On March 18, 1993, The Wall Street Journal published a front-page article dealing with chiropractic treatment of children. Labeling chiropractic as a nineteenth-century philosophy wearing the white smock of science, the article castigated chiropractors for treating children for “legions of childhood afflictions” (Smith 1993).

A year later, on February 4, 1994, ABC’s 20/20 aired “Handle with Care,” an episode based on secretly videotaped visits to the offices of seventeen chiropractors who treated ear infections in children. All of the chiropractors offered treatment lasting from several weeks to a lifetime. Treatment methods were based on diagnoses ranging from subluxated vertebrae to nutritional deficiency, weak glands, food sensitivity, and a short leg.

Chiropractic treatment of children has not been curtailed by such bad publicity. Today, building on a program that began in 1993, the International Chiropractic Association offers a postgraduate “Diplomate in Clinical Chiropractic Pediatrics” (DICCP) and publishes the “peer reviewed” Journal of Clinical Chiropractic Pediatrics. The diplomate program is a thirty-module, 360-plus-hour classroom course that takes place during weekends over a three-year period. There is no hospital training and no contact with diseased or injured children—only a “mandatory observational/training weekend at a chiropractic center for special needs children under multi-disciplinary care” (ICA Council 2009).

Both American chiropractic associations endorse chiropractic care for children. In a June 2008 joint press release, for example, the American Chiropractic Association’s (ACA) Council on Chiropractic Pediatrics and the Council on Chiropractic Pediatrics of the International Chiropractors Association (ICA) announced that the DICCP is now recognized by the ACA and its council as the official credential for specialization in chiropractic pediatrics (ACA 2007).

Noting increasing public support for chiropractic treatment of children, a January 2009 press release from the ACA offered this observation: “Survey data indicates that the percentage of chiropractic patients under 17 years of age has increased at least 8.5 percent since 1991. . . . Studies are beginning to show that chiropractic can help children not only with typical back and neck pain complaints, but also with issues as varied as asthma, chronic ear infections, nursing difficulties, colic and bedwetting” (ACA 2009).

A trend toward greater use of chiropractic by children has not gone unnoticed by the medical profession. An article in the January 2007 issue of Pediatrics (the official journal of the American Academy of Pediatrics) described chiropractic as the most common complementary and alternative medicine practice used by children, who made an estimated thirty million visits to U.S. chiropractors in 1997 (Vohra 2007). In 1998, children and adolescents constituted 11 percent of patient visits to chiropractors (Lee 2000).

Promoting a broad scope of practice for chiropractors who treat children, the ICA Council on Chiropractic Pediatrics offers links to abstracts from chiropractic journals that support chiropractic treatment for a variety of childhood ailments (ICA Pediatrics 2009). Chiropractors commonly claim to have an effective treatment for otitis media, asthma, allergies, infantile colic, and enuresis. While many of the pediatric conditions treated by chiropractors are self-limiting, treatment is offered for such serious conditions as cerebral palsy, epilepsy, myasthenia gravis, uveitis, ADHD, and Tourette’s syndrome. For the most part, treatment for all these conditions is based upon detection and correction of vertebral misalignment (subluxation) or spinal joint dysfunction (vertebral subluxation complex). An article titled “The Child Patient: A Matrix for Chiropractic Care” in the Journal of Clinical Chiropractic Pediatrics, for example, stated that “any alteration in form or function in the child may signal the presence of subluxation, and the subluxation may in turn alter the physiology of the child” (Fallon 2005). For wellness and preventive care, parents are advised that children should be checked for subluxations by a chiropractor six to twelve times per year (Fallon 2005).

A 2009 survey of chiropractors and parents of chiropractic pediatric patients, conducted by the International Chiropractic Pediatric Association, revealed that “the indicated primary reason for chiropractic care of children was ‘wellness care’” (Alcantara 2009). The reasons given for such care would indicate that normal spines of healthy children are being manipulated for “subluxation correction.”

