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Chiropractic (from Greek chiro- χειρο- "hand-" + praktikós πρακτικός "concerned with action") is a complementary and alternative medicine health care profession that focuses on diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system and their effects on the nervous system and general health. It emphasizes manual therapy including spinal manipulation and other joint and soft-tissue manipulation, and includes exercises and health and lifestyle counseling.^[1] Traditionally, it assumes that a vertebral subluxation or spinal joint dysfunction can interfere with the body's function and its innate ability to heal itself.^[2]

D. D. Palmer founded chiropractic in the 1890s and his son B.J. Palmer helped to expand it in the early 20th century.^[3] It has two main groups: "straights", now the minority, emphasize vitalism, innate intelligence, spinal adjustments, and subluxation as the leading cause of all disease; "mixers" are more open to mainstream and alternative medical techniques such as exercise, massage, nutritional supplements, and acupuncture.^[4] Most chiropractors practice in the U.S.; it is also well established in Canada and Australia.^[5]

For most of its existence chiropractic battled with mainstream medicine, and was sustained by the antiscience philosophy of the straights.^[6] Vaccination remains controversial among chiropractors.^[7] In recent decades chiropractic gained legitimacy and greater acceptance by physicians and health plans, enjoyed a strong political base and sustained demand for services, and became more integrated into mainstream medicine,^[8] and evidence-based medicine has been used to review research studies and generate practice guidelines.^[9] Opinions differ as to the efficacy of chiropractic treatment;^[10] the efficacy and cost-effectiveness of maintenance chiropractic care are unknown.^[11] Although spinal manipulation can have serious complications in rare cases,^[12] chiropractic care is generally safe when employed skillfully and appropriately.^[13]

Traditional and evidence-based chiropractic belief systems vary along a philosophical spectrum ranging from vitalism to materialism. These opposing philosophies have been a source of debate since the time of Aristotle and Plato. Vitalism, the belief that living things contain an element that cannot be explained through matter, was responsible for legally and philosophically differentiating chiropractic from conventional medicine and thereby helping ensure professional autonomy.^[15] Chiropractic also retains elements of materialism, the belief that all things have explanations, which forms the basis of science. Evidence-based chiropractic balances this dualism by emphasizing both the tangible, testable principle that structure affects function, and the untestable, metaphorical recognition that life is self-sustaining.^[14]

The chiropractor's purpose is to foster the establishment and maintenance of an organism-environment dynamic that is the most conducive to functional well-being of the person as a whole.^[14] Principles such as holism, naturalism, therapeutic conservatism, critical rationalism, and thoughts from the phenomenological and humanistic paradigms form an important part of the philosophy of chiropractic."^[16]

Chiropractors can adopt or share vitalist, naturalist, or materialist viewpoints and emphasize a holistic, patient-centered approach that appreciates the multifactorial nature of influences (i.e. structural, chemical, and psychological) on the functioning of the body in health and disease and recognizes the dynamics and interplay between lifestyle, environment, and health. This holistic paradigm is also blended with a biopsychosocial approach, which is also emphasized in chiropractic care. In addition, chiropractors also retain naturopathic and naturalist principles that suggest decreased "host resistance" of the body facilitates the disease process and that natural interventions are preferable towards strengthening the host in its effort to optimize function and return to homeostasis.^[14] Chiropractic care primarily emphasizes manipulation and other manual therapies as an alternative than medications and surgery.^[17]

Chiropractors also commonly use nutrition, exercise, patient education, health promotion and lifestyle counseling as part of their holistic outlook towards preventive health care.^[18] Chiropractic's claim to improve health by improving biomechanical and neural function by the manual correction of joint and soft tissue dysfunctions of the neuromusculoskeletal system differentiates it from mainstream medicine and other complementary and alternative medicine (CAM) disciplines, but is also rooted, in part, in osteopathy and eastern medicine interventions.^[16] All chiropractic paradigms emphasize the spine as their focus, but their rationales for treatment vary depending on their particular belief system.

