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Chiropractic – A Brief Overview, Part II

Last week I reviewed the history of chiropractic and discussed issues relating to its underlying claims and treatments for non-musculoskeletal indications. Today I will focus on chiropractic for back pain and similar indications.

Manipulative Therapy

There is evidence to support the very narrow indication of spinal manipulation for the symptomatic management of acute uncomplicated lower back strain. The good news for chiropractors is that this is a very common condition and does not respond well to conventional management – actually all treatments: medical management, physical therapy, manipulation, and even just patient education, appear to be equally and quite modestly effective.

There is a body of clinical studies that are relevant to the question of manipulation for lower back strain. A review of this research was published in 1989 by the RAND corporation, an independent research group that put together a panel of both physicians and chiropractors to review the available research on manipulative therapy. They concluded that evidence from 22 studies supported the use of manipulative therapy for acute uncomplicated lower back pain (again – no real pinched nerves). It is important to understand, however, that they were referring to manipulative therapy, not chiropractic. In fact only 4 of the 22 studies mentioned included chiropractors. In the other studies the manipulative therapy was performed by physicians and physical therapists.

The RAND study went on to enumerate a long list of situations in which spinal manipulation should not be performed, including evidence of nerve root compression. Other contraindications include a greater than 6 month duration, X-ray or clinical evidence of malignancy, failure to respond to manipulation or a history of not responding to manipulation, among others. They also concluded that there was insufficient evidence to justify the use of manipulation for most forms of chronic lower back pain. The study in no way supported chiropractic subluxation theory or the scope of chiropractic practice. Nor did it make any comparison between manipulation and other forms of treatment for low back pain.

Because of the popular confusion of chiropractic with manipulative therapy, and the use of manipulation for symptomatic treatment vs the pseudoscientific treatment of subluxations and innate intelligence – some chiropractors were able to exploit this and other positive studies of manipulation to advertise that “chiropractic works” as a way of promoting chiropractic treatments that have nothing to do with manipulation for lower back pain. The number of misrepresentations prompted Paul G. Shekelle, MD, MPH of the RAND corp. who designed the study to write:

“Through RAND’s process of monitoring the popular media, we have become aware of numerous instances where our results have been seriously misrepresented by chiropractors writing for their local paper or writing letters to the editor.”

There have been further studies since the 1989 review. The Meade study, which was published in the British Medical Journal in 1990, concluded that:

“For patients with low back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile long-term benefit in comparison with hospital outpatient management.”

There are some serious limitations of this study, however. The two treatment groups were not comparable, because the chiropractic group received 44% more treatment (costing 50% more) over twice as long a period of time and in a private setting. The outpatient physical therapy group was part of the National Health Service, and were noted to have limited resources and could not treat their patients in the same fashion that a private practitioner could.

Second, patients entered into the study were put through a medical screening process including X-rays that were interpreted by hospital radiologists. Between 25 and 50% of patients entering the study were eliminated because they were felt to have contraindications to manipulation. This fact alone makes it impossible to accurately apply the results of this study to the way chiropractic is practiced in the real world, where there is rarely independent radiological review or other medical screening. Of course, practices vary greatly, and some chiropractors do collaborate with physicians for medical screening.

A large 1998 study compared chiropractic to physical therapy to a third group that only received an informational booklet. The study concluded:

For patients with low back pain, the McKenzie method of physical therapy and chiropractic manipulation had similar effects and costs, and patients receiving these treatments had only marginally better outcomes than those receiving the minimal intervention of an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question.

The safety of manipulative therapy has not been adequately established. This 2001 review concludes:

The most valid studies suggest that about half of all patients will experience adverse events after chiropractic SM. These events are usually mild and transient. No reliable data exist about the incidence of serious adverse events. These data indicate that mild and transient adverse events seem to be frequent. Serious adverse events are probably rare but their incidence can only be estimated at present. Further prospective investigations are needed to define their incidence more closely.

A 2004 review of spinal manipulation and mobilizing for acute and chronic back and neck pain concluded:

Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP (neck pain). There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.

The research which has been done into the effectiveness of manipulative therapy can best be summarized as suggesting a role for spinal manipulation in the symptomatic treatment of uncomplicated low back pain, provided adequate medical screening is performed. This includes manipulation by some chiropractors, or by physical therapists, physiatrists and others. Manipulation is no more effective, and is often more expensive than, other forms of treatment – such as best medical management or simple physical therapy with good home back care.

