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NCAHF Fact Sheet on Chiropractic (2001)

William T. Jarvis, Ph.D.

Chiropractic is a controversial health care system that originated in the United States in 1895. The National Council Against Health Fraud (NCAHF) finds it remarkable that the chiropractic profession has existed for a century without having made a single notable contribution to the world's body of knowledge in the health sciences. The reason for this failure can be found in its origins and in the continued presence of antiscience attitudes. This includes the fields of the care and prevention of back pain and the value of spinal manipulative therapy (SMT), the areas in which chiropractic has dominated the health care services marketplace. Recent pronouncements on the value of manipulative therapy for back pain have involved medical research, not work done by doctors of chiropractic (DCs). DC publicists have been quick to grab the credit for these findings for marketing purposes, but deserve little credit. Some research projects are now under way, but chiropractic still does not play a significant role in researching the causes and treatment of the human ailments from which it derives most of its income.

In the Beginning . . .

Chiros (hand) + practos (practice) literally means "done by hand." Chiropractic was invented in 1895 by Daniel D. Palmer, a layperson in Davenport, Iowa [1]. Because he sold goldfish commercially, Palmer is referred to by some historians as a "fish monger." It is more interesting to know that he practiced magnetic healing beginning in the mid-1880s in Burlington, Iowa. Palmer searched for the single cause of all disease. The standard story about chiropractic's "discovery" is that Palmer believed he had found the single cause of disease when he "cured" the deafness of janitor Harvey Lillard by manipulating his spine. (Palmer may have learned spinal manipulation from Andrew Still's osteopathic school in Kirksville, Missouri). Lillard is said to have lost his hearing while working in a cramped, stooped position during which he felt something snap in his back.

Palmer's version of this event has always been disputed by Lillard's daughter, Valdeenia Lillard Simons. She says that her father told her that he was telling jokes to a friend in the hall outside Palmer's office and, Palmer, who had been reading, joined them. When Lillard reached the punch line, Palmer, laughing heartily, slapped Lillard on the back with the hand holding the heavy book he had been reading. A few days later, Lillard told Palmer that his hearing seemed better. Palmer then decided to explore manipulation as an expansion of his magnetic healing practice. Simons said "the compact was that if they can make [something of] it, then they both would share. But, it didn't happen." [2]

Chiropractic's true origin appears to have been of a more mystical nature than the Lillard tale denotes. Palmer was an active spiritualist and apparently believed that the idea of "replacing displaced vertebrae for the relief of human ills" came in a spiritualist séance through communication with the spirit of Dr. Jim Atkinson, a physician who had died 50 years earlier in Davenport [3]. As a young man, Palmer regularly walked the six or seven miles to the estate of his spiritualist mentor, William Drury [4]. It was one of Drury's followers who told him of her vision of a door with a sign on it reading "Dr. Palmer." She said that he one day would lecture in a large hall telling an audience about a new "revolutionary" method of healing the sick [5]. Predisposed to magnetic healing by his belief in spiritualism, Palmer was drawn to the practice by seeing the financial success of illiterate "Dr." Paul Caster of Ottumwa. Palmer's grandson described his technique:

He would develop a sense of being positive within his own body; sickness being negative. He would draw his hands over the area of the pain and with a sweeping motion stand aside, shaking his hands and fingers vigorously, taking away the pain as if it were drops of water [6].

Palmer began speculating that the flow of animal magnetism may become blocked by obstructions along the spine [7]. Palmer taught that chiropractic was "an educational, scientific, religious system" that "associates its practice, belief and knowledge with that of religion" and "imparts instruction relating both to this world and the world to come." "Chiropractic," Palmer stated, "sheds enlightenment upon physical life and spiritual existence, the latter being only a continuation of the former." [8] Individual chiropractors sometimes deny that they believe in Palmer's biotheological "Innate Intelligence," but when pressed as to their basis for practice, they must face the physiological facts described in a scientific brief on chiropractic:

If there is partial blockage of impulses in a nerve fibre . . . the impulse is transmitted more slowly in a zone of partial blockage, and resumes all its characteristics as soon as it reaches normal tissue. Thus, it is impossible for a partial blockage of nerve impulses in a particular zone to affect the flow, since the impulses would resume their normal flow [9].

