Chiropractic

Chiropractic is not regarded as a mainstream branch of medicine. Origins in "folk medicine" Chiropractic's origins lie in the folk medicine of bonesetting, Although a wide diversity of ideas exist among chiropractors, Some chiropractors claim spinal manipulation can have an effect on a variety of ailments such as irritable bowel syndrome and asthma. "Subluxation" as a Vitalist concept In science-based medicine, the term "subluxation" refers to an incomplete or partial dislocation of a joint, from the Latin luxare for "dislocate". Whereas 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. 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. 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. 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. 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. In 2005, the 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. 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." 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." 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." Some dissuade patients from seeking medical care, others have pretended to be qualified to act as a family doctor. Quackwatch, an alternative medicine watchdog, cautions against seeing chiropractors who: • 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: == Scope of practice ==

Chiropractors emphasize the conservative management of the neuromusculoskeletal system without the use of evidence-based medicines or surgery, It has been proposed that chiropractors specialize in nonsurgical spine care, instead of attempting also to treat other problems, but the more expansive view of chiropractic is still widespread. Mainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be complementary and alternative medicine (CAM); Many chiropractors believe they are primary care providers, and UK chiropractors, but the length, breadth, and depth of chiropractic clinical training do not support the requirements to be considered primary care providers, In a 2010 article on the history of manipulative therapy, the author opined that "physical therapy emerged and grew alongside osteopathy, chiropractic, and the evolving "scientific" medical profession. However, over the next 100 years, physical therapy, osteopathy, and chiropractic were destined to travel very different paths. In its country of origin, osteopathy would coalesce with the medical profession. Chiropractic would remain autonomous from, and highly competitive with, medicine. Physical therapy, whose roots lay in working alongside and cooperating with medical physicians, continues to do so." physical therapists work alongside and cooperate with mainstream medicine, and osteopathic medicine in the U.S. has merged with the medical profession. 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. Chiropractic diagnosis may involve a range of methods, including skeletal imaging, observational and tactile assessments, and orthopedic and neurological evaluation. but is not recognized by the American Chiropractic Association as being chiropractic. It remains controversial within certain segments of the veterinary and chiropractic professions. No single profession "owns" spinal manipulation, and there is little consensus on which profession should administer SM, raising concerns among chiropractors that other medical physicians could "steal" SM procedures from chiropractors. Two US states (Washington and Arkansas) prohibit physical therapists from performing SM, 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. == Treatments ==