The philosophy of chiropractic also stresses the importance of prevention and primarily utilizes a pro-active approach and a wellness model to achieve this goal.^[19] For some, prevention includes a concept of "maintenance care" that attempts to "detect and correct" structural imbalances of the neuromusculoskeletal system while in its primary, or functional state.^[20] The objective is early identification of mechanical dysfunctions to prevent or delay permanent pathological changes.^[21]

In summary, the major premises regarding the philosophy of chiropractic include:^[14]

• Holism

• non-invasive, emphasizes patient's inherent recuperative abilities
• recognizes dynamics between lifestyle, environment, and health
• spine and health are related in an important and fundamental way, and this relationship is mediated through the nervous system.^[15]
• recognizes the centrality of the nervous system and its intimate relationship with both the structural and regulatory capacities of the body
• appreciates the multifactorial nature of influences (structural, chemical, and psychological) on the nervous system

• Conservatism

• balances the benefits against the risks of clinical interventions
• emphasizes non-invasive treatments to minimize risk with a preference to avoid surgery and medication
• recognizes as imperative the need to monitor progress and effectiveness through appropriate diagnostic procedures
• prevents unnecessary barriers in the doctor-patient encounter

• Manual and biopsychosocial approaches

• strives toward early intervention, emphasizing timely diagnosis and treatment of reversible conditions before loss of functionality
• emphasizes a patient-centered model in which the patient is considered to be indispensable in, and ultimately responsible for, the maintenance of health^[15]
• approach of improving health through influencing function through structure primarily via manual therapies

Common themes to chiropractic care include holistic, conservative and non-medication approaches via manual therapy.^[22] Still, significant differences exist amongst the practice styles, claims and beliefs between various chiropractors.^[23]

Straight chiropractors are the oldest movement.^[24] They adhere to the philosophical principles set forth by D. D. and B. J. Palmer, and retain metaphysical definitions and vitalistic qualities. Straight chiropractors believe that vertebral subluxation leads to interference with an Innate intelligence within the human nervous system and is a primary underlying risk factor for almost any disease. Straights view the medical diagnosis of patient complaints (which they consider to be the "secondary effects" of subluxations) to be unnecessary for treatment. Thus, straight chiropractors are concerned primarily with the detection and correction of vertebral subluxation via adjustment and do not "mix" other types of therapies.^[25] Their philosophy and explanations are metaphysical in nature and prefer to use traditional chiropractic lexicon (i.e. perform spinal analysis, detect subluxation, correct with adjustment, etc.). They prefer to remain separate and distinct from mainstream health care.

Mixer chiropractors are an early offshoot of the straight movement. This branch "mixes" diagnostic and treatment approaches from naturopathic, osteopathic, medical, and chiropractic viewpoints. Unlike straight chiropractors, mixers believe subluxation is one of the many causes of disease, and they incorporate mainstream medical diagnostics and employ myriad treatments including joint and soft tissue manipulation, electromodalities, physical therapy, exercise-rehabilitation and other complementary and alternative approaches such as acupuncture. Mixers tend to be open to mainstream medicine.^[4] Mixers are the majority group.^[26]

Palmer hypothesized that vertebral joint misalignments, which he termed vertebral subluxations, interfered with the body's function and its inborn (innate) ability to heal itself.^[2] 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. D.D. Palmer, using a vitalistic approach, imbued the term subluxation with a metaphysical and philosophical meaning. He qualified this by noting that knowledge of innate intelligence was not essential to the competent practice of chiropractic.^[27] This concept was later expanded upon by his son, B.J. Palmer and was instrumental in providing the legal basis of differentiating chiropractic medicine from conventional medicine. In 1910, D.D. Palmer theorized that the nervous system controlled health:

"Physiologists divide nerve-fibers, which form the nerves, into two classes, afferent and efferent. Impressions are made on the peripheral afferent fiber-endings; these create sensations that are transmitted to the center of the nervous system. Efferent nerve-fibers carry impulses out from the center to their endings. Most of these go to muscles and are therefore called motor impulses; some are secretory and enter glands; a portion are inhibitory their function being to restrain secretion. Thus, nerves carry impulses outward and sensations inward. The activity of these nerves, or rather their fibers, may become excited or allayed by impingement, the result being a modification of functionality—too much or not enough action—which is disease."^[28]

The concept of subluxation remains unsubstantiated and largely untested, and a debate about whether to keep it in the chiropractic paradigm has been ongoing for decades.^[29] 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.^[29] This is still a continuing source of debate within the chiropractic profession as well, with some schools of chiropractic (for example, Palmer College of Chiropractic^[30]) still teaching the traditional/straight subluxation-based chiropractic, while others (for example, Canadian Memorial Chiropractic College^[31]) have moved towards an evidence-based chiropractic that rejects metaphysical foundings and limits itself to primarily neuromusculoskeletal conditions.^[32][33] A 2003 survey of North American chiropractors found that 88% wanted to retain the term vertebral subluxation complex, and that when asked to estimate the percent of visceral ailments that subluxation significantly contributes to, the mean response was 62%.^[34] In 2005, 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. It is essentially a functional entity, which may influence biomechanical and neural integrity.… This definition is different from the current medical definition, in which subluxation is a significant structural displacement, and therefore visible on static imaging studies."^[13]

Chiropractors are primary-contact health care practitioners who emphasize the conservative management of the neuromusculoskeletal system without the use of medicines or surgery.^[13] Although chiropractors have many attributes of primary care providers, chiropractic has more of the attributes of a medical specialty like dentistry.^[35] The practice of chiropractic medicine involves a range of diagnostic methods including skeletal imaging, observational and tactile assessments, orthopedic and neurological evaluation, laboratory tests,^[13] and specialized tests.^[1] A chiropractor may also refer a patient to an appropriate specialist, or co-manage with another health care provider.^[35] Common patient management involves:

• spinal manipulation and other manual therapies to the joints and soft tissues
• rehabilitative exercises
• health promotion
• electrical modalities
• conservative and complementary procedures
• lifestyle counseling.^[36]

Chiropractors generally cannot write medical prescriptions; a 2003 survey of North American chiropractors found that a slight majority favored allowing them to write prescriptions for over-the-counter drugs.^[34] A notable exception is the state of Oregon which is considered to have an "expansive" scope of practice of chiropractic, which allows chiropractors to prescribe over-the-counter substances and perform minor surgery.^[37] In some locations chiropractors (DCs) and veterinarians (DVMs) with additional training and certification can practice veterinary chiropractic which includes the diagnosis, treatment and rehabilitation of injured animals.^[38][39] However, the official position of the American Chiropractic Association is that applying manipulative techniques to animals does not constitute chiropractic and that veterinary chiropractic is a misnomer.^[40]

Chiropractic medicine is established in the U.S., Canada, and Australia, and is present to a lesser extent in many other countries.^[41] Similar to other primary contact health providers, chiropractors can specialize in different areas of chiropractic medicine. The most common post-graduate diplomate programs include neurology, sports sciences, clinical sciences, rehabilitation sciences, orthopedics and radiology which generally require 2–3 additional years of additional post graduate study and passing competency examinations.^[42]

Chiropractors obtain a first professional degree in the field of chiropractic medicine.^[43] The U.S. and Canada require a minimum 90 semester hours of undergraduate education as a prerequisite for chiropractic school, and at least 4200 instructional hours (or the equivalent) of full‐time chiropractic education for matriculation through an accredited chiropractic program.^[44][45] 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.^[13]

Upon graduation, there may be a requirement to pass national, state, or provincial board examinations before being licensed to practice in a particular jurisdiction.^[46][47] Depending on the location, continuing education may be required to renew these licenses.^[48][49]