Unsupported by science, chiropractors must either fall back on Palmer's pantheistic views or admit that the "subluxation" theory is erroneous. Without this theory, chiropractors are reduced to spinal manipulators whose primary treatment modality is shared by osteopaths, physiatrists, sports trainers, physical therapists, and others. Without subluxation theory, chiropractic's claim that it is a unique and comprehensive "alternative" to standard medicine is lost. D.D. Palmer had only modest success in promoting chiropractic. It was his son, B.J. Palmer, an eccentric promoter and Iowa radio industry pioneer, who developed chiropractic into a successful business enterprise.

Vitalistic Theory

According to fundamentalist chiropractic theory, spinal "subluxations" mechanically interfere with nerve flow (the "Innate Life Force"), weakening organs served by the nerves and making them more susceptible to disease. Thus:

Appeal

Chiropractic combines metaphysical and mechanistic explanations of health and disease in a simplistic fashion. DCs have repeatedly outperformed other providers in assessments of patient satisfaction [11-13]. DCs mostly treat back pain and are more sympathetic and supportive of patients' complaints. To DCs, back problems are significant to overall health, whereas physicians consider such problems minor and self-limiting.

Census

The American Chiropractic Association (ACA) estimates that there are between 55,000 and 70,000 chiropractors in the United States [14]. Dynamic Chiropractic, a newspaper sent to every chiropractor it can locate, circulates to about 60,000 chiropractors in the United States, including 10,000 in California [15]-the most in any state.

Legal Status

All 50 states and the District of Columbia attempt to regulate chiropractic via licensure. DCs are also licensed in several other countries. One of the most difficult aspects of regulating chiropractors is the ambiguity of their legally defined scope of practice. Most health care providers are limited to some precisely delineated structure or function of the body. For instance, dentists are limited to treating the oral cavity, podiatrists are limited to treating the feet, and optometrists are limited to correcting vision problems. Chiropractors are limited to analyzing and manipulating the back, but this is no limit at all if you accept the chiropractic paradigm, which holds that nerve "energy" is a metaphysical entity that travels from out of the cosmos, into the mind, down through the spine, and into every organ of the body and that chiropractors can detect interferences with that cosmic energy flow and restore full power through manipulation or other methods. Chiropractors allege that virtually all health problems may be affected by their "adjustments." They also assert that they can treat any condition that may benefit from improving the flow of an alleged cosmic energy that emanates either from the throne of God or the nucleus of the Big Bang-depending on one's fundamental beliefs. Limiting the scope of practice of ideological, nonmedical providers is the key to a great deal of consumer protection, but the practical problems of doing so can be confusing [16].

Factionalism

To understand the confused world of chiropractic, one must differentiate between chiropractic theory (aka, "philosophy") and chiropractic practitioner factions. Chiropractic is a conglomeration of factions in conflict. Most obvious is the dichotomy of "straights" versus "mixers," who are represented by two separate national organizations, the International Chiropractors Association and the ACA, respectively. At least a dozen different notions about how the spine should be corrected divide DCs. A government report has described the chaos within chiropractic:

Heated controversy regarding chiropractic theory and practice continues to exist. On-site and telephone discussions with chiropractors and their schools and associations, coupled with a review of background materials . . . result in a picture of a profession in transition and containing a number of contradictions. There continues to be some disagreement with the profession regarding which conditions are appropriate for chiropractic care and regarding appropriate parameters for treatment [17].

Scientific Status

Chiropractic theory has failed tests of both validity and reliability. The "subluxation," which is the foundation of its theory, has never been demonstrated to exist. Moreover, anatomist Edmund Crelin, PhD, twisted cadaver spines and found that nerves were not impinged as chiropractors postulate [18].

