COUNCIL ON CHIROPRACTIC

PRACTICE
Clinical Practice Guideline

Third Edition - 2008

“Vertebral Subluxation in
Chiropractic Practice”

1
Clinical Practice Guideline:

Vertebral Subluxation

In Chiropractic Practice

Published by:
Council on Chiropractic Practice

Copyright 2008 by Council on Chiropractic Practice

All rights reserved. This publication may not be reproduced, stored in a

retrieval system, or transmitted in whole or in part, in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise,
without prior written permission of the publisher.

ISBN: 978-1-60725-426-3

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Council on Chiropractic Practice
Executive Directors

Christopher Kent, D.C., J.D., F.C.C.I.

President, Council on Chiropractic Practice
Ramsey, New Jersey

Matthew McCoy, B.S., D.C.

Vice President, Council on Chiropractic Practice
Associate Professor – Clinical Sciences Life University
Marietta, Georgia

Terry Rondberg, D.C.

Treasurer, Council on Chiropractic Practice
President, World Chiropractic Alliance
Chandler, Arizona

Veronica Gutierrez, DC.

Secretary, Council on Chiropractic Practice
Private Practice
Arlington, Washington

Board Members

Robert H. Blanks, Ph.D

Professor, Cell Biology and Anatomy
University of Miami School of Medicine
Professor of Biomedical Sciences
Florida Atlantic University

W. Ralph Boone, D.C., Ph.D

Director of Research
Sherman College of Straight Chiropractic
Spartanburg, South Carolina

Steve Renner, D.C., D.A.C.S.

Member A. Board of Forensic Examiners
Private Practice
Washington State

William Sloane, J.D., LL.M, Ph.D,

Pro-Chancellor of the International University for Graduate Studies,

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Jay M. Holder, D.C., C.Ad., DACACD
President, American College of Addictionology & Compulsive Disorders
Private Practitioner
Developer - Torque Release Technique
Miami Beach, Florida

Barbara Bigham, BA
Consumer Member
Keizer, Oregon

Donald Epstein, DC
President
Network Spinal Analysis

Angelica Farrell DC
Private Practice
Rohnert, California

David Walls-Kaufman DC
Private Practice
Washington, DC

Yannick Pauli, DC
Private Practice
Lausanne, Switzerland

Peter Kevorkian DC
Board Member – Federation of Straight Chiropractors & Organizations
Private Practice
Westwood, Massachussetts

Myron Brown DC
Trustee, New Zealand College of Chiropractic.
Former Executive Vice President/Provost, Sherman College Of Chiropractic
Rock Hill, South Carolina

Donald Harte DC
Private Practice
San Francisco, California

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 CCP Guidelines 3rd Edition 2008

Disclaimer

The purpose of these guidelines is to provide the doctor of chiropractic with a

“user friendly” compendium of recommendations based upon the best available
evidence. It is designed to facilitate, not replace, clinical judgment.

As Sackett wrote, “External clinical evidence can inform, but can never
replace, individual clinical expertise, and it is this expertise that decides whether the
external evidence applies to the individual patient at all and, if so, how it should be
integrated into a clinical decision. Similarly, any external guideline must be
integrated with individual clinical expertise in deciding whether and how it matches
the patient’s clinical state, predicament, and preferences, and thereby whether it
should be applied.1

The most compelling reason for creating, disseminating, and utilizing clinical
practice guidelines is to improve the quality of health care. The recommendations
made in this guideline are specific to the clinical entity of vertebral subluxation and
are applicable to the stated goals of the guideline. Consistent with Sackett’s
statement, the recommendations are meant to be flexible based upon each patient
encounter and the goals of both the practitioner and the patient being cared for.

These guidelines are for informational purposes. Utilization of these

guidelines is voluntary. They are not intended to replace the clinical judgement of the
chiropractor. It is acknowledged that alternative practices are possible and may be
preferable under certain clinical conditions. The appropriateness of a given
procedure must be determined by the judgement of the practitioner and the needs
and preferences of the individual patient.

It is not the purpose or intent of these guidelines to provide legal advice, or to

supplant any statutes, rules, and regulations of a government body having
jurisdiction over the practice of chiropractic.

These guidelines address vertebral subluxation in chiropractic practice, and

do not purport to include all procedures which are permitted by law in the practice of
chiropractic. Lack of inclusion of a procedure in these guidelines does not
necessarily mean that the procedure is inappropriate for use in the practice of
chiropractic.

Participation in the guidelines development process does not necessarily

imply agreement with the final product. This includes persons who participated in the
technique conference, leadership conference, open forum, and peer review process.
Listing of names acknowledges participation only, not necessarily approval or
endorsement. The guidelines reflect the consensus of the panel, which gave final
approval to the recommendations.

1. Sackett DL. Editorial: Evidence-based medicine. Spine 1998; 23(10):1085.

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 CCP Guidelines 3rd Edition 2008

COUNCIL ON CHIROPRACTIC PRACTICE CLINICAL GUIDELINE NUMBER 1.

VERTEBRAL SUBLUXATION IN CHIROPRACTIC PRACTICE.

2008 UPDATE AND REVISION.

This document contains the changes, additions and revisions to the 1998 (1st
Edition) and 2003 (2nd Edition) Council on Chiropractic Practice Clinical Guideline.
Vertebral Subluxation in Chiropractic Practice, and is organized in the following
manner:

• Introduction to the development of Clinical Guideline Number 1 and the

updating and revision process for the 2nd and 3rd Editions.
• Description of the development methodology for the 1998, 2003 and
• 2008 documents.
• A description of the changes, additions and revisions to the
Recommendations, Sub-recommendations and Commentary as a result of
the 2008 review.
• If changes to a Recommendation have been made this is listed and
discussed.
• If changes in Commentary following any recommendation have been made
this is listed and discussed.
• If changes to a Conclusion have been made this is listed and discussed.
• If additional literature on the topic was found and reviewed then these
references are listed at the end of the chapter.
• If a Recommendation, Commentary or Conclusion was added that was not
included in the 1998 or 2003 Guidelines, these are noted.

IF A RECOMMENDATION, COMMENTARY OR THE LITERATURE REMAINS AS

IT DID IN THE 1998 OR 2003 GUIDELINES, A SIMPLE STATEMENT THAT THE
RECOMMENDATION, COMMENTARY OR LITERATURE REMAINS UNCHANGED
FOLLOWS THAT SECTION OR TOPIC.

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 CCP Guidelines 3rd Edition 2008

TABLE OF CONTENTS
I. Introduction and Methodology Page

The Council on Chiropractic Practice………………………………………. 8

Inclusion in the National guideline Clearing House………………………. 9
Overview of the development of the 1998 Guidelines……………………. 9
Guidelines Development Process and Methodology……………………... 10
Rationale and Importance of the Guidelines………………………………. 11
Vertebral Subluxation & Evidence-Based Practice……………………….. 15
Participants in the CCP Guideline Development Process……………….. 15
Mechanics of the Review……………………………………………………. 16
Ratings and Categories of Evidence………………………………………. 16
Scope………………………………………………………………………….. 18
Development………………………………………………………………….. 18
Dissemination…………………………………………………………………. 19
Review………………………………………………………………………… 19
Review, Updating and Revision of the 1998 and 2003 guidelines……… 19
Healthcare Costs: A National Dilemma…………………………………… 20
Cost-Effectiveness of Chiropractic Services………………………………. 21
Patient Preferences………………………………………………………….. 28
Referral Issues……………………………………………………………….. 29
Diagnosis……………………………………………………………………… 29
Asymptomatic Care………………………………………………………….. 30
The Role of Value Judgements…………………………………………….. 31
History of Chiropractic………………………………………………………. 31
ACC Position of Chiropractic……………………………………………….. 33
ACC representation of the chiropractic paradigm………………………… 33
ACC Clarification/Definition/Clinical Management of the Subluxation…. 34
2008 Updates and Revisions………………………………………………. 35
References…………………………………………………………………… 36

II. CCP Clinical Guidelines 3rd edition: Update and Revision

Section 1: History and Chiropractic Examination………………………. 55

Section 2: Instrumentation………………………………………………… 76
Section 3: Radiographic and Other Imaging……………………………. 115
Section 4: Clinical Impression and Assessment……………………….. 146
Section 5: Reassessment and Outcomes Assessment……………….. 154
Section 6: Modes of Adjustive Care……………………………………… 161
Section 7: Duration of Care for Correction of Vertebral Subluxation…. 205
Section 8: Chiropractic Care for Children……………………………….. 211
Section 9: Maternal Chiropractic Care…………………………………… 236
Section 10: Subluxation and Well-Being………………………………….. 247
Section 11: Behavioral and Mental Health Issues……………………….. 266
Section 12: Patient Safety, Privacy and Advocacy………………………. 279
Section 13: Professional Development……………………………………. 292

III. Appendix Material

Appendix 1: The CCP Workgroup…………………………………………. 295

Appendix 2: Methodological Standards for Practice Guidelines……….. 317
Appendix 3: Criteria for Choice of Peer-Reviewers……………………… 318

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 CCP Guidelines 3rd Edition 2008

I. INTRODUCTION AND METHODOLOGY

THE COUNCIL ON CHIROPRACTIC PRACTICE

In the summer of 1995, chiropractic history was made in Phoenix, Arizona

with the formation of the Council on Chiropractic Practice (CCP). This initial meeting
was attended by an interdisciplinary assembly of distinguished chiropractors, medical
physicians, basic scientists, attorneys, and consumer representatives. 1-2

The CCP was founded as an apolitical, non-profit organization. It is not

affiliated with any other chiropractic association. The development of the CCP
represents a grass-roots movement to produce practice guidelines which serve the
needs of the consumer, and are consistent with “real world” chiropractic practice.

The mission of the CCP is “To develop evidence-based guidelines, conduct

research and perform other functions that will enhance the practice of chiropractic for
the benefit of the consumer.”

The Council on Chiropractic Practice developed and published its first set of
clinical guidelines in 1998 titled Clinical Guideline Number 1 Vertebral Subluxation in
Chiropractic Practice.3 An abbreviated version of the document was also published in
the Journal of Vertebral Subluxation Research in November 1998.4

The CCP Guides were intended to be used by practicing chiropractors, health

care educators, chiropractic organizations, patients, insurance companies, attorneys,
governmental officials and any other individual or group needing information about
the practice of subluxation-centered chiropractic.

This guideline went on to become widely distributed and accepted within and
outside the chiropractic profession. Following publication the Council on Chiropractic
Practice mailed 50,000 copies of the document to licensed chiropractors in the
United States and a similar effort occurred in Canada with the document being
distributed throughout several provinces.5,6

Some state licensing boards and state associations either adopted the
guidelines as an acceptable standard of care and/or officially endorsed the document
including Washington and Indiana.7-9

On Mar. 17, 1999 Congressman Frank Pallone, Jr., of New Jersey who
serves on the Health and Environment Subcommittee of the House Commerce
Committee, addressed the Speaker of the House of the U.S. House of
Representatives and publicly commended the Council on Chiropractic Practice for
their efforts in developing and distributing the guidelines.10

In May 1999 the CCP Guidelines were ratified by the Manitoba Chiropractors
Association and in 2000 the CCP Guidelines were officially recognized by the
College of Chiropractors of Alberta and the Chiropractic Awareness Council of
Ontario also adopted the Guidelines.6, 11, 12

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 CCP Guidelines 3rd Edition 2008

Other licensing boards and professional associations in other countries have

adopted or endorsed the guidelines including the Israeli Doctors of Chiropractic
(IDOC) and the Chiropractors Association of Ireland.13, 14

In addition to the broad acceptance of the document, the guidelines

themselves were also reviewed and subsequently incorporated into a separate
guidelines document published by the International Chiropractors Association titled:
Recommended Clinical Protocols and Guidelines for the Practice of Chiropractic.15

The Council on Chiropractic Practice has been working with the World Health
Organization as that entity develops international guidelines for the practice of
chiropractic. As part of that effort the CCP worked with the World Chiropractic
Alliance and the World Health Organization to develop a document titled: Guidelines
on Training and Safety in Chiropractic.16

INCLUSION IN THE NATIONAL GUIDELINE CLEARING HOUSE

Following publication of the CCP Guidelines the document was submitted to

the National Guideline Clearinghouse (NGC) for consideration for inclusion. The
NGC is sponsored by the U.S. Agency for Health Care Research & Quality and is in
partnership with the American Medical Association and the American Association of
Health Plans. Their mission is as follows:

The NGC mission is to provide physicians, nurses, and other health professionals,
health care providers, health plans, integrated delivery systems, purchasers and
others an accessible mechanism for obtaining objective, detailed information on
clinical practice guidelines and to further their dissemination, implementation and
use.17

The AHRQ contracts with ECRI, a non-profit health services research

agency, to perform the technical work for the NGC. ECRI is an international non-
profit health services research agency and a Collaborating Center of the World
Health Organization. In November of 1998, following review by ECRI, the CCP
Guidelines were accepted for inclusion within the National Guideline Clearinghouse
and are presently the only chiropractic guidelines listed by the NGC.

OVERVIEW OF THE DEVELOPMENT OF THE 1998 GUIDELINES

In harmony with the general principles of guideline development at the time,

the CCP originally created a multidisciplinary panel, supported by staff, and led by a
project director. The guidelines were produced with input from methodologists
familiar with guidelines development.

The first meeting of the Council on Chiropractic Practice took place on June
8, 1995 in Chandler, Arizona and the Council was subsequently incorporated as a
non-profit organization. The first endeavour of the panel was to analyze available
scientific evidence revolving around a model, which depicts the safest and most
efficacious delivery of chiropractic care to the consumer. A contingent of panellists,
chosen for their respective skills, directed the critical review of numerous studies and
other evidence.

The process began with a detailed literature search which was broad in
nature utilizing both electronic search vehicles including Medline and MANTIS, the

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 CCP Guidelines 3rd Edition 2008

Cumulative Index to Nursing and Allied Health Literature (CINAHL) as well as stack
searches to ensure that all applicable literature relevant to vertebral subluxation in
chiropractic clinical practice was gathered. To further ensure that all relevant
literature and evidence was gathered and reviewed the panel held a second meeting
to interview technique developers to ascertain the degree to which their procedures
can be expressed in an evidence-based format. Individuals representing over thirty-
five named techniques participated. Others made written submissions to the panel.
The technique developers presented the best available evidence they had to
substantiate their protocols and assessment methods.

A primary goal of the panel was to stimulate and encourage field practitioners
to adapt their practices to improve patient outcomes. To achieve this objective, it
was necessary to involve as many practitioners as possible in the development of
workable guidelines. It was also important to the panel to secure input from field
practitioners who would be one class of the end users of any guidelines produced.

Consistent with the recommendations of AHCPR (now AHRQ), an “Open

Forum” was held where any interested individual could participate. Practitioners
offered their opinions and insights in regard to the progress of the panel. Field
practitioners who were unable to attend the Open Forum session were encouraged
to make written submissions. Consumer and attorney participants offered their input.
A meeting was also held with chiropractic consultants and organizational leadership
to secure their participation and gather feedback.

The literature and other information gathered during this process were reviewed
by a panel of experts who submitted critical review using an “Abstraction Form.” The
reviews included questions on:
• Interventions
• Outcomes
• Harms
• Instrumentation & Analysis
• Spinal Analysis
• Study Findings
• Study Design Flaws

After sorting and evaluating the evidence gathered in the literature search,
technique forum, leadership forum, written comments, open forum and the review
process, the panel rated and categorized the evidence. After sorting, evaluating,
rating and categorizing the evidence (rating and categorizing criteria is discussed
later in this document) an initial draft of the guidelines was prepared and distributed
to the panel for review and criticism. A revised draft was prepared based upon this
input.

International input from the field was obtained when the working draft guidelines
document was submitted to 195 peer reviewers in 12 countries. After incorporation of
the suggestions from these reviewers, a final draft was presented to the panel for
approval. This document was then submitted for proofreading and typesetting and
was subsequently published.

GUIDELINES DEVELOPMENT PROCESS AND METHODOLOGY

Since the original 1998 and 2nd 2003 version of the CCP Guidelines much
has been written on the subject of guidelines methodology and more information for

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 CCP Guidelines 3rd Edition 2008

guideline development has been made available. A detailed search of the guideline
development methodology and implementation literature published since 1995 was
undertaken by members of the guidelines committee and pertinent concepts and
procedures incorporated into the process.18-75 particularly, the panel sought to more
explicitly describe its methodology. While the methodology followed for the 1998
process was clearly described in various trade journals as well as amongst the
participants, the CCP Guides were criticized for not describing its methods
of development more clearly. Unfortunately, these criticisms were at times based on
guidelines development literature published only after the CCP guides were created
and distributed. This new literature was reviewed carefully and the recommendations
incorporated into the current process of revision and updating.

In particular the panel found the article by Shaneyfelt et al particularly

helpful.18 Many of the key elements outlined in the article were utilized in the
development of the guidelines and are used as topic headings throughout this
document. Table 1 summarizes these key elements.
Purpose of the CCP Guidelines

The CCP has developed practice guidelines for vertebral subluxation and one
of the purposes of these guidelines is to provide the doctor of chiropractic with a
“user friendly” compendium of recommendations based upon the best available
evidence. The purpose is to facilitate, not replace, clinical judgment and ultimately to
improve the quality of health care.

These guidelines are for informational purposes, utilization of these

guidelines is voluntary and they are not intended to replace the clinical judgment of
the chiropractor. It is acknowledged that alternative practices are possible and may
be preferable under certain clinical conditions. The appropriateness of a given
procedure must be determined by the judgment of the practitioner and the needs and
preferences of the individual patient.

It is not the purpose or intent of these guidelines to provide legal advice, or to

supplant any statutes, rules, and regulations of a government body having
jurisdiction over the practice of chiropractic.

These guidelines address vertebral subluxation in chiropractic practice, and

do not purport to include all procedures which are permitted by law in the practice of
chiropractic. They do not purport to include the management of conditions or clinical
findings other than vertebral subluxation and its components. Lack of inclusion of a
procedure in these guidelines does not necessarily mean that the procedure is
inappropriate for use in the practice of chiropractic. The reader is encouraged to
consult other guidelines that address the application of chiropractic in other clinical
situations.

Participation in the guidelines development process does not necessarily

imply agreement with the final product. This includes persons who participated in the
technique conferences, leadership conference, open forum, and peer review
process. Listing of names acknowledges participation only, not necessarily approval
or endorsement. The guidelines reflect the consensus of the panel, which gave final
approval to the recommendations.

RATIONALE AND IMPORTANCE OF THE GUIDELINES

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 CCP Guidelines 3rd Edition 2008

These guidelines for vertebral subluxation were developed because the

Council and its constituents recognized the need for guidelines that dealt specifically
with the vertebral subluxation and its management. Other guidelines have been
developed that address a myriad of conditions and symptoms reported to be
amenable to chiropractic intervention and/or spinal manipulation.60-62 These other
guidelines blur the boundaries regarding care for the amelioration of various pain
syndromes and at the same time blur the boundaries regarding the interventions
used to affect a response. In addition, none of these guidelines have been updated
since their original dissemination and one of them, the Mercy Guidelines, is
approaching a decade since publication.

One of the rationales for the development of a guideline specifically

addressing the clinical entity of vertebral subluxation is to bring clarity to the issue of
what entities, conditions, disorders, or symptoms chiropractors deal with and the
procedures they use to do it with. Clarity is considered an attribute of good practice
guidelines by the Institute of Medicine.63 An example of the clarity portrayed in the
CCP Guides would be the distinction between the terms adjustment and
manipulation. While a manipulation may be used by a host of health care providers to
affect joint function, only the chiropractor uses the adjustment to reduce or correct
vertebral subluxation. The CCP guides do not address the use of a chiropractic
adjustment for any other clinical situation.

The importance of this distinction cannot be overemphasized since the

profession of chiropractic entails many types of providers and the profession enjoys a
broad scope in most if not all jurisdictions. Because of this latitude in scope of
practice there are differing styles of practice based on the extent of the
implementation of procedures and management by individual chiropractors. Some
practitioners choose to practice at the extreme limits of their practice scope. This
means that chiropractors in Oregon, for example, may choose to diagnose and treat
gynecological problems because their scope allows for it and they desire to do so, or
they may elect to strictly limit their practice to the detection and correction of
vertebral subluxation.

It is the opinion of the Council that it would be prudent for those interested in
the applications of gynecological diagnosis and management for example, to consult
guidelines that address these issues as opposed to expecting that chiropractic
guidelines address all conditions and disorders that a particular scope allows.

There have historically been groups of chiropractors in the profession that

choose to practice in various ill defined categories where scope is the limiting or
expanding factor. These various groups are becoming more clearly defined and as a
result of this, more specific guidelines such as these that seek to address vertebral
subluxation only, are extremely important.76 The importance is manifested when
chiropractors address or get involved with payer groups, the government, legal
issues/groups and especially the consumers of the health care provided by
chiropractors. Recent accreditation and legal issues confronting the chiropractic
profession only serve to heighten the importance of these distinctions and the
importance of guidelines that address them.77, 78

The importance of a guideline that addresses vertebral subluxation is also

illustrated by the widespread adoption of the Association of Chiropractic Colleges
Paradigm Statement.79 This Statement was discussed briefly in the 1998 CCP
Guidelines publication, however since that time this Statement, developed and
signed by the Presidents of all of the North American Chiropractic Colleges, has
enjoyed unprecedented endorsement throughout the chiropractic profession.80 It has

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 CCP Guidelines 3rd Edition 2008

received such widespread support that some have remarked that never in the history
of the profession has there been this extent of agreement on anything. This
statement has been endorsed and/or adopted by every major national and
international chiropractic organization in the profession including:

The World Chiropractic Alliance

The Council on Chiropractic Practice
The Council on Chiropractic Education
The International Chiropractor's Association
The American Chiropractor's Association
The World Federation of Chiropractic
The Congress of Chiropractic State Associations
The Association of Chiropractic Colleges
The Foundation for Chiropractic Education & Research
The Federation of Chiropractic Licensing Boards
National Board of Chiropractic Examiners
The National Association of Chiropractic Attorneys

The Paradigm Statement defines the responsibility of chiropractors to include

the detection and correction of vertebral subluxation and its resultant neurological
interference. The existence of subluxation is in accordance with this paradigm
statement and the ACC defines the purpose, principles and practice of chiropractic
as the finding and reduction of vertebral subluxations, which will prevent and restore
health by removing interference to the body's inherent recuperative powers. This
document, among other things, states that chiropractic as a profession "focuses
particular attention on the subluxation."

Further to this, the majority of state laws and the United States Federal
Government all define the responsibility of chiropractors to include the detection and
correction of vertebral subluxation and its resultant neurological interference.

The assessment and management of vertebral subluxation is either taught as

part of the regular curriculum of all chiropractic colleges in North America or as part
of their post graduate programs. All of these programs, including the general
curriculum of the chiropractic colleges and the post graduate programs are approved
and accredited by the Council on Chiropractic Education which is subject to the rules
and authority of the United States Federal Government's Department of Education.
These schools also hold accreditation through various local and regional accrediting
bodies.

The Council on Chiropractic Education, mentioned above, accredits all of the

chiropractic programs in the United States and has reciprocal arrangements with
accrediting bodies in Europe and other regions. According to the Policies document
of the CCE: 81

The Council on Chiropractic Education (CCE) accepts the physiological

principles of organization in living things and the manifestation of the self-regulatory
mechanisms inherent in the body.

CCE accepts that the nervous system is vulnerable to disturbances resulting

from derangements of the neurobiomechanical system, including the vertebral
column and vertebral subluxations.

The educational process should be a reinforcement of the validity of the basic

principles of chiropractic and an encouragement to the student to apply those

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 CCP Guidelines 3rd Edition 2008

principles in his or her clinical programs, with emphasis given to detection and
correction of derangements of the neurobiomechanical system, including vertebral
subluxation.”

The American Medical Association, in its Guides to the Evaluation of Permanent

Impairment, lists the following as acceptable means to rate impairment: 82

• Impairment due to loss of muscle power and motor function,

• impairment due to abnormal motion of the spine,
• impairment due to loss of motion segment integrity,
• impairment due to disc problems,
• impairment due to pain or sensory deficit, and segmental
instability.

The above are, in fact, components of the Vertebral Subluxation Complex.83, 84

The Guidelines for Evaluation and Management Services published by the Health
Care Financing Administration of the United States Federal Government and the
American Medical Association (May 1997) 85 outline what an objective examination
should consist of and these include commonly used neuromusculoskeletal exam
procedures within chiropractic such as: postural analysis, palpation, assessment for
subluxation, range of motion and assessment of muscle tone. All of these are used to
assess and manage subluxation and are specifically addressed by the CCP
Guidelines.

The Federal Government of the United States specifically defines what

chiropractors do as the detection and correction of subluxation under Medicare and
Federal worker's compensation laws. Common to all state statutes is the adjustive
process being utilized to reduce subluxations and the resultant interference to nerve
transmission. A majority of states employ the term adjustment in licensing laws in
reference to the procedures applied by chiropractors and others additionally include
the concept of manipulation. A majority of states contain specific references to
responsibility for neurological complications of biomechanical origin (subluxation) and
over half the chiropractic profession practice in these states. In addition, many states
specifically discuss the concept of subluxation in their statutes by using the term and
for those that do not specifically use the term there is an implied understanding of the
concept in their statutes.

The existence of subluxation and its acceptance is spelled out in explicit detail by
published policy statements of chiropractic organizations86, 87 as well as federal and
state laws regulating the practice of chiropractic. The epidemiology of subluxation
has been researched since the inception of chiropractic over 100 years ago with
basic science and clinical research to further elucidate the nature of it continuing to
this day.

Considering the centrality of vertebral subluxation to the practice of chiropractic

and the profession, the importance of guidelines that specifically address it are
clearly needed. This is especially true considering that other guidelines addressing
chiropractic practice and procedures either do not address it at all or give only a
cursory consideration.88-90

A few individuals within the profession contend that the existence of subluxation
is questionable and have chided the CCP Panel for not addressing their contention in
its earlier publication.91-93 While the CCP Panel acknowledges that certain individuals

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and groups within the profession do make such an assertion, the Council does not
take such contentions seriously. The above review of the subluxation within the
chiropractic profession, government, state law, chiropractic educational bodies and
scientific literature serves as evidence of its entrenched status. Further, according to
Rome there are 296 variations and synonyms of subluxation used by medical,
chiropractic and other professions leading him to remark "It is suggested that with so
many attempts to establish a term for such a clinical and biological finding, an entity
of some significance must exist." 94 Additional discussions to shed light on the
concept of subluxation continue below.

VERTEBRAL SUBLUXATION & EVIDENCE-BASED PRACTICE

Evidence-based clinical practice is defined as “The conscientious, explicit,

and judicious use of the current best evidence in making decisions about the care of
individual patients... (it) is not restricted to randomized trials and meta-analyses. It
involves tracking down the best external evidence with which to answer our clinical
questions.” 95

This concept was embraced by the Association of Chiropractic Colleges in its

first position paper. This paper stated:

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 structural and/or

pathological articular changes that compromise neural integrity and
may influence organ system function and general health.

A subluxation is evaluated, diagnosed, and managed through the use

of chiropractic procedures based on the best available rational and
empirical evidence.96

PARTICIPANTS IN THE CCP GUIDELINE DEVELOPMENT PROCESS

The CCP has developed practice guidelines for vertebral subluxation with the
active participation of field doctors, consultants, seminar leaders, and technique
experts. In addition, the Council has utilized the services of interdisciplinary experts
in the Agency for Health Care Policy and Research (AHCPR), guidelines
development, research design, literature review, law, clinical assessment,
chiropractic education, and clinical chiropractic.

The Council additionally included consumer representatives at every stage of

the process and had individuals participating from several major chiropractic political
and research organizations, chiropractic colleges and several other major peer
groups. The participants in the guidelines development process undertaken by the
CCP are listed in Appendix 1.

Following the development of the guidelines and the construction of a draft of

the final recommendations the guidelines were reviewed by over 100 peer reviewers.
These reviewers were chosen based on several characteristics. See Table 3

The Guideline Panel, as well as the various reviewers, was solicited via
several announcements for participants in trade journals and/or individuals were

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 CCP Guidelines 3rd Edition 2008

directly approached by representatives of the panel and asked to participate. Those

who participated in the development and review of the 1998 process were
encouraged to participate once again.

MECHANICS OF THE REVIEW

The significant difference for the 2003 update and revision was the use of an
on line review process. Considering the sheer number of reviewers, the cost and
time involved in copying, mailing and waiting for feedback from this number of
reviewers would have prohibitive. This model of on line review worked well and it is
hoped that it will serve to assist other guidelines developers who face similar hurdles.

Essentially, the final draft of the guidelines revision was placed in a secure on
line Forum where reviewers were required to provide a LOGON and PASSWORD to
enter and access the draft. Once the individual reviewed the draft they then filled out
an on line form with any recommendations or changes. Their response was
immediately routed to the Project Manager for review and any needed action.
Recommendations for additions or changes to the draft based on this review were
then circulated electronically to the Panel for feedback. Other than an Assistant to
the Project Manager no individual received remuneration for work performed on
behalf of the Council to develop these guidelines.

RATINGS AND CATEGORIES OF EVIDENCE

During the process of updating and revising the CCP Guidelines the issue of
how to rate and categorize the evidence and scientific literature used resurfaced.

The original panel that developed the guidelines created a Ratings and
Categories of Evidence system that they felt would best allow for a clear and easily
understandable method of evaluating the evidence. This clarity served the panel well
and it was felt this would also best serve the end user as well as any future evaluator
of the guideline’s quality since, as discussed previously, one of the attributes of a
good clinical guideline has been defined as Clarity.

Other guidelines developers within the chiropractic profession have similarly

developed their own ratings and category of evidence schemes.15,60,61 The CCP
reviewed these schemes and felt that while they might have served those other
guidelines panels, they were too unwieldy and unnecessary in light of the fact CCP
was limiting its guideline recommendations to a single clinical entity – vertebral
subluxation. A review of the guideline development literature found no directive that
one or another rating or category of evidence scheme held more promise than
another or that there was a method that was more valid or reliable. The consensus of
the literature was that some method should be used and that method should be
explicitly stated.63

The following ratings and categories were utilized in the original 1998 version
of the CCP Guidelines and were also utilized in the updating and revision of the 2003
and 2008 CCP Guidelines:

RATINGS

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Established. Accepted as appropriate for use in chiropractic practice for the

indications and applications stated.

Investigational. Further study is warranted. Evidence is equivocal, or

insufficient to justify a rating of “established.”
Inappropriate. Insufficient favourable evidence exists to support the use of
this procedure in chiropractic practice.

CATEGORIES OF EVIDENCE

E: Expert opinion based on clinical experience, basic science rationale, and/or

individual case studies. Where appropriate, this category includes legal opinions.

L: Literature support in the form of reliability and validity studies, observational

studies, “pre-post” studies, and/or multiple case studies. Where appropriate, this
category includes case law.

C: Controlled studies, including randomized and non-randomized clinical trials of

acceptable quality.

LEVELS OF SCIENTIFIC PROOF

RCT
C
(Controlled
Clinical Trials Studies)
(non-randomized)

• Observational studies L
• Pre/Post studies
(Literature support)
• Multiple case reports
• Case Law (as appropriate)

• Clinical Experience,
• Basic Science rationale
• Individual case studies, E
• Legal Opinions (as appropriate) Expert Opinion
based on scientific
rationale, individual
case study or
legal opinion

Figure 1: Levels of Scientific Proof

These categories of evidence can best be thought of in a hierarchical fashion

as depicted in Figure 1. Note that the base of any culture of evidence, designated
as E on the rating scale, is expert opinion, basic science rationale, and/or individual
case studies; this base is also rich in legal opinions. Building upon this base of
evidence are the scientific literature supported studies (designated as L) composed

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of a variety of experimental designs (e.g., reliability/validity studies, observational and

pre/post studies, multiple case series, and where appropriate case law. Finally, at
the pinnacle, and building upon the weight of previous literature, are the controlled
studies (designated as C) using randomized or non-randomized design known as
clinical trials. These must be of appropriate design and acceptable quality to
advance the knowledge in this area.

SCOPE

Chiropractic is a dynamic profession. During a large part of the past century

educators and leaders in the field have engaged in an ideological debate over
professional identity on 1) scope of practice, 2) adjusting techniques, and 3)
philosophy. 97-114 Unfortunately, this debate has been fractious and divided the
profession into seemingly rival camps now best termed Broad Scope and Focused
Scope, groups previously termed “mixers” and “straights”, respectively. 115 In a
large, representative survey of chiropractors, the Broad scope group represented
34.3% of the profession and the focused scope 19.3%. However, they also found
that the plurality (46.4%) of chiropractors representing a “Middle Scope” group; this
group embraces both ends of the ideological spectrum.

However, a representative survey conducted with 687 randomly selected

chiropractors in the United States, Canada and Mexico reveals that when it comes to
the broad scope vs. focused scope label, the old stereotypes are misleading (see
below) and it was concluded that on most issues, broad scope and focused scope
chiropractors differ more in degree than in kind. 116

The report revealed that in spite of differences in scope of practice (broad

scope, middle scope and focused scope), adjusting technique and philosophy,
chiropractors as a group are surprisingly homogeneous. In particular, 88.1% agree
to term Vertebral Subluxation Complex (VSC) should be retained, 89.8% state that
adjustments should not be limited to musculoskeletal conditions and rate the
subluxation as a significant contributing factor in 62.1% of visceral ailments.
Similarly, the typical North American chiropractor performs a broad spectrum of
clinical services and practices aimed toward improving patient health lifestyle. Of
interest, 97.8% recommend exercise and 51% recommend weight loss counselling;
the other parameters of health lifestyle listed above were recommended by 86-94%.

These guidelines are written for the profession, but largely those
chiropractors who self-identify as focused- and middle-scope practitioners. In fact,
these individuals represent the majority (65.7%) of the profession who identify
themselves as subluxation-centered.

DEVELOPMENT

This 3rd Edition of Clinical Practice Guidelines “Vertebral Subluxation in

Chiropractic Practice” Guidelines were developed by the CCP Workgroup between
January 2007 and June 2008 (see appendix I for full membership of the group).

Literature searches were carried out in 2007-08 by searching Mantis, Medline

and the Cochrane Library. These were supplemented by hand searching the current
chiropractic journals, the references listed in key articles and personal collections.
The literature was updated until Spring 2008.

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The evidence was reviewed by members of the working panels and classified
according to the criteria of the US Agency for Health Care Policy and Research. 117

Each individual was sent a structured appraisal form, requesting evidence-

based comments. Replies were sent to the respondents, and, where appropriate,
changes made. Minor changes were also made in the light of new literature received
during the final review process up to the cut-off date of September 1, 2008.

During 2007-08, members of the CCP working group took responsibility for
drafting the first version of guidance on specific topics. This synthesis addressed the
content and precise wording of the text and recommendations and accuracy of the
grading of the evidence. Drafts were circulated within the Group for comment and
amendment and editing.

DISSEMINATION

This document will be disseminated to all stakeholders. It will also be

available on CD ROM and hosted on the Website of the Council on Chiropractic
Practice (www.ccp-guidelines.org) for downloading.

The draft document was placed on line and representative stakeholders were
invited to provide comments/suggestions for revision. These comments were
incorporated into the final document.

REVIEW

This document will be reviewed in May 2013 with the plan of submitting the
final version to the National Clearing House by September, 2013.

REVIEW, UPDATING AND REVISION OF THE 1998 & 2003 GUIDELINES

Since the guidelines process is one of continuing evolution, the Council on

Chiropractic Practice did not endeavour to develop a set of guidelines and then
cease to function. It was decided early in the process that the Council would continue
to exist and that new evidence would be considered at periodic intervals to update
the model of care defined by the guidelines. It was the decision of the Council on
Chiropractic Practice to keep to the five-year recommendation of the National
Guideline Clearinghouse for updating and revision.

In the spring of 2001 during the Council on Chiropractic Practice’s annual

meeting, the Council began the process of updating the 1998 guidelines. One of the
first steps was a meeting of technique developers and experts that occurred as part
of the same CCP meeting. Additional technique systems that were not involved in the
development of the original document participated and those previously involved
were invited to submit additional and/or supplemental material. Over 40 named
technique systems were represented at this meeting.

In the spring of 2002 during the annual meeting of the Council, the Guidelines
Committee was reconstituted, a Project Manager was appointed and the further
structure of the review, updating and revision was discussed and planned. A nearly
identical process was used for the updating and revision. The Project Manager, who
serves as Chair of the Guidelines Committee, assembled a panel of area experts

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who assisted in the search for literature, the subsequent gathering of that literature
and its critical assessment.

As in the original process an “Abstraction Form” was utilized and suggestions

for changes in the Ratings, Recommendations and Commentary were sought from
this panel and the Guidelines Committee as a whole. The literature and other
evidence utilized in the update spanned the time period1996-2003. The literature
search was evidenced based and broad in nature adhering to Sackett’s admonition
to track down “…the best external evidence with which to answer our clinical
questions.” The panel relied heavily on the peer reviewed chiropractic literature as
well as the general biomedical literature where applicable.

A detailed search of the guideline development methodology literature

published since 1995 was undertaken by members of the guidelines committee and
pertinent concepts and procedures incorporated into the process. Particularly, the
panel sought to more explicitly describe its methodology. While the methodology
followed for the 1998 process was clearly described in various trade journals as well
as amongst the participants, the CCP Guides were criticized for not describing more
clearly its methods of development.91-93 Unfortunately, these criticisms were at times
based on guidelines development literature published only after the CCP guides
were created and distributed. This literature was reviewed carefully and the
recommendations incorporated into this revision and updating.
A significant difference in the process for the updating and revision consisted
of easier access to literature due to improvements in electronic searching and the
developments of additional electronic databases that index chiropractic peer
reviewed literature. The literature was searched utilizing MANTIS, CINAHL, The
Index to Chiropractic Literature, Medline, individual electronic journal searches such
as the Journal of Manipulative and Physiological Therapeutics and the Journal of
Vertebral Subluxation Research. Hand and stack searches were also employed to
assure the most extensive gathering of relevant literature.
HEALTHCARE COSTS: A NATIONAL DILEMMA

Health care spending in the United States first exceeded $2 trillion in 2006,
and is projected to exceed $4.2 trillion by 2017.118 Federal forecasters have
projected that within a decade, health care expenditures will represent 20% of the
USA’s gross domestic product (GDP).119 According to a 2005 report by the California
Health Care Foundation, health care spending in 2003 was about 4.3 times the
amount spent on national defense.120 Medicare hospital insurance is projected to
become insolvent by 2019, the date of the predicted exhaustion of the Trust Fund.121

Where is the money going? It is clear that the overwhelming majority (ca. 70%)
is spent on chronic illnesses, 122 such as:

„ Cardiovascular disease and Stroke--$210 billion/yr

„ Diabetes--$92 billion/yr
„ Obesity-Related--$75 billion/yr
„ Arthritis--$22 billion/yr

What are we getting for it? Not as much as one would like. Despite the
tremendous cost of health care, both economic and human, the United States ranks
37th in overall health system performance of 191 countries evaluated by the World
Health Organization. 123 In 1994, an article in Journal of the American Medical
Association (JAMA) 124 noted that “180,000 die each year partly as a result of
iatrogenic injury, the equivalent of three jumbo-jet crashes every 2 days.” The

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situation remains grim. Medical errors and iatrogenic episodes are still a leading
cause of death in the United States.125

What happened to plans to implement preventative (i.e., wellness)

strategies? Relatively little of the current health care dollar goes to “health care.” It
supports “sick care”. Consider Medicare. The Medicare Act requires that covered
services be “reasonable and necessary for the diagnosis or treatment of an illness or
injury, or to improve the functioning of a malformed body member.” Specifically
excluded as “not medically necessary” is any form of preventative strategies, i.e.,
“maintenance care”, defined as follows: “A treatment plan that seeks to prevent
disease, promote health and prolong and enhance the quality of life, or maintain or
prevent deterioration of a chronic condition.” 126 This strategy and the philosophy
behind it are responsible for the current health care crisis in the USA.

According to Julie Louise Gerberding MD, MPH, Director for the United States
Center for Disease Control (CDC), the problems with health care goes well beyond
the direct costs of medical services. Gerberding states “…..only a nickel out of every
medical-care dollar spent in the USA goes toward keeping Americans healthy, many
countries have put more emphasis on health promotion than the United States." 127

Accordingly, the CDC has launched the “Healthiest Nation Campaign” to keep
Americans healthy by promoting prevention and integrating health into social policies
across all sectors of the economy (e.g., consider the broad-reaching implications of
promoting health by providing better public transportation to assistance with health-
related transportation, healthier environmental strategies, more bike and hiking trails,
and facilities for child-care enabling parents to attend regular health visits, etc.).

Economist Paul Zane Pilzer summarized the situation well: "The sickness
business is reactive. Despite its enormous size, people become customers only
when they are stricken by and react to a specific condition or complaint...the wellness
business is proactive. People voluntarily become customers -- to feel healthier, to
reduce the effects of aging, and to avoid becoming customers of the sickness
business. Everyone wants to be a customer of this earlier-stage approach to health."
128

COST-EFFECTIVENESS OF CHIROPRACTIC SERVICES:

Studies suggest that chiropractic, when implemented broadly, would result in

significant savings of health care dollars. 129-140 Substantial health benefits and cost
savings to the employer are documented when chiropractic benefits are added to the
employee benefits package. 141

One of the earliest and best estimates of the potential savings with chiropractic
comes from a 1996 study by Stano and Smith.133 Their study compares health
insurance payments and patient utilization patterns for episodes of care for common
lumbar and low back conditions treated by chiropractic vs. medical providers. Using
2 years of insurance claims data, this study examines 6,183 patients who had
episodes with medical or chiropractic first-contact providers. Multiple regression
analysis, to control for differences in patient, clinical, and insurance characteristics,
indicates that total insurance payments were substantially greater for episodes with a
medical first-contact provider. The mean total payment when DCs were the first
providers was $518, whereas the mean payment for cases in which an MD was the
first provider was $1,020,133 i.e., almost a 50% cost savings when chiropractors are
part of the health team.

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Several years later, a ground breaking randomized clinical trial (RCT) evaluated
the financial impact of provider assignment in the management of neck pain.142
Patients who saw general practitioners for neck pain were randomly allocated to
manual therapy (spinal mobilization), physiotherapy (mainly exercise) or general
practitioner care (counselling, education and drugs). Throughout this 52-week study,
patients rated their perceived recovery, intensity of pain and functional disability.
Manual therapy proved to be the most effective treatment for neck pain. The clinical
outcome measures showed that manual therapy resulted in faster recovery than
physiotherapy and general practitioner care. While achieving this superior outcome,
the total costs of the manual therapy-treated patients were about one-third the cost of
physiotherapy or general practitioner (MD) care.

The remaining parts of this section review the growing literature supporting
the cost-effectiveness of chiropractic across the various third-party payers in the
United States (Medicare, State Workman’s Compensation, Private insurance) and
Internationally.

MEDICARE:

Analyses in this age demographic have been conducted with insurance

databases comparing persons receiving chiropractic care with non-chiropractic
patients. One study consisted of senior citizens over 75 years of age. It was
reported that the persons receiving chiropractic care reported better overall health,
spent fewer days in hospitals and nursing homes, used fewer prescription drugs, and
were more active than the non-chiropractic patients. The chiropractic patients
reported 21% less time in hospitals over the previous 3 years.143

Another study surveyed 311 chiropractic patients, aged 65 years and older,
who had received chiropractic care for 5 years or longer. Chiropractic patients, when
compared with US citizens of the same age, spent only 31% of the national average
for health care services. There was a 50% reduction in medical provider visits. The
health habits of patients receiving maintenance care were better overall than the
general population, including decreased use of cigarettes and decreased use of non-
prescription drugs.144

A 2001 study, commissioned by the American Chiropractic Association,

examined cost, utilization and effects of chiropractic services on Medicare costs.145
The study compared program payments and service utilization for Medicare
beneficiaries who visited DCs and those who visited other types of physicians. The
results indicated that chiropractic care could reduce Medicare costs. Medicare
beneficiaries who had chiropractic care had an average Medicare payment of $4,426
for all Medicare services. Those who had other types of primary care had an
average of $8,103 Medicare payment for all Medicare services. The average per
claim average payment was also lower with chiropractic patients, being $133 per
claim compared to $210 per claim for individuals who did not have chiropractic care.

STATE WORKMAN’S COMPENSATION PROGRAMS:

Large retrospective studies have been conducted with data from workers’
compensation claims evaluating those receiving care from chiropractors vs.
physician providers for low back injuries. One study in Texas, analyzed claims from
1996-2001, and found that chiropractor costs were lowest of all providers. Their data

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clearly demonstrated that increased utilization of chiropractic care would lead to

declining costs relative to lower back injuries.146

An earlier analysis of worker's compensation claims was conducted in Florida

on claims from June through December of 1987.147 All of the claims analyzed were
related to back injuries. The main purpose of this study was to compare the cost of
osteopathic, medical and chiropractic doctors. The cost of drugs was not included in
the analysis. They conclude that individuals treated by chiropractors had significantly
fewer hospitalizations and lower claims than physicians. The study also concludes
that chiropractic care is a "relatively cost-effective approach to the management of
work-related injuries."

Another retrospective study of Florida workers’ compensation claims over a

five-year period from 1994-1999. In this study the average total cost for low-back
cases treated medically was $16,998 while chiropractic care was less than half
($7,309). Patients managed by chiropractors were found to reach maximum medical
improvement almost 28 days earlier than those treated exclusively by physicians.
These authors conclude that considerable cost savings and more efficient claims
resolution may be possible with greater involvement of chiropractic treatment in
specific low back cases and other specific musculoskeletal cases.148

An analysis of 5000 claims from 1986 and 5000 from 1989 were examined for
injured individuals in the Utah Worker Compensation Fund. The study compared
cost for those who received chiropractic care and those who received medical care
exclusively. From 1986 to 1989 the cost of care for chiropractic increased 12% while
medical care increased 71%. The replacement of wages increased 21% for those
receiving chiropractic care and 114% for those receiving medical care.149

Another study of workman’s compensation claims in Utah indicated that

health care costs for conditions with identical diagnostic codes were significantly
higher for medical claims than for chiropractic claims.150 The sample consisted of
3062 claims or 40.6% of the 7551 estimated back injury claims from the 1986
Workers' Compensation Fund of Utah. Findings indicate that cost for care was
significantly greater for medical vs. chiropractic claims.

An analysis has also been conducted of the Iowa State Workman’s’

compensation records. Investigators evaluated the claims from individuals in with
back or neck injuries in 1984.151 Of those who missed work and received
compensation, there was a substantial benefit. Those receiving chiropractic missed
on average 2.3 days from work than individuals where care was managed by MDs,
3.8 days less than individuals who saw DOs. Smaller disability claims were
associated with patients receiving chiropractic care for their injuries. On average, the
disability compensation paid to workers whose care was managed by chiropractors
was $263.66; it was $617.85 for care managed by MDs, and $1565.05 for those
managed by DOs.

The Workman’s’ Compensation program in Oregon has been evaluated in

several major studies. Nyiendo and colleagues examined 201 randomly selected
workers' compensation cases that involved low back injuries that were disabling.
The study found individuals who utilized DCs less frequently had a higher incidence
of injury-related hospital visits than those under care of physicians.152 A follow-up
study focused on time lost at work.153 For similar severities of injury, the median
missed work days was 9.0 days for those under care of DCs and 11.5 days for
exclusively under care of physicians. Individuals managed by chiropractors returned

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to work, on average, within one week or less. An important finding was that there
were no differences in lost work time for individuals managed by DCs and MDs as
long as there was no previous history of back injury. However, for claimants with a
history of low back problems, the median loss of work was almost four-times higher
when higher when managed by MDs (34.5 days) compared to management by
chiropractors (9 days). It was concluded that chiropractors are better able to manage
injured workers with a history of chronic low back problems and to return them more
quickly to productive employment.

PRIVATE (MANAGED-CARE) INSURERS:

Significant decreases in the utilization of medical services, and their attendant

costs, were noted when doctors of chiropractic or other “CAM oriented” practitioners
were used as primary care providers. In an Independent Care Association (IPA)
which permitted patients to select a doctor of chiropractic as their primary care
physician, an initial report concluded that when DCs served as the primary care
providers, there was a: 1) 43% decreases in hospital admissions, 2) 52% reduction
in pharmaceutical costs, and 3) 43% fewer outpatient surgeries and procedures.154
A follow-up study at the same facility, based on 70,274 member-months over a
seven-year period, demonstrated that when managed by chiropractors there is a
reduction of: 1) 60.2% in hospital admissions, 2) 59.0% in total hospital days, 3)
62.0% in outpatient surgeries and procedures, and 4) 85% pharmaceutical costs
when compared with medical doctors.155

In other studies, chiropractic care in general, and chiropractic care directed at

reduction of vertebral subluxation, in particular, have demonstrated positive effects
on physiological outcome measures. In a review of literature related to objective
physiological changes following chiropractic care, Hannon discusses more than
twenty studies documenting objective health benefits in subjects who were
specifically described as “asymptomatic,” “healthy,” “normal,” or “free from physical
injury.” Nearly an equal number of studies were found documenting objectively
measured health benefits in subjects in which no symptomatic presentation was
described.156

Two major studies evaluated a private health plan database to determine

whether chiropractic was being utilized as “substitution” care (for medical visits) or
whether it was an “add-on” to the corporate medical plan when they were offered a
chiropractic benefit. The study was conducted over a 4-year period, and involved
claims from 8 million members. The important finding was that patients use
chiropractic as a direct substitution for medical care, choosing chiropractic 34% of
the time. Of considerable importance to the employer and insurance company, the
chiropractic benefit rider did not increase the number of patients seeking care for
neuromusculoskeletal complaints.157
A parallel analysis was conducted in a subset of 1.7 million of these health
plan members. At issue were the employer costs of having a chiropractic benefit in
their HMO insurance plan.158 The data revealed that members with the chiropractic
benefit had lower overall total annual health care costs. Back pain patients with
chiropractic coverage also realized lower utilization of plain radiographs, low back
surgery, hospitalizations and MRI’s. Back pain episode-related costs were also 25%
lower for those with chiropractic vs. MD coverage ($289 vs. $399).
Another paper from this cohort concluded, on a per-episode basis, that the
use of advanced imaging, surgery, impatient care and plain-film radiographs was
reduced by the following amounts in the chiropractic benefit group: surgery, 32%;
advanced imaging, 37%; inpatient visits, 40%; and plain-film radiographs, 23%. This

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study supports the likelihood that substitution of chiropractic care for medical care for
the treatment of back and neck pain leads to less use of these other costly
procedures.159
In a final article from this cohort, the analysis of data from 1.7 million
subscribers over four years indicated that the employer groups with chiropractic
coverage had a younger population and significantly lower rates of common chronic
diseases than subscribers who had access only to medical care for neuro-
musculoskeletal complaints. The employers who chose the chiropractic rider had a
patient population with a more favourable risk profile, thereby decreasing the health
care costs of the health plan.160

COST- EFFECTIVENESS STUDIES CONDUCTED INTERNATIONALLY (Canada,

UK, and Australia):

Chiropractic is International. Thus, it is important to evaluate the cost-

effectiveness of the profession in other countries with different models of health-care
reimbursement. The studies reviewed below demonstrate the cost effectiveness of
chiropractic in Canada and UK where there is largely a single-party payer model, vs.
Australia where there is a hybrid (public-private) model comparable to the USA.

Canada: Several major feasibility studies were conducted by one of

Canada’s foremost health economist Pran Manga PhD, a professor at the University
of Ottawa and one of the architects of the Canada Health Act.161-163 At the time,
chiropractic was not covered by the Ontario Health Insurance Plan (OHIP). Their
first report in 1993, funded by the Ministry of Health of Ontario, concluded that
chiropractic coverage would result in greater utilization, but ultimately produce a net
savings in both direct and indirect costs of managing neuromusculoskeletal
disorders.

A revision of the study in 1998 further concluded that the potential savings to
the Ontario's healthcare system of as much as $380-$770 million by implementing
chiropractic.162 This extrapolated to a potential savings of two billion dollars if
implemented across all of Canada.

In making their recommendations, the Manga reports, as they have come to

be known, concluded that spinal manipulation is not only more cost effective than MD
care for musculoskeletal disorders, it is also safer and more effective than the
regiment of drugs, bed rest, and analgesics that standard of care being offered by
general practice medical doctors for low back pain patients.161

Again in year 2000, Ontario Health Economist Pran Manga PhD makes the
case that if chiropractic is further integrated into the health care system; he predicts
reduced costs and improved outcomes. He pointed to the extensive body of
literature which demonstrates that chiropractic is effective for neuromusculoskeletal
disorders and the repeated evidence that patients often prefer chiropractic care over
a medical approach. Evidence of effectiveness for medical care is not nearly as
convincing for management of neuromusculoskeletal conditions.163

However, In spite of the favourable recommendations, the Ontario

government in an attempt to reduce costs in the OHIP premiums, elected a complete
cancellation of patients’ chiropractic coverage in 2004. The Ontario Government
reported that eliminating chiropractic would save $47 million during the remainder of
that fiscal year and almost $100 million annually thereafter. By delisting chiropractic,

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there was some savings, but the substitute expenses incurred by the system when
patients turned to other providers far exceeded the amount saved as predicted by the
earlier Manga reports. Since this time, there have been multiple and often
contentious attempts to revise the OHIP system, stressing greater accountability and
evidence-based decision-making, but the costs continue to escalate and chiropractic
remains delisted.164

In Canada, there was one unusual example where cost savings with open
access to chiropractic could be evaluated. Until 1992, the residents of
Saskatchewan had full access to chiropractic under Medicare. Their use of
chiropractic services was comparable (av. 8 visits/yr) to the national average, 6-9
visits/yr, for access to all other providers.

Then, access to chiropractic was restricted in Saskatchewan. These

restrictions did not stop the long-term growth of the profession in that province.
Moreover, as a result of restriction of chiropractic services, the utilization of medical
doctors increased, as did overall health costs in Saskatchwan.

Private insurance and Medicare records in other provinces demonstrate that

patient access to chiropractors tends to be on an as-need basis, rather than a
provider generated demand that concerns health economists about the cost of care
provided by medical doctors.165

United Kingdom (UK): One recent study has evaluated the cost-effectiveness
of chiropractic in the UK.166 It compared the benefits of spinal manipulation and
exercise to “best care” in general practice for patients consulting for back pain. A
total of 1,287 patients were recruited, divided into treatment groups and followed for
more than one year. Patients receiving manipulation and exercise had lower relative
treatment costs and received more treatment benefits than those treated with general
medical care. The authors believe that their study was able to show convincingly
that manipulation alone and manipulation followed by exercise provided cost-
effective additions to general practice.

Australia: The utilization of chiropractic for workman’s’ compensation injuries

in Australia has been documented. Tuchin and Bonello167 reported preliminary
findings in an analysis of Work Cover Authority data from New South Wales. Of
1289 cases reviewed, 30% had back problems and 12% employed chiropractic care
for treatment of spinal injury and workers’ compensation claims. The total payments
for all cases using chiropractic and physiotherapy care were $25.2 million, which was
2.4% of the total payments. When 20 claims were chosen at random the average
chiropractic cost of care was $299.65, while the average medical cost was $647.20.
A trend in data collected indicated that when greater than 60% of total cost of
treatment came from chiropractors, the average missed work was 9.5 days. When
less than 60% of total cost of treatment came from chiropractic care the number of
days missed from work, on average, was five-times greater (i.e., 50.3 days).
An almost identical cost/benefit ratio was obtained in an Australian study by
Ebrall.131 His study reviewed claims to the Victorian Workcare Scheme over in a
twelve-month period involving work-related mechanical low-back pain. Management
by chiropractors vs. MDs was compared. Only 39% of claims reviewed and
managed by chiropractors required compensation, whereas 78% of those managed
by MDs required compensation. The average number of compensation days needed
for those managed by chiropractors was only 6.26 days, compared to 25.56 days for
those managed by medical practitioners.

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SUMMARY:

Representative surveys reveal that the number of individuals in North

America who utilize chiropractic is low (ca. 5-10%),168 and this low number has
remained unchanged for over 20 years. On the other hand, an analysis of all
available health databases in Canada, indicate that about 30-40% of total health care
costs are related directly or indirectly to issues involving the spine.169 The 4-8 fold
disparity between chiropractic utilization and health needs is disturbing from a
financial perspective, but it is also a concern for the safety and well-being of the
public.

Chiropractors are specifically trained in spinal care and have general training
in primary care mandated during their four-year chiropractic education.

In particular, the basic science and clinical training of chiropractors compares

favourably to that of four-year medical education programs. The public is often
unaware that education of Doctors of Chiropractic is at the same level as Medical
doctors (see Table 1 below). In fact, a recent comparison was conducted by
Sandefur and colleagues,170 to evaluate the primary care knowledge of a group of
final-term chiropractic students versus a sample of medical students just entering
their residency program. A team composed of MDs and DCs created a 100-item
exam to test the students’ training in 52 primary care tasks. The chiropractic
students performed almost as well as the medical students, except in the
musculoskeletal portion of the examination, in which the chiropractic students scored
higher.

