume= 16 | issue= 9 | pages= 1143–51 | pmid=27241208 | doi=10.1016/j.spinee.2016.05.018 | type= Systematic Review }}</ref> Reports of serious adverse events have occurred, resulting from spinal manipulation therapy of the lumbopelvic region.<ref>{{cite journal |vauthors=Hebert JJ, Stomski NJ, French SD, Rubinstein SM | title = Serious Adverse Events and Spinal Manipulative Therapy of the Low Back Region: A Systematic Review of Cases | journal = Journal of Manipulative and Physiological Therapeutics| volume = 38 | issue = 9 | pages = 677–91 | year = 2013 | pmid = 23787298 | doi = 10.1016/j.jmpt.2013.05.009 | url = http://researchrepository.murdoch.edu.au/id/eprint/15912/ | url-access = subscription }}</ref> Estimates for serious adverse events vary from 5 strokes per 100,000 manipulations to 1.46 serious adverse events per 10 million manipulations and 2.68 deaths per 10 million manipulations, though it was determined that there was inadequate data to be conclusive.<ref name=Gouveia /> Several case reports show temporal associations between interventions and potentially serious complications.<ref name=Hurwitz-2008 /> The published medical literature contains reports of 26 deaths since 1934 following chiropractic manipulations and many more seem to remain unpublished.<ref name=Ernst-death />

[[Vertebrobasilar artery stroke]] (VAS) is [[Association (statistics)|statistically associated]] with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.<ref name=Hurwitz-2008>{{cite journal |vauthors=Hurwitz EL, Carragee EJ, van der Velde G, Carroll LJ, Nordin M, Guzman J, Peloso PM, Holm LW, Côté P, Hogg-Johnson S, Cassidy JD, Haldeman S | title = Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders | journal = Spine| volume = 33 | issue = 4 Suppl | pages = S123–52 | year = 2008 | pmid = 18204386 | doi = 10.1097/BRS.0b013e3181644b1d | s2cid = 27261997 | doi-access = free }}</ref><ref>{{cite journal |vauthors=Paciaroni M, Bogousslavsky J | title = Cerebrovascular complications of neck manipulation | journal = European Neurology| volume = 61 | issue = 2 | pages = 112–18 | year = 2009 | pmid = 19065058 | doi = 10.1159/000180314 | doi-access = free }}</ref> Weak to moderately strong evidence supports causation (as opposed to statistical association) between [[cervical manipulation|cervical manipulative therapy]] (CMT) and VAS.<ref>{{cite journal |vauthors=Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM | title = Does cervical manipulative therapy cause vertebral artery dissection and stroke? | journal = [[The Neurologist|Neurologist]] | volume = 14 | issue = 1 | pages = 66–73 | year = 2008 | pmid = 18195663 | doi = 10.1097/NRL.0b013e318164e53d | s2cid = 18062970 }}</ref> There is insufficient evidence to support a strong association or no association between cervical manipulation and stroke.<ref name=Haynes>{{cite journal |vauthors=Haynes MJ, Vincent K, Fischhoff C, Bremner AP, Lanlo O, Hankey GJ | title = Assessing the risk of stroke from neck manipulation: a systematic review | journal = International Journal of Clinical Practice| volume = 66 | issue = 10 | pages = 940–47 | year = 2012 | pmid = 22994328 | pmc = 3506737 | doi = 10.1111/j.1742-1241.2012.03004.x }}</ref> While the biomechanical evidence is not sufficient to support the statement that CMT causes cervical artery dissection (CD), clinical reports suggest that mechanical forces have a part in a substantial number of CDs and the majority of population controlled studies found an association between CMT and VAS in young people.<ref name=Biller2014 /> It is strongly recommended that practitioners consider the plausibility of CD as a symptom, and people can be informed of the association between CD and CMT before administering manipulation of the cervical spine.<ref name=Biller2014>{{cite journal|last1=Biller|first1=J.|last2=Sacco|first2=R. L.|last3=Albuquerque|first3=F. C.|last4=Demaerschalk|first4=B. M.|last5=Fayad|first5=P.|last6=Long|first6=P. H.|last7=Noorollah|first7=L. D.|last8=Panagos|first8=P. D.|last9=Schievink|first9=W. I.|last10=Schwartz|first10=N. E.|last11=Shuaib|first11=A.|last12=Thaler|first12=D. E.|last13=Tirschwell|first13=D. L.|title=Cervical Arterial Dissections and Association With Cervical Manipulative Therapy: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association|journal=Stroke|year=2014|doi=10.1161/STR.0000000000000016|pmid=25104849|volume=45|issue=10|pages=3155–74|doi-access=free}}</ref> There is controversy regarding the degree of risk of stroke from cervical manipulation.<ref name=Haynes /> Many chiropractors state that, the association between chiropractic therapy and vertebral arterial dissection is not proven.<ref name=Ernst-death /> However, it has been suggested that the [[causality]] between chiropractic cervical manipulation beyond the normal range of motion and vascular accidents is probable<ref name=Ernst-death /> or definite.<ref name=Ernst-2010>{{cite journal | author = Ernst E | title = Vascular accidents after neck manipulation: cause or coincidence? | journal = International Journal of Clinical Practice| volume = 64 | issue = 6 | pages = 673–77 | year = 2010 | pmid = 20518945 | doi = 10.1111/j.1742-1241.2009.02237.x | s2cid = 38571730 | doi-access = free }}</ref> There is very low evidence supporting a small association between internal [[carotid artery dissection]] and chiropractic neck manipulation.<ref>{{cite journal|last1=Church|first1=Ephraim W|last2=Sieg|first2=Emily P|last3=Zalatimo|first3=Omar|last4=Hussain|first4=Namath S|last5=Glantz|first5=Michael|last6=Harbaugh|first6=Robert E|title=Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation|journal=Cureus|year=2016|doi=10.7759/cureus.498|pmid=27014532|volume=8|issue=2|pmc=4794386|page=e498|doi-access=free }}</ref> The incidence of internal carotid artery dissection following cervical spine manipulation is unknown.<ref>{{cite journal |vauthors=Chung CL, Côté P, Stern P, L'espérance G | title = The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature | journal = Journal of Manipulative and Physiological Therapeutics| volume = 38 | issue = 9 | pages = 672–6 | year = 2014 | pmid = 24387889 | doi = 10.1016/j.jmpt.2013.09.005 }}</ref> The literature infrequently reports helpful data to better understand the association between cervical manipulative therapy, cervical artery dissection and stroke.<ref>{{cite journal |vauthors=Wynd S, Westaway M, Vohra S, Kawchuk G | title = The quality of reports on cervical arterial dissection following cervical spinal manipulation | journal = PLOS ONE| volume = 8 | issue = 3 | page = e59170 | year = 2013 | pmid = 23527121 | pmc = 3604043 | doi = 10.1371/journal.pone.0059170 | bibcode = 2013PLoSO...859170W | doi-access = free }}</ref> The limited evidence is inconclusive that chiropractic spinal manipulation therapy is not a cause of [[intracranial hypotension]].<ref>{{cite journal|last1=Tuchin|first1=P.|title=A systematic literature review of intracranial hypotension following chiropractic|journal=International Journal of Clinical Practice|volume=68|issue=3|year=2014|pages=396–402|doi=10.1111/ijcp.12247|pmid=24372942|s2cid=5315779|doi-access=free}}</ref> Cervical intradural [[disc herniation]] is very rare following spinal manipulation therapy.<ref name=YangOh2016>{{cite journal|last1=Yang|first1=Hwan-Seo|last2=Oh|first2=Young-Min|last3=Eun|first3=Jong-Pil|title=Cervical Intradural Disc Herniation Causing Progressive Quadriparesis After Spinal Manipulation Therapy|journal=Medicine|volume=95|issue=6|year=2016|page=e2797|doi=10.1097/MD.0000000000002797|pmc=4753938|pmid=26871842}}</ref>