There is no credible evidence to support the contention that subluxation correction will restore or maintain health or that such subluxations even exist (College 1996; Mirtz 2009). Chiropractic journals publish hundreds of subluxation-based studies supporting chiropractic treatment for children but only a few studies disputing such treatment. Most medical researchers feel that claims based on the chiropractic vertebral subluxation theory do not have sufficient basis to warrant investigation. But such claims should not go unchallenged, especially when they involve treatment of children.

Contrary Opinions

To date, legitimate properly controlled studies have failed to support the claims of chiropractors who treat children for organic ailments. In the case of asthma, for example, a randomized, controlled trial of chiropractic spinal manipulation for children with mild or moderate asthma published in the New England Journal of Medicine revealed that “the addition of chiropractic spinal manipulation to usual medical care provided no benefit” (Balon 1998). A randomized, controlled trial of infantile colic treated with chiropractic spinal manipulation, published in a 2001 issue of Archives of Diseases in Childhood, concluded that “chiropractic spinal manipulation is no more effective than placebo in the treatment of infantile colic” (Olafdottir 2001). A recent systematic review of randomized clinical trials concluded that “there is no good evidence to show that spinal manipulation is effective for [treating] infant colic” (Ernst 2009).

There is evidence to indicate that soft-tissue manipulative techniques applied over the neck area might aid recovery from secretory otitis media (inflammation of the middle ear) by opening the eustachian tube to facilitate drainage of fluids from the middle ear (Mills 2003). Chiropractors who manipulate a child’s neck to correct subluxations might provide some symptomatic relief for otitis media by inadvertently stretching the eustachian tube. But the risk of such treatment would outweigh any possible benefit. (Although otitis media is normally self-limiting, it should be kept under observation by a pediatrician who can prescribe antibiotics, if needed, when there is acute otitis media with bacterial infection. Otitis media commonly occurs in children under three years of age. As the child grows older, an increase in the length and angle of the eustachian tube reduces chances of bacteria or viruses traveling from the throat to the middle ear.)

Considering the implausibility of the chiropractic vertebral subluxation theory, there is good reason to question the ability of chiropractors to diagnose and treat childhood ailments. A correct diagnosis notwithstanding, there is no evidence to support the belief that manipulating the spine of a child to correct vertebral subluxations would be appropriate treatment. A 1993 risk–benefit analysis of spinal manipulative therapy (SMT) for relief of lumbar or cervical pain, published in Online Neurosurgery, advised neurosurgeons that “potential complications and unknown benefits indicate that SMT should not be used in the pediatric population” (Powell 1993).

Considering the damage that manipulation might do to cartilaginous growth centers, there is no known justification for using spinal manipulation on an infant or a preadolescent child. Yet, many chiropractors recommend that the spine of a newborn baby be adjusted at birth to correct subluxations. According to the ICA Council on Chiropractic Pediatrics, “chiropractic care can never start too early” (ICA Home 2009).

Generally, pediatricians classify a child as being under eighteen years of age—before vertebral end plate growth is complete. In a child under the age of eight to ten years, the cartilaginous growth centers are too immature and too vulnerable to injury to be subjected to spinal manipulation. There is some speculation that injury to growth plates might result in spinal deformity (such as scoliosis or Scheuermann’s kyphosis) as growth progresses (O’Neal 2003). Such injury might not be detectable. “The incidence of subtle growth plate fractures following high-velocity [manipulation] techniques in children is surely under-appreciated because of the occult nature of these injuries” (O’Neal 2003).

The cartilaginous, flexible spine of a child is not as easily injured as an adult’s spine under normal circumstances. Referred pain caused by organic disease is not commonly experienced by children. When back pain in a child does occur, it is potentially more serious than back pain in an adult and should always be brought to the attention of a board-certified pediatrician.

