Mar 16 2012
Today’s guest article, by By Ragnvi E. Kjellin, DVM, and Olle Kjellin, MD, PhD, was submitted to a series of veterinary journals, but none of them wanted to publish it. ScienceBasedMedicine.org is pleased to do so.
Animal chiropractic is a relatively new phenomenon that many veterinarians may know too little about. In Sweden, chiropractic was licensed for humans in 1989, but not for animals. Chiropractors claim that their field is scientific, while others consider it to be a form of ”alternative medicine” with an implausible and unsubstantiated theoretical foundation and little evidence of efficacy. Chiropractic is not taught in medical or veterinary schools.
Courses in “veterinary chiropractic” are offered by two companies in Germany. In their classes, veterinarians and human chiropractors are purposely mixed. A recent malpractice case in Sweden involved one of their students, a veterinarian who was accused of injuring a horse with chiropractic neck manipulation. That case led us to inquire into the underlying theory, clinical practices, and training of “veterinary chiropractors”.
Human chiropractic was founded in 1895 when D.D. Palmer, a grocer and magnetic healer with no medical training, decided that 95% of all diseases were due to vertebral subluxations that blocked the flow through the spinal nerves to all muscles and organs of the body, including the brain, eyes and ears. Adjusting subluxations supposedly allows the body to heal itself by “innate intelligence.” Over a century later, there is still no evidence that such subluxations or “intelligence” exists.
Mainstream medicine has always been skeptical of chiropractic1. Even some chiropractors have criticized the practices of their colleagues2,3. Several recent meta-analyses of chiropractic for various ailments4,5,6 have concluded that musculoskeletal back and possibly neck pain may benefit from spinal manipulation therapy; but the results are not superior to other treatments, and there is no evidence of benefit for other ailments.
Considerable controversy surrounds the chiropractic field. It is therefore essential that veterinarians understand the facts about chiropractic before they consider practicing it, recommending it, or even condoning it for the animals they treat.
Materials and Methods
The web sites of two training companies in Germany, viz. the BackBone-Academy for Veterinary Chiropractic and Healing Arts (BBA) and the International Academy of Veterinary Chiropractic (IAVC) and their parent organizations were reviewed. The 500-page course compendium7 from the BBA was closely scrutinized. As most of the Swedish veterinarians who attended chiropractic courses did so at the BBA, the focus of the appraisal was set on this organisation. Their claims were weighed against whatever evidence that could be found in peer-reviewed articles in PubMed and Ovid Medline concerning human as well as animal chiropractic.
What is Chiropractic?
Chiropractic is very poorly defined.2 Claims include:
- ”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.
- Chiropractic [...] 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”8.
The subluxation is the core idea underlying chiropractic diagnosis and treatment. But there is no universally accepted definition. The original idea of a physical subluxation has not been substantiated, and neither have “functional and/or structural and/or pathological articular changes” been shown objectively to exist.
The subluxation concept is under constant debate within the chiropractic community3. A recent review of the literature by chiropractors searching for evidence that subluxations can affect health concluded that ”No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability”9. Despite this there are strong forces to preserve this concept10,11.
The standard chiropractic treatment is called adjustment or manipulation. Chiropractors claim that a “high velocity low amplitude” (HVLA) thrust in the plane of the joint will force it just slightly beyond its normal range of movement, but not so far as to cause an injury. This, they assert, will help the body to heal itself.
Chiropractic uses a plethora of treatment methods, though there seem to be no efforts to separate the chaff from the wheat12. Some are vigorous manipulations that cause audible cracking and popping sounds. Others consist of light touch or other methods that non-chiropractors may find strange. Many chiropractors mainly use physical methods directed at symptomatic areas, like physical therapists. Subluxation oriented chiropractors treat subluxations regardless of whether the patient has symptoms or not; healthy individuals, they say, need regular prophylactic adjustments. The courses and organizations of animal chiropractic under scrutiny here seem to belong to this latter group, as they emphasize the vertebral subluxation complex and its assumed effect on health and wellness.
History of Animal Chiropractic
Formal training in animal chiropractic was developed in the US during the 1990′s by the American Veterinary Chiropractic Association (AVCA), which was founded in 1988. From the very beginning, the basic course concept was to train veterinarians and (human) chiropractors together. In 2000, the AVCA was restructured into a professional organization and certifying agency for animal chiropractors. The training was then separated from AVCA and was named Options for Animals13. Later on, two independent training organizations were founded in the USA with the same basic concept. One of them is the Healing Oasis Wellness Center (HOWC).
