My article “Pediatric Chiropractic Care: The Subluxation Question and Referral Risk” was published in the 2016 February issue of the journal Bioethics. The abstract summarizes the message of the article:
Chiropractors commonly treat children for a variety of ailments by manipulating the spine to correct a “vertebral subluxation” or a “vertebral subluxation complex” alleged to be a cause of disease. Such treatment might begin soon after a child is born. Both major American chiropractic associations─the International Chiropractic Association and the American Chiropractic Association─support chiropractic care for children, care that includes subluxation correction as a treatment or preventive measure. I do not know of any credible evidence to support chiropractic subluxation theory. Any attempt to manipulate the immature, cartilaginous spine of a neonate or a small child to correct a putative chiropractic subluxation should be regarded as dangerous and unnecessary. Referral of a child to a chiropractor for such treatment should not be considered lest a bad outcome harms the child or leads to a charge of negligence or malpractice.1
The first objection to my article came in a January 30 Facebook posting by Milehighchiro, a subluxation-based group: (more…)
October is National Chiropractic Health Month (NCHM) and chiropractors can’t resist the opportunity to overstate, obfuscate, and prevaricate in celebration.
They do this in the face of some unfortunate (for them) statistics revealed by a recent Gallup Poll. The Poll was paid for by Palmer College of Chiropractic as part of an effort to increase the chiropractic share of the health care pie. (There is also a secondary analysis of the poll in the Journal of Manipulative and Physiological Therapeutics.) We’ll get to those stats in a few minutes.
But first, in celebration of NCHM, the American Chiropractic Association (ACA) has produced a set of six graphics chiropractors can download and display. Four of them fudge on the facts. Let’s take a look at these graphics, compare them to the evidence cited in support of their claims, and see where the ACA went astray. (The ACA also hosted a twitter chat yesterday with the hashtag #PainFreeNation.)
The study cited as evidence for this graphic actually compared both manual thrust manipulation (MTM) and mechanical-assisted manipulation (MAM) to each other as well as manipulation versus usual medical care (UMC). Although MAM, such as the Activator Method, is the second most common manipulation technique used by American chiropractors, is increasing in popularity among them, and is touted to be a safe and effective alternative to MTM, this study found that MTM is more effective (at 4 weeks) than MAM and that MAM had no advantage over UMC. But you don’t see that in this graphic.
Extreme rotation of the atlas on the axis (at the atlantoaxial joint) stretches the vertebral artery. In layman’s terms, 40% of a hanging.
I am off to Chicago for 5 days to wow the SMACC crowd with my ID/SBM acumen. I hope. Given that most of my multiple-personalities do not seem to be able to get any work done, I am forced to write a brief post this week, limited by the battery life on my MacBook Air. Whatever I get down on paper? pixels? RAM? before the battery dies as I fly over the Rockies will be the post. It is times like this I wish I had Gorskian typing skills.
SBM has discussed the many limitations of chiropractic: the low grades for entry into chiropractic school, the inadequate training, their reason d’être, subluxations and their adjustments being divorced from reality, the lack of efficacy of chiropractic for any process beyond low back pain (and even that is no better than safer interventions), the fondness of chiropractors for other useless pseudo-medicines, and their opposition to vaccines.
Hm. When I put it like that chiropractic does appear a little sketchy. But is chiropractic safe? It is a hands-on intervention, for a brief period of time applying the same force to the neck as about 40% of hanging from the neck until dead. So there is certainly the potential for chiropractic to cause harm. (more…)
The saga of chiropractic began in 1895 when D.D. Palmer, a magnetic healer, announced that “95 percent of all diseases are caused by displaced vertebrae, the remainder by luxations of other joints.” Palmer opened the first chiropractic school in Davenport, Iowa, offering a three-week course of study at the Palmer School and Cure, subsequently renamed the Palmer School of Chiropractic. The school was taken over by B.J. Palmer, the son of D.D. Palmer, in 1906. In 1910, the course of instruction was six months. Kansas and North Dakota were the first states to pass laws legalizing the practice of chiropractic (in 1913 and 1915). By 1921, the Palmer School of Chiropractic, requiring 18 months of study, had 2,000 students, reaching a peak enrollment of 3,600 in 1922. By 1923, 27 states had chiropractic licensing boards. Hundreds of chiropractic schools sprang up, some offering correspondence courses. There were no entrance requirements, anyone could become a chiropractor. H.L. Mencken wrote in the December 11th, 1924, issue of the Baltimore Evening Sun:
Today the backwoods swarm with chiropractors, and in most States they have been able to exert enough pressure on the rural politicians to get themselves licensed. Any lout with strong hands and arms is perfectly equipped to become a chiropractor. No education beyond the elements is necessary.1
Although Palmer’s subluxation theory was contrary to all known laws of anatomy and physiology, the theory was appealing to the general public. Medical science was in its infancy, struggling to find effective and safe remedies for disease and infection. There was no known cure for many common ailments, and many of the medicines used by physicians were ineffective or harmful. In the public marketplace, the door was wide open for snake oil salesmen, entrepreneurs, and opportunists who could mix a concoction or fabricate a new treatment guaranteed to work. With growing numbers of chiropractors treating disease and infection by adjusting the spine to relieve alleged pressure on spinal nerves, offering treatment claimed to be superior to medical care, members of the medical community felt an obligation to oppose what they viewed to be blatant, unbridled quackery.
An old Palmer illustration showing how a displaced vertebra could cause disease by pinching a spinal nerve.
