SaveYourself.ca •Sensible advice for aches, pains & injuries
 

Does Chiropractic Work?

An introduction to chiropractic controversies like aggressive billing, spinal adjustment as a panacea, treating kids, neck manipulation risks, and more

5,000 words, published 2006, updated Jan 5th, 2014
by Paul Ingraham, Vancouver, Canadabio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

A 2006 Gallup Poll found that chiropractic rated dead last among health professions with regard to ethics and honesty.1 Why? People are curious about the poor reputation of chiropractic,2 and confused about the nature of chiropractic.3 Often inspired by their own negative experiences, they ask me what I think.

This article is a survey of chiropractic controversies and issues that patients should be aware of.

I actually pay for chiropractic therapy myself on occasion, and I do recommend some chiropractic therapy to friends and readers. At the same time, I respect the judgement of many expert critics who believe that, “The concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt.”4

“Does chiropractic work?” is not really the right question

The first thing one wants to know about any treatment — alternative or otherwise — is whether it works. Until that is decided, all talk of qualifications, regulation, and so on is just vacuous bureaucratese.

Dr. David Colquhoun, “Doctor Who? Deception by chiropractors”

And yet “chiropractic” is many things. Does chiropractic work for what? Does what kind of chiropractic treatment work? How much treatment? Just asking if “chiropractic works” is not specific enough to have a meaningful answer. It is not really a fair question to ask of chiropractic as a whole. But it is nevertheless the question that people actually ask, and so we have to deal with it as well as we can.

I believe it’s obvious that some chiropractic therapy does “work” in certain ways, for some people, some of the time. The most important factor in the usefulness of chiropractic therapy is not the nature of chiropractic as a profession, but the skill and good sense of the particular chiropractor whose hands are on your neck. Ethical, intelligent practitioners of any helping profession will always deliver better care than less competent members of their own or any other profession. It’s important to Choose the Therapist, Not the Therapy. Consumers need to be aware of the issues to help them choose a chiropractor.

The best consumer guide to chiropractic therapy available, written by a chiropractor and America’s leading expert on pseudoscientific health care. If you want to know if chiropractic therapy “works,” stop reading my article and go get this book.

Am I qualified to criticize chiropractic? Am I biased?

I am not highly qualified, and I am extremely biased. And so all I will do here is summarize the issues in a readable way, and quote the opinions of experts who are qualified, and cite and summarize some of the same scientific evidence that they do. I have no wish to re-invent the wheel: there are already many excellent books available on this topic (see the further reading section at the end of the article). This is a quick tour of the topic, not a tour de force.

Judging the value of chiropractic therapy is best left to the experts who have already done it, to the progressive chiropractors and critics from within the profession like Dr. Samuel Homola,5 Dr. Donald Murphy,6 and Dr. Preston Long7; relatively progressive chiropractic regulatory agencies like the Chiropractors Registration Board of Victoria in Australia;8 activist physicians like Dr. Stephen Barrett,9 Dr. Stephen Novella,10 or the especially credible Dr. Edzard Ernst11 (who has such great experience with both medical science and alternative therapies); and science journalists like Simon Singh,12 who was in the news because he was sued for libel by the British Chiropractic Association for comments he wrote in a column in The Guardian in 2005, in connection with his book, Trick or Treatment: The Undeniable Facts About Alternative Medicine.13 The lawsuit failed, and the misguided attempt did serious harm to the reputation of chiropractic.

The fact that patients swear by us does not mean we are actually helping them. Satisfaction is not the same thing as effectiveness.

Chiropractor Preston Long, author of Chiropractic Fraud and Abuse: An insider's lament

An introduction to chiropractic controversies

Whatever anyone thinks about chiropractic, there is an undeniable history of scientific and ethical controversies swirling around the profession, from its earliest days to the present. What are those controversies? Why is chiropractic perpetually contentious?

  1. Chiropractic often involves many expensive but quick treatments,1415 and marketing and sales tactics that many people consider to be aggressive and distasteful, if not downright unethical, especially pre-paid treatment packages,16 and the hawking of many other services and products that are even more controversial that conventional chiropractic care.17 Do chiropractors sell too hard?
  2. ZOOM

    An example of the diversity of conditions that chiropractors claim that they can treat, from an advertisement.

