have supported its effectiveness for the treatment of (specifically) low back pain. there are several barriers between primary care physicians and chiropractors for having positive referral relationships which includes a lack of good communication. the medical establishment has not entirely accepted chiropractic care as mainstream. after 100 years, the chiropractic profession has failed to define a message that is understandable, credible, and scientifically valid. the future of chiropractic is uncertain due to the economic struggles and restrictions of the science and methods in chiropractic. chiropractic has seen considerable controversy within the profession over its philosophy. in connection with a controversial and divisive 2015 organizational split in the australian chiropractic community, an article described the profession's long standing and current problems: the chiropractic profession is notorious for its infighting, with quarrels over the value of vaccination, the evidence or lack thereof to support the theory of subluxation and whether spinal adjustments should be performed on children. allegations of patricide connected with the death of d.d. palmer the 2008 book trick or treatment states that in 1913 b.j. palmer ran over his father, d.d. palmer, during a homecoming parade at the palmer school of chiropractic. weeks later d.d. palmer died. the official cause of death was recorded as typhoid. the book trick or treatment indicated "it seems more likely that his death was a direct result of injuries caused by his son. indeed there is speculation that this was not an accident, but rather a case of patricide." a 1999 documentary study suggests d.d. palmer's widow may have also played a role in the patricide controversy. d.d. palmer's attending physicians were persuaded to change their opinions about the main cause of death. chiropractic historian joseph c. keating jr. has described the attempted patricide of d.d. palmer as a "myth" and "absurd on its face" and cites an eyewitness who recalled that d.d. was not struck by b.j.'s car, but rather, had stumbled. he also says that "joy loban, dc, executor of d. d.'s estate, voluntarily withdrew a civil suit claiming damages against b.j. palmer, and that several grand juries repeatedly refused to bring criminal charges against the son." a 1969 article stated that in july 1913 at the palmer school of chiropractic b.j. palmer:insisted on leading the alumni procession, but was prohibited from doing so by the marshal of the parade, who was a student at the school. an altercation ensued. b.j. drove up in his automobile. words passed between father and son. what happened after that depends on whom you believe. daniel david claimed that b.j. struck him with his automobile, and d.d.'s friends and allies later produced affidavits of witnesses to prove it. b.j. flatly denied it, and produced many more affidavits to this effect than d.d.'s cohorts were able to muster. ethics and claims a study of california disciplinary statistics during 1997–2000 reported 4.5 disciplinary actions per 1000 chiropractors per year, compared to 2.27 for medical doctors, and the incident rate for fraud was 9 times greater among chiropractors (1.99 per 1000 chiropractors per year) than among medical doctors (0.20). according to a 2006 gallup poll of u.s. adults, when asked how they would "rate the honesty and ethical standards of people in these different fields", chiropractic compared unfavorably with mainstream medicine. when chiropractic was rated, it "rated dead last amongst healthcare professions". while 84% of respondents considered nurses' ethics "very high" or "high", only 36% felt that way about chiropractors. other healthcare professions ranged from 38% for psychiatrists, to 62% for dentists, 69% for other medical doctors, 71% for veterinarians, and 73% for druggists or pharmacists. similar results were found in the 2003 gallup poll. chiropractic authors have placed these results in perspective in articles, with one writing that "we were the least trusted and least believed health care discipline", and another writing that chiropractors who use unethical marketing methods "poison the well" for others in the profession, and that they "might be responsible for the negative opinion people have about the ethics of the chiropractic profession." many chiropractors have sought to address their minor status within the u.s. medical community by attending practice-building seminars to assist chiropractors to persuade their patients of the efficacy of their treatments, increase their revenue, and boost their morale as unorthodox medical practitioners. historically the profession has often been accused of quackery, with the profession often responding negatively to such accusations. in its early days, the accusation of quackery was voiced in a 1913 editorial in the journal of the american medical association: (p. 29) chiropractic is a freak offshoot from osteopathy. disease, say the chiropractors, is due to pressure on the spinal nerves; ergo it can be cured by 'adjusting' the spinal column. it is the sheerest quackery, and those who profess to teach it make their appeal to the cupidity of the ignorant. its practice is in no sense a profession but a trade – and a trade that is potent for great harm. it is carried on almost exclusively by those of no education, ignorant of anatomy, ignorant even of the fundamental sciences on which the treatment of disease depends. the view that chiropractic was a trade, rather than a profession, was stated clearly by b.j. palmer, who asserted that chiropractic was founded on "a business, not a professional basis. we manufacture chiropractors. we teach them the idea and then we show them how to sell it". in more modern times (1991), when the president of the aca called accusations of quackery a "myth", chiropractic historian, joseph c. keating jr. responded by calling his comments "absurd" and stated: the so-called 'quackery myth about chiropractic' is no myth ... the kernels of quackery (i.e., unsubstantiated and untested health remedies offered as "proven") are ubiquitous in this profession. i dare say that health misinformation (if not quackery) can be found in just about any issue of any chiropractic trade publication (and some of our research journals) and much of the promotional materials chiropractors disseminate to patients. the recent unsubstantiated claims of the aca are exemplary ... it escapes me entirely how dr. downing, the aca, mpi, and dynamic chiropractic can suggest that there is no quackery in chiropractic. either these groups and individuals do not read the chiropractic literature or have no crap-detectors. i urge a reconsideration of advertising and