The ACA is equivocal on the idea of the existence and importance of spinal misalignments [19]. DCs have repeatedly failed field tests of reliability. Chiropractic public relations have exaggerated the significance of a British study that compared the satisfaction of patients with low back pain (screened for contraindications to manipulation) who received private practice DC care with others who were treated by physiotherapists in the government's Royal Hospital Service [13].

Chiropractors often misrepresent a review of mani-pulative therapy by the Rand Corporation [20,21] as proof of chiropractic's value. They generally do not reveal that:

A 1993 report by a Canadian economist, Pran Manga, who is a satisfied chiropractic patient, declared that chiropractic was safer, more effective, and more cost-effective than medical management of low back pain [22], but these conclusions were refuted by Rand's Dr. Paul Shekelle who noted that Manga had looked at "the exact same studies as the rest of us, and no one else has been able to come to those conclusions." [23] The Manga report was also severely criticized by Dr. Hamilton Hall, director of the Canadian Back Institute [24].

The Rand Corporation also reviewed the appropriateness of manipulation and mobilization of the cervical spine, employing the same technique it had used to evaluate SMT for back pain. Only 11.1% of 736 indications for cervical manipulation were judged appropriate by a panel of nine judges (four DCs, four MDs, and one MD-DC). The most important finding was the paucity of evidence for the benefit of these procedures [25]. The risks of cervical spine manipulation are well documented. (For details on workers compensation, and other studies involving chiropractic treatment of back pain, see the NCAHF consumer information statement on chiropractic back care.)

Antitrust Legal Victory

DCs won a highly publicized antitrust lawsuit in 1987. Chiropractic public relations messages have largely mis-represented its significance. The facts of the case help put it in proper perspective. From 1966 to 1980, the American Medical Association's code of ethics prohibited its members from collaborating with DCs. The change in 1980 apparently resulted from legal advice and not because the AMA felt that DCs had become acceptable. In 1976, several DCs filed an antitrust lawsuit (Wilk v AMA, et al) charging restraint of trade under the Sherman Antitrust Act, a law designed to ensure marketplace competition.

The AMA was acquitted in 1981, but the case was overturned on appeal. In the new trial, the plaintiffs asked only for an injunction to prohibit the AMA from ever again imposing an ethical restriction on its members to refer patients to DCs. The Sherman Act was meant to apply business, not to scientific affairs. An important legal question involved whether the AMA's ethical prohibition had been exempt from the Sherman Act. The AMA argued that the scientific aspects of patient care had been their reason for prohibiting members from collaboration. In 1987, Judge Susan Getzendanner decided that the AMA's concerns had been justified and were the dominating factor in its behavior (rather than economics). Nevertheless, she found the AMA guilty because it had failed to prove that its ethical boycott was reasonable and the least restrictive of competition.

Once the ethical boycott was determined to have been illegal, chiropractic propagandists labeled it a "conspiracy" and proclaimed that the AMA was found guilty of conspiring to eliminate chiropractic. Their message implies that the "conspiracy" was secret and medically unjustified and that the court's finding proved that chiropractic is a valid health care system. None of these is true. Judge Getzendanner stated that her ruling had no bearing on the validity of chiropractic and that the ethical boycott was done openly.

It must be noted that MDs are not required to refer patients to DCs and that referring physicians assume some risk for harm that comes to patients at the hands of practitioners to whom they were referred, particularly if there was reason to fear that the practitioner uses unscientific practices. Since some DCs reject cultism and pseudoscience, DCs must be evaluated on an individual basis. (See also: "Statement from AMA's General Counsel." JAMA 259:83, 1983.)