Spinal manipulation, which chiropractors call "spinal adjustment" or "chiropractic adjustment", is the most common treatment used in chiropractic care. 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. 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: Chiropractic biophysics technique uses inverse functions of rotations during spinal manipulation. Koren Specific Technique (KST) may use their hands, or they may use an electric device known as an "ArthroStim" for assessment and spinal manipulations. 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. , cervical and 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/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. 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. 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. 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. 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". 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. Specific guidelines concerning the treatment of nonspecific (i.e., unknown cause) low back pain are inconsistent between countries. Effectiveness Numerous controlled clinical studies of treatments used by chiropractors have been conducted, with varied results. Generally, the research carried out into the effectiveness of chiropractic has been of poor quality. 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. Chiropractic care benefits from the placebo response, but it is difficult to construct a trustworthy placebo for clinical trials of spinal manipulative therapy (SMT). The efficacy of maintenance care in chiropractic is unknown. It has only low-quality and inconsistent evidence of benefit, with no clear superiority over standard medical care. There is moderate quality evidence to support the use of SM for the treatment of acute lumbar radiculopathy and acute lumbar disc herniation with associated radiculopathy. 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. 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. 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. 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. 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. A 2010 systematic review found low level evidence that suggests chiropractic care improves cervical range of motion and pain in the management of whiplash. • Headache. There is no good evidence chiropractic helps with migraine. 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. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs, limited to low level evidence supporting chiropractic management of shoulder pain and limited or fair evidence supporting chiropractic management of leg conditions. • 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. A 2011 systematic review found moderate evidence to support the use of manual therapy for cervicogenic dizziness. There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine) and no scientific data for idiopathic adolescent scoliosis. 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 vision conditions. Other reviews have found no evidence of significant benefit for asthma, baby colic, bedwetting, carpal tunnel syndrome, fibromyalgia, gastrointestinal disorders, kinetic imbalance due to suboccipital strain (KISS) in infants, menstrual cramps, insomnia, postmenopausal symptoms, As there is no evidence of effectiveness or safety for cervical manipulation for baby colic, it is not endorsed. Safety The World Health Organization found chiropractic care in general is safe when employed skillfully and appropriately. Indirect risks of chiropractic involve delayed or missed diagnoses through consulting a chiropractor. 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; adverse reactions appear to be more common following manipulation than mobilization. The most frequently stated adverse effects are mild headache, soreness, and briefly elevated pain fatigue. Chiropractic is correlated with a very high incidence of minor adverse effects. Estimates vary widely for the incidence of these complications, A 2016 systematic review concludes that the level of reporting is unsuitable and unacceptable. Reports of serious adverse events have occurred, resulting from spinal manipulation therapy of the lumbopelvic region. X-rays recommends avoiding chiropractors who use full-body x-ray radiography The use of X-ray imaging in the case of vertebral subluxation exposes patients to harmful ionizing radiation for no evidentially supported reason. Chiropractors sometimes employ diagnostic imaging techniques such as X-rays and CT scans that rely on ionizing radiation. which increases cancer risk in proportion to the amount of radiation received. Research suggests that radiology instruction given at chiropractic schools worldwide seem to be evidence-based. QuackWatch cautions against seeing chiropractors who do full-body x-rays. Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (CMT) and VAS. There is insufficient evidence to support a strong association or no association between cervical manipulation and stroke. 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. There is controversy regarding the degree of risk of stroke from cervical manipulation. There is very low evidence supporting a small association between internal carotid artery dissection and chiropractic neck manipulation. The incidence of internal carotid artery dissection following cervical spine manipulation is unknown. The literature infrequently reports helpful data to better understand the association between cervical manipulative therapy, cervical artery dissection and stroke. The limited evidence is inconclusive that chiropractic spinal manipulation therapy is not a cause of intracranial hypotension. Cervical intradural disc herniation is very rare following spinal manipulation therapy. A 2012 systematic review concluded that no accurate assessment of risk-benefit exists for cervical manipulation. 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. 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. 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. 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. 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. 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. The cost-effectiveness of maintenance chiropractic care is unknown. 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. == Education, licensing, and regulation ==

Requirements vary between countries. In the U.S., chiropractors obtain a non-medical, accredited diploma in chiropractic. Chiropractic education in the U.S. has been criticized for failing to meet generally accepted standards of evidence-based medicine. 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. 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. Canada requires a minimum of 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. Graduates of the Canadian Memorial Chiropractic College (CMCC) are formally recognized to have at least 7–8 years of university level education. 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. Depending on the location, continuing education may be required to renew these licenses. 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. In the U.S., chiropractic schools are accredited through the Council on Chiropractic Education (CCE) while the General Chiropractic Council (GCC) is the body responsible for the regulation of chiropractic in the UK. 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. Today, there are 18 accredited Doctor of Chiropractic programs in the U.S., 2 in Canada, 6 in Australasia, and 5 in Europe. 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. Chiropractors often argue that this education is as good as, or better than, that of medical physicians, but most chiropractic training is confined to classrooms, with much time spent on theory, adjustment, and marketing. The chiropractic leaders and colleges have had internal struggles. 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 the highest debt-to-earnings ratios. Analyses by Quackwatch and the Sunlight Foundation found high rates of default on Health Education Assistance Loan (HEAL) student loans used for chiropractic programs. Among health professionals who were listed as in default on HEAL loans in 2012, 53% were chiropractors. 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." The International Chiropractor's Association (ICA) also has a set of professional canons. 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. launched a campaign to draw attention to the BCA legal case against science writer Simon Singh. In 2009, a number of organizations and public figures signed a statement entitled "The law has no place in scientific disputes". Chiropractors, especially in America, have a reputation for unnecessarily treating patients. 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. In 2009, a backlash to the 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, 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." The libel case ended with the BCA withdrawing its suit in 2010. == Reception ==