The two animal chiropractic courses in Germany, the BackBone-Academy and the International Academy of Veterinary Chiropractic (IAVC), have strong connections with their parent organizations in the US, HOWC and Options for Animals, respectively. There also are strong bonds between the course organizers and the control organizations AVCA and IVCA (the International Veterinary Chiropractic Association). Options for Animals and AVCA were founded by the same person, and two of the owners of the IAVC founded the IVCA. The animal chiropractors are certified and the courses accredited by the AVCA and IVCA. The intricate relations are depicted in Fig. 1.
Fig. 1. Organisation and association scheme of the appraised animal chiropractic enterprises.
The BBA course consists of five one-week modules: (I) cervical, (II) thoracolumbal, (III) sacropelvic, (IV) extremities and (V) integrated.
The curriculum contains established subjects like anatomy, neurology, biomechanics, pathology, etc., as well as more unconventional subjects such as adjustment techniques for “ribs, temporomandibular joints, tail and cranium.” Techniques taught include Logan Basic, Activator, and how to use “acupuncture, acupressure and applied kinesiology or magnetic therapy as well as physical modalities to speed up the healing process”.14
Other parts of the course are “Animal Chiropractic Philosophy” and “Chiropractic Basics” aimed at introducing the students to the vertebral subluxation complex. Under the heading “Chiropractic Pathology” they emphasize “the pathological changes of the joints, the body and compensatory mechanism that develop secondary to the vertebral subluxation complex”. Some of the ideas, techniques and methods taught warrant a closer look:
In craniosacral therapy the therapists use their hands to tune into what they call the craniosacral system. Working with the spine and the skull and its cranial sutures and fascia, the restrictions of nerve passages are said to be eased, the movement of cerebrospinal fluid through the spinal cord optimized, and misaligned bones restored to their proper position. They claim that they feel the pulse wave of the cerebrospinal fluid through the skull and along the spine to the sacrum, and even to the feet. The BBA compendium presents this as a useful technique to address the vertebral subluxation. Light touch will balance the craniosacral system and “remove restrictions in dura and fascia [and] cranial sutures”. This ignores the fact that the concepts underlying craniosacral therapy have been definitely refuted in several studies15-18. Even proponents find suture mobility to be no more than 0.07 mm even with very high distractive loads, though some still tend to regard this as “significant”19.
This technique regards the sacrum as the most important part of the body, and a “sacral subluxation” is said to cause impairments in the entire spine all the way up to the atlas20. According to a sample scenario in the BBA compendium, a right-sided ventro-caudal subluxation of the sacrum will cause lower cervical vertebrae to rotate to the right and the atlas to the left (called “Atlas left posterior”), and also cause a right paraspinal muscular spasm, a shorter right rear leg, and other abnormalities. To adjust the spinal subluxations, the sacrum has to be adjusted first. This is done with a very gentle touch with the thumb, “only 5 g”, on the lowest part of the sacrum21. The touch allegedly will cause a reflexive relaxation of the muscles, so that the sacrum can align itself. No scientific studies were found for Logan Basic.
The Activator Method
This is a system for diagnosis and treatment based on the idea that a difference in leg length will indicate where there is a need for adjustment. A small hand-held instrument with a spring-loaded mallet (Fig. 2) is then used ”to tap misaligned vertebrae back into place”22. The proponents claim that the Activator delivers a precise HVLA thrust, but that it is much gentler than the manual thrust and that they can direct the force more exactly23. (The thrust amplitude is up to about 4 mm.) The instrument also is claimed to be useful “for exciting a human spine at its natural frequency”24. In a British survey, 82% of the responding chiropractors said that they used an Activator25. Despite its long history and popularity, the Activator has been little studied and has not been validated for animals or humans26.
Fig. 2. Activator type of instrument for so-called Mechanical Force, Manually Assisted, Short Lever Chiropractic Adjustment.