Major Risks

Forceful neck manipulations can cause stroke and paralysis. A survey by the Stanford (University) Stroke Center found that within a 2-year period, 56 strokes had occurred among patients within 24 hours after receiving neck manipulation by a DC. One patient died, and 86% were left with permanent impairment. Most cases involved intervertebral artery damage. The age range of patients affected was 21 to 60 years, with most occurring in young individuals [26]. The Manitoba College of Physicians and Surgeons advised doctors to warn patients about the risks of neck manipulation after it was found that six cases of brain- stem injury resulting in permanent paralysis had occurred within the province in the previous 3 years. Manitoba has a population of about 1 million, and since not all go to DCs, such an incidence of injury greatly exceeds the estimated 1-in-10 million risk associated with such procedures [27]. A bibliography of 166 documented and 17 anecdotal reports of vertebrobasilar injury after SMT was published in 1996 [28].

Full-spine x-ray exposure of the type used by many DCs may cause cancer. Dosimetric calculations used to test the theory that full-spine x-rays help detect bony neoplasms, both a contraindication to manipulation of the spine and an early detection of cancer, led to the conclusion that a full-spine x-ray of a 25-year-old male is twice as likely to cause the patient's death from cancer than it is to detect a bony tumor [29]. A five-view lumbosacral series of x-rays exposes the gonads to 3,000 times more radiation than front-to-back and lateral chest x-rays. The National Academy of Sciences Research Council estimates that spinal radiography causes an estimated 100 to 200 deaths per year from various cancers [30].

Indirect harm attributable to chiropractors includes improper treatment as a result of failure to diagnose a condition [31,32] and the practice of many chiropractors to discourage parents from immunizing their children based on chiropractic philosophy [33­35].

In 1994, the chiefs of the departments of pediatrics and pediatric hospitals in Canada issued the following statement:

We wish to express our great concern over unscientific claims being made by Canadian chiropractors regarding the proper care of infants and children. These claims come from official statements from both the Canadian and Ontario Chiropractic Associations. Chiropractic treatment for such conditions as ear infections, infantile colic, newborn jaundice, spinal scoliosis and tonsillitis, amongst others, are being recommended in at least one major textbook being used at the Canadian Memorial Chiropractic College in Toronto. We call upon the governments of Ontario and Quebec, which have the only two chiropractic schools in Canada, to evaluate the courses being taught and the claims being made by the graduates of these schools regarding the treatment of infants and children. Contrary to the information being provided to parents and to the general public:

1. Chiropractic spinal manipulation is NOT required as a preventive therapy to maintain a child's health.

2. Chiropractic spinal manipulation is NOT an alternative for pediatric immunization. Books sold at the Canadian Memorial Chiropractic College in Toronto are anti-immunization in nature.

3. Chiropractic does NOT alter the course of, nor does it prevent in any way, childhood illness such as ear infections, asthma attacks, bed-wetting, or infantile colic.

4. Chiropractic use of x-rays of infants and children to diagnose so called vertebral subluxations is unscientific and of no value whatsoever. These x-rays can contribute, without any benefit to the child, to the future risk in the child of cancers and genetic damage. Parents should never allow their children's spines to be x-rayed by a chiropractor.

5. There is no scientific evidence whatsoever that the so-called chiropractic spinal adjustment results in any correction to a child's spine. These adjustments are ineffective and useless.

6. School boards should not authorize, and parents should not allow their children to attend, elementary school screening programs organized by chiropractors to detect scoliosis or any other postural deformities in children. Postural deformities of children such as scoliosis, kyphosis, or unequal leg lengths are not effectively treated by manipulation. In the great majority of instances, what a chiropractor may diagnose as scoliosis in a child is in fact a minor variation in a perfectly normal spine.

7. Parents should regard with extreme skepticism claims made by some other parents that their infants or children have been cured by chiropractic adjustments for such conditions as infant colic, recurrent ear infections, learning disorders, asthma, chronic abdominal cramps, or bed-wetting. However well meaning, such personal testimony is unreliable and is not a substitute for scientific fact. Parents should read the June 1994 issue of Consumer Reports magazine in which the clear recommendation is made not to allow any chiropractor to solicit children for chiropractic treatment.

