be pseudoscience. william t. jarvis emphasizes the commercial, rather than professional, nature of chiropractic:chiropractic is a controversial health-care system that has been legalized throughout the united states and in several other countries. in the united states in 1984, roughly 10.7 million people made 163 million office visits to 30,000 chiropractors. more than three fourths of the states require insurance companies to include chiropractic services in health and accident policies. the federal government pays for limited chiropractic services under medicare, medicaid, and its vocational rehabilitation program, and the internal revenue service allows a medical deduction for chiropractic services. chiropractors cite such facts as evidence of "recognition." however, these are merely business statistics and legal arrangements that have nothing to do with chiropractic's scientific validity. spinal manipulation the efficacy and safety of spinal manipulation are uncertain. a 2008 review found that with the possible exception of chronic back pain, chiropractic manipulation has not been shown to be effective for any medical condition. the efficacy and safety of chiropractic for children are particularly doubtful. a 2009 review found that "the best evidence available to date fails to demonstrate clinically relevant benefits of chiropractic for paediatric patients, and some evidence even suggests that chiropractors can cause serious harm to children". according to david colquhoun, chiropractic is no more effective than conventional treatment at its best, has a disadvantage of being "surrounded by gobbledygook about 'subluxations'", and, more seriously, it does kill patients occasionally. a 2009 defense of chiropractic, written by chiropractor alan breen, stated there is consistent evidence that manual therapies such as chiropractic manipulations are "helpful and generally produce moderate but significant and sustained improvement for back pain" and dismissed the suggestion that chiropractic does more harm than good as "specious". the author admitted, however, the possibility that chiropractic manipulation can cause strokes and even death. although rare, spinal manipulation, particularly of the neck, can result in complications that lead to permanent disability or death. these events can occur in both adults and children. a 2010 systematic review found that numerous deaths since 1934 have been recorded after chiropractic neck manipulation typically associated with vertebral artery dissection. x-ray procedures singh's 2008 book trick or treatment states that:chiropractors may x-ray the same patient several times a year, even though there is no clear evidence that x-rays will help the therapist treat the patient. x-rays can reveal neither the subluxations nor the innate intelligence associated with chiropractic philosophy, because they do not exist. there is no conceivable reason at all why x-raying the spine should help a straight chiropractor treat an ear infection, asthma or period pains. most worrying of all, chiropractors generally require a full spine x-ray, which delivers a significant higher radiation dose than most other x-ray procedures.practice guidelines aim to reduce unnecessary radiation exposure, which increases cancer risk in proportion to the amount of radiation received. research suggests that radiology instruction given at chiropractic schools worldwide is evidence-based, but that radiography is overused for low back pain. chiropractors use x-ray radiography to examine the bone structure of a patient. vertebral subluxation vertebral subluxation, the core concept of chiropractic, is not based on solid science. the concept of subluxation remains unsubstantiated and largely untested, and has been the subject of a debate about whether to keep it in the chiropractic paradigm that has lasted for decades. it has been argued that dogmatic commitment to subluxation is a significant barrier to chiropractic as a profession: it brings ridicule from the scientific community and perpetuates a marketing tradition in chiropractic that leads to charges of quackery. innate intelligence lon morgan, dc, a reform chiropractor, expressed his view of innate intelligence this way: "innate intelligence clearly has its origins in borrowed mystical and occult practices of a bygone era. it remains untestable and unverifiable and has an unacceptably high penalty/benefit ratio for the chiropractic profession. the chiropractic concept of innate intelligence is an anachronistic holdover from a time when insufficient scientific understanding existed to explain human physiological processes. it is clearly religious in nature and must be considered harmful to normal scientific activity." chiropractic historian joseph c. keating jr. articulated that "so long as we propound the "one cause, one cure" rhetoric of innate, we should expect to be met by ridicule from the wider health science community. chiropractors can't have it both ways. our theories cannot be both dogmatically held vitalistic constructs and be scientific at the same time. the purposiveness, consciousness and rigidity of the palmers' innate should be rejected." vaccination and water fluoridation many forms of alternative medicine are based on philosophies that oppose vaccination and have practitioners who voice their opposition. these include some elements of the chiropractic community. the reasons for this negative vaccination view are complicated and rest, at least in part, on the early philosophies which shape the foundation of these professions. chiropractors historically were strongly opposed to vaccination based on their belief that all diseases were traceable to causes in the spine, and therefore could not be affected by vaccines; d.d. palmer wrote, "it is the very height of absurdity to strive to 'protect' any person from smallpox or any other malady by inoculating them with a filthy animal poison." some chiropractors continue to be opposed to vaccination, one of the most effective public health measures in history. many deny the eradication of smallpox and believed it was renamed monkeypox. some chiropractic groups still oppose attempts to limit or eliminate nonmedical exemptions to vaccination. in march 2015, the oregon chiropractic association invited andrew wakefield, a discredited former doctor and chief author of a fraudulent research paper, to testify against senate bill 442, "a bill that would eliminate nonmedical exemptions from oregon's school immunization law." the california chiropractic association lobbied against a 2015 bill ending belief exemptions for vaccines. they had also opposed a 2012 bill related to vaccination