CHIROPRACTIC

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A SCIENTIFIC LOOK AT ALTERNATIVE MEDICINE

Chiropractic, Osteopathy, and Massage

Thomas J. Wheeler, Ph.D.

Associate Professor (retired), Department of Biochemistry and Molecular Biology,

University of Louisville School of Medicine, Louisville KY

thomas.wheeler@louisville.edu

Revised 2014

This is the second in a series of handouts originally developed for an elective course given to medical students at the University of Louisville School of Medicine.

Copyright 2014. Permission to copy for non-profit uses is granted as long as proper citation of the source is given.

DISCLAIMER: The material presented here is not medical advice. It represents the author's summary of scientific evidence concerning various topics. For medical advice, see your physician.

CHIROPRACTIC

Background

The general technique of spinal manipulation therapy is of ancient origins, and in 19th Century U.S. was used by folk healers, "bonesetters," and early osteopaths. Today it is used by various health practitioners, including orthopedists, physical therapists, osteopaths, etc.

The specific technique of chiropractic was invented by Daniel David Palmer in 1895, following his alleged healing of a deaf man by spinal manipulation (but nerves involved in hearing do not emerge from spine). "There is evidence to suggest that D.D. Palmer had learned manipulative techniques from Andrew Taylor Still (1828-1917), the founder of osteopathy." (Ernst (2008) J. Pain Symptom Manage. 35, 544-562)

There are an estimated 70,000 American chiropractors; licensed in all states. Estimated costs range from $2 to $8 billion/year. More than 25 million Americans visit chiropractors in a given year (nearly 200 million total visits), with the visits comprising about 30% of the visits to alternative practitioners. "However, there is a downward trend in the percentage of US adults using chiropractic services, which decreased from 9.9% to 5.6% between 1997 and 2006" (Bellamy, Institute for Science in Medicine White Paper, "Chiropractic"). Most of these visits are for neuromusculo-skeletal problems; 30-45% are for low back pain (the total medical cost for low back pain is estimated to be $26 billion/year; an estimated 25% of the population suffers from low back pain in a given year). The decrease in adult chiropractic care may be due to increasing use of other methods, such as massage, for dealing with back pain.

Chiropractors are trained in 4-year schools (15 federally accredited in the U.S.), which vary greatly in quality; D.C. degree. Enrollment in U.S. chiropractic colleges decreased 40% from 1996 to 2002, and then remained steady at about 10,000 through 2013.

"Chiropractic students have relatively little experience in actual patient care prior to going into practice. For the vast majority of chiropractic students, the only supervised clinical experience takes place during chiropractic college, usually in small campus clinics where the range of problems they encounter and manage is narrow. Chiropractors are not required to do any post-degree training, and chiropractic residencies are rare." (Bellamy, White Paper)

“As of 2002, more than 50 percent of health maintenance organizations (HMOs), more than 75 percent of private health care plans, and all state workers’ compensation systems covered chiropractic treatment. Chiropractors can bill Medicare, and over two dozen states cover chiropractic treatment under Medicaid.” (NCCAM, “About Chiropractic and Its Use in Treating Low-Back Pain”) A 2004 survey found that 87% of employers offered coverage for chiropractic.

Organizations

• International Chiropractic Association ("straights" - restrict practice to treatment of subluxations through manipulation)

• American Chiropractic Association (largest) ("mixers" - utilize other modes of treatment in addition to manipulation. About 4 times as many as "straights.")

• World Chiropractic Alliance - straights

• National Association for Chiropractic Medicine (reform). A group of chiropractors that renounced subluxation theory, and limited their practice to neuromusculo-skeletal problems. It had only about 100 members, and has now disbanded.

• National Upper-Cervical Chiropractic Association (NUCCA) - "have foregone typical 'full-spine manipulations,' limiting their practice to precise, delicate manual alignment of a single vertebra, C-1 or Atlas" (Bakris et al, J. Hum. Hypertens. 21, 347-352 (2007))

Principles of chiropractic

According to traditional chiropractic belief, misaligned vertebrae (subluxations) are the cause of, or a contributing factor to, most diseases (chiropractors like to use the word "dis-ease"). These can disturb nerves, immune system, and visceral organs. Thus, some chiropractors feel they are treating underlying causes of disorders when medical doctors treat symptoms. (Note: subluxation is also a medical term ("partial or incomplete dislocation"), but the medical usage refers to a much more severe abnormality than in the usage given by chiropractors.)