In the U.S., chiropractic schools are accredited through the Council on Chiropractic Education (CCE).^[50] 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.^[51] Today, there are 18 accredited Doctor of Chiropractic programs in the U.S.,^[52] 2 in Canada,^[53] and 4 in Europe.^[54] 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.^[10] Chiropractic education in the U.S. is divided into straight or mixer educational curricula depending on the philosophy of the institution.^[55]

Regulatory colleges and chiropractic boards in the U.S., Canada, and Australia are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.^[56][57] There are an estimated 53,000 chiropractors in the U.S. (2006),^[58] 6526 in Canada (2006),^[59] 2500 in Australia (2000),^[60] and 1,500 in the UK (2004).^[61]

Spinal manipulation is the most common treatment used in chiropractic care^[62] and is most frequently employed by chiropractors.^[63] It is a passive manual maneuver during which a three-joint complex is taken past the normal physiological range of movement without exceeding the anatomical boundary limit; its defining factor is a dynamic thrust, a sudden force that causes an audible release and attempts to increase a joint's range of motion. 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; in chiropractic care SMT most commonly takes the form of spinal manipulation.^[64] The medicinal use of spinal manipulation can be traced back over 3000 years to ancient Chinese writings. Hippocrates, the "father of medicine" used manipulative techniques,^[65] as did the ancient Egyptians and many other cultures. A modern re-emphasis on manipulative therapy occurred in the late 19th century in North America with the emergence of the osteopathic medicine and chiropractic medicine.^[66] SMT gained mainstream recognition during the 1980s.^[67] In the U.S., chiropractors perform over 90% of all manipulative treatments^[68] and consider themselves to be expertly qualified providers of spinal adjustment, manipulation and other manual treatments.^[69]

Manipulation under anesthesia or MUA is a specialized manipulative procedure that typically occurs in hospitals administered under general anesthesia.^[70] Typically, it is performed on patients who have failed to respond to other forms of treatment.^[71]

Chiropractic is the largest alternative medical profession in the U.S.^[4] and is the 3rd largest doctored profession behind medicine and dentistry in North America.^[72] The percentage of population that utilize chiropractic care at any given time generally fall into a range from 6% to 12% in the U.S. and Canada,^[73] with a global high of 20% in Alberta.^[74] The vast majority who seek chiropractic care do so for relief from back and neck pain and other neuromusculoskeletal complaints;^[75] most do so specifically for low back pain. Complementary and alternative medicine (CAM) practitioners such as chiropractors are often used as a complementary form of care to primary medical intervention.^[73] Satisfaction rates are typically higher for chiropractic care compared to medical care, with quality of communication seeming to be a consistent predictor of patient satisfaction with chiropractors.^[76] Despite high patient satisfaction scores, utilization of chiropractic care is sensitive to the costs incurred by the co-payment by the patient.^[77] The use of chiropractic is growing modestly; CAM as a whole is seeing wholesale increases.^[73] Employment of U.S. chiropractors is expected to increase 14% between 2006 and 2016, faster than the average for all occupations.^[78] A 2008 survey stated that 69% of DC chiropractors disagree with the categorization of chiropractic as CAM, with 27% having some preference for the term "integrated medicine."^[79]

Chiropractic was founded in the 1890s by Daniel David (D.D.) Palmer in Davenport, Iowa. Palmer, a magnetic healer, hypothesized that manual manipulation of the spine could cure disease. Although initially keeping the theory a family secret, in 1898 he began teaching it to a few students at his new Palmer School of Chiropractic. One student, his son Bartlett Joshua (B.J.) Palmer, became committed to promoting chiropractic, took over the Palmer School in 1906, and rapidly expanded its enrollment.^[3] Prosecutions and incarcerations of chiropractors for practicing medicine without a license grew common, and to defend against medical statutes B.J. invented a new vocabulary and argued that chiropractic was separate and distinct from medicine, asserting that chiropractors "analyzed" rather than "diagnosed", and "adjusted" subluxation rather than "treated" disease.^[6] Early chiropractors believed that all disease was caused by interruptions in the flow of innate intelligence, a vital 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.^[3][80] Early chiropractors also tapped into the Populist movement, emphasizing craft, hard work, competition, and advertisement, aligning themselves with the common man against intellectuals and trusts, among which they included the American Medical Association (AMA).^[3]

