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Chiropractic: from Greek chiro- χειρο- "hand-"
+ praktikós πρακτικός "concerned with action"
Pastiche of man thinking and writing; the ribs, vertebrae, and hip bones of a human skeleton; a hand holding another; and Leonardo's famous drawing of a man in square and circle


'Chiropractic' is a health care profession concerned with the diagnosis, treatment and prevention of disorders of the human body with emphasis on the role of the neuromusculoskeletal system, its specific conditions and their effects on general health. There is an emphasis on manual techniques, including joint adjustment and/or manipulation, with a particular focus on joint dysfunction/"subluxation" [1] [2] Chiropractic is the third largest doctoral profession, behind medicine and dentistry[3] and, in North America, are the largest complementary alternative medical (CAM) profession. [4] In the U.S., chiropractors perform over 90% of all manipulative treatments.[5]

Scope of Practice

Chiropractors, (also known as doctors of chiropractic or chiropractic physicians[6] in all but a handful of jurisdictions),[7] are primary contact, portal of entry health care practitioners who diagnose and conservatively manage (primarily but not exclusively) the neuromusculoskeletal system without the use of medicines or surgery,[1] The practice of chiropractic medicine involves a range of diagnostic methods including skeletal imaging, observational and tactile assessments, and orthopedic and neurological evaluation.[1] A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider.[8] 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, including prescribing natural substances, and lifestyle counseling.[9]

Education, licensing, and regulation

Chiropractors obtain a first professional degree in the field of chiropractic.[10] The curriculum content of North American chiropractic and medical colleges with regard to basic and clinical sciences has been more similar than not, both in the kinds of subjects offered and in the time assigned to each subject.[11] 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.[12] 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.[13] Graduates of the Canadian Memorial Chiropractic College (CMCC) are formally recognized to have at least 7–8 years of university level education.[14][15] The World Health Organization (WHO) guidelines suggest three major full-time educational paths culminating in either a 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.[1]

Upon graduation, there may be a requirement to pass national, state, or provincial board examinations before being licensed to practice in a particular jurisdiction.[16][17] Depending on the location, continuing education may be required to renew these licenses.[18][19] 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.[20]

Chiropractic is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries.[21] 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.[22][23] 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.[24] 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.[25] Today, there are 18 accredited Doctor of Chiropractic programs in the U.S.,[26] 2 in Canada,[27] 6 in Australasia,[28] and 5 in Europe.[29] 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.[30] 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.[14][15] Chiropractic curricula in the U.S. have been criticized for failing to meet generally accepted standards of evidence-based medicine.[31]

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.[32][33] There are an estimated 49,000 chiropractors in the U.S. (2008),[34] 6,500 in Canada (2010),[35] 2,500 in Australia (2000),[36] and 1,500 in the UK (2000).[37]

Diagnostic and Treatment Procedures

A core area of focus and expertise of chiropractors is the evaluation of the neuromusculoskeletal (NMS) system with a particular focus on the joints of the spine and extremities. In addition to physical, neurological, orthopedic, radiographic and laboratory tests a core and unique aspect of chiropractic care is the chiropractic examination, or manual palpation of the joint and soft tissues for structural and functional integrity. Manual therapy/techniques is the most common mode of therapy done in clinical chiropractic practice although adjunctive therapies are also used. Manual therapy consists of procedures by which the hands directly contact the body to treat the articulations or soft tissues. Spinal manipulative therapy is the defining procedure performed in clinical chiropractic practice. Chiropractic spinal manipulative therapy (CSMT) involves a high-velocity, low amplitude (HVLA) thrust to a dysfunctional (subluxated) joint(s to help improve biomechanical and neurological function. In the U.S., chiropractors perform over 90% of all manipulative treatments.[38]

Manipulation/Adjustment Techniques

Spinal manipulation, also known as"spinal adjustment" or "chiropractic adjustment", is the most common treatment used in chiropractic care.[39] 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; 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.[40] 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. Clinical skill in employing HVLA-SM thrusts depends on the ability of the practitioner to handle the duration and magnitude of the load.[41] 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.[40]

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 U.S. chiropractors in a 2003 survey:[39] 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), 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), Nimmo Receptor-Tonus Technique, Applied Kinesiology (which emphasises "muscle testing" as a diagnostic tool), and cranial.[42] 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.[43]

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 U.S. chiropractors in a 2003 survey: Diversified technique (full-spine manipulation; mentioned in previous paragraph), physical fitness/exercise promotion, corrective or therapeutic exercise, ergonomic/postural advice, self-care strategies, activities of daily living, changing risky/unhealthy behaviors, nutritional/dietary recommendations, relaxation/stress reduction recommendations, ice pack/cryotherapy, extremity adjusting (also mentioned in previous paragraph), Trigger point therapy, and disease prevention/early screening advice.[39]

A 2010 study describing Belgium chiropractors and their patients found chiropractors in Belgium mostly focus on neuromusculoskeletal complaints in adult patients, with emphasis on the spine. The diversified technique is the most often applied technique at 93%, followed by the Activator mechanical-assisted technique at 41%.[44] A 2009 study assessing chiropractic students giving or receiving spinal manipulations while attending a U.S. chiropractic college found Diversified, Gonstead, and upper cervical manipulations are frequently used methods.[45]