Although spinal manipulation has the potential to injure the spine of a child, few such injuries have been reported in the literature. A systematic review of thirteen studies, published up to June 2004, uncovered fourteen significant manipulation-related injuries in children up to eighteen years of age, nine of which were serious (e.g., subarachnoidal hemorrhage, paraplegia) and two of which were fatal (one child died from a brain hemorrhage and another from dislocation of the atlas following neck manipulation). Ten of the injuries were attributed to manipulation done by chiropractors, one to manipulation by a physiotherapist, and one to manipulation by a medical doctor; two injuries were caused by unspecified providers of manipulation. In twenty cases of harm caused by delayed diagnosis as a result of using manipulation, seven involved a delayed diagnosis of cancer; two children died because of delayed treatment for meningitis (Vohra 2007). The incidence of spinal injuries in children is reported to be 2 to 5 percent of all spine injuries (Hayes 2005).

A Questionable Approach

High-velocity, low-amplitude thrusting, commonly used by chiropractors, is usually the type of manipulation that injures a child’s spine. Most chiropractors who manipulate an infant’s spine may simply use light thumb pressure to “adjust” an allegedly misaligned vertebra, thus reducing possibility of injury. Although such treatment may be harmless, it has no known beneficial effect other than the calming effect of human touch. Some chiropractors may use a spring-loaded stylus or an electrically powered mallet in an attempt to tap vertebrae into alignment. Chiropractors who adjust newborn babies to correct subluxations may concentrate on the upper cervical (neck) area of the spine. The upper neck is more likely to be injured by delivery during birth and is most vulnerable to injury caused by manipulation. Pediatricians have observed that “the most common traumatically injured region of the immature spine is the first and second cervical vertebrae” (O’Neal 2003).

There is no credible evidence that chiropractors are able to find subluxations in the spine of an infant. It seems unlikely that a chiropractor could detect vertebral misalignment by palpating the flexible, cartilaginous spine of an infant through a thick layer of baby fat. I have always suspected that chiropractors who say they can use their fingertips to feel subluxations in a baby’s spine are either deceiving themselves or misinterpreting what they feel.

Some chiropractors use surface electromyography, thermography, leg-length checks, or some other questionable device or approach to locate subluxations. It goes without saying that chiropractors should not expose a child to unnecessary radiation by x-raying his or her spine in a search of elusive or nonexistent subluxations. In Canada, the Alberta Society of Radiology has recommended that radiologists refuse requests from chiropractors who ask for diagnostic imaging of any type involving children aged eighteen years or younger (Editorial 1998).

Of all the claims made by chiropractors, I regard the claims made by those who treat children to be the most problematic. I have always advised against manipulating the spine of a small child or a newborn baby for any reason. Manipulation of the spine of an adolescent child under the age of eighteen should be done in concert with an evaluation and a diagnosis provided by an orthopedist, preferably a pediatric orthopedic specialist. Caring for children is very different from caring for adults and requires a special expertise. Board-certified medical and osteopathic pediatricians are best qualified to provide appropriate care based on a correct diagnosis.

Although spinal manipulation is often recommended as a treatment for back pain, this recommendation does not often apply to children. When the U.S. Department of Health and Human Services published guidelines suggesting that spinal manipulation might be helpful in treating low back pain without radiculopathy (sciatic pain) when used within the first month of symptoms, its recommendations did not apply to children younger than eighteen years of age “since diagnostic and treatment considerations for this group are often different than for adults” (Bigos 1994). An adolescent child might benefit from appropriate manipulation designed to relieve symptoms caused by uncomplicated, mechanical-type back problems, but only if a definitive diagnosis has been provided by an orthopedist or a pediatrician. Use of unnecessary spinal manipulation in the treatment of children up to eighteen years of age for subluxation correction may delay appropriate treatment based on a correct diagnosis.

Some chiropractors believe that manipulating a child’s spine will stimulate the immune system and help prevent infection. On September 8, 2009, for example, the Journal of Pediatric, Maternal and Family Health Chiropractic issued a press release titled “Chiropractic Part of Swine Flu Prevention Program in Children.” The editor of the journal recommended that all children should be checked for vertebral subluxations before and during the flu season: “Since the nervous system has a direct effect on the immune system and because the spine houses and protects so much of the nerve system it is important to have your child’s spine checked for any interference” (McCoy 2009).