The body has an innate ability to be healthy, and thus can get well when subluxations are corrected. Chiropractors refer to the “Innate Intelligence” of the body, or “the Innate.” "'Innate intelligence' evolved as a theological concept, the representative of Universal Intelligence (=God) within each person." (Ernst (2008) J. Pain Symptom Manage. 35, 544-562)

There is no consensus as to exactly what subluxations are and how they affect the body. Note the vagueness of the following "consensus definition" given in a publication of the Foundation for Chiropractic Education and Research: "A subluxation is a complex of functional and/or structural and/or pathological changes that compromise neural integrity and may influence organ function and general health." Medicare regulations (2000) define a subluxation as “a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact.”

"The theoretical basis is that hyper- or hypomobile joints produce local or distant effects as a result of abnormal afferent and efferent nerve irritation from joints, synovial membrane, and other soft tissue." (Curtis and Bove (1992) J. Fam. Pract. 35, 551-555)

Two hypotheses: 1. biomechanical - subluxations put mechanical strain on soft tissues of the spine, eventually producing pain and further abnormalities. 2. nerve compression - subluxations produce compression of spinal nerves at intervertebral foramina.

"It has been theorized that edema or inflammation of tissues in or around the intervertebral foramen sometimes could cause enough pressure on the spinal nerve roots to interfere with nerve impulses passing through them." (DeVocht (2006) Clin. Orthop. Relat. Res. 444, 243-249)

"Chiropractors believe that spinal manipulation breaks fibrous adhesions within joints, or that it 'releases small tags from the joint capsule that might be entrapped within the joint,' or that it affects the mechanoreceptors of the joint, or that it modulates central nervous system excitability, or that it inhibits C-fiber mediated pain perception." (Ernst (2008) J. Pain Symptom Manage. 35, 544-562)

Subluxations are said to arise from physical trauma, mental stress, or chemical causes (malnutrition or drug ingestion).

"According to the chiropractic literature, subluxations begin their appearance in the spine even before birth. 'Intrauterine constraint,' plus the birth process itself, means that the neonate is likely to arrive with his or her spine already subluxated." (Bellamy (2010) Focus Altern. Complement. Ther. 15, 214-222)

In addition to motor and sensory nerves, the sympathetic nervous system is involved in controlling blood flow and can thus influence internal organs.

Shekelle (Spine 19, 858-861 (1994)):

There are four main hypotheses for lesions that respond to manipulation: 1) release of entrapped synovial folds or plica; 2) relaxation of hypertonic muscle by sudden stretching; 3) disruption of articular or periarticular adhesions; and 4) unbuckling of motion segments that have undergone disproportionate displacements.

Meeker and Haldeman (Ann. Intern. Med. 136, 216-227 (2002)) list five proposed mechanisms:

• "Alleviation of an entrapped facet joint inclusion or meniscoid that has been shown to be heavily innervated"

• "Repositioning of a fragment of posterior annular material from the intervertebral disc"

• "Alleviation of stiffness induced by fibrotic tissue from previous injury or degenerative changes..."

• "Inhibition of excessive reflex activity in the intrinsic spinal musculature or limbs and/or facilitation of inhibited muscle activity"

• "Reduction of compressive or irritative insults to neural tissue"

Some chiropractors speak of the "vertebral subluxation complex," which involves nerves, muscles, and spinal movement; some have abandoned the idea of subluxations entirely.

"The vertebral subluxation cannot be precisely defined because it is an abstraction, an intellectual construct used by chiropractors, chiropractic researchers, educators and others to explain the success of the chiropractic adjustment." (Koren, "Does the Vertebral Subluxation Exist?" http://www.chiro.org/LINKS/ABSTRACTS/Does_VS_Exist.shtml)

Practice and scope

Treatment: manipulation of vertebrae, usually by hand. Curtis and Bove (J. Fam. Pract. 35, 551-555 (1992)):

Manipulation is generally performed by taking joints to their end point of motion ("long lever" technique) and then isolating the joint to be manipulated by local pressure on prominences of the articulating bones within the stretched area ("short lever"). Once isolated, a high velocity but low amplitude thrust is delivered to the joint, and an audible noise usually signifies that the manipulation has been successful. Done properly, the procedure is painless and the joint has moved past its passive range of motion but not outside its range of anatomical integrity.