  3. The original “big idea” of chiropractic was that nearly any health problem can be cured by spinal manipulation. Today, many chiropractors still recommend chiropractic therapy for many problems beyond just low back and neck pain. Is this reasonable? Is there any scientific evidence that chiropractic therapy can prevent, help, or cure a wide variety of diseases and ailments?18 Only if “spinal subluxation” is actually the cause of them in the first place!1920
  4. Adjustment of the neck could be extremely dangerous. There are numerous class action lawsuits against chiropractors and chiropractic professional organizations for this reason.21 Is there a risk? Considering the stakes, is any risk acceptable? A large group of Canadian neurologists asks, “Is a headache worth dying for?”22 British scientists advocate abandoning it.23 The paper most cited for the defense, the Cassidy paper, does not hold up.24
  5. Spinal adjustment for acute low back pain has long been regarded as the best example of evidence-based care routinely offered by chiropractors. Nevertheless, some critics have pointed out that even this technique has been damned with overly faint praise — “positive” results so trivial that they actual prove there is no meaningful benefit. A major, credible 2012 science review supports that view with a completely negative conclusion.25
  6. Many chiropractors routinely treat children and even babies (and maybe break their necks26). Critics say this is a worrisome extreme of dangerous conduct in chiropractic: an intervention with higher risks and even more dubious benefits.

I’m not answering these questions here — I’m asking them. And I’m pointing out that they have been asked (and answered) for decades. Many credible critics rule against chiropractic on all of these issues and several others.

And while you might think that all chiropractors would defend themselves against these accusations, that’s not even the case. In fact, many chiropractors are also critical of common chiropractic beliefs and practices. Thus, one of the most important things to understand about chiropractic is that it is a divided profession: there is significant controversy within the profession itself.

Chiropractic is a divided profession

Chiropractors themselves have many disagreements about their own profession. There is a ideological chasm between a minority of chiropractors who want to modernize the profession, and traditional chiropractors who cling to the old ways and take the founding concepts literally. Chiropractors on either side of this chasm can be amazingly different. For instance, there is a strong theme of Christian fundamentalism among old school chiropractors that blends seamlessly with the work, as though chiropractic is a spiritual calling.27

The chiropractic profession was founded about a century ago by Daniel David Palmer. Chiropractic owes its existence to this one unusual man and his son — always referred to as “D.D.” and “B.J.” palmer — whose ideas remain the basis of the profession today. Both DD and BJ were colourful characters, and were arguably marketing geniuses. DD in particular was known for his extravagant ego. Here’s an entertaining example of his, er, rather flamboyant personal style:

I was the first to adjust the cause of disease .... The man who had the intellectual capacity to comprehend the displacement of the vertebrae; the mental abability to grasp the significance of nerve impingement; the power to conceive and discriminate between normal and abnormal positions; the foresight and wisdom to discern the outcome; the genius of originality to create such a unique science; the judgement needed for the occasion; the brain caliber of reasoning on this heretofore perplexing question — the cause of disease; the sense of touch required to discover a racked vertebra and the skill and tact to replace it, was the one destined to discover and develop the science which he named chiropractic.

Shall Chiropractic Survive?, by BJ Palmer

Wow! Clearly, DD’s arrogance was dialed up to 11. According to Palmer, “A subluxated vertebra … is the cause of 95 percent of all diseases.”28 Those were big words, and indeed they have been called the “big idea” in chiropractic ever since. In 1966, a group of physicians damningly wrote, “In all the years that they have been talking about them, chiropractors have never been able to furnish proof of these mysterious subluxations which they alone are able to see. They may convince their clients, but never have they provided proof of their pretensions to men of science.”29

Today, many chiropractors actually reject subluxation theory (although not enough of them do so publicly):

Chiropractic, which celebrated its centennial in 1995, is a curious mixture of science and pseudoscience, sense and nonsense. Much of it is based on the theory that misaligned spinal bones produce nerve interference that causes disease. Many chiropractors claim that correcting these misalignments (“subluxations”) can restore health and that regular spinal adjustments are essential to maintain it.

Neither logic nor scientific evidence supports such a belief. Although spinal manipulation can relieve certain types of back pain, neck pain, and other musculoskeletal symptoms, there is no scientific evidence that it can restore or maintain health. As a result of expressing my opinion on this subject, I have been called a chiropractic heretic.

The chiropractic profession has little tolerance for dissension. Its nonsense remains unchallenged by its leaders and has not been denounced in its journals. In fact, many chiropractic journals continue to publish articles that attempt to justify subluxation theory. Although progress has been made, the profession still has one foot lightly planted in science and the other firmly rooted in cultism. Without appropriate criticism, the good in chiropractic will never be sifted out, and competent chiropractors will not receive the recognition they deserve.

This book denounces the cultism in chiropractic but supports the appropriate use of spinal manipulation and the research efforts required to solidify its scientific basis. If you are contemplating or receiving chiropractic care, it might help protect both your pocketbook and your health.