promotion policies in chiropractic. in an article on quackery, w. t. jarvis has stated that "non-scientific health care (e.g., acupuncture, ayurvedic medicine, chiropractic, homeopathy, naturopathy) is licensed by individual states. practitioners use unscientific practices and deception on a public who, lacking complex health-care knowledge, must rely upon the trustworthiness of providers. quackery not only harms people, it undermines the scientific enterprise and should be actively opposed by every scientist." in a 2008 commentary, the chiropractic authors proposed that "the chiropractic profession has an obligation to actively divorce itself from metaphysical explanations of health and disease as well as to actively regulate itself in refusing to tolerate fraud, abuse and quackery, which are more rampant in our profession than in other healthcare professions", a situation which violates the social contract between patients and physicians. such self-regulation "will dramatically increase the level of trust in and respect for the profession from society at large." another chiropractic study documented that the largest chiropractic associations in the u.s. and canada distributed patient brochures which contained unsubstantiated claims. chiropractors, especially in america, have a reputation for unnecessarily treating patients. sustained chiropractic care is promoted as a preventative tool but unnecessary manipulation could possibly present a risk to patients. some chiropractors are concerned by the routine unjustified claims chiropractors have made. in english-speaking countries the majority of chiropractors and their associations appear to make efficacy claims that are unsupported by scientific evidence. claims not supported by solid evidence were made about asthma, ear infection, earache, otitis media, and neck pain. despite the claim from some chiropractors that spinal manipulation could treat infant colic, a 2009 review of chiropractic spinal manipulation for infant colic stated "the current evidence... does not show that chiropractic spinal manipulation is an effective treatment for infant colic." some new zealand chiropractors appeared to have used the title "doctor" in a new zealand yellow pages telephone directory in a way that implied they are registered medical practitioners, when no evidence was presented it was true. in new zealand, chiropractors are allowed to use the title 'doctor' when it is qualified to show that the title refers to their chiropractic role. a representative from the nz chiropractic board states that entries in the yellow pages under the heading of "chiropractors" fulfills this obligation when suitably qualified. if a chiropractor is not a registered medical practitioner, then the misuse of the title "doctor" while working in healthcare will not comply with the health practitioners competence assurance act 2003. uk chiropractic organizations and their members make numerous claims which are not supported by scientific evidence. many chiropractors adhere to ideas which are against science and most seemingly violate important principles of ethical behavior on a regular basis. the advice chiropractors gave to their patients is often misleading and dangerous. this situation, coupled with a backlash to the libel suit filed against simon singh, has inspired the filing of formal complaints of false advertising against more than 500 individual chiropractors within one 24-hour period, prompting the mctimoney chiropractic association to write to its members advising them to remove leaflets that make claims about whiplash and colic from their practice, to be wary of new patients and telephone inquiries, and telling their members: "if you have a website, take it down now" and "finally, we strongly suggest you do not discuss this with others, especially patients." simon singh has been supported by the charity sense about science, which has published this button in his favor. on 19 april 2008, simon singh wrote a cautionary article about chiropractic therapies in the guardian, which resulted in him being sued for libel by the british chiropractic association. singh wrote in the guardian criticizing the claims made by chiropractors about the efficacy of spinal manipulation in treating childhood ailments, among other things. he suggested there was "not a jot" of evidence to support such interventions for these ailments, and argued that the british chiropractic association "happily promotes bogus treatments". singh stated that he would "contest the action vigorously… there is an important issue of freedom of speech at stake." the article developed the theme of singh's published book trick or treatment? alternative medicine on trial, making various claims about the usefulness of chiropractic. commentators suggested this ruling could set a precedent to restrict freedom of speech to criticize alternative medicine. the charity sense about science launched a campaign to draw attention to this particular case. they issued a statement entitled "the law has no place in scientific disputes", which was signed by myriad signers representing science, journalism, publishing, arts, humanities, entertainment, skeptics, campaign groups and law. as of april 16, 2010, over 50,000 had signed. on april 1, 2010, in british chiropractic association v singh singh won his court appeal for the right to rely on the defense of fair comment. on april 15, 2010, the bca officially withdrew its lawsuit, thus ending the case. evidence for safety and efficacy evidence-based research into the efficacy of chiropractic techniques is motivated by concerns that are antithetical to its vitalistic origins. not all the criticism, however, has origins in the medical profession. some chiropractors are cautiously calling for reform. evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs antiscientific reasoning and unsubstantiated claims that are ethically suspect when they let practitioners maintain their beliefs to patients' detriment. it is widely held that chiropractic extends into areas of medicine beyond the limits of its efficacy. in the opinion of samuel homola, "a good chiropractor can do a lot to help you when you have mechanical-type back pain and other musculoskeletal problems. but until the chiropractic profession cleans up its act, and its colleges uniformly graduate properly limited chiropractors who specialize in neuromusculoskeletal problems, you'll have to exercise caution and informed judgment when seeking chiropractic care." quackwatch is critical of chiropractic. its founder, stephen barrett, has written that it is "absurd" to think that chiropractors are qualified to be primary care providers and considers applied kinesiology to