Manipulation vs. mobilization:

Manipulation is a hands-on procedure used to restore normal movement by loosening joints and stretching tight muscles. In some cases, manipulation will restore normal movement by unlocking a joint or by breaking down adhesions. A popping sound often occurs when a spinal joint is stretched a little beyond its normal range of motion. Mobilization can increase the range of motion of the arms, legs, and shoulders, but manipulation may be more effective in relieving pain and restoring normal movement in the spinal joints. (Homola (1999), “What a Rational Chiropractor Can Do For You” http://www.chirobase.org/07Strategy/goodchiro.html)

"Treatment is often continued for over three months, even in the absence of clinical improvement." (Ernst (2008) J. Pain Symptom Manage. 35, 544-562)

Herzog et al. (Spine 26, 2105-2111 (2001)) found that the high force of specific manipulation was quickly spread over a larger contact area. They concluded, “...the beneficial effects of SMTs [spinal manipulation treatments] may be associated with a generalized, nonspecific force in the vicinity of the target point, rather than a well-defined force applied precisely to the target point.”

LeFebvre et al. (J. Evid. Based Complement. Altern. Med. 18, 75-79 (2012)): "For basic musculoskeletal injuries and postural syndromes, chiropractors use 4 broad categories of therapeutic interventions: (a) joint manipulation and mobilization; (b) soft tissue manipulation and massage, (c) exercise and physical rehabilitation prescription, and (d) home care and activity modification advice. In addition, nutritional and dietary counseling, physical therapy modalities (eg, heat, ice, ultrasound, electromodalities), and taping/bracing are used as adjunct procedures."

There are numerous (100-200) techniques practiced by various chiropractors (Activator, Diversified, Gonsted, Grostic, BEST, Network, NUCCA, etc.)

A 2003 survey by the National Board of Chiropractic Examiners revealed that 70% of them employed "Activator Methods" and 38% applied kinesiology. A 2009 survey found that 94% provided nutritional/dietary recommendations, 41% acupressure, 39% homeopathy, and 12% acupuncture. (Activator Methods and applied kinesiology are discussed below, under "Arguments against chiropractic.")

In a small number of states, chiropractors are allowed to carry out other procedures such as “specialty diagnostic procedures, pelvic and rectal examinations, venipuncture for laboratory diagnosis, signing of birth and death certificates, and acupuncture using needles” (http://www.chiroweb.com/archives/ahcpr/chapter5.htm) or to perform school and sports physicals. "Many U.S. chiropractors also do blood and urine analyses and some engage in minor surgery. In Oregon, chiropractors are allowed to deliver babies..." (Ernst (2008) J. Pain Symptom Manage. 35, 544-562)

A 1998 survey found that chiropractors saw an average of 108 patients per week, with the following distribution of conditions: 38% low back pain, 28% neck pain, 14% headache, 14% other neuromusculoskeletal, 6% non-neuromusculoskeletal (gastrointestinal, asthma, hypertension, other).

Chiropractors recommend frequent checkups, X-rays (though the use of X-rays for diagnosis appears to be declining), and maintenance treatments. Some chiropractors claim that nearly all infants have subluxations that must be treated, and that children need regular adjustments to prevent childhood disease.

A 2007 survey found that 2.3% of children in the U.S. received chiropractic or osteopathic care during the year. This survey found that children were most often treated for back and neck pain. However, another survey of pediatric chiropractors found that most visits were for "wellness care" and non-musculoskeletal conditions (such as asthma and ear infections).

Some degree of integration with conventional health care. Many orthopedic surgeons and other physicians refer patients to chiropractors for treatment. Chiropractors are on staffs of some hospitals. Some clinics offer care by both M.D.'s and chiropractors.

Research: back pain (2000-present only)

1. Trials

• Hsieh et al. (Spine 27, 1142-1148 (2002)) - subacute back pain - chiropractic manipulation brought about significant improvement (compared to myofascial therapy) (but these were no more effective than back school).

• Hurwitz et al. (Spine 27, 2193-2204 (2002)), in a trial concerning low back pain, concluded that “After 6 months of follow-up, chiropractic care and medical care for low back pain were comparable in their effectiveness.”

• Giles and Muller (Spine 28, 1490-1503 (2003)) studied medication, acupuncture, and spinal manipulation for chronic spinal pain, and concluded that “manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication.” (They also noted that “However, the data do not strongly support the use of only manipulation...”)

• Haas et al. (J. Manipulative Physiol. Ther. 28, 555-563 (2005)), in a nonrandomized study, concluded that "Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients."