Chiropractors sometimes employ diagnostic imaging techniques such as X-rays and [[CT scan]]s that rely on [[ionizing radiation]].<ref name=Bussieres /> Although there is no clear evidence to justify the practice, some chiropractors still X-ray a patient several times a year.<ref name=Trick-or-Treatment/> Practice guidelines aim to reduce unnecessary radiation exposure,<ref name=Bussieres>{{cite journal |vauthors=Bussières AE, Taylor JA, Peterson C | title = Diagnostic imaging practice guidelines for musculoskeletal complaints in adults&nbsp;– an evidence-based approach&nbsp;– part 3: spinal disorders | journal = Journal of Manipulative and Physiological Therapeutics| volume = 31 | issue = 1 | pages = 33–88 | year = 2008 | pmid = 18308153 | doi = 10.1016/j.jmpt.2007.11.003 | url = http://jmptonline.org/article/S0161-4754(07)00314-4/fulltext | url-access = subscription }}</ref> which increases cancer risk in proportion to the amount of radiation received.<ref>{{cite book |author=Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation: Board on Radiation Effects Research" [[U.S. National Research Council|US National Research Council]] |title=Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2 |publisher=The National Academies Press |location=Washington, DC |year=2006 |isbn=978-0-309-09156-5 |doi=10.17226/11340 }}</ref> Research suggests that radiology instruction given at chiropractic schools worldwide seem to be evidence-based.<ref name=Ammendolia /> Although, there seems to be a disparity between some schools and available evidence regarding the aspect of radiography for patients with acute low back pain without an indication of a serious disease, which may contribute to chiropractic overuse of radiography for low back pain.<ref name=Ammendolia>{{cite journal |vauthors=Ammendolia C, Taylor JA, Pennick V, Côté P, Hogg-Johnson S, Bombardier C | title = Adherence to radiography guidelines for low back pain: A survey of chiropractic schools worldwide | journal = Journal of Manipulative and Physiological Therapeutics| volume = 31 | issue = 6 | pages = 412–18 | year = 2008 | pmid = 18722195 | doi = 10.1016/j.jmpt.2008.06.010 }}</ref>

=== Risk-benefit ===

A 2012 systematic review concluded that no accurate assessment of risk-benefit exists for cervical manipulation.<ref name="Haynes" /> A 2010 systematic review stated that there is no good evidence to assume that neck manipulation is an effective treatment for any medical condition and suggested a [[precautionary principle]] in healthcare for chiropractic intervention even if a causality with [[vertebral artery dissection]] after neck manipulation were merely a remote possibility.<ref name=Ernst-death/> The same review concluded that the risk of death from manipulations to the neck outweighs the benefits.<ref name=Ernst-death /> Chiropractors have criticized this conclusion, claiming that the author did not evaluate the potential benefits of spinal manipulation.<ref name=Ernst-response /> [[Edzard Ernst]] stated "This detail was not the subject of my review. I do, however, refer to such evaluations and should add that a report recently commissioned by the General Chiropractic Council did not support many of the outlandish claims made by many chiropractors across the world."<ref name=Ernst-response>{{cite journal | author = E Ernst | title = Response to critiques of deaths after chiropractic | journal = International Journal of Clinical Practice| volume = 65 | issue = 1 | page = 106 | year = 2011 | doi = 10.1111/j.1742-1241.2010.02568.x | s2cid = 72845939 | doi-access = free }}</ref> A 1999 review of 177 previously reported cases published between 1925 and 1997 in which injuries were attributed to manipulation of the cervical spine (MCS) concluded that "The literature does not demonstrate that the benefits of MCS outweigh the risks." The professions associated with each injury were assessed. Physical therapists (PT) were involved in less than 2% of all cases, with no deaths caused by PTs. Chiropractors were involved in a little more than 60% of all cases, including 32 deaths.<ref name="Di_Fabio_1/1/1999">{{cite web | last=Di Fabio | first=Richard P | date=January 1, 1999 | title=Manipulation of the Cervical Spine: Risks and Benefits | website=[[Physical Therapy (journal)|Physical Therapy]] | url=https://academic.oup.com/ptj/article/79/1/50/2857770 | access-date=November 1, 2021 | quote=Although the risk of injury associated with MCS appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (nonthrust passive movements). The literature does not demonstrate that the benefits of MCS outweigh the risks. Several recommendations for future studies and for the practice of MCS are discussed. }}</ref>

A 2009 review evaluating maintenance chiropractic care found that spinal manipulation is associated with considerable harm and no compelling evidence exists to indicate that it adequately prevents symptoms or diseases, thus the risk-benefit is not evidently favorable.<ref name="ErnstMaintenance2009">{{cite journal | author = Ernst E | title = Chiropractic maintenance treatment, a useful preventative approach? | journal = Preventive Medicine| volume = 49 | issue = 2–3 | pages = 99–100 | year = 2009 | pmid = 19465044 | doi = 10.1016/j.ypmed.2009.05.004 }}</ref>

=== Cost-effectiveness ===

A 2012 systematic review suggested that the use of spine manipulation in clinical practice is a [[cost-effective]] treatment when used alone or in combination with other treatment approaches.<ref>{{cite journal |vauthors=Michaleff ZA, Lin CW, Maher CG, van Tulder MW | title = Spinal manipulation epidemiology: Systematic review of cost effectiveness studies | journal = Journal of Electromyography and Kinesiology| volume = 22 | issue = 5 | pages = 655–62 | year = 2012 | pmid = 22429823 | doi = 10.1016/j.jelekin.2012.02.011 }}</ref> A 2011 systematic review found evidence supporting the cost-effectiveness of using spinal manipulation for the treatment of sub-acute or chronic low back pain; the results for acute low back pain were insufficient.<ref name=Lin2011>{{cite journal |vauthors=Lin CW, Haas M, Maher CG, Machado LA, van Tulder MW | title = Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review | journal = European Spine Journal| volume = 20 | issue = 7 | pages = 1024–38 | year = 2011 | pmid = 21229367 | pmc = 3176706 | doi = 10.1007/s00586-010-1676-3 }}</ref>

A 2006 systematic cost-effectiveness review found that the reported cost-effectiveness of spinal manipulation in the United Kingdom compared favorably with other treatments for back pain, but that reports were based on data from clinical trials without placebo controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain.<ref>{{cite journal | vauthors = Canter PH, Coon JT, Ernst E | title = Cost-Effectiveness of Complementary Therapies in the United Kingdom&nbsp;– A Systematic Review† | journal = Evidence-Based Complementary and Alternative Medicine| volume = 3 | issue = 4 | pages = 425–32 | year = 2006 | pmid = 17173105 | pmc = 1697737 | doi = 10.1093/ecam/nel044 | url =http://ecam.oxfordjournals.org/cgi/content/full/3/4/425 | archive-url = https://web.archive.org/web/20080511154423/http://ecam.oxfordjournals.org/cgi/content/full/3/4/425 | archive-date = 2008-05-11 }}</ref> A 2005 American systematic review of economic evaluations of conservative treatments for low back pain found that significant quality problems in available studies meant that definite conclusions could not be drawn about the most cost-effective intervention.<ref>{{cite journal |vauthors=van der Roer N, Goossens ME, Evers SM, van Tulder MW | title = What is the most cost-effective treatment for patients with low back pain? a systematic review | journal = Best Practice & Research Clinical Rheumatology| volume = 19 | issue = 4 | pages = 671–84 | year = 2005 | pmid = 15949783 | doi = 10.1016/j.berh.2005.03.007 }}</ref> The cost-effectiveness of maintenance chiropractic care is unknown.<ref name=Leboeuf-Yde-C>{{cite journal |vauthors=Leboeuf-Yde C, Hestbaek L | title = Maintenance care in chiropractic&nbsp;– what do we know? | journal = Chiropractic & Osteopathy| volume = 16 | page = 3 | year = 2008 | pmid = 18466623 | pmc = 2396648 | doi = 10.1186/1746-1340-16-3 | doi-access = free }}</ref>{{Primary source inline|date=July 2021}}

Analysis of a clinical and cost utilization data from the years 2003 to 2005 by an integrative medicine independent physician association (IPA) which looked the chiropractic services utilization found that the clinical and cost utilization of chiropractic services based on 70,274 member-months over a 7-year period decreased patient costs associate with the following use of services by 60% for in-hospital admissions, 59% for hospital days, 62% for outpatient surgeries and procedures, and 85% for pharmaceutical costs when compared with conventional medicine (visit to a medical doctor primary care provider) IPA performance for the same health maintenance organization product in the same geography and time frame.<ref>{{cite journal |vauthors=Sarnat RL, Winterstein J, Cambron JA | title = Clinical Utilization and Cost Outcomes From an Integrative Medicine Independent Physician Association: An Additional 3-Year Update | journal = Journal of Manipulative and Physiological Therapeutics| volume = 30 | issue = 4 | pages = 263–69 | date = May 2007 | pmid = 17509435 | doi = 10.1016/j.jmpt.2007.03.004 | s2cid = 613004 | url = http://www.jmptonline.org/article/S0161-4754(07)00076-0/abstract | url-access = subscription }}</ref>