Given these favourable comparisons with regards to training and clinical

skills, it is important to review the literature on cost-effectiveness that strongly favors
chiropractors serving as primary health providers. The literature reviewed above is
based upon an analysis of claims data from public (Medicare, Workman’s
Compensation) and private sources (HMO). It will be shown that there are major
cost savings among patients utilizing chiropractic care in addition to their regular
medical visits. This brief summary draws attention to the fact that Chiropractic is
grossly underutilized, and should be considered to ease the run-away costs of health
care in the United States and Worldwide.

Finally, a serious and meaningful restructuring of health care systems, as

proposed by the CDC with their new “Healthiest Nation Campaign” and the
restructuring proposed by the Manga Report in Canada, but not implemented, should
apply the lessons learned from the past. Dr. Don Nixdorf is one of Canada’s most
prominent chiropractors. For more than a decade, he has served as a member on
national and provincial agencies, Executive-Director of the British Columbia
Chiropractic Association since 1985, and a veteran of countless encounters with the
stakeholders of health care reform in Canada- the health ministers, other
professionals, media, insurance companies and community organizations. In his
recent book for the popular media, “Squandering Billions: Health Care in Canada”,
Nixdorf draws attention to the details the “Manga Report” and health reform concepts
of other prominent health economist.171 Accordingly, the 10 most common obstacles
to overcome in implementing successful health care reform include:

1. Patient awareness and accountability, to maintain a healthy lifestyle and

balance their personal interests with those of society.

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 CCP Guidelines 3rd Edition 2008

2. Reassessment of the basic reimbursement requirement only for “medically

necessary services”. Health is not the sole domain of the medical
establishment, and health claims and access need to be integrated across all
sectors of the economy.

3. When different services are being considered, governments need to

understand the difference between “substitution” (shifting care from one
sector of the economy, e.g., from primary care MDs to chiropractors or nurse
practitioners) vs. the typical bureaucratic interpretation of adding “additional”
costs (i.e., services not now covered, that would be covered over and above
current costs). Significant health care reform will require a “substation” of
providers and services, and not the “addition” of new services.

4. The bureaucracy and non-service delivery-related infrastructure must be

scrutinized and reduced at all levels.

5. Improve the non-competitive environment. There is insufficient competition

because of medical, dental and pharmaceutical monopolies.

6. The modes of primary care delivery, needs to be vastly improved from the
physician gate-keeper model to direct access to a variety of well-trained
providers (e.g., chiropractors, nurse practitioners).

7. Home care, convalescent hospitals and small surgi-centers should be

dramatically expanded, each with the aim of providing adequate “substitution”
139
for more expensive acute care hospitals and trauma centers.

8. Pharmaceutical utilization and costs are out of control and need to be

examined.

9. Manga states that “good policies work if the leaders are prepared to be
tough”. Frequently this is not the case, and will be an absolute requirement at
all levels for health care reform to be successful.

10. “Progress gets lost in minutiae” says Manga. Unanimous and even perfect
solutions prevent any improvements from taking place. Get started now with
a good (albeit not perfect) plan.

Potential benefits of increased chiropractic utilization may include reduced

medical costs, improved productivity, and effective techniques for coping with stress.
The benefits to society are potentially enormous and include economic and health-
related issues. We encourage the further exploration of conservative, subluxation-
centered chiropractic care on health outcomes and health care expenditures and
urge health policy officials to carefully consider ten-obstacles above in implementing
health policy reform.

PATIENT PREFERENCES

While the CCP Guidelines were developed for a wide variety of interested
parties the major group impacted by these guidelines is the consumers of health care

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services. An overriding theme as regards the establishment of health promotion

activities is the concept of patient empowerment.172, 173 Patients must have the right
to choose the type of health care they desire and not be restricted or forced to
acquire their care from practitioners they do not wish to see, to have procedures they
do not wish to have nor engage with systems of healing with which they disagree.

Every consumer of health care is ultimately responsible for his/her own health
choices and the patient’s expectations should be consistent with the provider’s goals.
If the patient perceives those goals as anything different, proper and safe choices
cannot be assured. Thus, it is important to recognize that chiropractic is a limited,
primary profession which contributes to health in one way by addressing the safe,
detection, location, and correction or stabilization of vertebral subluxation(s). It is
important that the chiropractor take the steps necessary to foster proper patient
perception and expectation of the practitioner’s professional goals and
responsibilities. Several topics related to this concept of patient preferences are
discussed below.

PATIENT REFERRAL ISSUES

Professional Referral: Professional referral requires authority and competence to

acquire accurate information concerning matters within the scope and practice of the
professional to whom a referral is made. There are two types of professional
referrals made by chiropractors:

(A) Intraprofessional referral: Chiropractors, by virtue of their professional

objective, education, and experience, have authority and competence to make direct
referrals within the scope and practice of chiropractic. Such a referral may be made
when the attending chiropractor is not able to address the specific chiropractic needs
of a particular patient. Under these circumstances, the chiropractor may refer the
patient directly to or consult with another chiropractor better suited by skill,
experience or training to address the patient’s chiropractic needs.

(B) Interprofessional referral: In the course of patient assessment and the

delivery of chiropractic care, a practitioner may encounter findings which are outside
his/her professional and/or legal scope, responsibility, or authority to address. e.g., 174
The chiropractor has a responsibility to report such findings to the patient, and record
their existence. Additionally, the patient should be advised that it is outside the
responsibility and scope of chiropractic to offer advice, assessment or significance,
diagnosis, prognosis, or treatment for said findings and that, if the patient chooses,
he/she may consult with another provider, while continuing to have his/her
chiropractic needs addressed.

DIAGNOSIS

While training and statute may allow the chiropractor broad diagnostic scope,
chiropractors may also elect to limit their practice and diagnostic scope to the
detection, characterization and care of vertebral subluxations, and determining the
safety and appropriateness of chiropractic care.

There exists a wide variety of health care practitioners, systems of health

care and cultural overlays that effect how the public utilizes health care services.
While every practitioner should be sensitive to this wide variety of cultural and
individual practices, it is not possible to dictate a particular class of provider that a

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patient must see for evaluation of unusual findings. This must be done on a case by
case basis and must be a decision the patient is empowered to make.

Nothing here absolves the chiropractor from knowing the limits of his or her
authority and skill, and from determining the safety and appropriateness of
chiropractic care. The chiropractor has a duty to disclose to the patient any unusual
findings discovered in the course of examination, and may collaborate with other
health professionals when it is in the best interests of the patient to do so.

ASYMPTOMATIC CARE

Chiropractic care to detect and correct vertebral subluxations may offer

benefits for all people, including those who do not demonstrate symptoms of a
disease or health condition.156

Therefore, the presence or absence of symptoms and/or a medical diagnosis

should not be a factor in determining the need for, or appropriateness of, chiropractic
analysis and/or adjustments, nor should the presence of symptoms be required by
any chiropractic board, insurance company or court of law to justify the rendering of
chiropractic care to any patient.

Further support for this can be found in the Association of Chiropractic

Colleges’ Position Paper No. 1, endorsed by all chiropractic colleges in the U.S. and
Canada and virtually every chiropractic organization in the world. It states in part:
"The practice of chiropractic includes: establishing a diagnosis; facilitating
neurological and biomechanical integrity through appropriate chiropractic case
management, and; promoting health" (section 3.0, The Chiropractic Paradigm).

The paper goes on to state: "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 structural and/or pathological articular
changes that compromise neural integrity and may influence organ system function
and general health; A subluxation is evaluated, diagnosed, and managed through the
use of chiropractic procedures based on the best available rational and empirical
evidence." (Section 4.0, The Subluxation). Nowhere does this defining document
state or imply that chiropractic is to be used only for patients exhibiting symptoms.

The use of health care procedures on asymptomatic patients is commonplace

in all medical and alternative care fields, both as “primary” and “secondary”
preventive measures and in recognition of the fact many health conditions do not
exhibit outward signs, particularly in their early stages. This stands in contrast to
“tertiary” prevention- i.e., sickness care- where disease is already present and
intervention is designed to reduce its negative impact by restoring function and
reducing disease-related complications.

The need for chiropractic care by asymptomatic patients is one that has been
widely supported by the chiropractic profession. It is estimated, based on the findings
of an expert panel of seven chiropractic researchers, that 97% of the chiropractic
profession provides chiropractic services to asymptomatic patients if subluxations are
present.4 A textbook published in 2008 and written through a collaborative work of an
entire clinical department at a chiropractic college echoes this key objective as a
vision statement in the preface of the text: “…. Conceived on the premise that people

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 CCP Guidelines 3rd Edition 2008

are better off when no vertebral subluxations are present, endeavor to address the
goal of empowering practitioners to assist individuals striving to live a vertebral
subluxation-free life. This core value, centered on vertebral subluxation, serves to
guide professional decision-making in various ways… To appreciate the value of
such a vision is necessary to consider the role of professional objectives in defining a
profession”. 247

A “Terms of Acceptance” is the recorded, written informed consent

agreement between a chiropractor and the patient. This document provides the
patient with disclosure of the responsibilities of the chiropractor and limits of
chiropractic, and the reasonable benefit to be expected.

This enables the patient to make an informed choice, based on their

preferences, either to engage the services of the chiropractor, aware of the intended
purpose of the care involved, or not to engage those services if the proposed goals
are not acceptable or not desired. This embodies the responsibility of assuring
patient preference and safety by not providing false or misleading promises, claims
or pretences to the patient.175-180

THE ROLE OF VALUE JUDGEMENTS

Clearly the individuals involved in the development of these guidelines share

common values regarding the existence of the vertebral subluxation and the
importance of identifying its manifestation in patients, followed by its reduction and/or
correction. This becomes obvious as one looks at the various backgrounds which the
individuals bring to the process. It can also be said that the Panel’s views on the
subluxation and the literature reviewed mirrors that of the average practicing
chiropractor. This general view of the subluxation is based on a recent
representative survey of chiropractors that found significant agreement amongst
chiropractors regarding the concept of subluxation and how it is diagnosed and
managed.98

Another issue that is somewhat apparent is the panel’s adherence to an

evidence-based model for evaluation and characterization of vertebral subluxation.
This additionally reflects the value placed on the objective identification of
subluxation and assessment of outcome following the introduction of care intended to
correct it. This is further reflected in a newly published textbook on the analysis,
location and correction of vertebral subluxation. Dr. Myron Brown writes in the
preface: the subluxation-centered approach “… is unique in its purpose and
precision (location, analysis and correction of vertebral subluxation) and can be
clearly distinguished from ‘manipulative therapies’ as applied to the condition-
centered model….”. 247

HISTORY OF CHIROPRACTIC

Chiropractic is the third largest health discipline in the United States, after
medicine and dentistry. The current number of approximately 60,000 licensed
chiropractors in the US is estimated to reach 100,000 by the year 2010.181
Chiropractic services are used more often than any other CAM providers,168 and the
satisfaction with chiropractic is high.182, 183

DD Palmer founded chiropractic in the 1890’s and his son BJ Palmer helped to
expand it in the early 1920s. As such chiropractic is a distinct health profession with
a separate scope of practice. Today the discipline is worldwide with the majority of
its members in the United States; 20% of all US chiropractors are located in

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California. Most members of the profession are unaffiliated, meaning that they do
not belong to, or are not active in, any professional organization. Affiliated
chiropractors belong to one of three professional organizations: the largest is the
American Chiropractic Association (ACA) and there are two smaller international
organizations the International Chiropractic Association (ICA) and the World
Chiropractic Alliance (WCA).

As with the other major health professions (medicine, nursing, dentistry),

chiropractic has established Evidence-Based Clinical Practice Guidelines developed
by a peer-review process. The first consensus based document was the Mercy
Guidelines.184 These were replaced by the first evidence based guidelines
developed by the Council of Chiropractic Practice (CCP). The first edition of the
CCP Clinical Practice Guidelines #1 Vertebral Subluxation in Chiropractic Practice
was published in 1998.185 The revised edition was published in 2003 186 and is the
only clinical practice guidelines for vertebral subluxation recognized by the National
Guideline Clearing House (www.guideline.gov) and is has been distributed to the
Health Ministers of 191 Nations.

The 19 colleges in the United States and Canada are accredited by the Council
for Chiropractic Education (CCE). CCE seeks to insure the quality of chiropractic
education by means of accreditation criteria to assess how effectively programs and
institutions plan, implement and evaluate their mission and goals, program
objectives, inputs, resources and outcomes of their chiropractic programs.
Chiropractic Colleges in other countries are accredited and evaluated by similar
agencies, e.g., Council on Chiropractic Education International (CCEI), The Council
on Chiropractic Education- Canada (CCEC and the Canadian Federation of
Chiropractic Regulatory and Educational Accrediting Board (CFCREAB), the
European Council on Chiropractic Education (ECCE), and for Australia and New
Zealand, the Council of Chiropractic Education- Australasia (CCEA)
A typical four-year chiropractic and medical curriculum are compared in Table 1
below: *

Subject Chiropractic Medicine

Anatomy 570 368

Biochemistry 150 120
Microbiology 120 120
Public Health 70 289
Physiology 305 142
Pathology 205 162
Total Basic Science 1,420 1,200
Total Clinical Science ** 3,406 3,467

Total contact Hours 4,826 4,667

(Basic + Clinical yrs)

** Total Clinical Science hrs Includes:

Chiropractic Science 1,975 -0-
Clerkships 1,405 3,467

Table 1: A comparison of typical curriculum content and hours from accredited four-
year programs in chiropractic and medicine. (* source: Center for Studies in Health

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Policy, Inc, Washington, DC. And unpublished data from Meredith Gonyea, PhD.
http://www.chiropracticresearch.org/NEWSSchiroeducation.htm.)

A close evaluation of Table 1, reveals that chiropractic education is highly

comparable to that of medicine, and includes considerable scholarship from
chiropractic college administrators, faculty and graduates.

Of particular interest during this past five-year Guidelines update, there has
been considerable growth of educational scholarship that focuses on at least ten
different topic areas:

1. Scope of Practice 187

2. Professionalism 188-197
3. Student Recruitment and Diversity 198
4. Clinical Skills and Competency 199-212
5. Curriculum and Educational Delivery 213-223
6. Student Assessment and Satisfaction 224-232
7. Teaching and Institutional Effectiveness 233-237
8. Patient Education 238-240
9. Research and Evidence-Based Chiropractic 241-245
10. Philosophy 246

As an overarching measure of quality control, the Presidents of the

Chiropractic Colleges have united together to form the Association of Chiropractic
Colleges (ACC) that represents all colleges and programs, accredited by the CCE.
The member Colleges of the ACC have recently drafted a consensus statement that
includes three important characterizations of the profession: 1) the ACC position on
chiropractic, 2) the ACC representation of the chiropractic paradigm-, and 3) the ACC
clarification regarding the definition and clinical management of the subluxation”.
These principles define the field of chiropractic, and are the foundation of the
profession (http://www.chirocolleges.org/)

ACC Position on Chiropractic: “Chiropractic is a health care discipline which

emphasizes the inherent recuperative power of the body to heal itself without the use
of drugs or surgery. The practice of chiropractic focuses on the relationship between
structure (primarily the spine) and function (as coordinated by the nervous system)
and how that relationship affects the preservation and restoration of health. In
addition, Doctors of Chiropractic recognize the value and responsibility of working in
cooperation with other health care practitioners when in the best interest of the
patient”.

ACC representation of the chiropractic paradigm:

PURPOSE: “The purpose of chiropractic is to optimize health”.

PRINCIPLE: “The body's innate recuperative power is affected by and

integrated through the nervous system”.

PRACTICE: “The practice of chiropractic includes: 1) establishing a

diagnosis, 2) facilitating neurological and biomechanical integrity
through appropriate chiropractic case management; and 3) promoting
health”.

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FOUNDATION: “The foundation of chiropractic includes philosophy,

science, art, knowledge, and clinical experience”.

IMPACTS: “The chiropractic paradigm directly influences the

education, research, health care policy and leadership, relationships
with other health care providers, professional stature, public
awareness and perceptions; and patient health through quality care”.

ACC Clarification on the Definition of Clinical Management of the Subluxation:

“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 pathologicalarticular changes that compromise neural integrity and
may influence organ system function and general health. A subluxation is evaluated,
diagnosed, and managed through the use of chiropractic procedures based on the
best available rational and empirical evidence.”

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 CCP Guidelines 3rd Edition 2008

II. COUNCIL ON CHIROPRACTIC PRACTICE CLINICAL GUIDELINE

NUMBER 3. VERTEBRAL SUBLUXATION IN CHIROPRACTIC
PRACTICE.

2008 UPDATE AND REVISION.

The remainder of this document contains the changes, additions and

revisions to the 2003 Council on Chiropractic Practice Clinical Guideline Number 2.
Vertebral Subluxation in Chiropractic Practice and is organized in the following
manner:

• A description of the changes, additions and revisions to the

Recommendations, Sub-recommendations and Commentary as a result of
the 2008 review.
• If changes to a Recommendation have been made this is listed and
discussed.
• If changes in Commentary following any recommendation have been made
this is listed and discussed.
• If changes to a Conclusion have been made this is listed and discussed.
• If additional literature on the topic was found and reviewed then these
references are listed at the end of the chapter.
• If a Recommendation, Commentary or Conclusion was added that was not
included in the 2003 Guidelines, this is noted.

If a Recommendation, Commentary or the literature remains as it did in the 2003

guidelines a simple statement that the Recommendation, Commentary or literature
remains “unchanged” follows that section/topic.

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 CCP Guidelines 3rd Edition 2008

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The Canadian Chiropractic Examining Board [Platform Presentation; The
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Chiropr Educ. 2006; 20(1): 31-32.

207. Lawson DM. Applying Generalizability Theory To High-Stakes Objectively

Structured Competency Examinations In A Naturalistic Environment [Platform
Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual
Conference, 2006]. J Chiropr Educ. 2006; 20(1): 30.

208. Lawson DM. Applying Structural Equation Modeling To Canadian Chiropractic

Examining Board Measures [Platform Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ.
2006; 20(1): 30-31.

209. Lopez DP, Owens JW, Piencikowski C. Can An Athletic Event Expose
Chiropractic Externs To Conditions They Will Frequently See In Practice?
[Poster Presentation; The Association Of Chiropractic Colleges' Thirteenth
Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 80-81.

210. Pfefer MT, Globe G, Maize H. Bridging The Gap: Introducing Chiropractic
Services At A University Student Health Medical Center [Poster Presentation;
The Association Of Chiropractic Colleges' Thirteenth Annual Conference,
2006]. J Chiropr Educ. 2006; 20(1): 82.

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 CCP Guidelines 3rd Edition 2008

211. Rashbaum RF, Triano JJ. Care Access And Distribution Patterns In
Coordinated, Integrative Care Settings [Poster Presentation; The Association
Of Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr
Educ. 2006; 20(1): 108.

212. Sciotti-Dishman VM, Meseke C. A Comparison Of Direct Assessment

Techniques Of Basic Science Knowledge At A Chiropractic College [Poster
Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual
Conference, 2006]. J Chiropr Educ. 2006; 20(1): 99-100.

213. Alattar MM. Learning Through Internet Educational Games [Poster

Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual
Conference, 2006]. J Chiropr Educ. 2006; 20(1): 48.

214. Bobak KA, Petrocco KL. Interactive Educational Methods In The

Development Of Clinical Reasoning Skills [Poster Presentation; The
Association Of Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J
Chiropr Educ. 2006; 20(1): 54-55.

215. Cleveland A, Kahan M, Globe G. Curriculum Revision Process: Steps To

Success [Poster Presentation; The Association Of Chiropractic Colleges'
Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 74-75.

216. Dougherty P. Chiropractic Education In A Federally Funded Geriatric

Education Center [Poster Presentation; The Association Of Chiropractic
Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1):
61-62.
217. Freedman AM, Till H. Thinking Outside The Box: Using Team-Based
Learning [Tbl] To Educate The [Cmcc] Board Of Trustees [Poster
Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual
Conference, 2006]. J Chiropr Educ. 2006; 20(1): 63-64.

218. Hoiriis KT, Preston K, Shadrix P. The Online Resources Workshop Series
[Poster Presentation; The Association Of Chiropractic Colleges' Thirteenth
Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 71-72.

219. Lawson D, Lafave MR, London C, Derbyshire P, Cross K. Moving

Chiropractic Education Into The Public Education Forum: The Mount Royal
Experience [Poster Presentation; The Association Of Chiropractic Colleges'
Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 75-76.

220. Lawson DM, Lawson MA. Evidence To Support The Assessment Of

Diagnostic Imaging Skills In Booklet Form Versus A Powerpoint Assessment
[Poster Presentation; The Association Of Chiropractic Colleges' Thirteenth
Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 78-79.

221. Plezbert JA. The Delivery Of A Web-Based Clinical Psychology Course In A

Chiropractic Curriculum [Poster Presentation; The Association Of Chiropractic
Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1):
92.
222. Plezbert JA. The Implementation Of A Geriatric Elective Course In The
Chiropractic Curriculum: Preparing For A Unique Specialty In Chiropractic
[Poster Presentation; The Association Of Chiropractic Colleges' Thirteenth
Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 93.

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 CCP Guidelines 3rd Edition 2008

223. Pryor M. The Development Of A Clinical Education Track Within A College Of

Chiropractic [Platform Presentation; The Association Of Chiropractic
Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1):
40-41.

224. CuIler L, Zaki I, Globe G. Student Satisfaction With Post-Lecture And Weekly
Quizzes [Poster Presentation; The Association Of Chiropractic Colleges'
Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 112.

225. Paustian KW. Academic Suspension: Productive Or Punitive [Platform

Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual
Conference, 2006]. J Chiropr Educ. 2006; 20(1): 40.

226. Rubin L, Dudt S. The Development And Implementation Of A Student

Success Center Within The University Setting [Poster Presentation; The
Association Of Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J
Chiropr Educ. 2006; 20(1): 96-97.

227. Russell BS. A Comparison Of Performance At Different Levels Of

Examinations In A Chiropractic College Program [Poster Presentation; The
Association Of Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J
Chiropr Educ. 2006; 20(1): 97.

228. Sikorski D. Lessons In Conducting A Survey On Student And Faculty

Satisfaction With Academic Programs [Poster Presentation; The Association
Of Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr
Educ. 2006; 20(1): 100-101.

229. Till H. Climate Studies: How Do Our First Year Students Experience Their
Educational Environment? [Poster Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ.
2006; 20(1): 106-107.

230. Tobias GS, Goubran EZ. Feedback On Students’ Learning Following An

Osce-Style Evaluation [Platform Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ.
2006; 20(1): 45-46.

231. Hoefer MT, Snelson K. Development Of An Institutional Effectiveness

Program For Educational Institutions: A Successful Case Study [Poster
Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual
Conference, 2006]. J Chiropr Educ. 2006; 20(1): 69-70.

232. Hoiriis KT, Franz R. Developing A Community For Faculty On Teaching And
Learning [Poster Presentation; The Association Of Chiropractic Colleges'
Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 70-71.

233. Homack DMJ. Collecting Analyzable Data On Student Performance During

Practical Examinations [Poster Presentation; The Association Of Chiropractic
Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1):
72.

234. McAulay BJ, Newlin SS. Success In Chiropractic Practice Phase II: A
Practitioner-Based Survey [Platform Presentation; The Association Of

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 CCP Guidelines 3rd Edition 2008

Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ.

2006; 20(1): 36-37.

235. Mrozek JP, Till H. Measuring Clinical Teaching Effectiveness In A

Chiropractic College Outpatient Clinic [Poster Presentation; The Association
Of Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr
Educ. 2006; 20(1): 86.

236. Peterson C. Effects Of Changes In Radiology Laboratory Teaching On The

Use Of Directed Learning Exercises And Study Approaches: A Comparison
Between First And Second Year Cohorts [Poster Presentation; The
Association Of Chiropractic Colleges' Thirteenth Annual Confer. J Chiropr
Educ. 2006; 20(1): 89.

237. Schneider MP. A retrospective Analysis of Patient files following the

implementation of a quality assurance program in a chiropractic teaching
clinic [ Poster Presentation; The Association of Chiropractic Colleges
Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 98-99.

238. Lund CJ. Chiropractic, Contemporary Culture, And Patient Education [Poster
Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual
Conference, 2006]. J Chiropr Educ. 2006; 20(1): 81.

239. Pfefer MT, Globe G, Terre L. How Much Health Promotion And Disease
Prevention Is Enough? Should Chiropractic Colleges Focus On Efficacy
Training In Screening For Family Violence? J Chiropr Educ. 2006; 20(2): 128-
137.

240. Pfefer MT, Globe G, Terre L. Innovative Roles For Chiropractors In The
Hospital Setting [Poster Presentation; The Association Of Chiropractic
Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1):
91.

241. Delaney PM, Fernandez CE. Evidence-Based Health Care In Medical And
Chiropractic Education: A Literature Review. J Chiropr Educ. 2004; 18(2):
103-115.

242. Harvey P, Goodell K. Evolution Of An Information Literacy Course For

Chiropractic Students: Lessons Learned In The Trenches [Poster
Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual
Conference, 2006]. J Chiropr Educ. 2006; 20(1): 65-66.

243. McCoy M, Schneider MP, Numeroff K. What Constitutes A Case? Developing

A Definition Of A Patient Case In A Chiropractic Educational Program
[Platform Presentation; The Association Of Chiropractic Colleges' Thirteenth
Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 42-43.

244. McCoy M. A Survey Of University Faculty Attitudes And Awareness About

Research And Scholarly Activity [Poster Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ.
2006; 20(1): 84-85.

245. Owens EF Jr, Mullin P, Nafziger R, Percuoco R. Using Technology To

Engage Faculty In Developing Assessment Outcomes [Platform Presentation;

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 CCP Guidelines 3rd Edition 2008

The Association Of Chiropractic Colleges' Thirteenth Annual Conference,

2006]. J Chiropr Educ. 2006; 20(1): 39.

246. Keating JC Jr. Several Pathways In The Evolution Of Chiropractic

Manipulation. J Manipulative Physiol Ther. 2003; 26(5):300-321.

247. Brown M, Donofrio J, et al., The Sherman System, Chiropractic Analysis &
Adjusting. Boston, Mass: Pearson Publishing, 2008.

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 CCP Guidelines 3rd Edition 2008

SECTION 1: History and Chiropractic Examination

1.1 CASE HISTORY

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

A thorough case history should precede the initiation of chiropractic care. The
elements of this history should include general information, reason for seeking
chiropractic care, onset and duration of any symptomatic problems, family history, past
health history, occupational history, and social history.

COMMENTARY

The purpose of the case history is to elicit information which might reveal salient points
concerning the patient’s spinal and general health that may lead the chiropractor to elect
appropriate examination procedures. The case history may provide information which will assist
the chiropractor in determining the safety and appropriateness of chiropractic care as well as
the nature of additional analytical procedures to be performed. History taking is considered a
key element of quality patient care necessary for effective doctor-patient communication and
improving patient health outcomes.1-6 Verbal, nonverbal and cognitive assessment are also
included in the patient history. The chiropractic case history should emphasize eliciting
information relevant to the etiology and clinical manifestations of vertebral subluxation.

1.2 CHIROPRACTIC EXAMINATION

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

The initial chiropractic examination shall include a case history and an

assessment for the presence of vertebral subluxation, which, if present, is to be noted
with regard to location and character. A review of systems may be conducted at the
discretion of the practitioner, consistent with individual training and applicable state
laws.

Reassessments may be conducted periodically throughout a course of

chiropractic care to assess patient progress. Such reassessments typically emphasize
re-examination of findings which were positive on the previous examination, although
need not be limited to same. Reassessment is also indicated in the case of trauma or
change in the clinical status of a patient.

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COMMENTARY

The term “Vertebral Subluxation” defines the chiropractic profession, and is distinct from
the term “subluxation” that is common domain medical term. The earliest non-chiropractic
English definition is attributed to Randall Holme in 1668. Holme defined subluxation as “a
dislocation or putting out of joint.” 10 In medical literature, subluxation often refers to an osseous
disrelationship which is less than a dislocation.11 However, B.J. Palmer, the developer of
chiropractic, hypothesized that the “vertebral subluxation” was unique from the medical use of
the term “subluxation” in that it also interfered with the transmission of neurological information
independent of what has come to be recognized as the action potential. Since this component
has yet to be identified in a quantitative sense, practitioners currently assess the presence and
correction of vertebral subluxation through parameters which measure its other components.12
These may include some type of vertebral biomechanical abnormality,13-19 soft tissue insult of
the spinal cord and/or associated structures20-54 and some form of neurological dysfunction
involving the synapse separate from the transmission of neurological information referred to by
Palmer.55-62

As noted, chiropractic definitions of subluxation include a neurological component. In

this regard, Lantz63 stated “common to all concepts of subluxation are some form of kinesiology
[al...Sic] dysfunction and some form of neurologic [al...sic] involvement.” In the position paper of
The Association of Chiropractic Colleges they defined subluxation as follows: “A subluxation is
a complex of functional and/or structural and/or pathological articular changes that compromise
neural integrity and may influence organ system function and general health.”64 The case
history and examination are means of acquiring information pertinent to the location and
analysis of subluxation. This information is primarily used to characterize subluxation regarding
its presence, location, duration, and type. Additionally, the information gained through analysis
guides the practitioner to ascertain which chiropractic techniques best suit the patient to effect
correction of the condition.

Data collected during the patient’s initial consultation and examination, pertaining to the
health history and presenting concerns, thus supports the decision-making process of the
practitioner. This information, relayed by the practitioner to the patient, further serves to
incorporate the patient into the decision-making process regarding chiropractic care.

1.2.1 ELEMENTS OF THE EXAMINATION

1.2.1.1 HISTORY

Important elements of the case history include previous and present social and
occupational events revealed by the patient; unusual sensations, moods or actions relative to
the patient, with dates of occurrence and duration; previous chiropractic and non-chiropractic
intervention; and other factors. The case history usually includes the following:

1. Patient clinical profile.

A. Age.
B. Gender.

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C. Occupation.
D. Other information germane to the presenting complaint, if any.

2. Primary reasons for seeking chiropractic care.

A. Primary reason.
B. Secondary reason.
C. Other factors contributing to the primary and second reasons.

3. Chief complaint, if one exists. This may include onset and duration of symptoms as well
as their subjective and objective characteristics, and location, as well as aggravating or
relieving factors.
A. Trauma, by etiology, when possible.
B. Chief complaint.
C. Characteristics of chief complaint.
D. Intensity/frequency/location, radiation/onset/location.
E. Aggravating/arresting factors.
F. Previous interventions (including chiropractic care), treatments, medications,
surgery.
G. Quality of pain, if present
H. Sleeping position and sleep patterns.

4. Family history.
A. Associated health problems of relatives.
B. Cause of parents’ or siblings’ death and age of death

5. Past health history.

A. Overall health status.
B. Previous illnesses.
C. Surgery.
D. Previous injury or trauma.
E. Medication and reactions.
F. Allergies.
G. Pregnancies and outcomes.
H. Substance abuse and outcomes.

6. Social and occupational history.

A. Level of education
B. Job description.
C. Work schedule.
D. Recreational activities.
E. Lifestyle (hobbies, level of exercise, drug use, nature of diet).
F. Psychosocial and mental health.

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1.2.1.1 CHIROPRACTIC ANALYSIS

Complementing the case history is the necessity of conducting a thorough
chiropractic analysis. This involves procedures which indicate the presence,
location, and character of vertebral subluxation. Inherent in this process is the
noting of unusual findings, both related and unrelated to vertebral subluxation.
This information is useful in determining the safety and appropriateness of
chiropractic care.

The analysis is based partly upon the recognition that vertebral subluxation
may be asymptomatic, yet still exert various physiological effects. Thus, by
assimilating information relative to certain body systems, the presence of
vertebral subluxation may be inferred. Examination protocols have been
developed by field practitioners and researchers. Many of these protocols have
been deemed acceptable by the various chiropractic educational institutions.
This acceptance is expressed either through adding the protocols to the
curriculum, or awarding continuing education credit to post-graduate seminars
instructing these protocols, thus judging them to be sufficient in safety, efficacy,
and validity to be included in clinical practice.

Manual palpation is a basic element of the chiropractic examination. This

aspect of analysis includes palpation of the bony elements of the spine and
includes assessment of the motion of the spine as a whole as well as the
individual vertebral motion segments. Palpation of the numerous muscles which
attach to and control the stability, posture, and motion of the spine is included.
Static vertebral position is analyzed for abnormality. The chiropractor is
additionally interested in locating areas of abnormal segmental motion to identify
hypermobile segments and segments with decreased joint play (hypomobility).
Palpation may also include evaluation of soft tissue compliance, tenderness,
and asymmetric or hypertonic muscle contraction. The presence of vertebral
subluxation may bring with it varying degrees of attendant edema, capsulitis,
muscle splinting, and tenderness to digital palpation. There may be tenderness
of the spinous processes upon percussion of these structures when vertebral
subluxation is present.

Neurological components of the subluxation, postural distortions and other

factors may bring deep and superficial myospasm to muscles of the spine,
pelvis and extremities. 65-75 Palpation may reveal myofascial trigger points
which are associated with the articular dysfunctions accompanying vertebral
subluxations. Muscular involvement may manifest as “taut and tender” fibers.

Visual inspection of the spine and paraspinal region may reveal areas of
hypo- or hyperemia associated with vertebral subluxation. Observation of
patient posture is an important element of chiropractic analysis.76-78 Posture has
far-reaching effects on physiology, biomechanics, psychology, and aesthetics.79
Proper body alignment relates to functional efficiency while poor structural
alignment limits function. Changes in posture are considered in some
chiropractic approaches as a measure of outcome. 80-85 Plain film radiographs,
as well as other forms of imaging may provide information concerning the

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integrity of osseous and soft tissues as well as juxtapositional relationships. 86-87

Other assessments such as leg length analysis,88-112 palpatory and strength
challenges 113-149 are also employed to assess states of muscular responses to
neurological facilitation. Spinal distortions and resultant neurological
interference may create postural or neurological reflex syndromes which result
in a functional change in apparent leg length. This information is also combined
with skin temperature assessments 150-157 and/or electromyography 158-186, 194-199
as well as technique-specific examination procedures to evaluate the integrity of
the nervous system. 200-206 Although clinical tradition supports the use of
orthopedic and neurological tests in chiropractic practice, research to support
the applicability of many of these tests to the assessment of vertebral
subluxation is lacking or negative.187-193 Orthopedic and neurological tests are
indicated only when relevant to the assessment of vertebral subluxation, or
when determining the safety and appropriateness of chiropractic care.

It is recognized that research will continue to evolve the most efficacious

applications of assessment techniques described in this document. However,
the literature is sufficiently supportive of their usefulness in regard to the
chiropractic examination to warrant inclusion as components of the present
recommendation.

The chiropractic examination may include, but not be limited to:

1. Clinical examination procedures.

A. Palpation (static osseous and muscular, motion).
B. Range of motion.
C. Postural examination.
D. Muscle strength testing.
E. Orthopedic/neurological tests.
F. Mental status examination procedures.
G. Quality of life assessment instruments.
H. Substance abuse and outcomes.

2. Imaging and instrumentation

A. Plain film radiography.
B. Videofluoroscopy.
C. Computerized tomography.
D. Magnetic resonance imaging.
E. Range of motion.
F. Thermography.
G. Temperature reading instruments.
H. Electromyography.
I. Pressure algometry.
J. Nerve/function tests.
K. Electroencephalography.

3. Review of systems.
A. Musculoskeletal.
B. Cardiovascular and respiratory.
C. Gastrointestinal.
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D. Genitourinary.
E. Nervous system.
F. Eye, ear, nose and throat.
G. Endocrine.

1.2.1.3 CLINICAL IMPRESSION

An appropriate interpretation of case history and examination findings is

essential in determining the appropriate application of chiropractic care within
the overall needs of the patient. The clinical impression derived from patient
information acquired through the examination process is ultimately translated
into a plan of corrective care, including those elements which are
contraindicated. The clinical impression serves to focus the practitioner on the
patient’s immediate and long-term needs. It is through this process that a clear
picture is created regarding the patient’s status relative to chiropractic care.

1.2.1.4 INITIAL CONSULTATION

The initial consultation serves the purpose of determining how chiropractic

care can benefit the patient. It is during this interchange that the practitioner
presents and discusses examination findings with the patient. Additionally,
during the initial consultation, the practitioner should take the opportunity to
present his/her practice objectives and terms of acceptance. The terms of
acceptance provides the patient with information regarding the objectives,
responsibilities and limitations of the care to be provided by the practitioner.
This reciprocal acknowledgment allows both practitioner and patient to proceed
into the plan of care with well-defined expectations.

While not limited to the following, it is suggested that the initial

consultation include the following parameters:

1. Description of chiropractic: Chiropractic is a primary contact health care

profession receiving patients without necessity of referral from other health care
providers. Traditionally, chiropractic focuses on the anatomy of the spine and its
immediate articulations, the existence and nature of vertebral subluxation, and a
scope of practice which encompasses the correction of vertebral subluxation, as
well as educating and advising patients concerning this condition, and its impact
on general health.

2. Professional responsibility: To assess the propriety of applying methods

of analysis and vertebral subluxation correction to patients; to recognize and
deal appropriately with emergency situations; and to report to the patient any
nonchiropractic findings discovered during the course of the examination,
making referral to other health professionals for care or for evaluation of
conditions outside the scope of chiropractic practice. 207-212 Such referral does
not obviate the responsibility of the chiropractor for providing appropriate

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chiropractic care.

3. Practice objective: The professional practice objective of the chiropractor

is to correct or stabilize the vertebral subluxation in a safe and effective manner.
The correction of vertebral subluxation is not considered a specific cure or
treatment for any specific medical disease or symptom. Rather, it is applicable
to any patient exhibiting vertebral subluxation, regardless of the presence or
absence of symptoms and diseases.

1.2.1.5 DUTY TO DIAGNOSE

It is imperative that the chiropractor be familiar with applicable statutes, rules, and
regulations for the jurisdictions in which each practice is located. Case law indicates a
division of opinion concerning a chiropractor’s duty to diagnose. The diagnostic
responsibility of a chiropractor is not uniform throughout the world.

A case in the Michigan Court of Appeals ruled that a chiropractor does not have a duty
to recognize and diagnose cardiac symptoms, or refer a patient to a medical practitioner.
The court held that doing so would require a chiropractor to undertake a “medical analysis”
beyond the scope of chiropractic practice.” 213

In a previous case, Attorney General v. Beno, the Supreme Court of Michigan held, “We
do not believe the Legislature intended to authorize chiropractors to engage in general
diagnostic techniques. Had such a result been intended, it could have been clearly
stated…Rather than authorizing general diagnostic techniques, the statute limited
chiropractors to those methods, which might reveal the existence of misaligned or displaced
vertebrae. We fail to see how taking urine samples or throat cultures will reveal the
existence of subluxations. 214

These cases, however, do not mean that a chiropractor does not have a duty to
diagnose. At issue is the extent of that duty. The scope of chiropractic is delineated by
statute. The Michigan statute defines chiropractic practice as including, inter alia,
“Diagnosis, including spinal analysis, to determine the existence of spinal subluxations or
misalignments that produce nerve interference, indicating the necessity for chiropractic
care.” 215 “Diagnosis” by a chiropractor in Michigan includes determining subluxation and
nerve interference. It does not include full-body medical diagnosis.

Two Wisconsin cases are instructive. In Kerkman v. Hintz,216 the Supreme Court of
Wisconsin noted, “For purposes of malpractice action against a chiropractor, chiropractor’s
decision to treat cannot be tested in accordance with medical knowledge; rather, it must be
tested in accordance with chiropractic knowledge.”

Furthermore, the Court stated, “The legislature has recognized the practice of
chiropractic as a separate and distinct health care discipline…By limiting chiropractors to
the use of chiropractic adjustments and the principles or techniques of chiropractic science
in the diagnosis, treatment or prevention of disease while prohibiting the use of traditional

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medical tools, e.g. drugs and surgery, the legislature has recognized that the practice of
chiropractic is distinct from the practice of medicine.”

In Kerkman, the Court very clearly defined the extent of a chiropractor’s duty to
diagnose: “In summary, we hold that a chiropractor has a duty to (1) determine whether the
patient presents a problem which is treatable through chiropractic means; (2) refrain from
further chiropractic treatment when a reasonable chiropractor should be aware that the
patient’s condition will not be responsive to further treatment; and (3) if the ailment
presented is outside the scope of chiropractic care, inform the patient that the ailment is not
treatable through chiropractic means.”

In Goldstein v. Janusz,217 the Court of Appeals of Wisconsin relied on Kerkman when it

ruled, “Chiropractors have no duty to recognize medical problems.” The rationale was that
“to do so would require chiropractors to make medical determinations which, under
Wisconsin law, they are not licensed to make.” The Court further noted “Although
chiropractors may take and analyze x-rays, they only do so for diagnostic or analytical
purposes in the practice of chiropractic.”

Should a chiropractor unlawfully perform procedures, which constitute the practice of

medicine, the DC may be subject to tort liability in addition to being charged with the
unauthorized practice of medicine.

In Treptau v. Beherens Spa, Inc., a chiropractor undertook to examine and treat a

patient’s foot using bandages and diathermy. The Wisconsin Supreme Court stated,
“Plaintiffs do not claim there was malpractice on the part of the defendant while Beherens
was engaged in the practice of chiropracty (sic) by chiropractic manipulation or adjustments
of the spine. Instead, plaintiffs contend there was malpractice when he and his associates
went beyond the practice of chiropracty (sic) and entered into the general field of the
practice of medicine…in so far as there was thus an invasion of the general field of that
practice, the methods thus used by defendant’s employees in diagnosis and treatment were
subject to the rules applicable to the practice of medicine and surgery.” 218

The court in Treptau relied on Kuechler v. Volgmann. The Kuechler court held, “When a
chiropractor assumes to diagnose and treat disease he must exercise the care and skill in
so doing that is usually exercised by a recognized school of the medical profession.”219

In Rosenberg v. Cahill 220, the New Jersey Supreme Court held that “chiropractic is a
subset of medicine” while acknowledging that a medical doctor is “not always qualified to
testify in cases involving the asserted malpractice of a chiropractor. The act of negligence
must involve the breach of a duty that the medical doctor can evaluate. When the standard
of care is within the doctor's field of expertise, and thus is common to both professions, the
doctor would be qualified to testify as an expert on that issue.”

Every chiropractor should be familiar with applicable state statutes, rules, and
regulations. A DC should also understand the implications of relevant case law. This
article is not a substitute for legal advice. It should, however, apprise the chiropractor of the
peril of unlawfully encroaching upon the practice of medicine.

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REFERENCES

1. Bates B. A guide to physical examination. Lippincott, Philadelphia, PA. 1982.

2. Saad M. Medical history taking records and forms control. J Can Chiro Assoc 1988.
3. Strachan G. Chiropractic physician records: essential for defence and new practice areas.
DC Tracts 1990; 2(6)315-321.
4. Vernon H. Clinical Note: S.O.R.E. A record keeping system for chiropractic treatment
visits. J Can Chiro Assoc 1990:34(2)93.

5. Miller KJ. Case history documentation. Journal of the American Chiropractic Association
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1995; 29-35, 37.
165. Hoyt W, Hunt Jr. H, De Paw M, et al. Electromyographic assessment of chronic low-back
pain syndrome. J Am Osteopath Assoc 1981; 80(11):728-730.
166. Kent C, Fitzsimons W. Admissibility of electromyographic findings in personal injury cases.
Digest Chiro Econ 1988; 30(5):43-46.
167. Kent C, Gentempo P. Medical evidence of soft tissue injury: legal aspects of paraspinal
EMG findings. Am Chiro 1990; 12(12):10-15.
168. Kent C, Gentempo P. Protocol and normative data for paraspinal EMG scanning in
chiropractic practice. J Chiro Research and Clinical Investigation 1990; 6(3):64-67.
169. Kent C, Hyde R. Potential applications for electromyography in chiropractic practice.
Digest Chiro Econ 1987; 30(2):20-25.
170. Kent C. Surface electrode EMG/lumbar spine. Transactions of the Consortium for
Chiropractic Research 1993; 8:48.
171. Komi P, Buskirk E. Reproducibility of electromyographic measurements with inserted wire
electrodes and surface electrodes. Electromyography 1970; 10:357.

172. Kondo M, Matsuda H, Kureya S, et al. Electrophysiological studies of intermittent

claudication in lumbar stenosis. Spine 1989; 14:862-866.
173. Konrad P, Owen J, Bridwell K. Magnetic stimulation of the spine to produce lower
extremity EMG responses: significance of coil position and the presence of bone. Spine
1994; 19(24): 2812-2818.
174. Marcarian D. Factors influencing the SEMG’s potential for continued future use.
Transactions of the Consortium for Chiropractic Research 1993; 8:51-52.
175. Meeker W, Matheson D, Milus T, et al. Lack of correlation between scanning EMG
asymmetries and history and presence of low back pain: analysis of pilot data. Proc of the
Int’l Conf on Spinal Manip 1990; 230-235.
176. Meeker W, Matheson D, Wong A, et al. Lack of evidence for a relationship between low
back pain and asymmetrical muscle activity using scanning electromyography. Proc of the
World Chiro Congress 1991.

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177. Meyer J. The current status on validity of thoracolumbar paraspinal scanning EMG as a
diagnostic test: a literature review. Transactions of the Consortium for Chiropractic
Research 1993; 8:21-47.
178. Meyer J. The validity of thoracolumbar paraspinal scanning EMG as a diagnostic test: an
examination of the current literature. J Manipulative Physiol Ther 1994; 17(8):539-551.
179. Myerowitz M. Scanning paraspinal surface EMG: a method for corroborating post-
treatment spinal and related neuromusculoskeletal symptom improvement. Journal of
Occupational Rehabilitation 1994; 4(3):171-179.
180. Papakyriakou M, Triano J. Effects of filtering on the evaluation of surface EMG signals.
Proc of the Int’l Conf on Spinal Manip 1993; 84.
181. Sandrini G, Antonaci F, Pucci E, et al. Comparative study with EMG, pressure alogmetry
and manual palpation in tension-type headache and migraine. Cephalalgia (CEPHDF) 1994;
14:451-457.
182. Shinomiya K, Komori H, Matsuoka T, et al. Neuroradiologic and electrophysiologic
assessment of cervical spondylotic amyotrophy. Spine 1994; 19(1):21-25.
183. Spector B, Eilbert L, Finando S, Fukuda F. Video integrated measurement system. J
Manipulative Physiol Ther 1982; 5(2):55-61.
184. Thompson D, Biederman H. Electromyographic power spectrum analysis of the paraspinal
muscles. Spine 1993; 18(15):2310-2313.
185. Triano J. Surface electrode EMG/lumbar spine: static paraspinal EMG scanning-clinical
utility and validity issues. Transactions of the Consortium for Chiropractic Research 1993;
8:53-58.
186. Triano J. The validity of thoracolumbar paraspinal scanning EMG as a diagnostic test:
examination of the current literature. J Manipulative Physiol Ther 1995; 18(7):482-483.

187. Strender LE, Sjoblom A, Sundell K, Ludwig R, Taube A. Interexaminer reliability in physical
examination of patients with low back pain. Spine. 1997; 22(7):814-20.
188. Leamon TB. Research to reality: a critical review of the validity of various criteria for the
prevention of occupationally induced low back pain disability. Ergonomics. 1994;
37(12):1959-74 0014-0139.
189. Breen A. The reliability of palpation and other diagnostic methods. J Manipulative Physiol
Ther. 1992; 15(1):54-6 0161-4754.
190. Porter RW, Trailescu IF. Diurnal changes in straight leg raising. Spine. 1990;15(2):103-6
0362-2436.
191. Nelson MA, Allen P, Clamp SE, de Dombal FT. Reliability and reproducibility of clinical
findings in low-back pain. Spine. 1979; 4(2):97-101 0362-2436.
192. Potter NA, Rothstein JM. Intertester reliability for selected clinical tests of the sacroiliac
joint. Phys Ther. 1985; 65(11):1671-5 0031-9023.
193. Matsumoto M, Fujimura Y, Toyama Y. Usefulness and reliability of neurological signs for
level diagnosis in cervical myelopathy caused by soft disc herniation. J Spinal Disord.
1996; 9(4):317-21.
194. Kent C, Gentempo P. Static and dynamic paraspinal surface EMG: an outcome
assessment for subluxation-based chiropractic care. International Review of Chiropractic.
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1995; 29-35, 37.

195. Kent C, Gentempo P. Dynamic paraspinal surface EMG: a chiropractic protocol.
Chiropractic Research Journal. 1993; 2(4):40-6.
196. Kent C, Gentempo P. Paraspinal EMG potentials in pediatric patients: preliminary
observations. Chiropractic Research Journal. 1992; 2(2):48-52.
197. Kent C, Gentempo P. Paraspinal EMG scanning in chiropractic practice: a review.
Chiropractic Research Journal. 1991; 2(1):41-9.
198. Gentempo P, Kent C, Hightower B, Minicozzi SJ. Normative data for paraspinal surface
electromyographic scanning using a 25-500 Hz bandpass. Journal of Vertebral Subluxation
Research. 1996; 1(1):43-46.
199. Kent C. Surface electromyography in the assessment of changes in paraspinal muscle
activity associated with vertebral subluxation: a review. Journal of Vertebral Subluxation
Research. 1997; 1(3):15-22.
200. Collins K, Pfleger B. The neurophysiological evaluation of subluxation complex:
documenting the neurological component with somatosensory evoked potentials.
Chiropractic Research Journal. 1994; 3)1):40-8.
201. Capria M. Somatosensory neurological evaluation of chiropractic manipulation.
Chiropractic: J Chiro Research and Clinical Investigation 1990; 6(3):56-58.

202. Carey PF. A suggested protocol for the examination and treatment of the cervical spine:
managing the risk. The Journal of the CCA 1995; 39(1): 35-40

203. BenDebba M, Heller J, Ducker TB, Eisinger JM. Cervical spine outcomes questionnaire.
Spine, 2002; 27(19): 2116-2124

204. Fjellner A, Bexander C, Faleij R, Strender LE. Interexaminer reliability in physical

examination of the cervical spine. J of Manipulative and Physiol Ther 1999; 22(8):511-
516

205. Sobel JS, Winters JC, Groenier K, Arendzen JH, Meyboom de Jong B. Physical
examination of the cervical spine and shoulder girdle in patients with shoulder
complaints. J. Manip Physio Ther 1997; 20(4): 257-520

206. Strender LE, Lundin M, Nell K. Interexaminer reliability in physical examination of the
neck. J. Manip Physio Ther 1997; 20(8): 516-520

207. Haas M, Smith M, Greene BR, Allareddy V. Intra-Professional And Inter-Professional

Referral Patterns Of Chiropractors. Chiropr & Osteopat. 2006; 14(1): Online access only
19 p.

208. Dunn AS, Towle JJ, Mcbrearty P, Fleeson S. Chiropractic Consultation Requests In The
Veterans Affairs Health Care System [Platform Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006;
20(1): 9.

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209. Haas M, Smith M, Greene BR, Allareddy V. Referral Patterns And Attitudes Of Primary
Care Physicians Towards Chiropractors. BMC Musculoskel Disord. 2006; 6(5): Online
access only 11 p.

210. Hawk C, Marchiori DM, Henkin AB. Social Communication Skills Of Chiropractors:
Implications For Professional Practice [Platform Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006;
20(1): 34-35.

211. Lillie G. Military Health Care And Chiropractic: Building Bridges. J Am Chiropr Assoc.
2004; 41(7): 44-45.

212. Rubin D. Triage And Case Presentations In A Chiropractic Pediatric Clinic. J Chiropr
Med. 2007; 6(3): 94-98.

213. Vos III J: D.C. not required to make “medical analysis”.

http://www.chiroweb.com/archives/19/07/19.html

214. 373 N.W.2d 544, 422 Mich. 293

215. MCL 333.1640(1); MSA 14.15(16401) (1)

216. 418 N.W.2d 795, 142 Wis.2d 404

217. 582 N.W.2d 78, 218 Wis.2d 683

218. 20 N.W.2d 108, 247 Wis.438

219. 192 N.W. 1015, 180 Wis. 238, 242-43

220. 99 N.J. 318, 492 A.2d 371, 53 USLW 2604

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SECTION 2: INSTRUMENTATION

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

Information is indicated for the qualitative and/or quantitative assessment of the

biomechanical and physiological components of vertebral subluxation. When using
instrumentation, baseline values should be determined prior to the initiation of care.

Commentary

The chiropractor uses a variety of procedures to assess the vertebral subluxation. These
methods may include history taking, physical examination, imaging procedures and
instrumentation. Though information gained from research and personal experience, the
chiropractor generally assigns a personal value to each procedure in a particular clinical
circumstance. The intent of this chapter is to describe clinical applications for the various
instruments that may be used by chiropractors in examining their patients for evidence of
vertebral subluxation.

Definition of instrumentation: The use of any tool or device used to obtain objective data,
which can be recorded in a reproducible manner, about the condition of the patient relative to
vertebral subluxation. Such instrumentation as that described below may provide information
concerning the biomedical and/or neurological aspects of vertebral subluxation.

2.1 POSTURAL ANALYSIS

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Postural analysis using plumb line devices, computerized and non-

computerized instruments may be used to evaluate changes in posture
associated with vertebral subluxation.

Commentary
Posture analysis is recommended for determining postural aberrations associated with
vertebral subluxation. The findings of such examinations should be recorded in the patient
record. In order to encourage standardization of reporting, it is suggested that findings be
recorded in a form consistent with manufacturers’ recommendations.
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Posture analysis may include the use of such devices as the plumb line, scoliometer and
posturometer.1-52 Posture is often analysed by x-ray methods 9-13 where the determination for
care is based on the radiographic profile. The procedure is often enhanced by a plumb line and
other vertical and horizontal lines.

It is recommended that posture also be assessed dynamically since

vertebral subluxation has been implicated in altering postural dynamics.1
High speed photography, electrogoniometry, accelerometry, electromagnetic,
and video-based systems have all been used to measure the segmental positions
and orientation of the moving body.2

2.2 BILATERAL AND FOUR-QUADRANT WEIGHT SCALES

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Bilateral and four-quadrant weight scales may be used to determine the weight
distribution asymmetries indicative of spinal abnormalities.

Commentary

Unequal weight distribution has been shown to be indicative of spinal abnormalities.53-58

Weight scales are a simple and effective means to determine weight distribution asymmetries.

2.3 MOIRE CONTOUROGRAPHY

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Moire contourography may be used to provide a photographic record of

changes in body contour associated with vertebral subluxation.

Commentary

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Moire contourography is a photographic technique which yields information regarding

body contours and their variations for the purpose of evaluating structural abnormality. It is
useful to the chiropractor because body surface asymmetries may be indicative of the presence
of vertebral subluxation.59-73

2.4 INCLINOMETRY

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Inclinometry may be used as a means of measuring motion against a

constant vertical component of gravity as a reference. Changes in ranges of
spinal motion may be associated with vertebral subluxation.

Commentary

Mechanical, electronic and fluid-filled inclinometers are available.74-78 Inclinometer

measurements have been thoroughly studied regarding their ability to measure complex
motions of the spine.79-132 Inclinometers are considered superior to goniometers for assessing
spinal motion.90 Inclinometers have been shown to be accurate within 10% of those obtained by
radiographic evaluation.91 Achieving acceptable reliability is dependent upon use of
standardized procedures.

2.5 GONIOMETRY

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Goniometry, computer associated or not, may be used to measure joint

motion. Inclinometry is superior to goniometry when standardized procedures
are employed.

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Commentary

A goniometer is a protractor that may be held in the proximity of the area being measured to
provide a means by which to determine degrees of motion.75 Although goniometry is common,
133-148
a wide range of variance has been reported.137-140 expressing up to 10o-15o error.141, 142

2.6 ALGOMETRY

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Algometry may be used to measure pressure-pain threshold. Changes

in sensory function associated with vertebral subluxation may produce changes
in pressure-pain thresholds.

Commentary

A pressure-pain threshold meter yields a measurement of when a patient feels a change

from pressure to tenderness as the device produces mechanical irritation of deep somatic
structures.149-165 Pressure-pain-threshold measurements produce acceptable levels of
reliability.149-157 Algometry has been shown to be very useful in measuring changes in
paraspinal tissue tenderness as the thresholds are symmetrical.157 This renders the procedure
applicable to chiropractic analysis.

2.7 CURRENT PERCEPTION THRESHOLD (CPT) TESTING

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Current perception threshold devices may be used for the quantitative

assessment of sensory nerve function. Alterations in sensory nerve function
may be associated with vertebral subluxation.

Commentary

The current perception threshold device is a variable voltage constant current sine wave
stimulator proposed as a simple non-invasive and quantitative measure of peripheral nerve
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function.166-184 One type of current perception threshold instrument, the neurometer, has been
shown to be appropriate for rapid screening for neural dysfunction.168

2.8 ELECTROENCEPHALOGRAPHY (EEG)

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Electroencephalographic (EEG) techniques including brain mapping and

spectral analysis, may be used to assess the effects of vertebral subluxation and
chiropractic adjustment associated with brain function.

Commentary

Standard EEG and computerized EEG techniques, including spectral analysis and brain
mapping, have been shown to change following chiropractic adjustments or manipulation.185-189
Such procedures may be useful in evaluating possible effects of chiropractic care on brain
function.

2.9 SOMATOSENSORY EVOKED POTENTIALS (SSEP)

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Somatosensory evoked potentials may be used for localizing neurological

dysfunction associated with vertebral subluxations.