• Eisenberg et al. (Spine 32, 151-158 (2007)): patients with acute low back pain were randomized to either usual care or a choice to add a complementary therapy (including chiropractic). Patients adding the therapy had greater satisfaction, but no reduction in symptoms, and incurred higher costs.

• Hancock et al. (Lancet 370, 1638-1643 (2007)): spinal manipulation did not decrease time to recovery from acute back pain.

2. Reviews and meta-analyses

• Ferreira at al. (Austral. J. Physiother. 48, 277-284 (2002)): "It is concluded that spinal manipulation does not produce clinically worthwhile decreases in pain compared with sham treatment, and does not produce clinically worthwhile reductions in disability compared with NSAIDs for patients with chronic low back pain. It is not clear whether spinal manipulation is more effective than NSAIDs in reducing pain of patients with chronic low back pain."

• Assendelft et al., Ann. Intern. Med. 138, 871-881 (2003), concluded that “There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain.”

• Cooper and McKee (Milbank Quart. 81, 107-138 (2003): “While randomized trials might have established once and for all that SMT is effective in the treatment of both acute and chronic low back and neck pain and that it is more effective in treating these disorders than other treatment approaches, the research to date has shown instead that SMT is effective in only a narrow subset of such patients and, in those circumstances, it is no more effective than other treatments.”

• Ernst and Canter (Physical Ther. Rev. 8, 85-91 (2003)), reviewing trials for back pain: "The effectiveness of chiropractic spinal manipulation is not supported by compelling evidence from the majority of randomised clinical trials."

• A review by Bronfort et al. (Spine J. 4, 335-356 (2004)) found some value for spinal manipulation therapy in treatment of low back pain and neck pain.

• Ernst (J. Pain Symptom Manage. 35, 544-562 (2008)), citing Canter and Ernst (Wien. Klin. Wochenschr. 117, 333-341 (2005)): "An evaluation of the 29 recent reviews of spinal manipulation for back pain concluded that those authored by chiropractors tended to generate positive results, whereas the others failed to demonstrate effectiveness."

• Cochrane review of spinal manipulation for chronic low-back pain (2011): "SMT appears to be as effective as other common therapies prescribed for chronic low-back pain...However, it is less clear how it compares to inert interventions such as sham (placebo) treatment...".• An update of the preceding review (Rubinstein et al., Spine 38, E158-E177 (2013)) concluded that "SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy."

3. Other reports

• American College of Physicians and American Pain Society guidelines (2007): patients whose low back pain does not improve with conventional treatment should consider alternative therapy, including spinal manipulation.

• National Center for Complementary and Alternative Medicine "Get the Facts" on spinal manipulation for low-back pain (2009), referring to the previous item, stated: "Overall, studies have shown that spinal manipulation can provide mild-to-moderate relief from low-back pain and appears to be as effective as conventional medical treatments."

Research: other conditions

1. Trials

• Chiropractic provided no benefit for asthma in children (Balon et al. (1998) New Engl. J. Med. 339, 1013-1020).

• Wiberg et al. (J. Manipulative Physiol. Ther. 22, 517-522 (1999)): spinal manipulation was effective in relieving infantile colic.

• Chiropractic was not effective for infantile colic (Olafsdottir et al. (2001) Arch. Dis. Child. 84, 138-141)

• Spinal manipulation was not effective for episodic tension-type headache (Bove and Nilsson (1998) JAMA 280, 1576-1579)

• Chiropractic spinal manipulation did not reduce hypertension (Goertz et al. (2002) J. Hypertens. 20, 2063-2068).

• A pilot study showed reduction of hypertension with adjustment of axis vertebra (Bakris et al, J. Hum. Hypertens. 21, 347-352 (2007)). However, the study has been criticized for the small sample size, small effect, and short study period.

• Study of neck pain (Hoving et al. (2006) Clin. J. Pain 22, 370-377): "Short term results (at 7 weeks) have shown that MT [manual therapy] speeded recovery compared with GP [general practitioner] care and, to a lesser extent, also compared with PT [physical therapy]. In the long-term, GP treatment and PT caught up with MT..."

• Bronfort et al. (Ann. Intern. Med. 156, 1-10 (2012)): "For participants with acute and subacute neck pain, SMT [spinal manipulation therapy] was more effective than medication in both the short and long term. However, a few instructional sessions of HEA [home exercise and advice] resulted in similar outcomes at most points."