Inside Chiropractic, by Samuel Homola, pvii

This controversy between chiropractors themselves is highly relevant to the consumer. The profession is divided between chiropractors who still embrace subluxation theory (known as “straight” chiropractors), and those who choose to limit their expertise and therapy to musculoskeletal health, especially spinal care (known as “mixers”).30 A chiropractic college instructor writes of this “well-known division between ‘straights’ and ‘mixers’” that “we are at risk of returning to the antiscientific and dogmatic traditions that we have worked so hard to shake off during the past several decades.”31 On the other hand, if subluxation theory is rejected, then

the whole rationale for chiropractic collapses, leaving chiropractors no justifiable place in modern medical care except as competitors of physical therapists in providing treatment of certain musculoskeletal conditions.

Dr. Harriet Hall, regarding Mirtz et al in The End of Chiropractic

Whatever the fate of the profession, you’d probably like to know what kind of a chiropractor is treating you today, a “straight” or a “mixer,” regardless of which you’d prefer. Unfortunately, it is nearly impossible for patients to tell which is which! And that is a serious problem for all chiropractors.

My chiropractor says this is because the top of my neck attaches to my head. Is that a common problem?

from the “chiropractors say the darndest things” file, as reported by Dr. Grumpy (Only Outside Sleepy Hollow)

Spinal manipulative therapy (SMT): Adjustment, manipulation and cracking of the spinal joints

Even if the idea of subluxation is discarded, is there justification for manipulating the spine for the treatment of pain? The idea of “adjusting” the spine refers to many different manual therapies that wiggle, pop and otherwise manipulate spinal joints. The correct umbrella term for these treatments is “spinal manipulative therapy” or SMT. Expert opinions on SMT range widely, with some prominent medical scientists expressing strong concerns, primarily because its provenance in chiropractic subluxation theory is dubious, but also because whatever benefits it has are clearly not major, and there are serious risks, even including paralysis and death in the case of SMT for the joints of the neck. (For more information about the risks of treating the neck, see What Happened To My Barber? Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and vomiting after massage therapy, with lessons for health care consumers.)

Despite all the controversy, there has been little high quality scientific research to determine whether or not SMT is safe and really works. Every published review of the literature comments on the lack of good quality evidence, making it impossible to be sure of anything.32 Even the most promising sources of research have had serious quality control problems.33

Nevertheless, if SMT works, it shouldn’t be so hard to prove it. Major reviews of that literature published in recent years came to underwhelming conclusions,3435 and recent experiments continue to damn SMT with faint praise, showing that it works only a little at best.36 The biggest and best review to date (Rubinstein et al) concluded that “SMT is no more effective in participants with acute low-back pain” than shams and placebos.37

Thus, SMT fails the “impress me” test — if it’s working any miracles, they must be rare and small ones.

And yet spinal joint popping in particular is something that people crave, and most clinicians — including myself, and including skeptics like Dr. Homola — believe that some forms of SMT can be helpful to some of their patients, some of the time. There seems to be almost no doubt that there is something of therapeutic interest going on in SMT in some cases.

There is no definitive evidence that spinal manipulative therapy is more effective than other forms of treatment for patients with acute or chronic low-back pain. However, manual therapists know from experience that spinal manipulation is often more effective for providing immediate short-term relief for some types of back pain.

“Can Chiropractors and Evidence-Based Manual Therapists Work Together?”

Scratching the itch you can’t reach: why joint popping feels good and possibly relieves pain

Occasionally, believe it or not, I recommended chiropractic therapy to my own patients. Sometimes I believed they needed more skilful and direct stimulation of spinal joints than I could provide myself, and I believed that the scientific evidence then showed that approriate spinal manipulation had the potential to help back pain in this way, with acceptable risks.

Many of them reported this kind of positive result from chiropractic treatment. I have experienced it myself on many occasions, and I have also observed many clients expressing relief and pleasure in response to incidental spinal “adjustments” — joint pops that occur in the course of doing massage therapy, little explosions as I slide up the spine.

Many people seem to feel that a happy spinal adjustment feels like “scratching an itch you can’t reach.” Why might that be?

Whatever you have been told before, and despite the availability of many explanations on the internet, the nature of joint popping is not well understood.38 It is firmly in that category of trivial mysteries for which there is simply no research funding, and as such it will probably remain unexplained for some time to come. We simply do not know.