Such extreme views find support in the basic definition of chiropractic and in official chiropractic publications. The National Board of Chiropractic Examiners, for example, advises that “psychoneuroimmunology has revealed an interrelationship between the central nervous system and immunity (consistent with chiropractic philosophy). . . . By manually manipulating vertebrae into their normal physiological relationship, chiropractic practitioners relieve interference with the nervous system along with accompanying symptoms.” Thus, “chiropractic management of childhood disorders primarily consists of adjusting concomitant spinal subluxations and providing specific nutritional advice and/or support and other palliative measures” (Christensen 2005).

All things considered, it’s an understatement to say that “pediatric chiropractic care is often inconsistent with recommended medical guidelines” (Lee 2000). Recommendation of any complementary alternative medicine (CAM) therapy that has a risk–benefit ratio that is not acceptable and is not supported in medical literature may make a referring physician liable for negligence if the referral causes harm by delaying necessary conventional treatment (Cohen 2005). For this reason, and with the best interest of children in mind, few physicians would consider referring a child to a chiropractor.

References

ACA Council on Chiropractic Pediatrics. 2007. Pediatric diplomate certification recognized by both ICA and ACA. Available online at www.acapeds
council.org/pressrelease.html (accessed September 21, 2009).

ACA. 2009. Increasing numbers of children receive pediatric chiropractic care. January. Available online at www.acatoday.org/press_css.cfm?CID=3247 (accessed September 21, 2009).

Alcantara J., J. Ohm, and D. Kunz. 2009. The safety and effectiveness of pediatric chiropractic: A survey of chiropractors and parents in a practice-based research network. Journal of Science and Healing 5(5): 290–295.

Balon, J., et al. 1998. A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma. New England Journal of Medicine 339(15): 1013–1020.

Bigos, S.J., et al. 1994. Acute Low Back Problems in Adults. Rockville, Maryland: U.S. Department of Health and Human Services. AHCPR Publication No. 95-0642.

Christensen, M., et al. 2005. Job Analysis of Chiropractic. Greeley, CO: National Board of Chiropractic Examiners.

Cohen, M.H., and K.J. Kemper. 2005. Complementary therapies in pediatrics: A legal perspective. Pediatrics 115(3): 774–780.

College of Physicians and Surgeons of the Province of Quebec. 1966. A scientific brief against chiropractic. New Physician. September. Available online at www.chirobase.org/05RB/CPSQ/00.html (accessed September 21, 2009).

Editorial. 1998. Alberta radiologists target chiropractors. Canadian Medical Association Journal 159(10): 1237.

Ernst, E. 2009. Chiropractic spinal manipulation for infant colic: A systematic review of randomized clinical trials. International Journal of Clinical Practice 63(9): 1351–1353.

Fallon, J. 2005. The child patient: A matrix for chiropractic care. Journal of Clinical Chiropractic Pediatrics (Supplement) 6(3).

Hayes J., and T. Arriola. 2005. Pediatric spinal injuries. Pediatric Nursing. 31(6): 464–467.

ICA Council. Diplomate in Chiropractic Pediatrics. Available online at www.icapediatrics.com/members-postgrad.php (accessed September 21, 2009).

ICA Pediatrics. Journal Abstracts. Available online at www.icapediatrics.com/reference-journals.php (accessed September 21, 2009).

ICA Home. Council on Chiropractic Pediatrics. Available online at www.icapediatrics.com (accessed September 21, 2009).

Lee, A., D. Li, and K. Kemper. 2000. Chiropractic care for children. Archives of Pediatrics and Adolescent Medicine 154: 401–407.

McCoy, M. 2009. Chiropractic part of swine flu prevention program in children. McCoy Press Research Update. September 8. Available online at http://researchupdate.mccoypress.net (accessed September 21, 2009).

Mills, V., et al. 2003. The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media. Archives of Pediatrics and Adolescent Medicine 157(9): 861–866.

Mirtz, T., et al. 2009. An epidemiological examination of the subluxation construct using Hill’s criteria of causation. Chiropractic and Osteopathy 17: 13. Available online at www.chiroandosteo.com/content/17/1/13 (accessed April 10, 2010).