8. We understand the concern of parents in regard to ear infections that they may feel their child has taken many antibiotics or may require a surgical procedure. These concerns should not lead the parents to believe that chiropractic adjustments, which have the emotional appeal of being medication free or "natural" are an alternative to what may very well be in the best overall interests of the child.

9. We welcome the scientific guidelines of the Orthopractic Manipulation Society International, under which manual therapy can be given in a responsible manner to adults who may require such care. We welcome warnings made in these guidelines about the unscientific use of x-rays and unscientific claims about treating pediatric conditions. We would encourage parents to seek their own personal care from their physical therapists, physicians, and chiropractors who adhere to the scientific guidelines of the Orthopractic Manipulation Society International.

10. The musculo-skeletal problems of infants and children can be managed in a safe, scientific, and responsible manner by the family physician, the orthopedic specialist, the physical therapist, and with medical consultation, those chiropractors who adhere to the orthopractic guidelines.

11. We believe it to be irresponsible, and a total waste of our limited financial resources for the governments of Ontario, Manitoba, Saskatchewan, Alberta and British Columbia to be providing millions of dollars of public funds for chiropractors to treat infants and children. This public fiscal support gives parents the false impression that society endorses the treatments. We call upon these governments to immediately suspend all chiropractic payments in the pediatric age group, i.e., up to 18 years [36].

Chiropractic Treatment of Childrens' Asthma. After a 3-week baseline evaluation, 91 children who had continuing symptoms of asthma despite usual medical therapy were randomly assigned to receive either active or simulated chiropractic manipulation (tantamount to placebo treatment) for 4 months. None had previously received chiropractic care. Each subject was treated by 1 of 11 participating DCs selected by parents according to location. The primary outcome measure was the change from baseline in the peak expiratory flow that was measured in the morning before the use of a bronchodilator at 2 and 4 months. Except for the treating DC and one investigator (who was not involved in assessing outcomes), all participants remained fully blinded to the treatment assignment throughout the study. The researchers found no significant differences in improvements between the two groups [37].

Chiropractic Reformers

In 1987, chiropractors who reject the metaphysical biotheology and antimedical attitudes of chiropractic but see value in manipulative therapy for limited conditions organized the National Association for Chiropractic Medicine (NACM) [38]. NACM practitioners focus on the conservative treatment of musculoskeletal conditions. Manual therapy is their main treatment, but the use of drugs such as pain relievers and muscle relaxants is considered desirable if they are legally available. NACM's open rejection of the subluxation theory and chiropractic philosophy and its acceptance of the scientific method set it apart from other factions within the chiropractic guild. This also has made it the target of scorn by chiropractic's true believers.

In 1994, NACM announced that it was giving up its struggle to reform mainstream chiropractic and was joining with an international group of manipulative therapists called orthopractors. NACM would become a U.S. chapter of the Orthopractic Manipulation Society (OMS) [23,39]. Orthopractic therapy involves restoring a greater range of motion to the joints of the body through gentle and gradual mobilization or more forceful manipulation. Among other things, orthopractors (a) provide patient education that is aimed at reducing pain and disability and having the patients become independent of care; (b) specifically reject the chiropractic subluxation theory; (c) do not use x-rays in diagnosis; (d) reject the use of manipulation to treat postural deformities in children (e.g., kyphosis, scoliosis, unequal leg lengths) or a variety of children's ailments (e.g., colic, eczema, learning disorders, infections, asthma, and more); (e) reject spinal manipulations for general health care; (f) support immunization; (g) reject the use of testimonials to promote their services; (h) reject homeopathy; and (i) advise against sales promotions by chiropractors such as family plans, lifelong spinal adjustments, free x-ray examinations, and elementary school screening programs for scoliosis [40].