Although D.D. and B.J. were "straight" and disdained the use of instruments, some early chiropractors, whom B.J. scornfully called "mixers", advocated their use. In 1910 B.J. changed course and endorsed X-rays as necessary for diagnosis; this resulted in a significant exodus from Palmer of the more conservative faculty and students. The mixer camp grew until by 1924 B.J. estimated that only 3,000 of the U.S.'s 25,000 chiropractors remained straight. That year, B.J.'s promotion of the neurocalometer, a new temperature-sensing device, was another sign of chiropractic's gradual acceptance of medical technology, although it was highly controversial among B.J.'s fellow straights. Despite heavy opposition by organized medicine, by the 1930s chiropractic was the largest alternative healing profession in the U.S.^[3] The longstanding feud between chiropractors and medical doctors continued for decades. Until 1983, the AMA labeled chiropractic "an unscientific cult" and held that it was unethical for medical doctors to associate with an "unscientific practitioner".^[81] This culminated in a landmark 1987 decision, Wilk v. AMA, in which the court found that the the AMA had engaged in unreasonable restraint of trade and conspiracy, and which ended the AMA's de facto boycott of chiropractic.^[8]

Serious research to test chiropractic theories did not begin until the 1970s, and was hampered by antiscientific and pseudoscientific ideas that sustained the profession in its long battle with mainstream medicine. By the mid 1990s there was a growing scholarly interest in chiropractic, which helped efforts to improve service quality and establish clinical guidelines that recommended spinal manipulation in some cases.^[6] In recent decades chiropractic gained legitimacy and greater acceptance by physicians and health plans, and enjoyed a strong political base and sustained demand for services; like other forms of complementary and alternative medicine, chiropractic became more integrated into mainstream medicine. 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.^[8]

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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.^[9] Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs antiscientific reasoning and makes unsubstantiated claims.^[82] 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.^[83] Evidence-based chiropractors possess the ability to apply research in practice. Continued education enhances the scientific knowledge of the practitioner.^[84]

The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Opinions differ as to the efficacy of chiropractic treatment; many other medical procedures also lack rigorous proof of effectiveness.^[10] Chiropractic care, like all medical treatment, benefits from the placebo response.^[85] The efficacy of maintenance care in chiropractic is unknown.^[11]

Research has focused on spinal manipulation (SM) in general,^[86] rather than specifically on chiropractic SM.^[9] There is little consensus as to who should administer the SM, raising concerns by chiropractors that orthodox medical physicians could "steal" SM procedures from chiropractors; the focus on SM has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.^[9] Many controlled clinical studies of SM are available, but their results disagree,^[87] and they are typically of low quality.^[88] It is hard to construct a trustworthy placebo for clinical trials of spinal manipulative therapy (SMT), as experts often disagree whether a proposed placebo actually has no effect.^[89] Although a 2008 critical review found that with the possible exception of back pain, chiropractic SM has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference,^[90] a 2008 supportive review found serious flaws in the critical approach, and found that SM and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments.^[91]

Available evidence covers the following conditions:

• Low back pain. There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain; methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the guidelines' reliability.^[92] A 2007 U.S. guideline weakly recommended SM as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,^[93] whereas the Swedish guideline for low back pain was updated in 2002 to no longer suggest considering SMT for acute low back pain for patients needing additional help, possibly because the guideline's recommendations were based on a high evidence level.^[92] A 2008 review found strong evidence that SM is similar in effect to medical care with exercise, and moderate evidence that SM is similar to physical therapy and other forms of conventional care.^[91] A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain.^[94] Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review (^[95]) stated that SM or mobilization is no more or less effective than other standard interventions for back pain.^[87]