• Scoliosis was not improved by chiropractic (Lantz and Chen (2001) J. Manipulative. Physiol. Ther. 24, 385-393)

• Recovery from whiplash injuries was slower in patients using chiropractic (Côté et al. (2005) Arch. Intern. Med. 165, 2257-2263).

2. Reviews and meta-analyses

• Balon and Mior (Ann. Allergy Asthma Immunol. 93(Suppl. 1), S55-S60 (2004)): “There is currently no evidence to support the use of chiropractic SMT as a primary treatment for asthma or allergy.”

• Cochrane review (2005): “there is insufficient evidence to support or refute the use of manual therapy for patients with asthma.”

• Cochrane review on carpal tunnel syndrome (2003): “Trials of...chiropractic care did not demonstrate symptom benefit when compared to placebo or control.”

• Hunt et al. (Hand Therapy 14, 89-94 (2012)): "There is insufficient evidence to suggest that chiropractic is effective for the treatment of CTS [carpal tunnel syndrome]."

• Canadian Coordinating Office for Health Technology Assessment (2003): “no convincing evidence that spinal manipulation alone can affect the duration of infantile colic symptoms.”

• Reid and Rivett (Man. Ther. 10, 4-13 (2005)): studies of manual therapy for cervicogenic dizziness were positive but of low methodological quality.

• Cochrane review (2004): spinal manipulation provided no benefit for treatment of dysmenorrhea.

• Bronfort et al. (J. Manipulative Physiol. Ther. 24, 457-466 (2001)): "SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache."

• Astin and Ernst (Cephalalgia 22, 617-623 (2002)): “Despite claims that spinal manipulation is an effective treatment for headache, the data available to date do not support such definitive conclusions.

• Cochrane review (2004) found evidence for effectiveness of spinal manipulation for short-term treatment of migraine, short-term treatment of chronic tension-type headache, and short- and long-term treatment of cervicogenic headache (but ineffective when added to massage for episodic tension-type headache).

• Lenssinck et al. (Pain 112, 381-388 (2004)): insufficient evidence to support effectiveness of spinal manipulation for tension-type headache.

• Posadzki and Ernst (Complement. Ther. Med. 20, 232-239 (2012)): "The evidence that spinal manipulation alleviates tension-type headaches is encouraging but inconclusive."

• Pauli (2007) (J. Vert. Sublux. Res. (Jan. 15), 1-12): studies "suggested a positive effect of chiropractic care in individuals suffering from learning disabilities and dyslexia. However, the various methodological weaknesses of those studies preclude any definitive conclusions and all the results are therefore to be considered preliminary."

• Ernst (Prev. Med. 49, 99-100 (2009)): "No compelling evidence was found to indicate that chiropractic maintenance therapy effectively prevents symptoms or diseases."

• Cochrane review for mechanical neck disorders (2004): manipulation and/or mobilization plus exercise was of value.

• Posadzki and Ernst (Focus Altern. Complement. Ther. 17(1), 22-26 (2012)) reviewed spinal manipulation for pediatric conditions (colic, kinetic imbalance, nocturnal enuresis, and otitis media): "None of the systematic reviews generated conclusive evidence to suggest that spinal manipulation is an effective treatment for any paediatric condition."

• Ernst and Posadzki (Focus Altern. Complement. Ther. 17(1), 9-14 (2012)): "Few rigorous trials have tested the effectiveness of chiropractic manipulation for the treatment of and/or prevention of sports injuries. Thus, the therapeutic value of this approach for athletes remains uncertain."

• Meta-analysis by Ernst (Fam. Pract. 17, 554-556 (2000)) of spinal manipulation in general: “The results available to date suggest that the therapeutic success of spinal manipulation is largely due to a placebo effect.”

• Review by Ernst (N. Z. Med. J. 116, U539 (2003)): value of chiropractic for non-spinal conditions is not supported by data from rigorous clinical trials.

• Ernst and Canter (J. Roy. Soc. Med. 99, 192-196 (2006)): "data do not demonstrate that spinal manipulation is an effective intervention for any condition." (Disputed by Bronfort et al. (2006) Chiropr. Osteopat. 14, 14)

• Hawk et al. (J. Altern. Complement. Med. 13, 491-512 (2007)): "Evidence from controlled studies and usual practice supports chiropractic care (the entire clinical encounter) as providing benefit to patients with asthma, cervicogenic vertigo, and infantile colic. Evidence was promising for potential benefit of manual procedures for children with otitis media and elderly patients with pneumonia."

Arguments in favor of chiropractic

Many studies and reviews indicating value of spinal manipulation for back pain (see Research section).