== Education, licensing, and regulation ==
{{Main|Chiropractic education|List of chiropractic schools}}
Requirements vary between countries. In the U.S. chiropractors obtain a non-medical accredited diploma in the field of chiropractic.<ref>{{cite web|url=http://nces.ed.gov/ipeds/glossary/?charindex=F|title=Glossary|publisher=National Center for Education Statistics, [[U.S. Dept. of Education]]|access-date=2009-06-05|archive-date=2009-06-04|archive-url=https://web.archive.org/web/20090604050407/http://www.nces.ed.gov/ipeds/glossary/?charindex=F}}</ref> Chiropractic education in the U.S. has been criticized for failing to meet generally accepted standards of [[evidence-based medicine]].<ref>{{cite journal|vauthors=Marcus DM, McCullough L|title=An evaluation of the evidence in 'evidence-based' integrative medicine programs|journal=Academic Medicine|volume=84|issue=9|pages=1229–34|year=2009|doi=10.1097/ACM.0b013e3181b185f4|pmid=19707062|doi-access=free}}</ref> The curriculum content of North American chiropractic and medical colleges with regard to basic and clinical sciences has little similarity, both in the kinds of subjects offered and in the time assigned to each subject.<ref>{{cite journal |vauthors=Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M | title = A comparative study of chiropractic and medical education | journal = Alternative Therapies in Health and Medicine| volume = 4 | issue = 5 | pages = 64–75 | date = September 1998 | pmid = 9737032 }}</ref> Accredited chiropractic programs in the U.S. require that applicants have 90 semester hours of undergraduate education with a [[grade point average]] of at least 3.0 on a 4.0 scale. Many programs require at least three years of undergraduate education, and more are requiring a bachelor's degree.<ref>{{cite web|url=http://www.chirocolleges.org/prospective_students.html|title=Prospective students|publisher=Association of Chiropractic Colleges|access-date=2009-07-23|archive-url=https://web.archive.org/web/20090814171533/http://www.chirocolleges.org/prospective_students.html|archive-date=2009-08-14}}</ref> Canada requires a minimum three years of undergraduate education for applicants, and at least 4200 instructional hours (or the equivalent) of full-time chiropractic education for matriculation through an accredited chiropractic program.<ref>{{cite web|url=http://www.chirofed.ca/english/pdf/Standards-for-Accreditation-of-Doctor-of-Chiropractic-Programmes.pdf|title=Standards for Accreditation of Doctor of Chiropractic Programmes|date=2011-11-26|publisher=Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards|access-date=2014-08-02|archive-date=2015-09-23|archive-url=https://web.archive.org/web/20150923202912/http://www.chirofed.ca/english/pdf/Standards-for-Accreditation-of-Doctor-of-Chiropractic-Programmes.pdf}}</ref> Graduates of the [[Canadian Memorial Chiropractic College]] (CMCC) are formally recognized to have at least 7–8 years of university level education.<ref name=CMCCMediaRelations>{{cite web |url= https://www.cmcc.ca/news/CMCC%20Backgrounder%202015.pdf |archive-url=https://web.archive.org/web/20190226193153/https://www.cmcc.ca/news/CMCC%20Backgrounder%202015.pdf |archive-date=2019-02-26 |url-status=live|title= CMCC Backgrounder 2015 |publisher= [[Canadian Memorial Chiropractic College]] |access-date= 26 February 2019 }}</ref><ref name=GovOntario>{{cite web |url=http://www.edu.gov.on.ca/eng/general/postsec/degreegr.html |title=Degree Authority in Ontario |publisher=Ontario Ministry of Training, Colleges and Universities |access-date=2010-12-14}}</ref> The World Health Organization (WHO) guidelines suggest three major full-time educational paths culminating in either a [[Chiropractic education|DC, DCM, BSc, or MSc]] degree. Besides the full-time paths, they also suggest a conversion program for people with other health care education and limited training programs for regions where no legislation governs chiropractic.<ref name=WHO-guidelines />

Upon graduation, there may be a requirement to pass national, state, or provincial board examinations before being [[licensed]] to practice in a particular jurisdiction.<ref>{{cite web |url=http://life.edu/node/94 |title=State chiropractic licensure |access-date=2009-06-05 |year=2008 |publisher=[[Life University]]  |archive-url=https://web.archive.org/web/20090801072938/http://www.life.edu/node/94 |archive-date=2009-08-01 }}</ref><ref>{{cite web |url=http://chirofed.ca/english/becoming.html |title=Becoming a chiropractor |publisher=Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards |access-date=2009-06-05 |archive-date=2009-06-15 |archive-url=https://web.archive.org/web/20090615181538/http://www.chirofed.ca/english/becoming.html  }}</ref> Depending on the location, [[Continuing education#Continuing education for professionals|continuing education]] may be required to renew these licenses.<ref>{{cite journal | author = Grod JP | title = Continuing health education in Canada | journal = The Journal of the Canadian Chiropractic Association| volume = 50 | issue = 1 | pages = 14–17 | year = 2006 | pmid = 17549163 | pmc = 1839972 }}</ref><ref>{{cite journal |vauthors=Stuber KJ, Grod JP, Smith DL, Powers P | title = An online survey of chiropractors' opinions of Continuing Education | journal = Chiropractic & Osteopathy| volume = 13 | issue = 1 | page = 22 | year = 2005 | pmid = 16242035 | pmc = 1282582 | doi = 10.1186/1746-1340-13-22 | doi-access = free }}</ref> Specialty training is available through part-time postgraduate education programs such as chiropractic [[orthopedics]] and sports chiropractic, and through full-time residency programs such as [[radiology]] or orthopedics.<ref>{{cite book |chapter-url=http://chiroweb.com/archives/ahcpr/chapter3.htm |chapter=Chiropractic training |vauthors=Coulter ID, Adams AH, Sandefur R |year=1997 |title=Chiropractic in the United States: Training, Practice, and Research |pages=17–28 |veditors=Cherkin DC, Mootz RD |url=http://curziechiropractic.com/forms/ahcpr/uschiros.pdf |access-date=2008-05-11 |location=Rockville, MD |publisher=Agency for Health Care Policy and Research |oclc=39856366  |archive-url=https://web.archive.org/web/20080625173624/http://curziechiropractic.com/forms/ahcpr/uschiros.pdf |archive-date=2008-06-25 }} AHCPR Pub No. 98-N002.</ref>

In the U.S., chiropractic schools are accredited through the [[Council on Chiropractic Education]] (CCE) while the General Chiropractic Council (GCC) is the statutory governmental body responsible for the regulation of chiropractic in the UK.<ref>{{cite web |title=The Council on Chiropractic Education (CCE) |url=http://cce-usa.org/ |publisher= The Council on Chiropractic Education |access-date=2008-07-05 }}</ref><ref>{{cite web |url=http://www.gcc-uk.org/ |title=The General Chiropractic Council |access-date=2020-05-02 }}</ref> The U.S. CCE requires a mixing curriculum, which means a straight-educated chiropractor may not be eligible for licensing in states requiring CCE accreditation.<ref name=Morrison /> CCEs in the U.S., Canada, Australia and Europe have joined to form CCE-International (CCE-I) as a model of accreditation standards with the goal of having credentials portable internationally.<ref name=CCEI>{{cite web| url = http://www.cceintl.org/About_Us.html| title = About Us| access-date = 2010-09-30| publisher = [[Councils on Chiropractic Education International]]| archive-url = https://web.archive.org/web/20101118013746/http://www.cceintl.org/About_Us.html| archive-date = 2010-11-18}}</ref> Today, there are 18 accredited Doctor of Chiropractic programs in the U.S.,<ref>{{cite web|title=Accredited Doctor of Chiropractic programs|url=http://cce-usa.org/adcp.php|publisher=The Council on Chiropractic Education|access-date=2008-02-22|archive-url = https://web.archive.org/web/20080214031937/http://www.cce-usa.org/adcp.php|archive-date = 2008-02-14}}</ref> 2 in Canada,<ref>{{cite web|url=http://chirofed.ca/english/accreditation.html|title=Accreditation of educational programmes|publisher=Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards|access-date=2009-06-05|archive-date=2009-05-18|archive-url=https://web.archive.org/web/20090518022905/http://www.chirofed.ca/english/accreditation.html}}</ref> 6 in Australasia,<ref name=CCEA>{{cite web| url = http://www.ccea.com.au/Accreditation/Program%20Accreditation%20Status.htm| title = Program Accreditation Status| access-date = 2010-09-30| publisher = Council on Chiropractic Education Australasia| archive-url = https://web.archive.org/web/20110217092348/http://ccea.com.au/Accreditation/Program%20Accreditation%20Status.htm| archive-date = 2011-02-17}}</ref> and 5 in Europe.<ref>{{cite web|url=http://www.cce-europe.com/accredited-institutions.html|title=Institutions holding Accredited Status with the ECCE|publisher=[[European Council On Chiropractic Education]]|date=2010-11-01|access-date=2014-08-02|archive-date=2014-07-22|archive-url=https://web.archive.org/web/20140722063913/http://www.cce-europe.com/accredited-institutions.html}}</ref> All but one of the chiropractic colleges in the U.S. are privately funded, but in several other countries they are in government-sponsored universities and colleges.<ref name=DeVocht /> Of the two chiropractic colleges in Canada, one is publicly funded ([[UQTR]]) and one is privately funded ([[CMCC]]). In 2005, CMCC was granted the privilege of offering a professional health care degree under the Post-secondary Education Choice and Excellence Act, which sets the program within the hierarchy of education in Canada as comparable to that of other primary contact health care professions such as medicine, dentistry and optometry.<ref name=CMCCMediaRelations /><ref name=GovOntario />