Olafdottir E., et al. 2001. Randomised controlled trial of infantile colic treated with chiropractic spinal manipulation. Archives of Disease in Childhood 84(2): 138–141.

O’Neal, M.L. 2003. The pediatric spine: Anatomical and dynamic considerations preceding manipulation. Comprehensive Therapy 29(2): 124–129.

Powell, F.C., et al. 1993. A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain. Neurosurgery Online 33(1): 73.

Smith, T. 1993. Chiropractors seeking to expand practice take aim at children. Wall Street Journal. March 18, 4A.

Vohra, S., et al. 2007. Adverse events associated with pediatric spinal manipulation: A systematic review. Pediatrics 119(1): e275–e283.

In 1895, D.D. Palmer, a grocer and magnetic healer, announced that “Ninety-five percent of all diseases are caused by displaced vertebrae, the remainder by luxations of other joints” (Homola 1963). Palmer claimed that he had cured deafness and heart trouble by adjusting the spine (Wardwell 1992). He concluded that most diseases could be cured by adjusting vertebrae to remove interference with “nerve vibrations” that flowed from the brain to the spinal cord and out through openings between the vertebrae (Palmer 1914). Palmer’s questionable and anecdotal claims gave birth to the profession of chiropractic.

Today, the chiropractic profession agonizes over the definition of chiropractic, which has changed little except in wording used to explain how adjusting the spine can restore and maintain health. For many years, the vertebral subluxation theory was explained in a very simple way: a vertebra out of its normal position encroached upon spinal nerves, interfering with the flow of nerve impulses to the tissues and organs supplied by the affected nerve. Certain spinal nerves supplied certain organs. Adjustment of a selected vertebra would release vital nerve flow so that so-called “innate intelligence” could heal the body (Wardwell 1992). This theory has since been rejected and ridiculed by the scientific community.

New Definition for an Old Approach

Facing the realization that pressure on a spinal nerve cannot be demonstrated to be a cause of organic disease and that slight displacement of a vertebra does not compress a spinal nerve, defenders of the subluxation theory further theorized that abnormal joint function could affect general health by triggering nerve impulses from proprioceptors, nociceptors, mechanoreceptors, and other monitors of joint function. There are no appropriately controlled studies, however, to indicate that any type of dysfunction in structures of the spinal column is a cause of organic disease (Nansel 1995).

It is the consensus of the chiropractic profession’s schools and leaders that chiropractic should not be limited to treatment of back pain and should focus on treatment of general health problems. In July 1996, the Association of Chiropractic Colleges (ACC), representing sixteen North American chiropractic colleges, drafted a new paradigm stating that “Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health” (Association 1996). Such a subluxation has never been proven to exist.

In 1997, the Foundation for Chiropractic Education and Research (FCER), supporting the vague, untestable, and all-inclusive ACC paradigm, published a monograph titled The Role of Subluxation in Chiropractic. Noting that a vertebral subluxation complex (VSC) “may not be detectable by any of the current technological methods,” the monograph explained, “[The VSC] embraces the holistic nature of the human body, including health, well-being, and the doctor/patient relationship as well as the changes in nerve, muscle, connective, and vascular tissues which are understood to accompany the kinesiologic aberrations of spinal articulations” (Rosner 1997).

The ACC paradigm was endorsed by the International Chiropractic Association and the American Chiropractic Association in November 2000 and by the World Federation of Chiropractic in May 2001.

A random survey of 1,102 active North American chiropractors in 2003 revealed that 88.1 percent of 687 respondents believed that the term “vertebral subluxation complex” should be retained by the chiropractic profession. The respondents also believed that vertebral subluxation is a significant contributing factor in 62.1 percent of visceral ailments. The majority believed that spinal adjustment should not be limited to treatment of musculoskeletal problems (McDonald 2003).