Commentary

Somatosensory and dermatomal evoked potentials are used for localizing neurological
abnormalities in the peripheral and central conducting pathways. These findings are useful as
objective indicators of the level or levels of involvement.190-213 One study reported that improved
nerve root function was observed in subjects who received a high-velocity chiropractic thrust:
similar changes were not observed in controls.190

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2.10 SKIN TEMPERATURE INSTRUMENTATION

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Temperature reading devices employing thermocouples, infrared

thermometry, or thermography (liquid crystal, telethermography, multiple IR
detectors etc.) may be used to detect temperature changes in spinal and
paraspinal tissues related to vertebral subluxation.

Commentary

The measurement of paraspinal cutaneous thermal asymmetries and other

measurements of anomalies have been shown to be a mode of sympathetic nervous system
assessment, 214-247 which may be used as one indicator of vertebral subluxation. Demonstrable
changes in thermal patterns have been observed following chiropractic adjustment.59, 219
Thermocouple instruments have been shown to demonstrate an acceptable level of reliability
and clinical utility applicable to the assessment of vertebral subluxation-related changes.214, 216,
223, 231, 238, 244, 246
Normative data have been collected concerning the degree of thermal
asymmetry in the human body in healthy subjects.232 These values may serve as one standard
in the assessment of sympathetic nerve function and the degree of asymmetry as a quantifiable
indicator of possible dysfunction.233

2.11 SURFACE ELECTROMYOGRAPHY

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L, C

Surface electrode electromyography, using hand-held electrodes, or affixed

electrodes, may be used for recording changes in the electrical activity of
muscles associated with vertebral subluxation.

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Commentary

Surface electromyographic (SEMG) techniques using both hand-held electrodes and

affixed electrodes are widely used 248-330 and have demonstrated an acceptable level of
reliability for general clinical usage.248-353, 255-262, 270-277, 278 Other studies have demonstrated that
significant changes in muscle electrical activity occur following adjustment or spinal
manipulation.252, 254, 267, 277 Protocols and normative data for paraspinal EMG scanning in
chiropractic practice have been published.263-266, 268-269 Surface EMG techniques may be used
to assess changes in paraspinal muscle activity associated with vertebral subluxation and
chiropractic adjustment.

2.12 MUSCLE STRENGTH TESTING

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Muscle strength testing may be used to determine bilateral differences or

other differences in patient resistance. These differences may be characterized
by the experienced examiner based on various technologies. Manual,
mechanized and computerized muscle testing may be used to determine changes
in the strength and other characteristics of muscles. These changes may be a
result of alterations of function at various levels of the neuromuscular system
and/or any other system related to the patient. Such changes may be associated
with vertebral subluxation.

Commentary

Muscle testing as a means of evaluation and diagnosis of patients within chiropractic as

well as other disciplines, is well documented.331-373 Muscle testing techniques may be used to
assess the effect of vertebral subluxation on various aspects of muscle strength. Research has
shown manual muscle testing to be sufficiently reliable for clinical practice. 333, 334, 338, 340, 349-351,
355, 370
Studies concerning manual muscle testing have also demonstrated electromyographic
differences associated with various muscle weaknesses, and differences in somatosensory
evoked potentials associated with weak versus strong muscles.331, 332 Other studies have
demonstrated clinical utility and reliability of hand-held muscle strength testing devices.336, 337, 341,
352

Muscle strength and endurance testing may be used to ascertain and track muscle force
generation and neuromuscular status. Clinically, it may be useful to quantify differences in
strength between limbs or bodily segments. The evaluation of strength may be characterized
by the experienced examiner based on various technologies. Manual, mechanized and

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computerized muscle testing may be used to determine changes in the strength and other
characteristics of muscles. These changes may be a result or a cause of alterations of function
at various levels of the neuromuscular system and/or any other system related to the patient.
Vertebral subluxation may be associated with alterations in muscular strength and has the
potential to affect multiple organ systems and overall health.358-361

2.13 QUESTIONNAIRES

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Questionnaires may be used in the assessment of the performance of

activities of daily living, pain perception, patient satisfaction, general health
outcomes, patient perception outcomes, mental health outcomes, and overall
quality of life, throughout a course of chiropractic care. Questionnaires provide
important information, but should not be used as a substitute for physical
indicators of the presence and character of vertebral subluxation.

Commentary

There are a variety of questionnaires of demonstrated reliability and validity which may
be used to document outcomes,374-410 including pain and symptoms, although these are not
necessary correlates of vertebral subluxation. However, correction of vertebral subluxation and
reduction of the abnormal spinal and general functions associated with it may be accompanied
by reduction or elimination of pain and symptoms. It must be emphasized that the clinical
objective of chiropractic care is the correction of vertebral subluxations. No questionnaires exist
which assess the presence or correction of vertebral subluxation. Therefore, it is inappropriate
to employ questionnaires to determine the need for chiropractic care, but questionnaires are
appropriate as one aspect of monitoring patient progress and the effectiveness of subluxation-
centered care.

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2.14 HEART RATE VARIABILITY

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Heart rate variability may be used to assess autonomic dysfunction

associated with vertebral subluxation.

Commentary

Variability in heart rate reflects the vagal and sympathetic function of the autonomic
nervous system, and has been used as a monitoring tool in clinical conditions characterized by
altered autonomic nervous system function.411 Spectral analysis of beat-to-beat variability is a
simple, non-invasive technique to evaluate autonomic dysfunction.412

Heart rate variability analysis has been used in the assessment of diabetic neuropathy
and to predict the risk of arrhythmic events following myocardial infarction.413 The technique has
also been used to investigate autonomic changes associated with neurotoxicity,414 physical
exercise.415 anorexia nervosa,416 brain infarction,417 angina,418 and panic disorder.419 Normative
data on heart rate variability have been collected.420-422 This technology appears to hold promise
for assessing overall fitness. Gallagher et al. 423 compared age matched groups with different
lifestyles. These were smokers, sedentary persons, and aerobically fit individuals. They found
that smoking and a sedentary lifestyle reduces vagal tone, whereas enhanced aerobic fitness
increases vagal tone. Dixon et al. 424 reported that endurance training modifies heart rate control
through neurocardiac mechanisms.

In occupational health, the effects of various stresses of the work environment of heart
patients and asymptomatic workers may be evaluated using heart rate variability analysis.425
Heart rate variability has been shown to be responsive to chiropractic care.426-427

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2.15 COMPUTER ASSISTED DIFFERENTIAL SPINAL COMPLIANCE

Sub-Recommendation (New) Rating: Established

Evidence: E, L

Computer assisted differential spinal compliance instruments may be used

to assess changes in spinal and paraspinal tissue compliance associated with
vertebral subluxation.

Commentary

Computer assisted differential spinal compliance instruments employ a piezoelectric

sensor to record the signal that is reflected after a light force is introduced into the spine
and paraspinal tissues. These devices are often employed in conjunction with multiple
impulse adjusting instruments. 428-432

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358. Bohannon RW, Andrews AW. Standards for judgments of unilateral impairments in
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364. Jaric S. Muscle Strength Testing. Use of Normalisation for Body Size. Sports Medicine
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369. Bonello R, Pollard HP, Bablis P. The Ileocecal Valve Point And Muscle Testing: A
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373. Marquina N, Zhang J, Conable K, Corneal J, Hambrick T. Investigation Of Methods And

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388. Cherkin DC. Patient satisfaction as an outcome measure. J Chiropracic Tech 1990; 2(3)
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389. Haas M, Jacobs G, Raphael R, et al. Responsiveness and applicability of two functional
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390. Haas M, Nyiendo J. Diagnostic utility of the McGill Pain Questionnaire and the Oswestry
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391. Hagino C, Papernick L. Test-retest reliability of the ‘CMCC Low Back Status Questionnaire
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for Laypersons.’ Proc of the Int’l Conf on Spinal Manip A/M 1993; 47.
392. Hains F, Waalen J, Mior S. Psychometric properties of the Neck Disability Index; final
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393. Hawk C, Wallace H, Dusio M. Development of a global well-being scale: A study of
reliability, validity and responsiveness. Proc of the Int’l Conf on Spinal Manip 1994; 41-42.
394. Jaeschke R, Singer J, Guyatt G. A comparison of seven-point and visual analogy scales:
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395. Lawlis G, Cuencas R, Selby D, et al. The development of the Dallas Pain Questionnaire:
An assessment of the impact of spinal pain on behavior. Spine 1989; 14(5)511-516.
396. Love A, Leboeur C, Crisp T. Chiropractic chronic low back pain sufferers and self-report
assessment methods. Part I. A reliability study of the visual analogue scale, the pain
drawing and the McGill. J Manipulative Physiol Ther 1989; 12(1)21-25.
397. Nylendo J, Haas M, Jones R. Using the SF-36D (General Health Questionnaire) in a pilot
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patients. Proc of the Int’l Conf on Spinal Manip FCER, Arlington, VA. 172, 1991.
398. Sawyer, C. Patient satisfaction as a chiropractic research outcome. Proc Int’l
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399. Blanks RHI, Schuster T, Dobson M. A retrospective assessment of Network
Care using a survey of self-rated health, wellness and quality of life. Journal
of Vertebral Subluxation Research, 1997; 1(4):15-31.

400. Breen AC, Bolton JE. The Bournemouth Questionnaire: A short form comprehensive
outcome measure. I. Psychometric properties in back pain patients. J. Manip Physiol
Ther October 1999 (22:8)

401. Enebo BA. Outcome measures for low back pain: Pain inventories and functional
disability questionnaires. Chiro. Tech. February 1998(10:1)

402. Fish RG, Bolton JE. Responsiveness of the revised Oswestry Disability questionnaire.
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403. Sigrell H. Expectations of chiropractic patients: The construction of a questionnaire. J.

Manip. Physiol. Ther. September 2001 . Volume 24. Number 7.

404. Schwab F, Dubey A, Pagala M, Gamez L, Farcy JP. Adult scoliosis: a health
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405. BenDebba M, Heller J, Ducker TB, Eisinger JM. Cervical spine outcomes questionnaire:
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406. Korovessis P, Dimas A, Iliopoulos P, Lambiris E. Correlative analysis of lateral vertebral

radiographic variables and medical outcomes study short-form health survey: a
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407. Hanscom B, Lurie JD, Homa K, Weinstein JN. Computerized questionnaires and the
quality of survey data. Spine. 2002 Aug 15;27(16):1797-801.

408. Jenkinson C, Coulter A, Gyll R, Lindstrom P, Avner L, Hoglund E. Measuring the

experiences of health care for patients with musculoskeletal disorders (MSD):
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409. Schwab F, Dubey A, Pagala M, Gamez L, Farcy JP. Adult scoliosis: a health
assessment analysis by SF-36. Spine. 2003 Mar 15;28(6):602-6.

410. Bulbulian R, Perillo M. Responsiveness Of The Bournemouth And Oswestry

Questionnaires: A Prospective Pilot Study. J Manipulative Physiol Ther. 2003; 26(2):77-
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411. van Ravenswaaij-Arts CM, Kollee LA, Hopman JC, Stoelinga GB: "Heart rate variability."
Ann Intern Med 1993;118(6):436.

412. DeDenedittis G, Cigada M, Bianchi A, et al: "Autonomic changes during hypnosis: a

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413. Kautzner J, Camm AJ: "Clinical relevance of heart rate variability." Clin Cardiol
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414. Murata K, Landrigan PJ, Araki S: "Effects of age, gender, heart rate, tobacco and
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415. Nakamura Y, Yamamoto Y, Muraoka I: "Autonomic control of heart rate during physical
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416. Petretta M, Bonaduce D, Scalfi L, et al: "Heart rate variability as a measure of autonomic
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417. Abnormal heart rate variability as a manifestation of autonomic dysfunction in

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418. Kamalesh M, Burger AJ, Kumar S, Nesto R: "Reproducibility of time and frequency
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420. O'Brien IA, O'Hare P, Corrall RJ: "Heart rate variability in healthy subjects: effect of age
and the derivation of normal ranges for tests of autonomic function." Br Heart J
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421. Toyry J, Mantysaari M, Hartikainen J, Lansimies E: "Day-to-day variability of cardiac

autonomic regulation parameters in normal subjects." Clin Physiol 1995;15(1):39.

422. Sato N, Miyake S, Akatsu J, Kumashiro M: "Power spectral analysis of heart rate
variability in healthy young women during the normal menstrual cycle." Psychosom Med
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423. Gallagher D, Terenzi T, de Meersman R: "Heart rate variability in smokers, sedentary,

and aerobically fit individuals." Clin Auton Res 1992;2(6):383.

424. Dixon EM, Kamath MV, McCartney N, Fallen EL: "Neural regulation of heart rate
variability in endurance athletes and sedentary controls." Cardiovasc Res
1992;26(7):713.

425. Kristal-Boneh E, Raifel M, Froom P, Ribak J: "Heart rate variability in health and
disease." Scand J Work Environ Health 1995;21(2):85.

426. Igarashii Y, Budgell BS: Case study: response of arrhythmia to spinal manipulation.
Chiropractic Journal of Australia 2000;30(3):92.

427. Zhang J: Short-term power spectrum analysis of heart rate variability of chiropractic
students in college. Chiropractic Research Journal 2000;7(2):70.

428. Evans JM: Differential Compliance Measured by the Function Recording and Analysis
System in the Assessment of Vertebral Subluxation. Journal of Vertebral Subluxation
Research, Vol. 2, No. 1, 1998

429. Evans JM, Collins D: The Clinical Application of Differential Compliance Methodology to
Joint Fixation Identification and Resolution Using the PulStarFRAS™ Journal of
Vertebral Subluxation Research, Vol. 2, No. 3, 1998

430. Evans JM, Collins D: Similarities and Differences Between X-ray Analysis And
Computerized Fixation Imaging of the Cervical Spine. Presented at the Seventh Annual
National Subluxation Conference Sponsored by Sherman College of Straight
Chiropractic Spartanburg South Carolina October 1999

431. Evans JM, Hill CR, Leach RA, Collins DL: The Minimum Energy Hypothesis: A Unified
Model Of Fixation Resolution. J Manipulative and Physiol Ther 25 (2), February 2002

432. Leach RL, Parker PL, Veal PS: PulStar Differential Compliance Spinal Instrument: A
Randomized Interexaminer and Intraexaminer Reliability Study. J Manipulative Physiol
Ther. 2003; 26(8):493-501.

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SECTION 3: RADIOGRAPHIC AND OTHER IMAGING

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

Diagnostic imaging procedures may be utilized to characterize the biomedical

manifestations of vertebral subluxation, and to determine the presence of
conditions which affect the safety and appropriateness of chiropractic care.

3.1 PLAIN FILM RADIOGRAPHY

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Plain film radiography is indicated: to provide information concerning the

structural integrity of the spine, skull and pelvis; the misalignment component of
the vertebral subluxation; the foraminal alteration component of the vertebral
subluxation; and the postural status of the spinal column. Imaging procedures,
including post-adjustment radiography, should be performed only when clinically
necessary. It is common for lines of mensuration to be drawn on the radiographs
to assess subluxation and alignment. These procedures may be done by hand,
or the chiropractor may utilize computerized radiographic digitization
procedures.

Commentary

In considering the use of imaging methods employing ionizing radiation as a component

of patient assessment, the clinician should determine if the methods of subluxation correction,
patient safety, and management require the use of such procedures. The patient should be
asked about any conditions which may contraindicate certain imaging procedures.

Reliability studies of several systems of biomechanical analysis, including radiographic

marking systems, have been published. Imaging is a necessary component of a number of
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different chiropractic analyses. The preponderance of evidence supports the reliability of these
procedures when properly performed.1-8, 12, 15-27, 29-32, 36-39, 42-61, 64-68, 70-79, 163-185 Moreover,
radiographic imaging has revealed statistically significant changes in the direction of atlas
positioning following chiropractic adjustment(s) 14, 28, 33-35, 156-158 The effect of chiropractic care on
lateral curvature of the cervical spine has been investigated, with significant changes in the
cervical curve noted in patients receiving chiropractic care.9, 62, 63, 69, 159-162, 188-190

3.2 DOSAGE AND SHEILDING

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Imaging procedures employing ionizing radiation should be performed

consistent with the principles of obtaining films of high quality with minimal
radiation. This may include the use of gonad shielding, compensating filters, and
appropriate film-screen combinations.

Commentary

A number of dosimetry studies using supplemental filtration and single-speed screens

have revealed that in the case of 14 x 36 inch AP full-spine radiographs, the radiation levels
were less than sectional films of like-sized subjects. Shielding of radiosensitive structures may
be used when it does not obliterate structures of clinical interest. Such shielding results in a
reduction of radiation exposure.10, 11, 13, 192-198

Conclusion

The judicious use of spinographic techniques can be valuable in characterizing aspects

of the biomechanical manifestations of vertebral subluxation.156, 186, 187, 232-238 The use of post-
adjustment radiographs may also assist the chiropractor in determining effects of chiropractic
adjustments on the spine when other less hazardous examination techniques cannot reveal the
desired information.

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3.3 VIDEOFLUOROSCOPY

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Videofluoroscopy may be employed to provide motion views of the spine

when abnormal motion patterns are clinically suspected. Videofluoroscopy may
be valuable in detecting and characterizing spinal kinesiopathology associated
with vertebral subluxation.

Commentary

A videofluorscopic system consists of an x-ray generator capable of operating at low (1/4

to 5) milliamperage settings, an x-ray tube assembly, an image intensifier tube, a television
camera, digital tape, DVD recorders and a monitor. The heart of the system is the image
intensifier tube. This tube permits imaging at very low radiation levels. It is used instead of
intensifying screens and film as an image receptor.

The role of videofluoroscopy in the evaluation of abnormalities of spinal motion has been
discussed in textbooks, medical journals, and chiropractic
publications.19, 20, 23, 80-83, 140, 155, 201, 202, 206-215, 217-224, 231, 265 Studies have appeared in the literature
comparing the diagnostic yield of fluoroscopic studies versus plain films, as well as reporting
abnormalities detected by fluoroscopy which could not be assessed using plain films.191, 203-205,
216, 225, 228-230

Reliability has been addressed in a number of studies.200, 226, 227, 259 Additionally, in a
study evaluating the interexaminer reliability of fluoroscopic detection of fixation in the mid-
cervical spine, two examiners reviewed 50 videotapes of fluoroscopic examinations of the
cervical spine. The examiners achieved 84 percent agreement for the presence of fixation, 96
percent agreement for the absence of fixation, and 93 percent total agreement. The Kappa
value was 0.80 (p< 0.001). The authors concluded, “The current data indicate that VF
determination of fixation in the cervical spine is a reliable procedure.” 226, 259

Conclusion

Observational and case studies support the use of videofluoroscopy to evaluate

vertebral motion when this information cannot be obtained by other means.

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3.4 MAGNETIC RESONANCE (MR) IMAGING

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

MR imaging may be employed to assess suspected neoplastic, infectious

and degenerative conditions of the spine and related tissues as well as the stages
of subluxation degeneration. Its use is generally restricted to instances where
the desired information cannot be obtained by less costly procedures.

Commentary

Magnetic resonance imaging enables clinicians to obtain clear images of the human
body without ionizing radiation.
Literature supports the use of MR imaging for the detection and characterization of
numerous manifestations associated with subluxation degeneration.84-107, 141-154, 239-243, 257 These
studies cover a spectrum of phenomena, including:
1. Osseous misalignment
2. Intervertebral disc desiccation and degeneration
3. Osteophytosis
4. Corrugation/hypertrophy of the ligamentum flava
5. Spinal canal stenosis
6. Foraminal stenosis
7. Disc herniation and disc bulging
8. Facet asymmetry
9. Facet degeneration
10. Altered cerebrospinal fluid dynamics
11. Cord compression
12. Gliosis and myelomalacia
13. Spinal cord atrophy

Conclusion

MRI may be employed to disclose manifestations of vertebral subluxation when this

information cannot be obtained by more cost-effective means. MRI is also appropriate for
evaluating patients with clinical evidence of conditions which may affect the safety and
appropriateness of chiropractic procedures.

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3.5 COMPUTED TOMOGRAPHY (CT)

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

CT imaging may be employed to assess osseous and soft tissue pathology

in the spine and contiguous tissues. Its use is generally restricted to instances
where the desired information cannot be obtained by less costly procedures.

Commentary

Computed tomography (also referred to as CT of CAT scanning) is an imaging technique

which produces axial (cross sectional) images of body structures using x-radiation. Computer
reconstruction methods may be used to depict other planes.
Manifestations of subluxation degeneration which may be demonstrated by CT scanning
include disc lesions, spinal canal stenosis due to infolding of the ligamentum flava,
osteophytosis, and bony aclerosis.108-139, 154, 244-246, 255, 256, 258, 265 In addition, CT may be used to
evaluate developmental variance and pathologies which could affect the chiropractic
management of a case.

Conclusion

CT may be employed to disclose manifestations of vertebral subluxation when this

information cannot be obtained by more cost-effective means. CT is also appropriate for
evaluating patients with clinical evidence of conditions which may affect the safety and
appropriateness of chiropractic procedures, particularly fractures, degenerative changes, and
osseous pathology.

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3.6 SPINAL ULTRASONOGRAPHY

Sub-Recommendation (Unchanged) Rating: Established- SC Size

Investigational- inflammation
Evidence: E, L (SC size)
I, L (inflammation)

Spinal ultrasonography may be used to evaluate the size of the spinal canal
(SC), and to detect pathologies in the soft tissue surrounding the spine. It
applications in the assessment of the facet inflammation and nerve root
inflammation remain investigational at this time.

Commentary

Sonographic imaging is a technique which utilizes echoes for ultrasonic waves to

produce an image on a cathode ray tube. Sonographic techniques have been employed to
measure the lumbar canal, as well as determining focal stenosis and disc disease.247-254, 266, 267-
272

A small study compared sonographic results in patients with back pain previously
examined by MRI, x-ray and standard orthopedic examination. The study concluded that the
correlation with MRI, x-ray, orthopedic and neurologic examination was approximately 90
percent. 252

Conclusion

The low cost, availability, ease of application, and noninvasive nature of sonographic
imaging make it an attractive addition to the chiropractor’s armamentarium. Furthermore, it has
the potential to image various components of the vertebral subluxation. However, caution must
be exercised in evaluating the claims of promoters of sonographic equipment, particularly those
relating to the assessment of nerve root inflammation and facet joint disease. Further research
toward the establishment of chiropractic protocols should be undertaken to explore the clinical
utility of spinal sonography in chiropractic practice.

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3.7 RADIOISOTOPE SCANNING (Nuclear Medicine Studies)

Sub-Recommendation (Unchanged) Rating: Established

Evidence: E, L

Radioisotope scans performed by qualified medical personnel may be used

by a chiropractor to determine the extent and distribution of pathological
processes which may affect the safety and appropriateness of chiropractic care
when this information cannot be obtained by less invasive means.

Commentary

In this procedure, bone-seeking radioisotopes are injected, and an image is produced

demonstrating the degree of uptake of the radioisotopes. The examination is sensitive to
regional changes in osseous metabolism, but is not specific. Abnormal bone scans may be due
to metastasis, infection, fracture, osteoblastic activity or other pathology.260-264 No studies or
case reports were found linking abnormal bone scans with vertebral subluxation. Bone scans
may have limited value in determining the safety and appropriateness of chiropractic
procedures.

Conclusion

Radioisotope scans have a limited role in chiropractic practice. Bone scans are a
sensitive, but nonspecific indicator of abnormal metabolic activity in bone.

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3.8 Radiographic Digitizing Analysis

Sub-Recommendation Rating: Established

Evidence: E, L

Computerized X-ray analysis may be used by chiropractors to objectively

analyze the biomechanical and misalignment improprieties related to vertebral
subluxation. Clinical necessity is justified for assessing the degree of insult and
the effect upon the patient’s health and future well-being by way of impairment
rating.

Commentary

Diagnostic imaging methods may be utilized for obtaining information concerning the
vertebral subluxation and other malpositioned articulations and structures, primarily the osseous
misalignment component. Although advanced imaging can provide important information
regarding foraminal alteration and possible nerve impingement, it is also possible to
demonstrate aberrant motion and position which may impact upon the safety, appropriateness
and outcome of chiropractic care.

Computer aided digitizing mensuration analysis software has demonstrated accuracy to

0.0023 mm. While hand mensuration should not be overlooked, it cannot approach the
accuracy attainable with advanced computer technology. Computer aided digitizing mensuration
analysis provides biomechanical analyses with a high degree of accuracy in order to make a
chiropractic differential diagnosis and/or to determine care protocols. Mensuration also provides
a definitive baseline for follow-up radiological examinations as an assessment of outcome.273-351

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317. National Osteoporosis Foundation [Cummings, S. R.]: Report: Assessing Vertebral

Fractures. Bone & Min. Res. 1995, 10(4): 518-523. (Under Abstracts)

318. Neumann, P., Nordeall, A. et al: Traumatic Instability of the Lumbar Spine; A Dynamic in
Vitro Study of the Flexion-Distraction Injury. SPINE, 20(10), 1995.

319. Osterhouse, M., Tepe, R., Kettner, N., McVey, M., Reliability of the Penning Method for
Cervical Intersegmental Motion Assessment: A Pilot Study; Journal of the
Neuromusculoskeletal System, Vol. 10, No.2, Summer 2002 p53

320. Panjabi, M. M. et al., Mechanical behavior of the human lumbar and lumbosacral spine
as shown by three-dimensional load-displacement curves. JBJS, 1994, 76-A (3):413-
424.

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321. Panjabi, MM et al. On the understanding of clinical instability. Spine, 1994, 19(23):
2,642-2,650.

322. Panjabi, MM: Cervical spine models for biomechanical research. Spine, 1998,
23(24):2,684-2,700.

323. Pettersson, K et al., Decreased spinal canal width in patients with whiplash. Spine, 1995,
20(15):1,664-1,667.

324. Provoost, J.: The Vertebral Animator: A window to education and research. 16th Annual
Upper Cervical Conference, Nov. 20-21, 1999, Life University, Marietta, GA.

325. Rajnics, P., Pomero, V., Templier, A., Lavaste, F., Illes, T.: Computer-Assisted
Assessment of Spinal Sagittal Plain Radiographs. Journal of Spinal Disorders. Vol. 14,
No.2, pp135-142 2001

326. Rochester RP. Inter- and intra-examiner reliability of the upper cervical x-ray marking
system: A third and expanded look. CRJ. 1994; 3(1):23-31.

327. Rochester RP & Owens EF. Patient placement error in rotation and its affect on the
upper cervical measuring system. CRJ 1996; 3(2): 40-53.

328. Rome PL. Usage of chiropractic terminology in the literature: 296 ways to say
"subluxation." Chiropractic Technique 1996; 8(1):12.

329. Rosner, AL: The Role of Subluxation in Chiropractic. FCER. 1997.

330. Ross, JK (McGill) et al., Atlas-Axis facet asymmetry. Spine, 1999, 24(12):1,203-1,209.

331. Sasai, K et al., Cervical curvature after laminoplasty for spondylotic myelopathy
involvement of yellow ligament, semispinalis cervicis muscle, and nuchal ligament. J of
Spinal Disorders, 2000, 13(1):26-30.

332. Seemann DC. A reliability study using a positive nasium to establish laterality. Upper
Cervical Monograph 1994; 5(4):7, 8.

333. Shea, KG et al., A comparison of manual versus computer-assisted radiographic

measurements: intraobserver measurement variability for Cobb angles. Spine, 1998,
23:551-555.

334. Singer, K. P et al., Computer-assisted curvature assessment, and Cobb angle

determination of the thoracic kyphosis. Spine, 1994, 19(12): 1381-1384. (Under
Abstracts)

335. Suh, CH: Three-dimensional computerized x-ray analysis of the upper cervical spine: a
progress report. 15th Annual Upper Cervical Conference, Life University. 1998.

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336. Suh, CH & Smith, CG: Computerized X-ray analysis for the Life Upper Cervical
Adjustment Technique. (Due for completion in 2000)

337. Taylor J et al. Interpretation of abnormal lumbosacral spine radiographs: A test

comparing students, clinicians, radiology residents, and radiologists in medicine and
chiropractic. Spine 1995; 20(10):1147-1154.

338. Thorkeldsen A & Breen A: Gray scale range and the marking of vertebral coordinates on
digitized radiographic images. J Chiro 1994; 17(6):359-363.

339. Troyanovich, SJ et al., Intra- and interexaminer reliability of the Chiropractic Biophysics
lateral lumbar radiographic mensuration procedure. J. Manip Physio Ther 1995,
18(8):519-524.

340. Troyanovich SJ et al., Chiropractic biophysics (CBP) technique. Chiropractic Technique,

1996 8(1):30-35.

341. Troyanovich SJ et al., Radiographic mensuration characteristics of the sagittal lumbar

spine from a normal population with a method to synthesize prior studies of lordosis. J
Spinal Disord, 1997 10(5):380-6.

342. Royanovich SJ et al., Structural rehabilitation of the spine and posture: rationale for
treatment beyond the resolution of symptoms. J. Manip Physio Ther 1998, 21(1):37-50.

343. Troyanovich SJ et al., Further analysis of the reliability of the posterior tangent lateral
lumbar radiographic mensuration procedure: concurrent validity of computer-aided X-ray
digitization. J. Manip Physio Ther 1998, 21(7):460-7. (Under Abstracts)

344. Troyanovich SJ (Harrison) et al., Chiropractic biophysics digitized radiographic

mensuration analysis of the anteroposterior lumbopelvic view: a reliability study. J.
Manip Physio Ther 1999 Jun, 22:5, 309-15. (Under Abstracts)

345. Van Tulder MW (Assendelft) et al., Spinal radiographic findings and nonspecific low back
pain. A systematic review of observational studies. Spine 1997 Feb 15; 22(4):427-34.

346. Vogt, M., Rubin, D. et al: Lumbar Olisthesis and Lower Back Symptoms in Elderly White
Women- The Study of Osteoporosis Fractures. SPINE 23(23), 1998.

347. Wiegand R, Wilke, S.: Creating a biomechanical travel card that illustrates the
segmental, regional and global organization of the spinal system. 16th Annual Upper
Cervical Conference, Nov. 20-21, 1999, Life University.

348. Wiegand R, Wilke, S.: Quantitative Assessment of form and function of the cervical
spine in the sagittal plane. 16th Annual Upper Cervical Conference, Nov. 20-21, 1999,
Life University, Marietta, GA

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349. Wiegand R, Wilke ST: Graphical analysis and frequency distribution of dysfunctional
motion segments of the cervical spine in the sagittal plane. J of Chiropractic Education,
1999, 13(1):50-51.

350. Wirtz DC et al., Errors of computer-assisted migration analysis in conventional

radiographs of femoral hip implants-an experimental study. Archives of Orthopaedic and
Trauma Surg. 1999, 119(1/2):50-56.

351. Yi-Kai, L. et al: Diagnostic Value on Signs of Subluxation of Cervical Vertebras with
radiological Examination. J. Manip Physio Ther 22(9), 1998.

352. Troyanovich SJ, Sanghak O Harrison, Harrison DD, Harrison DD, Payne MR, Taduesz
J. Janik, Holland B. Chiropractic biophysics digitized radiographic mensuration analysis
of the anteroposterior lumbopelvic view: A reliability study. J. Manip Physio Ther 1999;
22(5): 309-315

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SECTION 4: CLINICAL IMPRESSION AND ASSESSMENT

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

Practitioners should develop a method of patient assessment which includes a

sufficient diversity of findings to support the clinical impression as related to vertebral
subluxation. 1-24 In this regard, it is considered inappropriate to render an opinion
regarding the appropriateness of chiropractic care without a chiropractic assessment,
including a physical examination of the patient by a licensed chiropractor. When
management of patient care is carried out in the collaborative setting, the chiropractor as
a primary contact health care provider is the only professional qualified to determine the
appropriateness of chiropractic care. The unique role of the chiropractor is separate
from other health disciplines, 25-35 and should be clarified for both the patient and other
practitioners. The patient assessment, specific to the technique practiced by the
chiropractor, 36- 50 should minimally include a biomechanical and neurophysiological
component. It is inappropriate to make a retrospective determination of the clinical need
for care rendered prior to the assessment.

Commentary (Unchanged)

The procedures employed in the chiropractic assessment may include some or all of the,
but are not limited to the following:

Physical examination:
Palpation (static osseous, static muscle, motion)
Range of motion
Postural examination
Comparative leg length (static, flexed, cervical syndrome)
Manual muscle tests
Nerve function tests
Mental status examination and psychosocial assessment

Instrumentation examination:
Range of motion
Thermography
Temperature reading instruments
Muscle testing
Electromyography
Pressure algometry
Nerve-function tests
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Electroencephalography and brain mapping

Bilateral and four quadrant weight scales
Heart Rate Variability

Imaging examination:
Spinography
Videofluoroscopy
Computerized tomography
Magnetic resonance imaging
Radiographic Digitizing Analysis

Following the determination of a clinical impression, the patient should be made aware of the
findings and consent to the proposed plan of care.

Literature support for the use of these technologies may be found in the chapter on chiropractic
examination, instrumentation and diagnostic imaging (Chapters 1-2).

*See Chapters on Instrumentation and Imaging for related Commentary and references

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4.1 RECORD KEEPING

Sub-Recommendation (unchanged) Rating: Established

Evidence: E, L

Since record-keeping practices may be technique/method specific and may

depend on the practice objective of the practitioner, chiropractors should develop a
method of reporting the care they provide to their patients that is consistent with their
practice objectives. Record keeping systems for practitioners who limit their care to the
analysis and correction of vertebral subluxation should minimally reflect the
segments/regions adjusted and the techniques or methods employed if they are not self-
evident. Other pertinent information may be included on an as needed basis.

*This Sub-recommendation is in no way meant to contradict other recommendations

made in these Guidelines that address issues related to Outcome Assessment, History
and Examination, Duration of Care and Instrumentation.

Commentary

Since the determination of the necessity for past, present and future care can only be
made when all relevant information is contained in the patient records, the issue of record
keeping is an important one.

Many chiropractors provide care solely directed at addressing vertebral subluxation and
its related components. The record-keeping practices of these chiropractors will normally
contain descriptions of the care that is unique to his/her particular method or technique system.
These methods for recording subluxation and their correction can be highly idiosyncratic. These
recordings should be considered acceptable as long as they adequately describe the care being
provided to reduce, correct or stabilize the subluxation.

Attending chiropractors should not need to provide anything more than a simple legend
that describes any non-standard abbreviations or descriptions regarding their note taking. Notes
indicating the level(s), type, positions, listing, coordinates of subluxation(s) should be
considered adequate. Notes may also contain information regarding the methods used to
correct the subluxation(s). If a particular method is to be used on each visit it should not be
considered necessary that the attending chiropractor describe this each and every visit as this
would be redundant. Brief notations as to any deviation from the plan should be considered
adequate.

In many cases chiropractors are expected or required to structure their notes in an

S.O.A.P type format. However, if a patient is undergoing "wellness" type care, does not present
with symptoms, and is purely undergoing subluxation analysis and resultant reduction it may not
be always be necessary to provide subjective reports (S) from the patient and/or a detailed

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assessment (A). The notes in such a case may only indicate the information pertaining to the
objective, subluxation oriented chiropractic findings and the resultant plan to correct them during
that visit. The assessment (A) might be considered redundant in such a case since this
information (listings, coordinates, segments adjusted etc) may exist in the objective (O) section.
Further, if the practice objective of the chiropractor is narrowly focused on subluxation then the
practitioner may not have a listing of diagnoses other than subluxation and these might be listed
in the objective section already. More detailed assessments as to long term response to care
may be handled during re-examinations. Chiropractic spinal evaluation, evaluation for
subluxation and other similar terms should be considered an appropriate subjective (O) notation
when applicable.

Beyond the plans (P) for that particular visit additional notations regarding future plans
may or may not be necessary depending on the type of care or method being rendered. Simply
noting that the patient should return as needed (PRN) should be considered acceptable
depending on the nature of the case.

Other note taking formats should be considered acceptable such as DAP notes.

D = DATA
A= ASSESSMENT
P= PLAN

In this system the subjective and objective portions of the note are combined and might
be more amenable to chiropractic note-taking where the practitioner’s goals revolve more
around wellness care. Other similar methods of note taking should be considered acceptable as
long as pertinent information is provided. The use of abbreviated notations, examination
checklists, and computerized notation systems should be encouraged and considered
acceptable as long as patient care is not compromised.

The construction of detailed narrative reports or progress reports may be advantageous

in a situation involving litigation or reporting to a third party for various reasons. If this is
necessary for the third party to make a decision regarding payment or some other need, then
the requesting party should expect to compensate the attending chiropractor for their time, effort
and energy expended to compile such a detailed report. Administrative costs and time
associated with the recording, storage, copying and retrieval of patient records, if overly
burdensome, can interfere with what is best for the patient, may distract the doctor from the task
at hand, and use up valuable resources.

The performance and/or recording of extraneous examination procedures that are not
germane to the evaluation of a particular patient should be discouraged as this wastes time,
money and energy and adds nothing to the patient's health benefit. This would include any
mandate that an attending chiropractor perform some predetermined procedure(s) such as
provocative orthopedic manoeuvres or extensive neurological examination procedures,
especially if these procedures have been shown to be unreliable or invalid.

The determination of the need for such procedures should be made on a case by case
basis and considered necessary only if indicated by the patient's presenting complaints or if a

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need becomes apparent through the patient history or initial examination findings and so long as
they are consistent with the chiropractor’s practice objective.

If the performance of a particular examination procedure will add nothing to the

determination of what the attending chiropractor is going to do with the patient then it should be
apparent that this procedure is not necessary in the care of that particular patient.

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16. Hospers LA, Sweat RW, Hus L, et al. Response of a three year old epileptic child to
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18. Wagnon, R. Finally, an objective instrument for assessing the effects of chiropractic
intervention. Am Chiro 1991; 13(2):20-22.
19. La Francis, M. A chiropractic perspective of atlantoaxial instability in Down’s syndrome. J
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Manipulative Physiol Ther 1990; 13(3):157-160.

20. Whittingham W, Ellis W, Molyneux T. The effects of manipulation (toggle recoil technique)
for headaches with upper cervical joint dysfunction: A pilot study. J Chiro 1994; 17(6):369-
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Physiol Ther 1995; 18(5):293-297.
24. Williamson S. Effect of unilateral spinal adjustments on goniometrically-assessed cervical
lateral-flexion end-range asymmetries in otherwise asymptomatic subjects. J Manipulative
Physiol Ther 1990; 13(7):418.
25. Leach RA. The chiropractic theories: A synopsis of chiropractic research, 2nd ed. Williams
& Wilkins, Baltimore, MD, 1986.
26. Palmer DD. The science, art and philosophy of chiropractic. Published by the author,
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27. Palmer BJ. The science of chiropractic. Palmer School of Chiropractic, Davenport, IA,
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28. Jamison J. Chiropractic as conventional health care. J Aust Chiro Assoc 1989; 15(2):55-
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29. Janse J. Chiropractic and children. J Can Chiro Assoc 1979; 23(3).
30. Ressel OJ. Chiropractic and children: A rationale for care. Intl Rev Chiro 1986; 42:44-50.
31. Schneier M, Burns R. Atlanto-occipital hypermobility in sudden infant death syndrome.
Chiropractic (J Chiro Res Clin Inves) 1991; 7(2):33-38.
32. Vear H. The role of chiropractic in preventive health care. J Can Chiro Assoc 1974;
18(4):10-3.

33. Webster LL. Subluxation at birth and early childhood. Int’l Chiro Pediatric Assoc, Stone
Mountain, GA, 1989.
34. Sawyer C, Bergmann T, Good D. Attitudes and habits of chiropractors concerning
referral to other health care providers. J Manipulative Physiol Ther 1988; 11:480-483.
35. Seventh Report to the President & Congress on the Status of Health Personnel. U.S.
Dept. of Health and Human Services, 1990.

36. Souza T: Which orthopedic tests are really necessary?" In: Lawrence DJ (Ed):
"Advances in Chiropractic. Volume 1. Chicago. Mosby, 1994.

37. McCarthy KA: Improving the clinician's use of orthopedic testing: an application to low
back pain. Top Clin Chiropr 1994; 1(1):42.

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38. Deyo RA, Rainville J, Kent DL: What can the history and physical examination tells us
about low back pain? JAMA 1992; 268(6):760.

39. Walsh MJ: Evaluation of orthopedic testing of the low back for nonspecific lower back
pain. J. Manip Physio Ther 1998; 21(4):232.

40. Van den Hoogen HM, Koes BW, van Eijk JT, Bouter LM: On the accuracy of history,
physical examination, and erythrocyte sedimentation rate in diagnosing low back pain in
general practice. Spine 1995; 20(3):318.

41. Potter NA, Rothstein JM: Intertester reliability for selected clinical tests of the sacroiliac
joint. Phys Ther 1985; 65(11):1671.

42. Maigne JY, Aivaliklis A, Pfefer F: Results of sacroiliac pain provocation tests in 54
patients with low back pain. Spine 1996; 21(16):1889.

43. Cote P, Kreitz B, Cassidy J, Thiel H: The validity of the extension-rotation test as a
clinical screening procedure before neck manipulation: a secondary analysis. J. Manip
Physio Ther 1996; 19:159.

44. Terrett AGJ: Vertebrobasilar stroke following manipulation. NCMIC, Des Moines, 1996.
Page 32.

45. Wheeler JD. Diagnosis: Poverty Complex. The American Chiropractor, 1998; May/June:
14

46. Barge FH. Diagnosis-Is there a middle ground? Today’s Chiropractic, 1998; July/August:
104-105

47. Barge FH. Diagnosis and responsible doctoring. Today’s Chiropractic, 1998;
September/October: 110-112

48. McMillin AD. The role of diagnostic instrumentation in the evaluation of spine trauma.
Top Clin Chiro, 1998; 5(3); 46-53

49. Caputo LA, Cusimano MD, Steiman I. A Study of the Frequency of Delayed Diagnosis of
Neurological Conditions by Primary Contact Health Care Providers. Journal of
Chiropractic Education. 1997 MAR; 10(4): 81-86

50. Injeyan HS, Gotlib AC, Crawford JP. The Clinical Laboratory in Chiropractic Practice:
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DEC; 41(4): 221-230

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SECTION 5 REASSESSMENT AND OUTCOMES ASSESSMENT

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

Determination of the patient’s progress must be made on a per-visit and periodic

basis. This process provides quantitative and qualitative information regarding the
patient’s progress which is utilized to determine the frequency and duration of
chiropractic care. Per-visit reassessment should include at least one analytical
procedure previously used. This chosen testing procedure should be performed each
time the patient receives chiropractic care.

Concomitant with this process, the effectiveness of patient care may also be
monitored through the development of an outcomes assessment plan. Such a plan may
utilize data from the patient examination, assessment and reassessment procedures.
Patient-reported quality of life instruments, mental health surveys, and general health
surveys are encouraged as part of the outcomes assessment plan. The analysis of data
from these sources may be used to change or support continuation of a particular
regimen of patient care and/or change or continue the operational procedures of the
practice.

Commentary

The reassessment provides information to determine the necessity of an adjustment on

a per-visit basis. Partial reassessment involves duplication of two or more preceding positive
analytical procedures. Full reassessment involves duplication of three or more preceding
positive analytical procedures. Any additional or complementary analytical procedures should
be performed as indicated by the patient’s clinical status. The frequency of partial and full
reassessments should be at the discretion of the practitioner, consistent with the objectives of
the plan of care.
A substantial body of literature attests to the methods and significance of measuring
outcomes.1-104 For the practicing chiropractor the implication is that regular evaluations of
practice and procedures provides a form of quality control. Outcomes assessments can alert
the practitioner to problems with, as well as reinforce aspects of practice which might otherwise
be overlooked. In addition, on-going evaluation provides information about the clinical value of
care to both patients and third-party providers. It is important to point out that there is no one
“ideal” way to assess outcomes. While the responsibility to conduct this type of assessment
rests with the chiropractor, so does the choice of how it is to be implemented.

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measurements. J Can Chiro Assoc 1982; 26(3):97-100.
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34. Cooperstein R, Gardner R, Hansel D. Concordance of two methods of motion
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38. Diakow P. Thermographic assessment of sacroiliac syndrome: report of a case. J Can

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39. Dreyer P, Lantz CA. Chiropractic management of herniated disc. Restoration of disc
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42. Flesia J. The vertebral subluxation complex: an integrative perspective. ICA Intl Rev
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43. Granger M, McDowell S. An investigation of the effect of chiropractic treatment upon
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44. Grostic J. Roentgenographic measurement of Atlas laterality and rotation: a
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45. Haas M, Nylendo J. Lumbar motion trends and correlation with low back pain. A
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46. Haas M, Nylendo J. Diagnostic utility of the McGill questionnaire and the Oswestry
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47. Haldeman S. Spinal manipulation therapy in the management of low back pain. HE
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48. Hansen D. Development and use of clinical algorithms in chiropractic. J Manip Physiol
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49. Gerzog W, Conway P, Willcox B. Effects of different treatment modalities on gait
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50. Homewood AE. The neurodynamics of the vertebral subluxation complex, 3rd ed.
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51. Hsieh J, Phillips R. Reliability of manual muscle testing with a computerized
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53. Jaeschke R, Singer J, Guyatt G. A comparison of seven-point and visual analog scales:
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58. Keating JC. Rationalism and empiricism vs. the philosophy of science in chiropractic.
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59. Kent C, Gentempo P. The documentary basis for diagnostic imaging procedures in the
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61. Koss I. The spinal cord as organizer of disease, Process I. J Am Osteo Assoc 1976;
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63. Lawlis G, Cuencas R, Selby D, McCoy C. The development of the Dallas Pain
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64. Lovell F, Rothstein J, Personius W. Reliability of clinical measurements of lumbar
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65. Manello D. Leg length inequality: a review. Proc Sixth Annual Conf on Research and
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67. Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical
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70. Nansel DD, Peneff A, Quitoriano J. Effectiveness of upper vs. lower cervical
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71. Nylendo J, Haas M, Jones R. Using the SF-36D (General Health Questionnaire) in a
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23, 1991.
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75. Russell G, Raso V, Hill D, McIvor J. A comparison of four computerized methods for
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76. Sandoz R. Some physical mechanisms and effects of spinal adjustments. Ann Swiss
Chiro Assoc 1976; 6(2):91-142.
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79. Sharpless SK. Susceptibility of spinal roots to compression block. Res Status of Spinal
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92. Boone WR, Dobson GJ. A proposed vertebral subluxation model reflecting traditional
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95. Hagino C, Papernick L. Test-retest reliability of the ‘CMCC low back status
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99. Whitton M. Outcomes assessment: its relationship to chiropractic and
managed health care. J Chiro 1994; 31(7)37-40.
100. Stano M. A comparison of health care costs for chiropractic and
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101. McCoy M. Subluxation and objective outcome assessment procedures in

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102. Yeoman’s SG, Liebensen C. Quantitative functional capacity evaluation: The missing
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SECTION 6: MODES OF ADJUSTIVE CARE

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

Adjusting procedures should be selected which are determined by the practitioner

to be safe and effective for the individual patient. No mode of care should be used which
has been demonstrated by critical scientific study and field experience to be unsafe or
ineffective in the correction of vertebral subluxation.

Commentary
This chapter is concerned with the modes of adjustive care (techniques) associated with the
correction of vertebral subluxation. The literature reveals many articles on adjusting modes.
These articles include technique descriptions, various applications of techniques, and reliability
studies usually assessing inter- and intra-examiner reliability. A number of review articles
provide discussion of the modes of care. Available research data has been complemented with
professional opinion, derived from two separate forums of chiropractic experts’ The International
Straight Chiropractic Consensus Conference, Chandler, Arizona (1992) and the Council on
Chiropractic Practice Symposium on Chiropractic Techniques, Phoenix, Arizona, (1996), both of
which served to validate procedures by common knowledge and usage.

The intent of this chapter is not to include nor exclude any particular technique, but rather to
provide a guideline, drawing upon the commonality of various techniques, which contributes to
the chiropractic objective of correcting vertebral subluxation. Any technique which does not
espouse the correction of subluxation would be considered outside the scope of the Guidelines.

A list of descriptive terms and definitions related to chiropractic adjustive care as

commonly practiced follows:

Adjustment: The correction of a vertebral subluxation.

Adjustic Thrust: The specific application of force to facilitate the correction of

vertebral subluxation.

Adjusting Instruments: Fixed or hand-held mechanical instruments used to deliver

a specific, controlled thrust to correct a vertebral subluxation.

Amplitude: Magnitude; greatness of size or depth.

Blocking Technique: The use of mechanical leverage, achieved through positioning of the
spine or related structures, to facilitate the correction of vertebral subluxation.

Cleavage: The movement of one vertebra between two other vertebrae.

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Concussion: An adjustic thrust produced by arrested momentum.

Momentum is the result of weight (mass) in motion and also of speed. An
adjustic concussion depends more on speed than mass.

High Velocity Thrust with Recoil: A controlled thrust delivered such that the
time of impact with the vertebra coincides with the chiropractor’s contact
recoil, thus setting the vertebra in a specific directional motion.

Impulse: A sudden force directionally applied to correct a malpositioned joint.

Low Velocity Thrust with Recoil: A controlled thrust administered at low

speed with a sudden pull-off by the practitioner, setting the segment in
motion.

Low Velocity Thrust without Recoil: A controlled thrust administered at low

speed coupled with a sustained contact on the segment adjusted.

Low Velocity Vectored Force without Recoil: A short or long duration

(usually ranging from 1 to 20 seconds) contact with the segment being
adjusted, with or without a graduation of force.

Manually Assisted Mechanical Thrust: A manually delivered specific thrust

enhanced by a moving mechanism built into the adjusting table.

Manipulation: The taking of a joint past its passive range of motion into the
paraphysiological space but not past the anatomic limit, accompanied by
articular cavitation (Kirkaldy-Willis). It is not synonymous with chiropractic
adjustment, which is applied to correct vertebral subluxation.

Multiple Impulse: Impulses delivered in rapid succession.

Recoil: The bouncing or springing back of an object when it strikes

another object.

Tone: The normal degree of nerve tension.

Thrust: The act of putting a bony segment in motion using a directional force.

Toggle: A mechanical principle wherein two levers are hinged at an elbow

giving mechanical advantage. Combinations of toggles may be used to
multiply or strengthen mechanical advantage.

Toggle Recoil with Torque: A method of using the toggle with rotation (twist) as the
toggle straightens, causing the adjusting contact to travel in a spiral path.

Torque: A rotational or twisting vector applied when adjusting certain vertebral

subluxations.

Velocity: The speed with which a thrust is delivered.

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Attempts have been made by certain regulatory and licensing agencies, state boards,
insurance companies and managed care organizations to categorize certain chiropractic
technique systems as more efficacious than others. These categorizations are then used to
disallow the use of the technique, deny entrance into a managed care program or sanction the
chiropractor for utilizing such a technique. Many times these categorizations are based upon
such items as whether they are part of the regular educational program at chiropractic
institutions and/or are substantiated by the existence of peer reviewed literature.

Since the Missions of chiropractic educational institutions and programs are not uniform,
it is unrealistic to expect that all institutions would expose their students to specific techniques.
Further, additional techniques are offered through the post graduate programs of many
chiropractic institutions, state association conventions and various other educational programs
affiliated with the profession.

Since there are purported to be over 300 named techniques in use within the profession
it is unrealistic to expect that every chiropractor would be proficient in each of these techniques.
Lastly, these 300 plus techniques have not been compared to one another in such a fashion
that any individual or group could ascertain that one technique is more efficacious than another.

Given the state of research regarding the efficacy of techniques and technique systems
the best empirical evidence suggests that direct and indirect measures of outcome related to
vertebral subluxation and its components are the manner to best determine efficacy of
technique application. Examples of these include various health outcomes, physical,
biomechanical and physiological measurements – many of which are discussed in these
guidelines.

Conclusion
Considerable evidence substantiates the adjustment being administered for the purpose of
correction of vertebral subluxation.1-11 Studies regarding the different modes 4, 12-521 compare
low force methods to those employing a high velocity thrust without recoil, and low velocity
vectored force without recoil, high velocity thrust with recoil, low velocity thrust with and without
recoil, manually and mechanically assisted thrusts, blocking techniques, and sustained force.
These studies are often presented in the context of effects on various physical and
physiological parameters. Although providing useful information, the majority of these studies
are limited by uncontrolled variables and lack of statistical power. They do, however,
demonstrate that the application of various modes of adjustive care is accompanied by
measurable changes in physical and physiological phenomena. The importance of this
information, in terms of its linkage to processes used by the body in the correction of
subluxation, will be assessed through continued research.

The CCP guidelines consider the modes of adjustive care that are 1) in common usage,
and 2) which adhere to one or more of the descriptive terms presented in this chapter, as
appropriate for correction of subluxation. However, studies regarding their theoretical basis and
efficacy are often conducted by advocates of (those practicing or instructing) the respective
techniques. While the information attained in the numerous investigations is not in question,
since many of the studies have not passed the scrutiny of peer and editorial review, it is
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suggested that the advocates of particular modes of adjustive care encourage research by
chiropractic colleges, independent universities and other facilities to extend the level of
credibility already achieved.

Continuing research and reliability studies are necessary to better understand and
refine the underlying mechanisms of action common to the various modes of adjustive care. In
addition, it is suggested that more observational and patient self-reporting studies be conducted
which deal with quality of life assessments and overall “wellness,” to demonstrate the pattern of
health benefits which heretofore have been the purview of the patient and the practitioner. A
conference sponsored by U.S. Department of Health and Human Services, Public Health
Service Agency for Health Care Policy and Research, proposed many different approaches for
studying the effects of treatments for which there is no direct evidence of health outcomes. 522

The CCP recognizes that many subluxation-based chiropractors do not adhere, in totality,
to the current hypothetical model thus far described. These practitioners consider two
additional components. One is interference with the transmission of nonsynaptic neurological
information which is homologous to the Palmer concept of mental impulse. The other limits the
misalignment component of the subluxation to the vertebrae and their immediate articulations.
While these practitioners may adhere to some concepts of other subluxation models, their
practice objectives are based on correction of the vertebral subluxation as proposed by Palmer,
which has recently been elaborated by Boone and Dobson.523-525

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55. Epstein D. Network spinal analysis: A system of health care delivery within the subluxation-
based chiropractic model. Journal of Vertebral Subluxation Research, 1996; 1(1):3.
56. Cox JM. Managing low back pain cases with distraction adjustment procedures. Today’s
Chiro 1993; 22:48-54.
57. Turchin C. Light force techniques for children: An introduction to gentle adjusting
techniques for the lower extremity. ICA Review 1993; 49:21-27.
58. Bergmann TF. Various forms of chiropractic technique. Chiropractic Technique 1993; 5:53-
55.
59. Bergmann TF. Short lever, specific contact articular chiropractic technique. J Manipulative
Physiol Ther 1992; 15:591-595.
60. Triano JJ. Studies on the biomechanical effect of a spinal adjustment. J Manipulative
Physiol Ther 1992; 15:71-75.
61. Bergmann TB, Peterson DH, Lawrence DJ. Chiropractic Technique. New York, Churchill
Livingstone 1993; 127-128.

62. Cremata EE, Plaugher G, Cox WA. Technique system application: The Gonstead
approach. Chiropractic Technique 1991; 3:19-25.
63. Good C. An analysis of diversified (lege artis) type adjustments upon the assisted-resisted
model of intervertebral motion unit prestress. Chiropractic Technique 1992; 4:117-123.
64. Evans DP, Burke MS, Lloyd KN, et al. Lumbar spinal manipulation on trial: 1. Clinical
assessment. Rheum Rehabil 1978; 17:46-53.
65. Tran TA, Kirby JD. The effectiveness of upper cervical adjustment upon the normal
physiology of the heart. ACA J Chiro 1977; XIS:58-62.
66. Briggs L, Boone WR. Effects of a chiropractic adjustment on changes in pupillary diameter:
A model for evaluating somatovisceral response. J Manipulative Physiol Ther 1988; 11:181-
189.
67. Palmer DD. The chiropractor’s adjuster, the science, art and philosophy of chiropractic.
Portland, Ore. Portland Printing House, 1910.
68. VanRumpt R. Directional non-force technique notes. Beverly Hills, Calif, Directional Non-
Force Technique, 1987.
167
 CCP Guidelines 3rd Edition 2008

69. Osterbauer PJ, Fuhr AW. The current status of activator methods chiropractic technique,
theory, and training. Chiropractic Technique 1990; 2:168.
70. Bartol KM. A model for the categorization of chiropractic treatment procedures.
Chiropractic Technique 1991; 3:78.
71. Kaminski M, Boal R, Gillette RG, et al. A model for the evaluation of chiropractic methods.
J Manipulative Physiol Ther 1987; 10:61.
72. Kaminski M. Evaluation of chiropractic methods. Chiropractic Technique 1990; 2:3.
73. Osterbauer PJ, Fuhr AW, Hildebrandt RW. Mechanical force manually adjusted short lever
chiropractic adjustment. J Manipulative Physiol Ther 1992; 15:309-317.
74. Smith DB, Fuhr AW, Davis BP. Skin accelerometer displacement and relative bone
movement of adjacent vertebrae in response to chiropractic percussion thrusts. J
Manipulative Physiol Ther 1989; 12:26-37.
75. Triano JJ. The biomechanics of the chiropractic adjustment. J Manipulative Physiol Ther
1992; 15:71-75.
76. Van Rumpt R. Directional non-force technique notes. In Directional Non-Force Technique.
Beverly Hills, Calif, 1987.
77. Thompson C. Technique Reference Manual. Thompson Educational Workshops. Ill, SM &
Williams Manufacturing, 1987.