Whatever a joint pop really is, it probably providees a novel sensory experience: a little blast of proprioceptive stimulation.39 Since all living systems seem to thrive on sensory input, and generally suffer without it, I speculate that a joint crack essentially feels like getting “unstuck,” and is analogous to finally getting to stretch your legs after getting off a long flight — which is not intended to trivialize it.

The strength of this idea is that it just isn’t claiming much: it both accounts for the extremely satisfying feeling that many people report, but without promising the moon. Indeed, it also seems consistent with another widely reported feature of SMT: the benefits often don’t last long! Soon the “itch” needs to be “scratched” again. It also could explain why the benefits of SMT are so variable and uncertain: it is highly dependent on many factors. For instance, whether a joint crack feels “refreshing” to you depends on how you feel about the whole idea of joint cracking.

The fear of spinal adjustment

Unfortunately, many people are not comfortable with having their spinal joints “cracked” or manipulated.

This is one of those “there are two kinds of people in the world” things: some people crave spinal joint cracking, expertly applied or otherwise, and to others it seems like fingernails on a chalkboard. My wife, for instance, wants at least one spine-cracking hug per day, and clearly becomes impatient when it has been too long since the last one! Other people would view such a hug as an alarming assault — people with such anxiety about spinal joint popping typically have never been to chiropractor and never will, or they take a dim view of what happened to them when they reluctantly tried it.

“I will never let a chiropractor touch me again” is just as common a patient report as “I have to get adjusted at least once a month.”

Clearly, those who find joint cracking to be unpleasant are not good candidates for “scratching the itch” with a nice round of lumbar facet joint explosions! You know who you are, and you don’t really need to be reading this: chiropractic is certainly not going to work for you!

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

Further Reading

Here are some books I recommend:

And some more immediately accessible resources:

Notes

  1. Gallup poll: Americans have low opinion of chiropractors' honesty and ethics. ChiroWeb.com. 2006. BACK TO TEXT
  2. When I was a Registered Massage Therapist (2000-2009), my clients asked me about it frequently. That was the original inspiration for this article — I wrote it for my clients, like many of the older articles on SaveYourself.ca. BACK TO TEXT
  3. Homola. Finding a Good Chiropractor. Archives of Family Medicine. 1998. Chiropractic is a puzzling profession because, according to Sam Homola, a chiropractor himself, it “is one of the most controversial and poorly defined healthcare professions with recognition and licensure … it has the confusing image of a back specialty capable of treating a broad scope of health problems.” BACK TO TEXT
  4. Ernst. Chiropractic: a critical evaluation. Journal of Pain & Symptom Management. 2008. PubMed #18280103. BACK TO TEXT
  5. Samuel Homola, Doctor of Chiropractic, is a second-generation chiropractor who has dedicated himself to defining the proper limits on chiropractic and to educating consumers and professionals about the field. He is hardly the only critic of his own profession, but he is probably the most famous and widely read. His 1963 book, Bonesetting, Chiropractic, and Cultism, supported the appropriate use of spinal manipulation to treat some spinal pain but renounced the common chiropractic dogma that spinal adjustment is a panacea. I strongly recommend his 1999 book Inside Chiropractic: A Patient’s Guide. It provides an incisive look at chiropractic’s history, benefits, and shortcomings.

    BACK TO TEXT
  6. How Can Chiropractic Become a Respected Mainstream Profession? The Example of Podiatry. Murphy et al. chirobase.org. 2008. Dr. Murphy is one of five research-oriented chiropractors that have bared their profession’s shortcomings in a 2008 article that calls for “dramatic changes” and states that chiropractic “finds itself in a situation in which it is rated dead last amongst healthcare professions with regard to ethics and honesty.” This readable document is an excellent survey of the problems with the chiropractic profession. BACK TO TEXT
  7. Dr. Long is the author of a 2013 book, Chiropractic Fraud and Abuse. You can read an excerpt of it — “Twenty Things Most Chiropractors Won’t Tell You” — which is in the same spirit as this article… but much harsher. BACK TO TEXT
  8. In 2008, THE CRBV proposed new standards that attack common chiropractic beliefs and practices, particularly in the case of treating children. Although perhaps not obviously “fightin’ words” to the general public, within the world of therapy the CRBV’s proposal is a strong attack on the philosophical foundations of subluxation-based chiropractic: “There is currently an overwhelming lack of good quality scientific evidence to support the use of spinal manipulation in the treatment of [disease]. Non-indicated, unreliable and invalid diagnostic tools, instruments or methods and unnecessary diagnostic imaging procedures are to be avoided.” The draft document goes on to condemn unnecessary X-ray examination, especially for children, and the use of surface electromyography (SEMG) or thermography for diagnosis. These common diagnostic methods are described as “innappropriate.” I think that such opinions are both credible, given the source, and of great concern. And this CRBV is hardly the only chiropractic regulator responding to a need to clamp down on such pratices — it is just a good recent example. BACK TO TEXT
  9. Dr. Stephen Barrett, a retired psychiatrist, is America’s most prominent scientific medicine activist. (I am pleased to know Dr. Barrett a little bit myself, having exchanged several notes with him over the years, and spoken with him at some length on the phone on one occasion.) In addition to founding the prominent websites QuackWatch and Chirobase, Dr. Barrett operates 23 websites in all; edits Consumer Health Digest (a weekly electronic newsletter); is medical editor of Prometheus Books; and has been a peer-review panelist for several top medical journals. He has written more than 2,000 articles and delivered more than 300 talks at colleges, universities, medical schools, and professional meetings. His dozens of books include The Health Robbers: A close look at quackery in America and seven editions of the college textbook Consumer Health: A guide to intelligent decisions.