Chiropractic Consensus versus Scientific Consensus

Scientific consensus does not support the theory that vertebral misalignment or “subluxation” is a cause of organic disease (College 1996, Crelin 1973, Jarvis 2001, National Council Against Health Fraud 2005). Spinal nerves primarily supply musculoskeletal structures. Organ function is governed by the autonomic nervous system in concert with psychic, chemical, hormonal, and circulatory factors. Autonomic cranial and sacral nerves that supply the body’s organs do not pass through movable joints. Spinal nerves are commonly irritated or compressed by bony spurs, herniated discs, and other abnormalities in the spine. Even the most severe compression of a spinal nerve, however, which cripples the supplied musculoskeletal structures, does not cause organic disease. It is unreasonable to assume that slight misalignment of a vertebra or an undetectable vertebral subluxation complex can cause disease or ill health when those effects do not occur because of gross displacement of a vertebra or as a result of impingement of a spinal nerve.

There is considerable evidence that spinal manipulation can be helpful in treating some types of back pain (Bigos 1994, Shekelle 1991), but “there appears to be little evidence to support the value of spinal manipulation for nonmusculoskeletal conditions” (Shekelle 1998).

Choices for the Future

Back pain is one of this nation’s most common medical problems, accounting for $50-100 billion in health costs annually (Pelletier 2002). Despite the need for a back-pain specialty that combines the use of spinal manipulation with physical therapy modalities, it does not appear that the chiropractic profession plans to take advantage of the growing back-pain market by specializing.

Spinal manipulation is only one treatment of many available in the treatment of back pain. A back-pain specialty would require the use of a variety of physical treatment methods in concert with various medical specialties. Chiropractors who adjust subluxations to restore and maintain health do not qualify as back specialists. Chiropractic as an alternative method of primary care for general health problems is far from being accepted by the scientific community.

A 2005 report by the Institute for Alternative Futures reported that the future of chiropractic is uncertain because of economic challenges and the limitations in chiropractic science and methods. The Institute predicted four possible scenarios for chiropractic: (1) slow, steady growth as support mounts for the use of manipulation in the treatment of back and neck pain; (2) a downward spiral from competition and healthcare costs; (3) evidence-based collaboration in the care of neuromusculoskeletal conditions; or (4) chiropractors will become healthy life doctors “specializing in preventing disease with health-management plans” (Institute 2005).

Concerned that the chiropractic profession “has failed to define itself in a way that is understandable, credible and scientifically coherent,” a group of evidence-based chiropractors offered a model for “spine care” that focuses primarily on treatment for back pain. The purpose of the plan is to “help integrate chiropractic care into the mainstream delivery system while still retaining self-identity for the profession” (Nelson 2005). The plan was not well-received by the chiropractic profession at large, which is loathe to restrict chiropractic treatment to back pain, preferring instead to claim a broad scope of health problems as its purview.

On June 15, 2005, the World Federation of Chiropractic, at its Eighth Biennial Congress, unanimously agreed that chiropractors should be identified as “spinal health care experts in the health care system . . . with emphasis on the relationship between the spine and the nervous system” (World 2005). This definition fails to place proper limitations upon chiropractors who use spinal adjustments to treat general health problems, plunging the profession deeper into pseudoscience and away from establishing an identity for chiropractors as back-pain specialists. Most states continue to define chiropractic as a method of adjusting vertebral subluxations to restore and maintain health, allowing chiropractic treatment of almost any ailment.

Filling a Niche in Mainstream Health Care

If the chiropractic profession continues to define itself as a method of health care based on the relationship between the spine and the nervous system rather than as a method of treating back pain, it seems likely that physical therapists and other practitioners of physical medicine will step in and offer manipulation along with physical therapy modalities in the treatment of back pain. According to the American Physical Therapy Association, “Physical therapy, by 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists. Consumers will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services. Physical therapists will hold all privileges of autonomous practice” (American 2005).

Many physical therapists are already using manipulation/mobilization techniques. Of the 209 physical therapy programs in the United States, 111 now offer Doctor of Physical Therapy (DPT) degrees. About thirty-five states now grant physical therapists direct access to patients (Institute 2005), and there are nearly three times as many physical therapists (137,000) as chiropractors (49,000) (Bureau 2005).