Chiropractic is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries. It is viewed as a marginal and non-clinically–proven attempt at complementary and alternative medicine, which has not integrated into mainstream medicine. 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. 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). 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. Switzerland In Switzerland, only trained medical professionals are allowed to offer chiropractic. Since 1995, chiropractors have been licensed to prescribe a limited set of pharmaceuticals, which were expanded in 2018. A 2010 survey found that 72% of Swiss chiropractors considered their ability to prescribe nonprescription medication as an advantage for chiropractic treatment. There are approximately 300 chiropractors in Switzerland. United Kingdom 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. 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. United States and Canada In 2025, the American Chiropractic Association reported that 70,000 practitioners were active in the United States. 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, with a global high of 20% in Alberta in 2006. 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. In 2002–03, the majority of those who sought chiropractic did so for relief from back and neck pain and other neuromusculoskeletal complaints; 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. Utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient. As of 2007 7% of the U.S. population is being reached by chiropractic. They were the third largest medical profession in the US in 2002, following physicians and dentists. Employment of U.S. chiropractors was expected to increase 14% between 2006 and 2016, faster than the average for all occupations. Since 1972, chiropractic treatment of the spine has been covered by Medicare, the US federal health insurance program in the United States. In 1974 the United States Commissioner of Education officially listed the Council on Chiropractic Education as a "Nationally Recognized Accrediting Agency". This allowed for eligibility for federal education and research grants, student eligibility for federal loans, and gave increased legitimacy for chiropractic as a profession overall. Modernly, chiropractors often work in collaboration with primary care physicians and other medical specialists; the American College of Physicians recommends spinal manipulation therapy as an alternative to pain-relieving drugs for low back pain. Most states require insurers to cover chiropractic care, and most HMOs cover these services. Chiropractors are not normally licensed to write medical prescriptions or perform major surgery in the United States). 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. 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. A 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for over-the-counter drugs. In 2024, the University of Pittsburgh announced a Doctor of Chiropractic program—the first of its kind at a public research intensive university. ==History==

Chiropractic's origins lie in the folk medicine practice of bonesetting, in which untrained practitioners engaged in joint manipulation or resetting fractured bones. Chiropractic is classified as a field of pseudomedicine. 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. Although initially keeping chiropractic a family secret, in 1898 Palmer began teaching it to a few students at his new Palmer School of Chiropractic. 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. D. D. and B. J. both seriously considered declaring chiropractic a religion, which might have provided legal protection under the U.S. constitution, but decided against it partly to avoid confusion with Christian Science. Thousands of chiropractors were prosecuted for practicing medicine without a license, and D. D. and many other chiropractors were jailed. Holism assumes that health is affected by everything in an individual's environment; some sources also include a spiritual or existential dimension. In contrast, reductionism in chiropractic reduces causes and cures of health problems to a single factor, vertebral subluxation. 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. A variant of chiropractic called naprapathy originated in Chicago in the early twentieth century. Straights (Vitalists) versus Mixers (Materialists) By 1914, chiropractors had begun to divide into two groups: "Straights", adherents of the Palmers' supernatural vitalist beliefs, and "Mixers" who sought to integrate Chiropractic into science-based mainstream medicine. Folk argues that "osteopathy underwent a 'Straight-Mixer' debate between traditional vitalists and a faction that embraced the new medical science". 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. 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. Restraint of trade decision 1989 The AMA labeled chiropractic an "unscientific cult" in 1966, and until 1980 advised its members that it was unethical for medical doctors to associate with "unscientific practitioners". This culminated in a landmark 1987 decision, Wilk v. AMA, in which the court found that the AMA had engaged in unreasonable restraint of trade and conspiracy, and which ended the AMA's de facto boycott of chiropractic. In recent decades chiropractic gained legitimacy and greater acceptance by medical physicians and health plans, and enjoyed a strong political base and sustained demand for services. 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 therapists and other health professions. The profession responded by marketing natural products and devices more aggressively, and by reaching deeper into alternative medicine and primary care. == Public health ==

Some chiropractors oppose vaccination and water fluoridation, which are common public health practices. Most chiropractic writings on vaccination focus on its negative aspects, 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. 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. == Controversy ==

Throughout its history chiropractic has been the subject of internal and external controversy and criticism. According to Daniel D. Palmer, the founder of chiropractic, subluxation is the sole cause of disease and manipulation is the cure for all diseases of the human race. A 2003 profession-wide survey A critical evaluation stated "Chiropractic is rooted in mystical concepts. This led to an internal conflict within the chiropractic profession, which continues today." Chiropractors, including D. D. Palmer, were jailed for practicing medicine without a license. For most of its existence, chiropractic has battled with mainstream medicine, sustained by antiscientific and pseudoscientific ideas such as subluxation. Collectively, systematic reviews have not demonstrated that spinal manipulation, the main treatment method employed by chiropractors, is effective for any medical condition, with the possible exception of treatment for back pain. Chiropractic remains controversial, though to a lesser extent than in past years. ==See also==