    BACK TO TEXT
  10. Dr. Steve Novella is an academic neurologist on full-time faculty at Yale University School of Medicine. That in itself would be career enough for me, but Dr. Novella is almost frighteningly productive above and beyond his professional duties at Yale. He is the co-founder and President of the New England Skeptical Society, Associate Editor of The Scientific Review of Alternative Medicine, a contributing editor of QuackWatch, author and contributor to numerous columns, blogs and podcasts, most notably the popular podcast Skeptic’s Guide to the Universe, which has many tens of thousands of listeners and is my own favourite podcast.

    BACK TO TEXT
  11. Dr. Edzard Ernst possesses a rare mixture of significant expertise and experience with both scientific and so-called “alternative” medicine, and consequently has become one of the most interesting and credible experts on the subject. He qualified as a physician in Germany in 1978 where he also completed his MD and PhD theses, but has also received training in acupuncture, homoeopathy, massage therapy and spinal manipulation. His experience and research have made him one the most credible and interesting critics of alternative medicine in general, and chiropractic in particular, along with science journalist co-author Simon Singh (see below). His 2008 interview in New Scientist is an interesting introduction (see Bond). Dr. Ernst has published more than 40 books — including the current book Trick or Treatment, and last year (right up my alley) Complementary therapies for pain management — and in excess of 1000 articles in the peer-reviewed medical literature and has been given visiting professorships in Canada and the US. His work has been awarded with 13 scientific prizes.

    BACK TO TEXT
  12. Simon Lehna Singh, MBE, is an Indian-British author of Punjabi background, who has specialised in writing about mathematical and scientific topics in an accessible manner. Most recently and relevant to this article and this website, Mr. Singh wrote Trick or Treatment with prominent scientist co-author Dr. Edzard Ernst (just mentioned above). Mr. Singh’s written works also include Fermat's Last Theorem (about one of the most difficult problems in mathematics), The Code Book (about cryptography and its history) and Big Bang (about the Big Bang theory and the origins of the universe). He has also produced documentaries and works for television to accompany his books, is a trustee of NESTA, the National Museum of Science and Industry.BACK TO TEXT
  13. Simon Singh’s legal battle with the British Chiropractic Association is a good example of why I increasingly avoid criticizing chiropractors directly myself. Instead I simply refer SaveYourself.ca readers to more prominent critics who are backed by organizations and lots of academic credibility. Mr. Singh, however, is “just” a science writer fighting for the right to free speech and scientific analysis, and can use all the public support he can get: please see the Sense About Science campaign page “Sign up now to keep the libel laws out of science!” and join the Facebook group For Simon Singh and Free Speech — Against the BCA Libel Claim BACK TO TEXT
  14. Don't Pay or Contract in Advance for Chiropractic Visits at a "Discount" Price. Barrett. ChiroBase.org. 2009.

    In this short article, Dr. Barrett describes a range of chiropractic over-prescription practices. The bottom line is that, “Even if chiropractic treatment can legitimately help a problem, it is not possible to know in advance that a large specified number of visits will be needed.”

    See the next note for an example of chiropractic over-prescription. I have encountered substantial chiropractic over-prescription and “contracts” for excessive chiropractic therapy repeatedly in my own career. BACK TO TEXT
  15. For example, consider the case of Gertrude West, a retired attorney, who sought help for knee pain from chiropractor Donald Harte in Marin County, California. Harte advised West to have intensive care for “subluxation degeneration” of her spine, and West signed 100 visits with a discount for advance payment but severe penalties for discontinuing. After 49 visits over a 4-month period, she concluded that she was not being helped and asked that payment for the unused visits be refunded. When Harte refused, she sued him. A trial judge ruled that West had been misled and the penalty clause was “unconscionable,” and this was upheld by a small claims appeals court in the spring of 2009. BACK TO TEXT
  16. Chiropractic gimmickry. Homola. www.sciencebasedmedicine.org. 2012.