78. Nansel DD, Waldorf The, Cooperstein R. Effect of cervical spinal adjustments on lumbar
paraspinal muscle tone: Evidence for facilitation of intersegmental tonic neck reflexes. J
Manipulative Physiol Ther 1993; 16:91-95.
79. Hessel BW, Herzog W, Conway PIW, et al. Experimental measurement of the force exerted
during spinal manipulation using the Thompson technique. J. Manipulative Physiol Ther
1990; 13:448-453.
80. Herzog W. Biomechanical studies of spinal manipulative therapy. J Can Chiro Assoc
1991; 35:156-164.
81. Kawchuk GN, Herzog W, Hasleer EM. Forces generated during spinal manipulative
therapy of the cervical spine. J Manipulative Physiol Ther 1992;15:275-278.
82. Gal JM, Herzog W, Kawchuk G, et al. Movements of vertebrae during PA adjustment to
unembalmed cadavers. Proceedings of the 1993 International Conference on Spinal
Manipulation, Montreal, Foundation of Chiropractic Education and Research, 1993; 15.
83. Herzog W, Gal J, Conway P, et al. Vertebral movement during spinal manipulative therapy.
Proceedings of the 1993 International Conference on Spinal Manipulation, Montreal,
Foundation of Chiropractic Education and Research,
1993; 14.
84. Lee M, Svensson NL. Effect of loading frequency response of the spine to lumbar
posteroanterior forces. J Manipulative Physiol Ther 1993; 16:439-446.
85. Wood J, Adams AA, Hansmeter D. Force and time characteristics of Pierce technique
cervical adjustments. Chiropractic: J Chiro Research and Clinical Investigation 1994; 9:39-
44.
86. Bergmann TF. Chiropractic technique: An overview. Advances in Chiropractic 1995; 2:429-
431.
168
 CCP Guidelines 3rd Edition 2008

87. Activator Methods Chiropractic Technique [Book Review] by Arlan W. Fuhr, John R.
Green, Christopher J. Colloca and Tony S. Keller. Todays Chiro Jan/Feb 1997; 1(26):
112.

88. Ahadpour A. J Changes in Brain Function after Manipulation of the Cervical Spine
[Letter; Comment]. Manip Physiol Ther Sep 1998; 7(21) 495.

89. Alattar M, Webster SK. Literature Review: Mechanisms of Physiological Responses to

Chiropractic Adjustment. CRJ Spr 1999; 1(6): 14-22.

90. Alcantara Joel, Heschong R, Plaugher G, Alancantara Joey. Chiropractic management

of a patient with subluxations, low back pain and epileptic seizures. J. Manip Physio
Ther 1998; 21(6): 410-418

91. Alcantara Joel, Plaugher G, Klemp DD, Salem C. Chiropractic care of a patient with
Temporomandibular disorder and Atlas Subluxation. J. Manip Physio Ther 2002; 25(1):
63-70

92. Alcantara Joel, Plaugher G, Thornton RE, Salem C. Chiropractic Care of a patient with
Vertebral Subluxation and unsuccessful surgery of the cervical spine. J. Manip Physio
Ther 2001; 24(7): 477-482

93. Alcantara Joel, Steiner DM, Plaugher G, Alcantara Joey. Chiropractic management of a
patient with Myasthenia Gravis and Vertebral Subluxation. J. Manip Physio Ther 1999;
22(5): 333-340

94. Alcantra J, Plaugher G, Abblett DE. Management of a patient with a lamina fracture of
the sixth cervical vertebra and concomitant subluxation. J. Manip Physio Ther 1997;
20(2): 113-123

95. Amalu WC. Upper Cervical Management of Primary Fibromyalgia and Chronic Fatigue
Syndrome Cases. Todays Chiro May/June 2000; 3(29): 76-86.

96. Anderson AV. Changes in Brain Function after Manipulation of the Cervical Spine
[Letter; Comment]. J Manip Physiol Ther Sep 1998; 7(21): 498-499.

97. Andrew, TL. Improvements in Motion and Pain Scores after Cervical Manipulation in a
Professional Acrobat with Acute Cervical Zygapophyseal Joint Pain. J Sports Chiro &
Rehab Dec 2000; 4(14): 111-117.

98. Annis RS. Activator Methods Chiropractic Technique [Book Review] by Arlan W Fuhr,
John R. Green, Christopher J. Colloca, Tony S. Keller. J. Can. Chiro. Assoc. Jun 1999;
2 (43): 126-127.

169
 CCP Guidelines 3rd Edition 2008

99. Anthony DL. Flexion-distraction: Motorized or non-motorized? Am Chiro Jul/Aug 1998;

4(20): 20-22+.

100. Backhouse DP, Kelly DD, Murphy BA. Use of a Mental Rotation Reaction-time Paradigm
to Measure the Effects of Upper Cervical Adjustments on Cortical Processing: a Pilot
Study. J Manip Physiol Ther May 2000; 4(23): 246-251.

101. Bagnell LC, Gardner-Bagnell K. Analysis and Adjustment for Breech Presentations.
Todays Chiro Mar/Apr 1999; 2(28): 54-57.

102. Bakker M. Clinical Brief: Does An Audible Release Improve The Outcome Of A
Chiropractic Adjustment? [Case Report; Review]. J Can Chiropr Assoc. 2004; 48(3):
237-239.

103. Barker D, Schneider MJ, Galioto AC. Treatment of Cervical Disc Protrusions via
Instrumental Chiropractic Adjustment. J Manip Physiol Ther Sep 1998; 7(21): 499-502.

104. Bateman C. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther May 1998; 4(21): 304.

105. Beffa R, Mathews R. Does The Adjustment Cavitate The Targeted Joint? An
Investigation Into The Location Of Cavitation Sounds. J Manipulative Physiol Ther. 2004;
27(2):Online access only 5 p.

106. Behrendt M. Reduction of psoriasis in a patient under Network Spinal Analysis care: A
case report. J. Vertebral Subluxation Res. Vol. 2, No. 4.

107. Biggs L, Colloca CJ, Mierau D, Triano JJ, Symons BP, Taylor SH, Arnold ND. A Review
Of The Literature Pertaining To The Efficacy, Safety, Educational Requirements, Uses
And Usage Of Mechanical Adjusting Devices. Part 1 Of 2 [Review]. J Can Chiropr
Assoc. 2004; 48(1):74-88.

108. Bilgrai-Cohen K, Chiropractic Treatment of the Musculoskeletal System During

Pregnancy Journal Of The American Chiropractic Association May 1997: 33-34, 90.

109. Bilton D, Gorman F, Stephens D. The Step Phenomenon in the Recovery of Vision with
Spinal Manipulation: a Report on Two 13-yr-olds Treated Together. J Manip Physiol
Ther Nov/Dec 1997; 9(20): 628-633.

110. Blum CL, "Chiropractic Treatment of Mild Head Trauma: A Case History" Proceedings of
the 2002 International Conference on Spinal Manipulation, Toronto Ontario, Canada, Oct
2002;:136-8.

170
 CCP Guidelines 3rd Edition 2008

111. Blum CL, "Incongruent sacro-occipital technique examination findings: Two unusual
case histories." Proceedings of the ACC Conference IX, Journal of Chiropractic
Education Spr 2002; 16(1): 67.

112. Blum CL, Back From the RAC Journal of the California Chiropractic Association 2000
Sep; 25(7): 14-5.

113. Blum CL, Esposito V, Esposito C, Orthopedic Block Placement and its Affect on the
Lumbosacral Spine and Discs: Three Case Studies with Pre and Post MRIs,
Proceedings of the ACC Conference X, Journal of Chiropractic Education Spr 2003;
17(1): 48.

114. Blum CL, Piera GJ, Dwyer PJ. Coughing To Release The Dura In Category Iii Patients
Experiencing Sciatica: Report Of 3 Cases. Chiropr J Aust. 2004; 34(3):82-86.

115. Blum CL, The Compendium of SOT Peer Reviewed Published Literature 1984-
2000 Journal of Vertebral Subluxation Research Nov 2002; 4(4);123-124]

116. Blum CL, Two Unusual Case Histories and Sacro Occipital Technique California
Chiropractic Association Journal Aug 2001: 28-9,32.

117. Blum, CL, "Chiropractic and Pilates Therapy for the Treatment of Adult Scoliosis",
Journal of Manipulative and Physiological Therapeutics, May 2002.; 25(4) [Full Text
JMPT Article]

118. Blum, CL, "Cranial Therapeutic Treatment of Down’s Syndrome" Chiropractic

Technique", May 1999; 11(2): 66-76.

119. Blum, CL, "Role of Chiropractic and Sacro Occipital Technique in Asthma", Journal of
Chiropractic Medicine, Mar 2002; 1(1): 16-22.:

120. Blum, CL, "Role of Chiropractic and Sacro Occipital Technique in Asthma", Chiropractic
Technique, Nov 1999; 10(4): 174-180.

121. Blum, CL, "Spinal/Cranial Manipulative Therapy and Tinnitus: A Case History,"
Chiropractic Technique, Nov 1998; 10(4): 163-8.

122. Blum, CL, Curl, DD, "The Relationship between Sacro-Occipital Technique and
Sphenobasilar Balance. Part Two: Sphenobasilar Strain Stacking," Chiropractic
Technique, Aug 1998; 10(3): 101-107.

123. Bohacek S, Jonckheere E. Chaotic modelling in Network Spinal Analysis: Nonlinear

conanical correlation with alternating conditional expectation (ACE): A preliminary report.
J. Vertebral Subluxation Res. Vol. 2, No. 4.

124. Bolton JE, Hurst H. Assessing The Clinical Significance Of Change Scores Recorded On
Subjective Outcome Measures. J Manipulative Physiol Ther. 2004; 27(1): 26-35.
171
 CCP Guidelines 3rd Edition 2008

125. Bonci AS, Verni LJ The Effect of Cranial Adjusting on Hypertension: A Case Report
[Letter; Comment] Chiropractic Technique 1998 Nov; 10(4): 179-80.

126. Boneva D, Kessinger R. Bell's Palsy and the Upper Cervical Spine. CRJ Fall 1999; 2(6):
47-56.

127. Boneva D, Kessinger R. Changes in Visual Acuity in Patients Receiving Upper Cervical
Specific Chiropractic Care. J Vert Sublux 1998; 3(2): 43-49.

128. Bortolotto J. Reflex Sympathetic Dystrophy: an Enigmatic Improvement with Spinal

Manipulation. J Can Chiro Assoc Dec 2000; 4(44): 245-251.

129. Bradley-Popovich GE. Therapeutic Modalities For Athletic Injuries [Book Review] By
Craig R. Denegar. J Chiropr Med. 2003; 2(1):41.

130. Brantingham JW, Dimou ES, Wood T. A Randomized, Controlled Trial (With Blinded
Observer) Of Chiropractic Manipulation And Achilles Stretching Vs. Orthotics For The
Treatment Of Plantar Fasciitis. J Am Chiropr Assoc. 2004; 41(9):32-42.

131. Breen AC, Evans DW. Biomechanical Model For Mechanically Efficient Cavitation
Production During Spinal Manipulation: Prethrust Position And The Neutral Zone. J
Manipulative Physiol Ther. 2006; 29(1):72-82.

132. Briggs J. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther Sep 1998; 7(21): 495.

133. Bronfort G, Assendelft WJJ, Evans R, Bouter L, Haas M. Efficacy of Spinal Manipulation
for Chronic Headache: a Systematic Review. J Manip Physiol Ther Sep 2001; 7(24):
457-466.

134. Bronfort G, Evans RL, Gay RE. Distraction Manipulation Of The Lumbar Spine: A
Review Of The Literature. J Manipulative Physiol Ther. 2005; 28(4):266-273.

135. Bronfort G, Gay RE, Ilharreborde B, Zhao Kd ,Berglund LJ, An N. The Effect Of Axial
Distraction With And Without Flexion And Extension On Nuclear Pressure And Stress
Distribution In Lumbar Intervertebral Discs [Platform Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006;
20(1):12-13.

136. Buchberger DJ. Use of Active Release Techniques in the Postoperative Shoulder: a
Case Report. J Sports Chiro & Rehab. Jun 1999; 2(13): 60-65.

172
 CCP Guidelines 3rd Edition 2008

137. Budgell BS, Igarashi Y. Response of Arrhythmia to Spinal Manipulation: Monitoring by

ECG with Analysis of Heart-rate Variability. JNMS Fall 2001; 3(9): 97-102.

138. Buhler CF. Objective Neuro-proprioceptive Muscle Testing to Define Subluxations and
the Affect of Chiropractic Adjustments on Aberrant Motor Functions. DC Tracts 1997; 4
(9): 10-15.

139. Burd D, Hoiriis KT, Owens EF. Changes in General Health Status During Upper Cervical
Chiropractic Care: a Practice-based Research Project Update. CRJ Fall 1999; 2(6): 65-
70.
140. Burke JR, Papuga O. Motor Learning And Drop Jump Techniques: Effects Of Orthotic
Intervention On Neuromuscular Adaptations And Performance Gains [Platform
Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual Conference,
2006]. J Chiropr Educ. 2006; 20(1):4.

141. Buttigieg D. Clinical Application Of Neuromuscular Techniques, Volume 2: The Lower

Body [Book Review] By Leon Chaitow And Judith Walker Delany. Australas Chiropr &
Osteopat. 2003; 11(1):39.

142. Caldwell SG, Nguyen HT, Resnick DN. Interexaminer Reliability of Activator Methods'
Relative Leg-length Evaluation in the Prone Extended Position. J Manip Physiol Ther
Nov/Dec 1999; 9(22): 565-569.

143. Cambron JA, Gudavalli MR, Mcgregor M, edlicka J, Ghanayem AJ, Patwardhan AG,
Furner SE. Amount Of Health Care And Self-Care Following A Randomized Clinical Trial
Comparing Flexion-Distraction With Exercise Program For Chronic Low Back Pain.
Chiropr & Osteopat. 2006; 14(1):Online access only 30 p.

144. Cameron M. Myofaction: Myofascial Manipulation [Book Review] By Rowland Benjamin.

Australas Chiropr & Osteopat. 2003; 11(1):40.

145. Canadian Chiropractic Association Position Statement Articular Adjustments/spinal

Manipulation. J Can Chiro Assoc Mar 1997; 1(41): 7-8.

146. Carrick FR, Lantz CA. Changes in Brain Function after Manipulation of the Cervical
Spine [Letter; Comment]. J Manip Physiol Ther Jul/Aug 1998; 6(21): 426-428.

147. Carrick FR. Changes in Brain Function after Manipulation of the Cervical Spine
[Comment]. J Manip Physiol Ther May 1998; 4(21): 300-302.

148. Carrick FR. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther May 1998; 4(21): 295-297.

173
 CCP Guidelines 3rd Edition 2008

149. Carrick FR. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther May 1998; 4(21): 302-303.

150. Carrick FR. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther May 1998; 4(21): 303-304.

151. Carrick FR. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther Sep 1998; 7(21): 496-497.

152. Carrick FR. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther Sep 1998; 7(21): 497.

153. Carrick FR. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther Sep 1998; 7(21): 498-499.

154. Carrick FR. Changes in Brain Function after Manipulation of the Cervical Spine. J Manip
Physiol Ther Oct 1997; 8(20): 529-545.

155. Chaitow L. Raymond L. Nimmo and the Evolution of Trigger Point Therapy, 1929-1986
[Letter; Comment]. J Manip Physiol Ther Oct 1998; 8(21): 575.

156. Chea H. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther Sep 1998; 7(21): 495-496.

157. Chinappi, AS, Getzoff, H, "A New Management Model for Treating Structural-based
Disorders, Dental Orthopedic and Chiropractic Co-Treatment," Journal of Manipulative
and Physiological Therapeutics, 1994; 17: 614-9.

158. Chinappi, AS, Getzoff, H, "Chiropractic/Dental Cotreatment of Lumbosacral Pain with

Temporomandibular Joint Involvement," Journal of Manipulative and Physiological
Therapeutics, Nov/Dec 1996; 19(9): 607-12.

159. Chinappi, AS, Getzoff, H, "The Dental-Chiropractic Cotreatment of Structural Disorders

of the Jaw and Temporomandibular Joint Dysfunction," Journal of Manipulative and
Physiological Therapeutics, Sep 1995; 18(7): 476-81.

160. Christensen HW, Hoilund-Carlsen PF, Licht PB. Is There a Role for Premanipulative
Testing Before Cervical Manipulation? J Manip Physiol Ther Mar/Apr 2000; 3(23): 175-
179.

174
 CCP Guidelines 3rd Edition 2008

161. Cima J, A Basic Course in the Treatment of the Cranial Sacral Mechanism, Part 1: A
Three Part Series on the Philosophy, Science and Art of Cranial Care The American
Chiropractor Mar 2001; 23(2): 42-4.

162. Cima J, A Basic Course in the Treatment of the Cranial Sacral Mechanism, Part 2: A
Three Part Series on the Philosophy, Science and Art of Cranial Care The American
Chiropractor May 2001; 23(3): 14-6.

163. Cima J, A Basic Course in the Treatment of the Cranial Sacral Mechanism, Part 3: A
Three Part Series on the Philosophy, Science and Art of Cranial Care The American
Chiropractor Jul 2001; 23(4): 40, 42-3.

164. Cima J, The Cranial Concept The American Chiropractor Jan 2001; 23(1): 45-6.

165. Clecak P. Giving patients “ reasonable counsel:” The case of contact reflex analysis
(CRA). The American Chiropractor, 1996; September/October: 13,23,52,60

166. Clecak P. Giving patients “reasonable counsel:” The case of contact reflex analysis
(CRA). The American Chiropractor, 1996; July/August: 18, 20, 21, 23, 53

167. Clemen MJ. Mobilizing Adjustments for the Geriatric Spine. ICA Review Jun 1999; 3
(55): 48-53.

168. Cohen JH. Raymond L. Nimmo and the Evolution of Trigger Point Therapy, 1929-1986
[Letter; Comment]. J Manip Physiol Ther Oct 1998; 8(21): 575.

169. Coleman R, Harrison D, Fischer T, Harrison O. Correlation and quantification of Relative

2-Dimensional Projected Vertebral Endplate Z-Axis rotations with 3-dimensional Y-axis
vertebral rotations and focal spot elevations. J. Manip Physio Ther 2000, 23(6): 414-419

170. Coleman RR, Harrison DE, Bernard BB. The effects of combined x-axis translations and
y-axis rotation on projected lamina junction offset. J. Manip Physio Ther 2001; 24(8):
509-513

171. Collins DL, Evans JM, Grundy RH. Pilot Study Of Patient Response To Multiple Impulse
Therapy For Musculoskeletal Complaints. J Manipulative Physiol Ther. 2006; 29(1):pp.
Online access only 7 p.

172. Collins DL, Evans JM, Grundy RH. The Efficiency Of Multiple Impulse Therapy For
Musculoskeletal Complaints. J Manipulative Physiol Ther. 2006; 29(2):pp. Online access
only 9 p.

173. Colloca CJ, Fuhr AW, Keller TS. Validation of the Force and Frequency Characteristics
of the Activator Adjusting Instrument: Effectiveness as a Mechanical Impedance
Measurement Tool. J Manip Physiol Ther. Feb 1999; 2(22): 75-86.

175
 CCP Guidelines 3rd Edition 2008

174. Colloca CJ, Fuhr AW. Movements of Vertebrae During Manipulative Thrusts to
Unembalmed Human Cadavers. Letter. J Manip Physiol Ther Feb 1998; 2(21): 128-129.

175. Colloca CJ, Harrison DD, Harrison DD, Keller TS, Normand MC, Black P. Comparison
Of Mechanical Force Of Manually Assisted Chiropractic Adjusting Instruments. J
Manipulative Physiol Ther. 2005; 28(6):414-422.

176. Colloca CJ, Harrison DD, Harrison DE, Keller TS, Moore RJ. Three-Dimensional
Vertebral Motions Produced By Mechanical Force Spinal Manipulation. J Manipulative
Physiol Ther. 2006; 29(6):425-436.

177. Colloca CJ, Harrison DE ,Keller TS, Gunzburg R, Moore RJ. Three-Dimensional
Intersegmental Motion Validation Of Mechanical Force Spinal Manipulation [Platform
Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual Conference,
2006]. J Chiropr Educ. 2006; 20(1):27.

178. Colloca CJ, Keller TS, Gunzburg R. Biomechanical And Neurophysiological Responses
To Spinal Manipulation In Patients With Lumbar Radiculopathy. J Manipulative Physiol
Ther. 2004; 27(1):1-15.

179. Colloca CJ, Keller TS. Stiffness and Neuromuscular Reflex Response of the Human
Spine to Posteroanterior Manipulative Thrusts in Patients with Low Back Pain. J Manip
Physiol Ther Oct 2001; 8(24): 489-500.

180. Colloca CJ, Polkinghorn BS. Chiropractic Treatment of Coccygodynia via Instrumental
Adjusting Procedures Using Activator Methods Chiropractic Technique. J Manip Physiol
Ther. Jul/Aug 1999; 6(22): 411-416.

181. Connelly, DM, Rasmussen, SA, "The Effect of Cranial Adjusting on Hypertension: a
Case Report," Chiropractic Technique, May 1998; 10(2): 75-78.

182. Conway P J. Clinical Biomechanics of Spinal Manipulation [Book Review] by Walter

Herzog. Can Chiro Assoc Mar 2001; 1(45): 66.

183. Conway, CM; Chiropractic Care Of A Pediatric Glaucoma Patient: A Case Study Journal
of Clinical Chiropractic Pediatrics. 1997 Oct; 2(2): 155-6.

184. Cooperstein R, Fuhr AW, Lantz C, Perle SM, Schneider MJ. Rating Specific Chiropractic
Technique Procedures For Common Low Back Conditions [Letter; Comment]. J
Manipulative Physiol Ther. 2003; 26(1):60-64.

185. Cooperstein R, Haneline M. Weighing The Reliability And Validity Of Clinical Tests.
JACA Online. 2006; 43(7):Online access only p 19-22.

176
 CCP Guidelines 3rd Edition 2008

186. Cooperstein R, Lisi A, Correlation of Ankle Joint Complex Range of Motion, Leg Checks,
PSIS Measurements, and Radiological Findings Proceedings of the ACC Conference X,
Journal of Chiropractic Education Spr 2003; 17(1): 51.

187. Cooperstein R, Lisi AJ, Morschhauser E. Chiropractic Philosophy & Clinical Technique:
Blocking Procedures: An Expanded Approach. J Am Chiropr Assoc. 2004; 41(1):44-46.

188. Cooperstein R, Lisi AJ, O'Neill CW, Lindsey DP, Cooperstein E, Zucherman JF.
Measurement Of In Vivo Lumbar Intervertebral Disc Pressure During Spinal
Manipulation: A Feasibility Study [Platform Presentation; The Association Of Chiropractic
Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1):33.

189. Cooperstein R, Thomas R, Claus C. Full-Spine Specific Chiropractic Technique. J Am

Chiropr Assoc. 2003; 40(1):20-21.

190. Cooperstein R. Activator Methods Chiropractic Technique. Chiro Tech Aug 1997; 3(9):
108-114.

191. Cooperstein R. Assessing Chiropractic Patients First Seen By Medusa. JACA Online.
2006; 43(6):Online access only p 13-14.

192. Cooperstein R. Chiropractic Philosophy And Clinical Technique: Technique Consortium:

Acc Meeting, March 11-14, 2004. J Am Chiropr Assoc. 2004; 41(5):38-41.

193. Cooperstein R. Gonstead Chiropractic Technique (Gct). J Chiropr Med. 2003; 2(1):16-
24.

194. Cooperstein R. The Importance Of Repeated Measurements. J Am Chiropr Assoc. 2003;

40(6):30-31.

195. Cooperstein R. The Modified Rotary Break. J Am Chiropr Assoc. 2004; 41(12):22-23.

196. Cooperstein R. The Pre-Stressed Anterior Thoracolumbar Adjustment. J Am Chiropr

Assoc. 2004; 41(6):38-40.

197. Coopertein R, "Padded Wedges for Lumbopelvic Mechanical Analysis" Journal of the
American Chiropractic Association, Oct 2000: 24-6.

198. Courtis G, Young M, Chiropractic management of idiopathic secondary amenorrhea: a

review of two cases British Journal of Chiropractic Apr 1998; 2(1):12-4.

199. Cox JM II, Cox JM. Cox Automated Axial Distraction Adjusting of the Lumbar Spine:
Protocol and Case Study. Todays Chiro Mar/Apr 1997; 2 (26): 42-45.

177
 CCP Guidelines 3rd Edition 2008

200. Cox Jm II, Cox JM. Cox Automated Axial Distraction Adjusting of the Lumbar Spine:
Protocol and Case Study. Todays Chiro Jan/Feb 1997; 1(26): 46-54.

201. Cox JM. Cox Distraction Adjustment [Audio Lecture] DC Tracts 1997; 4(9): 2-9.

202. Crisera PN, "The cytological implications of primary respiration", Medical Hypotheses,
Jan 2001; 56 (1): 40-51

203. Croft AC, Hamelin MT. Chiropractic Manipulation of the Neck with Horner's Syndrome
and Internal Carotid Artery Dissection. J Am Chiro Assoc April 2002; 4 18-20.

204. Debono VF, Kruse RA, Schliesser JS. Klippel-Feil Syndrome with Radiculopathy,
Chiropractic Management Utilizing Flexion-distraction Technique: a Case Report. JNMS
Winter 2000; 4(8): 124-131.

205. DeCamp ON, Objective Analysis of the Lumbo-Sacral Complex and Occiput, Today's
Chiro, Sep/Oct 1994; 23(5):8-90

206. DeCamp ON, The TMJ and Dysfunction of the Lumbo-Pelvic Complex Today's Chiro,
Jul/Aug 1994; 23(4) 20-25

207. Donnelly BL. Trigger Point Therapy [Audio Lecture]. DC Tracts 1997; 4(9): 4-7.

208. Dr. D.A. Versendaal and Contact Reflex Analysis. The American Chiropractor, 1996;
November/December: 9 & 34

209. Dreyfuss PH, Michaelsen MR. Manipulation under Joint Anesthesia/analgesia: a

Proposed Interdisciplinary Treatment Approach for Recalcitrant Spinal Axis Pain of
Synovial ... Adv Chiro 1997; 4: 41-68.

210. Dulhunty JA. A mechanical and graphical evaluation of the Gonstead pelvic radiographic
analysis. Chiropractic Journal of Australia, 1997; 27(3): 98-110

211. Elster EL. Upper Cervical Chiropractic Management of a Patient with Parkinson's
Disease: A Case Report. J Manip Physiol Ther Oct 2000; 8(23): 573-577.

212. Elster EL. Upper Cervical Management of 10 Parkinson's Disease Patients. Todays
Chiro Jul/Aug 2000; 4(29): 36-48.

213. Elster EL. Upper Cervical Protocol for Five Multiple Sclerosis Patients. Todays Chiro
Nov/Dec 2000; 6(29): 76-92.

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214. Epstein D. Network Spinal Analysis: A system of health care delivery within the
subluxation based chiropractic model. J. Vertebral Subluxation Res. Vol. 1, No. 1 August
1996.

215. Eriksen K, Owens EF Jr. Upper Cervical Post X-ray Reduction and its Relationship to
Symptomatic Improvement and Spinal Stability. CRJ 1997; 2(4): 10-17.

216. Eriksen K. Management of Cervical Disc Herniation with Upper Cervical Chiropractic
Care. J Manip Physiol Ther Jan 1998; 1(21): 51-56.

217. Evans RL, Boline PD, Sawyer CE. A Feasibility Study of Chiropractic Spinal
Manipulation versus Sham Spinal Manipulation for Chronic Otitis Media with Effusion in
Children. J Manip Physiol Ther Jun 1999; 5(22): 292-298.

218. Fallon JM. The Role of the Chiropractic Adjustment in the Care and Treatment of 332
Children with Otitis Media. J Clin Chiro Peds Oct 1997; 2(2): 167-183.

219. Fallon, JM; Fysh, PN; Chiropractic Care of the Newborn with Congenital Torticollis
Journal of Clinical Chiropractic Pediatrics. 1997 Jan ; 2(1): 116-21.

220. Fallon, JM; The Role of the Chiropractic Adjustment in the Care and Treatment of 332
Children with Otitis Media Journal of Clinical Chiropractic Pediatrics. 1997 Oct; 2(2)
:167-83.

221. Fallon, JM; Vallone, S; Treatment Protocols for the Chiropractic Care of Common
Pediatric Conditions: Otitis Media and Asthma Journal of Clinical Chiropractic Pediatrics.
1997 Jan ; 2(1): 113-5.

222. Farmer, JA, Blum, CL, "Dural Port Therapy", Journal of Chiropractic Medicine, Spr 2002;
1(2): 1-8.

223. Fuhr AW, Colloca CJ. Evaluation and Management of Common Clinical Syndromes
Utilizing Activator Methods Chiropractic Technique [Audio Lecture]. DC Tracts 1998; 4
(10): 3-8.

224. Fuhr AW, Menke JM. Status Of Activator Methods Chiropractic Technique, Theory, And
Practice. J Manipulative Physiol Ther. 2005; 28(2):e1-e20.

225. Fuhr AW, Smith JC. Rating Specific Chiropractic Technique Procedures For Common
Low Back Conditions [Letter; Comment]. J Manipulative Physiol Ther. 2003; 26(1):57-60.

179
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226. Gal JM, Herzog W, Kawchuk GN, Conway PJ, Zhang YT. Forces and relative vertebral
movements during SMT to unembalmed post-rigor human cadavers: peculiarities
associated with joint cavitation. J. Manip Physio Ther 1995; 18(1): 4-9

227. Gatterman MI, Coopertein R, Lantz C, Perle SM, Schneider MJ, "Rating Specific
Chiropractic Technique Procedures for Common Low Back Conditions" Journal of
Manipulative and Physiological Therapeutics, Sep 2001;24(7):449-56.

228. Gatterman MI. Toward Assessment of Spinal Manipulation Competence. Chiro Tech
Nov 1997; 4(9): 162-170.

229. Gemmell H, Gosselin G, Cucciolillo A. Development, Validity And Reliability Of A Novice

Adjusting Simulator For The Thoracic Spine: Preliminary Investigation. Clin Chiropr.
2006; 9(4):170-175.

230. Gemmell H, Miller P. Comparative Effectiveness Of Manipulation, Mobilisation And The

Activator Instrument In Treatment Of Non-Specific Neck Pain: A Systematic Review.
Chiropr & Osteopat. 2006; 14(1):Online access only 16 p.

231. Gemmell H, Miller P. Interexaminer Reliability Of Multidimensional Examination

Regimens Used For Detecting Spinal Manipulable Lesions: A Systematic Review
[Review]. Clin Chiropr. 2005; 8(4):199-204.

232. Gemmell HA, Miller PJ. Patient Centred Care In Chiropractic Practice. Clin Chiropr.
2004; 7(3):141-146.

233. Gemmell HA, Wilson FJH, Read DT. Activator As A Therapeutic Instrument: Survey Of
Usage And Opinions Amongst Members Of The British Chiropractic Association. Clin
Chiropr. 2006; 9(2):70-75.

234. Getzoff H, Sacro Occipital Technique (SOT): A Method of Chiropractic Proceedings of

Pathways to Success – Credentialing and Technique Validity: Assessing the
Comparative Validity of Chiropractic Techniques, 28 Jun 1996: 1-4.

235. Getzoff H, Sacro Occipital Technique Assessment ACA Council on Technic-

Proceedings of the Third National Symposium on the Comparison of Chiropractic
Procedures: "The Cervical Subluxation Complex"- Seattle Washington Feb 1995: 69-73.

236. Getzoff H, Ten Reasons Why I Like Sacro Occipital Technique 9th Annual Clinical
Meeting of the American Academy of Pain Management, Las Vegas, NV, Sep 1998.

237. Getzoff H. Disc Technique: An Adjusting Procedure For Any Lumbar Discogenic
Syndrome. J Chiropr Med. 2003; 2(4):pp. 142-144.

238. Getzoff HI, Chinappi AS Possible Manifestation of Temporomandibular Joint Dysfunction

on Chiropractic Cervical X-Ray Studies [Letter; Comment] J Manip Physiol Ther 1999
Nov/Dec; 22(6): 421-422.
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 CCP Guidelines 3rd Edition 2008

239. Getzoff, H, "Cranial Mandibular Motion Technique", Chiropractic Technique, Nov 1996;
8(4): 182-5.

240. Getzoff, H, "Sacro Occipital Technique Categories: a System Method of Chiropractic",

Chiropractic Technique, May 1999; 11(2): 62-5.

241. Getzoff, H, "The Step Out-Toe Out Procedure: A Therapeutic and Diagnostic
Procedure," Chiropractic Technique, Aug 1998; 10(3): 16-8.

242. Getzoff, H, Gregory, TM, "Chiropractic Sacro-Occipital Technique Treatment of

Arthrogryposis Multiplex Congenita," Chiropractic Technique, May 1996; 8(2); 83-7.

243. Gibbons P, Moran RW. Intraexaminer and Interexaminer Reliability for Palpation of the
Cranial Rhythmic Impulse at the Head and Sacrum. J Manip Physiol Ther Mar/Apr 2001;
3(24): 183-190.

244. Gibbons RW, Cohen JH. Raymond L. Nimmo and the Evolution of Trigger Point
Therapy, 1929-1986. J Manip Physiol Ther Mar/Apr 1998; 3(21): 167-172.

245. Giles LGF, Muller R. Chronic Spinal Pain Syndromes: a Clinical Pilot Trial Comparing
Acupuncture, a Nonsteroidal Anti-inflammatory Drug, and Spinal Manipulation. J Manip
Physiol Ther Jul/Aug 1999; 6(22): 376-381.

246. Gillet JJ. New light on the history of motion palpation. Commentary. J. Manip Physio
Ther 1996; 19(1): 52-59

247. Gin RH, Green BN. George Goodheart, Jr., D.C., and a History of Applied Kinesiology. J
Manip Physiol Ther Jun 1997 5(20): 331-337.

248. Gleberzon BJ, Chiropractic "Name Techniques": A Review of the Literature J Can
Chiropr Assoc 2000;45(2): 86-99.

249. Gleberzon BJ, Incorporating Named Techniques into a Chiropractic College Curriculum:
A Compilation of Investigative Reports The Journal of Chiropractic Education
2000;14(1): 33-4.

250. Gleberzon BJ. Chiropractic “Name Techniques”: a review of the literature. J Can Chiropr
Assoc, 2001; 45(2): 86-99

251. Gordon RC. An Evaluation of the Experimental and Investigational Status and Clinical
Validity of Manipulation of Patients under Anesthesia: a Contemporary Opinion
[Commentary]. J Manip Physiol Ther Nov/Dec 2001; 9(24): 603-611.

181
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252. Gordon RC. Chiropractic Economics of Manipulation under Anesthesia. Chiro Econ Apr
1999; 3(41): 48-52.

253. Gosling CM, Holmes M, Gibbons PF. Short-term Effects of Cervical Manipulation on
Edge Light Pupil Cycle Time: a Pilot Study. J Manip Physiol Ther Sep 2000; 7(23): 465-
469.

254. Gosselin G, Van Zoest GJM. Three-Dimensionality Of Direct Contact Forces In

Chiropractic Spinal Manipulative Therapy. J Manipulative Physiol Ther. 2003; 26(9):549-
556.

255. Gray DC, Monygomery PR. Distraction/Flexion Side-Posture Manipulation For The
Treatment Of Low-Back Pain And Lumbopelvic Dysfunction. J Am Chiropr Assoc. 2003;
40(10):36-40.

256. Guadagnino MR. Flexion/distraction Manipulation of a Patient with a Proven Disc

Herniation. JNMS Jul 1997; 2(5): 70-73.

257. Gudavalli MR. Force And Speed Characteristics Of Double Transverse Posterior To
Anterior Thoracic Adjustments By Different Chiropractors [Platform Presentation; The
Association Of Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr
Educ. 2006; 20(1):17-18.

258. Gunzburg R, Colloca CJ, Fuhr AW, Vandeputte K, Keller TS. Neurophysiologic
Response to Intraoperative Lumbosacral Spinal Manipulation. J Manip Physiol Ther Sep
2000; 7(23): 447-457.

259. Haas M, Raphael R, Panzer D, Peterson D. Reliability of manual end-play palpation of

the thoracic spine. Chiropractic Technique, 1995; 7(4): 120-124

260. Hack GD, The Anatomical Basis for the Effectiveness of Chiropractic Spinal
Manipulation in Treating Headache Proceedings of the 1998 International Conference on
Spinal Manipulation: Vancouver, British Columbia, Canada July 16-19, 1998: 114-15.

261. Hains F, Hains G. Combined Ischemic Compression and Spinal Manipulation in the
Treatment of Fibromyalgia: a Preliminary Estimate of Dose and Efficacy. J Manip Physiol
Ther May 2000; 4(23): 225-230.

262. Haldeman S, Rubinstein SM. Cervical Manipulation to a Patient with a History of

Traumatically Induced Dissection of the Internal Carotid Artery: a Case Report and
Review of the Literature on Recurrent Dissections. J Manip Physiol Ther Oct 2001;
8(24): 520-525.

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263. Haldeman S. J. Neurologic Effects of the Adjustment. Manip Physiol Ther Feb 2000; 2
(23): 112-114.

264. Haldeman S. Outcomes Research on Spinal Manipulation. J Am Chiro Assoc May 1998;
5(35): 42-45+.

265. Haneline MT, Cooperstein R, Young MD ,Ross J. Determining spinal level using the
inferior angle of the scapula as a reference landmark: A retrospective analysis of 50
radiographs. J Can Chiropr Assoc. 2008; 52(1):pp. 24-29.

266. Harman RD Hawk C. Preliminary Study of the Effects of a Placebo Chiropractic

Treatment with Sham Adjustments [Letter; Comment]. J Manip Physiol Ther. May 2000;
4(23): 294.

267. Harrison DD, Janik TJ, Troyanovich SJ, Holland B. Comparisons of lordotic cervical
spine curvatures to a theoretical ideal model of the static sagittal cervical spine. Spine
1996;21(6):667-675.

268. Harrison DE, Harrison DD, Cailliet R, Troyanovich SJ, Janik TJ, Holland B. Cobb method
or Harrison posterior tangent method. Spine 2000;25(16):2072-2078.

269. Harrison DE, Harrison DD, Troyanovich SJ. Three dimensional spinal coupling
mechanics: Part I. A review of the literature. J Manip Physiol Ther 1998;21(2):101-113.

270. Harrison DE, Holland B, Harrison DD, Janik TJ. Further reliability analysis of the
Harrison radiographic line- drawing methods: Crossed ICCS for lateral posterior
tangents and modified Risser-Ferguson method on AP views. J Manip Physiol Ther
2002;25(2):93-98.

271. Hartvigsen J, Wulff Christensen H, Nilsson N J. The Effect of Spinal Manipulation in the
Treatment of Cervicogenic Headache. Manip Physiol Ther Jun 1997; 5(20): 326-330.

272. Hawk C, Morter MT, The use of measures of general health status in chiropractic
patients: A pilot study. Palmer Journal of Research 2(2):39-45

273. Hawk C, Rupert RL, Hall S, Colonvega M, Boyd J. Comparison Of Bioenergetic

Synchronization Technique And Customary Chiropractic Care For Older Adults With
Chronic Musculoskeletal Pain. J Manipulative Physiol Ther. 2006; 29(7):540-549.

274. Hawk C. Chiropractic: More than Spinal Manipulation. J Chiro Humanities 1998; 1(8):
71-76.

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275. Hayes J, Orbach G. Changes in Brain Function after Manipulation of the Cervical Spine
[Letter; Comment]. J Manip Physiol Ther Sep 1998; 7(21): 495-496.

276. Hein T. Some Effects of Chiropractic Manipulation on Reflux Oesophagitis: a Case

Report. British Journal of Chiropractic August 1999; 3(3): 59-61.

277. Hemler DE, Aspegren DD, Wright RE. Manipulation under Epidural Anesthesia with
Corticosteroid Injection: Two Case Reports. J Manip Physiol Ther Nov/Dec 1997; 9(20):
618-621.

278. Henry G. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther May 1998; 4(21): 303-304.

279. Herzog J. Use of Cervical Spine Manipulation under Anesthesia for Management of
Cervical Disk Herniation, Cervical Radiculopathy, and Associated Cervicogenic
Headache... J Manip Physiol Ther Mar/Apr 1999; 3(22): 166-170.

280. Herzog W, Drover JM, Forand DR. Influence Of Active Release Technique On
Quadriceps Inhibition And Strength: A Pilot Study. J Manipulative Physiol Ther. 2004;
27(6):408-413.

281. Herzog W, Gal J, Kawchuk GJ. Movements of Vertebrae During Manipulative Thrusts to
Unembalmed Human Cadavers. Manip Physiol Ther Jan 1997; 1(20): 30-40.

282. Herzog W, Harrison DD. Torque: an Appraisal of Misuse of Terminology in Chiropractic

Literature and Technique [Letter; Comment]. J Manip Physiol Ther May 2000; 4(23): 98-
299.

283. Herzog W, Mcmorland G, Suter E. Short-Term Effects Of Spinal Manipulation On H-

Reflex Amplitude In Healthy And Symptomatic Subjects. J Manipulative Physiol Ther.
2005; 28(9):667-672.

284. Herzog W, Symons BP, Leonard T, Nguyen H. Reflex Responses Associated with
Activator Treatment. J. Manip Physiol Ther Mar/Apr 2000 3(23): 155-159.

285. Herzog W. Movements of Vertebrae During Manipulative Thrusts to Unembalmed

Human Cadavers. J Manip Physiol Ther Jun 1998; 5(21): 373-374.

286. Herzog W. Mechanical and physiological responses to spinal manipulative treatments.

JNMS, 1995; 3(1): 1-9
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287. Herzog W. Torque: Misuse of a Misused Term. J Manip Physiol Ther Jan 1998; 1(21):
57-59.

288. Hesse N, Chiropractic Innovator: Dr. Major B. DeJarnette Today's Chiropractic,

Sep/Oct 2000; 29(5): 60-6.

289. Hestœk L, Leboeuf-Yde C, "Are chiropractic tests for the lumbo-pelvic spine reliable and
valid? A systematic critical literature review", Journal of Manipulative and Physiological
Therapeutics May 2000;23:258–75

290. Hewitt EG, Chiropractic Care For Infants with Dysfunctional Nursing: A Case Series
Journal of Clinical Chiropractic Pediatrics. 1999 May ; 4(1): 241-4.

291. Hill F, Shaffie M. Changes in Brain Function after Manipulation of the Cervical Spine
[Letter; Comment]. J Manip Physiol Ther May 1998; 4(21): 304.

292. Hochman JI , S.O.T.: General Adjusting Strategy and Category II Today's Chiro, Jul/Aug
1996; 25(4):50-55.

293. Hochman JI, Dynamic Spinal Analysis: Pelvic and Lumbo-Pelvic Today's Chiro, May/Jun
1999; 28(3): 30-42.

294. Hochman JI, Dynamic Spinal Analysis: The Cervical and Dorsal Spine Today's Chiro,
Sept/Oct 1999; 28(5): 32-6.

295. Hochman JI, S.O.T Category I: Dural Dysfunction Today's Chiro, Jan/Feb 1997;26 (1)
:30-41

296. Hochman JI, S.O.T. Category II - Review and Completion, Today's Chiro, Sep/Oct 1996;
25 (5): 36-38.

297. Hochman JI, S.O.T. Category III: Care of the Low Back Patient, Today's Chiro, Nov/Dec
1996; 25(6) :32-36.

298. Hochman JI, Sacro Occipital Technique: An Introduction Today's Chiro, Mar/Apr 1996;25
(2): 46-50.

299. Hochman JI, Sacro Occipital Technique: The Categorization Procedure Today's Chiro,
May/Jun 1996; 25 (3): 22-26.

300. Hochman JI. Dynamic spinal analysis: Pelvic and Lumbo-Pelvic. Part I. Today’s
Chiropractic 1999; May/June; 30-42

301. Hochman JI. Dynamic spinal analysis: The Cervical and dorsal spine. Part II. Today’s
Chiropractic 1999; Sept/Oct: 32-36
185
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302. Hochman JI. The Effect Of Sacro Occipital Technique Category II Blocking On Spinal
Ranges Of Motion: A Case Series. J Manipulative Physiol Ther. 2005; 28(9):pp. 719-
723.

303. Hochman JI. The Effect Of Sacro-Occipital Technique Category II Blocking On Spinal
Ranges Of Motion: A Prospective Case Series [Poster Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006;
20(1):pp. 69.

304. Hoiriis KT, Pfleger B, Owens EF Jr. Changes in General Health Status During Upper
Cervical Chiropractic Care: a Practice-based Research Project. CRJ 1997; 2(4): 18-26.

305. Holtrop DP, "Resolution of Suckling Intolerance in a 6-month-old Chiropractic Patient"

Journal of Manipulative and Physiological Therapeutics, Nov/Dec 2000;23(9):615-18.

306. Homack DMJ. Technique Review: Derifield-Thompson Leg Length Analysis And
Adjusting Protocol. Chiropr J Aust. 2005; 35(1):16-20.

307. Hong S, Duray SM, Morter HB, Zhang Q, Examination of Variations in Dense
Connective Tissue Attachments for the Rectus Capitis Posterior Minor to the Dura
Mater. Proceedings of the ACC Conference IX, Journal of Chiropractic Education Spr
2002; 16(1): 19-20.

308. Howat J, Varley P, Complementary Therapies Chiropractic Dentistry Monthly Feb 1998;
4(2): 16-25

309. Howitt SD. Lateral Epicondylosis: A Case Study Of Conservative Care Utilizing Art® And
Rehabilitation [Case Report]. J Can Chiropr Assoc. 2006; 50(3):pp. 182-189.

310. Hubka MJ, Delaney PM, Phelan SP. Rotary Manipulation for Cervical Radiculopathy:
Observations on the Importance of the Direction of the Thrust. J Manip Physiol Ther
Nov/Dec 1997; 9(20): 622-627.

311. Hubka MJ, Phelan SP, Delaney PM. Rotary Manipulation for Cervical Radiculopathy:
Observations on the Importance of the Direction of the Thrust. J Manip Physiol Ther
Nov/Dec 1997; 9(20): 622-627.

312. Hubka MJ. Palpation for spinal tenderness: a reliable and accurate method for
identifying the target of spinal manipulation. Chiropractic Technique, 1994; 6(4): 5-8

313. Hubka, MJ, Phelan SP. Interexaminer reliability of palpation for cervical spine
tenderness. J. Manip Physio Ther 1994; 17(9): 591-595

186
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314. Humphreys C, Eck JC, Circolone NJ. Spinal Manipulation for Low-back Pain: a Review
of Goals, Patient Selection, Techniques and Risks. J Am Chiro Assoc Jun 1999; 6(36):
44-54.

315. Hunt J, Clemen MJ. CDC Protocol for Static Upper Cervical Testing. Todays Chiro
Jul/Aug 1997; 4(26): 36-41.

316. Hurwitz EL, Murphy DR, Gregory AA. Manipulation In The Presence Of Cervical Spinal
Cord Compression: A Case Series [Case Report]. J Manipulative Physiol Ther. 2006;
29(3):236-244.

317. Hutti LJ. Logan Basic Technique: Purpose and Application. Todays Chiro Nov/Dec 1998;
6(27): 54-55.

318. Hyman C. Chiropractic Adjustments and Erb's Palsy: a Case Study. J Clin Chiro Peds
Oct 1997; 2(2): 157-160.

319. Jackson BL, Barker WF, Pettibon BR, et al. Reliability of the Pettibon Patient Positioning
System for Radiographic Production. Vol. 4, No. 1. October 2000.

320. Jamison JR. The Chiropractic Adjustment: a Case Study of Chiropractor Explanations
and Patient Understanding. Chiro Tech Nov 1998; 4(10): 143-149.

321. Jansen RD. The Effects of Spinal Manipulation on the Intensity of Emotional Arousal in
Phobic Subjects Exposed to Threat Stimulus: a Randomized...[Letter; J Manip Physiol
Ther Jul/Aug 1998; 6(21): 429-432+.

322. Jende A, Peterson CK. Validity of static palpation as an indicator of atlas transverse
process asymmetry. European Journal of Chiropractic, 1997; 45: 35-42

323. Jonckheer EA, Lohsoonthorn P, Boone, R. Dynamic Modeling of Spinal

Electromyographic Activity During Various Conditions. 2003 American Control
Conference. June 2003. Denver Colorado.

324. Kale MU, Keeter T. A mechanical analysis of the side posture and knee-chest specific
adjustment techniques. Chiropractic Technique, 1996; 9(4): 179-184

325. Kale MU, Keeter TJ. A Mechanical Analysis of the Side Posture and Knee-chest Specific
Adjustment Techniques. Vert Sublux 1997; 3(1): 35-41.

187
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326. Kawchuk GN, Liddle TR, Prasad NG, Mcleod RC, Li T, Zhu Q. Variability Of Force
Magnitude And Force Duration In Manual And Instrument-Based Manipulation
Techniques. J Manipulative Physiol Ther. 2006; 29(8):611-618.

327. Kawchuk GN, Perle SM. The Effect Of Line Of Drive On Vertebral Acceleration [Platform
Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual Conference,
2006]. J Chiropr Educ. 2006; 20(1):26.

328. Keating JC James F. McGinnis, D.C., N.D., C.P. (1873-1947): Spinographer, Educator,
Marketer and Bloodless Surgeon Chiropractic History, 1998; 18(2): 63-79.

329. Keating JC Jr, Fleet GT. Thurman Fleet, D.C. and the Early Years of the Concept-
therapy Institute. Chiro Hist Jun 1997; 1(17): 57-65.

330. Keeter T, Kale MU. A Mechanical Analysis of the Side Posture and Knee-chest Specific
Adjustment Techniques. J Vert Sublux 1997; 3(1): 35-41.

331. Keller TS, Colloca CJ, Drinkwater J. Validation of the Force and Frequency
Characteristics of the Activator Adjusting Instrument: Effectiveness as a Mechanical
Impedance...[Letter; Comment] J Manip Physiol Ther. Oct 1999; 8(22): 548-551.

332. Keller TS, Colloca CJ. Mechanical Force Spinal Manipulation Increases Trunk Muscle
Strength Assessed by Electromyography: a Comparative Clinical Trial. J Manip Physiol
Ther Nov/Dec 2000; 9(23): 585-595.

333. Kenin S, Humphreys BK, Hubbard B, Cramer GD, Attachments from the Spinal Dura to
the Ligamentum Nuchae: Incidence, MRI Appearance, and Strength of Attachment
Proceedings of the 2000 International Conference of Spinal Manipulation 2000 Sep:
202-4.

334. Kim HW, Ko Yj, Rhee WI, Lee JS, Lim JE, Lee SJ, Im S, Lee JI. Interexaminer Reliability
And Accuracy Of Posterior Superior Iliac Spine And Iliac Crest Palpation For Spinal
Level Estimations. J Manipulative Physiol Ther. 2007; 30(5):386-389.

335. Kim P, Hsu W, Busse JW. Diagnosing Post-traumatic Syringomyelia Prior to

Manipulation. JNMS Sep 1999; 3(7): 107-111.

336. Kirstukas SJ, Backman JA. Physician-applied Contact Pressure and Table Force
Response During Unilateral Thoracic Manipulation. J Manip Physiol Ther Jun 1999;
5(22): 269-279.

337. Kissinger R. Changes in Pulmonary Function Associated with Upper Cervical Specific
Chiropractic Care. J Vertebral Subluxation Res. 1997; 3(1): 43-49.
188
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338. Klingensmith RD, Blum CL The relationship between pelvic block placement and
radiographic pelvic analysis. 10th Annual Vertebral Subluxation Research Conference
Hayward, CA, Dec 7-8, 2002

339. Klingensmith RD, Chiropractic Evaluation and Care for Lumbosacral Pain American
Academy of Pain Management Washington DC, Sep 1996.

340. Knudsen JT, Patel P, Fournier JT, Schliesser JS, Fonda SD, Tuck NR Jr, Cramer GD.
Effects of Side-posture Positioning and Side-posture Adjusting on the Lumbar
Zygapophysial Joints as Evaluated by Magnetic Resonance Imaging: a Before and after
Study with Randomization. J Manip Physiol Ther Jul/Aug 2000; 6(23): 380-394.

341. Knutson Ga, Owens Ef Jr. The Sacroiliac Sprain: Neuromuscular Reactions, Diagnosis,
And Treatment With Pelvic Blocking [Review Literature]. J Am Chiropr Assoc. 2004;
41(8):32-39.

342. Knutson GA. Abnormal Upper Cervical Joint Alignment and the Neurologic Component
of the Atlas Subluxation Complex. CRJ 1997 2(4)

343. Knutson GA. Rapid Elimination of Chronic Back Pain and Suspected Long-term Postural
Distortion with Upper Cervical Vectored Manipulation: a Novel Hypothesis for CRJ Fall
1999; 2(6): 57-64.

344. Knutson GA. Significant Changes in Systolic Blood Pressure Post Vectored Upper
Cervical Adjustment vs. Resting Control Groups: a Possible Effect of the
Cervicosympathetic and/or Pressor Reflex. J Manip Physiol Ther. Feb 2001; 2(24):
101-109.

345. Knutson GA. Thermal Asymmetry of the Upper Extremity in Scalenus Anticus Syndrome,
Leg-length Inequality and Response to Chiropractic Adjustment. J Manip Physiol Ther
Sep 1997; 7(20): 476-481.

346. Knutson GA. Upper Cervical Post X-ray Reduction and its Relationship to Symptomatic
Improvement and Spinal Stability [Letter; Comment]. CRJ 1997; 2(4): 42-45.

347. Kotheimer WJ. The effects of magnetic fields in subluxation analysis. Today’s
Chiropractic 1997; March/April: 32-35

348. Lantz CA, Chen J. Effect of chiropractic intervention on small scoliotic curves in younger
subjects: A time-series cohort design. J. Manip Physio Ther 2001; 24(6): 385-393

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349. Lauretti W. What Are the Risks of Chiropractic Neck Adjustments? J Am Chiro Assoc
Sep 1999; 9(36): 42-44+.

350. Law A. Diversified Chiropractic Management in the Treatment of Osteoarthritis of the

Knee: a Case Report. J Can Chiro Assoc Dec 2001; 4(45): 232-240.

351. Lawrence DJ. Your Body Can Talk: the Art and Application of Clinical Kinesiology [Book
Review] by Susan L. Levy and Carol Lehr. Chiro Tech May 1997; 2(9): 85.

352. Leboeuf-Yde C, Hansen BE, Simonsen T. Motion Palpation Of The Lumbar Spine - A
Problem With The Test Or The Tester. J Manipulative Physiol Ther. 2006; 29(3):208-
212.

353. Lee M, Latimer J, Adams RD. The Effects of High and Low Loading Forces on Measured
Values of Lumbar Stiffness. J Manip Physiol Ther Mar/Apr 1998; 3(21): 157-163.

354. Lee SW. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther Sep 1998; 7(21): 496-497.

355. Lewit K. Motion palpation: It’s time to accept the evidence. Letters to the editor. J. Manip
Physio Ther 1999; 22(4): 260-261

356. Liebenson C. Motion palpation: It’s time to accept the evidence. Letter to the editor. J.
Manip Physio Ther 1999; 22(9): 631-633

357. Lisi A. The Centralization of Phenomenon and its Implications for Chiropractic Side-
posture Adjustment of Lumbar Disc Patients. J Am Chiro Assoc Dec 1999; 12(36): 48-
49.

190
 CCP Guidelines 3rd Edition 2008

358. Lisi AJ, Cooperstein R, Morschhauser E, "A pilot study of provocation testing with pelvic
wedges: Can prone blocking demonstrate a directional preference?" Proceedings of the
ACC Conference IX, Journal of Chiropractic Education Spr 2002; 16(1): 30-1.

359. Lisi AJ. The Centralization Phenomenon in Chiropractic Spinal Manipulation of

Discogenic Low Back Pain and Sciatica. J Manip Physiol Ther Nov/Dec 2001; 9(24):
596-602.

360. Mackey JC. Myofascial Techniques [Audio Lecture]. Dc Tracts 1998; 4(10): 2

361. Maigne JY, Guillon F. Highlighting of Intervertebral Movements and Variations of

Intradiskal Pressure During Lumbar Spine Manipulation: a Feasibility Study. J Manip
Physiol Ther Oct 2000; 8(23): 531-535.

362. Matthews R, Wood TG, Colloca CJ. A Pilot Randomized Clinical Trial on the Relative
Effect of Instrumental (Mfma) Versus Manual (Hvla) Manipulation in the Treatment of
Cervical Spine Dysfunction. J Manip Physiol Ther May 2001; 4(24): 260-271.