Regulatory colleges and chiropractic boards in the U.S., Canada, Mexico, and Australia are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.<ref>{{cite web| url = http://www.chiropracticcanada.ca/en-us/FactsFAQs.aspx| title = Canadian Chiropractic Association FAQs| access-date = 2010-10-02| publisher = Canadian Chiropractic Association |archive-url=https://web.archive.org/web/20090817225255/http://www.chiropracticcanada.ca/en-us/FactsFAQs.aspx |archive-date=2009-08-17}}</ref><ref>{{cite web| url = http://pacex.fclb.org/Information/FAQ/tabid/364/Default.aspx| title = Federation of Chiropractic Licensing Boards FAQ| access-date = 2010-10-02| publisher = [[Federation of Chiropractic Licensing Boards]]}}</ref> There are an estimated 49,000 chiropractors in the U.S. (2008),<ref name=BLS>{{cite web|url=http://www.bls.gov/oco/ocos071.htm|title=Chiropractors|publisher= [[U.S. Bureau of Labor Statistics]]|access-date=2008-07-05|year=2007}}</ref> 6,500 in Canada (2010),<ref>{{cite web| url = http://www.chiropracticcanada.ca/en-us/AboutUs/ChiropracticInCanada.aspx| title = Canadian Chiropractic Association: Chiropractic in Canada| access-date = 2010-10-02| publisher = Canadian Chiropractic Association| archive-url = https://web.archive.org/web/20100527103605/http://www.chiropracticcanada.ca/en-us/AboutUs/ChiropracticInCanada.aspx| archive-date = 2010-05-27}}</ref> 2,500 in Australia (2000),<ref name=Campbell /> and 1,500 in the UK (2000).<ref>{{cite book|title= The Chiropractic Profession: Its Education, Practice, Research and Future Directions|author= Chapman-Smith D|year=2000|chapter= Current status of the profession|isbn=978-1-892734-02-0|publisher=NCMIC|location= West Des Moines, IA}}</ref>

Chiropractors often argue that this education is as good as or better than medical physicians', but most chiropractic training is confined to classrooms with much time spent learning theory, adjustment, and marketing.<ref name="Morrison"/> The fourth year of chiropractic education persistently showed the highest stress levels.<ref name=Hester2013 /> Every student, irrespective of year, experienced different ranges of stress when studying.<ref name=Hester2013>{{cite journal |vauthors=Hester H, Cunliffe C, Hunnisett A | title = Stress in chiropractic education: a student survey of a five-year course | journal = Journal of Chiropractic Education| volume = 27 | issue = 2 | pages = 147–51 | year = 2013 | pmid = 23957319 | pmc = 3791907 | doi = 10.7899/JCE-13-4 }}</ref> The chiropractic leaders and colleges have had internal struggles.<ref name=Johnson2010 /> Rather than cooperation, there has been infighting between different factions.<ref name=Johnson2010 /> A number of actions were posturing due to the confidential nature of the chiropractic colleges in an attempt to enroll students.<ref name=Johnson2010>{{cite journal | author = Johnson C | title = Reflecting on 115 years: the chiropractic profession's philosophical path | journal = Journal of Chiropractic Humanities| volume = 17 | issue = 1 | pages = 1–5 |date=December 2010  | pmid = 22693471 | pmc = 3342796 | doi = 10.1016/j.echu.2010.11.001 }}</ref>{{clarify|reason=What actions? Confidential nature?|date=June 2017}}

In 2024, [[Oregon Public Broadcasting]] reported on the high debt burden of students who pursued degrees in alternative medicine. Ten different chiropractic programs were ranked among the 47 US graduate programs with highest debt to earnings ratios.<ref name="opb-part2">{{cite news |last1=Camhi |first1=Tiffany |title=Oregon alternative medicine students face a long road to loan forgiveness |url=https://www.opb.org/article/2024/08/30/oregon-alternative-medicine-loan-forgiveness/ |access-date=28 October 2024 |work=OPB |date=30 August 2024 |language=en}}</ref><ref name="scorecard-data">{{cite web |author1=U.S. Department of Education |title=Most Recent Data by Field of Study |url=https://ed-public-download.app.cloud.gov/downloads/Most-Recent-Cohorts-Field-of-Study_06102024.zip |website=U.S. Department of Education College Scorecard |archive-url=https://web.archive.org/web/20240909175033/https://ed-public-download.app.cloud.gov/downloads/Most-Recent-Cohorts-Field-of-Study_06102024.zip |archive-date=9 September 2024}}</ref> Analyses by Quackwatch and the [[Sunlight Foundation]] found high rates of default on Health Education Assistance Loan (HEAL) student loans used for chiropractic programs.<ref name="sunlight">{{cite web |last1=Rosiak |first1=Luke |title=Chiropractics lobbied for special student loans, defaulted in droves : Sunlight Foundation |url=https://sunlightfoundation.com/2010/01/12/chiropractics-lobbied-special-student-loans-defaulted-droves/ |website=Sunlight Foundation |access-date=29 October 2024 |date=12 January 2010}}</ref><ref name="mirtz">{{cite web |last1=Mirtz, DC |first1=Timothy |title=The Student Loan Mess: Why Chiropractic Is in Trouble|url=https://quackwatch.org/chiropractic/edu/loan/ |website=Quackwatch |access-date=29 October 2024 |date=23 April 2003}}</ref><ref name="default-rates">{{cite web |title=Chiropractic Student Loan Default Rates (1999 to 2012)|url=https://quackwatch.org/chiropractic/edu/default/ |website=Quackwatch |access-date=29 October 2024 |date=12 March 2018}}</ref> Among health professionals who were listed as in default on HEAL loans in 2012, 53% were chiropractors.<ref name="default-rates"/>

=== Ethics ===
{{Main|Chiropractic professional ethics}}

The chiropractic oath is a modern variation of the classical [[Hippocratic Oath]] historically taken by physicians and other healthcare professionals swearing to practice their professions ethically.<ref>{{cite journal |vauthors=Simpson JK, Losco B, Young KJ | title = Development of the murdoch chiropractic graduate pledge | journal = Journal of Chiropractic Education| volume = 24 | issue = 2 | pages = 175–86 | year = 2010 | pmid = 21048880 | pmc = 2967342 | doi=10.7899/1042-5055-24.2.175}}</ref> The American Chiropractic Association (ACA) has an ethical code "based upon the acknowledgement that the social contract dictates the profession's responsibilities to the patient, the public, and the profession; and upholds the fundamental principle that the paramount purpose of the chiropractic doctor's professional services shall be to benefit the patient."<ref>{{Cite web|author=Staff|title=Code of Ethics|publisher=[[American Chiropractic Association]]|url=http://www.acatoday.org/content_css.cfm?CID=719|access-date=2014-02-11|archive-url=https://web.archive.org/web/20140222140728/http://www.acatoday.org/content_css.cfm?CID=719|archive-date=2014-02-22}}</ref> The [[International Chiropractor's Association]] (ICA) also has a set of professional canons.<ref>{{Cite web|author=Staff|title=ICA code of Ethics|publisher=[[International Chiropractor's Association]]|url=http://www.chiropractic.org/ica/ethics.htm|archive-url=https://web.archive.org/web/20140405120410/http://www.chiropractic.org/ica/ethics.htm|archive-date=2014-04-05}}</ref>