• Whiplash and other neck pain. There is no overall consensus on manual therapies for neck pain.^[96] A 2008 review found evidence that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SM, mobilization, supervised exercise, low-level laser therapy and perhaps acupuncture are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves prognosis.^[97] A 2007 review found that SM and mobilization are effective for neck pain.^[96] Of three systematic reviews of SM published between 2000 and May 2005, one reached a positive conclusion, and a 2004 Cochrane review (^[98]) found that SM and mobilization are beneficial only when combined with exercise, the benefits being pain relief, functional improvement, and global perceived effect for subacute/chronic mechanical neck disorder.^[87] A 2005 review found consistent evidence supporting mobilization for acute whiplash, and limited evidence supporting SM for whiplash.^[99]

• Headache. A 2006 review found no rigorous evidence supporting SM or other manual therapies for tension headache.^[100] A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.^[101] A 2004 review found that SM may be effective for migraine and tension headache, and SM and neck exercises may be effective for cervicogenic headache.^[102] Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of SM.^[87]

• Other. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs,^[103] and a lack of higher-quality publications supporting chiropractic management of leg conditions.^[104] A 2007 literature synthesis found fair evidence supporting assurance and advice to stay active for sciatica and radicular pain in the leg.^[94] There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine)^[105] and no scientific data for idiopathic adolescent scoliosis.^[106] 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 asthma, cervicogenic dizziness, and baby colic, 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, dizzinesss, and vision conditions.^[107] Other reviews have found no evidence of benefit for baby colic,^[108] bedwetting,^[109] fibromyalgia,^[110] or menstrual cramps.^[111]

Chiropractic care in general is safe when employed skillfully and appropriately. Manipulation is regarded as relatively safe, but as with all therapeutic interventions, complications can arise, and it has known adverse effects, risks and contraindications. Absolute contraindications to spinal manipulative therapy are conditions that should not be manipulated; these contraindications include rheumatoid arthritis and conditions known to result in unstable joints. Relative contraindications are conditions where increased risk is acceptable in some situations and where low-force and soft-tissue techniques are treatments of choice; these contraindications include osteoporosis.^[13] Although most contraindications apply only to manipulation of the affected region, some neurological signs indicate referral to emergency medical services; these include sudden and severe headache or neck pain unlike that previously experienced.^[112]

Spinal manipulation is associated with frequent, mild and temporary adverse effects,^[112][12] including new or worsening pain or stiffness in the affected region.^[113] They have been estimated to occur in 34% to 55% of patients, with 80% of them disappearing within 24 hours.^[112] Rarely, spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death; these can occur in adults^[12] and children.^[63] The incidence of these complications is unknown, due to rarity, high levels of underreporting, and difficulty of linking manipulation to adverse effects such as stroke, a particular concern.^[12] Several case reports show temporal associations between interventions and potentially serious complications. Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.^[97] Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.^[114]

A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings.^[115] A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain, but that reports are 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.^[116] 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.^[117] The cost-effectiveness of maintenance chiropractic care is unknown.^[11]

Although vaccination is one of the most cost-effective forms of prevention against infectious disease, it remains controversial within the chiropractic community. Most chiropractic writings on vaccination focus on its negative aspects,^[7] claiming that it is hazardous or ineffective.^[118] Evidence-based chiropractors have embraced vaccination, but a minority of the profession rejects it, as original chiropractic philosophy traces diseases to causes in the spine and states that diseases cannot be affected by vaccines. The American Chiropractic Association and the International Chiropractic Association support individual exemptions to compulsory vaccination laws, and a 1995 survey of U.S. chiropractors found that about a third believed there was no scientific proof that immunization prevents disease.^[119] The Canadian Chiropractic Association supports vaccination; surveys in Canada in 2000 and 2002 found that 40% of chiropractors supported vaccination, and that over a quarter opposed it and advised patients against vaccinating themselves or their children.^[7]

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