Other Uses of Chiropractic

Many chiropractors also use spinal manipulation for other indications, without evidence to support their safety and effectiveness. For example, neck manipulation for headache is not uncommon, despite a lack of adequate evidence for efficacy. The study most often cited by chiropractors to support manipulation for migraine compared neck manipulation to 25mg of Elavil for 8 weeks vs combined therapy and found no difference in outcome. They conclude from this that neck manipulation works as well as medical management.

However, 25mg of Elavil is too low a dose for most patients to response, and the duration of treatment before a response is typically seen is 6-8 weeks. Often a significant response is only seen after several months, and after increasing the dose to between 50-100mg per day. In other words, they used an inadequate control – a treatment that would not be expected to work. Therefore, the more reasonable conclusion to reach from this study is that chiropractic manipulation does not work for migraine. Also, the lack of any additive effect is consistent with pure placebo response.

A recent Cochrane review from 2004 of physical treatments for headaches, including manipulation, concluded:

The clinical effectiveness and cost-effectiveness of non-invasive physical treatments require further research using scientifically rigorous methods.

“Requires further research” means that there is no currently proven benefit.

With neck manipulation there is also a concern for serious risk. Although the statistical risk is low, there are reported cases of stroke and even death following neck manipulation, resulting from arterial dissection – a tear in an artery in the neck. There is insufficient evidence to conclude firmly what the risk is, but given the soft evidence for a benefit for neck manipulation even a small chance of a serious side effect like stroke is likely not justified.

Many chiropractors also offer “maintenance therapy” – regular visits for manipulation to prevent disease or symptoms. There is no evidence and no biological plausibility to justify maintenance chiropractic manipulation.

This critical summary by Edzard Ernst, in my opinion, is appropriate.

The core concepts of chiropractic, subluxation and spinal manipulation, are not based on sound science. Back and neck pain are the domains of chiropractic but many chiropractors treat conditions other than musculoskeletal problems. With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition. Manipulation is associated with frequent mild adverse effects and with serious complications of unknown incidence. Its cost-effectiveness has not been demonstrated beyond reasonable doubt. The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.

Conclusion

The chiropractic profession has its roots firmly planted in pure pseudoscience, but despite this there happens to be a plausible role for spinal manipulation for the limited indication of uncomplicated lower back strain. Further research is needed to explore subgroups, cost effectiveness, safety, and whether or not there is any legitimate role for neck manipulation.

Due, it seems, to the personality and personal beliefs of B.J. Palmer, the chiropractic profession has had an ongoing hostile relationship with mainstream scientific medicine. This is unfortunate. Also, the profession has expanded its philosophy and practice to the point that there are now many separate professions all practicing under the banner of chiropractic, leading to much public confusion and poor to nonexistent maintenance of a standard of care within chiropractic.

The chiropractic profession is in need of serious reform. They are unlikely to accept the recommendations of an outsider like myself, but I am going to give them anyway.

First, the profession needs to clean house. Much like the Flexner report did a century ago for medicine – closing most medical school because they were substandard, the chiropractic profession needs to go through a similar purging.

- This means rejecting completely subluxation theory, including the notion of innate intelligence and the existence of mysterious chiropractic subluxations.

- Along with subluxation theory, chiropractors should condemn the use of manipulative therapy to treat medical conditions and diseases, including asthma, ear infections, ulcers, migraines, and other conditions.

- The chiropractic profession should endorse the principles of science-based medicine and dedicate themselves to high standards of science and transparency. This includes subjecting their treatments to more clinical research, changing their practice based upon the evidence, exploring the risks as well as the benefits of their own treatments, and internally policing their practitioners in order to maintain an adequate standard of care across their profession.

- Chiropractors should seek to align themselves with other science-based professions. This includes endorsing science-based public health measures, like immunization. They should not foster hostility toward science-based practitioners, and they should refer patients to other specialists when appropriate.

- Chiropractors should not seek to expand their scope of practice beyond their training and ability. They should not present themselves as primary care providers, nor lobby for regulations to allow them to do so.

- Chiropractors can thrive as a health-care profession as experts in back care and physical medicine. This would provide them with a sufficiently broad scope of practice to be viable, in an area where there is a great need for expertise and symptomatic management. In fact, many science-based chiropractors do just fine within this scope, and provide a best-practice model for their profession.

- The chiropractic profession should purge from their training and practice modalities other than spinal manipulation that are pseudoscientific – including iridology, applied kinesiology, homeopathy, and nutritional pseudoscience. Of course, the medical profession now needs to do this too, as pseudoscience has infiltrated mainstream medicine, but that is a separate article. Also, the percentage of chiropractors using such methods is far greater than within mainstream medicine, and is therefore much more of a problem.