In addition to organizing like-minded practitioners, establishing a new profession requires the passage of new practices acts by state legislatures, the development of education and training programs, and the marketing of the profession in a competitive setting. Political resistance to reform by traditional DCs and organized chiropractic is strong. The idea of an orthopractic profession was such a serious threat to chiropractic in the United States that state licensing boards threatened to discipline chiropractors who identify themselves as ortho-practors. The organizational effort was squelched because orthopractors lacked the resources to simultaneously organize a new profession and defend against aggressive legal actions in state after state. Despite its inability to establish an evidence-based guild of manipulative therapy practitioners in the United States, orthopractic made its mark by describing what a legitimate profession would look like.

The Future of Chiropractic

At least 70% of adults will experience low back pain (LBP) at some time in their lives. Back symptoms usually begin in the third or fourth decade of life, peak on incidence in the 40s and early 50s, and decline rapidly thereafter. There has been no sex differences in incidence noted. Although acute LBP is a self-limiting illness, it can persist for a considerable time [41]. The main advantage of SMT is that it can provide more rapid relief in about one third of patients. There is more information on the value of manipulation by non-DCs than there is for DCs. However, NCAHF believes that our society has sufficient need for preventing (through ergonomics) and treating back pain (by manipulative therapy and medication) to sustain limited-scope health care providers under the entitlement of "chiropractors." This will require greater attention to scientific research on the appropriate applications of SMT, expanding chiropractic training to include pharmacology, and rewriting state chiropractic practice acts to limit their scope of practice. Western States Chiropractic College (Portland, Oregon) is working in this direction and has changed the name of its diploma to "Doctor of Chiropractic Medicine." Sectarian DCs are objecting vociferously to this advancement toward science. Precisely what will become of chiropractic in the future is uncertain. NCAHF believes that as some factions become more scientific, antiscientific chiropractic groups will continue to exist within chiropractic until it becomes economically impossible for them to survive.

Consumer Beware

B.J. Palmer considered chiropractic to be a business, not a profession. He advised DCs to advertise and to sell their patients on the philosophy of chiropractic. Chiropractic education is proprietary (i.e., a business of its own). Unlike physicians, DCs do not go into residency programs after graduation. They are dumped on the marketplace to survive by whatever means necessary. Having been taught to be entrepreneurs, many sell whatever they can to make money. DCs regularly invade fields of health care in which they have no real skill (e.g., dietetics, physical therapy, sports medicine, pediatrics, and even veterinary medicine). Despite the obvious conflict of interest involved, many DCs sell dietary supplements, homeopathic remedies, herbal remedies, and other items directly to their patients. DCs take formal courses in practice-building that teach methods of deception. Consumers are often no match for the schemes and scams DCs invent.