A 2008 commentary proposed that the chiropractic profession actively regulate itself to combat abuse, fraud, and [[quackery]], which are more prevalent in chiropractic than in other health care professions, violating the [[social contract]] between patients and physicians.<ref name=Murphy-pod /> According to a 2015 Gallup poll of U.S. adults, the perception of chiropractors is generally favorable; two-thirds of American adults agree that chiropractors have their patient's best interest in mind and more than half also agree that most chiropractors are trustworthy. Less than 10% of US adults disagreed with the statement that chiropractors were trustworthy.<ref>{{Cite web|title = Majority in U.S. Say Chiropractic Works for Neck, Back Pain|url = http://www.gallup.com/poll/184910/majority-say-chiropractic-works-neck-back-pain.aspx|access-date = 2015-09-13|website = Gallup Inc.|date = 8 September 2015}}</ref><ref>{{Cite journal|title = Public Perceptions of Doctors of Chiropractic: Results of a National Survey and Examination of Variation According to Respondents' Likelihood to Use Chiropractic, Experience With Chiropractic, and Chiropractic Supply in Local Health Care Markets|journal = Journal of Manipulative and Physiological Therapeutics|date = 2015-01-01|doi = 10.1016/j.jmpt.2015.08.001|pmid = 26362263|first1 = William B|last1 = Weeks|first2 = Christine M|last2 = Goertz|first3 = William C|last3 = Meeker|first4 = Dennis M|last4 = Marchiori|volume=38|issue = 8|pages=533–44|doi-access = free}}</ref>
[[File:Logolibelsmall2.png|thumb|right|The charity [[Sense about Science]] launched a campaign to draw attention to the [[British Chiropractic Association v Singh|BCA legal case]] against science writer [[Simon Singh]].<ref>{{cite news|title=A pivotal moment for free speech in Britain |newspaper=[[The Guardian]] |date=April 15, 2010 |url=https://www.theguardian.com/science/blog/2010/apr/15/simon-singh-libel-reform}}</ref> In 2009, a number of organizations and public figures signed a statement entitled "The law has no place in scientific disputes".<ref>{{cite web |title=The BHA re-publishes Simon Singh's article on chiropractic therapy |publisher=[[British Humanist Association]] |date=July 29, 2009 |url=https://humanism.org.uk/2009/07/29/news-331/}}</ref>]]
Chiropractors, especially in America, have a reputation for unnecessarily treating patients.<ref name=Trick-or-Treatment /> In many circumstances the focus seems to be put on economics instead of health care.<ref name=Trick-or-Treatment /> Sustained chiropractic care is promoted as a preventive tool, but unnecessary manipulation could possibly present a risk to patients.<ref name=Ernst-eval /> Some chiropractors are concerned by the routine unjustified claims chiropractors have made.<ref name=Ernst-eval /> A 2010 analysis of chiropractic websites found the majority of chiropractors and their associations made claims of effectiveness not supported by scientific evidence, while 28% of chiropractor websites advocate lower back pain care, which has some sound evidence.<ref>{{cite journal |vauthors=Ernst E, Gilbey A | title = Chiropractic claims in the English-speaking world | journal = The New Zealand Medical Journal| volume = 123 | issue = 1312 | pages = 36–44 | year = 2010 | pmid = 20389316 }}</ref>

The US [[Office of the Inspector General]] (OIG) estimated that for calendar year 2013, 82% of payments to chiropractors under [[Medicare Part B]], a total of $359 million, did not comply with Medicare requirements.<ref name=ACSH2017/> There have been at least 15 OIG reports about chiropractic billing irregularities since 1986.<ref name=ACSH2017>{{cite web|url=http://acsh.org/news/2017/01/02/medicare-overpayments-chiropractors-are-widespread-10670|title=Medicare Overpayments to Chiropractors Are Widespread|author=Stephen Barrett|publisher=American Council on Science and Health|date=2017-01-02}}</ref>

In 2009, a [[backlash (sociology)|backlash]] to the [[British Chiropractic Association v Singh|libel suit filed by the British Chiropractic Association]] (BCA) against [[Simon Singh]] inspired the filing of formal complaints of false advertising against more than 500 individual chiropractors within one 24-hour period,<ref name=withdraw>{{cite web |url=http://blogs.nature.com/news/thegreatbeyond/2009/06/chiropractic_group_advises_mem_1.html |title=The Great Beyond: Chiropractic group advises members to 'withdraw from the battleground' |publisher=Nature.com |author=Lucas Laursen |access-date=20 June 2009}}</ref><ref>{{cite web |url=http://blogs.nature.com/news/thegreatbeyond/2009/06/chiropractic_complainers_ident.html |title=The Great Beyond: Complaints converge on chiropractors |publisher=Nature.com |author=Lucas Laursen |access-date=20 June 2009}}</ref> 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."<ref name=withdraw /> An editorial in ''Nature'' suggested that the BCA may have been trying to suppress debate and that this use of English libel law was a burden on the right to freedom of expression, which is protected by the [[European Convention on Human Rights]].<ref>{{cite journal | title = Unjust burdens of proof | journal = Nature| volume = 459 | issue = 7248 | page = 751 | date = June 2009 | pmid = 19516290 | doi = 10.1038/459751a | bibcode = 2009Natur.459Q.751. | doi-access = free }}</ref> The libel case ended with the BCA withdrawing its suit in 2010.<ref name="news">{{cite news|title=Case dropped against Simon Singh|author=Pallab Ghosh|url=http://news.bbc.co.uk/1/hi/sci/tech/8621880.stm|work=BBC News|date=2010-04-15}}</ref><ref name="Mark Henderson">{{cite news|newspaper=Times Online|url=http://business.timesonline.co.uk/tol/business/law/article7098157.ece|archive-url=https://web.archive.org/web/20110611200255/http://business.timesonline.co.uk/tol/business/law/article7098157.ece|url-status=dead|archive-date=June 11, 2011|title=Science writer Simon Singh wins bitter libel battle|author=Mark Henderson|location=London|date=2010-04-16}}</ref>

== Reception ==

Chiropractic is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries.<ref name=global-strategy>{{cite web |url=http://chiropracticdiplomatic.com/strategies/global_strategy.pdf |title=Global professional strategy for chiropractic |vauthors=Tetrault M |publisher=Chiropractic Diplomatic Corps |year=2004 |access-date=2008-04-18  |archive-url=https://web.archive.org/web/20080625173624/http://chiropracticdiplomatic.com/strategies/global_strategy.pdf |archive-date=2008-06-25 }}</ref> It is viewed as a marginal and non-clinically–proven attempt at [[complementary and alternative medicine]], which has not integrated into mainstream medicine.<ref name=V-H />

=== Australia ===

In [[Australia]], there are approximately 2488 chiropractors, or one chiropractor for every 7980 people.<ref name="Leach 364–378">{{Cite journal|last=Leach|first=Matthew J.|date=2013-08-01|title=Profile of the complementary and alternative medicine workforce across Australia, New Zealand, Canada, United States and United Kingdom|journal=Complementary Therapies in Medicine|volume=21|issue=4|pages=364–378|doi=10.1016/j.ctim.2013.04.004|pmid=23876568|issn=0965-2299}}</ref> Most private health insurance funds in Australia cover chiropractic care, and the federal government funds chiropractic care when the patient is referred by a medical practitioner.<ref>{{cite journal |vauthors=Xue CC, Zhang AL, Lin V, Myers R, Polus B, Story DF | title = Acupuncture, chiropractic and osteopathy use in Australia: a national population survey | journal = BMC Public Health| volume = 8 | page = 105 | year = 2008 | pmid = 18377663 | pmc = 2322980 | doi = 10.1186/1471-2458-8-105 | doi-access = free }}</ref> In 2014, the chiropractic profession had a registered workforce of 4,684 practitioners in Australia represented by two major organizations – the Chiropractors' Association of Australia (CAA) and the Chiropractic and Osteopathic College of Australasia (COCA).<ref name=AdamsLauche2017/> Annual expenditure on chiropractic care (alone or combined with osteopathy) in Australia is estimated to be between AUD$750–988 million with musculoskeletal complaints such as back and neck pain making up the bulk of consultations; and proportional expenditure is similar to that found in other countries.<ref name=AdamsLauche2017/> While Medicare (the Australian publicly funded universal health care system) coverage of chiropractic services is limited to only those directed by a medical referral to assist chronic disease management, most private health insurers in Australia do provide partial reimbursement for a wider range of chiropractic services in addition to limited third party payments for workers compensation and motor vehicle accidents.<ref name=AdamsLauche2017/>