363. McCoy M, Pryor M. Radiographic Findings That May Alter Treatment Identified On
Radiographs Of Patients Receiving Chiropractic Care In A Teaching Clinic [Poster
Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual Conference,
2006]. J Chiropr Educ. 2006; 20(1): 93-94.

364. McGill SM, Bereznick DE, Ross JK. Location Of Applied Forces During Side Posture
Lumbar Manipulation: Where Should Forces Be Applied To Produce Cavitation?
[Platform Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual
Conference, 2006]. J Chiropr Educ. 2006; 20(1): 2.

365. McGill SM, Lehman GJ, Vernon H. Effects of a Mechanical Pain Stimulus on Erector
Spinae Activity Before and After a Spinal Manipulation in Patients with Back Pain: a
Preliminary Investigation. J Manip Physiol Ther Jul/Aug 2001; 6(24): 402-406.

366. McGill SM, Lehman GJ. The Influence of a Chiropractic Manipulation on Lumbar
Kinematics and Electromyography During Simple and Complex Tasks: a Case Study. J
Manip Physiol Ther Nov/Dec 1999; 9(22): 576-581.

367. McGill SM, Seaman DR. The Influence of a Chiropractic Manipulation on Lumbar
Kinematics and Electromyography During Simple and Complex Tasks: A Case Study
[Letter; Comment] J Manip Physiol Ther Jul/Aug 2000; 6(23): 437-438.

368. McMorland G, Herzog W, Suter E. Decrease in Quadriceps Inhibition after Sacroiliac

Joint Manipulation in Patients with Anterior Knee Pain. J Manip Physiol Ther Mar/Apr
1999; 3(22): 149-153.

191
 CCP Guidelines 3rd Edition 2008

369. Menke JM, Cooper SR, Pfefer MT. Comparison Of Mechanical Force, Manually Assisted
Activator Manipulation Versus Manual Side-Posture High-Velocity, Low-Amplitude
Manipulation In Patients With Low Back Pain: A Randomized Pilot Study. J Chiropr
Educ. 2006; 20(1): 90.

370. Meyer JJ. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther Sep 1998; 7(21): 498-499.

371. Michaelsen MR. Manipulation under Joint Anesthesia/analgesia: a Proposed

Interdisciplinary Treatment Approach for Recalcitrant Spinal Axis Pain of Synovial Joint
Origin. J Manip Physiol Ther Feb 2000; 2(23): 127-129.

372. Miller JA, Bulbulian R, Sherwood WH, Kovach M. The Effect of Spinal Manipulation and
Soft Tissue Massage on Human Endurance and Cardiac and Pulmonary Physiology: a
Pilot Study. J Sports Chiro & Rehab Mar 2000; 1(14): 11-15.

373. Miscoe M. An Evaluation Of The Significance Of Joint Dysfunction And Its Impact On
The Reporting Of Manipulation In Rehabilitative Encounters.. J Am Chiropr Assoc. 2003;
40(9):pp. 28-31.

374. Moodley M, Brantingham JW. The Relative Effectiveness of Spinal Manipulation and
Ultrasound in Mechanical Pain: Pilot Study. Chiro Tech Nov 1999; 4(11): 164-168.

375. Moran RW, Gibbons P. Intraexaminer and interexaminer reliability for palpation of the
cranial rhythmic impulse at the head and sacrum. J. Manip Physio Ther 2001; 24(3):
183-190

376. Morningstar MW, Strauchman MN, Gilmour G. Adolescent Idiopathic Scoliosis

Treatment Using Pettibon Corrective Procedures: A Case Report. J Chiropr Med. 2004;
3(3): 96-103.

377. Morter T, Schuster, TL. Changes in salivary ph and general health status following the
clinical application of Bio-energetic Synchronization. J. Vertebral Subluxation Res. 2(1)
1998.

378. Morter T. The theoretical basis and rationale for the clinical application of Bioenergetic
Synchronization. J. Vertebral Subluxation Res. 2(1) January 1998.

379. Mullin L. Radiographic Variability Of The Intercrestal Line [Platform Presentation; The
Association Of Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr
Educ. 2006; 20(1): 37.

380. Mullin LE. Dr. Clarence S.Gonstead: Observing the Life and Accomplishments of a
Chiropractic pioneer. Today’s Chiropractic, 1998; May/June: 32-37

381. Murphy BA, Kelly DD, Backhouse DP. Use of a Mental Rotation Reaction-time Paradigm
to Measure the Effects of Upper Cervical Adjustments on Cortical Processing: a Pilot
Study. J Manip Physiol Ther. May 2000; 4(23): 246-251.

192
 CCP Guidelines 3rd Edition 2008

382. Murphy DR. Post-traumatic Syringomyelia: Absolute Contraindication to Manipulation? A

Report of Two Cases. JNMS 06 2000; 2(8): 54-58.

383. Nelson CF, Evans R, Bronfort G. The Efficacy of Spinal Manipulation, Amitriptyline and
the Combination of Both Therapies for the Prophylaxis of Migraine Headache. J Manip
Physiol Ther Oct 1998; 8(21): 511-519.

384. Nelson L, Aspegren D, Bova C. The Use of Epidural Steroid Injection and Manipulation
on Patients with Chronic Low Back Pain. J Manip Physiol Ther May 1997; 4(20): 263-
266.

385. Nicholson WR. Chronic Spinal Pain Syndromes: a Clinical Pilot Trial Comparing
Acupuncture, a Nonsteroidal Anti-inflammatory Drug, and Spinal Manipulation [Letter] J
Manip Physiol Ther May 2000; 4(23): 297-298.

386. Nilsson N, Whittingham W. Active Range of Motion in the Cervical Spine Increases after
Spinal Manipulation (Toggle Recoil). J Manip Physiol Ther Nov/Dec 2001; 9(24): 552-
555.

387. Noone P. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther May 1998; 4(21): 302-303.

388. Nordsteen J, Nilsson N, Wiberg JMM. The Short-term Effect of Spinal Manipulation in
the Treatment of Infantile Colic: a Randomized Controlled Clinical Trial with a Blinded
Observer. J Manip Physiol Ther Oct 1999; 8(22): 517-522.

389. Normand MC,Marcotte J, Black P. Measurement Of The Pressure Applied During Motion
Palpation And Reliability For Cervical Spine Rotation. J Manipulative Physiol Ther. 2005;
28(8): 591-596.

390. NUCCA: Protocols and perspectives. A textbook for the National Upper Cervical
Chiropractic Association. First Edition. Thomas MD, Editor. National Upper Cervical
Chiropractic Research Association. Monroe, Michigan.

391. Oleski SL Smith GH, Crow WT. Radiographic Evidence of Cranial Bone Mobility Cranio:
The Journal of Craniomandibular Practice; Jan 2002; 20(1):34-8.

392. Oliver C, Timchur MD, Mccarthy PW. Short Communication. To Adjust Or Not To
Adjust? The Importance Of Careful X-Ray Interpretation [Case Report]. Clin Chiropr.
2007; 10(3): 119-121.

393. Owens EF, Hoiriis KT, Burd D. Changes in General Health Status During Upper Cervical
Chiropractic Care: Pbr Progress Report. CRJ 1998; 1(5): 9-16.

193
 CCP Guidelines 3rd Edition 2008

394. Pederick FO, "A Kaminski-type evaluation of cranial adjusting", Chiropractic Technique,
Feb 1997;9(1): 1-15.

395. Pederick FO, "Developments in the Cranial Field", Chiropractic Journal of Australia, Mar
2000;30(1):13-23.

396. Pederick FO, A Preliminary Single Case Magnetic Resonance Imaging Investigation Into
Maxillary Frontal-Parietal Manipulation And Its Short-Term Effect Upon The Intercranial
Structures Of An Adult Human Brain [Letter] J Manip Physiol Ther 1995 Feb; 18(2): 116-
17.

397. Perle SM. Searching For Chiropractic Literature: A Study Of Medline Indexing Of The
<I>Journal Of Manipulative And Physiological Therapeutics</I> [Poster Presentation;
The Association Of Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J
Chiropr Educ. 2006; 20(1): 88.

398. Perri VL Applying the Conjugate Gaze Adjusting Technique Today's Chiropractic,
Sep/Oct 2000; 29(5): 42-51

399. Peterson KB, Milus TB. The Effects of Spinal Manipulation on the Intensity of Emotional
Arousal in Phobic Subjects Exposed to Threat Stimulus: a Randomized...[Letter; J Manip
Physiol Ther Jul/Aug 1998; 6(21): 432-434.

400. Peterson KB. The Effects of Spinal Manipulation on the Intensity of Emotional Arousal in
Phobic Subjects Exposed to Threat Stimulus: a Randomized...[Letter;]. J Manip Physiol
Ther Jul/Aug 1998; 6(21): 429-432+.

401. Peterson KB. The Effects of Spinal Manipulation on the Intensity of Emotional Arousal in
Phobic Subjects Exposed to a Threat Stimulus: a Randomized...J Manip Physiol Ther
Nov/Dec 1997; 9(20): 602-606.

402. Pfefer, MT, Rasmussen S, Uhl NS, Cooper S, Treatment of a lumbar disc herniation
utilizing sacro occipital chiropractic technique Proceedings of the ACC Conference X,
Journal of Chiropractic Education Spr 2003; 17(1): 72.

403. Phillips CJ, Birth Trauma - Antibiotic Abuse - Vaccine Reaction: A Single Case Report. J
Am Chiro Assoc Sep 1996; 9: 57-59, 61.

404. Phillips CJ, Chiropractic and Pediatrics Cranial Compression and Distraction: a Possible
Implication in Otitis Media Proceedings of the 1994 International conference on Spinal
Manipulation: Palm Springs, California Jun 10-11, 1994: 136-39.

405. Phillips CJ, Meyer JJ, Chiropractic Care, Including Craniosacral Therapy, During
Pregnancy: A Static-Group Comparison of Obstetric Interventions during Labor and
Delivery Journal of Manipulative and Physiological Therap 1995 Oct ;18(8): 525-9.

194
 CCP Guidelines 3rd Edition 2008

406. Phillips, C; An Effective Drug-Free Approach To Premature Contractions International

Review of Chiropractic. 1998 Oct; 54(5):76-81.

407. Phillips, C; Back Labor: A Possible Solution for a Painful Situation International Review
of Chiropractic. 1997 Jul; 53(4): 51-5.

408. Phongphua C, Azad A, Hawk C. Preliminary Study of the Effects of a Placebo

Chiropractic Treatment with Sham Adjustments. J Manip Physiol Ther Sep 1999; 7(22):
436-443.

409. Phongphua C, Hawk D, Bleecker J. Preliminary Study of the Reliability of Assessment

Procedures for Indications for Chiropractic Adjustments of the Lumbar Spine. J Manip
Physiol Ther Jul/Aug 1999; 6(22): 382-389.

410. Pick MG, Anatomy & physiology of cranial motion: A look into the various intercranial
rhythmic motions and their effects upon the brain, meninges and cranial bones
Association of Swiss Chiropractors Conference: BŸrgenstock Hotels and Resorts :
September 18, 1998.

411. Pick MG, Beyond the Neuron Integrative Bodywork: Towards Unifying Principles
International Conference, London: University of Westminster and Journal of Bodywork
and Movement Therapies 16/18 Nov 2001.

412. Pick MG, Cranial palpation: Hand utilization techniques & cranial rhythmic identification
Association of Swiss Chiropractors Conference: BŸrgenstock Hotels and Resorts :
September 18, 1998.

413. Pick MG, Morphology of the cranial vault sutures: A comprehensive description of the
vault sutures interarticular unions and developing a working knowledge toward their
manipulative strategies Association of Swiss Chiropractors Conference: BŸrgenstock
Hotels and Resorts : September 18, 1998.

414. Pick MG, Spinal-cranial morphology and physiology: A review of the relationships
between osseous, meningeal and neuronal structures and their role in the craniosacral
respiratory rhythms Association of Swiss Chiropractors Conference: BŸrgenstock Hotels
and Resorts : September 18, 1998.

415. Pick, MG, "A Preliminary Single Case Magnetic Resonance Imaging Investigation into
Maxillary Frontal-Parietal Manipulation and its Short-Term Effect upon the Intercranial
Structures of an Adult Human Brain," Journal of Manipulative and Physiological
Therapeutics, Mar-Apr 1994; 17(3): 168-73.

416. Plaugher G, Alcantara J, Doble RW. Missed sacral fracture before chiropractic
adjustment. J. Manip Physio Ther 1996; 19(7): 480-483

417. Plaugher G, Alcantara J, Hart CR. Management of the patient with a chance fracture of
the lumbar spine and concomitant subluxation. J. Manip Physio Ther 1996; 19(8): 539-
551

418. Plaugher G, Alcantara J. Adjusting the pediatric spine. Top Clin Chiro, 1997; 4(4): 59-69

195
 CCP Guidelines 3rd Edition 2008

419. Plaugher G, Long CR, Alcantara J, Silveus AD, Wood H, Lotun K, Menke J, Meeker WC,
Rowe SH. Practice-based randomized controlled-comparison clinical trial of chiropractic
adjustments and brief massage treatment at sites of subluxation in subjects with
essential hypertension: pilot study. J. Manip Physio Ther 2002; 25(4): 221-239

420. Plaugher G. Cranial Manipulation Theory and Practice: Osseous and Soft Tissue
Approaches by Leon Chaitow. J Manip Physiol Ther Jun 2000; 5(23): 371.

421. Plaugher G. Structural rehabilitation of the spine and posture: Rationale for treatment
beyond the resolution of symptoms. Letter to the editor. J. Manip Physio Ther 1999;
22(7): 1-2

422. Plaugher G. Structural rehabilitation of the spine and posture: Rationale for treatment
beyond the resolution of symptoms. Letter to the editor. J. Manip Physio Ther 2000;
23(6): 1

423. Plaugher G. Three-dimensional spinal coupling mechanics-Part II: Implications for

chiropractic theories and practice. Letter to the editor. J. Manip Physio Ther 1999; 22(5):
1-3

424. Polkinghorn BS, Colloca CJ. Chiropractic Treatment of Postsurgical Neck Syndrome
with Mechanical Force, Manually Assisted Short-lever Spinal Adjustments. J Manip
Physiol Ther. Nov/Dec 2001; 9(24): 589-595.

425. Polkinghorn BS, Colloca CJ. Treatment of Symptomatic Lumbar Disc Herniation Using
Activator Methods Chiropractic Technique. J Manip Physiol Ther. Mar/Apr 1998; 3(21):
187-196.

426. Polkinghorn BS. Treatment of Cervical Disc Protrusions via Instrumental Chiropractic
Adjustment. J Manip Physiol Ther Feb 1998; 2(21): 114-121.

427. Pollard H, Mealing D, Stephens D. Treatment of Visual Field Loss by Spinal

Manipulation: a Report on 17 Patients. JNMS Sum 1998; 2(6): 53-66.

428. Potter L, Mccarthy C, Oldham J. Intraexaminer Reliability Of Identifying A Dysfunctional

Segment In The Thoracic And Lumbar Spine. J Manipulative Physiol Ther. 2006; 29(3):
203-207.

529. Pratt ES. Applying Grostic Biomechanics to Other Adjusting Techniques. Todays Chiro
May/June 2000; 3(29): 36-46.

430. Prax JC. Upper Cervical Chiropractic Care of the Pediatric Patient: a Review of the
Literature. J Clin Chiro Peds May 1999; 1(4): 257-263.

431. Pringle RK, Wyatt LH. The Appropriate Use Of Radiography In Clinical Practice: A
Report Of Two Cases Of Biomechanical Versus Malignant Spine Pain [Case Report].
Chiropr & Osteopat. 2006; 14(1): Online access only 23 p.

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 CCP Guidelines 3rd Edition 2008

432. Pringle RK. Motion palpation: It’s time to accept the evidence. Letters to the editor. J.
Manip Physio Ther 1999; 22(3): 181-191

433. Przybylak JF. Challenging Tone: a Protocol for Mobility-impaired Patients. Todays Chiro
Jan/Feb 2000; 1(29): 60-64.

434. Rasmussen SA, S.O.T. Cranial Adjustments Basis, Effects and Case Study, Today's
Chiro, Mar/Apr 1998; 27 (2):40-44.

435. Rathore S. Use Of Mckenzie Cervical Protocol In The Treatment Of Radicular Neck Pain
In A Machine Operator. J Can Chiropr Assoc. 2003; 47(4):291-297.

436. Redmond PD, Miller EB. Changes in Digital Skin Temperature, Surface
Electromyography, and Electrodermal Activity in Subjects Receiving Network Spinal
Analysis Care. J. Vertebral Subluxation Res. 1998; 3(2): 87-95.

437. Remeta EM, Indicators for Disc Herniation Supported by Magnetic Resonance Imaging
(MRI): Poster Presentation 9th Annual Clinical Meeting of the American Academy of
Pain Management, Las Vegas, NV, Sep 1998.

438. Reynolds C. Reduction of Hypolordosis of the Cervical Spine and Forward Head Posture
with Specific Upper Cervical Adjustment and the Use of a Home ...CRJ 1998; 1(5): 23-
27.

439. Rivett DA, Snodgrass SJ, Robertson VJ. Manual Forces Applied During Posterior-To-
Anterior Spinal Mobilization: A Review Of The Evidence. J Manipulative Physiol Ther.
2006; 29(4): 316-329.

440. Rogers RG. The Effects of Spinal Manipulation on Cervical Kinesthesia in Patients with
Chronic Neck Pain: a Pilot Study. J Manip Physiol Ther Feb 1997; 2(20): 80-85.

441. Rosen M Sacro Occipital Technique [Technique Overview by Matthew McCoy “The
Adjustment”] The American Chiropractor Mar 2001; 23(3): 26,31, 34.

442. Runnels S. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther Sep 1998; 7(21): 495.

443. Sanders GE, Unger JF Cranial Distortion and Category II Pelvic Blocking – A Pilot
Study: Poster Presentation (Diagnostic Sciences) Proceedings of the Scientific
Symposium - 1997 World Chiropractic Congress: Tokyo, Japan Jun 6-8, 1997: 252

444. Saunders ES, Woggon D, Cohen C, Robinson DH. Improvement of cervical lordosis and
reduction of forward head posture with anterior head weighting and proprioceptive
balancing protocols. J. Vertebral Subluxation Res. Vol. 2003. April 27.

197
 CCP Guidelines 3rd Edition 2008

445. Savoie SM. Best Practices In Clinical Chiropractic [Book Review] By Robert D. Mootz
And Howard Vernon. J Am Chiropr Assoc. 2003; 40(8):46.

446. Scheurmier N, Breen AC. A Pilot Study of the Purchase of Manipulation Services for
Acute Low Back Pain in the United Kingdom. J Manip Physiol Ther Jan 1998; 1(21): 14-
18.

447. Schneider M, Homonai R, Moreland B, Delitto A. Interexaminer Reliability Of The Prone

Leg Length Analysis Procedure. J Manipulative Physiol Ther. 2007; 30(7): 514-521.

448. Schneider, MJ, Cox, JM, Polkinghorn BS, Blum, CL, Getzoff, H, Troyanovich, Sj. "Grand
Rounds Discussion: Patient with Acute Low Back Pain: Harvey Getzoff, Discussant,"
Chiropractic Technique, Jan 1999; 11(1): 2-4.

449. Schneider, MJ, Cox, JM, Polkinghorn BS, Blum, CL, Getzoff, H, Troyanovich, Sj. "Grand
Rounds Discussion: Patient with Acute Low Back Pain: Charles Blum, Discussant,"
Chiropractic Technique, Jan 1999; 11(1): 19-20.

450. Schuster TL, Dobson M, Blanks RH. Wellness Lifestyles. 10th Annual Meeting of the
International Society for Quality of Life Research. Prague, Czech Republic. November
2003.

451. Seaman DR. Antiquated Concepts Related to Chiropractic Technique. Part I: A Case
Against Mental Impulses and Nerve Interference. Chiro Tech Aug 1999; 3(11): 95-100.

452. Seaman DR. Can Spinal Adjustments and Manipulation Mask Ongoing Pathologic
Conditions? J Manip Physiol Ther Mar/Apr 1999; 3(22): 171-179.

453. Seaman DR. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther May 1998; 4(21): 295-297.

454. Seemann DC. Anatometer Measurements: a Field Study: Intra- and Inter-examiner
Reliability and Pre to Post Changes Following an Atlas Adjustment CRJ Spr 1999; 1(6):
7-11.

456. Shara K, Bells’ Palsy, A Chiropractic Case Study. Kansas Chiropractic Association
Journal, 1999 Jan/Feb;1:21-2,24.

457. Shearer HM, Trim A. An Unusual Presentation And Outcome Of Complex Regional Pain
Syndrome: A Case Report. J Can Chiropr Assoc. 2006; 50(1):pp. 20-26.

458. Siegfried GR. Cranial Adjustment: the Bilateral Nasal Specific. Am Chiro Nov/Dec 1998;
6(20): 43.

198
 CCP Guidelines 3rd Edition 2008

459. Skogsbergh DR, Mcgregor M, Triano JJ. Use of Chiropractic Manipulation in Lumbar
Rehabilitation. J Am Chiro Assoc Jul 1998; 7(35): 47-48+.

460. Slade SC, Keating JL. Unloaded Movement Facilitation Exercise Compared To No
Exercise Or Alternative Therapy On Outcomes For People With Nonspecific Chronic
Low Back Pain: A Systematic Review. J Manipulative Physiol Ther. 2007; 30(4): 301-
311.

461. Smith JL. Effects of Upper Cervical Subluxation Concomitant with a Mild Arnold-Chiari
Malformation: a Case Study. CRJ 1997; 2(4): 77-81.

462. Snyder BJ, Toftness D, Nosco D, Balcavage W, Nindl G, Zhang J. Comparison Of A

Triaxial Fluxgate Magnetometer And Toftness Sensometer For Body Surface Emf
Measurement. J Can Chiropr Assoc. 2004; 48(4): 273-281.

463. Snyder BJ, Vernor L, Zhang J. The Effect Of Low Force Chiropractic Adjustments On
Body Surface Electromagnetic Field. J Can Chiropr Assoc. 2004; 48(1): 29-35.

464. Snyder BJ, Zhang J. The Effect Of Low Force Chiropractic Adjustments For 4 Weeks On
Body Surface Electromagnetic Field. J Manipulative Physiol Ther. 2005; 28(3): 159-163.

465. Snyder BJ. Thermographic Evaluation for the Role of the Sensometer: Evidence in the
Toftness System of Chiropractic Adjusting. Chiro Tech May 1999; 2(11): 57-61.

466. Stephens D, Pollard H, Bilton D. Bilateral Simultaneous Optic Nerve Dysfunction after
Periorbital Trauma: Recovery of Vision in Association with Chiropractic Spinal
Manipulation Therapy. J Manip Physiol Ther Nov/Dec 1999; 9(22): 615-621.
467. Stillwagon G, Stillwagon K. The Pierce-Stillwagon Technique Procedures and Analysis.
Part I of II. Today’s Chiropractic 1998; March/April: 34-39

468. Stillwagon G, Stillwagon K. The Pierce-Stillwagon Technique Procedures and Analysis.

Part II of II. Today’s Chiropractic 1998; May/June: 38-48

469. Stillwagon K, Stillwagon G. The Pierce-Stillwagon Technique: Procedures and Analysis.

Part I of II. Todays Chiro Mar/Apr 1998; 2(27): 34-39.

470. Stuber KJ. Specificity, Sensitivity, And Predictive Values Of Clinical Tests Of The
Sacroiliac Joint: A Systematic Review Of The Literature. J Can Chiropr Assoc. 2007;
51(1): 30-41.

471. Such GW. Upper Cervical Synthesis: Integrative Manual Care of the Occipitoatlantal
Joint. Chiro Tech Aug 1999; 3(11): 116-124.

472. Sweat RW, Sweat MH, Cuthbert S. Chiropractic Atlas Orthogonal Technique for the
Care of Senior Citizens. Todays Chiro May/Jun 1998; 3(27): 86-91.

199
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473. Sweeney A. Resolution of Enuresis with Chiropractic Adjustments in Romania: Two

Case Reports. ICA Review Jul/Aug 1997; 4(53): 69-74.

474. Tabar, J, "Treatment of Sacroiliac Joint: A review of Procedures" Chiropractic

Technique, Nov 1997; 9(4) : 185-92

475. Tepe R, Skaggs CD, George JW, Busold D, Keuss S. The Effects Of Active Release
Technique On Carpal Tunnel Patients: A Pilot Study [Platform Presentation; The
Association Of Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr
Educ. 2006; 20(1): 14-15.

476. Tepe R, Skaggs CD, George JW, Clewis J, House R, Schlobohm E. Comparison Of
Active Release Technique And Proprioceptive Neuromuscular Facilitation For Improving
Hamstring Flexibility: A Randomized Controlled Trial [Platform Presentation; The
Association Of Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr
Educ. 2006; 20(1): 15-16.

477. Tepe R, Skaggs CD, George JW, Prather H, Busold D, Keuss S. The Effects Of Active
Release Technique On Carpal Tunnel Patients: A Pilot Study [Clinical Trial]. J Chiropr
Med. 2006; 5(4): 119-122.

478. Textbook of Logan Basic Methods [Book Review] by Hugh B. Logan. Todays Chiro
Nov/Dec 1998; 6(27): 109-110.

479. Thompson DM, Vrugtman RP, Johnson KM, Dicks SK, Unger-Boyd M, Correlation of
Lateral Pelvic Sway to Variances of Pain along the Inguinal Ligaments: A Pilot Study,
Proceedings of the ACC Conference X, Journal of Chiropractic Education Spr 2003;
17(1): 76.

480. Tranter S, Anthony D. Technique: Motorized Flexion-distraction and Motion Adjusting.

Am Chiro Nov/Dec 1997; 6(19): 26-27.

481. rayanovich S, Harrison DD. Chiropractic Biophysics Technique. Adv Chiro 1997; 4: 321-
348.

482. Triano JJ. When it Comes to Spinal Manipulation, Skill Still Counts. J Am Chiro Assoc
Jun 1999; 6(36): 28-30.

483. Troyanovich SJ, Harrison D, Roudebush M. Changes in Brain Function after

Manipulation of the Cervical Spine [Letter]. J Manip Physiol Ther May 1998; 4(21): 297-
299.

484. Troyanovich SJ, Harrison DD, Colloca CJ. Torque Misuse Revisited. J Manip Physiol
Ther Nov/Dec 1998; 9(21): 649-655.

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485. Troyanovich SJ, Harrison DE, Harrison DD. Structural rehabilitation of the spine and
posture: Rationale for treatment beyond the resolution of symptoms. J Manip Physiol
Ther 1998;21(1):37-50.

486. Troyanovich SJ, Herzog W, Harrison DD. Commentary: Torque Misuse Revisited [Letter;
Comment]. J Manip Physiol Ther Jun 1999; 5(22): 347-348.

487. Troyanovich SJ, Snyder BJ. Thermographic Evaluation for the Role of the Sensometer:
Evidence in the Toftness System of Chiropractic Adjusting [Letter; Comment]. Chiro
Tech Nov 1999; 4(11): 186.

488. Troyanovich SJ. Chiropractic Philosophy & Clinical Technique: Mechanical Traction As A
Measure Of Reducing Subluxations Of The Lumbar Lordosis. J Am Chiropr Assoc. 2003;
40(12):24-27.

489. Troyanovich SJ. Motion palpation: It’s time to accept the evidence. Commentary. J.
Manip Physio Ther 1998; 21(8): 568-571

490. Turk DR. Changes in Brain Function after Manipulation of the Cervical Spine [Letter;
Comment]. J Manip Physiol Ther Sep 1998; 7(21): 497.

491. Unger J, The Effects of a Pelvic Blocking Procedure Upon Muscle Strength: A Pilot
Study Conference Proceedings of the Chiropractic Centennial 1995 Jul: 376-7.

492. Unger JF Temporomandibular Joint Dysfunction (TMJD): Work Shop [In English and
Japanese] Proceedings of the Scientific Symposium - 1997 World Chiropractic
Congress: Tokyo, Japan Jun 6-8, 1997: 274.

493. Unger JF, Jr, "The Effects of a Pelvic Blocking Procedure upon Muscle Strength: a Pilot
Study," Chiropractic Technique, Nov 1998; 10(4): 50-5.

494. Unger JF, The Legacy of a Chiropractor, Inventor and Researcher: Dr. Major Bertrand
DeJarnette Conference Proceedings of the Chiropractic Centennial Foundation:
Davenport, Iowa, Sep 14-16, 1995: 35-6.

495. Updyke WE. Congruence Between Decisions to Initiate Chiropractic Spinal Manipulation
for Low Back Pain and Appropriateness Criteria in North America ...J Am Chiro Assoc
Oct 1998; 10(35): 36-37.

496. Updyke WF. Vertebral Artery Flow and Cervical Manipulation: an Experimental Study
[Comment] J Am Chiro Assoc March 2000; 3(37): 50-51.

497. Van Loon, M; Colic with Projectile Vomiting: A Case Study Journal of Clinical
Chiropractic Pediatrics. 1998 Aug; 3(1): 207-10.

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498. Van Schalkwyk R, Parkin-Smith GF. A Clinical Trial Investigating the Possible Effect of
the Supine Cervical Rotatory Manipulation and the Supine Lateral Break Manipulation in
the Treatment of Mechanical Neck Pain: a Pilot Study. J Manip Physiol Ther Jun 2000; 5
(23): 324-331.

499. Vernon H. Qualitative Review of Studies of Manipulation-induced Hypoalgesia. J Manip

Physiol Ther Feb 2000; 2(23): 134-138.

500. Vernon H. Spinal Manipulation for Chronic Low Back Pain: a Review of the Evidence.
Top Clin Chiro Jun 1999; 2(6): 8-12.

501. Versendaal DA, Ulan F. Contact Reflex Analysis (CRA) and Applied Clinical Nutrition.
The American Chiropractor, 1998; March/April: 18-20

502. Vinton KJ. Chiropractic Case Management: Founded on Tone. Todays Chiro May/Jun
1999; 3(28): 68-80.

503. Wallace HL, Frogley HR. Manipulation for Headache Patients: a Brief Introduction of a
Novel Technique. Chiro Tech Feb 1998; 1(10): 11-18.

504. Wallace J, Gudgel JW. The Feedforward Mechanism As It Is Related To The Prone Leg
Check: A Review [Poster Presentation; The Association Of Chiropractic Colleges'
Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 66-67.

505. Walters P. Gonstead pelvic analysis evaluation. Letter to the editor. Chiropractic Journal
of Australia, 1998; 28(1): 26

506. Ward G, Pollard H. The Effect of Upper Cervical or Sacroiliac Manipulation on Hip
Flexion Range of Motion. J Manip Physiol Ther Nov/Dec 1998; 9(21): 611-616.

507. Ward G, Pollard H. The Effect of Upper Cervical or Sacroiliac Manipulation on Hip
Flexion Range of Motion. J Manip Physiol Ther Nov/Dec 1998; 9(21): 611-616.

508. West DT, Mathews RS, Miller MR, Effective Management of Spinal Pain in One Hundred
Seventy-seven Patients Evaluated for Manipulation under Anesthesia. J Manip Physiol
Ther Jun 1999; 5(22): 299-308.

509. Whittingham W, Nilsson N. Active Range of Motion in the Cervical Spine Increases after
Spinal Manipulation (Toggle Recoil). J Manip Physiol Ther Nov/Dec 2001; 9(24): 552-
555.

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510. Wiegand R, Marquina N, Zhang J. Low Level Laser Therapy On Knee Osteoarthritis
[Poster Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual
Conference, 2006]. J Chiropr Educ. 2006; 20(1): 83-84.

511. Williams HA. Manipulation under Anesthesia: Review of the Literature and Discussion of
the State of the Art. J Am Chiro Assoc Dec 1997; 12(34): 32-34+.

512. Williams HA. Part II. Manipulation under Anesthesia: Key Aspects. J Am Chiro Assoc
Jan 1998, 1(35): 44-49.

513. Williams HA. Part III: Manipulation under Anesthesia: Discussion and Critique. J Am
Chiro Assoc Feb 1998; 2(35): 53-55.

514. Winterstein JF. Spinal Manipulation for Low Back Pain: a Review of Goals, Patient
Selection, Techniques, and Risks [Letter; Comment], Eck et Al. J Am Chiro Assoc Sep
1999; 9(36): 18.

515. Wryneck [Book Review] by Fred H. Barge. Todays Chiro Nov/Dec 1998; 6(27): 108-109.

516. Yi-kai L, Shi-Zhen Z, Qing-An Z. The Effect of Cervical Traction Combined with Rotatory
Manipulation on Cervical Nucleus Pulposus Pressures. J Manip Physiol Ther Feb 1998;
2(21): 97-100.

517. Yochum TR. Raymond L. Nimmo and the Evolution of Trigger Point Therapy, 1929-1986
[Letter; Comment]. J Manip Physiol Ther Oct 1998; 8(21): 575.

518. Zemelka WH. Low Force Chiropractic Adjusting with the "Segmental Drop System." Am
Chiro Mar/Apr 1997; 2(19): 28-29+.

519. Zemelka WH. Low Force Chiropractic Adjusting with the "Segmental Drop System." Am
Chiro Mar/Apr 1997 2(19): 28-29+.
520. Zhang J, Conable K, Hambrick T. Applied Kinesiology In Chiropractic [Poster
Presentation; The Association Of Chiropractic Colleges' Thirteenth Annual Conference,
2006]. J Chiropr Educ. 2006; 20(1): 112-113.

521. Zhang JQ, Snyder BJ, Nosco D. Effects of the toftness chiropractic adjustment for
children with acute otitis media. J. Vertebral Subluxation Res. Vol. 2003 (XXX)

522. Methodology Perspectives. Clinical Practice Guideline Development. US Department of

Health and Human Services, Public Health Service, Agency for Health Care Policy and
Research, 1994; 5-12.
523. Boone WR, Dobson GJ. A proposed vertebral subluxation model reflecting traditional

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concepts and recent advances in health and science. Journal of Vertebral Subluxation
Research 1996; 1(1) 19-30.
524. Boone WR, Dobson GJ. A proposed vertebral subluxation model reflecting traditional
concepts and recent advances in health and science: Part II. Journal of Vertebral
Subluxation Research 1996; 1(2):23-30.
525. Boone WR, Dobson GJ. A proposed vertebral subluxation model reflecting traditional
concepts and recent advances in health and science: Part III. Journal of Vertebral
Subluxation Research 1997; 1(3)25-33.

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SECTION 7: Duration of Care for Correction of Vertebral Subluxation

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

Since the duration of care for correction of vertebral subluxation is patient

specific, frequency of visits should be based upon the reduction and eventual
resolution of indicators of vertebral subluxation. Since neither the scientific nor clinical
literature provides any compelling evidence that substantiates or correlates any specific
time period for the correction of vertebral subluxation, this recommendation has several
components which are expressed as follows:

a) Based on the variety of assessments utilized in the chiropractic profession, the

quantity of indicators may vary, thus affecting the periodicity of their appearance and
disappearance, which is tantamount to correction of vertebral subluxation.

b) Vertebral subluxation, not being a singular episodic event such as a strain or sprain,
may be corrected but reappear, which necessitates careful monitoring and results in a
wide variation in the number of adjustments required to affect a longer-term correction.

c) Based on the integrity of the spine in terms of degree and extent of degeneration, the
frequency of assessments, and the necessity for corrective adjustments, may vary
considerably.

d) Because the duration of care is being considered relative to the correction of

vertebral subluxation, it is independent of clinical manifestations of specific
dysfunctions, diseases, or syndromes. Treatment protocols and duration of care for
these conditions are addressed in other guidelines, which may be appropriate for any
practitioner whose clinical interests include alleviation of such conditions.

Commentary

Attempts have been made to identify an appropriate number and frequency of chiropractic
visits based on type of condition and degree of severity.1-24 Unfortunately, these
recommendations are based merely on consensus, and research to support these
recommendations is lacking. Moreover, little to no delineation has been made in the duration
of care literature base between care for specific symptomatic profiles such as low-back pain,
and long-term subluxation-specific care.

Two studies were found which addressed quality of life issues in patients under
chiropractic care. One large, well-designed retrospective study assessing patient
reported quality of life found no clinical end point where improvement reached a
plateau.25 A second study involved a detailed examination of a database collected
during a randomized clinical trial testing the effectiveness of a comprehensive geriatric
assessment program. It was reported that compared to non-chiropractic patients,

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chiropractic patients in this population were less likely to have been hospitalized, less
likely to have used a nursing home, more likely to report a better health status, more
likely to exercise vigorously, and more likely to be mobile in the community.
Furthermore, they were less likely to use prescription drugs.26

It is the position of the Guideline Panel that individual differences in each patient and the
unique circumstances of each clinical encounter preclude the formulation of “cookbook”
recommendations for frequency and duration of care.

The appropriateness of chiropractic care should be determined by objective

indicators of vertebral subluxation.

Chiropractors are encouraged to employ a clinically driven variable length of care format
in which the duration of care is determined by each individual patient’s progress toward meeting
measurable objectives, set in individualized care plans and identified during individual
assessment. This application ensures that patients are not over- or underutilizing a health-care
resource and are currently receiving the best possible care.

When developing a care plan based on reduction, correction and stabilization of the
subluxation the attending chiropractor should take into consideration many associated and
aggravating factors. These will include details about the extent and character of the patient's
subluxation. For example: How long have they been subluxated? How is this subluxation
affecting biomechanics, their nervous system, muscles, ligaments and involved joints? The
relationship between X-ray findings, chiropractic and physical exam findings and
instrumentation readings may need to be correlated.

It is important to consider the patient's age in respect to their subluxation and how the
age will impact the outcome. Since physical trauma is one of the potential causes of subluxation
it is important to consider whether or not the patient had previous injuries, traumas or accidents.
This should not be limited to single instances of trauma but also consider repetitive injuries,
microtrauma on a daily basis etc. These should all be considered in terms of how they will
interfere with subluxation correction and affect long term outcome.

Other co-existing health conditions may also affect the patient’s response to care since if
a patient is dealing with chronic health problems of any sort this may impede progress. The
patient’s work and home life demands may also have a bearing on how much of a correction
they attain and should be considered in determining in a care plan and prognosis. The patient's
sleeping habits may interfere with long-term correction and stabilization of the subluxation and
should be considered.

A patient’s ability to exercise or their lack of compliance to a prescribed exercise

regimen may impede their progress and diminish their response. And in some cases the
patient’s weight may have a bearing on their recovery. Other factors include smoking, alcohol,
nutritional problems and socio-emotional aspects of their life.

Justification for high frequency initial and extended wellness care plans should be based
on a combination of basic science, technique, objective assessment of physiological function,
structural changes and quality of life issues. The practitioner should ideally choose from several
of these to develop their care plan and to justify its implementation.

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No matter which of the various models of vertebral subluxation one chooses to address
in clinical practice there are two components that are common to all models. These components
are Kinesiopathology and Neuropathology. Kinesiopathology deals with issues related to
misalignment and/or abnormal motion and neuropathology deals with the neurological changes
related to the abnormal motion and/or misalignment.27

In discussing kinesiopathology the most significant basic science information relative to

this is Wolf’s Law, which states:

As bones are subjected to stress demands in weight bearing

posture, they will model or alter their shape accordingly. 28

Wolf’s Law has a less well-known corollary for soft tissue called: Davis’ Law that states:

Soft tissue will model according to imposed demands.29

These two Laws form the foundation of the rheology associated with subluxation and these
rheological properties are essential elements in the epidemiology of vertebral subluxation, which
must be considered with regards to care plans that have as their goal to make structural
changes. Rheology is the study of the change in form and the flow of matter including elasticity,
viscosity and plasticity. The longer a subluxation is allowed to set in the further along the path
of immobilization degeneration the subluxation is allowed to progress.30 The extent of
immobilization degeneration and the patient’s individual ability to reverse it may be a
determining factor in the frequency of the initial care plan and its duration. This will also affect
long term care whether from a palliative or wellness perspective once a substantial correction
has been made.

The other significant basic science issue related to frequency and duration of care has to
do with neuroplasticity.31-40 This has to do with the nervous system’s propensity to undergo
“plastic” changes and learn to habituate a response and is a fundamental aspect of the nature of
self-regulating repair processes that use the plasticity of the nervous system as it's conduit. In
order to overcome plastic neurological changes that have set in secondary to subluxation the
nervous system will need to “rewire” in order to create new plastic changes for the better. This
may necessitate frequent adjustments and other inputs into the CNS over a long duration in
order to make these changes. This neuroplasticity and the accompanying rheological changes
discussed above secondary to subluxation are what need to be overcome in order for the
patient to have a reduction in vertebral subluxation.

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REFERENCES

1. Balduc H. How chiropractic care can promote wellness. Northwestern College of

Chiropractic, Bloomington, MN.
2. Coile J, Russel C. “Promoting health,” the new medicine: reshaping medical practice and
health care management. Aspen Publ, Inc, Rockville, MD 1990;151-166.
3. Coulter ID. The patient, the practitioner, and wellness: Paradigm lost, paradigm gained. J
Manipulative Physiol Ther 1990; 13(2):107-111.
4. Flesia JM (President, Renaissance International and President, Chiropractic Basic Science
Research Foundation). Vertebral subluxation degeneration complex, a review of therapeutic
necessity for FSC well patient care, in: Seminar Notes (The New Renaissance, “Global
Chiropractic ... one patient at a time”), 7-36, including the 496 various papers, referenced
therein.
5. Hildebrandt R. Chiropractic physicians as members of the health care delivery system: The
case for increased utilization. J Manipulative Physiol Ther 1980; 3(1):23-32.
6. Jamison J. Chiropractic as conventional health care. J Aust Chiro Assoc 1989; 15(2):55-
59.
7. Jamison J. Preventive chiropractic and the chiropractic management of visceral conditions:
Is the cost to chiropractic acceptance justified by the benefits to health care? J Aust Chiro
Assoc 1991; 9(3):95-101.
8. Vear H. The role of chiropractic in preventive health care. J Can Chiro Assoc1974;
18(4):10-3.
9. Olson RE. Chiropractic/physical therapy treatment standards: a reference guide. Data
Management Ventures, Inc. Atlanta, GA, 1987.
10. Lang MG (chm) et al. Oregon chiropractic practices and utilization guidelines for
neuromusculoskeletal conditions. Oregon Chiropractic Practice and Utilization Guidelines
Committee.
11. Minnesota Chiropractic Association. Standards of practice. Roseville, MN,1991.
12. Ohio State Chiropractic Association. The chiropractic manual for insurance personnel.
Columbus, Ohio, 1988-1990.
13. Hansen DT (ed). Chiropractic standards and utilization guidelines in the care and treatment
of injured workers. Chiropractic Advisory Committee, Department of Labor and Industries,
State of Washington, 1988.
14. Leblanc F (ed). Scientific approach to the assessment and management of activity-related
spinal disorders. Spine 1987; 12:16-21.

15. Haldeman S. Presidential address, North American Spine Society: Failure of the pathology
model to predict back pain. Spine 1990; 15:718-24.
16. Frymoyer J. Back pain and sciatica. N Engl J Med 1988; 318:291-300.
17. Mayer T, Gatchel R. Functional restoration for spinal disorders: A sports medicine
approach. Philadelphia, Lea & Febiger, 1988.
18. Bronfort G. Chiropractic treatment of low-back pain: a prospective survey. J Manipulative
Physiol Ther 1986; 9:99-133.
19. Phillips RB, Butler R. Survey of chiropractic in Dade County, Florida. J Manipulative
Physiol Ther 1982; 5:83-9.

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20. Phillips R. A survey of Utah chiropractic patients. ACA J Chiro 1981;18:113-28.

21. Guifu C, Zongmin L, Zhenzhong You, Jiaghua W. Lateral rotatory manipulative maneuver in
the treatment of subluxation and synovial entrapment of lumbar facet joints. The Trad Chin
Med 1984; 4:211-12.
22. Jarvis KB, Phillips RB, Morris EK. Cost per case comparison of back injury claims of
chiropractic versus medical management for conditions with identical diagnostic codes. J
Occup Med 1991; 33:847-52.
23, Sullivan MD, Turner JA, Romano J. Chronic pain in primary care identification and
management of psychosocial factors. J Fam Pract 1991; 32:193-199.
24. Waddell G, Main CJ, Morris EW, DiPaola M, Gray L. Chronic low back pain, psychologic
distress and illness behavior. Spine 1984; 9:209-13.
25. Blanks RH, Schuster TL, Dobson M. A retrospective assessment of network care using a
survey of self-rated health, wellness, and quality of life. Journal of Vertebral Subluxation
Research 1997; 1(4):15-31.
26. Coulter I, Hurwitz E, Aronow H, Cassata D, Beck J. Chiropractic patients in a
comprehensive home-based geriatric assessment, follow-up and health promotion
program. Topics in Clinical Chiropractic 1996; 3(2):46-55.

27. Kent, C. Models of vertebral subluxation. Journal of Vert. Subluxation Res. Vol. 1, No. 1.
August 1996.

28. Wolff J; Maquet P, Furlong R, trans. The Law of Bone Remodelling. Berlin, Germany:
Springer-Verlag; 1986.

29. Functional Progressions for Sport Rehabilitation by Steven R. Tippett, MS,PT,SCS,ATC,

and Michael L. Voight, MED,PT,SCS,OCS,ATC. Published by Human Kinetics,
Champlain, IL. Copyright 1995.

30. Lantz, C.A. Immobilization Degeneration and the Fixation Hypothesis of the Chiropractic
Subluxation. Chiropractic Research Journal. Vol. 1 No. 1. 1988.

31. Peterson-Felix S, Curatola M. Neuroplasticity-an important factor in acute and chronic

pain. Swiss Med Wkly, Jun 2002; 132(21-22): 273-278.

32. Munte TF, Altenmuller E, Jancke L. The musician’s brain as a model of neuroplasticity.
Nat Rev Neurosci., Jun 2002; 3(6): 473-478.

33. Melzack R, Coderre TJ, Katz J, Vaccarino AL. Central neuroplasticity and pathological
pain. Ann N Y Acad Sci., Mar 2001; 933: 157-174

34. Corner MA, van Pelt J, Wolters PS, Baker RE, Nuytinck RH. Physiological effects of
sustained blockade of excitatory synaptic transmission on spontaneously active
developing neuronal networks-an inquiry into the reciprocal linkage between intrinsic
biorhythms and neuroplasticity in early ontogeny. Neurosci Biobehav Rev., Mar 2002;
26(2): 127-185

35. Bergado-Rosado JA, Almaguer-Melian W. Cellular mechanisms of neuroplasticity. Rev

Neurol., Dec 2000; 1-15; 31(11): 1074-1095.

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36. Carli G. Neuroplasticity and clinical pain. Prog Brain Res., 2000; 129: 325-330. .

37. Grafman J. Conceptualizing functional neuroplasticity. J Common Disord., Jul-Aug 2000;

33(4): 345-355; quiz 355-356.

38. Trojan S, Pokorny J. Theoretical aspects of neuroplasticity. Physiol Res., 1999; 48(2):
87-97.

39. Azmitia EC. Serotonin neurons, neuroplasticity, and homeostasis of neural tissue.
Neuropsychopharmacology, Aug 1999; 21(2 Suppl): 33A-45S.

40. Goldman S, Plum F. Compensatory regeneration of the damaged adult human brain:
neuroplasticity in a clinical perspective. Adv Neurol. 1997; 73:99-107.

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SECTION 8: CHIROPRACTIC CARE FOR CHILDREN

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

Since vertebral subluxation may affect individuals at any age, chiropractic care may
be indicated at any time after birth. As with any age group, however, care must be taken to
select adjustment methods most appropriate to the patient’s stage of development and
overall spinal integrity. Parental education by the subluxation-centered chiropractor
concerning the importance of evaluating children for the presence of vertebral subluxation
is encouraged.

Commentary
Schneier and Burns 1 published the results of a blinded study describing the
relationship of atlanto-occipital hypermobility to sudden infant death syndrome
(SIDS). These authors described the phenomenon of “atlas inversion” where the
posterior arch of C-1 enters the foramen magnum. They further stated, “Relative
measurements suggested that a correlation existed between instability in the atlanto-occipital
articulation and sudden infant death syndrome.” Instability is a manifestation of vertebral
subluxation. These findings corroborate those of Gilles, Bina and Sotrel in their paper, “Infantile
atlanto-occipital instability.” 2 These investigators studied 17 infant cadavers. Eleven were
SIDS cases and six were non-SIDS cases. Ten of the 17 cases demonstrated atlas inversion,
and all ten cases were in the SIDS group. These authors also suggested that atlanto-occipital
instability may be a factor in other conditions. They stated, “At this early stage in the
development of our notions about the potential contribution of atlanto-occipital instability to
deaths in infants, it is very difficult to assess the role of this proposed mechanism in the death
of an infant with a conventional disease. Thus, one might anticipate that the ‘controls’ will be
contaminated by children who had a conventional disease, but whose death was, in fact,
caused by this mechanism.”

Towbin 3 addressed the clinical significance of spinal cord and brain stem injury at birth,
noting that such damage is often latent and undiagnosed. According to Towbin, “Death of the
fetus may occur during delivery or, with respiratory function depressed, a short period after
birth. Infants who survive the initial effects may be left with severe nervous system defects. In
some, the neurologic sequellae are attributable directly to the primary lesion in the cord or brain
stem; in others, secondary cerebral damage results, and a consequence of the imposed period
of hypoxia at birth.” Chesire 4 described three cases of traumatic myelopathy in children without
demonstrable vertebral trauma. In this paper, the classical mechanism of trauma is said to be
hyperextension of the cervical spine in a difficult breech delivery. Although tetraplegia may
result, the x-rays are described as “usually normal.”

Complicated deliveries represent a higher risk to the child of suffering spinal

cord damage during the birth process. High cervical spinal cord injury in neonates is a
specific complication of forceps rotation. The vacuum extractor exerts considerable
traction force. Fetal skull fracture can result, and its true incidence may be higher than
expected, considering that few neonates with normal neurologic behavior undergo skull
x-ray.5-7 Byers 8 published an excellent review paper addressing spinal cord damage

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during the birth process. Traction and rotational stresses applied to the spinal axis
were listed as causes of spinal cord injury during birth.

The vagus nerve is involved in mechanisms associated with control of tidal

volume, breathing rate, and respiratory reflexes. Sachis et al.9 performed histological
examinations of the vagus nerve in infants who died of SIDS and those who died of
other conditions. Significant differences were noted between the two groups. Several
hypotheses were proposed by authors to explain the data, including damage to the
vagus nerve resulting in delayed development.

Gutman 10 described how “relational disturbance” between occiput and atlas can
lead to “blocked atlantal nerve syndrome” in children and adults. The author listed a
variety of conditions which appear clinically related to this syndrome. Although SIDS
was not discussed as an entity, the author stated that a brain stem component is a
part of this syndrome. It was concluded that for those affected, “manual treatment” by
a qualified practitioner is appropriate.

In her paper “Physical stresses of childhood that could lead to need for chiropractic
care,” presented at the first National Conference on Chiropractic and Pediatrics,
McMullen 11 stated, “Any condition that arises to change the normal birth process…
frequently results in subluxation at the level of greatest stress. This conclusion is
supported by a number of recent papers.12-22 Severe subluxation resulting in nerve
damage may be clinically obvious at birth (e.g., Bell’s, Erb’s and Klumpke’s palsies);
however, more frequently the trauma remains subclinical with symptoms arising at a
later time. These symptoms include, but are not limited to, irritability, failure to thrive
syndrome and other neurological signs and behavioral problems, 60-87 gastrointestinal
issues (e.g., colic and irritable bowel syndrome), 23-41 asthma and respiratory problems,
42-59
ophthalmic symptoms, 88, 89 postural and musculoskeletal disorders, 90-93 and
those syndromes associated with lowered immune responses 94, 95 and chronic middle
ear infections. 96-105 These subluxations should be analyzed and corrected as soon as
possible after birth to prevent these associated conditions.”

Bonci and Wynne 106 and Stiga 107 published papers discussing the relationship
between chiropractic theory and SIDS etiology. Banks et al.108 stated “Functional
disturbances in the brainstem and cervical spinal cord areas related to the
neurophysiology of respiration may contribute the clinical factors associated with
sudden infant death syndrome...Any process, whether genetic, biochemical,
biomechanical or traumatic, that alters normal development of the respiratory control
centers related to spinal constriction and compression following birth trauma may be
contributory to sudden infant death syndrome.” 109-114

Other traumatic events of childhood may produce vertebral subluxations.

Orenstein et al.115 Did a retrospective chart review involving 73 children who presented
at a children’s hospital with cervical spine injuries. Sixty-seven percent of these
injuries were traffic related resulting from motor-vehicle crashes. The injured children
were passengers in an automobile, pedestrians, or bicyclists. The mean age of the
patients surveyed was 8.6 years, with bimodal peaks at 2 to 4 and 12 to 15 years. The
authors noted that younger children sustained more severe injuries than older children.
Distraction and subluxation injuries were the most common injuries in children aged 8
years and younger. Fractures were more common in older children.

Glass et al.116 evaluated 35 children with lumbar spine injuries following blunt
trauma. Thirty-one of these children were injured in motor-vehicle crashes.

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Abnormalities noted on plain radiographs and CT scans included subluxation, dies-

traction, and fracture alone or in combination. The authors stated, “Children involved
in motor-vehicle crashes are at a high risk for lumbar spine injuries… Lumbar spine
radiographs are necessary in all cases with suspected lumbar spine injury…” This
paper underscores the need to evaluate the entire spine in cases of motor-vehicle
accidents, not just the cervical region. It may be cited when claims for lumbar
radiographs are questioned in cases of children involved in car accidents.

Rachesky et al. 117 reported that on the cervical spine radiographs of children
under 18 they examined, vehicular accidents accounted for 36% of radiographic
abnormalities. It was further stated that clinical assessment of a complaint of neck
pain or involvement in a vehicular accident with head trauma would have identified all
cases of cervical spine injury.

Other authors have described aspects of cervical spine injuries in children involved in
motor-vehicle accidents. Hill et al.118 noted that 31% of the pediatric neck injuries reviewed
were the result of motor-vehicle accidents. In younger children (under 8 years of age)
subluxation was seen more frequently than fracture. Agran 119 stated that non-crash vehicular
events may cause injuries to children. Noncrash events discussed in this paper included
sudden stops, swerves, turns, and movement of unrestrained children in the vehicle.

Roberts et al. 120 described a case where a child involved in a motor-vehicle accident
sustained a “whiplash” injury resulting in immediate neck and back pain. Neurobehavioral
abnormalities increased in the two-year period following the accident. Four years after the
accident, symptoms persisted. Position emission tomography (PET scan) demonstrated
evidence of brain dysfunction.

The clinical manifestations of pediatric cervical spine injury may be diverse. Biedermann 121
stated that a wide range of pediatric symptomatology may result from suboccipital strain. The
disorders reported include fever of unknown origin, loss of appetite, sleeping disorders, asymmetric
motor patterns, and alterations of posture. Maigne 109 stated that trauma to the cervical spine and
head can cause such problems as headaches, vestibular troubles, auditory problems and psychic
disturbances. Gutmann 122 discussed the diverse array of signs and symptoms which can occur as
a result of biomechanical dysfunction in the cervical spine. Others have also reported various
pathoneurophysiological changes in children,123-128 as well as reduction of pathology following
chiropractic care.23-27, 42-45, 62, 127-128 In the chiropractic literature, Clow 42 published a paper
addressing pediatric cervical acceleration/deceleration injuries.

Two peer reviewed journals, Chiropractic Pediatrics and the Journal of Clinical Chiropractic
Pediatrics are being published to disseminate critically reviewed papers in this field.
Additionally, courses in pediatrics are offered at the professional and postgraduate levels at
accredited chiropractic colleges and by the International Chiropractic Pediatric Association.
Finally, it must be remembered that chiropractic shows some benefit even from the moment of
conception, and in the fertility issue itself. A number of case reports have documented improved
fertility in woman undergoing chiropractic care. 130-141 This issue is examined in greater detail in
Section 9 (below).

The pediatric case history and physical examination necessarily differ in content and scope
from those of adult patients. Even taking into consideration the difference between the two
populations, however, a recent quasi meta-analysis reveals an extremely low risk for
chiropractic pediatric patients receiving adjustments.61

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The Chiropractic Care of Children

Although the history of manual therapy is lost to antiquity, the first documentation of
manual therapy can be traced to Hippocrates (460 BC to 375 BC) when he taught his students
to apply a high velocity low amplitude (HVLA) thrust on a gibbus or a prominent vertebra
followed with advice to exercise.142 There is no reason to believe that children, like adults,
suffered from similar maladies and therefore would be candidates to similar care, manual
therapy or otherwise. Within chiropractic, there are indications that the chiropractic care of
children has been around since the profession’s inception.143 A chiropractor by the name of M.
Kueck wrote Old Dad Chiro that, “I think I have all Chiros beat on the youngest patient. Our
daughter was adjusted when she was one day and two hours of age….” Palmer’s response
was, “BJ’s child was adjusted when he was 4 hours old…”

In the modern era, we look to the 1990s when, contemporaneous with the seminal
publication by Eisenberg and colleagues144 that found one in three Americans used some form
of alternative therapy at a cost of $13.7 billion with $10.3 billion paid out of pocket, Spigelblatt
and colleagues145 published their findings on the frequency and sociodemographic factors
associated with complementary and alternative medicine (CAM) use by children. Based on 1911
completed questionnaires, approximately 11% (N=208) indicated having consulted one or more
CAM practitioners for their complaint. Of the various types of CAM therapies used (i.e.,
homeopathy, naturopathy, oligotherapy, acupuncture, etc.), chiropractic was the most popular to
address complaints involving the respiratory, ear-nose and throat and musculoskeletal systems.
In 1994, Lee and colleagues146 characterized the chiropractic care of children. The authors
extrapolated that 30 million pediatric visits were made to chiropractors in the US in 1998 at a
cost of $1 billion with approximately $510 million paid out-of-pocket by parents. The 2005 Job
Analysis of Chiropractic, published by the National Board of Chiropractic Examiners147, confirms
the continuing popularity of chiropractic for children with the findings that the percentage of
patients under 17 years of age has increased by 8.5% compared to a 1991 survey of
practitioners. The chiropractic care of children therefore represents a significant aspect of
chiropractic and pediatric care in general.