- Chiropractic colleges should change their curriculum so that they are more uniform and more in line with modern scientific concepts and practice.

I harbor no illusions that anything like what I have described above will happen anytime soon, if ever. I hold out a little hope, as there is a small minority of chiropractors who also endorse what I have outlined and are trying to reform their profession from within. I wish them well, and I eagerly await the day that I can feel comfortable with the average chiropractor as an allied science-based health professional.

Until then, in my opinion, public criticism of pseudoscientific claims and practices within chiropractic is the only ethical response.

Posted in: Chiropractic

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25 thoughts on “Chiropractic – A Brief Overview, Part II

  1. isylvan says:

    Dr. Novella:

    My sincerest thanks for this series on chiropractic. I’m a medical student, and we are taught next to nothing about what a chiropractor does. The impression we are left with is that they are “experts of the spine” (“They study anatomy for FIVE YEARS!”) and that it is “probably safe” to refer patients with back pain, neck pain and even headaches to them. Nowhere are we told about their belief in the elan vital and their claims to be able to heal medical conditions by “spinal realignment”. I wish more of this could enter the curriculum.

  2. Joe says:

    There is a saying that the difference between a rational chiro and a large pizza is the pizza can feed a family of four. When they divest their work of the bogus activities, the available work will be too little to keep many of them employed. Already, there is too much competition for customers. That is why they are trying to get into things such as primary care and the military.

  3. Joe says:

    There have been several analyses concerning the BCA’s “plethora” of information concerning the usefulness of chiropractic for visceral illness.

    This site has a link to the BCA’s PDF document which is no longer protected against copy-paste actions (as the original was) http://www.ministryoftruth.me.uk/2009/06/18/examining-the-bcas-plethora-of-evidence/

    This site has a good list of other, relevant sites at the bottom of the post (above the comments) http://layscience.net/node/598

    Unfortunately for the Singh libel suit (BCA v Singh), the judge has decided that when Singh called the treatments “bogus” he called them “knowingly fraudulent” not just “useless,” and it is difficult to prove what someone knows. Currently, Singh is appealing that decision. Thus, although the BCA statement shows they have no reliable support for their beliefs, that is not the issue- unless Singh prevails in his appeal.

  4. These two posts about chiropractic therapy are very valuable. As noted in the first installment, some chiropractors go well beyond the use of manipulations in circumstances where they are warranted (uncomplicated lower back pain). Of special concern to me are the many recommendations for use of chiropracty for improving children’s learing and behavior. Learning Disabilities (including dyslexia), Autism, mental retardation, attentiona deficit disorder (ADHD), and other similar problems have not been successfully treated with chiropractic manipulations. Friends of people who are employing chiropractice therapy for such problems should actively dissuade them from doing so. All of us should politely but clearly call “bologna” when we hear others making recommendations of chiropractic treatments for such problems.

    Over on LD Blog I published additional comments on this topic.

  5. chemweezer says:

    If chiropractic works for lower back pain, and it appears as though there is evidence to support this, it shouldn’t be specific to chiropractic, but should become mainstream medicine. In that case, why not implement the idea in medical school for physical therapists? This way, this potentially useful method from chiropractic is not longer associated with the rest of the pseudoscience b.s. promoted by chiropractic. Also, since physical therapy is a legitimate science-based medicine, it falls under the ethical guidelines of responsible medical associations.

    Of course, this would never happen, but I think it would be helpful to knock a leg out from under chiropractic. Start performing their only potentially legitimate treatment, and there becomes less excuse to refer anyone to chiropractic as a regular physical therapist can perform it safely as well without adding the pseudoscience.

  6. Calli Arcale says:

    chemweezer — many physical therapists and MDs already practice spinal manipulation. It is also very popular among osteopaths (DOs), who receive training very similar to MDs and are generally licensed to do all the same things (my second child was delivered by a c-section performed by an obstetric surgeon with a DO).

    So spinal manipulation is indeed already performed by mainstream medical practitioners. Of course, many MDs will still refer patients to DCs instead of DOs or physical therapists.

  7. Diane Jacobs says:

    chemweezer ->“If chiropractic works for lower back pain, and it appears as though there is evidence to support this, it shouldn’t be specific to chiropractic, but should become mainstream medicine. In that case, why not implement the idea in medical school for physical therapists?”

    This boat left the dock a long time ago. SMT has been taught to PTs for decades in most countries.

    chemweezer -> “This way, this potentially useful method from chiropractic is not longer associated with the rest of the pseudoscience b.s. promoted by chiropractic. Also, since physical therapy is a legitimate science-based medicine, it falls under the ethical guidelines of responsible medical associations.”