exemptions. on april 24, 2015, wakefield received two standing ovations from the students at life chiropractic college west when he told them to oppose senate bill sb277, a bill which proposes limits on non-medical vaccine exemptions. responding to his critics, he stated that "t doesn't matter if i go to the grave discredited. i don't care what they say about me. in fact, i have nothing to lose now. this is such an important issue." wakefield had previously been a featured speaker at a 2014 "california jam" gathering of chiropractors, as well as a 2015 "california jam" seminar, with continuing education credits, sponsored by life chiropractic college west. in response to threatening activities by anti-vaccination activists, the california medical association (cma) sent a warning letter to california chiropractic association president brian stenzler, whom they could document had encouraged the stalking of lobbyists who supported senate bill sb277. the cma also filed a police report. early opposition to water fluoridation included chiropractors in the u.s. some chiropractors oppose water fluoridation as being incompatible with chiropractic philosophy and an infringement of personal freedom. more recently, other chiropractors have actively promoted fluoridation, and several chiropractic organizations have endorsed scientific principles of public health. ownership of spinal manipulation while no single profession "owns" spinal manipulation (sm), and there is little consensus as to which profession should administer sm, chiropractors have expressed concern that orthodox medical physicians and physical therapists could "steal" sm procedures from chiropractors. chiropractors regularly introduce bills into state legislatures to further prohibit non-chiropractors from performing sm, and they are opposed by physical therapist organizations. two u.s. states (washington and arkansas) prohibit physical therapists from performing sm, while some states allow them to do it only if they have completed advanced training in sm. in the most restrictive states, sm is limited to chiropractors and medical physicians. notable incidents and lawsuits robbie basho, 45, an american musician, died during a chiropractic visit on february 28, 1986, when an "intentional whiplash" experiment caused blood vessels in his neck to rupture, leading to a fatal stroke. caitlin jensen, 28, a student at georgia southern university, visited chiropractor t. j. harpham, of richmond hill family chiropractic in richmond hill, georgia on june 16, 2022, to have her neck adjusted following complaints of stiffness. during the adjustment, four arteries in jensen's neck were dissected, resulting in cardiac arrest, a stroke, and a traumatic brain injury. she was reportedly without a pulse for 10 minutes until she could be revived. she was left with almost full-body paralysis, capable of only blinking her eyes and moving her left thumb. her injuries also subsequently removed her ability to eat and breathe on her own, resulting in doctors forming gastrostomy and tracheotomy tubes in her stomach and neck areas respectively. jeremy lynn youngblood, 30, an employee of the city of ada, oklahoma, died on june 11, 2011, from complications of an acute cerebellar stroke. the injuries were determined by the coroner to have been caused by a neck adjustment performed by an unnamed chiropractor employed by power chiropractic clinic. authorities did not comment on whether charges of negligence would be filed against power chiropractic clinic or not. according to assistant police chief carl allen did reveal that youngblood complained of disorientation and began vomiting in the minutes following the adjustment and clinic staff did not call 911. youngblood was driven to valley view regional hospital, now mercy hospital ada, by his father and died two days later. james turner, 11, of ontario, canada, was left with lower body paralysis, muscle weakness, and fecal incontinence after having his neck adjusted by chiropractor v. gary dyck. dyck performed two adjustments on turner, the first on july 24, 2000, and the second on july 25, 2000, and caused the infarction of a ganglioglioma, a benign spinal tumor. he underwent emergency surgery at the royal victoria hospital in barrie. the lawsuit, brought by turner's parents, alan and jill turner, claimed that dyck had shown negligence in that he did not perform x-rays to determine if the adjustments would resolve turner's initial complaints of neck pain and that had he done so, dyck would have noticed the tumor. dyck passed away in 2017. samantha cools, 22, an olympic athlete from alberta, canada, suffered ruptured tendons after her chiropractor, based in switzerland, over-rotated her neck during an adjustment. the injury had a devastating effect on her performance at the 2008 summer olympics in beijing, china, as the injury left her unable to eat or train for five weeks. kimberly lee strohecker, 30, of pennsylvania, died after a series of seizures left her unable to drink or walk and caused the contents of her stomach to aspirate into her lungs, causing pneumonia. strohecker, an epileptic, had been advised by her chiropractor, joanne m. gallagher of life expression chiropractic center of sugarloaf, pennsylvania, to stop taking her anticonvulsant medication if she wished to cure herself. when strohecker began experiencing seizures every 10 to 15 minutes, gallagher reassured her that she was fine and told her to not visit a hospital as they would treat her with anticonvulsants, which could kill her. strohecker died on april 29, 1999, and her family filed suit against gallagher. gallagher plead guilty to one count mail fraud, stemming from an attempt to bill medicaid for treatment that supposedly took place after strohecker's death, agreed to pay the family $500,000 in restitution. she was fined $9,100 and sentenced to 18 months in prison. gallagher attempted to appeal the revocation of her license 2005 but was unsuccessful. in 2012, she was twice denied a license to practice massage in the state of pennsylvania. she was later able to resume work with life expression chiropractic center as a registered craniosacral therapist, with the website stating that gallagher "transitioned" from chiropractic care to craniosacral therapy, with no mention of her criminal history or her involvement in strohecker's death. she is still working in the field as of september 2022. andrew arnold, a chiropractor from melbourne, australia, was banned from treating children under the age of 12 after a video of him holding a 2-week-old newborn upside down surfaced online, sparking outrage. he is the owner of cranbourne family chiropractic.