Unique Biomechanical Features of the Pediatric Spine

The chiropractic care of children is simply not a scaled-down version of the care of the
adult. In addition to the findings that pediatric patients present to the chiropractor for a variety of
conditions with an emphasis on non-musculoskeletal and wellness care,148 the approach to
patient care must be tempered with due consideration to the unique biomechanical features of
the pediatric spine within the context of the pathogenesis of the vertebral subluxation complex
(VSC).149 Furthermore, within the pediatric population, such considerations are unique for those
of the newborn versus a 3 year old versus a 6 year old versus a 12-13 year old. These features
include growth, malleability, adaptability, hypermobility, changing spinal contours, changing
applied forces and an immature neuromusculoskeletal system. Let us examine these features in
the context of chiropractic care and the pathogenesis of the VSC.

A dynamic process, growth of the pediatric spine and the individual occurs at all levels of
complexity at the molecular level to organs and tissue systems. Anatomically, consider that the
height of the C0 is approximately 50% that of the adult. Furthermore, the horizontal orientation
of the C0-C1 functional spinal unit (FSU) is much flatter.150 Add to this the higher head to body
mass ratio, there are higher torque and shear forces at the C0-C1 and C1-C2 FSU. The results
are that the upper cervical spine in the child is prone to subluxation (i.e., lateral displacement of

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the atlas). Additionally, consider the varying forces applied to the newborn in the process of
birth. Recent publications indicate that major birth trauma occurs in 3% of all live-born infants,
accounts for 2% of all neonatal mortality, and accounts for 10% of all neonatal deaths in full-
term infants.151-153 In the sagittal plane, the joint surfaces are more steeply aligned with the facet
joints more shallow and angled. With underdeveloped spinous processes and physiologic
anterior wedging of the vertebral bodies, these factors in addition to those mentioned above
contribute to hypermobility – an increase in physiologic range of motion.

In a study involving 160 pediatric patients with no history of cervical spine trauma, 46%
of children less than 8 years old had pseudosubluxation of C2 on C3 on lateral flexion and
extension radiographs of the cervical spine.154 In situations involving trauma such as that in
hyperflexion/hyperextension injuries, these pseudosubluxated segments may be more prone to
injury in the way of subluxation. With respect to malleability, the pediatric spine is easily
deformed with external applied forces. For our purpose, consider deformational plagiocephaly, a
condition where the child’s head and possibly his or her face are deformed as a result of
prenatal and/or postnatal external molding forces. Deformational plagiocephaly has been
attributed to intrauterine constraint, premature birth, the use of forceps and vacuum extraction
during delivery, dystocia, malposition and malpresentation pregnancies, multiple birth, and
primiparity.155 Risk factors include the male gender, non-varying head position when asleep,
sleeping supine, developmental delay, and lower activity level. Placing the child in the prone
position when awake for 5 minutes a day seems to be a protective factor.155 Cranial techniques
have been found to be effective in correcting deformational plagiocephaly.156-157

What of adaptability – the ability to withstand and adapt to stresses? This is often true of
the pediatric patient with presenting complaints that are sub-clinical in nature. With the infant’s
inability to fully communicate, the chiropractor must be astute with his/her history and physical
examination. The patient’s demeanor (i.e., is the child described as more “fussy”?), the
frequency and character of his/her crying, napping time and duration, and feeding habits must
be taken into consideration and must augment the hands-on physical examination/findings of
the patient. Chiropractors have always advocated for a physiologically aligned spine not only
for cosmetic appearance (i.e., proper posture) but also for proper functioning of the spine and
the whole person. We instill in our patients that a properly aligned spine leads to the
maintenance and restoration of health. Towards this end, consider the body of literature on this
topic as published by Harrison and colleagues.158 In the area of prevention, one needs only
consider the findings by Kumar and colleagues159 that demonstrated that effective maintenance
of a saggital plane in the lumbar spine leads to alleviation of negative outcomes such as
segmental degeneration.

Degenerative processes do take place in the young spine and continue well into
adulthood if not addressed.160 With respect to saggital curvatures, the neonate begins with a
slight lordosis in the cervical and lumbar spine and a slight kyphosis in the thoracic spine. As the
child grows, the saggital spinal alignment has been found to change.161 This changing spinal
contour requires constant adaptations in the morphology and orientation of the pelvis (i.e.,
skeletal loads, muscle fatique and energy expenditure) to maintain an adequate sagittal balance
and appropriate configuration in the lumbopelvis.162 Mac-Thiong and colleagues163
demonstrated that there exists a significant statistical correlation between adjacent anatomical
regions of the spine. From the point of view of a kinematic chain, the pelvic incidence and sacral
slope affect the development of the lumbar lordosis, the thoracic kyphosis and presumably the
cervical lordosis. In view of the physiologic and morphologic changes that occur during spinal
development and efforts to maintain an adequate spinal balance, chiropractic care is indicated
and would be prudent even in the absence of pain symptoms. Restoration and maintenance of

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spinal alignment is the cornerstone of chiropractic care. Failure to address misalignment in

childhood may lead to pathology in adulthood.

Consider the finding by Hestbaek and colleagues164 that found low back pain in
adolescence was a significant risk factor for low back pain in adulthood with odds ratios as high
as four. Lastly, the pediatric spine is associated with an immature neuromusculoskeletal system.
As such, supporting soft tissue structures (i.e., muscles, ligaments, tendons) have mechanical
properties inferior compared to that of the adults to withstand changing and applied forces.
Additionally, reflex effects that are well developed in the adult are just beginning to be
established as the child matures. As such, intentional forces applied to the spine in the way of
an adjustment must be tempered to prevent sprain and strain injuries to the FSUs. Although no
studies thus far have measured the forces applied to the pediatric spine utilizing an HVLA type
thrust; using a straight posterior-to-anterior HVLA thrust to the transverse process of T3-T10
reinforced with hypothenar contact, Herzog and colleagues165 measured an average peak total
force was 238.2 N over a target area of 25 mm2 in asymptomatic adults. For children, a fraction
of this may be applied with HVLA-type maneuvers ranging from 30-70 N of force.166

Evidence-Based Pediatric Chiropractic

In a recent publication, Gotlib and Rupert167 performed a systematic review of the

literature on the use of chiropractic for a variety of pediatric conditions. The authors found that
low levels of scientific evidence supported chiropractic care for various pediatric health
conditions. The evidence rested primarily with clinical experience, descriptive case studies and
very few observational and experimental studies. This systematic review was an update to a
systematic review performed by the authors in 2005168 that found similar findings. We do not
disagree with the findings of Gotlib et. al.167-168 per se. In fact the authors are to be commended
for their contribution to chiropractic research.

As defined by Sackett and colleagues,169 evidenced-based practice is defined as the

conscientious, explicit, and judicious use of current best research evidence, the integration of
the clinical expertise of the clinician and the thoughtful identification and compassionate use of
an individual patient’s predicaments, rights, and preferences in making clinical decisions about
their care. Towards this end, the review by Gotlib and colleagues167-168 provide an incomplete
assessment of the state of chiropractic research on the chiropractic care of children. There is a
growing movement among CAM providers and researchers that recognize that existing research
methodologies and dependence on randomized controlled clinical trials as the “gold standard”
may not be sufficient or appropriate for CAM therapies.170 As pointed out by Verhoef and
colleagues,171 non-allopathic therapies such as chiropractic are complex with individualized
rather than standardized treatments. With a holistic and vitalistic approach to patient care,
chiropractic addresses non-specific, multifactorial elements of the patient beyond the specific
condition at hand (i.e., restoring homeostasis in the person). Recruitment for RCTs may be
incongruent with a person’s beliefs, practices and general worldview and as already exemplified
in chiropractic research, an appropriate sham/placebo treatment may be impossible to identify.
Lastly, RCTs minimized or exclude the impact of non-specific effects (i.e., patient-provider
relationship) whereas in chiropractic, these effects are embraced.

As such, chiropractic and other CAM therapies may be more amenable to whole
systems research (WSR). Whole systems can be defined as ‘‘approaches to health care in
which practitioners apply bodies of knowledge and associated practices in order to maximize
the patients’ capacity to achieve mental and physical balance and restore their own health,
using individualized, non-reductionist approaches to diagnosis and treatment.’’172 Furthermore,

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assessing the evidence in pediatric chiropractic research using traditional methods such as
systematic reviews becomes painfully obvious in its limitations. Only a handful of pediatric
conditions (i.e., asthma and colic) under chiropractic care have research utilizing RCTs.
Therefore, a meta-analysis cannot be performed with systematic reviews. However, the use of
qualitative research in both allopathic and non-allopathic care has gained some ground in recent
years. Qualitative research investigates phenomena in their natural context and generates
specific information regarding the why and how of individual experiences. One specific
approach of qualitative research is meta-synthesis. Defined as “the bringing together of findings
on a chosen theme, the results of which should, in conceptual terms, be greater than the sum of
the parts”,173 meta-synthesis may also provide a tangible approach to the evaluation of research
thus far published. Hawk and colleagues174 recently developed a checklist to evaluate the merits
of chiropractic research in the context of WSR. Although preliminary in nature, the checklist is
the only one of its kind created by chiropractors and specific for chiropractic. For meta-
synthesis, the cross-case analysis approach is performed where categories are identified in
individual studies and then refined and cross-referenced with other studies. The WSR and
meta-synthesis approach to the chiropractic care of children with otitis media is applied here as
an example.

Systematic Review of the Literature on the Chiropractic Care of Children with Otitis
Media: Incorporating Whole Systems Research and Qualitative Meta-Synthesis.

To perform the systematic review, a comprehensive search was performed to identify all
relevant reports pertaining to the chiropractic care of children (age ≤ 18 years) with otitis media.
The following electronic databases were searched: MANTIS [1965-2008]; ICL [1984-2008];
Pubmed [1966-2008]; EMBASE [1974-2008], AMED [1975-2008], CINAHL [1965-2008], Alt-
Health Watch [1965-2008] and PsychINFO [1965-2008]. Key words used were otitis media
(OM), ear infections, acute otitis media(AOM), chronic otitis media (COM), otitis media with
effusion (OME) in combination and chiropractic incorporating the Boolean operators and the
application of related words when appropriate. The search was limited to publications in the
English language and in peer-reviewed journals. Additionally, chiropractic journals (i.e., Journal
of Manipulative and Physiological Therapeutics, Journal of the Canadian Chiropractic
Association, Clinical Chiropractic, The Chiropractic Journal of Australia and the Journal of
Clinical Chiropractic Pediatrics) were hand-searched for the last five years for possible relevant
materials. Key informants and experts in the field were also contacted to provide assistance in
providing relevant literature. The gray literature was also searched as well as the bibliography
lists of all retrieved articles and relevant studies.

The title and abstracts of all articles generated from the electronic database search as
well as from the reference lists of relevant articles and other data sources were examined for
their appropriateness for this review. The full manuscripts of reports relevant to the chiropractic
care of children were retrieved by applying the following set of eligibility criteria: (1) the study
was a primary investigation/report (i.e., case reports, case series, case control, randomized
controlled trials and survey or surveillance studies) in a peer-reviewed journal; (2) part or all of
the study population was 18 years or younger and; (3) the topic involved the care of a patient
with otitis media.

A systematic review of the literature on the chiropractic care of children revealed 20

articles.175-194 These consisted of the following: four commentaries, a survey study, six case
reports, five case series, three prospective cohort studies and one prospective, parallel-group,
observer-blinded, randomized feasibility study on the chiropractic care of children with chronic
OM. The WSR checklist and results of the WSR scoring are provided in Table 1. A total of 15

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studies were amenable for WSR evaluation. The average score was 7.06 (median=7; mode=8).
Based on the rating score by Hawk and colleagues (5) (maximum score = 11; 0-3 = low; 4-7 =
medium; 8-11 = high quality); the peer-reviewed literature on the chiropractic care of children
are of “medium” quality.

The case analysis approach to the literature examined various aspects of the
management. To date, the article by Lamm and Ginter190 provides for the most comprehensive
description on the management approach for chiropractors on the care of patients with otitis
media. This is augmented by the diagnostic approach to the care of the patient with otitis media
by Bowers191 Based on the published literature, the approach to the patient with otitis media
begins with a history and physical examination. The prevailing findings from the history
examination were unsuccessful medical care with antibiotics despite recurrence and chronicity
of otitis media. The physical examination procedure incorporated both aspects of allopathic and
chiropractic approaches. In 8 of the 14 publications, an otoscopic examination was performed to
further augment the diagnosis of otitis media. The study by Fallon188 demonstrated the clinical
utility of the tympanogram as an examination and outcomes instrument in the care of patients
with otitis media. Essential to patient care was in determining the sites of spinal subluxations
upon which the adjustment is predicated upon and dependent on the specific technique utilized
by the attending clinician.

With respect to the chiropractic care rendered, Activator Methods, Gonstead Technique,
Toftness Technique, Chiropractic Biophysics and Diversified Technique were utilized. Although
spinal examination and care involved both regional and fullspine approaches, there was an
emphasis or focus on adjustments to the upper cervical spine. Only one case described utilizing
a cranial technique. Two authors, Evans180 and Erickson194 utilized a dietary intervention while
Fysh184 and Erickson194 utilized soft-tissue manipulation to enhance lymphatic flow in cervical
region. Surprisingly, no studies described the use of homeopathic remedies, which from a
clinical point of view is commonly utilized by chiropractors.

This systematic review of the literature on the chiropractic care of children with otitis
media utilizing WSR and meta-synthesis highlights the detection and correction of spinal
subluxations augmented with adjunctive modalities. This approach to patient care would seem
universal in patients with other pediatric conditions such as enuresis, asthma, colic, etc. Based
on our findings utilizing WSR evaluation and qualitative meta-synthesis, the chiropractic care of
pediatric patients is evidence-based. The systematic review reflected the notion that
chiropractors utilize best practices, depend on their collective clinical expertise and are mindful
of the needs and wants of the patient/parent.

The Safety of Pediatric Chiropractic

In addressing the role of the evidence-based clinician on the safety and effectiveness of
manual therapy for children, including chiropractic. Huijbregts195 points out that there is no clear
evidence of harm. Furthermore, research on outcome and harm for one treatment approach
cannot be applied to all. Given the continued popularity and utilization of chiropractic for
children, there are ongoing concerns regarding their safety and effectiveness196 both from within
and outside the profession.

Ernst,197 in a systematic review of the literature addressed the issue of adverse events
associated with unconventional therapies in children. Most of the adverse events were
associated with herbal medications due to contamination with toxic plant material, heavy metals,
or adulterated with synthetic drugs. The adverse events described included bradycardia, brain

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damage, cardiogenic shock, diabetic coma, encephalopathy, heart rupture, intravascular

haemolysis, liver failure, respiratory failure, toxic hepatitis and death. With respect to the use of
SMT in children, Ernst197 referenced the paper by Di Fabio198 that examined 177 cases involving
SMT of the cervical spine as reported in 116 articles published between 1925 and 1997.
Although the subjects’ age ranged from 4 months to 87 years, the majority of the cases involved
adult patients. Ernst197 further described one case of an infant with congenital torticollis treated
with chiropractic spinal manipulation.199 Within a few hours of this therapy the child suffered
from respiratory distress, quadriplegia and seizures. A holocord astrocytoma with excessive
acute necrosis was found and resected.

To address the issue of safety of pediatric osteopathic spinal manipulative therapy

(OMT), Hayes and Bezilla200 performed a retrospective review of medical records of pediatric
patients receiving osteopathic manipulative therapy (OMT) looking for documentation of
treatment-associated aggravations and complication as previously defined. Of 502 records
reviewed, 346 files met inclusion criteria (i.e., patient received ≥ 2 office visits) for analysis. No
OMT-related complications were documented. Nine percent (N=31) of 346 patients reported an
OMT-associated aggravations. Hayes and Bezilla200 concluded that OMT appears to be a safe
treatment modality for the pediatric population.

Vohra and her colleagues201 recently performed a systematic review of the literature on
the adverse events associated with pediatric SMT. Using 8 databases and spanning a period 0f
104 years, Vohra et. al.201 found 14 instances of adverse events associated with pediatric SMT.
The adverse events documented included irritability (N=1) and loss of consciousness (N=1),
midback soreness (N=1), acute lumbar pain (N=1), headache and stiff neck (N=1), severe
neurological deficits (N=5), Anterior dislocation of atlas and fracture of odontoid axis at C2
(N=1), atlas dislocation (N=1) and eventual death (N=2). Considering that the chiropractic
adjustment is the primary treatment approach of chiropractors, not surprisingly, the majority of
cases (10 of 14 cases) were attributed to chiropractic. A critical appraisal by Alcantara202 on the
adverse events attributed to chiropractic by Vohra et.al.201 provided convincing arguments
against cause and effect inferences to chiropractic care and the resultant adverse events. Five
of the 10 cases were minor, self-limiting, and did not require hospitalization or medical attention.
In the cases involving severe neurological loss, fracture or death, a pre-existing condition or
history of trauma preceded the chiropractic care. As Alcantara202 pointed out, cetaris parabis,
the findings by Vohra et.al.201 would seem to indicate that pediatric chiropractic is safe.

Recently, Miller and Benfield203 reported possible adverse outcomes with pediatric
chiropractic care at the Anglo European College of Chiropractic. From 697 children receiving a
total of 5242 chiropractic treatments (with 85% of parents reporting an improvement), 7 parents
reported an adverse effect. The authors reported a reaction rate of approximately 1 child in 100,
or one reaction reported for every 749 treatments. No serious complications resulting from
chiropractic treatment were reported by the authors. Despite the reported and perceived safety
reported by Miller and Benfield,203 the expectation of 1 report of an adverse event for every 100
children receiving chiropractic care is disagreeable. First, three of the 7 cases were in fact not
adverse events per se but more likely “perceived” or misinterpreted by the authors as an
adverse event on initial interpretation. Secondly, the reported adverse events were based solely
on reports on the part of the parent(s) of excessive crying of their child within a teaching
institution. No further documentation in support of an adverse event beyond crying was
assessed. In most of the cases, the children were receiving care for infantile colic with one for
KISS Syndrome. As pointed out by the principle author (Miller) in a separate publication,204
infantile colic and KISS Syndrome are conditions of childhood characterized with excessive
crying. The extent to which care rendered by chiropractic students is similar or dissimilar to care

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rendered by experienced and/or licensed practitioners was not addressed by the authors. The
issue of confounding was also not addressed by Miller and Benfield. The rates of adverse
events reported by Miller and Benfield203 are therefore suspect and arguably much less than
they report.

The International Chiropractic Pediatric Association recently launched their Practice-

Based Research Network to address research on the chiropractic care of children. On the issue
of safety, a study modeled on the work of Hayes and Bezilla200 was launched to examine
treatment associated aggravations and complications associated with chiropractic care of
children. Aggravations and complications were operationally defined so that aggravations were
“worsening of symptoms” while complications involve such situations as fractures, dislocations,
stroke, death, etc. Based on preliminary findings thus far, a survey of chiropractors provided
care to 577 children for a total of 5438 clinical encounters - no treatment-associated
complications have been documented and less than 4 cases of treatment-associated
aggravation have been reported (unpublished data).

The results were similar with the parent survey from 239 children attending a total of
1735 visits. No documentation of treatment-associated complications was made with 2
instances of treatment-associated aggravation (unpublished data). All reported aggravations
(from chiropractor and parent survey) were minor, self-limiting, and did not require
hospitalization or medical attention. More importantly, the complaints were addressed by the
treating chiropractor in subsequent visits and did not dissuade the parents from continuing
chiropractic care for their child.

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Table 1. Whole Systems Research checklist and WSR scoring of studies on the chiropractic care of children.

WSR Checklist References WSR

Scoring
1 Intervention included entire clinical encounter (rather than single procedure
only)
1a • Intervention tested “package” of care Phillips (35) 7
2 Patient preferences/expectations assessed Burnier (36) 5
2a • Treatment preference or expectations assessed
3a • Practitioner could use clinical judgment to modify procedures Heagy (37) 8
3b • Practitioner could use clinical judgment to modify number of visits, Peet (38) 7
duration of care
4 Intervention representative of usual practice Evans (39) 8
4a • Delivered by experienced practitioners
4b • Procedures/protocols based on usual practice, as documented by case Marko (40) 6
reports, case series or large observational studies

4c • Principal investigator delivered treatments (-1) Webster (41) 8

4d • Fees for services were representative of usual practice Fysh (43) 8
5a • “Real-life” comparisons such as no treatment, waiting list, or standard Froehle (44) 8
medical care used

5b • Sham/placebo procedure same as procedures used in usual practice (such Thomas (45) 8
as soft-tissue therapy) (-1)
Fallon (47) 7
6a • Primary outcomes were patient-based measures (pain, function, health
status)
Sawyer and 7
6b • Satisfaction assessed Colleagues (51)
Saunders (51) 6
7a • Health status or QOL instrument administered pre- and post-intervention
Zhang et. al. (52) 7
Erickson and 6
colleagues (53)
Mean Score= 7.06 (Median=7;
Mode= 8)

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79. Krawchuk C, Epstein EC. Diagnostic Corner. Chiropractic Management Of Children With
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183. Johnson ME. Studies critique accepted medical treatment of otitis media – chiropractic
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185. Froehle R. Ear Infection: A Retrospective Study Examining Improvement from

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186. Thomas D. Irritable child with chronic ear effusion/infections. Chiropractic Pediatrics
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187. Vallone S, Fallon JM. Treatment Protocols for the Chiropractic Care of Common
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190. Lamm L, Ginter L. Otitis Media: A Conservative Chiropractic Management Protocol

Topics in Clinical Chiropractic 1998;5(1): 18-28

191. Sawyer, CE.; Evans, RL.; Boline, PD.; Branson, R.; Spicer, A.; A Feasibility Study of
Chiropractic Spinal Manipulation Versus Sham Spinal Manipulation for Chronic Otitis
Media With Effusion in Children J Manipulative Physiol Ther 1999;22(5): 292-8

192. Saunders L. Chiropractic treatment of otitis media with effusion: a case report and
literature review of the epidemiological risk factors that predispose towards the condition
and that influence the outcome of chiropractic treatment Clinical Chiropractic 2004;7(4):
168-173

193. Zhang JQ, Snyder BJ. Effect of the Toftness Chiropractic Adjustments for Children with
Acute Otitis Media Journal of Vertebral Subluxation Research 2004; 2004:1-4

194. Erickson K, Shalts E, Kligler B. Case study in integrative medicine: Jared C, a child with
recurrent otitis media and upper respiratory illness. Explore (NY) 2006;2(3):235-7

195. Huijbregts PA. Manual therapy in children: Role of the evidence-based clinician. J
Manual Manipulative Ther 2006; 14:7-9

196. Fearon J. Complementary therapies: knowledge and attitudes of health professionals.

Pediatric Nurs 2003;15:31-5

197. Ersnt E. Serious adverse effects of unconventional therapies for children and
adolescents: a systematic review of recent evidence. Eur J Pediatr 2003; 162: 72–80

198. Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Phys Ther. 1999
Jan;79(1):50-65

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199. Shafir Y and Kaufman BA. Quadraplegia after chiropractic manipulation in an infant with
congenital torticollis caused by a spinal cord astrocytoma. J Pediatr

200. Hayes NM, Bezilla TA. Incidence of iatrogenesis associated with osteopathic
manipulative treatment of pediatric patients. J Am Osteopath Assoc 2006; 106:605-8

201. Vohra S, Johnston BC, Cramer K, Humphreys K. Adverse events associated with
pediatric spinal manipulation: a systematic review. Pediatrics 2007; 119:e275-83

202. Alcantara J. Adverse Events associated with pediatric spinal manipulation: a systematic
review. What does the data really show? World Federation 9th Bienial Conference.
Vilaamoura, Portugal. May 17-24, 2007

203. Miller JE, Benfield K. Adverse effects of spinal manipulative therapy in children younger
than 3 years: a retrospective study in a chiropractic teaching clinic. J Manipulative
Physiol Ther 2008; 31(6):419-23.

204. Miller J. Cry babies: a framework for chiropractic care. Clinical Chiropractic 2007;10:139-
146.

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SECTION 9: MATERNAL CHIROPRACTIC CARE

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

In pregnancy a woman’s body experiences numerous biomechanical adaptations

and physiological changes. These changes often have an adverse affect on her neuro-
musculo-skeletal system affecting quality of life in pregnancy, birth outcome and the
future well-being of her baby. Because of these physiological compensations,
practitioner care must be taken to select the specific analysis and adjustment most
appropriate for the complex changes throughout the various stages of pregnancy. The
increased potentials for spinal instability in the mother and the resulting subluxations in the
woman’s spine throughout pregnancy affect the health and well-being of both her and her
baby. This warrants regular chiropractic check-ups in all women throughout pregnancy.
Patient education pertinent to chiropractic care in pregnancy is encouraged.

Commentary

The doctor of chiropractic plays an essential role in both the mother and baby’s musculoskeletal
and nerve system throughout pregnancy and in preparation for birth. Weight gain, compensating
postural changes and hormonally induced ligament laxity add to the woman’s propencity
towards spinal subluxations in pregnancy. An increase of spinal subluxations lead to an
elevation in low back pain affecting quality of life and labor outcome. Spinal subluxations also
affect neurological function of the uterus affecting pregnancy and birth outcome. Additionally,
the loss of biomechanical integrity of the mother’s pelvic muscles and ligaments and their
resulting uterine support may adversely cause a condition known as intrauterine constraint
affecting infant positioning in pregnancy and birth.

Varney’s Midwifery text states, “The potential for damage in pregnancy and the postpartum
period to a woman’s neuro-musculo-skeletal structure is great. Shifts in the center of gravity
forward and slightly up destabilize her posture and realign the carriage of weights and forces
through her joints, predisposing nerves, muscles, bones, and connective tissues to damage.
Increased levels of relaxin and elastin further aggravate this situation.”1 Gait compensations and
increased biomechanical loads lead to further strain on spinal segments and their supporting
structures.

Female sacroiliac joints tend to be flatter, with a wider retroarticular space and longer
interosseous ligaments, all promoting greater mobility.2 As hormonal changes affect supporting
musculature and ligament laxity, there is an increase in spinal and sacroilloiac articulations
compensation and mobility. If a motion segment is compensating for a lack of mobility at an
adjacent level, then these segments may become more hypermobile.3,4

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Chiropractors Forester and Anrig write, “Maternal weight gain is most significant during this
gestational period. This contributes largely to the profound biomechanical compromise of the
lumbosacral spine. With a drastic shift in the gravitational weight bearing of the mother, pelvic
musculoskeletal function, principally of the sacroiliac and hip joints is imperiled. This leads to
often significant soft tissue structure changes such as hypertonicities or ligament laxity, which in
turn creates biomechanical instability. Not just the lumbosacral spine but compensatorily, the
thoracic and even cervical spines acquire a diversity of combinations of aberrant segmental and
global motion. The unfortunate typical short radius sacral curve of later pregnancy provides the
foundational imbalance for thoracic hyperkyphosis and cervical kypholordosis. Cellular edema
and inflammation, along with anatomical yielding of the intervetebral foraminae, generate
neurophysiology of the important spinal nerve tissues with resultant cellular and aggregate
tissue malfunction. Summarily, the potential for extensive vertebral subluxation complex in the
maternal patient is physiologically inherent for the last 3 gestational months.5

Varney’s midwifery states, “In the antepartal period, changes in posture occur gradually and can
be responsible for a great many discomforts over the course of the pregnancy.”6 The prevalence
of low back pain during pregnancy can be as low as 42.5%7 and as high as 90%8 One study
revealed that 28% of women experience back pain by the twelfth week of gestation.9 Because
of the biomechanical compensations discussed above, it is not unusual for pregnant women to
experience pain in multiple areas of her spine including sacral, lumbar, thoracic, cervical and
cranial.

Low Back Pain in Pregnancy

Back pain in pregnancy is a frequent clinical problem. Out of 200 women, seventy-six percent
reported back pain at some time during pregnancy. Sixty-one percent reported onset during the
present pregnancy. 30% with the highest pain score reported great difficulties with normal
activities.10

Another study showed One survey reports the prevalence of LBP in pregnant women to be
about 50% . It further states that the most common reason for severe low back pain in
pregnancy was dysfunction of the sacroiliac joints.11

It is important to note that the prevelance of back pain in pregnancy, the need to address these
concerns without the harmful effects of drugs and the significance of this pain on the woman’s
quality of life and function are all significant reasons to establish safe and reliable models of
care as provided by chiropractic adjustments for this population.12-15

Currently, most published research on chiropractic care in pregnancy addresses the efficacy of
the adjustment for the resolution of low back pain. One study revealed that 75% of women who
received chiropractic adjustments during their pregnancy stated that they experienced relief of
their pain and discomfort. 16 Two other studies address the incidence of increased LBP in
pregnancy and the positive results of spinal and pelvic adjustments.17,18 Another study
concludes that intensive spinal adjustments are not only effective for the initial intensive care of
low back pain, the authors also suggest that maintenance spinal adjustments after initial
intensive care may be beneficial to patients to maintain subjective post intensive disability
levels.19

Another study looked at back pain in both pregnancy and delivery and found a statistically
significant association of back pain between the two events. The group of women who received
chiropractic adjustments also experienced less pain during labor.20

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This study not only recommended adjustments for low back pain in pregnancy, it recommended
on-going maintenance care beyond the initial symptomatic, initial intensive care. Based on the
results, the researchers concluded: "This study appears to confirm previous reports showing
that LBP and disability scores are reduced after spinal manipulation. It also shows the positive
effects of preventive chiropractic treatment in maintaining functional capacities and reducing the
number and intensity of pain episodes after an acute phase of treatment.21

Maternal and Infant Physiological Function in Pregnancy

In studies done on laboratory animals a relationship between vertebral lesions in the lumbar
area and interference to physiological function of that region were noted. It was also suggested
that upper cervical lesions contributed to physiological disturbances in the mother such as:
cardiac and thyroid malfunction, and sexual disturbances. Of further interest was that lesions in
these laboratory animals produced miscarriages, behavioral changes, premature births,
stillbirth, “runty” offspring, and early death of the young. In human pregnancy, Burns noted that
women with vertebral lesions had pregnancies and labors that were abnormal compared with
non-lesioned pregnant women. Further various obstetrical complications occurred with mothers
suffering from lumbar lesions.22,23

In regards to the health of the developing young rabbits, the offspring of lesioned mothers
demonstrated stunted growth, erratic behavior, slow development and implications of anatomic
deformities.22 Chiropractic textbook author, Plaugher, recommends, additional studies are
clearly warranted based on these results with animals.24

Biomechanical Pelvic Balance for Optimal Fetal Positioning and Safer, Easier Birth
Outcomes

Additionally, subluxation of the sacrum in the pregnant pelvis may be a major contributing factor
to intrauterine constraint. Intrauterine constraint is defined as any forces external to the
developing fetus that obstructs the normal movement of the fetus.

The link between a biomechanical dysfunction and an in utero constraint situation is the
ligamentous attachments of the uterus the bony maternal pelvis. The sacral torsion thought to
be transmitted by ligaments to the uterus, creating an uneven muscular tension in the uterine
walls. This muscular dysbalance constricts fetal motion so it does not have the freedom any
more to turn into the vertex position. Anatomically the uterus is suspended by 3 major
ligaments a) the broad ligaments b) the uterosacral ligaments and c) the round ligaments

The broad ligaments are double layers of peritoneum extending from either sides of the uterus
to the lateral walls and floor of the pelvis. The base of the broad ligament, which is quite thick, is
continuous with the connective tissue of the pelvic floor. These ligaments are the most important
ones for the proper position of the uterus and preventing uterine prolaps.

Each uterosacral ligament extends from an attachment posterolaterally to the supravaginal

portion of the cervix to encircle the rectum, and thence insert into the fascia over the second
and third sacral vertebrae. The uterosacral ligaments are composed of connective tissue and
some smooth muscle and are covered by peritoneum. They prevent the uterus from displacing
anterior and inferior. It is proposed by this author, that a sacral joint dysfuntion and subsequent
sacral rotation may transmit a unilateral force by the uterosacral ligament on to the uterus
torquing the uterus and resulting in a restricting tension within the uterine wall.

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The round ligaments extend from lateral, superior portion of the uterus towards the labia major,
inserting with the inguinal ligament within a fold of the peritoneum continuous with the broad
ligament. They are comprised of smooth muscle cells continuous directly with those of the
uterine wall and a certain amount of connective tissue. They prevent the uterus from moving
posterior, keeping it in a normal anterior position. It is proposed by this author, that unilateral
tension in the round ligament as caused by a torqued uterus from sacral dysfunction increases
uterine tension and imbalance.25

Forrester and Anrig say, “Specifically, sacral rotation causes an anterior torquing mechanism on
the uterine ligaments and musculature, decreasing space and altering the environment for the
fetus… When correction of the sacral subluxation occurs, the structure and therefore the
function of the uterine structures are improved allowing the fetus to position itself properly.”26

Intrauterine constraint contributes to abnormal fetal positioning in pregnancy and labor. Fetal
presentations other than cephalic or positions other than anterior may result in frequent birth
complications for the mother and baby.

Intrauterine constraint in pregnancy may cause irregular spinal development of the fetus as well.
Compromised spinal development of the baby may have permanent adverse effects on the
baby’s nerve system. Forrester and Anrig write: “The critical effects of in-utero constraint
involve the biomechanical considerations on fetal development., the potential for a reduced
efficiency in labor resulting in a longer harder labor process with an increased incidence of
anoxia, brain damage, asphyxia, prolapse of the umbilical cord and intrauterine death and a
greatly elevated propensity toward operative delivery which exacerbates the danger of trauma
to the neonate.”27

Therefore chiropractic care in pregnancy increases quality of life for the mother and also has
significant implications on the future health and well-being of the infant.

Techniques

Many specific chiropractic analysis and techniques have adapted protocols to suit the pregnant
patient. Some post graduate college courses specific to perinatal chiropractic include:
Gonstead, Thompson, Logan, SOT, Activator, Diversified.

One specific chiropractic analysis and diversified adjustment, the Webster technique was
developed particularly for the pregnant patient. The Webster technique has been utilized to
correct the muscular skeletal causes of intrauterine constraint.28-37 resulting in better fetal
presentation and positioning at birth. The Webster technique is defined as “a specific
chiropractic analysis and adjustment that reduces interference to the nerve system, facilitates
balance in the pelvic muscles and ligaments, which in turn reduces torsion in the woman’s
uterus, alleviating intrauterine constraint, and optimizing fetal positioning.”38

There are several text books and reference manuals in chiropractic which each address the
importance of chiropractic care in pregnancy.39-43 Each text includes some or all of reasons for
chiropractic care throughout pregnancy discussed above.

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Safety

There are no known contraindications to chiropractic spinal and pelvic adjustments throughout
pregnancy.

Chiropractic adjustments characterized as high-velocity, low amplitude thrusts are frequently

applied to sites of vertebral subluxations in the pregnant patient. To date, no reported adverse
events have been associated with this type of care.

The International Chiropractic Pediatric Association has conducted two Practiced Based
Research Surveys relevant to pregnancy. Both studies received IRB approval from Life
University.

Preliminary results of the ICPA’s first PBRN: Chiropractic Care and the Webster Technique
collected data from 274 cases. No adverse effects were reported. 13 aggravations (slight
soreness post first adjustment with 100% resolution) were noted by the doctors. The results of
these preliminary findings PBRN have been presented at several conferences and have been
submitted for publication.44

The ICPA’s second PBRN: Chiropractic Care in Pregnancy is still in progress. At the time of this
writing, there were over 100 cases submitted. To date, no adverse affects were reported by
either the doctor or patient. Only two aggravations (slight soreness post first adjustment with
100% resolution ) were reported by the doctors. In 48 of the cases submitted, the doctor used
the Webster technique. The remaining adjusting techniques used were those described above
in the Technique section of this paper.

A recent survey study conducted by the ICPA of 214 midwives in the US reported: 100% of the
midwives perceived chiropractic to be safe for pregnant patients. This paper has been submitted
for publication.44

Perinatal Chiropractic and Its Supportive Role in Natural Birthing

In addition to continuously staying abreast of academic knowledge and clinical adjustive skills
pertinent to care in pregnancy, it is important that the doctor of chiropractic understand the
biomechanics of the pregnant female pelvis and its relationship to the neuro muscular causes
of dystocia. Dystocia is abnormal function in labor and is the number one cause for invasive
intervention in birth that leads to trauma and subluxation in the mother and infant.

In Williams Obstetrics Textbook, the authors define dystocia as “Abnormal Labor.” They further
emphasize, “Dystocia is very complex, and although its definition- abnormal progress in labor
seems simple, there is no consensus as to what ‘abnormal progress’ means. Thus, it seems
prudent to attempt a better understanding of normal labor in order to determine departures from
normal.”45

Williams Obstetrics list the causes of dystocia to be:

1. Abnormalities of the expulsive forces— either uterine forces insufficiently strong or

inappropriately coordinated to efface and dilate the cervix (uterine dysfunction), or
inadequate voluntary muscle effort during the second stage of labor. (Power)
2. Abnormalities of the maternal bony pelvis– that is pelvic contraction (Passage)

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3. Abnormalities of presentation, position, or development of the fetus (presented in

chapter 19) (Passenger)
4. Abnormalities of the soft tissue of the reproductive tract that form an obstacle to fetal
descent.46

When examined from a neuro-muscular perspective, each of these causes of dystocia may
potentially be prevented with specific chiropractic adjustments of the pregnant woman’s spine
and pelvis throughout pregnancy in preparation for birth. In other words, each cause of dystocia
is addressed with specific, regular chiropractic care throughout pregnancy.

Correlating the causes of dystocia with the corrective accomplishments of the chiropractic
adjustment is as follows:

1. Uterine dysfunction may very well be caused by a decrease in adequate nerve

innervation to the uterus which normally initiates strong contractions and maintains
adequate muscle function throughout labor. Additionally, dilation of the cervix is
dependant on normal nerve innervation. Spinal and cranial adjustments throughout
pregnancy and during birth restore adequate nerve supply to the uterus and therefore
normal function to the uterus. Normal uterine function is imperative for the prevention of
dystocia.47-53
2. Pelvic contraction is defined by William’s Obstetrics as misalignment of the pelvic bones
(particularly sacral displacement) caused by physical trauma to the woman. Specific
chiropractic adjustments offer the means for sacral and pelvic realignment reducing the
prevalence of sacral displacement leading to dystocia.
3. Abnormalities of presentation, position or development are known to be caused by
intrauterine constraint. Preliminary studies with the Webster technique are
demonstrating the musculoskeletal relationship between sacral adjustments, the
alleviation of intrauterine constraint and therefore optimal fetal positioning. Optimal foetal
positioning is a key ingredient in the prevention of dystocia.28-38
4. Preliminary, clinical findings are showing reduction in fibroids and migration of placenta
attachment to more desirable positions while the patient is under chiropractic care. Both
fibroids and placental position are examples of the soft tissue of the reproductive tract
that form an obstacle to fetal descent. Data is currently being collected from doctors of
the International Chiropractic Pediatric Association (ICPA, Inc) in regards to the
association of chiropractic adjustments and the reduction of these obstacles.

Understanding these neuro muscular contributors of dystocia provide the doctor of chiropractic
with even greater technical expertise, higher patient compliance and an increase of inter-
professional referrals with birth care providers.

Birth Outcome

There have been several studies emphasizing the significance of spinal and cranial adjustments
as performed by trained doctors for the prevention or elimination of dystocia 47, 48, 49, 50, 51

Additional benefits relevant to birth outcome have included: Decreases in the following: labor
time, meconium staining of amnionic fluid, preterm delivery, umbilical cord prolapsed, use of
forceps, and c-sections.47-53

C-section are determined mainly by the failure of labor to progress (dystocia). In the US, over
one fourth of all children born annually are delivered by c-section.54 The Wrold Health

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Organization recommends that the c-section rate should be about 10-15%.55.With this increased
c-section rate comes its questionable validity and the accompanying adverse effects to both the
mother and infant.56

Therefore, the prevention of dystocia by nautral non-invasive methods and its service in public
health is reason enough for further research into the association of chiropractic care for better
birth outcome.

Conclusion

There is much to be done in the clinically based research arena to continue to substantiate the
efficacy of chiropractic care in pregnancy. Beyond the presence of back pain or other overt
symptoms, regular chiropractic adjustments during pregnancy offer promise in the reduction of
the neuromuscular causes of dystocia. This increases the opportunity for the mother and baby
to have a safer, easier more natural birth experience. All pregnant women should be routinely
examined throughout pregnancy by a Doctor of Chiropractic for the presence of VSC.
Facilitating a healthy pregnancy and restoring a normal physiological environment with the
chiropractic adjustment for natural birth is well within the chiropractic scope of practice.

References

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23- Burns L. Vertebral lesions and the course of pregnancy and animals. J Am
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38- The Webster Technique Defined

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Research. March 11, 2008, pp 1-5.

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54- Department of Health and Human Services' Agency for Healthcare Research and
Quality (AHRQ). Statistical Brief #11: Hospitalizations Related to Childbirth, 2003
http://www.ahrq.gov/news/nn/nn081506.htm and
http://www.hcupus.ahrq.gov/reports/statbriefs/sb11.pdf

55- World Health Organization http://www.who.int/en/

56- International Cesarean Awareness Network (ICAN) http://www.ican-

online.org/pregnancy/cesarean-fact-sheet

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SECTION 10: SUBLUXATION AND WELL-BEING

RECOMMENDATION (new) Rating: Established

Evidence: E, L

"Doctors of Chiropractic advise and educate patients and communities in structural and
spinal hygiene and healthful living practices." 1

"Doctors of Chiropractic establish a doctor/patient relationship and utilize adjustive and

other clinical procedures unique to the chiropractic discipline. Doctors of Chiropractic
may also use other conservative patient care procedures, and, when appropriate,
collaborate with and/or refer to other health care providers." 1

Commentary:

These recommendations are from the 1996 Paradigm Statement by the Association of
Chiropractic College (ACC), and come from the section titled "Health Promotion".1 The entire
document was generated by the membership of the ACC, composed of the senior leadership
from all the CCE-Accredited Chiropractic Colleges, provide the basis by which chiropractors
conduct themselves professionally and clinically.

The CCP Guidelines address a distinct manner in which chiropractic clinicians utilize this
information along with feedback and empirical results from each patient. For this reason, the
Guidelines are not linked to various diseases or conditions the patient may or may not have,
before or after care has initiated as can be the intent of some chiropractic intervention. cf. 2-49

The World Health Organization defines health as being "a state of complete physical,
mental, and social well-being, and not merely the absence of disease or infirmity." 50 Given this
broad definition of health, epistemological constructs borrowed from the social sciences may
demonstrate health benefits not disclosed by randomized clinical trials. Health benefits such as
improvement in self-reported quality-of-life, decreased health care costs, behaviors associated
with decreased morbidity, and patient satisfaction may be evaluated using such methods.

This performance-based domain focuses the doctor-patient relationship on the

standards set by personal baselines and establishes guidelines for the utility of various
chiropractic techniques. This type of chiropractic care is in a context with other non-invasive
disciplines and is stratified into discrete application-based domains across a spectrum of
parameters related to well-being.

Techniques and methods for correcting subluxation must be judged on their intended
outcome and most if not all chiropractic techniques have some physiological and/or structural

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outcome that measures their results. Further, some techniques have as their goals -
improvement in quality of life, an improved sense of well-being and a better sense of
relationship with the patient’s environment and society.

Several studies discussed previously warrant further discussion in this context. Blanks,
Schuster and Dobson 51 published the results of a retrospective assessment of subluxation-
based chiropractic care on self-related health, wellness and quality of life. This is the largest
study of its kind ever undertaken regarding a chiropractic population. After surveying 2,818
respondents in 156 clinics, a strong connection was found between persons receiving
chiropractic care and self-reported improvement in health, wellness and quality-of-life. 95% of
respondents reported that their expectations had been met, and 99% wished to continue care.

Coulter et al.52 performed an analysis of an insurance database, comparing persons

receiving chiropractic care with non-chiropractic patients. The study consisted of senior citizens
over 75 years of age. It was reported that the persons receiving chiropractic care reported better
overall health, spent fewer days in hospitals and nursing homes, used fewer prescription drugs,
and were more active than the non-chiropractic patients.

Rupert, Manello, and Sandefur 53 surveyed 311 chiropractic patients, aged 65 years and
older, who had received "maintenance care" for five years or longer. Chiropractic patients
receiving maintenance care, when compared with US citizens of the same age, spent only 31%
of the national average for health care services. There was a 50% reduction in medical provider
visits. The health habits of patients receiving maintenance care were better overall than the
general population, including decreased use of cigarettes and decreased use of nonprescription
drugs. Furthermore, 95.8% believed the care to be either "considerably" or "extremely" valuable.

Rupert 54 reports that 79% of chiropractic patients have maintenance care recommended
to them, and nearly half of those comply. In an online survey with 3018 respondents by Miller,55
62% responded affirmatively when asked, "Although you feel healthy, would you follow your
family member's lead and visit a doctor who focuses on wellness and prevention just so you can
stay feeling that way?"

Several additional studies have addressed this issue since the publication of the 1998
Guidelines. One of the studies consisted of a three arm randomized clinical trial with two control
groups (one of which was placebo controlled). This was a single blind study utilizing
subluxation-centered chiropractic care implemented in a residential addiction treatment
setting.56, 57 A total of 98 subjects (14 female and 84 male) were enrolled in the year and a half
study. 100% of the Active (chiropractic) group completed the 30-day program, while only 24
(75%) of the Placebo group and 19 (56%) of the Usual Care group completed 30 days.

The Active group showed a significant decrease in anxiety while the Placebo group
showed no decrease in anxiety. The frequency of visits to the Nurse's station was monitored
during the course of the study and among the Active treatment group only 9% made one or
more visits, while 56% of the Placebo group and 48% in the Usual Care group made such visits.
This poor performance by the placebo group suggests that the chiropractic care had no positive
placebo effect.

Treatment was five days per week over a period of 30 days, for a total of 20 treatment
encounters. Therefore, a 100% retention rate was achieved in a residential treatment setting
using subluxation-centered chiropractic. The possible mechanism for such a response is
elaborated on in an earlier paper by Holder et al, in which they describe the Brain Reward

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Cascade in relationship to vertebral subluxation and its role in resolving (RDS) Reward
Deficiency Syndrome.57

In a review of the research literature, Hannon58 describes over forty studies where
people with no symptoms of disease experienced objective health benefits under chiropractic
care. Dr. Hannon’s conclusion is a positive statement on the effects of chiropractic on human
potential and healing: “Improved function can be objectively measured in asymptomatic
individuals following chiropractic care in a number of body systems often by relatively non-
invasive means. It is plausible that chiropractic care may be of benefit to every function of the
body and have the potential for long-term, overall health benefit to those receiving chiropractic
care.”

Cohort studies require large numbers of well-characterized patients to properly control

for all patient variables. A large cohort study by Blanks and colleagues,51 include the analysis of
2818 patients from 160 offices through the United States, Canada, Puerto Rico, and
Australia.51,71,72 Because of the need to control for the many different types of adjustment
techniques currently being used in chiropractic, and the potential impact of the adjustment
technique on outcome, their studies have been limited to only one chiropractic technique called
Network Spinal Analysis. Results indicated that patients reported significant positive perceived
change (p< 0.000) in all four domains of health, as well as, overall quality of life. Effect sizes for
these difference scores were all large (>0.9). Wellness was assessed by summing the scores
for the four health domains into a combined wellness scale, and comparing this combined scale
“presently” and “before Network.” These benefits are evident from as early as 1-3 months under
care, and appear to show continuing clinical improvements in the duration of care intervals
studied, with no indication of a maximum clinical benefit. These findings are somewhat limited
because they apply only to NSA and are difficult to apply to chiropractic in general because of
the many different techniques employed. The research design was cross-sectional, meaning
that one can only conclude a statistical association between NSA and self-reported changes in
QOL and not a cause-effect relationship. Finally, although an important first step, these patient-
cantered outcomes must be correlated with clinical and objective outcome measures, and be
documented over time to show causality, i.e., a cause-effect link between the intervention and
the health outcome benefits.

A second series of papers by Schuster et al.71,72 performed an analysis on patient data

from one of the chiropractic techniques (Network Spinal Network Analysis, NSA) and examined
outcomes in relation to health lifestyle practices and self–reported health and wellness. The
study was a cross-sectional, self-administered survey that included two thousand five hundred
and ninety-six (2,596) patients from 156 offices of doctors who were members of the
Association for Network Chiropractic (currently titled Association for Network Care); estimated
response rate was 69%. Exogenous variables entered into the structural equation model include
gender, age, education, income marital status, ailments, life change, and trauma. A wellness
construct consisted of calculated difference scores between two referents, “presently” and
“before Network” care, for self-reported items representing wellness domains of physical state,
mental-emotional state, stress evaluation, and life enjoyment. Positive reported change in nine
items assembled into dietary, health practices, and health risk dimensions serve as indicators of
the construct of changes in health lifestyle practices. The NSA care construct consisted of
duration of care in nine months, awareness of energy, and awareness of breathing since
beginning network care.

Of the exogenous variables only gender, age, and education remain in the final
structural equation model, indicating that chiropractic self-reported wellness benefits are greater

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among women, younger, and better-educated patients. This study provides further evidence
that the health and wellness survey instruments are particularly appropriate for investigating
wellness-oriented disciplines such as practiced by the overwhelming majority (93.6%) of
chiropractors as indicated by a recent national poll.50

Biomarkers of Wellness: Wellness has become a popular concept that has been applied
by the mass media to fitness and self-help products and services, work-site wellness/health
promotion programs, and biomedical research incorporating health-related quality-of-life
assessments.59 Self-rated health (SRH), a formalized measure of subjective health, has been
found to be an independent predictor of clinical outcome and mortality. 61 Even when numerous
health status indicators are available, poor SRH is independently associated with increased
mortality in different socioeconomic groups, in different age groups, in men and women, over
time and among persons with or without chronic illness.62-67

It has been previously shown that low ratings of health are strongly associated with low
fitness and energy, daily discomforts, and presence of pain.67 However, until recently the
mechanisms for these associations were unknown. In the last decade, it has become
increasingly clear that signals from the immune system also affect the brain circuits to produce
changes in behavior, cognition, and emotion. This coordinated set of changes is collectively
called sickness behavior, and is caused by pro-inflammatory cytokines such as interleukin (IL)-
1, IL-6 and tumor necrosis factor (TNF)-α.68 In sickness, the individual experiences nonspecific
symptoms of weakness, listlessness, changed sleep patterns, hyperalgesia and decreases in
motivation and appetite.68, 69 Lekander et al.70 examined the immune status of 265 consecutive
primary health care patients (174 women and 91 men), in relation to self–rated and physician-
rated health. Self-rated health correlated with levels of IL-1β (r = 0.27; p < .001), IL-1ra (r = 0.19;
p < .05) and TNF- α (r = 0.46; p < .001) in women but not in men. Thus, poorer subjective health
was associated with of higher levels of inflammatory cytokines. Even when controlling for age,
education, physical health, and diagnoses in multiple regression analyses, self-rated health was
an independent and more robust predictor of cytokine levels than physician-rated health. The
exciting finding from Lekander et al. 70 suggests that an individual’s health perception may be
coupled to circulating cytokines.

The basic science research related to chiropractic is growing.73-77 Several recent studies
have begun to identify the chemical mediators of pain reduction and other physiological benefits
of the adjustment. A recent study by Ineyan et al. determined that the adjustment was
associated with reduction in circulating proinflammatory cytokines but substance P often
associated with pain mediation. 74 Another study on acute low back pain patients found that pain
scores and endogenous opioids (beta-endorphine) levels were closely linked. 75 Other candidate
peptides mediating these effects have been proposed.76

However, one of the most exciting recent findings linking the chiropractic adjustment with
general health and well-being comes from the study of Kent and colleagues in 2005.67 These
authors assessed the short- and long-term effects of chiropractic on serum thiol levels in
asymptomatic subjects. Serum thiol was choses as a measure of human health status,
because it is a surrogate marker of DNA repair enzyme activity, most notably poly ASP-ribose
polymerase or PARP. In this case-controlled retrospective analysis, serum thiol levels were
examined in patients with active disease (n=46) and compared with levels in age-matched
asymptomatic subjects (n=21) with 8-52 weeks of care. Mean serum thiol levels were lowest in
patients with active disease and neuromuscular complaints, and highest in asymptomatic
individuals undergoing chiropractic care. They concluded “Asymptomatic or primary wellness
subjects under chiropractic care demonstrated higher mean serum thiol levels than patients with

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active disease and produced some values that were higher than normal wellness values.”
Additional studies are required, but it appears that the chiropractic adjustment can affect the
even the fundamental properties of cellular function, repair, and post-translational (epigenetic)
activities.

Modern biology recognizes three “supersystems” in the body (nervous, endocrine, and
immune systems) that interact functionally at many levels to control all life functions. There is
now strong evidence that chiropractic can impact all three of these systems. The nervous
system is discussed separately (see SECTION 10).

In this section, the evidence for chiropractic’s influence on the other two supersystems is
discussed, namely the immune system and endocrine system.

In terms of immune function, small clinical trial and case reports document changes in
immune status of patients under care. 78-80 Immune system related diseases such as allergic
asthma81-87 are documentd in case reports to show improvement with chiropractic. Factors that
medically alter immune status, such as immunization, remain a concern for some chiropractors
and policies are developed to discuss these issues with patients.88, 89 There are also reports of
secondary benefits of chiropractic in patients suffering from disorders of the endocrine system,
eg., hypothyroidism and diabetes . 90, 91

One of the very exciting recent breakthoughts, is the impact of chiropractic care in areas
of womans health, likely to result from beneficial effects on the adjustment on the reproductive
and endocrine systems. A large number of case reports and case-controlled series have
evaluated the effects of the chiropractic adjustment of fertility,92-112 regulation of the menstral
cycle and pelvic dysfunction,113-116 ease of delivery and control of peripartituational pain,117-123
hormone replacement therapy.124 There is also a growing discussion about devising guidelines
for counceling patients with metastatic cancer, 125-128 health-education, perceptions and
recruitme of woman into chiropractic research studies.129-135 Finally, a great deal of scholarship
has been directed towards the role of chiropractors in educating patients about the psychosocial
aspects of health. Woman are frequently the health surregots, and champions of social reform
such as homelessness, but they are also targeted by domestic violence. These woman’s health
topics are receiving more and more attention by chiropractors.136-141

However, in what might be termed chiropractic greatest gift, the field has led the
wellness revolution in health promotion and disease prevention. By educating patients about
health promoting activities the chiropractic profession has taken the lead in primary and
secondary prevention. Some have termed the concept the “Chiropractic Lifestyle”, nicely
defined almost 15 years ago by Dr. Cheryl Hawk “….In addition to specific care of the spine,
chiropractors usually suggest therapeutic exercises, general fitness recommendations and
advice on nutrition, vitamins, weight loss, smoking cessation, and relaxation techniques.”142
These shared health beliefs, values and behaviors have been assessed in chiropractors,60 and
patients in large representative surveys.51 In a major survey of chiropractors, their
overwhelming support and commitment to the “chiropractic lifestyle” demonstrated that 97.8%
recommend exercise, 93.6% maintenance/wellness care, 93.2% made ergonomic
recommendations, 87.7% provide general nutritional advice, and 86.4% recommended stress
reduction activities.60

As described previously, sophistocated structural equation modeling of self-reported

data from individuals under chiropractic care indicate that life style behavioral change, acquired
while under care, impacts health along a path in the derived health model which is almost as

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important as the adjustment itself.71,72 The combination of regular chiropractic care and lifestyle
modification was considered optimal in the model for promoting general self-reported health.

Many research articles have been written during the five-year review period about the
health promotion and disease prevention aspects of chiropractic.145-193 These have covered a
broad range of topics including chiropractic, nutrition and exercise, the role of patient preference
and perceptions, client-centered wellness education for smoking cessassion, etc., fall and
accident prevention, and preventive and healthy aging strategies. Many of these were
educational documents or case or case-series reports. Of note, a study by Rupert conducted a
representative survey of chiropractors that concluded their general acceptance of the health
promotion and prevention strategies for chiropractors.40 Rupert and colleagues evaluated the
health promotion services administered to US chiropractic patient age 65 and older.39 Several
comprehensive reviews of the overall topic of health promotion attitudes of chiropractors have
been published by Hannon,58 Hawk et al.165 and McDonald et al.60

Summary: Chiropractors have historically recommended initial care plans that involve a
high frequency of visits as well as extended care plans of long duration to encompass corrective
care and wellness based care. Care plans that do not base care solely on the presence or
absence of symptoms have as their basis some very fundamental scientific laws that govern the
connective tissue and neurological responses to abnormal biomechanical loads and
neurological interference while also addressing the quality of life issues discussed above. The
goal of care becomes the reversal of these insidious processes and an enhanced sense of well-
being so that any judgment of that care must take into consideration those outcomes as well as
outcomes related to the technique being applied.