    You’d think..

    chemweezer -> “Of course, this would never happen, but I think it would be helpful to knock a leg out from under chiropractic. Start performing their only potentially legitimate treatment, and there becomes less excuse to refer anyone to chiropractic as a regular physical therapist can perform it safely as well without adding the pseudoscience.”

    What if as a technique it is embedded so far into pseudoscience that it’s almost inextricable? Yes, there is an evidence base to support it, for a quite small number of patients with back pain, but I still cannot distinguish this evidence base from the other sorts of tooth fairy science that HH has discussed. Barry Beyerstein said that anything that did not take into account the nervous system was pseudoscience. I submit that very few people currently practicing SMT or researching it do so from any stance other than biomechanical, subluxation or other similar heuristic treatment constructs with little if any connection to understanding of the nervous system and none whatsoever to pain science.

  8. nobs says:

    # Calli Arcaleon 01 Jul 2009 at 4:12 pm
    re: manipulation “……… It is also very popular among osteopaths (DOs), ”

    “very popular”???? Really? Only 2% of US-DOs perform manipulation……making your claim of “very popular” an exaggeration.

  9. Harriet Hall says:

    nobs – Can you provide a reference for the 2% figure? If you can, I would like to add it to my talk on chiropractic. It supports a point I try to make.

  10. nobs says:

    Harriet- I am still waiting on some references I requested from you……….

    Wanna trade?

  11. Calli Arcale says:

    nobs — I don’t have any figures or anything, but manipulation has always been taught in osteopathic schools. The name “osteopath” is kind of a clue — “osteo” means “of or pertaining to the skeletal system”, after all. And of the three osteopaths I know personally, two perform various manipulative procedures. (The third is an opthomologist, so it’s not as relevant to his practice.)

  12. OZDigger says:

    Australian authorities will review the use of the common pain-killer drug paracetamol, after concerns were raised in the United States about possible side-effects, including liver failure.

    Three US advisory committees have recommended the maximum daily dosage be reduced, but the main regulator is yet to make a final decision.

    Interesting how really important topics like this seem to get lost in the haze of practitioner bashing.

  13. DevoutCatalyst says:

    “Interesting how really important topics like this seem to get lost in the haze of practitioner bashing.”

    You’re joking, right? What practitioner bashing are you referring to?

  14. Scott says:

    “Interesting how really important topics like this seem to get lost”

    Lost how? Based on the press coverage, it certainly looks like a triumph for SBM to me. Obtaining more data and revisiting earlier conclusions based on it is definitely a good thing, and very scientific.

    Or are you trying to make the ludicrous old claim that mainstream medicine isn’t perfect so sCAM is necessarily better? I’d advise you not to, in that case, since that argument is not even wrong.

  15. Harriet Hall says:

    The Tylenol news involves no new science. We have long known and quantified the dangers of acetaminophen overdose. The old recommendations were, and are, scientifically valid. The new recommendations were proposed because people take more than the old labels recommend, sometimes deliberately and sometimes because they don’t realize they are taking other meds like cold remedies that also contain acetaminophen.

    I don’t see it as a triumph of SBM, but as a regulatory response to try to protect consumers who don’t understand the science.

  16. “very popular”???? Really? Only 2% of US-DOs perform manipulation……making your claim of “very popular” an exaggeration.

    Where did you get that?
    I can’t seem to find that number. I doubt this number because AOA residency programs for family medicine require teaching osteopatic manipulation, and because there are 1 year fellowships in osteopathic manipulation as well.

  17. Scott says:

    I see it as science, since the motivation was the empirical observation that people do, in fact, take more than recommended. Hypothesis (old labels are sufficient), observation (people take more than they should), hypothesis falsified.

  18. jackpot12 says:

    I am a former Chiropractor, graduated top 10% from Palmer Iowa, took lots of seminars, spent thousands of hours thinking about these issues…….

    The profession is full of delusion yes, that is a no brainer and partially the reason I knew before I even graduated that I did not want to be a Chiropractor, but I stuck it out anyways.

    Chiropractic is mostly personal charisma, business and salesmanship. I would guess 80%+ of the results of any chiropractors work comes from the power of belief and suggestion (ie.. placebo). People want hope and they enjoy the story that their body is capable of healing itself or that all illness has a purpose or whatever metaphysical idea makes them feel empowered. It makes them feel better already just being told this story.

    Several of my old friends in chiropractic who have successful businesses tell me that they get better results with techniques that do not involve spinal manipulation. We call them non-force techniques. In my opinion, these techniques do absolutely nothing at all physically to the spine. Yet I totally believe my friends when they tell me they get the best results using these techniques.

