Editing Chiropractic (section)

== 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"/>}}