AK is a diagnostic method where muscle strength is tested. It is based on the idea that the individual’s subconscious knows where in the body the problem originates, and that the muscle strength decreases when that part of the patient’s body is touched27. For instance, the patient is asked to extend an arm and resist the therapist’s pressure against it. If the patient has a knee problem, the muscle strength in the arm decreases when the therapist touches the knee. AK is also used to diagnose nutrient deficiencies, allergies and other ailments. Allergies are diagnosed if muscle strength appears to decrease when the patient holds a sealed vial of allergen in the other hand28. For animals (and small children), they test a surrogate person who is in contact with the patient29. One of the BBA instructors claims that “[m]uscle testing, when applied with knowledge, experience and passion, give the veterinarian an invaluable way to communicate with your patients and ask them the questions you’ve always wanted to ask them”30. We have not found any study corroborating these ideas31-34. On the contrary, the best evidence shows it is equivalent to coin tossing35.
Fig. 3. Applied Kinesiology using a surrogate person.
The instructors of the BBA, seven veterinarians and two chiropractors, are introduced on the web site. None of the veterinarians is a licensed chiropractor; they were trained at animal chiropractic courses in the US or Germany. Most of them practice acupuncture; some use applied kinesiology, osteopathy, and magnet therapy. The head instructor, Dr. Pedro Rivera, is also trained in homeopathy. Together with his wife, a massage and herbal therapist, he founded the Healing Oasis Wellness Center (HOWC) mentioned above. Both of the chiropractors and three of the veterinarians at the BBA are connected with the HOWC. This company organizes animal chiropractic courses and runs a veterinary hospital that focuses on alternative and integrative care, providing veterinary spinal manipulation, veterinary Chinese herbology, veterinary massage, veterinary homeopathy, veterinary acupuncture, mainstream veterinary care, and Feng Shui.
The BBA compendium of animal chiropractic encompasses some 500 pages. Large parts deal with anatomy, neurology, pathology, saddle fit, etc. Other parts deal with the philosophy of chiropractic, specific treatment techniques, business tips, and more. Some of the sections are remarkable and deserve special mention:
Module I claims that ”[t]he calcification process of cranial sutures is SLOW and UNEVEN. It is NOT completed even in the aged animal!” (Upper case and exclamation mark as in the original.) Their emphases seem to imply that they want their students to believe that these rigid, fibrous, highly interdigitated joints are actually possible to move to a significant and clinically useful extent. We have not identified any scientific support for this idea in the literature, but it obviously is necessary in order to rationalize Craniosacral Therapy.
It is widely accepted in mainstream medicine that neck manipulation in humans can cause strokes. There are hundreds of documented cases36,37 and a plausible pathoanatomical mechanism (injury to the vertebral artery in its tortuous passage through and around the atlas). But many chiropractors have denied any possible causal relationship, claiming that stroke at neck manipulation is a mere coincidence in persons who were going to have this stroke anyway, citing a study that actually fails to substantiate its hypothesis38.
In Module V, the BBA mentions the risk of chiropractic stroke but downplays its significance, saying it is less than the risk of dying under conventional medical care. However, a Swedish case of veterinary malpractice39 indicates that neck manipulation of a horse may be associated with stroke, which otherwise is unheard of in horses. This horse developed symptoms such as ataxia, dysphagia, and facial hemiparesis, compatible with a lateral medullary infarction (Wallenberg syndrome), which is typical of ischemia in the vertebrobasilar artery region. The horse died of esophageal obstruction some 18 months later.
Under this heading the BBA cites four irrelevant references that fall very short of giving any validity to chiropractic in general, much less to animal chiropractic. The first one is the Manga Report, funded by the Ontario Ministry Of Health, Canada 199340. This political (not scientific or medical) report only dealt with the treatment of low back pain and concluded that chiropractic services were useful and more cost-effective than current medical treatment and should receive public funding.
The second reference is not even about chiropractic but about lumbosacropelvic anatomical variations in racehorses41. The third reference reports inconsistent variations in nerve signals from paraspinal muscle proprioceptors on manipulative-like loads in anesthetized cats, with no discussion of whether these findings had any clinical significance42. BBA’s fourth reference is a symposium abstract from 1999, not a peer reviewed article.
Our research into veterinary chiropractic revealed that chiropractic as such is based on a pre-scientific, vitalistic belief system that can neither be proved nor falsified, and that the information provided for the courses in animal or veterinary chiropractic raises several concerns.