Of the 2,005 chiropractors who participated in a 2015 survey, 62.4% were male and the average age was 42.1 (SD = 12.1) years.<ref name=AdamsLauche2017/> Nearly all chiropractors (97.1%) had a bachelor's degree or higher, with the majority of chiropractor's highest professional qualification being a bachelor or double bachelor's degree (34.6%), followed by a master's degree (32.7%), Doctor of Chiropractic (28.9%) or PhD (0.9%).<ref name=AdamsLauche2017/> Only a small number of chiropractor's highest professional qualification was a diploma (2.1%) or advanced diploma (0.8%).<ref name=AdamsLauche2017>{{cite journal|last1=Adams|first1=Jon|last2=Lauche|first2=Romy|last3=Peng|first3=Wenbo|last4=Steel|first4=Amie|last5=Moore|first5=Craig|last6=Amorin-Woods|first6=Lyndon G.|last7=Sibbritt|first7=David|title=A workforce survey of Australian chiropractic: the profile and practice features of a nationally representative sample of 2,005 chiropractors|journal=BMC Complementary and Alternative Medicine|volume=17|issue=1|page=14|year=2017|issn=1472-6882|doi=10.1186/s12906-016-1542-x|pmc=5217252|pmid=28056964 |doi-access=free }}{{CC-notice|cc=by4|url=https://bmccomplementalternmed.biomedcentral.com/articles/10.1186/s12906-016-1542-x|author(s)=Jon Adams, Romy Lauche, Wenbo Peng, Amie Steel, Craig Moore, Lyndon G. Amorin-Woods, and David Sibbritt}}</ref>

=== Germany ===
In Germany, chiropractic may be offered by medical doctors and alternative practitioners. Chiropractors qualified abroad must obtain a German non-medical practitioner license. Authorities have routinely required a comprehensive knowledge test for this, but in the recent past, some administrative courts have ruled that training abroad should be recognised.<ref>{{cite web |title=Freedom of Profession for Chiropractors in Germany |url=https://www.aclanz.de/en/october-17-2014-2 |website=ACLANZ |publisher=aclanz Rechtsanwälte |access-date=16 June 2023}}</ref>

=== Switzerland ===
In Switzerland, only trained medical professionals are allowed to offer chiropractic. There are 300 chiropractors in Switzerland.<ref>{{cite web |title=ChiroSuisse - Organisation |url=https://www.chirosuisse.ch/de/chirosuisse/organisation |website=www.chirosuisse.ch |publisher=Schweizerische Gesellschaft für Chiropraktik|access-date=16 June 2023 |language=de}}</ref>

=== United Kingdom ===

In the United Kingdom, there are over 2,000 chiropractors, representing one chiropractor per 29,206 people.<ref name="Leach 364–378"/> Chiropractic is available on the [[National Health Service]] in some areas, such as [[Cornwall]], where the treatment is only available for neck or back pain.<ref>{{cite web |url= https://www.bbc.co.uk/news/uk-england-cornwall-23669971 |title= Chiropractic treatment available on NHS in Cornwall |date= August 13, 2013 |access-date= August 18, 2013 |work= BBC News}}</ref>

A 2010 study by questionnaire presented to UK chiropractors indicated only 45% of chiropractors disclosed to patients the serious risk associated with manipulation of the cervical spine and that 46% believed there was possibility patients would refuse treatment if the risks were correctly explained. However 80% acknowledged the ethical/moral responsibility to disclose risk to patients.<ref>{{cite journal |vauthors=Langworthy JM, Forrest L | title = Withdrawal rates as a consequence of disclosure of risk associated with manipulation of the cervical spine | journal = Chiropractic & Osteopathy| volume = 18 | page = 27 | year = 2010 | pmid = 20977721 | pmc = 3161389 | doi = 10.1186/1746-1340-18-27 | doi-access = free }}</ref>

=== United States and Canada ===

The percentage of the population that utilizes chiropractic care at any given time generally falls into a range from 6% to 12% in the U.S. and Canada,<ref name=Lawrence-Meeker>{{cite journal |vauthors=Lawrence DJ, Meeker WC | title = Chiropractic and CAM utilization: a descriptive review | journal = Chiropractic & Osteopathy| volume = 15 | page = 2 | year = 2007 | pmid = 17241465 | pmc = 1784103 | doi = 10.1186/1746-1340-15-2 | doi-access = free }}</ref> with a global high of 20% in Alberta in 2006.<ref>{{cite magazine |url=http://chiroweb.com/archives/25/06/02.html |title= Chiropractic in Alberta: a model of consumer utilization and satisfaction |magazine=Dynamic Chiropractic |volume=25 |issue=6 |vauthors= Crownfield PW |year=2007}}</ref> In 2008, chiropractors were reported to be the most common CAM providers for children and adolescents, these patients representing up to 14% of all visits to chiropractors.<ref name=Kemper />

There were around 50,330 chiropractors practicing in North America in 2000.<ref name="Leach 364–378"/> In 2008, this has increased by almost 20% to around 60,000 chiropractors.<ref name="Ernst-eval" /> In 2002–03, the majority of those who sought chiropractic did so for relief from back and neck pain and other neuromusculoskeletal complaints;<ref name="Hurwitz" /> most do so specifically for low back pain.<ref name="Hurwitz" /><ref name="Lawrence-Meeker" /> The majority of U.S. chiropractors participate in some form of managed care.<ref name="CooperMcKee2003" /> Although the majority of U.S. chiropractors view themselves as specialists in neuromusculoskeletal conditions, many also consider chiropractic as a type of primary care.<ref name="CooperMcKee2003" /> In the majority of cases, the care that chiropractors and physicians provide divides the market, however for some, their care is complementary.<ref name="CooperMcKee2003" />

In the U.S., chiropractors perform over 90% of all manipulative treatments.<ref>{{cite web |url=http://www.chirobase.org/05RB/AHCPR/12.html  |title=Chiropractic in the United States:Training, Practice, and Research |first1=Daniel C. |last1=Cherkin |first2=Robert D. |last2=Mootz |access-date=2010-10-01 |year=2010 |publisher=Chirobase}}</ref> Satisfaction rates are typically higher for chiropractic care compared to medical care, with a 1998 U.S. survey reporting 83% of respondents satisfied or very satisfied with their care; quality of communication seems to be a consistent predictor of patient satisfaction with chiropractors.<ref>{{cite journal | author = Gaumer G | title = Factors associated with patient satisfaction with chiropractic care: survey and review of the literature | journal = Journal of Manipulative and Physiological Therapeutics| volume = 29 | issue = 6 | pages = 455–462 | year = 2006 | pmid = 16904491 | doi = 10.1016/j.jmpt.2006.06.013 }}</ref>

Utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient.<ref name=Chapman-Smith/> The use of chiropractic declined from 9.9% of U.S. adults in 1997 to 7.4% in 2002; this was the largest relative decrease among CAM professions, which overall had a stable use rate.<ref>{{cite journal |vauthors=Tindle HA, Davis RB, Phillips RS, Eisenberg DM | title = Trends in use of complementary and alternative medicine by US adults: 1997–2002 | journal = Alternative Therapies in Health and Medicine| volume = 11 | issue = 1 | pages = 42–49 | year = 2005 | pmid = 15712765 }}</ref> As of 2007 7% of the U.S. population is being reached by chiropractic.<ref>{{cite magazine |magazine=Dynamic Chiropractic  |volume=25|issue=19|year=2007|last=Stanley |first=G.|title= The Sustainability of Chiropractic|url=http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=52341 }}</ref> They were the third largest medical profession in the US in 2002, following physicians and dentists.<ref name=Bailey2002>{{cite book|author=Eric J. Bailey|title=African American Alternative Medicine: Using Alternative Medicine to Prevent and Control Chronic Diseases|url=https://books.google.com/books?id=g83lie1RiUMC&pg=PA26|year=2002|publisher=Greenwood Publishing Group|isbn=978-0-89789-747-1|pages=26ff}}</ref> Employment of U.S. chiropractors was expected to increase 14% between 2006 and 2016, faster than the average for all occupations.<ref name=BLS />

In the U.S., most states require insurers to cover chiropractic care, and most [[HMO]]s cover these services.<ref name=Kemper>{{cite journal |vauthors=Kemper KJ, Vohra S, Walls R| title = American Academy of Pediatrics. The use of complementary and alternative medicine in pediatrics | journal = Pediatrics| volume = 122 | issue = 6 | pages = 1374–1386 | date = December 2008 | pmid = 19047261 | doi = 10.1542/peds.2008-2173 | last5 = Provisional Section On Complementary | doi-access = free }}</ref>