References

  1. Beck BL. Magnetic healing, spiritualism chiropractic: Palmer's union of methodologies. Chiropractic History 11(2):11­16, 1991.
  2. Westbrooks B. The troubled legacy of Harvey Lillard: the black experience in chiropractic. Chiropractic History 2(1)46­53, 1982.\
  3. Palmer DD. Textbook of the Science, Art and Philosophy of Chiropractic. Portland Printing House, 1910, pp. 11­12.
  4. Gielow V. Old Dad Chiro: Biography of D.D. Palmer. Davenport, IA: Bauder Brothers, 1981, p. 26.
  5. Maynard J. Healing Hands. Mobile, AL: Jonorm Publishing, 1981, p. 10.
  6. Palmer, David Daniel. The Palmers: A Pictorial Life Story. Davenport, IA: Bauder Brothers (undated), p. 76.
  7. Fuller R. Alternative Medicine and American Religious Life. New York: Oxford University Press, 1989, p. 69.
  8. Palmer DD. The Chiropractor. Los Angeles: Beacon Light, 1914, p. 4.
  9. College of Physicians and Surgeons of the Province of Quebec. A scientific brief against chiropractic. The New Physician, Sept 1966.
  10. Homewood AE. The Neurodynamics of the Vertebral Subluxation. St. Petersburg, FL: Valkyrie Press, 1973.
  11. Kane RL and others. Manipulating the patient; comparison of the effectiveness of physician and chiropractic care. Lancet 1:1333­1336, 1974.
  12. Cherkin D, MacCornack F. Patient evaluations of low back pain care family physicians and chiropractors. Western Journal of Medicine 150:351­355, 1989.
  13. Meade TW and others. Low back pain of mechanical origin: Randomized comparison of chiropractic and hospital outpatient treatment. British Medical Journal 300:1431­1437, 1990.
  14. Frequently asked questions. American Chiropractic Association Web site, accessed October 31, 2001.
  15. Circulation breakdown. Dynamic Chiropractic, April 9, 2001.
  16. Cohen MH. Scope of practice limitations on unconventional providers: The case of chiropractic. Alternative and Complementary Therapies, March­April 1996, pp. 110­114.
  17. Inspection of Chiropractic Services Under Medicare. Chicago: Department of Health and Human Services, Office of Analysis, Aug 1986.
  18. Crelin EM. A scientific test of the chiropractic theory. American Scientist 61:574­580, 1973.
  19. Chiropractic: State of the Art 1994-1995. Arlington, VA: American Chiropractic Association, 1994.
  20. The Appropriateness of Spinal Manipulation for Low-Back Pain, Project Overview and Literature Review. Santa Monica, CA: Rand Corp, 1991.
  21. Shekelle PG. RAND misquoted. ACA Journal of Chiropractic 30(7):59­63, 1993.
  22. Manga P and others. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain. Richmond Hill, Ontario, Canada: Kenelworth Publishing, 1993.
  23. Chiropractors. Consumer Reports 59:383­390, 1994.
  24. Lowry F. Orthopedists have bone to pick with economist over report on chiropractic. Canadian Medical Association Journal 150:1878­1881, 1994.
  25. Coulter ID and others. The Appropriateness of Manipulation and Mobilization of the Cervical Spine. Santa Monica, CA: Rand Corporation, 1996.
  26. Lee KP and others. Neurological complications following chiropractic manipulation: A survey of California neurologists. Neurology 45:1213­1215, 1995.
  27. Brosnahan M. After six paralyzed in Manitoba college warns neck manipulation dangerous. The Medical Post, Jan 28, 1986, p. 23.
  28. Terett AGJ. Vertebrobasilar Stroke Following Manipulation. West Des Moines, IA: National Chiropractic Mutual Insurance Company, 1996.
  29. Fickel TE. An analysis of the carcinogenicity of full spine radiography. ACA Journal of Chiropractic 23(5):61­66, 1986.
  30. Hockberger RS. Meeting the challenge of low back pain. Emergency Medicine, Aug 15, 1990, p. 99.
  31. Nickerson HJ and others. Chiropractic manipulation and children. Journal of Pediatrics 121:172, 1992.
  32. Modde PJ. Malpractice is an inevitable result of chiropractic philosophy and training. Legal Aspects of Medical Practice, Feb 1979, pp. 20­24.
  33. Nelson CA. Why chiropractors should embrace immunization. ACA Journal of Chiropractic, May 1993, pp. 79­85.
  34. WCA adds legal action to immunization arsenal. The Chiropractic Journal 6(5):1, 1992.
  35. Gunter GT. Immunization: A review for chiropractors. Today's Chiropractic, Sept­Oct 1986, pp. 15­18.
  36. Haslam RHA and others. Statement of the chiefs of the departments of pediatrics of pediatric hospitals in Canada. Aug 19, 1994.
  37. Balon J and others: A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. New England Journal of Medicine 339:1013­1020, 1998.
  38. Slaughter R. Chiropractors want new profession. Medical World News, Aug 10, 1987, p. 58.
  39. NACM seeks to create new profession: Orthopractors. Dynamic Chiropractic, May 20, 1994.
  40. Orthopractic Manipulation Society of North America (pamphlet). Beaconsfield, Quebec, Canada, 1994.
  41. Croft PR and others. Outcome of low back pain in general practice: A prospective study. British Medical Journal 316:1356­1359, 1998.

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This article was revised on November 8, 2001.