"...spinal manipulation used in the treatment of back pain has a plausible basis that makes it acceptable in mainstream health care. Although manipulation may not be any more effective than other treatment methods in improving recovery from back pain, it has been the author's experience as a practising chiropractor that use of hands-on manipulation in the treatment of mechanical-type back pain will sometimes provide more immediate and dramatic relief of symptoms than other forms of therapy." (Homola (2013) Focus Alternat. Complement. Ther. 18, 89-94)

Large number of satisfied patients. Seen as more caring than medical doctors. Effectiveness of "laying on hands." “...regardless of the objective clinical response, patients consistently express more satisfaction with chiropractic care than with other forms of treatment...They also return more often to chiropractors when their symptoms recur...This phenomenon does not appear to be related to manipulation per se...Rather, it seems to stem from the entire ‘chiropractic encounter,’ which includes sensitivity to patients as individuals, effective communication, and a holistic approach to health and disease...Touch, empathy, and the transmission of positive expectations are critical elements...” (Cooper and McKee (2003) Milbank Quart. 81, 107-138; citations within the text omitted)

Hertzman-Miller et al. (Am. J. Public Health 92, 1628-1633 (2002)), in a study of patient satisfaction, concluded that “Communication of advice and information to patients with low back pain increases their satisfaction with providers and accounts for much of the difference between chiropractic and medical patients’ satisfaction.”

Patients may be able to get an appointment much more quickly than with a physician.

Acknowledged by scientists to relieve pain and secondary muscle spasms caused by restricted joint mobility. (However, the same can be accomplished by manipulation therapy by non-chiropractors. "Today, with increasing numbers of physical therapists incorporating manipulation in their treatment armamentarium, physicians and other healthcare providers can refer a patient to a department of physical therapy for spinal manipulation, thus avoiding the problems associated with searching for a chiropractor who uses manipulation appropriately." (Homola (2013) Focus Alternat. Complement. Ther. 18, 89-94))

Arguments against chiropractic

1. Issues concerning the definition, evidence for, and effects of subluxations

No evidence to support the existence of subluxations. A study on cadavers (Crelin) found that spinal misalignment cannot impinge on nerves. Minor nerve compression should have very little effect on nerve impulse transmission.

"...each year millions of patients, including children, are diagnosed as having and are treated for a non-existent condition, all of which is perfectly legal as long as the patient's problem is defined in terms of the non-existent condition." (Bellamy (2010) Focus Alternat. Complement. Ther. 15, 214-222)

"A recent study by academic chiropractors 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.' Another independent study by academic chiropractors revealed that 'despite the controversies and paucity of evidence the term subluxation is still found often within the chiropractic curricula of most North American chiropractic programs.'" (Homola (2013) Focus Alternat. Complement. Ther. 18, 89-94)).

Chiropractors cannot define what aspect of nerve impulse is affected by subluxation.

“In fact, there is inadequate basic science data to substantiate the VSC [vertebral subluxation complex], and there are few (if any) randomized, controlled, clinical trials of spinal manipulation that have monitored presumed indicators of the putative VSC. Therefore, it is not appropriate to claim that by manipulating the VSC, a therapeutic benefit in humans or animals can be achieved. Furthermore, even if such lesions could be shown to exist, in the human spine, the commonly used diagnostic measures to detect them are not reproducible or reliable.” (D. Ramey et al., in Complementary and Alternative Veterinary Medicine Reconsidered)

"...the lack of evidence underpinning the subluxation is widely admitted in the chiropractic literature. This lack of evidence prompted the British General Chiropractic Council...to issue guidance to chiropractors that the vertebral subluxation complex is [sic] 'is taught only as an historical concept,' that 'there is no clinical research base to support the belief that it is the cause of disease or health concerns,' and essentially stating that it is inappropriate to make such claims in advertising or practice." (Bellamy, White Paper)

Scientifically invalid view of the role of nervous system in all organ function.