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67. Undèn AL, Elofsson S: Self-rated health in a European Perspective, Swedish council for
planning and coordination of research, 2000; 41-54.

68. Dantzer R. Cytokine-induced sickness behavior: where do we stand? Brain Behav

Immun 2001; 15:7-24.

69. Watkins LR, Maier SF. Implications of immune-to-brain communication for sickness and
pain. Proc Natl Acad Sci USA 1999; 96:7710-3.

70. Lekander M, Elofsson S, Neve I-M, Hansson L-O, Unden A-L. Self-rated health is related
to levels of circulating cytokines. Psychosomatic Medicine 66:559-563

71. Schuster, T.L., Dobson, M., Jaregui, M., Blanks, R.H.I. Wellness lifestyles II: Modeling
Relationships Between Wellness, Health Lifestyle Practices, and Network Spinal
Analysis. J. Alternative and Complementary Med. 10(2):357-368, 2004.
72. Schuster, T.L., Dobson M, Jaregui, M. Blanks, R.H.I. Wellness Lifestyles 1: A
Theoretical Framework Linking Wellness, Health Lifestyles, and Complementary and
Alternative Medicine. J. Alternative and Complementary Med. 10(2):349-356, 2004.
73. Budgell B, Cramer G, Henderson C, Khalsa PS, Pickar JG. Basic Science Research
Related To Chiropractic Spinal Adjusting: The State Of The Art And Recommendations
Revisited. J Manipulative Physiol Ther. 2006; 29(9): 726-761.

74. Injeyan HS, Teodorczyk-Injeyan JA, Ruegg R. Spinal Manipulative Therapy Reduces
Inflammatory Cytokines But Not Substance P Production In Normal Subjects. J
Manipulative Physiol Ther. 2006; 29(1): 14-21.

75. Sanders GE, Reinert O, Tepe R, Maloney P. Chiropractic adjustive manipulation on

subjects with acute low back pain: visual analogy pain scores and plasma beta-
endorphin levels. J Manipulative Physiol Ther 1990; 13:391-5.

76. Johnson IP. Hypothesis: A Candidate Peptide Mediating Some Of The Effects Of The
Chiropractic Adjustment [Poster Presented At The 1St College Of Chiropractors’
Research Conference, 16Th June 2006, Bma House, London, Uk]. Clin Chiropr. 2006;
9(4): 193.

77. Kent C, Campbell CJ, Banne A, Amiri A, Pero R. Surrogate Indication Of DNA Repair In
Serum After Long Term Chiropractic Intervention – A Retrospective Study. J Vert Sublux
Res. 2005; 0(18): Online access only 5 p.

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78. Boone WR, Oswald P, Holt K, Singh K, Ashton A, Beck R. Long Term Assessment Of
Blood Indices And Immune Panel Profiling Of Subjects Receiving Chiropractic Care: A
Pilot Study. J Vert Sublux Res. 2006; 0(21): Online access only 11 p.

79. Boone WR, Oswald P, Holt K, Singh K, Ashton A, Beck R. Physical, Physiological, And
Immune Status Changes, Coupled With Self-Perceptions Of Health And Quality Of Life,
In Subjects Receiving Chiropractic Care: A Pilot Study. J Vert Sublux Res. 2006; 0(5):
Online access only 6 p.

80. Rix GDW, Owen DE. The Effect Of Chiropractic Manipulation On Serum Levels Of
Immunoglobulin M [Conference Abstract]. Eur J Chiropr. 2003; 48(2):55-56.

81. Chalk CS, Chalk AJ. Probiotics And Allergy: Current Understanding And Application For
The PCCP (Primary Care Chiropractic Physician). J Chiropr Med. 2003; 2(4): 131-133.

82. Nielsen NH, Bronfort G, Bendix T, Madsen F, Weeke B. Chronic asthma and chiropractic
spinal manipulation: a randomized clinical trial. Clin Exp Allergy. 1995; 25:80-8.

83. Fujimoto T. Resolution Of Allergic Dermatitis In An Infant Undergoing Toftness

Technique [Case Report]. J Vert Sublux Res. 2007; 0(27): Online access only 6 p.

84. Schetchikova NV. Asthma, An Enigmatic Epidemic (Part 1). J Am Chiropr Assoc. 2003;
40(6):22-29.

85. Schetchikova NV. Asthma: An Enigmatic Epidemic (Part II). Asthma Treatment. J Am
Chiropr Assoc. 2003; 40(7): 30-37.

86. Gibbs AL. Chiropractic Co-Management Of Medically Treated Asthma [Case Report].
Clin Chiropr. 2005; 8(3): 140-144.

87. Balon J, Aker PD, Crowther ER, Danielson C, Cox PG, O’Shaughnessy D, et al., A
comparison of active and simulated chiropractic manipulation as adjunctive treatment for
childhood asthma. N Engl J Med 1998;339:1013-20.

88. Injeyan HS, Page SA, Verhoef MJ, Russell ML. Immunization And The Chiropractor-
Patient Interaction: A Western Canadian Study. J Manipulative Physiol Ther. 2006;
29(2): 156-161.

89. Injeyan HS, Verhoef MJ, Russell ML, Mutasingwa D. Canadian Chiropractors'
Perception Of Educational Preparation To Counsel Patients On Immunization. J
Manipulative Physiol Ther. 2006; 29(8): 643-650.

90. Pollard H, Bablis P. Hypothyroidism: A New Model For Conservative Management In

Two Cases. Chiropr J Aust. 2004; 34(1): 11-18.

91. Valli J. Chiropractic Management Of A 46-Year-Old Type 1 Diabetic Patient With Upper
Crossed Syndrome And Adhesive Capsulitis [Case Report]. J Chiropr Med. 2004; 3(4):
138-144.

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92. Adams JP. Chiropractic And Nutritional Management And Its Effect On The Fertility Of A
Diabetic Amenorrheal Patient: A Case Report. J Vert Sublux Res. 2003; 12: Online
access only 2 p.

93. Anderson-Peacock E. Reduction Of Vertebral Subluxation Using Torque Release

Technique With Changes In Fertility: Two Case Reports [Case Report]. J Vert Sublux
Res. 2003; 19: Online access only 6 p.
94. Bedell L. Successful Pregnancy Following Diagnosis Of Infertility And Miscarriage: A
Chiropractic Case Report. J Vert Sublux Res. 2003; 2: Online access only 7 p.

95. Behrendt M. Insult, Interference And Infertility: An Overview Of Chiropractic Research. J

Vert Sublux Res. 2003; 2: Online access only 8 p.

96. Borggren CL. Pregnancy And Chiropractic: A Narrative Review Of The Literature. J
Chiropr Med. 2007; 6(2): 70-74.

97. Dimarco DB. The Female Patient: Enhancing And Broadening The Chiropractic
Encounter With Pregnant And Postpartum Patients. J Am Chiropr Assoc. 2003;
40(11):18-24.

98. Kaminski TM. Female Infertility And Chiropractic Wellness Care: A Case Study On The
Autonomic Nervous System Response While Under Subluxation Based Chiropractic
Care And Subsequent Fertility [Case Report]. J Vert Sublux Res. 3; 2: Online access
only 10 p.

99. Lyons DD. Response To Gonstead Chiropractic Care In A 27 Year Old Athletic Female
With A 5 Year History Of Infertility [Case Report]. J Vert Sublux Res. 2003; 9: Online
access only 3 p.

100. Nadler A. Torque Release Technique™ In The Clinical Management Of Infertility

Related To Cultural Or Religious-Based Lifestyle [Case Report]. J Vert Sublux Res.
2003; 16: Online access only 3 p.

101. Pollard H, Bablis P, Monti DA. Resolution Of Anovulation Infertility Using Neuro
Emotional Technique; A Report Of 3 Cases [Case Report]. J Chiropr Med. 2006; 5(1):
13-21.

102. Pollard H, Mchardy A, Bablis P. Two Reports Of Resolution Of Polycystic Ovary

Syndrome-Induced Anovulation In Females Receiving Neuro Emotional Technique.
Chiropr J Aust. 2006; 36(1): 2-8.

103. Ressel O. A Commentary On Infertility. J Vert Sublux Res. 2003; 24: Online access only
2 p.

104. Rosen MG. Sacro Occipital Technique Management Of A Thirty Four Year Old Woman
With Infertility [Case Report]. J Vert Sublux Res. 2003; 17: Online access only 4 p.

105. Schmitz A, Lutterbey G, Von Engelhardt L, Von Falkenhausen M, Stoffel M. Pathological

Cervical Fracture After Spinal Manipulation In A Pregnant Patient. J Manipulative Physiol
Ther. 2005; 28(8): 633-636.

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106. Senzon SA. Successful In Vitro Fertilization In A Poor Responder While Under Network
Spinal Analysis Care: A Case Report. J Vert Sublux Res. 3; 14: Online access only 6 p.

107. Shelley J. Healthy Pregnancy In A Previously Infertile Patient Following D.N.F.T.

[Directional Non-Force Technique] Chiropractic Care: A Case Report. J Vert Sublux Res.
2003; 8: Online access only p. 1-7.

108. Spears LG. A Narrative Review Of Medical, Chiropractic, And Alternative Health
Practices In The Treatment Of Primary Dysmenorrhea [Review]. J Chiropr Med. 2005;
4(2): 76-88.

109. Stuber KJ. The Safety Of Chiropractic During Pregnancy: A Pilot E-Mail Survey Of
Chiropractors’ Opinions. Clin Chiropr. 2007; 10(1): 24-35.

110. Vilan R. The Role Of Chiropractic Care In The Resolution Of Migraine Headaches And
Infertility [Case Report]. J Clin Chiropr Pediatr. 2004; 6(1): 338-341.

111. Walsh MJ, Polus BI. A randomized, placebo-controlled clinical trial on the efficacy of
chiropractic therapy on premenstrual syndrome. J Manipulative Physiol Ther. 1999;
22:582-5.

112. Young A, Pauc R. Foetal Distress And Birth Interventions In Children With
Developmental Delay Syndromes: A Prospective Controlled Trial. Clin Chiropr. 2006;
9(4): 182-185.

113. Bull PW, Genders WG ,Hopkins SS, Lean EK. Dysmenorrhea And Pelvic Dysfunction: A
Possible Clinical Relationship. Chiropr J Aust. 2003; 33(1):23-29.

114. Holtzman DA, Petrocco-Napuli KL, Burke JR. Prospective case series on the effects of
lumbosacral manipulation on dysmenorrhea [case report]. J Manipulative Physiol Ther.
2008; 31(3): 237-246.

115. Pedersen P, Andrew C. A Study Into The Effectiveness Of Chiropractic Treatment For
Pre- And Postpartum Women With Symphysis Pubis Dysfunction. Eur J Chiropr. 2003;
48(3):77-95.

116. Sorensen G, Stoddard A, Hunt MK, Herbert JR, Ockene JK, Avrunin, JS, Walsh MJ,
Polus BI. A randomized, placebo-controlled clinical trial on the efficacy of chiropractic
therapy on premenstrual syndrome. J Manipulative Physiol Ther. 1999;22:582-5.

117. Ford LM. Diagnostic Corner. A Perspective On Pregancy-Linked Back And Pelvic Pain
In Chiropractic Practice. DC Tracts. 2004; 16(3): 6-11.

118. Miller J, Stevens P, Worthington S. Is Chiropractic Care Beneficial To Help Alleviate The
Musculoskeletal Back Pain Of Pregnancy? [Lecture Presented At The European
Chiropractors' Union Convention, Heidelberg, Germany, 29-31 May 2003]. Eur J Chiropr.
2003; 51(2):117-123.
119. Skaggs CD, Ducar D. Conservative Management Of Groin Pain During Pregnancy: A
Descriptive Case Study [Case Report]. J Chiropr Med. 2005; 4(4): 195-199.

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120. Skaggs CD, Ducar D. Low Back Endurance Strength In Post-Partum Women: A Pilot
Study [Platform Presentation; The Association Of Chiropractic Colleges' Thirteenth
Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 43-44.

121. Skaggs CD, George JW, Nelson DM, Gross G, Prather H, Thompson PA. Back And
Pelvic Pain In An Underserved United States Pregnant Population: A Preliminary
Descriptive Survey. J Manipulative Physiol Ther. 2007; 30(2): 130-134.

122. Van Kessel-Cobelens AM, Verhagen AP, Mens JM, Snijders CJ, Koes BW. Pregnancy-
related pelvic girdle pain: intertester reliability of 3 tests to determine asymmetric mobility
of the sacroiliac joints. J Manipulative Physiol Ther. 2008; 31(2): 130-136.

123. Vianin M, Skaggs CD, Prather H, Winchester BA. A Manual Therapy And Exercise
Approach To Meralgia Paresthetica In Pregnancy: A Case Report. J Chiropr Med. 2006;
5(3): 92-96.

124. Wyatt LH. Patient Page: For Your Health, Hormone Replacement Therapy [Patient
Education Handout]. J Am Chiropr Assoc. 2003; 40(12): 29-30.

125. Guebert GM, Osterhouse MD. Bilateral Acrometastasis Secondary To Breast Cancer. J
Manipulative Physiol Ther. 2004; 27(4): 275-279.

126. Verbeeck A. Bone Metastases From Breast Cancer: Guidelines For Diagnosis [Case
Report]. J Manipulative Physiol Ther. 2004; 27(3): 211-215.

127. Nolet PS, Jensen A, Diwan MA. Oral Squamous Cell Carcinoma: An Atypical
Presentation Mimicking Temporomandubular Joint Disorder [Case Report]. J Can
Chiropr Assoc. 2004; 48(4): 266-272.

128. Rectenwald R. A case study of back pain and renal cell carcinoma [case report]. J
Chiropr Med. 2008; 7(1): 24-27.

129. Evans R, Hawk C, Long CR, Cambron JA. Recruitment And Accrual Of Women In A
Placebo-Controlled Clinical Pilot Study On Manual Therapy. J Manipulative Physiol Ther.
2004; 27(5): 299-305.

130. Jamison JR. The Chiropractic Adjustment: The Patients' Perception [Case Report].
Chiropr J Aust. 2005; 35(1): 4-8.

131. Knott R. A 38-Year-Old Female With Chronic Cervicalgia: Case Presentation [Case
Report]. Clin Chiropr. 2004; 7(2): 53-54.

132. Leroy NR. Uterine Fibroids: An Integrative Approach. J Chiropr Med. 2004; 3(1): 15-19.

133. Sibbritt D, Adams J, Young AF. A Profile Of Middle-Aged Women Who Consult A
Chiropractor Or Osteopath: Findings From A Survey Of 11,143 Australian Women. J
Manipulative Physiol Ther. 2006; 29(5): 349-353.

134. Skaggs CD, George JW, Tunstall AC, Tepe RE. The Effects Of Active Release
Technique On Hamstring Flexibility: A Pilot Study. J Manipulative Physiol Ther. 2006;
29(3): 224-227.

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135. Wessely MA, Klingelschmitt V. A 38-Year-Old Female With Chronic Cervicalgia: Case
Discussion [Case Report]. Clin Chiropr. 2004; 7(2): 100-104.

136. Bedell L. Chiropractic Care Of A Battered Woman: A Case Study [Case Report]. J Vert
Sublux Res. 2006; 0(20): Online access only 6 p.

137. Behrendt M,Morgenstern A. Chiropractic For Humanity: Chiropractic Care For The
Homeless, Hungry, And Isolated. J Vert Sublux Res. 2004; 26: online.

138. Bhandari M, Shearer HM, Forte ML, Dosanjh S, Mathews DJ. Chiropractors' Perceptions
About Intimate Partner Violence: A Cross-Sectional Survey. J Manipulative Physiol Ther.
2006; 29(5): 386-392.

139. Kunau PL. Chiropractic Prenatal Care: A case series illustrating the need for special
equipment, examination procedures, techniques and supportive therapies for the
pregnant patient. J of Clinical Chiropractic Pediatrics 1999; 4(1): 264-277

140. Walsh MJ, Polus BI. The frequency of positive common spinal clinical examination
findings in a sample of premenstrual syndrome sufferers. J Manipulative and Physiol
Ther 1999; 22(4): 216-220

141. Blum CL. The Resolution Of Chronic Colitis With Chiropractic Care Leading To
Increased Fertility [Case Report]. J Vert Sublux Res. 2003; 14():pp. Online access only 6
p.
142. Hawk C, Dusio ME. A survey of 492 US chiropractors on primary care and prevention-

143. Himmelstein J, Hammond, SK. The effects of a health promotion-health protection

intervention on behavior change: The Well Works Study. Am J

144. Yates RG, Lamping DL, Abram NL, Wright C "Effects of Chiropractic Treatment on Blood
Pressure and Anxiety: A Randomized, Controlled Trial" JMPT 1988; 11(6): 484-488.

145. Austin WF. Take Steps To Prevent Surgery. J Am Chiropr Assoc. 2003; 40(3):16-18.

146. Austin WM, Zhang J. Effect Of Exercise And Custom-Made Flexible Orthotics On Blood
Pressure And Heart Rate Variability [Platform Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006;
20(1): 46-47.

147. Bernat P. Patient Page: For Your Health, Don'T Take Arthritis Lying Down [Patient
Education Handout]. J Am Chiropr Assoc. 2004; 41(3): 29-30.

148. Bernat P. Patient Page: For Your Health, Nutrition Advice For A Healthy New You
[Patient Education Handout]. J Am Chiropr Assoc. 2004; 41(1): 29-30.

149. Blum CL, Mirtz TA, Greene L, Globe G. Patient Preference For Wellness Care: Is It On
The Menu? [Poster Presentation; The Association Of Chiropractic Colleges' Thirteenth
Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 53-54.

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150. Brockman S. The Role Of Chiropractic Manipulation In Promoting An Individual’s

Perception Of Psychological Well Being. Clin Chiropr. 2007; 10(1): 8-23.

151. Clancy FF. Patient Page: For Your Health: Back Pain And Chiropractic [Patient
Education Handout]. J Am Chiropr Assoc. 2004; 41(11): 29-30.

152. Descarreaux M, Lafleur C, Trepanier M-C, Lalonde C. Prescription D’Exercices Dans Le

Cadre D’Une Pratique Chiropratique: Un Sondage. J Can Chiropr Assoc. 2004; 48(4):
282-290.

153. Descarreaux M, Teasdale N, Blouin JS, Drolet M, Papadimitriou S. Efficacy Of

Preventive Spinal Manipulation For Chronic Low-Back Pain And Related Disabilities: A
Preliminary Study. J Manipulative Physiol Ther. 2004; 27(8): 509-514.

154. Druger M, Mayer JM, Miller J, Ploutz-Snyder LlL, Graves JE, Udermann BE, Verna JL.
Exercise Therapy For Low Back Pain: Chiropractors' Patterns Of Use And Perceptions
Of Educational Quality. J Chiropr Educ. 2003; 17(2):105-112.

155. Epstein DM. The Transition Of Network Spinal Analysis Care: Hallmarks Of A Client-
Centered Wellness Education Multi-Component System Of Health Care Delivery. J Vert
Sublux Res. 2004; 5: online.

156. Evans MW Jr. Communicating Your Health Message To Patients. J Am Chiropr Assoc.
2004; 41(4): 20-23.

157. Evans MW Jr. Modification Of A Local Smoking Ordinance; A Case-Report Of

Chiropractic Health Advocacy [Case Report]. J Chiropr Med. 2006; 5(1): 32-37.

158. Evans MW. Health Promotion And Chiropractic: Act Now. J Am Chiropr Assoc. 2003;
40(3):22-24.

159. Evans MW. The ABC's Of Health Promotion And Disease Prevention In Chiropractic
Practice. J Chiropr Med. 2003; 2(3): 107-110.

160. Gatterman M. Wellness In Practice: Fibromyalgia. J Am Chiropr Assoc. 2004; 41(6): 22-
24.

161. Gatterman MI. The Patient-Centred Paradigm: A Model For Chiropractic Health
Promotion And Wellness. Chiropr J Aust. 2006; 36(3): 92-96.

162. Haneline MT. Chiropractic Involvement In Preventing Falls Among The Elderly. J Am
Chiropr Assoc. 2003; 40(4):24-29.

163. Hawk C, Evans Mw JR, Boyd J. Smoking Cessation Education For Chiropractic Interns:
A Theory-Driven Intervention. JACA Online. 2006; 43(5): Online access only p 13-19.

164. Hawk C, Evans Mw JR, Strasser SM. An Educational Campaign To Increase

Chiropractic Intern Advising Roles On Patient Smoking Cessation. Chiropr & Osteopat.
2006; 14(1): Online access only 25 p.

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165. Hawk C, Long CR, Perillo M, Boulanger KT. A Survey Of Us Chiropractors On Clinical
Preventive Services. J Manipulative Physiol Ther. 2004; 27(5): 287-298.

166. Hawk C. Is It Time To Adjust Our Thinking About Subluxation. JACA Online. 2006;
43(5): Online access only p 20-22.

167. Hawk C. When Worldviews Collide: Maintaining A Vitalistic Perspective In Chiropractic

In The Postmodern Era. J Chiropr Humanit. 2005; 12(1): Online access only p 2-7.

168. Hawk CK. Diagnostic Corner. Putting Prevention And Wellness Into Your Practice. DC
Tracts. 2005; 17(1): 5-7.

169. Hyland JK. Wellness In Practice [Editorial]. J Am Chiropr Assoc. 2004; 41(5): 42.

170. Jamison JR. Expectations: A Potent Trigger To Non-Specific Intervention In Chiropractic

Practice. Chiropr J Aust. 2004; 34(2): 63-67.

171. Jamison JR. Menopause: A Case Study Of Chiropractic Patients' Information Interests.
Chiropr J Aust. 2004; 34(1): 2-10.

172. Jamison JR. Prescribing Wellness: A Case Study Exploring The Use Of Health
Information Brochures [Case Report]. J Manipulative Physiol Ther. 2004; 27(4): 262-266.

173. Johnson J, Killinger LZ. Healthy People 2010: Chiropractic Clinical Teaching Faculty
Knowledge, Perceptions And Plans Of Action [Platform Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006;
20(1): 28.

174. Johnson J, Killinger LZ. National Public Health Week: One Chiropractic College’s
Community Intervention To Promote Healthy Aging [Platform Presentation; The
Association Of Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr
Educ. 2006; 20(1): 25-26.

175. Killinger LZ. Chiropractic Adjusting And The Aging" Patient". J Am Chiropr Assoc. 2003;
40(11):26-28.

176. Kirk R, Mirtschink S, Hoiriis K, Luong H. Quality Of Life Changes In A Disadvantaged,

Underserved Chiropractic Patient Population: A Retrospective Case Series Report [Case
Report]. J Vert Sublux Res. 2005; 0(15): Online access only 3 p.

177. Kirk R, Shepherd C. Spinal Hygiene And Its Impact On Health And General Well Being.
J Vert Sublux Res. 2004; 16: online.

178. Kirk R. Developing A Spinal Health Promotion Initiative: Use Of An Expert Seed Panel
And Electronic Delphi Consensus Process [Platform Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006;
20(1): 29.

179. Kirk R. Spinal Health Promotion And Wellness: It's Our Time. J Am Chiropr Assoc. 2004;
41(10): 46-47.

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180. Kline CM. Part I: Chiropractic Home Exercises: What, Why, & How. JACA Online. 2006;
43(3): Online access only p 2-6.

181. Kline CM. Part Ii: Chiropractic Home Exercise Programs--Ergonomics & Compliance.
JACA Online. 2006; 43(4): Online access only p 2-6.

182. Knutson GA, Owens EF Jr. Active And Passive Characteristics Of Muscle Tone And
Their Relationship To Models Of Subluxation /Joint Dysfunction Part II. J Can Chiropr
Assoc. 2003; 47(4): 269-283.

183. Knutson GA, Owens EF. Active And Passive Characteristics Of Muscle Tone And Their
Relationship Models Of Subluxation/Joint Dysfunction Part I. J Can Chiropr Assoc. 2003;
47(3): 168-179.

184. Kurtz JT. A Chiropractic Case Report In The Treatment And Rehabilitation Of
Swimmer's Shoulder. J Am Chiropr Assoc. 2004; 41(10): 32-38.

185. McClelland G, Griffith C. Wellness In Practice: A Call To Action: We Need Your Help. J
Am Chiropr Assoc. 2004; 41(7): 42-43.

186. McClelland G. Chairman's Message: Embracing The Best Practices And Wellness Care
[Editorial]. J Am Chiropr Assoc. 2004; 41(6): 8-9.

187. Polus BI, Walsh MJ, Webb MN. The Role Of The Cervical Spine In Balance And Risk Of
Falling In The Elderly. Chiropr J Aust. 2004; 34(1): 19-22.

188. Schetchikova N. Patient Page: For Your Health: Osteoarthritis-Not Only A Disease Of
The Elderly? [Patient Education Handout]. J Am Chiropr Assoc. 2004; 41(9): 29-30.

189. Schetchikova NV. Patient Pages: Healthy Living: Preventing Steroid Use In Youth
[Patient Education Handout]. JACA Online. 2006; 43(1): Online access only p 17-18.

190. Schetchikova NV. Patient Pages: Healthy Living: The Mystery Of Fibromyalgia [Patient
Education Handout]. JACA Online. 2006; 43(2): Online access only p 15-16.

191. Shaw G. Too Pumped: Chiropractic And The Steroid Problem. JACA Online. 2006;
43(5): Online access only p 6-9.

192. Wyatt LH. Patient Page: For Your Health, Staying Fit As You Get Older [Patient
Education Handout]. J Am Chiropr Assoc. 2004; 41(4): 29-30.

193. Wyatt LH. Patient Pages: Healthy Living: Are You Drinking Enough Water? [Patient
Education Handout]. JACA Online. 2006; 43(3): Online access only p 16-17.

194. Morgan JP, Dickey JL, Hunt HH, Hudgins PM. A controlled trial of spinal manipulation in
the management of hypertension. J Am Osteopath Assoc. 1985;85:308-13.

195. Morgan WE, Morgan CP. The Tertiary Care Chiropractic Practice. J Am Chiropr Assoc.
2004; 41(5):pp. 23-27.

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SECTION 11: BEHAVIORAL AND MENTAL HEALTH ISSUES

RECOMMENDATION (new) Rating: Established

Evidence: E, L

Chiropractic is not a treatment for specific behavioral or mental health conditions.

However, chiropractic care is established as a clinical strategy that may improve the
clinical status of persons with general health issues and certain behavioral or mental
health conditions.

Commentary

The chiropractic profession has been actively involved in the field of what is now broadly
termed “neuroscience” since it’s founding in 1895 by D.D. Palmer. Neuroscience is a
compendium of health disciplines including psychology, behavioural science, psychiatry, and
neurology. This section reviews the historical involvement of chiropractic in mental health
aspects of neuroscience from its inception over 100 years ago. The strong neurological
perspective prospered during a four decade period from 1920-1960,1 at which time there was a
division into two ideological groups (focused- vs. broad-scope) that persist today. The
dominant, broad-scope group focusing largely on the spine and musculoskeletal system, and
focused-scope, albeit smaller faction, retaining the earlier neuromuscular skeletal roots and
focus upon detection, analysis and correction of the subluxation.

This historical review is followed by the evidence-based documentation supporting the

neuroscience rationale of chiropractic.

Historical perspective:

The inventor of chiropractic, D.D. Palmer, described a postulated mechanism for

“insanity.” According to his son, B.J. Palmer, “D.D. Palmer was the first man to discover that
insanity was caused by displaced cervical vertebrae, that by replacing them the patient could be
restored to normal condition.” 4 B.J. Palmer himself wrote, “If an atlas is subluxated it makes
abnormal the functions of the brain …What is to be done in insanity? Go back to cause? Adjust
that and return that brain to its normal capacity and capability. Interpretation then will be normal
and expression follows likewise, then what have you? Coordination—health, in all that the word
implies. ” 5

Willard Carver, an attorney and chiropractor, authored several books exploring the
relationship of psychology to physiology and chiropractic. Carver wrote, “Between the
Psychology and the Physiology I have built the Biologic bridge that scientifically connects these
two very important departments of human experience.” 6 Carver was a controversial figure, as
he advocated utilizing adjunctive therapies to supplement the adjustment of vertebral
subluxations.

In the era from the 1920s to the 1960s, several chiropractic inpatient facilities were
operated that catered to patients suffering from “Nervous and mental disorders.” Two of these
were located in Davenport Iowa. In 1922, the Chiropractic Psychopathic Sanitarium was
established. The facility was later known as Forest Park Sanitarium. North Dakota Judge A. W.

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Ponath noted that at the North Dakota state mental hospital, the "cure and discharge rate"
ranged from 18-27%, compared to 65% at the chiropractic facility in Forest Park.7 Clear View
Sanitarium was an inpatient chiropractic psychiatric facility that operated in Davenport, IA, from
1926 to 1961. In 1951, Clear View was acquired by the Palmer School of Chiropractic. Dr. W.
Heath Quigley, who directed the sanitarium, described the clinical protocol: "Each day, each
patient was examined with the neurocalometer (NCM). If the clinician interpreted the NCM to
indicate nerve impingement, the patient was adjusted." The NCM, crude by modern day
standards, is often thought of as the forerunner of the galvanic skin response used as an
indirect of sympathetic outflow to sweat glands in the skin. Quigley reported that the rooms
were "sunny and bright," and that meals included "large servings of fresh vegetables...from a
garden." 8

Unfortunately, both institutions closed, (Forest Park in 1959 and Clear View in 1961) in
large measure because of third-party pay issues. Insurance companies often refused to pay the
costs of care. Iowa statutes at the time did not provide for licensing specialized hospitals; only
full service medical hospitals could be licensed.9 Clear View functioned legally as a nursing
home, and was never licensed as a hospital.

The 1970s saw a renewed interest in chiropractic care and mental health issues. In
1973, Dr. Herman S. Schwartz, a chiropractor, published a book titled "Mental Health and
Chiropractic: A Multidisciplinary Approach." 10 In 1949, Dr. Schwartz had published a
preliminary report of 350 patients afflicted with a "nervous or mental disorder" and reported that
the majority of them showed improvement under chiropractic care.11 Dr. Schwartz was active
in the ACA Council on Mental Health (formerly Council on Psychotherapy), which survived
through the '70s, but no longer exists.

Evidence-based rationale supporting neurologic chiropractic:

In 1983, Dr. Quigley published an article describing a four decades period, from 1920-
1960, where "treatment of the mentally ill was a highly motivated discipline within the
chiropractic profession." 1 Several years later Dr. Goff, an Ed.D., published a review of the
theory and practice of "chiropractic treatment for mental illness." 12

Interest in this field continues. Blanks, Schuster and Dobson 13 published the results of a
retrospective assessment of subluxation-based chiropractic care on self reported health,
wellness and quality of life. These authors specifically assessed questions about patient “Mental
and Emotional Well-Being” and “Stress Indicators”. This is, to our knowledge, the largest study
of its kind ever undertaken regarding a chiropractic population. After surveying 2,818
respondents in 156 practices, a strong connection was found between persons receiving
Network care and self reported improvement in health, wellness and quality of life.

Genthner et al.19 reported on a series of 15 patients with a history of depression. The

Beck Depression Inventory II was used to measure the baseline level of depression and any
post care changes following orthospinology care. A paired t-test demonstrated significant
improvement in depression test scores with chiropractic. Depression relief is noted with
chiropractic care in other studies. e.g. 15, 16

At the moment, the mechanism(s) underlying chiropractic effects on depression are

unclear. Depression is complex to diagnose and treat and can have multiple etiologies.
Genetics is one predictive factor. It can also be “situational” such as with bouts of depression

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accompanying the loss of a loved one, job or ones health.cf 17 Situational depression often
accompanies serious illness or pain, and will resolve when the illness or pain syndrome is
treated.18 Additional research is required, but it could be argued that chiropractic effects on
depression acts on the “situational” components of depression, i.e., the patients depression
improves as their presenting complaint is treated by care. An important clue about depressive
symptoms comes from several new epidemiological studies with identical twins. A comparison
of the genetically identical siblings, resulted in the conclusion that depressive symptomatology is
close correlated with metabolic syndrome,19 and independent measures of abnormal autonomic
outflow, i.e., lower heart rate variability.20 These studies are consistent with the hypothesis that
genes and other factors (environmental, diet, exercise, trauma, stress, etc.) promoting
inflammation (leading to metabolic syndrome and cardiovascular stress response) are involved
in the pathogenesis of depressive disorders. Future studies will need to control for general
medical status and proinflammatory events to better understand the mechanism(s) underlying
the effects of the adjustment on depressive disorders.

A systematic review of psychological outcomes in randomized controlled trials (RCTs)

described the results of 12 RCTs of spinal manipulation which had adequately reported
psychological outcomes. The authors concluded that there was some evidence that spinal
manipulation improved psychological outcomes compared with verbal interventions employed
with the control group.21

Other small studies and case reports have reported favorable outcomes in persons with
behavioral and mental health issues following chiropractic care22-32 These include disease-
related33 or post traumatic stress disorder,34 attention deficit hyperactivity disorder (ADHD),35-38
general health status measured using the RAND-36 and Global Well-Being Scale,39-40 quality of
life in public safety personnel,41 learning disabilities and dyslexia,42-43 and autism.44 Studies
regarding addiction and compulsive disorders have been discussed in Section 9.

Similarly, there are small studies and case reports demonstrating benefits with certain
neurological disorders such as multiple sclerosis and Parkinson’s disease45 (however, see46),
Bell’s palsy,46 Cerebral palsy,48 the autonomic outflow and its effect on stress, blood pressure,
heart rate variability and somatovisceral effects,49-82 myasthenia gravis,83 headaches,84-87
tempromandibular joint disorder,88-90 and vertigo, dizziness and motion sickness.90-93 In
particular, the latter seems relevant as a model of secondary maladaptation to neck trauma
given the functional interaction of the vestibular, visual and neck joint afferents in the etiology of
cervicogenic vertigo/dizziness.94,95

Lastly, there are a variety of general neurological health issues that are supported by
small studies and case reports and one clinical trial. These are mentioned here given their
connection with the neurological (neuro-musculoskeletal) model of chiropractic.66-125 The clinical
trial is important because it examined the effects of combining manual therapy and exercise on
respiratory function in normal individuals.106 Normal subjects (n = 20; aged 18-28 years) were
randomized into three groups: exercise only, manual therapy only and combined exercise and
manual therapy consisting of 6 intervention sessions over a 4-week period. The control
(exercise only) group showed a decrease in forced vital respiratory capacity(FVC) and forced
expiratory volume in the first second (FEV1); the manual therapy showed a significant increase
in both FVC and FEV1, and subjects receiving combined manual therapy showed a double
benefit, i.e., increased FVC and FEV1 immediately after the adjustment followed by an additional
increases after exercise. Such studies are important because they demonstrate the potential for
manual therapy (and exercise) to improve respiratory function even in healthy individuals, and
thereby improve sports performance via extended exercise potential.

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16. Wyatt LH. Patient Pages: Healthy Living, Chronic Pain And Depression [Patient
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24. Brotski J. Rett Syndrome: A Literature Review [Review]. J Clin Chiropr Pediatr. 2007;
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25. Brown N. The Use Of Chiropractic Adjustments As A Complementary Approach To

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26. Bryner P, Hayek R, Leboeuf-Yde C, Meeker WC, Tucker J, Pedersen EN, Cosman D,
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29. Rupert RL, Song XJ, Xu DS, Vizcarra C. Onset And Recovery Of Hyperalgesia And
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30. Simpson S. The Palliative Care Of A Post-Polio Syndrome Patient [Case Report]. Clin
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31. Smith-Nguyen EJ. Two Approaches To Muscular Torticollis [Case Report]. J Clin Chiropr
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44. Khorshid KA, Sweat RW, Zemba DA, Zemba BN: Clinical Efficacy of Upper Cervical
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45. Elster EL. Eighty-One Patients With Multiple Sclerosis And Parkinson’S Disease
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46. Adams A, Lawrence D, McGregor M. Commentary in response to JVSR article: Eighty-

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47. Alcantara J, Plaugher G, Van Wyngarden DL. Chiropractic Care Of A Patient With
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48. Kent C, McCoy M, Malakhova E, Safronov Y, Scire P. Improvement In Paraspinal

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49. Baker L. Somatovisceral Aspects Of Chiropractic: An Evidence-Based Approach [Book

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50. Bakkum BW, Cramer GD, Henderson CNR, Hong S-P. Does Subluxation Actually Affect
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51. Bakkum BW, Appleyard RF. Thoracic Manipulation Acutely Resets Heart Rate Variability
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52. Zhang J, Enix D. Age And Gender On Heart Rate Varibility In Normal Subjects [Platform
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53. Burke JM, Cunningham BM, Grimm DR. The Effects Of Upper Thoracic Spinal
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54. Christensen HW, Hoilund-Carlsen PF, Manniche C, Vach W, Haghfelt T, Gichangi A.

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55. Fox RB, Librone PA. Mesothelioma Presenting With Neck And Shoulder Symptoms: A
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56. Karason AB, Drysdale IP. Somatovisceral Response Following Osteopathic Hvlat: A
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57. McCormick J. Improvement In Noctural Enuresis With Chiropractic Care: A Case Study
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72. Donaubauer KA. Chiropractic Care And Management Of An Adult Hydrocephalic Patient
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75. McCullough T. Diagnostic Corner. Thoracic Subluxation Associated With Visceral

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77. Nosco D, Zhang J, Dean D, Floros M. Effect Of Chiropractic Care On Heart Rate
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79. Smith M, Wells K, Ellerbrook M. Diagnosis Of Chest Pain In The Chiropractic Practice
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80. Snyder B, Zhang J. Toftness System Of Chiropractic Adjusting On Back Pain And
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85. Moore MK. Upper Crossed Syndrome And Its Relationship To Cervicogenic Headache.
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87. Elster EL. Treatment Of Bipolar, Seizure, And Sleep Disorders And Migraine Headaches
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89. Long CR, Devocht JW, Zeitler DL, Schaeffer W. Chiropractic Treatment Of
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90. Blum CL Globe G. Assessing The Need For Dental - Chiropractic Temporomandibular
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91. Wicks TA. Treatment Of Vertigo With C2 Chiropractic Adjustment: A Case Report. J Am
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92. Cuthbert SC. Proposed Mechanisms And Treatment Strategies For Motion Sickness
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93. Elster EL. Sixty Patients With Chronic Vertigo Undergoing Upper Cervical Chiropractic
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94. Gross AR, Goldsmith C, Hoving JL, Haines T, Peloso P, Aker P, Santaguida P, Myers C.
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95. Bracher ES, Almeida CI, Almeida RR, Duprat AC, Bracher CB. A combined approach for
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96. Budgell B. Invited Commentary: Self-Reported Nonmusculoskeletal Responses To

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97. Bull P, De Silva A, Murray G. Spinal Accessory Nerve (Cranial Nerve Xi) Palsy Following
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98. Bull P, Love Z. Management Of Dyspepsia: A Chiropractic Perspective. Chiropr J Aust.

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99. Carpenter T, Mohammadian P, Gonsalves A, Hummel T, Tsai C. Areas Of Capsaicin-

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100. Caso ML. Evaluation Of Chapman'S Neurolymphatic Reflexes Via Applied Kinesiology:
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101. Cunningham BM, Grimm DR, Burke JR. Autonomic Nervous System Function Among
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102. Di Duro JO. Improvement In Hearing After Chiropractic Care: A Case Series [Case
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103. Diakow PR , Humphreys BK, Pucci AR. The Effect Of Body Position On Verticality
Perception Using The Rod And Frame Test [Poster Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006;
20(1): 94-95.

104. Duray SM, Quist DM. Resolution Of Symptoms Of Chronic Constipation In An 8-Year-
Old Male After Chiropractic Treatment [Case Report]. J Manipulative Physiol Ther. 2007;
30(1): 65-68.

105. Engel R. The Effect Of Combining Spinal Manipulation With Exercise On Respiratory
Function [Platform Presentation; The Association Of Chiropractic Colleges' Thirteenth
Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 10.

106. Engel RM, Vemulpad S. The Effect Of Combining Manual Therapy With Exercise On
The Respiratory Function Of Normal Individuals: A Randomized Control Trial. J
Manipulative Physiol Ther. 2007; 30(7): 509-513.

107. Haavik Taylor H, Murphy B. Altered sensorimotor integration with cervical spine
manipulation. J Manipulative Physiol Ther. 2008; 31(2): 115-126.

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108. Harrison DD, Harrison DE, Haas JW, Bymers B. Conservative Treatment Of A Patient
With Syringomyelia Using Chiropractic Biophysics Protocols [Case Report]. J
Manipulative Physiol Ther. 2005; 28(6): Online access only 7 p.

109. Jamison JR. Insomnia: Does Chiropractic Help. J Manipulative Physiol Ther. 2005;
28(3): 179-186.

110. Kier A, Timchur MD, Mccarthy PW. A Case Report Of An Uncommon Cause Of Cauda
Equina Symptoms [Case Report]. J Manipulative Physiol Ther. 2007; 30(6): 459-465.

111. Knaap SFC, Jonasson AK. Gastroesophageal Reflux Disease In An 8-Year-Old Boy: A
Case Study [Case Report]. J Manipulative Physiol Ther. 2006; 29(3): 245-247.

112. Lensgraf AG, Young KJ. Ependymoma Of The Spinal Cord Presenting In A Chiropractic
Practice: 2 Case Studies [Case Report]. J Manipulative Physiol Ther. 2006; 29(8): 676-
681.

113. Lisi AJ, Bhardwaj MK. Chiropractic High-Velocity Low-Amplitude Spinal Manipulation In
The Treatment Of A Case Of Postsurgical Chronic Cauda Equina Syndrome. J
Manipulative Physiol Ther. 2004; 27(9): 574-578.

114. Macmillan HB. Effect Of Chiropractic Care In Sleeping Patens Of A Nine-Month-Old

Infant With Birth Induced Vertebral Subluxation [Case Report]. J Clin Chiropr Pediatr.
2006; 7(1): 466-468.

115. Marsillo R, Vitale A, Tarnoff E. Clinical Assessment And Rehabilitation Of A Stroke

Patient [Platform Presentation; The Association Of Chiropractic Colleges' Thirteenth
Annual Conference, 2006]. J Chiropr Educ. 2006; 20(1): 35-36.

116. Morningstar MW. Improvement Of Lower Extremity Electrodiagnostic Findings Following

A Trial Of Spinal Manipulation And Motion-Based Therapy. Chiropr & Osteopat. 2006;
14(1): Online access only 6 p.

117. Morter MT Jr, Rupert RL, Daniel DM, Mckinzie CL. Treatment Of Chronic Nonresponsive
Patients With A Nonforce Technique. J Manipulative Physiol Ther. 2005; 28(4): 259-264.

118. Murphy B, Marshall P. The Effect Of Sacroiliac Joint Manipulation On Feed-Forward

Activation Times Of The Deep Abdominal Musculature. J Manipulative Physiol Ther.
2006; 29(3): 196-202.

119. Murphy DR, Morris NJ. Cervical Epidural Abscess In An Afebrile Patient: A Case Report.
J Manipulative Physiol Ther. 2006; 29(8): 672-675.

120. Nelson Hassel T. Pediatric Cephalgia [Case Report]. J Clin Chiropr Pediatr. 2004; 6(2):
383-386.

121. Parkin-Smith GF, Davison S. The Possible Effect Of Upper Cervical Chiropractic
Manipulation On Short-Term Lymphocytic Response: A Pilot Study. Eur J Chiropr. 2003;
51(1):19-28.

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122. Smith DL, Dainoff MJ, Smith JP. The Effect Of Chiropractic Adjustments On Movement
Time: A Pilot Study Using Fitts Law. J Manipulative Physiol Ther. 2006; 29(4): 257-266.

123. Te Kolstee R, Miller JM, Knaap SFC. Routine Screening For Abuse: Opening Pandora'S
Box. J Manipulative Physiol Ther. 2004; 27(1): 63-65.

124. Spegman AM, Lynch O. Partnership To Improve Pain Management Of Persons In

Residential Alcohol And Drug Treatment [Poster Presentation; The Association Of
Chiropractic Colleges' Thirteenth Annual Conference, 2006]. J Chiropr Educ. 2006;
20(1): 103.

125. Vallone S. The Role Of Subluxation In Sensory Integration Dysfunction And The Effect
Of The Chiropractic Adjustment: A Case Series [Case Report]. J Clin Chiropr Pediatr.
2006; 7(1): 469-479.

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SECTION 12: PATIENT SAFETY, PRIVACY, AND ADVOCACY

12.1 Patient Safety

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

Patient safety encompasses the entire spectrum of care offered by the chiropractor.
Consequently, it is important to define at the onset, the nature of the
practice as well as the limits of care to be offered. Minimally this should
include a “Terms of Acceptance” document between the practitioner and the
patient. Additionally, all aspects of clinical practice should be carefully chosen
to offer the patient the greatest advantage with the minimum of risk.

Commentary (new)
Patient safety is assured by more than the practitioner’s causing no harm. Since every
consumer of health care is ultimately responsible for his/her own health choices, patient safety
is also a matter of the availability of accurate and adequate information with which the patient
must make these choices. The patient’s expectations should be consistent with the provider’s
goals. If the patient perceives those goals as anything different, proper and safe choices
cannot be assured. Thus, it is important to recognize that chiropractic is a limited, primary
profession which contributes to health by addressing the safe detection, location, and correction
or stabilization of vertebral subluxation(s). It is important that the chiropractor take the steps
necessary to foster proper patient perception and expectation of the practitioner’s professional
goals and responsibilities. It is within this context that patient safety is addressed in this chapter.

A “Terms of Acceptance” is the recorded written informed consent agreement between a

chiropractor and the patient. This document provides the patient with disclosure of the
responsibilities of the chiropractor and limits of chiropractic, and the reasonable benefit to be
expected. This enables the patient to make an informed choice either to engage the services of
the chiropractor, aware of the intended purpose of the care involved, or not to engage those
services if the proposed goals are not acceptable or not desired. This embodies the
responsibility of assuring patient safety by not providing false or misleading promises, claims or
pretences to the patient.1-9

Professional Referral: Professional referral requires authority and competence to acquire

accurate information concerning matters within the scope and practice of the professional to
whom a referral is made. There are two types of professional referrals made by chiropractors:

Intraprofessional referral: Chiropractors, by virtue of their professional

objective, education, and experience, have authority and competence to make
direct referrals within the scope and practice of chiropractic. Such a referral
may be made when the attending chiropractor is not able to address the
specific chiropractic needs of a particular patient. Under these circumstances,
the chiropractor may refer the patient directly to or consult with another
chiropractor better suited by skill, experience or training to address the
patient’s chiropractic needs.

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Interprofessional referral: In the course of patient assessment and the

delivery of chiropractic care, a practitioner may encounter findings which are
outside his/her professional and/or legal scope, responsibility, or authority to
address. The chiropractor has a responsibility to report such findings to the
patient, and record their existence. Additionally, the patient should be advised
that it is outside the responsibility and scope of chiropractic to offer advice,
assessment or significance, diagnosis, prognosis, or treatment for said
findings and that, if the patient chooses, he/she may consult with another
provider, while continuing to have his/her chiropractic needs addressed.

Patient Safety

Considerable visibility and public scrutiny surrounds possible risks associated with
Spinal Adjustment and Manipulation.22, 66, 67, 103 Non-serious side effects are relatively common
and may consist of localized discomfort, headache, or fatigue that resolves within 24-48 hours.51
The concern raised by scientific and popular media reports in the United States and Canada are
that chiropractic “manipulation” of the cervical spine is associated with stroke.10-21

However, not only is the incidence stroke difficult to determine with chiropractic
adjustment, some argue that there is no rationale for linking chiropractic adjustment with
vascular dissection at all.22 Case reports of adverse events following spinal “manipulation” are
common as are published commentaries on the relative risks of chiropractic.23-58 However, solid
scientific evidence of a causal relationship between such adverse events and the “manipulation” is
lacking.59-75 Furthermore, spinal adjustment and spinal manipulation are not synonymous terms. In
the case of strokes purportedly associated with “manipulation,” the panel noted significant
shortcomings in the literature. The relevant literature follows:

Lee 76 attempted to obtain an estimate of how often practicing neurologists in

California encountered unexpected strokes, myelopathies, or radiculopathies following
“chiropractic manipulation.” Neurologists were asked the number of patients evaluated
over the preceding two years who suffered a neurological complication within 24 hours
of receiving “chiropractic manipulation.” Fifty-five strokes were reported. The author
stated, “Patients, physicians, and chiropractors should be aware of the risk of
neurologic complications associated with chiropractic manipulation.” No support was
offered to substantiate the premise that a causal relationship existed between the
stroke and the event(s) of the preceding 24 hours.

In a letter to the editor, Myler 77 writes, “I was curious how the risk of fatal
stroke after cervical manipulation, placed at 0.00025% 78 compared with the risk of
(fatal) stroke in the general population of the United States.” According to data
obtained from the National Center for Health Statistics, the mortality rate from stroke in
the general population was calculated to be 0.00057%. If these data are correct, the
risk of a fatal stroke following “cervical manipulation” is less than half the risk of fatal
stroke in the general population.

Jaskoviak79 reported that not a single case of vertebral artery stroke

occurred in approximately five million cervical “manipulations” at the National
College of Chiropractic Clinic from 1965 to 1980.

Osteopathic authors Vick, et al. 80 reported that from 1923 to 1993, there
were only 185 reports of injury associated with “several million treatments.”

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Pistolese 81 has constructed a risk assessment for pediatric chiropractic patients. His
findings covering approximately the last 30 years indicate a risk of a neurological and/or
vertebrobasilar accident during a chiropractic visit about one in every 250,000,000 visits.

An article in the “Back Letter” 82 noted that “In scientific terms, all these figures are
rough guesses at best... There is currently no accurate data on the total number of cervical
manipulations performed every year or the total number of complications. Both figures would
be necessary to arrive at an accurate estimate. In addition, none of the studies in the medical
literature adequately control for other risk factors and co-morbidities.”

Leboeuf-Yde et al. 83 suggested that there may be an over-reporting of

“spinal manipulative therapy” related injuries. The authors reported cases involving two fatal
strokes, a heart attack, a bleeding basilar aneurysm, paresis of an arm and a leg, and cauda
equina syndrome which occurred in individuals who were considering chiropractic care, yet
because of chance, did not receive it. Had these events been temporally related to a
chiropractic office visit, they may have been inappropriately attributed to chiropractic care.

In many cases of strokes attributed to chiropractic care, the “operator” was not a
chiropractor at all. Terrett 84 observed that “manipulations” administered by Kung Fu
practitioner, GPs, osteopaths, physiotherapists, a wife, a blind masseur, and an Indian barber
were incorrectly attributed to chiropractors. As Terrett wrote, “The words chiropractic and
chiropractor have been incorrectly used in numerous publications dealing with SMT injury by
medical authors, respected medical journals and medical organizations. In many cases, this is
not accidental; the authors had access to original reports that identified the practitioner involved
as a non-chiropractor. The true incidence of such reporting cannot be determined. Such
reporting adversely affects the reader’s opinion of chiropractic and chiropractors.”

Another error made in these reports was failure to differentiate “cervical manipulation”
from specific chiropractic adjustment. Klougart et al.85 published risk estimates which
revealed differences which were dependent upon the type of technique used by the
chiropractor.

The panel found no competent evidence that specific chiropractic adjustments cause
strokes. Although vertebrobasilar screening procedures are taught in chiropractic colleges, and
some ongoing research to detect pre-existing contra-indications 86-99 no reliable screening
tests were identified which enable a chiropractor to identify patients who are at risk for stroke.

After examining twelve patients with dizziness reproduced by extension rotation and twenty
healthy controls with Doppler ultrasound of the vertebral arteries,
Cote, et al.100 concluded, “We were unable to demonstrate that the extension-rotation test is a
valid clinical screening procedure to detect decreased blood flow in the vertebral artery. The
value of this test for screening patients at risk of stroke after cervical manipulation is
questionable.” Terrett 101 noted, “There is no evidence which suggests that positive tests have
any correlation to future VBS (vertebrobasilar stroke) and SMT (spinal manipulative therapy).”
Despite this lack of evidence, some have suggested that failure to employ such tests could
place a chiropractor in a less defensible position should litigation ensue following a CVA.102

A systematic review of the available literature in chiropractic published in the 1st Edition
of the CCP Guidelines (1998)76-85, 100-102 concluded, “The panel found no competent evidence
that specific chiropractic adjustments cause stroke”. Indeed, no serious complications have
been found in more than 73 controlled clinical trials or in any of the prospectively evaluated case
series published to date. c.f. 104 Jaskoviak 39 reported that not a single case of vertebral artery

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stroke occurred in approximately five million cervical “manipulations” at the National College of
Chiropractic fro 1965-1980. Shekelle et al.105 report the incidence of serious complications
from lumbar spinal manipulation as extremely rare, representing an estimated 1 case per million
patients. The risk of cerebrovascular accident from upper cervical manipulation was estimated
to range from 1 in 400,000 63 to 3-6 in 10,000,000.67 Reliability of these estimates is an issue
because they are based upon retrospective study design or practitioner report and represent
estimates at best.

In contrast, hard evidence was produced by a large cohort study, representing 99% of
chiropractors in Demark evaluated over a ten year period 1978-1988. From this population
there were five serious complications and one death representing approximately one serious
complication for every 1 million cervical adjustments.

From the medical literature it is know that patients with vertebralbasilar disease are
largely asymptomatic for years. It is, therefore, uncertain whether these serious complications
resulted from the adjustment or whether the mechanical forces applied to the spine aggravated
underlying pathology.66 Adding further to the difficulties of interpretation and, in particular, the
correlation of chiropractic adjustment and stroke, Kent22 points out that the incidence of stroke in
the general population is 0.00057% (National Center for Health Statistics). Estimates of stroke
from chiropractic of 0.00025% by Dabbs and Lauretti63 are less than twice that in the general
population.

12.2 Patient Privacy

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

Respecting patients' right of privacy has always been both an ethical and a legal
duty. New federal regulations place specific, enforceable obligations on most
chiropractors and their employees. Knowledge of and compliance with these regulations
is essential in order to remain in practice.

Commentary (added)

Chiropractors have always had an ethical obligation to safeguard confidential information

that they obtain from and about their patients. Some states have adopted laws codifying this
duty, and most states recognize a private cause of action in tort for invasion of privacy.

It is not always clear, however, where the outer boundaries of this obligation are located.
May a chiropractor discuss a person's condition with his or her parent or spouse? Such a
question might have been answered in the past on the basis of the doctor's view of the patient's
best interest. In the twenty-first century, however, the answer must be informed by a myriad of
federal and state statutes, regulations and court decisions. Violations of these laws may result
in lawsuits, revocation or suspension of licenses, and/or debarment from Medicare.

One manner in which chiropractors can limit their exposure to liability, while meeting
their patients expectations at the same time, is by posting a Notice of Privacy Practices is his or

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her office and by handing a copy to every new patient (and by repeating this process every time
a change is made in the text of the Notice). This is required of those doctors who are covered
by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and is a sound legal
practice for every healthcare professional to state his policy in advance and then adhere to it.

It is also mandated by HIPAA, and important for all chiropractors, to have patients (or the
parents or guardians of minor patients) sign an "Authorization for Use or Disclosure of
Information for Purposes Requested by Chiropractor" and a "Consent for Purposes of
Treatment, Payment & Healthcare Operations" before collecting, utilizing, transmitting or
disclosing any "protected health information" as that phrase it defined by law.

Finally, it is mandated by HIPPA to have a "Business Associate Agreement" signed by all those
vendors and others who might have access to protected health information.107-113

The foregoing are to be regarded as minimum clinical practice guidelines and not as a
comprehensive legal analysis of the law of privacy nor as a substitute for the opinion of an
attorney licensed in the state in which the chiropractor conducts his or her practice.

12.3 PATIENT ADVOCACY

RECOMMENDATION (new) Rating: Established

Evidence: E, L

Patient advocacy is an important part of advancing safety, efficacy and utilization

of chiropractic services. Effective patient advocacy programs promote quality, safety,
appropriateness of service, support patient choice of adjustive care and appropriateness
of referrals inside and outside the profession.

Commentary:

A strong patient advocacy program ensures informed and effective programs for patient
privacy, quality control, patient’s rights and responsibilities, conditions of acceptance, and
favourable policy. To organize and carry out the operations of the advocacy program
chiropractors need to develop required infrastructure (websites, patient newsletters, education
materials, etc.). There is extensive literature in the field to assist with informing patients about
the profession, the type of care they will receive in the office, wellness perspectives of learning
about the “chiropractic lifestyle”, and special, health promotion and disease prevention literature
(e.g., nutrition, exercise, smoking cessation, etc.). The reader is directed to the literature
summarized in Sections 9 and 10. Other specific references of patient advocacy are listed
below.