Given a choice, it seems likely that informed consumers who seek treatment for back pain would prefer the services of a physical therapist whose therapeutic armamentarium is limited to treatment of musculoskeletal problems rather than the controversial services of a chiropractor who adjusts the spine to restore and maintain health. In 2002, only about 7.4 percent of the population was seeing a chiropractor annually (Tindle 2005). I suspect that this percentage would increase if the chiropractic profession identified itself as a specialty that deals with back pain and related problems.

References

• American Physical Therapy Association. 2005. APTA Vision Sentence and Vision Statement for Physical Therapy 2020. Available at www. apta.org/About/aptamissiongoals/visionstatement. Accessed October 1, 2005.
• Association of Chiropractic Colleges. 1996. A position paper on chiropractic. Journal of Manipulative Physiological Therapeutics 19:633-37.
• Bigos, S., O. Bowyer, G. Braen, et al. 1994. Acute Low Back Problems in Adults. Clinical Practice Guidelines No. 14. AHCPR publication No. 95-0642. Rockville, Md.: Agency for Health Care Policy and Research.
• Bureau of Labor Statistics, U.S. Department of Labor. 2005. Occupational Outlook Handbook. Washington, D.C.: Office of Occupational Statistics and Employment Projection, 2004-2005.
• College of Physicians and Surgeons of the Province of Quebec. 1996. A scientific brief against chiropractic. The New Physician, September.
• Crelin, E.S. 1973. A scientific test of the chiropractic theory. American Scientist 61:574-80.
• Homola, S. 1963. Bonesetting, Chiropractic, and Cultism. Panama City, Fla.: Critique Books.
• Institute for Alternative Futures. 2005. The Future of Chiropractic Revisited 2005-2015. Available at www.altfutures.com. Accessed October 1, 2005.
• Jarvis, W.T. 2001. NCAHF Fact Sheet on Chiropractic. National Council Against Health Fraud. Available at www.ncahf.org/articles/c-d/chiro.html. Accessed October 1, 2005.
• McDonald, W., K. Durkin, S. Iseman, et al. 2003. How Chiropractors Think and Practice. Ada, Ohio: Ohio Northern University.
• Nansel, D., and M. Szlazak. 1995. Somatic dysfunction and the phenomenon of visceral disease simulation: A probable explanation for the apparent effectiveness of somatic therapy in patients presumed to be suffering from true visceral disease. Journal of Manipulative Physiological Therapeutics 18:379-97.
• National Council Against Health Fraud. 2005. Position Paper on Chiropractic. Available at www.ncahf.org/pp/chirop. Accessed October 1, 2005.
• Nelson, C., D. Lawrence, J. Triano, et al. 2005. Chiropractic as spine care: A model for the profession. Chiropractic and Osteopathy 13:9. Available at www.chiroandosteo.com/content/13/1/9. Accessed October 1, 2005.
• Palmer, D.D. 1914. The Chiropractor. Montana: Kessinger Publishing Company.
• Pelletier, K.R., and J.A. Astin. 2002. Integration and reimbursement of complementary and alternative medicine by managed care and insurance providers: 2000 update and cohort analysis. Alternative Therapies in Health and Medicine 8:38-39.
• Rosner, A. 1997. The Role of Subluxation in Chiropractic. Des Moines, Iowa: Foundation for Chiropractic Education and Research.
• Shekelle, P.G., A.H. Adams, M.R. Chassin, et al. 1991. The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review. Santa Monica, Calif.: RAND
• Shekelle, P.G. 1998. What role for chiropractic in health care? New England Journal of Medicine 339:1074-1075.
• Tindle, H.A., R.B. Davis, R.S. Phillips, and D.M. Eisenberg. 2005. Trends in use of complementary and alternative medicine by U.S. adults: 1997?2003. Alternative Therapies in Health and Medicine 11:42-49.
• Wardwell, W. 1992. History and Evolution of a New Profession. St. Louis, Mo.: Mosby Year-Book.
• World Federation of Chiropractic. 2005. WFC Consultation on the Identity of the Chiropractic Profession, June 15, 2005. Available at www.wfc.org, Identity Consultation. Accessed October 1, 2005.