Continuing progress in scientific medicine has led to more detailed explanations for the causes of disease, often at the molecular level, but no information emerges linking disease to subluxations. "Neither the existence nor clinical significance of the chiropractic subluxation is recognised outside of chiropractic and no other healthcare profession utilises its concepts." (Bellamy (2010) Focus Alternat. Complement. Ther. 15, 214-222)

"The problem, simply, is that there is no need for Palmer's Postulates. There never has been a set of facts or phenomena concerning the relationship between the spine and health that require Palmer's postulates to understand them. The spine/health theory does not rest on any foundation of careful, comprehensive, and reliable observational data." (Nelson et al. (2005) Chiropr. Osteopat. 13, 9)

Not all nerves appear to be within the scope of chiropractic manipulation. Twelve pairs of cranial nerves exit at the base of the skull and do not involve the spine; these are not only involved in the senses of the head, but also go to the neck and many abdominal organs. The five pairs of sacral nerves exit from fused vertebrae in the lower spine; these innervate pelvic organs and parts of the legs. The parasympathetic nervous system requires only the cranial and sacral nerves. Why should manipulation of the 26 pairs of more accessible spinal nerves have such profound effects compared to the other 17 pairs?

If subtle changes in spinal alignment (even caused by mental stress) can have profound health effects, how is it possible for the much larger bends and shocks encountered in everyday life (to say nothing about in athletics such as gymnastics) not to leave us all ill or disabled?

Medically recognized spinal disorders, which are much more severe than those alleged to occur in chiropractic subluxations, do not produce the effects on other parts of the body which are alleged to result from subluxations. Moreover, "In the absence of fracture or pathology, such as disc herniation or osteophyte formation, vertebral misalignments rarely affect spinal nerves." (Homola (2013) Focus Altern. Complement. Ther. 18, 89-94)

Chiropractors differ among themselves as to which areas of spine are important. They also differ widely in the techniques which they use. "No two chiropractors can agree on how to treat a specific ailment or which vertebrae to adjust." (Homola (2010) Focus Altern. Complement. Ther. 15, 284-287)

"It seems unlikely that a chiropractor could detect vertebral misalignment by palpating the flexible, cartilaginous spine of an infant through a thick layer of baby fat." (Homola (2010) Skeptical Inquirer 34, 50-53)

Vertebrae differ considerably in their symmetry and mobility, both within and between individuals; difficult to assess abnormalities or "restricted mobility."

Chiropractors are not trained or permitted to use most sophisticated spinal diagnostic methods. Radiologists find it necessary to inject opaque dyes into the spinal canal in order to visualize changes involved in some serious spinal disorders. However, chiropractors claim to be able to assess much more subtle disorders by X-rays without using such enhancement.

A Rand Corp. study of manipulation and mobilization of the cervical spine judged that only 11% of indications for manipulation were appropriate, and that there was little evidence of the effectiveness of the procedure.

Pain arising from spinal problems may mimic symptoms of organic disease; "...it is not unreasonable that this somatic visceral-disease mimicry could very well account for the 'cures' of presumed organ disease that have been observed over the years in response to various somatic therapies (e.g., spinal manipulation, acupuncture, Rolfing, Qi Gong, etc.) and may represent a common phenomenon that has led to 'holistic' health care claims on the part of such clinical disciplines." (Nansel and Szlazak (1995) J. Manipulative Physiol. Ther. 18, 379-397)

"Persons who believe that they have subluxations or vertebrae out of place causing a health problem may be subject to a powerful placebo effect when the spine is popped, leading them to believe that their condition is being helped or cured by replacement of a vertebra. Such popping does not mean that a vertebra was out of place...After vertebrae have been manipulated to produce cavitation, it may take three or four hours for the joint surfaces to settle back together so that the vertebrae can be popped again. This popping sound may produce fear that failure to get regular adjustments to pop or align the vertebrae will result in development of illness - a nocebo effect often exploited by chiropractors who have asymptomatic patients coming back on a regular basis for 'preventive maintenance.'" (Homola (2011), Science-Based Medicine blog, Dec. 30)

Nansel and Szlazak (J. Manipulative Physiol. Ther. 18, 379-397 (1995)): "At present, we are aware of not a single appropriately controlled study that has convincingly established that spinal manipulation represents a valid curative strategy for the treatment of any true visceral disease, even though scientifically unsubstantiated claims of such therapeutic efficacy continue to be all too prevalent throughout the chiropractic profession."

Nansel and Szlazak (ibid.): "Indeed, current concepts regarding the physiology (and pathophysiology) of the autonomic nervous system do not support the notion that even sustained, maximal sympathetic activity involving various organs and tissues would create ischemic responses of any real consequence."

Homola (Scientific Rev. Alternative Med. 5(1), 45-53 (2001)): “Injury to a spinal nerve may result in some autonomic disturbance in the portion of the skin supplied by the damaged nerve, but visceral functions are protected by a widespread, overlapping nerve supply from a number of sympathetic (autonomic) ganglia located outside the spinal column.”