    An good overview of dubious practices in chiropractic care other the standard chiropractic treatment.

    Sam Homola offers a disturbing overview of pre-paid treatments: “One of the most disturbing complaints I hear comes from chiropractic patients who have paid thousands of dollars in advance for a course of treatment lasting several months─after succumbing to a high-pressure sales pitch involving scare tactics. These patients have usually opted to discontinue treatment because symptoms have either worsened or disappeared. Most have signed a contract, however, that does not allow a refund, even if the treatment regimen was not completed. Some have used a chiropractic “health care credit card” to borrow the advance payment from a loan company, leaving the patient legally bound to repay the loan.” See his article for more. BACK TO TEXT
  17. The (American) National Board of Chiropractic Examiners occasionally publishes a Job Analysis of Chiropractic. Dr. Stephen Barrett: “The reports are interesting because they provide a basis to assess the minimum extent of irrational practices among chiropractors.” For instance, the 2003 survey, for example, found that 37.6% used applied kinesiology muscle testing and 25.7% used Palmer upper cervical. And the 2009 survey found that 38.6% prescribe homeopathic remedies, and a whopping 94.4% offer “nutritional/dietary recommendations” — hardly what most people think of when they make an appointment with a chiropractor, but the selling of nutrtitional supplements is clearly a lucrative part of many chiropractic offices. The value of all of these services is much more in question than “standard” chiropractic spinal adjustment. BACK TO TEXT
  18. Most scientific evidence about chiropractic therapy is of poor quality, plagued by common methodology errors, like abuses of statistics that tend to make chiropractic study results seem more “significant” than they are. For instance, chiropractors routinely claim that the benefits of spinal adjustment are “proven,” but Williams found that clinical trials have “shown an effect size for manipulation that is less than the threshold for what is clinically worthwhile.” In other words, spinal adjustment might be proven to do something … just not much. For much more information about these kinds of errors, see Not So Significant After All: A lot of research makes scientific evidence seem more “significant” than it is. BACK TO TEXT
  19. Mirtz et al. An epidemiological examination of the subluxation construct using Hill's criteria of causation. Chiropractic & Osteopathy. 2009. PubMed #19954544.

    This landmark paper penned by four chiropractors is a strong indictment of a philosophical pillar of their own profession. Although a bit of a moving target over the years, subluxation theory generally refers to idea that spinal joint dysfunctions have broad health significance, which has been a major component of chiropractic thought since the founding of the profession. The authors analyze and condemn it: “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.”

    And yet it’s been there for more than a century, I’d like to add.

    Dr. Harriet Hall explained the significance of the paper in an article for ScienceBasedMedicine.org, The End of Chiropractic.

    BACK TO TEXT
  20. SY Ingraham. Spinal Nerve Roots Do Not Hook Up to Organs! One of the key “selling points” for chiropractic care is the anatomically impossible premise that your spinal nerve roots are important to your general health. SaveYourself.ca. 2495 words. Chiropractic care has an anatomically impossible premise: that spinal nerve roots determine your general health. BACK TO TEXT
  21. Do a Google search for “class action lawsuit chiropractic.” It’s remarkable. BACK TO TEXT
  22. Statement of Concern to the Canadian Public from Canadian Neurologists Regarding the Debilitating and Fatal Damage Manipulation of the Neck May Cause to the Nervous System. Neck911.com. 2009. BACK TO TEXT
  23. Wand et al. Should we abandon cervical spine manipulation for mechanical neck pain? Yes. British Medical Journal. 2012. PubMed #22677796. BACK TO TEXT
  24. Cassidy et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008. PubMed #18204390.

    Since its publication, “the Cassidy paper” has been the defensive citation used by chiropractors to respond to accusations that neck adjustments involve a risk of stroke, and therefore should not be conducted without proven benefit and informed consent. The abstract seems to strongly exonerate chiropractors: “We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.”

    “But abstracts are like movie trailers,” as Dr. Mark Crislip wrote. “They give a flavor of the movie, but often leave out many important plot devices and characters. … If you were to read this article in its entirety, you would not be so sanguine about the safety of chiropractic.” He goes on to explain exactly why in one of the earliest popular posts on ScienceBasedMedicine.org, Chiropractic and Stroke: Evaluation of One Paper.