Although obscured by controversy, there is evidence to indicate that spinal manipulation can be as effective as conventional treatment methods in relieving low-back pain.1,2,3,4 This grain of truth mixed with chiropractic vertebral subluxation theory that encompasses a broad scope of ailments makes it difficult for the average person to distinguish between appropriate and inappropriate use of manipulation by chiropractors. A person who is satisfied with chiropractic manipulative treatment for back pain might be led to believe that the same treatment can be used to treat a variety of organic ailments by correcting “vertebral subluxations.” Such treatment is usually described as a “chiropractic adjustment.”
A manual chiropractic adjustment
Although chiropractic care based on subluxation theory has been rejected by the scientific community, spinal manipulation used in the treatment of mechanical-type back pain has a plausible basis that makes it acceptable in mainstream healthcare. A good back-cracking back rub provided by a chiropractor or some other manual therapist can be a pleasurable, pain-relieving experience, and this can be a preferred method of treatment for some types of back pain. But you should be well-informed enough to know where to draw the line in separating subluxation-based chiropractic adjustments from appropriate use of generic spinal manipulation if you should consider treatment by a chiropractor. Otherwise, you might become the victim of the bait-and-switch tactics of chiropractors who offer you treatment for back pain and then attempt to indoctrinate you in subluxation theory.
Much of what follows in this article has been said before in other articles of mine posted on this site. An up-to-date summary of basic concerns about chiropractic care, however, might be useful for new readers and others, including professionals, who want a brief overview for quick reference in seeking answers to questions about the problematic aspects of chiropractic use of spinal manipulation.
ChiroNexus recently listed the top 10 chiropractic studies of 2013. In my experience, chiropractic studies tend to be of poor quality. A media report says “study shows chiropractic works for X,” and when I look for the study it turns out to be a single case report or an uncontrolled study. When Simon Singh was sued by the British Chiropractic Association for saying chiropractic treatment for certain childhood ailments was bogus, the BCA responded with a list of 29 studies they said provided evidence for their claims. Steven Novella showed that out of 29 studies on the list, only 17 actually constituted evidence for 4 clinical claims, and those 17 were poor quality, cherry-picked, and too weak to support the claims. I have a copy of a chiropractic textbook entitled Somatovisceral Aspects of Chiropractic: An Evidence-Based Approach and there is nothing in it that would qualify as credible evidence to a science-based thinker. Chiropractic commenters on SBM have told us that modern chiropractic rejects the “subluxation” paradigm and relies on evidence, and I am always willing to look at new evidence and give chiropractors another chance to convince me that a reform movement is really underway, so I looked up the top 10 studies and read them. I was not impressed.
Note: This is a long article with mind-numbing details that will not be of interest to most readers. Feel free to scroll down to the Summary section. You can just read the bold-faced headings describing the claims of each study on the way down.
Also note: For those who want more detail, the “Study #” headings are links to the full text when available online, or to the PubMed citation.
“Complementary and alternative medicine,” as pediatrician and fellow blogger John Snyder aptly stated in a recent journal article on CAM and children,
is a term used to describe a disparate, poorly defined set of practices and treatment modalities presumed to be distinct from so-called ‘conventional medicine’.
As we have discussed here at Science-Based Medicine, this amorphous concept facilitates a convenient fluidity in delineating the parameters of CAM. Without a clear definition, CAM (and integrative medicine) proponents are able to rebrand plausible and evidence-based practices such as diet, exercise and relaxation as CAM, a tactic we at SBM call “bait and switch.” This results in inflation in the figures of CAM use (important because CAM is all about popularity) and claims that CAM “works.”
I spent 43 years in private practice as a “science-based” chiropractor and a critic of the chiropractic vertebral subluxation theory. I am often asked how I justified practicing as a chiropractor while renouncing the basic tenets of chiropractic. My answer has always been: I was able to offer manipulation in combination with physical therapy modalities as a treatment for mechanical-type back pain—a service that was not readily available in physiotherapy or in any other sub-specialty of medicine.
If I had it to do over again, however, I would study physical therapy rather than chiropractic. Considering the controversy that continues to surround the practice of chiropractic, I would not recommend that anyone spend the time, effort, and money required to earn a degree in chiropractic. Physical therapy, which is now beginning to include spinal manipulation in its treatment armamentarium, may offer better opportunity for those interested in manual therapy. Properly-limited, science-based chiropractors are now essentially competing with physical therapists who use manual therapy. Unfortunately, only a few chiropractors have renounced the vertebral subluxation theory, making it difficult to find a “good chiropractor.” I consider physical therapy to be more progressive and more evidence based. For this reason, I generally recommend the manipulative services of a physical therapist rather than a chiropractor.
There are some science-based chiropractors who use manipulation appropriately, but until the chiropractic profession abandons the implausible vertebral subluxation theory and is defined according to standards dictated by anatomy, physiology, and neurology, I would not describe it as a science-based profession.
Daniel David Palmer, creator of the nebulous subluxation and father of chiropractic.
Chiropractic originated in 1895 when D.D. Palmer claimed to have restored deaf janitor Harvey Lillard’s hearing by manipulating his spine. This makes no anatomical sense, and few if any chiropractors claim to be able to reverse deafness today. But now a chiropractic website is attempting to vindicate D. D. Palmer. They list deafness among a long (wrong) list of “Conditions That Respond Well to Chiropractic”
They list 6 supporting studies. Three are case reports, two are case series, and one is a review of the literature that is labeled in its title as “A Search to Validate” D.D. Palmer. (more…)
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.
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.