Physio-therapeutic methods


Although there is inter and intraprofessional disagreement about the role of chiropractors as primary care providers in the mainstream health care system, contemporary chiropractic practice resembles more a medical specialty like dentistry or podiatry with a specialized focus. [8] It has been proposed that chiropractors specialize in nonsurgical spine care, instead of attempting to also treat other problems,[8][46] but the more expansive view of chiropractic is still widespread.[47] Mainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be complementary and alternative medicine (CAM);[48] and a 2008 study reported that 31% of surveyed chiropractors categorized chiropractic as CAM, 27% as integrated medicine, and 12% as mainstream medicine.[49] Aligning with conventional medicine could give chiropractors more university affiliation and access to hospitals and long-term facilities; aligning with the CAM movement could bring more patients looking for nonmedical approaches.[50]


(for History, see Chiropractic history)

Assimilation into Mainstream

Chiropractic has gained greater acceptance among medical physicians and health plans in the U.S.,[51] and evidence-based medicine has been used to review research studies and generate practice guidelines.[52] Many studies of treatments used by chiropractors have been conducted. Collectively, systematic reviews of this research has demonstrated that spinal manipulation is effective. Spinal manipulation has been alleged to have serious complications in rare cases (about 1.4/1,000,000),[53] this is clearly less than the risk of taking an aspirin tablet, and thus chiropractic care is generally safe when employed skillfully and appropriately.[1]

Chiropractic is autonomous, and in some ways competitive with mainstream medicine.[54] Osteopathy enjoys medical licensing only in the US. Outside the U.S. it remains primarily a manual medical system, with mostly less recognition than Chiropractic;[55] physical therapists work as a part of mainstream medicine, and osteopathic medicine in the U.S. has merged with the medical profession.[54] Members distinguish these competing professions with rhetorical strategies that include claims that, compared to other professions, osteopaths use a wider variety of treatment procedures; and that physical therapists emphasize machinery and exercise.[56] Chirorpactors, uniquely use a high velocity, low intensity form of manipulation which requires a far higher degree of training and experience to effectively utilize. This may account for the difference in effectiveness of treatment, when one compares these approaches. In a landmark study in 1990 published in the British medical journal involving 741 patients, Chiropractic manipulation was found to be significantly superior to ANY other method of treating low back pain. The same group was followed and in 1995 the BMJ published the follow-up study showing that those results were still demonstrable in that patient population. Later studies showing lesser results apparently did NOT include Chiropractic methods of manipulation and this may be the reason for the significant difference.

WorldWide presence

Chiropractic is established in the U.S., Canada, and Australia, and is present to a lesser extent in as many as 90 other countries.[21]


For Accreditation see: Educational accreditation

Regulatory boards

For Regulatory boards see: Regulatory boards

Utilization, satisfaction rates, and third party coverage

In the U.S., chiropractic is the third largest healing arts profession,[4] and is the third largest doctoral profession, behind only medicine and dentistry.[57] The percentage of population that utilizes chiropractic care at any given time generally falls into a range from 6% to 12% in the U.S. and Canada,[58] with a global high of 20% in Alberta.[59] Chiropractors are the most common CAM providers for children and adolescents, who consume up to 14% of all visits to chiropractors.[60] The vast majority who seek chiropractic care do so for relief from back and neck pain and other neuromusculoskeletal complaints;[61] most do so specifically for low back pain. Practitioners such as chiropractors are often used as a complementary form of care to primary medical intervention.[58] 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.[62]

Insurance coverage

For Insurance coverage see Insurance coverage

Evidence basis

The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under managed care. [52] Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs what is considered by many chiropractic researchers to be antiscientific reasoning and unsubstantiated claims,[2][63][64][65] that have been called ethically suspect when they let practitioners maintain their beliefs to patients' detriment.[2] 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.[66] Continued education enhances the scientific knowledge of the practitioner.[67]


Manual therapies commonly used by chiropractors are effective for the treatment of low back pain,[68] [69] and might also be effective for the treatment of lumbar disc herniation with radiculopathy,[70][71] neck pain,[72] some forms of headache,[73][74] and some extremity joint conditions.[75][76] The efficacy and cost-effectiveness of maintenance chiropractic care are unknown.[77] Chiropractic care is generally safe when employed skillfully and appropriately.[1] Spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or fatal complications in exceedingly rare cases.[53]


A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings.[78] A 2006 systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation in the United Kingdom compared favorably with other treatments for back pain, but that reports were based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain.A 2005 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.[79] The cost-effectiveness of maintenance chiropractic care is unknown.[77]

Safety issues

For Safety, see Chiropractic safety

Public health

Most chiropractors do NOT oppose reasonable vaccination or water fluoridation, which are common public health practices. Although within the chiropractic community there are significant disagreements about vaccination,[80][36] one of the most cost-effective public health interventions available.[81] Most chiropractors have embraced a reasonable approach to vaccination, but some of the profession, as in any large group rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that vaccines interfere with healing.

The American Chiropractic Association and the International Chiropractors Association support individual exemptions to compulsory vaccination laws. A 1995 survey of U.S. chiropractors found that about a third believed there was no scientific proof that immunization prevents disease. [36] The Canadian Chiropractic Association supports vaccination;[80] a survey in Alberta in 2002 found that 25% of chiropractors advised patients for, and 27% against, vaccinating themselves or their children.[82]

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.[83]


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