    BACK TO TEXT
  25. Rubinstein et al. Spinal manipulative therapy for acute low-back pain. Cochrane Database of Systematic Reviews. 2012. PubMed #22972127.

    If it were possible to report good news about spinal manipulation, it would be in this large Cochrane review of the science. Unfortunately, the good news is not here to report. Historically, spinal manipulative therapy (SMT, a.k.a. chiropractic adjustment) for acute low back pain has been regarded as the best example of evidence-based care routinely offered (primarily) by the chiropractic profession. Even many fierce critics of chiropractic have supported this claim (or at least left it alone while focusing on other issues, e.g. the risks of cervical manipulation). Nevertheless, critics have pointed out that even this “best” use of SMT has been damned with faint praise by the research.

    This meta-analysis supports the most critical view: the authors concluded that “SMT is no more effective in participants with acute low-back pain” than shams and placebos. Despite this, the rest of their conclusions seem crafted to prolong the controversy. They explain to clinicians why they should still refer patients for SMT (“preferences” and “costs”); they say that more research is needed to “examine specific subgroups.” (This is based on the rather faint hope that SMT might work so well for an unknown subcategory of patients that they can pull up the average.) And they say there’s a need for “an economic evaluation,” but a treatment cannot be “cost effective” if it is not effective.

    BACK TO TEXT
  26. Sep 28, 2013, an Australian scandal started with this: Call for age limit after chiropractor breaks baby’s neck. The original report read: “A baby’s neck has been broken by a chiropractor in an incident doctors say shows the profession should stop treating children.” It may or may not have actually happened. The allegation was denied by the Chiropractors’ Association of Australia with an equally predictably disingenuous mixture of spin, assertion and avoidance of the real issues. What is clear is that “the response of the chiropractic profession to these cases is unsatisfactory, to say the least,” writes Dr. Novella. For a complete summary of the incident, see The chiropractic war with reality rages on…. See BACK TO TEXT
  27. I overheard a fine example: a chiropractor speaking to a patient about an upper cervical treatment said, “Your neck is now in God’s alignment.” It wasn’t just an adjustment, it was holy! Many religious chiropractors make a strong connection between spinal adjustment and getting right with God. I have seen chiropractic offices festooned with religious imagery. Any health care professional can be religious, but it’s a pretty safe bet that chiropractic has a higher percentage of Christian fundamentalists than any profession other than clerics. BACK TO TEXT
  28. Palmer. The Science, Art and Philosophy of Chiropractic. 1910. BACK TO TEXT
  29. College of Physicians and Surgeons of the Province of Quebec. The scientific brief against chiropractic. The New Physician, Sept 1966. Yes, this an old source! However, “men of science” (and women) remain unconvinced. The spirit of this statement is just as valid as it was more than forty years ago. BACK TO TEXT
  30. Biggs et al. Canadian chiropractors’ attitudes towards chiropractic philosophy and scope of practice: implications for the implementation of clinical practice guidelines. Journal of the Canadian Chiropractic Association. 1997. Less than 19 percent of Canadian chiropractors “reject traditional chiropractic philosophy as espoused by D.D. and B.J. Palmer and emphasize the scientific validation of chiropractic concepts and methods.” BACK TO TEXT
  31. Keating. The Specter of Dogma. Journal of the Canadian Chiropractic Association. 2001.

    From the text: “… despite all of these genuinely progressive steps, the chiropractic profession here in North America may be slipping backwards. I perceive that we are at risk of returning to the antiscientific and dogmatic traditions that we have worked so hard to shake off during the past several decades. This apparently unrecognized reversion to the uncritical and unskeptical tendencies of early day chiropractic has everything to do with politics and economics and nothing to do with science. For more than a century chiropractors have fended off the efforts of organized, political medicine to ‘contain and eliminate’ this profession. In the process, deep rifts have formed among chiropractors. I’m not speaking here merely of the well-known division between ‘straights’ and ‘mixers,’ but more importantly about the chasm between those who would see chiropractic progress as a scientific healing art and those who are committed to old-time biotheology and ‘phoooolosophy.’ Today, chiropractors are hungry, one might even say desperate, for unity. It is this deeply felt yearning for unity, I believe, which places the scientific integrity of the profession at risk. We are at risk of accepting dogma and pseudoscience and ambiguous platitudes in order to come together.”