==History==
{{Main|History of chiropractic}}
[[File:Daniel_David_Palmer.jpg|thumb|right|Daniel David (D. D.) Palmer, founder of chiropractic]]
Chiropractic's origins lie in the [[folk medicine]] practice of [[bonesetter|bonesetting]], in which untrained practitioners engaged in joint manipulation or resetting fractured bones.<ref name=Ernst-eval />  
Chiropractic was founded in 1895 by [[Daniel David Palmer|Daniel David (D. D.) Palmer]] in [[Davenport, Iowa]]. Palmer, a [[Magnetic healing|magnetic healer]], hypothesized that manual manipulation of the spine could cure disease.<ref name=Baer /> The first chiropractic patient of D. D. Palmer was [[Harvey Lillard]], a worker in the building where Palmer's office was located.<ref name=History-Primer /> He claimed that he had severely reduced hearing for 17 years, which started shortly following a "pop" in his spine.<ref name=History-Primer /> A few days following his adjustment, Lillard claimed his hearing was almost completely restored.<ref name=History-Primer /> Another of Palmer's patients,  Samuel Weed, coined the term ''chiropractic'', from [[Ancient Greek|Greek]] {{lang|grc|χειρο-}} {{lang|grc-Latn|[[wikt:chiro#English|chiro-]]}} 'hand' (itself from {{lang|grc|[[wikt:χείρ#Ancient Greek|χείρ]]}} {{lang|grc-Latn|cheir}} 'hand') and {{lang|grc|[[wikt:πρακτικός#Ancient Greek|πρακτικός]]}} {{lang|grc-Latn|praktikos}} 'practical'.<ref>{{cite web |url=http://www.oxforddictionaries.com/us/definition/american_english/chiropractic |archive-url=https://web.archive.org/web/20130503112929/http://oxforddictionaries.com/us/definition/american_english/chiropractic  |archive-date=May 3, 2013 |title=chiropractic |year=2014 |work=[[Oxford English Dictionary]] |publisher=[[Oxford University Press]]}}</ref><ref>{{cite web |url=http://www.oxforddictionaries.com/us/definition/american_english/chiro- |archive-url=https://web.archive.org/web/20140812213145/http://www.oxforddictionaries.com/us/definition/american_english/chiro-  |archive-date=August 12, 2014 |title=chiro- |year=2014 |work=[[Oxford English Dictionary]] |publisher=[[Oxford University Press]]}}</ref> Chiropractic is classified as a field of [[pseudomedicine]].<ref name=Swanson2015>{{cite book |vauthors=Swanson ES |title=Science and Society: Understanding Scientific Methodology, Energy, Climate, and Sustainability |chapter-url=https://books.google.com/books?id=tQmhCgAAQBAJ&pg=PA65 |year=2015 |publisher=Springer |isbn=978-3-319-21987-5 |page=65 |chapter=Pseudoscience}}</ref>

Chiropractic competed with its predecessor osteopathy, another medical system based on magnetic healing; both systems were founded by charismatic midwesterners in opposition to the conventional medicine of the day, and both postulated that manipulation improved health.<ref name=Baer>{{cite journal |journal=Medical Anthropology Quarterly |year=1987 |volume=1 |issue=2 |pages=176–193 |title=Divergence and convergence in two systems of manual medicine: osteopathy and chiropractic in the United States |vauthors=Baer HA |doi=10.1525/maq.1987.1.2.02a00030 |doi-access=free }}</ref> Although initially keeping chiropractic a family secret, in 1898 Palmer began teaching it to a few students at his new [[Palmer School of Chiropractic]].<ref name=Martin /> One student, his son [[Bartlett Joshua Palmer|Bartlett Joshua (B. J.) Palmer]], became committed to promoting chiropractic, took over the Palmer School in 1906, and rapidly expanded its enrollment.<ref name=Martin/>

Early chiropractors believed that all disease was caused by interruptions in the flow of innate intelligence, a [[vitalistic]] nervous energy or life force that represented God's presence in man; chiropractic leaders often invoked religious imagery and moral traditions.<ref name=Martin /> D. D. Palmer said he "received chiropractic from the other world".<ref name="Religion">[http://www.chiro.org/Plus/History/Persons/PalmerDD/PalmerDD's_Religion-of-Chiro.pdf "D. D. Palmer's Religion of Chiropractic"]&nbsp;– Letter from D. D. Palmer to P. W. Johnson, D.C., May 4, 1911. In the letter, he often refers to himself with [[Royal we|royal third person terminology]] and also as "Old Dad".</ref> D. D. and B. J. both seriously considered declaring chiropractic a religion, which might have provided [[Free Exercise Clause of the First Amendment|legal protection under the U.S. constitution]], but decided against it partly to avoid confusion with [[Christian Science]].<ref name=Martin /><ref name="Religion" /> Early chiropractors also tapped into the [[Populism|Populist]] movement, emphasizing craft, hard work, competition, and advertisement, aligning themselves with the common man against intellectuals and [[Trust (19th century)|trusts]], among which they included the [[American Medical Association]] (AMA).<ref name=Martin />

[[File:Bartlett joshua palmer.JPG|thumb|right|upright=0.75|[[B. J. Palmer]], early developer of chiropractic]]
Chiropractic has seen considerable [[Chiropractic controversy and criticism|controversy and criticism]].<ref name=DeVocht /><ref name=Homola/> Although D. D. and B. J. were "straight" and disdained the use of instruments, some early chiropractors, whom B. J. scornfully called "mixers", advocated the use of instruments.<ref name=Martin /> In 1910, B. J. changed course and endorsed X-rays as necessary for diagnosis; this resulted in a significant exodus from the Palmer School of the more conservative faculty and students.<ref name=Martin /> The mixer camp grew until by 1924 B. J. estimated that only 3,000 of the United States' 25,000 chiropractors remained straight.<ref name=Martin /> That year, B. J.'s invention and promotion of the neurocalometer, a temperature-sensing device, was highly controversial among B. J.'s fellow straights. By the 1930s, chiropractic was the largest alternative healing profession in the U.S.<ref name=Martin />

[[File:Harvey Lillard.jpg|thumb|left|upright=0.75|[[William Harvey Lillard|Harvey Lillard]], first chiropractic patient]]
Chiropractors faced heavy opposition from organized medicine.<ref name=History-Primer /> D. D. Palmer was jailed in 1907 for practicing medicine without a license.<ref name="Jail">[http://www.chiro.org/Plus/History/Persons/PalmerDD/Gregory,Alva-chrono.pdf] — Chiro.org</ref>{{fcn|date=February 2023}} Thousands of chiropractors were prosecuted for [[Health care provider#Practicing without a license|practicing medicine without a license]], and D. D. and many other chiropractors were jailed.<ref name=History-Primer /> To defend against medical statutes, B. J. argued that chiropractic was separate and distinct from medicine, asserting that chiropractors "analyzed" rather than "diagnosed", and "adjusted" subluxations rather than "treated" disease.<ref name=History-Primer /> B. J. cofounded the Universal Chiropractors' Association (UCA) to provide legal services to arrested chiropractors.<ref name=History-Primer /> Although the UCA won their first test case in Wisconsin in 1907, prosecutions instigated by state medical boards became increasingly common and in many cases were successful. In response, chiropractors conducted political campaigns to secure separate licensing statutes, eventually succeeding in all fifty states, from Kansas in 1913 through Louisiana in 1974.<ref name=History-Primer /> The longstanding feud between chiropractors and [[medical doctor]]s continued for decades. 