    The other thing is that spinal manipulation does make people sore and in many cases leaves them with persistent effects they do not tell anyone about. When I went to various fairs with a booth and my advertising, I was shocked at how many people would tell me they had been hurt by a Chiropractor. In my brief time in practice I even saw people with persistent neurological issues (permanently wobbling necks due to damaged mechanoreceptors in the spinal joints). They never told their chiropractors about these things out of embarrassment and, I believe, out of a desire to want to support Chiropractic.

    There are some real benefits to manipulation for some people that I have seen with my own eyes. But my thought is that if all the people who did not receive anything other than placebo were culled from the patient population, most chiropractic practices would go out of business quickly.

    People love their chiropractors. They love to be given hope, to be empowered, to be touched. I believe the techniques and beliefs within Chiropractic are almost total delusional bullcrap. Despite trying for years to find something to believe in within the profession I could not. And I could not find it within myself to sell a placebo effect for a living.

    One thing I have learned about this absurd world we live in- sometimes sheer bullcrap helps people. If you look at the most common ailments chiropractors profess to help with, they are all stress related- the problems most easily influenced by belief and suggestion. Stress exacerbates the symptomatology of many of these common ailments- pain syndromes, headaches, virtually anything related to the autonomic nervous system. A simple touch, a simple story- though completely fictitious and ultimately delusional, can rewire the mind and a person’s pain perception. The experience of pain is something like- nociception + 2 X perception.

    I have never met a Chiropractor who believed that everything they did was a placebo effect. Those sorts of people are probably just like me and can’t practice. But I have known very smart people who think they are actually doing something analytical when they are doing nothing at all. I had one guy tell me- “I spend all day in the room working out puzzles on people’s bodies”. In reality he was doing nothing at all- no cracking, manipulation etc.. only light touches here and there, yet he thought he was working out “puzzles on people’s bodies” as if he could analyze his way to a more effective placebo.

    Of course he would never say that he was doing anything related to the placebo, and that’s why he can sell his water by the river and still sleep at night.

    You can read the rest of my story here:

    http://duplicitous46xyprimate.blogspot.com/search?updated-min=2007-01-01T00%3A00%3A00-08%3A00&updated-max=2008-01-01T00%3A00%3A00-08%3A00&max-results=50

  19. Newcoaster says:

    JACKPOT12

    Thanks for an insiders point of view. From my experience as an ER doctor, I often see people injured by chiropractic “adjustment”. Do they go back to the chiropractor, or wake them up at 2am when their back is spasming? No, they come to the ER screaming for morphine.

    My guess is most people don’t complain to/about their DC with the same willingness they have to complain about doctors to our regulatory authorities. I don’t know what sort of regulatory oversight chiros have, and if complaints lead to disciplinary action or license suspension.

    On a (sort of) related topic, I just recently saw a patient who had been to the TCM “doctor” for herbal treatment of her vitiligo. After a few weeks she developed nausea, abdominal pain, and became jaundiced. When she mentioned this to the TCM practitioner, she was told to take 1/2 the dose. I had her stop the herbs, and her liver function tests are falling and she’s feeling better.

    However, when I told her that she was directly harmed, and that there are literature reports of people dying from acute hepatitis from TCM herbs, she was not interested in lodging a complaint. She “didn’t want to hurt his feelings” ??!!

    Heavy sigh.

  20. Calli Arcale says:

    I think in general, people are not willing to complain to the practitioner who hurt them, whether that practitioner be a DC, an MD, or even something totally unrelated to health care, like a bank. How many people, when changing to a different cable provider, tell the first provider why they were dissatisfied? Though the circumstances are quite different, I think there must be a root cause behind all these different reluctancies to complain. If the flight attendant is rude and you never choose that airline again, will the airline ever know why? And given the volume of their customers, will they ever even notice that they’ve lost you?

    So even if there’s strong regulation, one major problem is that most malpractice will never be reported. People evidently don’t much like complaining, at least to anybody who can do something about it. They’ll rant about the bad service to a stranger on the street, but not to the actual provider, and it feels awkward to submit a formal complaint. Most people would rather just switch providers and get on with their lives, apparently.

  21. nobs says:

    Touching anecdotes Jackpot and Newcoaster- However this is supposed to be a “science-based” forum/blog. You provided no “science-based” evidence for your declarations. Not even any links to science-based evidence to support your anecdotes.

  22. Joe says:

    @ nobs on 15 Jul 2009 at 9:47 am

    You must be joking. You have not offered any science-based evidence, yourself.

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