    BACK TO TEXT
  32. Fernandez-de-las-Penas writes “There are few published randomized controlled trials analyzing the effectiveness of spinal manipulation and/or mobilization … in the last decade.” Bronfort: “There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up.” The 2006 Cochrane review of SMT found only 39 experiments to analyze, and most of those had small sample sizes. BACK TO TEXT
  33. Ernst et al. An independent review of NCCAM-funded studies of chiropractic. Clin Rheumatol. 2011. PubMed #21207089.

    Dr. Edzard Ernst is a highly qualified critic of sloppy researchers in alternative medicine. In this review of The National Center for Complementary and Alternative Medicine (NCCAM) studies of chiropractic therapy, he finds that “their quality was frequently questionable. Several randomized controlled trials failed to report adverse effects and the majority was not described in sufficient detail to allow replication.” But if NCCAM cannot produce the best quality studies of alternative medicine, who can? No organization has ever been better funded (or motivated) to validate alternative therapies.

    Ernst concludes: “It seems questionable whether such research is worthwhile.”

    BACK TO TEXT
  34. Rubinstein et al. Spinal manipulative therapy for acute low-back pain. Cochrane Database of Systematic Reviews. 2012. PubMed #22972127.

    If it were possible to report good news about spinal manipulation, it would be in this large Cochrane review of the science. Unfortunately, the good news is not here to report. Historically, spinal manipulative therapy (SMT, a.k.a. chiropractic adjustment) for acute low back pain has been regarded as the best example of evidence-based care routinely offered (primarily) by the chiropractic profession. Even many fierce critics of chiropractic have supported this claim (or at least left it alone while focusing on other issues, e.g. the risks of cervical manipulation). Nevertheless, critics have pointed out that even this “best” use of SMT has been damned with faint praise by the research.

    This meta-analysis supports the most critical view: the authors concluded that “SMT is no more effective in participants with acute low-back pain” than shams and placebos. Despite this, the rest of their conclusions seem crafted to prolong the controversy. They explain to clinicians why they should still refer patients for SMT (“preferences” and “costs”); they say that more research is needed to “examine specific subgroups.” (This is based on the rather faint hope that SMT might work so well for an unknown subcategory of patients that they can pull up the average.) And they say there’s a need for “an economic evaluation,” but a treatment cannot be “cost effective” if it is not effective.

    BACK TO TEXT
  35. Bronfort et al. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine. 2004.

    This large and complex review comes to no firm, simple conclusions. It presents tentative evidence that some kinds of SMT are probably effective under some conditions.

    BACK TO TEXT
  36. Jüni et al. A randomised controlled trial of spinal manipulative therapy in acute low back pain. Annals of the Rheumatic Diseases. 2009. PubMed #18775942.

    In this reasonably good test of SMT, researchers took a hundred patients with nasty, fresh cases of low back pain, and delivered half of them into the care of chiropractors, and the other half into “standard care” — advice and ordinary pain medications, namely. Note that it has often been argued that SMT is best for acute low back pain, not chronic, so this is right in chiropractic’s strike zone: if there is anything special, anything even remotely impressive about SMT, it should have done rather well in this contest. It should actually pretty much pull out a can of whupass on “advice and meds.” It didn’t.

    SMT and standard care did equally well — or equally poorly, if you prefer. All the patients had the same experience that pretty much everyone with chronic back pain has. The researchers found that “SMT is unlikely to result in relevant early pain reduction in patients with acute low back pain.”

    BACK TO TEXT
  37. Despite this, the rest of their conclusions seem crafted to prolong the controversy. They explain to clinicians why they should still refer patients for SMT (“preferences” and “costs”); they say that more research is needed to “examine specific subgroups.” (This is based on the rather faint hope that SMT might work so well for an unknown subcategory of patients that they can pull up the average.) And they say there’s a need for “an economic evaluation,” but if a treatment is not effective, it can’t be “cost effective.” If it were possible to report good news on this topic, these authors would probably do so. But they have not. BACK TO TEXT
  38. For many years now I have been looking forward to getting around to writing an article all about this. Unfortunately, I have not yet made the time. Meanwhile, suffice it to say that the dominant theory of joint popping depends on the concept of “cavitation” — the rapid formation and explosive collapse of bubbles in a liquid due to pressure changes. The theory is full of holes and doesn’t begin to explain many features of joint popping, in particular the “recharge” phenomenon, wherein joints that supposedly cavitated nicely just a moment ago need to be left alone for seconds, minutes or hours before they can cavitate again. Also, the cavitation hypothesis does not explain why there is such significant variation between individuals and between joints. It is, in short, almost certainly wrong or incomplete. BACK TO TEXT
  39. Proprioception is the sense of position and movement. See The True Sixth Sense. BACK TO TEXT