First, several of the subjects included in the curricula are patently pseudoscientific, lacking any biological plausibility, and even are irreconcilable with modern biomedical knowledge, e.g., the illusion that examiners can feel a craniosacral cerebrospinal fluid pulse; the idea that cranial bones can be repositioned in adults; the idea that subluxations exist in the sacrum of horses and can be adjusted with “five grams pressure” or a little mechanically assisted tap, whose proposed mechanisms of action seem rather absurd2. Of all subjects mentioned, Applied Kinesiology is the most bizarre and its surrogate testing beyond all reason. To include all this outlandish nonsense in courses for veterinarians is an insult to their profession.
Second, chiropractic is strongly connected with other unproven or disproven alternative methods, which is obvious from the CVs of the instructors and the range of treatments that the Healing Oasis (HOWC) proffers in its web site.
Third, chiropractic calls itself scientific, but is based on a philosophy that the body can heal itself after adjustment of subluxations, not on any objective evidence. Nobody has been able to show that chiropractic subluxations exist, much less that they affect any functions of the nervous system to cause any illness.
Fourth, while in human studies there is weak support for some small beneficial effect of manipulation on low back pain, in animals there is no scientific support for any chiropractic manipulation treatment at all. Nevertheless, in all web pages and the BBA compendium the subluxation is presented as an obvious fact and the various methods and techniques as if they were well validated.
Courses that contain pre-scientific belief systems, pseudoscientific methods, imaginative ideas and unsubstantiated assertions have no place in veterinary medicine.
Animal chiropractic courses have only existed for a couple of decades and are given by a small number of zealots who are approved by one another. The merits of such accreditations have to be strongly questioned. We also question the basic concept of mixing veterinarians and human chiropractors in the same classes. How much veterinary medicine can the chiropractors learn in such a short time, and how much are the veterinarians influenced by the chiropractors’ strong faith and their skewed portrayal of the scientific evidence concerning chiropractic?
At the outset of this study, we expected that courses in chiropractic given by veterinarians for veterinarians would have selected elements credibly deemed to be applicable to animal care. However, this was not the case. The instructors and course materials do not discriminate between fantasy and reality but include even the most implausible ideas.
Animal chiropractic and the veterinary chiropractic courses scrutinized here mix science, pseudoscience and fantasy and make no visible effort to show which is which. They give biased information and refer to more or less irrelevant articles to make the courses look serious and credible. Many of the methods taught lack evidence as well as plausibility and are clearly outside the realm of medical science. We found no evidence for the use of animal chiropractic in veterinary medicine.
The authors wish to thank Dr. Harriet Hall, Dr. Brennen McKenzie, and Dr. David Ramey for valuable advice on various versions of this article.
About the Authors
Ragnvi E. Kjellin, DVM, is a graduate of the Swedish Veterinary University. She has always been a realist and skeptic, and has been keeping a scrutinizing eye over the Altmed frontier since a long time. She never stops being astonished of the gullibility of so many people. In the 1980′s there were not many alternative methods in veterinary medicine in Sweden, but they seem to be gaining ground at an accelerating pace. The Singh & Ernst book Trick or Treatment was a wake-up call, and she reviewed it in the Swedish Veterinary Journal.
Ragnvi has long had a particular interest in chiropractic, not only as it is the potentially most dangerous form due to direct injuries, but also as it cunningly has managed to put up and hide behind such a sciency facade that even many scientifically educated persons seem to have difficulties seeing through the obfuscation. The greatest shock was when she realized that even some veterinarians, i.e., persons with the same education as herself, were strong believers of animal chiropractic. And to her great dismay, even the Swedish Veterinary Journal regularly announces the courses in animal chiropractic!
She wrote a critical article on animal chiropractic in the Journal — and got some remarkably hostile comments in subsequent issues.
Olle Kjellin, MD, PhD, is a Swedish radiologist and speech physiologist with a special interest in statistics and research methodology as well as in most medical subjects. Though not currently a researcher, he is a hungry but critical consumer of research papers. His MD is from Uppsala University, Sweden, and PhD (or, formally, Dr Med Sci) from Faculty of Medicine, Tokyo University, Japan. He also has an MA in linguistics, phonetics and modern languages from Stockholm University, Sweden. He can’t keep silent when he sees unsupported methods sneaking into the regular health care sector, and he has had several open conflicts with his employer and leading politicians against flimsy bullshit in the psychiatry sector.
Ragnvi and Olle share interests as above and have spent several years together researching all kinds of pseudoscientific ideas, mainly those with medical claims, and chiropractic in particular.
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