===Restraint of trade decision 1989===
The AMA labeled chiropractic an "unscientific [[cult]]" in 1966,<ref name=Chiro-PH>{{cite journal |vauthors=Johnson C, Baird R, Dougherty PE, Globe G, Green BN, Haneline M, Hawk C, Injeyan HS, Killinger L, Kopansky-Giles D, Lisi AJ, Mior SA, Smith M | title = Chiropractic and public health: current state and future vision | journal = Journal of Manipulative and Physiological Therapeutics| volume = 31 | issue = 6 | pages = 397–410 | year = 2008 | pmid = 18722194 | doi = 10.1016/j.jmpt.2008.07.001 | doi-access = free }}</ref> and until 1980 advised its members that it was unethical for medical doctors to associate with "unscientific practitioners".<ref>{{cite journal | author = Cherkin D | title = AMA policy on chiropractic | journal = American Journal of Public Health| volume = 79 | issue = 11 | pages = 1569–70 | date = November 1989 | pmid = 2817179 | pmc = 1349822 | doi = 10.2105/AJPH.79.11.1569-a }}</ref> This culminated in a landmark 1987 decision, ''[[Wilk v. American Medical Association|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.<ref name=CooperMcKee2003/>

===Growing scholarly interest===
Serious research to test chiropractic theories did not begin until the 1970s, and is continuing to be hampered by antiscientific and [[pseudoscientific]] ideas that sustained the profession in its long battle with organized medicine.<ref name=History-Primer /> 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.<ref name=History-Primer>{{cite web|title=Chiropractic history: a primer |last1=Keating |first1=J. C. Jr |last2=Cleveland |first2=C. S. III |last3=Menke |first3=M. |url=http://ahc.memberclicks.net/assets/documents/ChiroHistoryPrimer.pdf |year=2005 |access-date=2008-06-16 |publisher=Association for the History of Chiropractic  |archive-url=https://web.archive.org/web/20140424011335/http://ahc.memberclicks.net/assets/documents/ChiroHistoryPrimer.pdf |archive-date=2014-04-24 }}</ref>

In recent decades chiropractic gained legitimacy and greater acceptance by medical physicians and [[health plan]]s, and enjoyed a strong political base and sustained demand for services.<ref name=CooperMcKee2003/> However, its future seemed uncertain: as the number of practitioners grew, evidence-based medicine insisted on treatments with demonstrated value, managed care restricted payment, and competition grew from [[massage therapist]]s and other health professions.<ref name=CooperMcKee2003/> The profession responded by marketing natural products and devices more aggressively, and by reaching deeper into alternative medicine and primary care.<ref name=CooperMcKee2003/>

== Public health ==
{{further|Vaccine controversy#Alternative medicine|Water fluoridation controversy}}
Some chiropractors oppose [[vaccination]] and [[water fluoridation]], which are common [[public health]] practices.<ref name=Murphy-pod /> Within the chiropractic community there are significant disagreements about vaccination, one of the most cost-effective public health interventions available.<ref name=WardleFrawley2016>{{cite journal|last1=Wardle|first1=Jon|last2=Frawley|first2=Jane|last3=Steel|first3=Amie|last4=Sullivan|first4=Elizabeth|title=Complementary medicine and childhood immunisation: A critical review|journal=Vaccine|volume=34|issue=38|year=2016|pages=4484–4500|doi=10.1016/j.vaccine.2016.07.026|pmid=27475472}}</ref> Most chiropractic writings on vaccination focus on its negative aspects,<ref name=Busse /> claiming that it is hazardous, ineffective, and unnecessary.<ref name=Campbell /> Some chiropractors have embraced vaccination, but a significant portion of the profession rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that vaccines interfere with healing.<ref name=Campbell /> The extent to which anti-vaccination views perpetuate the current chiropractic profession is uncertain.<ref name=Busse /> The American Chiropractic Association and the International Chiropractors Association support individual exemptions to compulsory vaccination laws, and a 1995 survey of U.S. chiropractors found that about a third believed there was no scientific proof that immunization prevents disease.<ref name=Campbell/> The Canadian Chiropractic Association supports vaccination;<ref name=Busse/> a survey in Alberta in 2002 found that 25% of chiropractors advised patients for, and 27% against, vaccinating themselves or their children.<ref name=":0">{{cite journal |vauthors=Russell ML, Injeyan HS, Verhoef MJ, Eliasziw M | title = Beliefs and behaviours: understanding chiropractors and immunization | journal = Vaccine| volume = 23 | issue = 3 | pages = 372–379 | year = 2004 | pmid = 15530683 | doi = 10.1016/j.vaccine.2004.05.027 }}</ref>

Early opposition to water fluoridation included chiropractors, some of whom continue to oppose it as being incompatible with chiropractic philosophy and an infringement of personal freedom. Other chiropractors have actively promoted fluoridation, and several chiropractic organizations have endorsed scientific principles of public health.<ref>{{cite journal |vauthors=Jones RB, Mormann DN, Durtsche TB | title = Fluoridation referendum in La Crosse, Wisconsin: contributing factors to success | journal = American Journal of Public Health| volume = 79 | issue = 10 | pages = 1405–1408 | year = 1989 | pmid = 2782512 | pmc = 1350185 | doi = 10.2105/AJPH.79.10.1405 }}</ref> In addition to traditional chiropractic opposition to water fluoridation and vaccination, chiropractors' attempts to establish a positive reputation for their public health role are also compromised by their reputation for recommending repetitive lifelong chiropractic treatment.<ref name=Murphy-pod />

== Controversy ==
{{main|Chiropractic controversy and criticism}}
Throughout its history chiropractic has been the subject of internal and external controversy and criticism.<ref name=Kaptchuk-Eisenberg /><ref name=Jaroff>{{cite magazine|last=Jaroff|first=Leon|title=Back Off, Chiropractors!|url=http://content.time.com/time/health/article/0,8599,213482,00.html|date=27 February 2002|magazine=[[Time (magazine)|Time]]|access-date=7 June 2009}}</ref> According to [[Daniel D. Palmer]], the founder of chiropractic, [[vertebral subluxation|subluxation]] is the sole cause of disease and manipulation is the cure for all diseases of the human race.<ref name=Ernst-eval/><ref name=ChiropractorsAdjuster1910>{{cite book|vauthors= Palmer DD|title= The Chiropractor's Adjuster: Text-book of the Science, Art and Philosophy of Chiropractic for Students and Practitioners|url=https://www.scribd.com/doc/45233534/s-Adjuster-1910|location=Portland, Oregon|publisher= Portland Printing House Co|year=1910|oclc=17205743|quote=A subluxated vertebra&nbsp;... is the cause of 95 percent of all diseases&nbsp;... The other five percent is caused by displaced joints other than those of the vertebral column.}}</ref> A 2003 profession-wide survey<ref name=McDonald /> found "most chiropractors (whether 'straights' or 'mixers') still hold views of innate intelligence and of the cause and cure of disease (not just back pain) consistent with those of the Palmers."<ref name=Brown2014>{{cite news|first=Candy|last=Gunther Brown |title=Chiropractic: Is it Nature, Medicine or Religion?|url=http://www.huffingtonpost.com/candy-gunther-brown-phd/chiropractic-is-it-nature_b_5559654.html|work=[[HuffPost]]|date=July 7, 2014}}</ref> A critical evaluation stated "Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today."<ref name=Ernst-eval /> Chiropractors, including D. D. Palmer, were jailed for [[Practicing medicine without license|practicing medicine without a license]].<ref name=Ernst-eval /> For most of its existence, chiropractic has battled with [[mainstream medicine]], sustained by antiscientific and pseudoscientific ideas such as subluxation.<ref name=History-Primer /> Collectively, systematic reviews have not demonstrated that spinal manipulation, the main treatment method employed by chiropractors, is [[Efficacy#Medicine|effective]] for any medical condition, with the possible exception of treatment for [[back pain]].<ref name=Ernst-eval /> Chiropractic remains controversial, though to a lesser extent than in past years.<ref name=DeVocht/>

==See also==
{{Portal|Medicine}}
* [[Chiropractic education]]
* [[Chiropractic schools]]
* [[Councils on Chiropractic Education International]]
* [[List of topics characterized as pseudoscience]]
* [[Toftness device]]
* [[World Federation of Chiropractic]]

== References ==
{{Reflist}}

== Further reading ==
* {{cite book |editor=Barrett S |editor-link=Stephen Barrett |author=Long PH |title=Chiropractic Abuse: An Insider's Lament |publisher=American Council on Science & Health |year=2013 |isbn=978-0-9727094-9-1}}
* {{cite encyclopedia|encyclopedia=The Skeptic Encyclopedia of Pseudoscience |volume=1 |url=https://books.google.com/books?id=Gr4snwg7iaEC&pg=PA308 |publisher=ABC-CLIO |isbn=978-1-57607-653-8 |pages=308– |author=Homola S |title=Chiropractic: Conventional or Alternative Healing? |year=2002 |editor=Shermer M}}
* {{cite journal | author = Menke JM | title = Do Manual Therapies Help Low Back Pain?: A Comparative Effectiveness Meta-Analysis | journal = Spine| volume =  39| issue =  7| date = January 2014 | pmid = 24480940 | doi = 10.1097/BRS.0000000000000230 | type = Meta-analysis | pages=E463–72| s2cid = 25497624 }}

== External links ==
{{sisterlinks|d=Q658096|c=Category:Chiropractic|n=no|b=no|v=no|voy=no|s=1922 Encyclopædia Britannica/Chiropractic |m=no|mw=no|species=no}}
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* [[World Federation of Chiropractic]] - [http://www.wfc.org website]

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[[Category:Chiropractic| ]]
[[Category:Manual therapy]]
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