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35. Haneline MT. Continued Misuse Of The Medical Literature Regarding Vertebral Basilar
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50. Sedat J, Haynes M. Stroke After Chiropractic Manipulation As A Result Of Extracranial

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51. Senstad O, Leboeuf-Yde C, Borchgrevink C. Frequency and characteristics of side

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52. Terrett AG. Vertebrobasilar stroke after spinal manipulation therapy. Adv Chiro, 1997; 4:
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53. Thiel H, Kusiar W, Osborne N. Post-manipulative stroke: A study of two cases. British
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54. Thiel H. Clinical Governance, Clinical Risk Management And The Chiropractic
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55. Triano JJ, Haneline M. Cervical Artery Dissection. A Comparison Of Highly Dynamic
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56. Tuling JR, Tunks E. Thalamic pain syndrome (central post-stroke pain) in a patient
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57. Turgut M. Ischemic stroke secondary to vertebral and carotid artery dissection following
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58. Wenban, A. Critical appraisal of an article about harm: Chiropractic adjustment and
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59. Cashley MAP, Cashley MA, Mcwilliam R, Steen L. BUSIMAN study: The background
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60. Cohn, A. A review of the literature regarding stroke and chiropractic. J. of Vert.
Subluxation Res. Vol. 4 No. 3.

61. Crawford CM, Hurtgen-Grace K, Talarico E, Marley J. Abdominal Aortic Aneurysm: An

Illustrated Narrative Review. J Manipulative Physiol Ther. 2003; 26(3):184-195.

62. Croft AC. Manipulopathy: The Risk Of Cervical Arterial Dissection, And Cerebrobascular
Accident, And Chiropractic Manipulative Therapy. J Am Chiropr Assoc. 2003; 40(7):22-
25.

63. Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs. NSAIDA for the
treatment of neck pain. JMPT 1995; 18:530.

64. Ernst E. Manipulation of the cervical spine: a systematic review of case reports of
serious adverse events, 1995-2001. Med J Aust., Apr 2002; 176(8): 376-380

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65. Haldeman S, Kholbeck FJ, McGregor M. Stroke, cerebral artery dissection, and cervical
spine manipulation therapy. J Neurol., Aug 2002; 249(8):1098-1104

66. Haldeman S, Kohlbeck FJ, McGregor M. Risk factors and precipitating neck movements
causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation.
Spine. 1999; 24:785-94.

67. Hurwitz EL, Aker PD, Adams AH, Meeder WC, Skekelle PG. Manipulation and
mobilization of the cervical spine. A systematic review of the literature. Spine. 1996;
21:1746-60.

68. Jensen TW. Vertebrobasilar Ischemia And Spinal Manipulation. J Manipulative Physiol
Ther. 2003; 26(7): 443-447.

69. Kapral MK, Bondy SJ. Cervical manipulation and risk of stroke. CMAJ, Oct 2001; 907-
908

70. Linda S. Williams and José Biller Vertebrobasilar dissection and cervical spine
manipulation: a complex pain in the neck. Neurology 2003 60: 1408-1409

71. McCoy, M. Stroke and chiropractic: Sorting fact from fiction. J. of Vert. Subluxation Res.
Vol. 4 No. 3.

72. Parenti G, Orlandi G, Bianchi M, Renna M, Martini A, Murri L. Vertebral and carotid
artery dissection following chiropractic cervical manipulation. Neurosurg Rev., Oct 1999;
22(2-3): 127-129

73. Rosner, A. Chiropractic Perils. J. of Vert. Subluxation Res. Vol. 4 No. 3.

74. Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari P, Albers GW, Gress DR.
Spinal manipulative therapy is an independent risk factor for vertebral artery dissection.
Neurology 2003 60: 1424-1428.

75. Wenban A. Epidemiology: The science that cried ‘causation’ one too many times. J.
Vert. Subluxation Res. Vol. 4 No. 3.

76. .Lee K. Neurologic complications following chiropractic manipulation: a survey of California

neurologists. Neurology 1995; 45:1213.

77. Myler L. Letter to the editor. J Manipulative Physiol Ther 1996; 19:357.

78. Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs. NSAIDS for the
treatment of neck pain. J Manipulative Physiol Ther 1995; 18:530.

79. Jaskoviac P. Complications arising from manipulation of the cervical spine. J Manipulative
Physiol Ther 1980; 3:213.

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80. Vick D, McKay C, Zengerle C. The safety of manipulative treatment: review of the literature
from 1925 to 1993. JAOA 1996; 96:113.

81. Pistolese RA. Risk assessment of neurological and/or vertebrobasilar complications in the
pediatric chiropractic patients. Journal of Vertebral Subluxation Research 1998; 2(2): In
Press.

82. What about the serious complications of cervical manipulation? The Back Letter 1996;
11:115.

83. Leboeuf-Yde C, Rasmussen LR, Klougart N. The risk of over-reporting spinal manipulative
therapy-induced injuries; a description of some cases that failed to burden the statistics. J
Manipulative Physiol Ther 1996; 19:536.

84. Terrett AGJ. Misuse of the literature by medical authors in discussing spinal manipulative
therapy injury. J Manipulative Physiol Ther 1995; 18:203.

85. Klougart N, Leboeuf-Yde C, Rasmussen LR. Safety in chiropractic practice,

Part I; The occurrence of cerebrovascular accidents after manipulation to the
neck in Denmark from 1978-1988. J Manipulative Physiol Ther 1996; 19:371.

86. Cagnie B, Jacobs F, Barbaix E, Vinck E, Dierckx R, Cambier D. Changes In Cerebellar

Blood Flow After Manipulation Of The Cervical Spine Using Technetium 99M-Ethyl
Cysteinate Dimer. J Manipulative Physiol Ther. 2005; 28(2): 122-127.

87. Calvino N, Holsworth R. Nutritional inadequacy, hyperhomocystinemia, and

antiphospholipid antibody syndrome as a predisposing agent in cerebral vascular
accidents and vertebrobasilar strokes associated with manipulation, part Two. J Am
Chiro Assoc, Nov 2002; 11(39): 34-36.

88. Clemen M, King W. Computerized system aids stroke recovery. Today’s Chiropractic
Sep/Oct, 1998; 5(27): 52-54

89. Cote P. Screening for stroke: Let’s show some maturity! J Can Chiro Assoc, Jun 1999;
2(43): 72-74

90. French S, Pollard H, Walker B, Vitiello A, Cameron M, Reggars J, Werth P, Comrie D.

Risk Management For Chiropractors And Osteopaths: Iimaging Guidelines For
Conditions Commonly Seen In Practice [Practice Guideline]. Australas Chiropr &
Osteopat. 2003; 11(2):41-48.

91. French S, Pollard H, Walker B, Vitiello A, Cameron M, Reggars J. Risk Management For
Chiropractors And Osteopaths: Neck Manipulation & Vertebrobasilar Stroke. Australas
Chiropr & Osteopat. 2003; 11(1):15-Sep.

92. Good C, Herzog W. Internal Forces Sustained By The Vertebral Artery During Spinal
Manipulative Therapy [Letter; Comment]. J Manipulative Physiol Ther. 2003; 26(5): 338-
340.

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93. Haynes MJ. Vertebral arteries and cervical movement: Doppler ultrasound velocimetry
for screening before manipulation. J. Manip Physiol Ther, Nov-Dec 2002; 25(9): 556-
567. Review

94. Holsworth R, Calvino N. Nutritional inadequacy, hyperhomocystinemia, and

antiphospholipid antibody syndrome as a predisposing agent in cerebral vascular
accidents and vertebrobasilar strokes associated with manipulation, part one. J Am
Chiro Assoc, Oct 2002; 10(39):

95. Kawchuk GN, Wynd S, Anderson T. Defining The Effect Of Cervical Manipulation On
Vertebral Artery Integrity: Establishment Of An Animal Model. J Manipulative Physiol
Ther. 2004; 27(9): 539-546.

96. Mitchell JA. Changes In Vertebral Artery Blood Flow Following Normal Rotation Of The
Cervical Spine. J Manipulative Physiol Ther. 2003; 26(6): 347-351.

97. Rivett DA, Sharples KJ, Milburn PD. Effect of premanipulative tests on vertebral artery
and internal carotid artery blood flow: a pilot study. JMPT, Jul-Aug 1999; 22(6): 368-375

98. Rubinstein SM, Leboeuf-Yde C, De Koekkoek TE, Pfeifle CE, Van Tulder MW.
Predictors of adverse events following chiropractic care for patients with neck pain. J
Manipulative Physiol Ther. 2008; 31(2): 94-103.

99. Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery
during spinal manipulative therapy. J. Manip Physiol Ther, Oct 2002; 25(8): 504-510 Pub
Health 1998; 88:1685-1690.
100. Cote P, Kreitz B, Cassidy J, Thiel H. The validity of the extension-rotation
test as a clinical screening procedure before neck manipulation: a secondary
analysis. J Manipulative Physiol Ther 1996; 19:159.
101. Terrett AGJ. Vertebrobasilar stroke following manipulation. NCMIC, Des
Moines, 1996, page 32.
102. Ferezy JS. The Chiropractic Neurological examination. Aspen Publishers.
Gaithersburg, MD 1992.

103. Assendelft WJ, Bouter LM, Knipschild PG. Complications of spinal manipulation:
a comparative review of the literature. J Fam Pract. 1996;42:475-80.

104. Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream

and alternative medicine. Complementary and Alternative Medicine Series, David M.
Eisenberg and Ted J. Kaptchuk series Ed. Ann Intern Med 2002; 136:216-227.
105. Skekelle PG, Adams AH, Chassin MR, Hurwitz, EL, Brook RH. Spinal manipulation
for low-back pain. Ann Intern Med. 1992 Oct 1;117(7):590-8.

106. Dvorak J, Orelli F. How dangerous is manipulation of the cervical spine: case report and
results of a survey. Manual Medicine. 1985; 2:1-4.

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107. Cohen MH. Complementary and Alternative Medicine: Legal Boundaries and
Regulatory Perspectives. Baltimore, Johns Hopkins University Press, 1998.

108. Cohen MH. Beyond Complementary Medicine: Legal and Ethical Perspectives on
Health Care and Human Evolution. Ann Arbor, University of Michigan Press, 2000.

109. Cohen MH. Future Medicine: Ethical Dilemmas, Regulatory Challenges and
Therapeutic Pathways to Health Care. Ann Arbor, University of Michigan Press, 2002.

110. Cohen MH. A Healers' Code of Ethics Preamble.

http://www.michaelhcohen.com/article6.html.

111. Crellin J, Ania F. Professionalism and Ethics in Complementary and Alternative

Medicine. New York, Haworth Integrative Healing Press, 2002.

112. Sloane WM. Jaffee: The Licensed Psychotherapist's Right to Remain Silent. Con-
Text: J Am College of Counsellors 1997; 4(1):27-33.

113. Sloane WM. Privacy in the office: New regulations call for changes in chiropractic
practice procedures. http://www.worldchiropracticalliance.org/hipaa/explanation.htm
(2002).

114. Sloane WM. Privacy in the office: Are you a "covered entity"?
http://www.worldchiropracticalliance.org/hipaa/covered.htm (2002).

115. U.S. Dept. of Health & Human Services. Centers for Medicare and Medicaid Services.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA).
http://www.cms.gov/hipaa (2002).

116. U.S. Dept. of Health & Human Services. Office for Civil Rights - HIPAA. Medical
Privacy - National Standards to Protect the Privacy of Personal Health Information.
http://www.hhs.gov/ocr/hipaa (2003).

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SECTION 13: PROFESSIONAL DEVELOPMENT

RECOMMENDATION (Unchanged) Rating: Established

Evidence: E, L

The science, art and philosophy of chiropractic, and hence its practice, continues
to expand in understanding and development. Continuing professional development, as
in all responsible health professions, is a necessary component of maintaining a high
standard for both the practitioner and the profession. Continuing development should
be directed to areas germane to each individual practice, including but not limited to
credentialing, continuing education programs, participation in professional
organizations, technique protocols and application, radiographic and other imaging,
instrumentation, philosophy, research, practice liability issues, legal issues, and ethics.

Since all state licensing jurisdictions are ultimately responsible for patient health
and safety, these guidelines recommend that all subjects congruent with state law be
considered appropriate for continuing education credits in respective states.

Commentary

Continuing professional development is currently widely mandated by most

licensing jurisdictions, or encouraged through most professional organizations. Perhaps the
most compelling reason for advocating this type of on-going education is to afford practitioners
the opportunity to keep abreast of the most current developments in chiropractic which serve to
enhance patient care and safety. To maintain the continuing level of education (both voluntary
and mandatory) an affordable fee for even the beginning practitioner is desirable.

The fact that most programs are conducted by individuals skilled in the topics presented
also provides a high level of knowledge and information delivered in a relatively short period.
Thus, professional development serves not only the practitioner, but also the patient through a
broad base of acquired skills that benefit both.1-14

In addition to formal postgraduate education courses, other opportunities for professional

development may include:

- Reading scholarly journals

- Attending scientific symposia
- Participation in research
- Publication of clinical and scientific papers
- Audio and videocassette courses
- Teleclasses
- Distance education programs

There has been an emphasis on moving from an input-based system to an outcomes-

based system regarding continuing education. That is, proposals to modify existing continuing
education offerings in the chiropractic profession to reflect adult learning models. Up to the
present, continuing education has emphasized passive learning approaches that have as their

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chief outcome measure some sort of documentation that the doctor sat through a particular
number of hours in the subject. This tells the licensing body nothing about what was learned or
what competency was achieved. Likewise, it drives the practitioner’s focus not toward mastery
or applicability to day-to-day practice, but rather toward satisfying a numerical requirement.
None of the recent literature reviewed discussed using periodic examinations of licensed
practitioners as a way to ensure continued professional development and competence, although
some of the chiropractic news press has reported that this is a looming possibility.

To be more specific, the literature on this subject reports that the driving factors in
ongoing professional development include increasing levels of public scrutiny, an increased
marketplace emphasis on quality assurance and the growing popularity of evidence-based
practice models. We have moved into an information age, and it is clear that keeping up with
the discipline requires regular engagement with a variety of materials. Professional
development based upon these motivations should ultimately benefit the patients under the care
of chiropractic practitioners.

Because the dominant model of chiropractic continuing education has been centered
upon verification of attendance rather than demonstrable change in knowledge, skills or
attitudes that will improve patient care or enhance professional competencies, chiropractors
may find transition to a new model challenging.

Suggested approaches to this type of professional development include portfolio-based

and experiential models. Whereas traditional lecture-based formats have the teacher as the
deliverer of content, in these formats the teacher functions as a facilitator. A major challenge for
regulatory bodies that wish to implement these models relates to adequate assessment and
documentation – regulatory boards must certify to the public that practitioners are maintaining
an appropriate level of training and are keeping up with new developments in their field to
ensure quality care. So, while a shift from documenting attendance to tracking learning goals in
a portfolio makes sense for adult learners, it creates difficulties for those who must evaluate the
work done by practitioners to stay current or acquire new knowledge or skills.
It is difficult to come up with valid and reliable criteria upon which someone’s learning plan or
portfolio will be judged. Further, such a protocol would require training evaluators.

There is also a shift in the location of continuing educational programs. With the
proposed moves to adult learning models, the practitioner not only develops a set of learning
goals and a plan for achieving them, but also takes responsibility for creating learning
opportunities and experiences – often in the setting of his/her own practice. Again, verification
that work is actually being done becomes a question for regulatory bodies. This question also
arises when more traditional continuing education programs are delivered via distance
education.

Such programs must have internal checks to verify that the person completing the work
on-line is the licensee seeking credit. Some states have been quicker than others to move
toward acceptance of distance education programs for relicensure. Continuing education
delivered in this format presents a couple of very obvious advantages to the practitioner – it can
be completed at the doctor’s convenience without requiring travel.

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REFERENCES

1. Hildebrandt RW. Chiropractic continuing education: A critical review. Am J Chiro Med

1989; 2(3):89-92.
2. Rayles MD. Professional ethics. Wadsworth Publishing Co., Belmont, CA1981; 75.
3. Houle CO. Continuing learning in the professions. Jossey-Bass Publishers, San Francisco
1980; 76-123.
4. Official Directory Federation of Chiropractic Licensing Boards. Greeley, CO, 1993.
5. Council on Chiropractic Education. Standards for chiropractic institutions. West Des
Moines, IA 1990; Council on Chiropractic Education.
6. Davis I. Ethics: an analysis and a theory. J Chiro 1990; 27(4):20-23.
7. Federation of Chiropractic Licensing Boards. Official Directory of the Federation of
Chiropractic Licensing Boards. Kremmling, CO, Federation of Chiropractic Licensing
Boards, 1989. Annual.
8. Haldeman S, Ed. Modern developments in the principles and practice of chiropractic:
based on a conference sponsored by the International Chiropractors Association, Anaheim,
CA, February 1979. New York, Appleton-Century-Crofts 1980; 390.
9. Haldeman S. Philosophy and the future of chiropractic. J Chiro 1990; 27(7):23-28.
10. Kelner M, Hall O, Coulter I. Chiropractors: do they help? A study of their education and
practice. Toronto, Fitzhenry & Whiteside 1980; 303
11. Lawrence DJ. Research and responsibility. J Manipulative Physiol Ther 1984; 7(3):179-
181.
12. Mauer EL. Selected ethics and protocols in chiropractic. Gaithersburg, MD, Aspen
Publishers 1991; 273.
13. Rosenthal SF. A sociology of chiropractic. Lewiston, NY, Edwin Mellen Press, 1986. 15.
14. Chiropractic standards of practice and quality of care. (HJ Vear Ed.) Aspen Publishers,
Gaithersburg, MD, 1991, pp 303.

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APPENDIX 1: THE CCP 2008 REVISION & UPDATE WORKGROUP

Robert H. Blanks PhD

Professor of Cell Biology and Anatomy
University of Miami Miller School of Medicine
Miami, FL

Christopher Kent DC, FCCI, JD

President
Council on Chiropractic Practice
Ramsey, NJ

Matthew McCoy BS, DC

Associate Professor Clinical Sciences
Life University College of Chiropractic
Marietta, GA
Editor, Journal of Vertebral Subluxation Research

Robert H. Blanks PhD

Professor of Cell Biology and Anatomy
University of Miami Miller School of Medicine
Miami, FL

Karen Numeroff, DC
Director of Clinical Testing and Remediation
Life University College of Chiropractic
Marietta, GA

Anquonette Stiles, B.S.

Research Assistant
Life University College of Chiropractic
Marietta, GA

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Peer Reviewers – 2008 Revision & Update

Max McGee Christian Bartels, D.C.

USA USA

Rainer Dallmann Ronen Mendi DC

Germany Israel

John Hart Peter Morgan, DC

USA USA

Dr. Steven Lindner Randall Laurich

USA USA

Douglas R. Patterson D.C. Dr. John W. Baird

USA Canada

Daniel Knowles Dr Harold H George, Jr.

USA USA

Anthony Telesha David Evans

USA USA

RJ Sandstrom Bill Mulhall

USA Canada

Mark Pearson-Gills Dr Richard Sawyer

United Kingdom Australia

Joseph A. La Barbera Wesley S. Mullen Jr. DC LCP DPhCs FICA

USA USA

J. Zimmerman Leif J. Hoagland

USA USA

Scott D. Hoffer D.C. Tom Smith

USA USA

Kristina Ring D.C. Nick Hodgson

USA Australia

Mark Botha D.C. Scott Glocke, DC

USA USA

Rainer Dallmann Alan T. Hudson

Germany USA

Richard Barwell
Peter Robb DC USA
Australia
Kerry B. Woods

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USA Jamie Richards

Canada
David Stuart
Canada Aaron Austin
USA
Dr Brian Miller DC, FICPA, CCWP
USA Peter R, Markovic DC
US
Dr. Steve Thiele
USA Kevin Charles Smith, DC, CCSP
USA
Rick Hasemeier
USA Kathleen O. Smith, DC, DICCP
USA
William Lawler
USA Nathan Cintron
USA
John C. D'Ambrosio
USA Daniel Beebe
USA
Delaney J Carlson DC
USA Douglas Stockel
USA
Letty Urban
USA Dr Bryan Ludwig
USA
Dr. John V. Rennicks
Canada Joseph F. Amato
USA
Robert Martines
USA Jean-Jacques Lob
Australia
Geoffrey D. Norton, DC
USA
Masoud Shamaeizadeh
William Hall USA
USA
Huy Kim Hoang MD DC
USA
Myron D. Brown, DC
USA Gerald A Zuker, DC
USA
Wayne Batterman
USA Dr. Paul Holdsworth
Canada
Ronen Mendi DC
Israel Dr. Diane Meyer
Canada
Jay Holder
USA Ray Nannis
USA

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Michael Quartararo
Dr. Ronald J. Aragona USA
USA
Stephen F. Renner, D.C.
Robin G Taylor D.C. USA
New Zealand
Peter Kevorkian
Donald Epstein USA
USA
John F. Carlyle
Bradley Anchors D.C. USA
USA
Michael D. Clancey, D.C.
James P. Shearman, DC USA
USA
Erick Bingham
Charles N. Edwards, DC USA
USA
Alan Stewart
Russell Derhak USA
USA
Patrick Falkowski DC
Jeffrey A Cronk, DC, CICE USA
USA
Christopher L. Higgins, D.C.
Adam McBride, D.C. USA
USA
Dr. Ernest P. Miron
Canada
Dr. Pinchas Noyman
Israel Joseph J. Aromola DC
USA
John Cafferty, Dc, DACS, LCP, DPhCS,
FICA, CIIE Richard Habighorst, D.C.
USA USA

Robert Abbruzzese DC Dr. Allan P. Long D.C.

USA USA

Jeff Haygood, D.C. Robert Baric

USA USA

Dr. Steven J. Silk Robert Johnson

Canada USA

John Bueler, Jr., DC Rob Sinnott, DC, LCP, DPhCS

USA USA

Zachary Wells Dr. Jeremy Frigo D.C.

USA USA

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Scott Wruck
USA Jeff Glesinger
USA
Jason Barritt DC
USA Dr Sean Chartier
USA
Terry Rondberg
USA Jason L. Smith, D.C.
USA
Daniel J. Eoriatti
USA Dr. Ernest Chupp
Paraguay
Jayme Gawith, DC
USA
Dr. Thomas P. Smith
Mark Postles USA
Australia
Warren Jahn
USA
James Brady, D.C.
US Dr. Tracy L. Gabbert
USA
David Beisiegel DC
USA Robert Wiedemann
USA
Walter Piekarczyk, D.C.
USA Mahsa Shemshadi
Iran
Dr. Daniel R. Laframboise
USA Keith E. Denton, D.C.
USA
Joseph Pilsl
USA Barb Smith
USA
James Raker DC
USA Andrea Pritchett, DC
USA
Jarrod Nichols
USA Dr. Minal Gandhi
Canada
Heather Rice
USA Dr. Liz Anderson-Peacock
Canada
Matthew McCoy
USA Joel Alcantara
Canada
Christopher Kent
USA Christina Cunliffe
United Kingdom
Majera Majidi, DC
USA

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Stephen Marini
USA Kirk Eriksen
USA
Lee Carroll
China
Ari Dishkin
Jeanne Ohm Australia
USA
Hazel Faulkner
David Koch UK
USA
Peter Snodgrass
Alisha Davis Australia
USA
Anthony Carrino
Ingrid Hamel USA
USA
Justin Ohm
Eric Krebs USA
USA
Curtis Fedorchuk
Tricia Arndt USA
USA

Alicia Grundy
USA

Sean Manning
USA

Gregg Stern
USA

Annette Gouker
USA

Daniel Laframboise
USA

Diane Meyer
USA

Anne Spicer
USA

Lynn Kerew
USA

Yannick Pauli
Switzerland

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Peer Reviewers – 1998 & 2003

Donald Acton, D.C. Bart Bishop, D.C.

Asheville, NC Whittier, CA

Robert W. Adams, D.C. Lisa K. Bloom, D.C.

Sonoma, CA Waterloo, NY

Joseph F. Amato, D.C James R. Bowman, D.C.

Kingsport, TN Plover, WI

Michael P. Amato, D.C. John S. Blye, D.C.

Staunton, VA Lynnwood, WA

Richard J. Aragon, D.C. Robert Braile, D.C.

Tuczon, AZ Powder Springs, GA

Darrell Atchley, D.C. Jim Brandau, D.C.

Lovington, NM Livingston, MT

Warren Atkinson, D.C. Marvin Braun, D.C.

Chelsea, MI Gregory, SD

Joe Awender, II, D.C. Erich Breitenmoser, D.C.

Redwood City, CA Temecula, CA

John Babich, D.C. William V.Brennan, D.C.

Kent, WA Seaford, NY

Jay M. Baker, D.C. David J. Brotman, D.C.

Federal Way, WA Mesa, AZ

R. Douglas Baker, D.C. Brian Burns, D.C.

Davenport, IA Tampa, FL

George Banitch, D.C. James R. Caballero, D.C.

Montclair, NJ Oxnard, CA

Fred Barge, D.C. John Cafferty, D.C.

Lacrosse, WI Gresham, OR

Richard A.Barone, D.C. Michael Cerami, D.C.

Williamston, SC Salt Lake City, UT

Kevin M. Baum, D.C. Pippa R. Chapman, D.C.

Ballwin, MO Pearisbours, VA

Darren R. Bell, D.C. Jean-Jaques Chatrousse, D.C.

Derby, KY Santa Maria, CA

Teresa Berry, D.C. Allan Cherkin, D.C.

Las Vegas, NV Patchogue, NY

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Christopher Cianci, D.C. Norris Erickson, D.C.

Easton, MD Aurora, IL

Michael Clark, D.C. Bobby D. Findley, Jr., D.C.

Rochester, NH Myrtle Beach, SC

Joseph Clauss, D.C. Curtis Ficenec, D.C.

Plattsburg, NY Fargo, ND

Michael Clusserath, D.C. Terry Findley, D.C.

Kent, WA Dover, DE

David E.Cox, D.C. Gregg J. Fisher, D.C.

Bluff, CA Montoursville, PA

Hal Crowe, D.C. Elliott Foster, D.C.

Brunswick, GA E. Rutherford, NJ

Harold Culver, D.C. Glenn Gabai, D.C.

Marlow, OK Pennington, NJ

John R. Currier, D.C. Angela Gambale, D.C.

Burnsville, MN Swampscott, MA

Kenneth A.Curtis, D.C. Harvey Garcia, D.C.

Rock Hill, SC Anderson, SC

Jason A. Deitch, D.C. Chuck Gibson, D.C.

Oakland, CA Laguna Hills, CA

Dusan Djukich, D.C. David Ginsberg, D.C.

Dixon, CA Geneva, IL

Thomas C. DoAmico, D.C. Michael R. Girard, D.C.

Davie, FL Hudson, MA

Susan K. Dorgai, D.C. Phillip Goforth, D.C.

Glen Gardner, NJ Socorro, NM

Jim Dubel, D.C. Stephen R. Goldman, D.C.

Red Bank, NJ Hicksville, NY

Lonney D. Edwards, D.C. George Goodman, D.C.

Fresno, CA Chesterfield, MO

Rhody Edwards, D.C. Robert Gregory, D.C.

Kailua-Kona, HI Jackson, MS

Donald Epstein, D.C. David T. Gruda, D.C.

Boulder, CO Erie, PA

Kirt Ericksen, D.C. Bruce Grundy, D.C.

Dothan, AL Peachtree City, GA

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James O. Hagen, D.C. Dale Kenney, D.C.

Spokane, WA Algona, WI

Lance Hager, D.C. Dean Kerr, D.C.

Rock Springs, WY Chino, CA

Samuel Haley, D.C. David Kerschner, D.C.

Little Rock, AR E. Greenbush, NY

Michael Henderson, D.C. Mark Kimes, D.C.

Herndon, VA Salines, CA

Gregory Hertzberg, D.C. David J. Klida, D.C.

Chandler, AZ East Pointe, MI

Dennis Heskett, D.C. David Koch, D.C.

Murray, KY Spartanburg, SC

Robert Hoffman, D.C. Michael J. Kudlas, D.C.

Oyster Bay, NY Kalamazoo, MI

Bruce Homsey, D.C. Wayne B. Ladd, D.C.

Glendale, AZ Bunker Hill, IN

D.D. Humber, D.C. Ernerst Laubach, D.C.

Marietta, GA Muncy, PA

John Incledon, D.C. William Lawler, D.C.

Fishkill, NY Waterville, ME

Kevin Jackson, D.C. Alan J. Lichter, D.C., F.I.C.A.

Sarasota, FL Washington, DC

Spence J. Jahner, D.C. Craig Longworth, D.C.

Bozeman, MT Akron, OH

Joshua J. Joaquin, D.C. Mark D. Losagio, D.C.

Rindge, NH Bethleham, PA

Karl R.O.S. Johnson, D.C., L.C.P., (Hon.) Sean P. Mahoney, D.C.

Shelby Township, MI Colchester, VT

Willard Johnson, D.C. Michael Manginelli, D.C.

Cullman, AL Irvington, NJ

Paul Johnston, D.C. Charles Masarsky, D.C.

Shreveport, LA Vienna, VA

Michael Kale, D.C. Donald Mears, D.C.

Spartanburg, SC Enfield, CT

David Kats, D.C. Rayce Meyers, D.C.

Lincoln, NE San Mateo, CA

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 CCP Guidelines 3rd Edition 2008

Robert McCarthy, D.C. John Russo, D.C.

Greenville, NC Oakdale, NY

Gary R. McLeon, D.C. Fred Schofield, D.C.

Three Rivers, MI Glendale, AZ

Brian Patrick Miller, D.C. Jay H. Schwartz, D.C.

Crescenta, CA Pomere, NY

James Milliron, D.C. Jeffrey Shay, D.C.

Yakima, WA Muscatine, IA

J.G. Moellendorf, D.C. James P. Shearman, D.C.

Sturgeon Bay, WI Omaha, NE

Wesley Mullen, Jr., D.C. David Shores, D.C.

Mountaintop, PA Encinitas, CA

Lee A. Newman, D.C. David Singer, D.C.

Pittsburgh, PA Clearwater, FL

Keith J. O’Connell, D.C. Michael West Shreeve, D.C.

Waldwick, NJ Tampa, FL

Donald W. Olson, D.C. Nick Spano, D.C.

Auburn, WA Canton, PA

Nicholas Opie, Jr., D.C. Laura Sparks, D.C.

Kailua, HI Athens, OH

Mark A. Pederson, D.C. Brian Stearns, D.C.

Hudson, WI Salem, OR

Dennis Perman, D.C. Richard J. Stephenson, D.C.

Huntington, NY Bryan, TX

Richard A. Pistolese, D.C. Lawrence J. Suchoff, D.C.

Atlanta, GA New City, NY

Herbert Reaver, D.C. Joseph J. Teff, D.C.

Pisgah, OH Middleton, WI

Max Reinecke, D.C. Christopher I. Thornell, D.C.

Sioux Falls, SD Hiawatha, IA

Bradbury Robinson, D.C. David Toftness, D.C.

Norfolk, VA Amery, WI

David L. Rozeboom, D.C. Gordon Toftness, D.C.

St. Louis, MO Amery, WI

Henry Rubinstein, D.C. Larry Troxell, D.C.

Miami, FL Parkview, IA

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 CCP Guidelines 3rd Edition 2008

Jack K. Van Dervort, D.C. Peter Amlinger, D.C.

Meadville, PA Mississauga, Ontario, Canada

Scott Walker, D.C. Elizabeth Anderson-Peacock, D.C.

Encinitas, CA Barrie, Ontario, Canada

James Warner, D.C. Jim Apostopoulos, D.C.

Keizer, OR Toronto, ON, Canada

Marion Weber, D.C. Mark Baerwaldt, D.C.

Vienna, VA Milano, Italy

James M. Wehner, D.C. John Baird, D.C.

Pittsburgh, PA Markham, ON, Canada

Scott White, D.C. Stephen Barker, D.C.

Ft. Collins, CO Brantford, ON, Canada

Heather Whittle, D.C. K.E. Libby Barlow, D.C.

Kennesaw, GA Salt Spring Island B, Canada

Jerry L. Wood, D.C. Andrew Bartolich, D.C.

Citrus Heights, CA Lismore, Australia

Andrew Wymore, D.C. Matthew Bateman, D.C.

Overland, KS Bullen, Australia

Brian Zaleski, D.C. Yves Belanger, D.C.

Vacaville, CA Levis Que, Canada

Michael S. Zeigler, D.C. Sigurd Berndt, HP

High View, WV Laufen, Germany

Peter Zid, D.C. Albert Berti, D.C.

Chicago, IL Burnaby, BC, Canada

Janine Adams, D.C. Martin Bezeau, D.C.

Happy Valley, Australia Sainte-Rose, Que, Canada

Karola Albrecht-Kumi, HP Natlie Bird, D.C.

Berlin, Germany Stephens, Australia

David Aldenhoven, D.C. Margie Bishop-Funnell, D.C.

Moonee Ponds, Australia Rotorua, New Zealand

Doug Alderson, D.C. Michael Bishopp, D.C.

North Vancouver, BC, Canada North Mackay, Australia

Helen Alevaki, D.C. Licesio Blanco, D.C.

North Carlton, Australia Leon, Spain

Peter Alfalla, D.C. Linda Blythe, D.C.

Lima, Peru Carrara, New Zealand

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 CCP Guidelines 3rd Edition 2008

Grant Bond, D.C. Frank Chastellas, D.C.

Wollongong, Australia Manosque, France

W. Ralph Boone, D.C. James Chestnut, B.Ed., MSc

Auckland, New Zealand Victoria, BC, Canada

Matthew Bourke, D.C. Duane L. Clark D.C.

Avalon, Australia Unity, SK, Canada

Richard R. Bray, D.C. Robert Cohen, D.C.

Windsor Ontario, Canada Mississauga, Ontario, Canada

Michael Brickman, D.C. Gary Coleman, D.C.

Toronto, Ont, Canada Traralgon, Australia

Gilles Brive, D.C. Martha Collins, D.C.

Castellon, Spain Kingston, Ontario, Canada

Milan Brkljac, D.C. K. Laurie Colquhoun, D.C.

Parramatta, Australia Clinton, Ontario, Canada

Jeremy Brown, D.C. Jeffery Conrad, D.C.

Burlington, Ontario, Canada Bellerive, Australia

Frank Brunzendorf Julie Constanza, D.C.

Leipzig, Germany Mississauga, Ontario, Canada

Thomas Burge, D.C. Robert Cranfield, D.C.

S Surrey, Canada Norvale, Ontario, Canada

Garry Butwell, D.C. Tony Croke, D.C.

Georgetown, Ontario, Canada Gisborne, VIC, Australia

Marco Caravaggio, D.C. Raef Dakka, D.C.

Lanciano CH, Italy Yamma Serner, Israel

Johanna Carlo, D.C. Rainer Dallmann, HP

Toronto, Ontario, Canada Berlin, Germany

David Carson, D.C. Andre de Voos, D.C.

New Westminster, BC, Canada Den Dolder, Netherlands

Kelly Carson, D.C. Michael Degen, PT

Williams Lake, BC, Canada Bregenz, Austria

Joseph Castelli, D.C. Ian Deitch, D.C.

Majadahonda, Madrid, Spain Rosanna, Australia

Winston Chan, D.C. Helene Denis, D.C.

Montreal, Canada Peterborough, Ontario, Canada

Paul Charest, D.C. Lana Denny, D.C.

Anjou, Que, Canada Orange, Australia

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 CCP Guidelines 3rd Edition 2008

Pierre Deslauriers, D.C. Matthew Flanagan, D.C.

Surrey, BC, Canada Neuwry County, Northern Ireland

Hartmut Dethloff, HP David Fletcher, D.C.

Leipzig, Germany Pickering, Ontario, Canada

Jone Dies-Keys, D.C. Brett Foote, D.C.

New Market, Ontario, Canada Ballarat, Australia

Ari Diskin, D.C. G. Foran D.C.

Fitzroy, VIC, Australia Vancouver, Canada

Bernhard Dittrich, HP Mark Foullong, D.C.

Mannheim, Germany Orangeville, Ontario, Canada

Theresa Dobson, D.C. Andrea Fretti, D.C.

Oakland, New Zealand Dundaf, Ontario, Canada

Mark Dyrholm, D.C. John Funnell

Three Hills, AB, Canada Rotorua, New Zealand

Colin Elkin, D.C. Jose Maria Galetto, D.C.

Branford, Ontario, Canada Santa Fe, Argentina

Ray Ellis, D.C Steven Gall, D.C.

Drayton Valley, AB, Canada Winnipeg, MB, Canada

Stephen Ely, D.C. Michael Gallinger

Barrie, Ontario, Canada Edmonton, AB, Canada

Mitsumasa Endo Chris Garwah, D.C.

Kawasaki, Japan Dawson Creek, BC, Canada

Lloyd Esak, D.C. Clifford Geddes, D.C.

Vermillion, AB, Canada Chapleau, Canada

Christian Farthing, D.C. Ben N.M.George, D.C.

Kent, United Kingdom Howick, South Africa

John Fay, D.C. Thor Gilbertson, D.C.

Dublin, Ireland Edmonton, AB, Canada

Brian Ferguson, D.C. Laurent Goldstein

Orangeville, Ontario, Canada Richmond, Canada

Andrea Ferretti, D.C. Tobias Concharoff, D.C.

Dundaf, Ontario, Canada Barcelona, Spain

George Fett, D.C. Brain G. Graham, D.C.

Rome, Italy Portage La Prairie M, Canada

Matthew Flanagan, D.C. Kim Greene-Desaulniers, D.C.

Cheswick, London, United Kingdom White Rock, BC, Canada

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 CCP Guidelines 3rd Edition 2008

Colleen Greer, D.C. Natessa Henville, D.C.

Edmonton, AB, Canada Wynnum, QLD, Australia

Urs Gruber, HP Peter Herron, D.C.

Cham, Switzerland Bowmanville, ON, Canada

Rainer Grunow, Sporttherapist Deanne Hill, D.C.

Berlin, Germany Guelph, Ontario, Canada

Pierre Guillot, D.C. Nicholas Hodgson, D.C.

Quebec, Que, Canada Ocean Grove, VIC, Australia

N.Y. Guriel, D.C. Paul Holdsworth, D.C.

Prahran, VIC, Australia North Vancouver, BC, Canada

Henrik Gyrst, D.C. Roger Hollingsworth, D.C.

Odense, Denmark Waterloo, Ontario, Canada

Peter Gyrst, D.C Kevin Holroyd, D.C.

Odense, Denmark West Bank, BC, Canada

Karina Gyrst, D.C. Jamin Horner

Odense, Denmark Bletchingley, Surrey, United Kingdom

Clarnece Haitsma, D.C. Dominique Hort, D.C.

Lacombe, AB, Canada Lugano, Switzerland

Robyn Hall, D.C. Patricia Hort, D.C.

Hyde Park, SA, Australia Calgary, AB, Canada

Allan Halowski, D.C. Notburga Hoth, HP

Calgary, AB, Canada Potsdam, Germany

Samantha Harman, D.C. Peter Hough, D.C.

Corinda, QLD, Australia Ottawa, ON, Canada

Brad Harper, D.C. Aaron Hoy, D.C.

Grand Cayman Island Vancouver, BC, Canada

Liana Harper, D.C. Travis Hughes, D.C.

Coalbale, AB, Canada Rosana, VIC, Canada

David Harris, D.C. Jorge Ippolito, D.C.

Lane Cove, NSW, Australia Cordoba, Argentina

Cameron Harrison, D.C. Laura Iverson

Edison, AB, Canada Surrey, BC, Canada

Lawson Heath, D.C. Rosemary Jabbour, D.C.

Shailer Park, QLD, Australia Paramatta, NSW, Australia

David Hendrey, D.C. Barbara James, D.C.

Mentone, VIC, Canada Kelowna, BC, Canada

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 CCP Guidelines 3rd Edition 2008

Paul Jensen, D.C. Sylvain Lauzon, D.C.

Svolvaer, Norway Laval, PQ, Canada

Randall Jones, D.C. Paul Lawrence, D.C.

Murcia, Spain Dover Gardens, SA, Australia

James Kaminski, D.C. Ely Lazar, D.C.

Fergus, ON, Canada Shenton Park, WA, Australia

Steven Katz, D.C. Jay Lepp, D.C.

Fairfield, Victoria, Australia Coquitlam, BC, Canada

Greg Kendall, D.C. Graham Le Lievre, D.C.

Wodonga, Vic SA, Australia Maylands, SA, Australia

Andrew Kerr, D.C. Francois LeBlanc, D.C.

Modbury, Canada Moncton, NB, Canada

Thomas Kerr, D.C. Donald Leck, D.C.

Belleville, ON, Canada North York, ON, Canada

Krisma Keswani, D.C. Hance Limboro, D.C.

Gawler, Australia Sydney, Australia

Peter Kewin, D.C. Rex Lin, D.C.

London, ON, Canada ChuPei city, HsinChu, Taiwan,
R.O.C.
Justin Kim, D.C.
Cambridge, ON, Canada Carsten Lizio
Wetzikon, Switzerland
Kenneth Koehler, D.C.
Noordwijk, Holland Jean-Jacques Lob, D.C.
Villasanta, Italy
Adam Konanz, D.C.
Penticton, BC, Canada Paul Lockhart, D.C.
Carlton, NSW, Australia
Kelly Kramp, D.C.
New Liskeard, ON, Canada William Logan, D.C.
Norwood, SA, Australia
Mark Lacey, D.C.
Mornington, VIC, Australia David C.Lovsin, D.C.
Kanata, ON, Canada
Caroline Lambert, D.C.
Paris, France Jeff Lowthian, D.C.
Kanata, ON, Canada
Annette Langlois, D.C.
Brantford, ON, Canada Ed Lubberdink, D.C.
Willowdale, ON, Canada
Phillippa Langrell, D.C.
Rotorua, New Zealand Silvia Graciela Luduena, D.C.
Cordoba, Argentina
Ib Laursen, D.C.
Nestved, Denmark Carl Lundgren, D.C.
Surco Lima, Peru

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 CCP Guidelines 3rd Edition 2008

Nick Maczysyn, D.C. Mark C. Mitchell, D.C.

Burleigh Heads, QLD, Australia Cambridge, ON, Canada

Sandra J.Malpass, D.C. Richard Mitton, D.C.

Ancaster, ON, Canada Hamilton, VIC, Australia

Kahlid Mankal , D.C. W. Russell Mock, D.C.

Ottawa, ON, Canada Vermont, VIC, Australia

John Manson, D.C. Brett Moore, D.C.

Catania, Italy Oakville, Ont, Canada

Henri Marcoux, D.C. Glenn Moore, D.C.

Winnipeg, MB, Canada Thornhill, ON, Canada

Robert Marin, D.C. Athol Morris, D.C.

Hove, SA, Australia Reservoir, VIC, Australia

Michel Marmier, D.C. Asher Nadler, D.C.

Anglet, France Jerusalem, Israel

R.H. Mayall, D.C. Bruce Naherniak, D.C.

Hamilton, Ontario, Canada Winnipeg, MB, Canada

William McCallum, D.C. Scott Naherniak, D.C.

Thunder Bay, Ontario, Canada Winnipeg, MB, Canada

Kevin McKenzie, D.C. Brian Nantais, D.C.

Nelson, BC, Canada Tecumseh, ON, Canada

David McLachlan, D.C. Craig Nelson, D.C.

Toronto, ON, Canada Mornington, VIC, Australia

Bronwyn McNamara, D.C. Helen Nitschke, D.C.

Buddina, QLD, Australia Plympton, SA, Australia

Peter Meininger, HP Jamie Neely, D.C.

Berlin, Germany London, Ont, Canada

Enrico Mele, D.C. Alan O’Connor, D.C.

Salerno, Italy Ayre, ON, Canada

Gregorio Merkier, D.C. Rolf Osthus, D.C.

Cordova, Argentina Levanger, Norway

Diane Meyer, D.C. Ingjerd Osthus, D.C.

Oakville, ON, Canada Levanger, Norway

Paul Meyer, D.C. Adrian Osypiv, D.C.

Kitchener, ON, Canada Maroochydore, QLD, Australia

Ernest P. Miron, D.C. Paul Ottinger, D.C.

Winnipeg, MB, Canada Napoli, Italy

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 CCP Guidelines 3rd Edition 2008

Alicia Beatriz Palacios, D.C. Angus Pyke, D.C.

Cordoba, Argentina Port Melbourne, VIC, Australia

Andrew Paul, D.C. Jenny Quirk, D.C.

Sydney, NSW, Australia Hyde Park, SA, Australia

Yannick Pauli, D.C. Nicole Quodling, D.C.

Lausanne, VD, Switzerland Gawler, SA, Australia

Mark Pearson-Gills Colin Rance

Wantirna, South Victoria, Australia Edlesborough, Dunstabel, United
Kingdom
Ken Peever, D.C.
Mississauga, ON, Canada Michael Reid, D.C.
Ottawa, Ont, Canada
Sharon Peterkin, D.C.
Pickering, ON, Canada David Reinhart, D.C.
Kitchener, ON, Canada
Robert Pike, D.C.
Keswick, ON, Canada John Rennicks, D.C.
Toronto, ON, Canada
Robert Pisanu, D.C.
Sassari, Italy Ogi J. Ressel, D.C.
Burlington, ON, Canada
James Pizzadilli, D.C.
Anchorage, Alaska Anthony Richards, D.C.
Dee Why, DSW, Australia
Karen Ponesky, D.C.
Berlin, Germany Malcolm Ritchie, D.C.
Bundall, QLD, Australia
Henri Pops, D.C.
Winnipeg, AB, Canada Peter Robb, D.C.
Mittagona, NSW, Australia
Stephen C. Porter, D.C.
North Bay, ON, Canada Helen Roberts, D.C.
Christchurch, New Zealand
Mark Postles, D.C.
Budding, QLD, Australia Heather Robson, D.C.
Niagara Falls, ON, Canada
Delores Press, D.C.
Vancouver, BC, Canada Christina Rodes, D.C.
Alderley, QLD, Australia
Tom Preston, D.C.
North Bay, ON, Canada Anthony Rose, D.C.
Highton, Victoria, Australia
Mark Preyser, D.C.
Kenilworth, South Africa Tony Rose, D.C.
Jan Juc, VIC, Australia
Terry D. Procyshen, D.C.
Strathmore, AB, Canada Murray Rosen, D.C.
Calgary, AB, Canada
Mike Pyfron, D.C.
Nassau, Bahamas Robert Ryles, D.C., C.H.
Sakurajyosui, Setagaya-ku, Japan

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 CCP Guidelines 3rd Edition 2008

Edward Michael Saltys, D.C. Frazer Smith, D.C.

Algarve, Portugal Smith Falls, ON, Canada

Mauricio Sandino, D.C. Gary Smith, D.C.

Gandia (Valencia), Spain Cessnock, NSW, Australia

Ibrahim Sayed, HM Peter Snodgrass, D.C.

Harland, Austria Norwood, SA, Australia

Frank Schoellhammer, HP Freddie So, D.C.

Pforzheim, Germany Oakville, ON, Canada

Liam Schubel, D.C. Jeremy Spanton, D.C.

Lima, Peru Woking, Surrey, England

Kurt-Juergen Schwarz, HP Mike Staffen, D.C.

Berlin, Germany Sudbury, ON, Canada

Andrew Scott, D.C. Marc St-Denis, D.C.

Woodbridge, ON, Canada Ottawa, ON, Canada

Gerard Scott-Herridge, D.C.

Winnipeg, MB, Canada John E.K. Stevens, D.C.
Nassau, Bahamas
Christopher Scrase, D.C.
Dorval, Que, Canada Lynn Stevens, D.C.
Nassau, Bahamas
Timothy Sharp, D.C.
Edmonton, AB, Canada Greg Stiles, D.C.
Edmonton, AB, Canada
Greg Shaw, D.C.
Oakville, ON, Canada Jim Stinear, D.C.
Auckland, New Zealand
Susan Shaw, D.C.
Barrie, Ontario, Canada Mike Storey, D.C.
Peterborough, Ont, Canada
Dean Short, D.C.
Kenmore, QLD, Australia Robert Straub, D.C.
Janschwalde, Germany
Laina Shulman, D.C.
London, ON, Canada Carsen Tannberg, D.C.
Corrimal, NSW, Australia
Steven Silk, D.C.
Wiarton, ON, Canada Eduardo Tarago, D.C.
Casilda Santa Fe, Argentina
Greg Sim, D.C.
Ararat, VIC, Australia Robin Taylor, D.C.
Takapuna Auckland, New Zealand
Warren Sipser, D.C.
Elwood, VIC, Australia Jean Theroux, D.C.
Laval, QU, Canada
Robert Skleryk, D.C.
Surrey, BC, Canada Gary Thomson, D.C.
Calgary, AB, Canada

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C. Gus Tsiapalis, D.C. Rod Weiland, D.C.

Toronto, ON, Canada Chatswood, NSW, Australia

Mark Tulloch, D.C. Luis Weiss, HP

Nepeon, ON, Canada Muenchen, Germany

Alejandro Turelli, D.C. Adrian Wenban, D.C.

Cordoba, Argentina Spain

Nicole Unger, HP,RN William Werner, D.C.

Hude, Germany Hagersville, ON, Canada

John Van Der Meulen, D.C. David Paul Weyrauch, D.C.

Dandenong, VIC, Australia North York, ON, Canada

Renato Van Putten, D.C. David Whitfield, D.C.

Oranjestad, Aruba Port Elizabeth, South Africa

Gregory Veggia, D.C. Kathy Wickens, D.C.

Barcelona, Spain Perth, ON, Canada

Edith Veillette, D.C. Troy Wielgosz, D.C.

Gatineau, PQ, Canada Kelowna, BC, Canada

Jennifer Verreault, D.C. John Wight, D.C.

Joliette, PQ, Canada Edinburgh, Scotland

Ron Wagner, D.C. Daniel Wilhelmus, D.C.

Parkhill, ON, Canada Simcoe, ON, Canada

J. Bruce Walton, D.C. Charles Wilson, D.C.

Guelph, ON, Canada Quito, Equador

Randy Warchola, D.C. Christopher Wilson, D.C.

St. Paul, AB, Canada High River, AB, Canada

Sinclair Warner, D.C. Jeff Winchester, D.C.

Southerwood, East London, South Africa Waterloo, Ontario, Canada

Neil Watkins, D.C. Kellie Wood, D.C.

Swan River, MB, Canada Oak Park, VIC, Australia

Ronald Watkins, D.C. Lawrence Woods, D.C.

Chonbari, Thailand Dublin, Ireland

Alana Way, D.C. Katsuhisa Yoneyama, D.C.

Kingston, ON, Canada Minato-Ku, Tokyo, Japan

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 CCP Guidelines 3rd Edition 2008

Technique Panel – 1998 & 2003

Dr. Paul A. Jaskoviak
Dr. Robert Clyde Affolter Contact Reflex Analysis
Post-graduate Faculty
Sherman College of Straight Chiropractic Dr. Joanne Jezequel
Advanced Technique Review
Dr. Ron Aragona
Applied Spinal Biomechanical Engineering Dr. Christopher John
Directional Non-Force Technique
Dr. David Bellin
Thompson Technique Dr. Jesse Jutkowitz
Advanced Biostructural Correction
Dr. Fred H. Barge
Barge Method Dr. Renee Kale
Kale Technique
Dr. Charles Blum
SOTO, USA Dr. Wallace King
King Concept Technique
Dr. Sue Brown
Bio-Geometric Integration Dr. Robert Klingensmith
SOTO-USA
Dr. Christopher Colloca
Dr. David Leaf
Dr. Christina Cunliffe International College of Applied
McTimoney Technique Kinesiology

Dr. Ralph Davis Dr. Howard Lewis

Upper Cervical Technique Sacro-Occipital Research Society
International
Dr. Leander Eckard
Leander Technique Dr. Jack Masche
Concept Therapy
Dr. Donald Epstein
Network Spinal Analysis Dr. Yannick Pauli
NSA/Torque Release
Dr. Kirk Eriksen
Orthospinology Dr. Burl Pettibon
Pettibon Biomechanics
Dr. Patrick Foran
NUCCA/Grostic Dr. Dennis Woggon
Pettibon Biomechanics
Dr. Jay Hafner
Mr. Richard Pistolese
Dr. Jay M. Holder Pediatric Technique
Torque Release Technique
Dr. John Pryzbylak
Dr. Rob Jackson XYZ Analysis
Thompson Technique
Dr. Keith Rau
Dr. Barbara James Extraspinal Technique
Micro-Chiropractic
Dr. Marty Rosen
Dr. Spence Jahner SOTO-USA
Pierce Technique

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 CCP Guidelines 3rd Edition 2008

Dr. David Rozeboom Dr. Jeannie Ohm

SORSI Webster In-Utero Constraint Technique

Dr. Henry Sanon Dr. Richard Grostic

Torque Release Technique Grostic Technique

Dr. Simon Senzon Dr. R.B. Mawhinney

Mawhinney Technique
Dr. Glenn Stillwagon
Pierce-Stillwagon Technique Dr. Lowell Ward
Stressology
Dr. James Thompson
Thompson Technique Dr. Catherine Franklin
Concept Therapy
Dr. Steve Troyanovich
Dr. Robert Kessinger
Dr. Adrian Wenban Upper Cervical Specific

Dr. Ray Wiegand Dr. Michael Burcon

Logan Technique Burcon Cervical Specific

Dr. Linda Mullin Dr. Mark Postles

Gonstead Technique Sacro–Occipital Technique

Dr. David Toftness Dr. Robert Wiegand

Toftness Technique Access Technique

Dr. Michael Hawkinson Dr. Robert Goodman

Toftness Technique NUCCA

Dr. Victor Frank Dr. Donald Gran

Total Body Modification Palmer College Technique Department

Dr. Ted Morter Dr. Pete Hilgartner

Bio-Energetic Synchronization Technique Pettibon Biomechanics

Dr. Liz Anderson Peacock Dr. Roger Morrison

Pediatrics Blair Technique

Dr. Jerry Hochman Dr. John Pinto

Dynamic Spinal Analysis Atlas Orthogonality

Dr. Donald W. Olson Dr. Stuart Warner

Applied Spinal Biomechanical Engineering Pediatric Technique

Dr. Roy Sweat Dr. Mark Filippi

Atlas Orthogonality
Dr. Harold George
Dr. Scott Walker Pierce/Stillwagon Technique
Neuro-emotional Technique
Dr. Margaret Banitch
Dr. Matthew McCoy Blair Technique
Mears Technique
Dr. Mark Dietch
Motion Palpation

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 CCP Guidelines 3rd Edition 2008

Dr. Steve Ward

Stressology

Dr. George Fleet

Concept Therapy

Dr. Zahra Yousefi

Directional Non-Force Technique

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 CCP Guidelines 3rd Edition 2008

Appendix 2: Methodological Standards for Practice Guidelines

Adapted From: Shaneyfelt, T.M., Mayo-Smith, M.F., Rothwangl, J. Are Guidelines Following
Guidelines? The Methodological Quality of Clinical Practice Guidelines in the Peer-Reviewed
Medical Literature. JAMA, May 26, 1999 – Vol 281, No. 20. With the Permission of the
Journal of the American Medical Association

Frequency of Adherence to Methodological Standards on Guideline Development and Format

1. Purpose of the guideline is specified

2. Rationale and importance of the guideline are explained
3. The participants in the guideline development process and their areas of expertise are
specified.
4. Targeted health problem or technology is clearly defined
5. Targeted patient population is specified
6. Intended audience or users of the guideline are specified
7. The principal preventive, diagnostic, or therapeutic options available to clinicians and
patients are specified
8. The health outcomes are specified
9. The method by which the guideline underwent external review id specified
10. An expiration date or date of scheduled review is specified.

Frequency of Adherence to Methodological Standards on Evidence Identification and Summary

11. Method of identifying scientific evidence is specified

12. Time period from which evidence is reviewed is specified.
13. The evidence used is identified by citation and referenced
14. Method of data extraction is specified
15. Method for grading or classifying the scientific evidence is specified
16. Formal methods of combining evidence or expert opinion are used and described.
17. Benefits and harms of specific health practices are specified
18. Benefits and harms are quantified
19. The effect on health care costs from specific health practices is specified
20. Costs are quantified

Frequency of Adherence to Methodological Standards on the Formulation of Recommendations

21. The role of value judgments used by the guideline developers in making
recommendations is discussed
22. The role of patient preferences is discussed
23. Recommendations are specific and apply to the stated goals of the guideline
24. Recommendations are graded according to the strength of the evidence
25. Flexibility in the recommendations is specified

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 CCP Guidelines 3rd Edition 2008

Appendix 3: Criteria for Choice of Peer-Reviewers

Peer Reviewers were chosen based on several characteristics including but not
limited to:

• Technique expertise
• Involvement in Regulatory Board Activity
• Experience in research or publication
• Experience in chiropractic education
• Knowledge of chiropractic education accreditation standards
• Hold advanced post graduate degrees in chiropractic sciences and/or other
specialties within chiropractic
• Practice experience
• International practice
• Specialty practice i.e. pediatrics
• Political Experience
• Legal expertise
• Experience in Guideline Development Methodology
• Vendors with an interest in chiropractic guidelines
• Patients
• Government experts

318