Nelson et al. (Chiropr. Osteopat. 13, 9 (2005)): "To date chiropractic has not demonstrated that it can deliver on the promise of prevention. It is difficult to make the case that chiropractic, uniquely or distinctively among health professions, is concerned with, and capable of providing effective preventive care...the proposition of chiropractic as the 'wellness profession' is not defensible."

2. Side effects

Spinal manipulations have resulted in fractures, disk ruptures, strokes, even fatalities (though such complications are rare considering the enormous number of treatments)

a. Vertebrobasilar artery dissection and stroke

A review (Assendelft et al., J. Fam. Pract. 42, 475-480 (1996)) noted that there was a special danger to the cervical arteries during rotation of the head. It was recommended that practitioners employing rotary cervical manipulation be avoided. (However, chiropractors argue that the incidence of serious complication is only one in a million, much less than with drug treatment.) DiFabrio (Phys. Ther. 79, 50-65 (1999)) reviewed the risks of manipulation of the cervical spine (MCS): “The literature does not demonstrate that the benefits of MCS outweigh the risks.”

More recent estimates of the incidence of stroke following chiropractic cervical manipulation have ranged from 1.3 per 100,000 visits (Rothwell et al., Stroke 32, 1054-1060 (2001)) to 1 in 6 million visits (Haldeman et al., Can. Med. Assoc. J. 165, 907-908 (2001)). In the former study, patients under 45 suffering vertebrobasilar accidents were five times more likely than controls to have visited a chiropractor in the preceding week. Another study found that neck manipulations were responsible for 20% of strokes in patients under 45. A case-controlled study by Smith et al. (Neurology 60, 1424-1428 (2003)) concluded that “SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain.”

Cassidy (Spine 33, S176-S183 (2008)) reported that vertebrobasilar artery (VBA) stroke was associated equally with visits to chiropractors and visits to primary care providers, suggesting that patients had already undergone VBA dissection and were seeking treatment for related headache or neck pain. However, it this were the case, chiropractors should not be carrying out manipulation of the neck. Ernst (Perfusion 23, 73-74 (2010) and Int. J. Clin. Pract. 64, 673-677 (2010)) has pointed out flaws in this study. Many of the strokes occur immediately after manipulation. Also, they occur after treatment for a variety of symptoms, not those associated with preexisting VBA dissection.

b. Other

A review by Ernst (J. Pain Symptom Manage. 21, 238-242 (2001)) concluded 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” (partly because only patients who return for treatment were questioned, and those experiencing serious complications would be unlikely to do so). In a 2008 update, Ernst (J. Pain Symptom Manage. 35, 544-562) wrote: "Since then, two further prospective studies (n=465 and 336, respectively) reported that such adverse effects occur in 61% and 30% of patients."

Hurwitz et al. (Spine 13, 1477-1484 (2005)) found that 30% of patients obtaining chiropractic treatment for neck pain had adverse symptoms as a result. “Given the possible higher risk of adverse reactions and lack of demonstrated effectiveness of manipulation over mobilization, chiropractors should consider a conservative approach for applying manipulation to their patients, especially those with severe neck pain.”

Patients may be delayed in or prevented from obtaining necessary medical care (see Butler, A Consumer's Guide to "Alternative Medicine," pp. 83-4: given symptoms of ulcer and heart condition, chiropractors recommended manipulation rather than referring to physician).

Possibility that repeated forceful thrusts will continue to re-injure affected areas.

There is some concern that while the chiropractic adjustment may offer short-term relief, the repeated movements beyond the normal range of motion may eventually cause tissue damage.

Ernst (Br. J. Sports Med. 37, 195-196 (2003)): “Osteoporosis should be regarded as a contraindication for chiropractic spinal manipulation. Yet, in practice, no reliable diagnostic methods are available to chiropractors for identifying osteoporosis, and no threshold values have been determined for people at risk.”

Overuse of X-rays (radiation exposure)

Cost of unnecessary treatments. "Diagnosis and treatment of chiropractic subluxations adds a substantial burden to health care costs with no return in terms of benefit." (Bellamy, White Paper)

Psychological: dependence on "maintenance" treatments for continued health

3. Aspects of pseudoscience

"Theory" originated by a layman who engaged in quackery.

"Subluxation" vaguely defined (such that it cannot be measured) and not scientifically established. Definitions keep changing over the years.

Palmer referred to interference with "Innate Intelligence," a nonscientific and nonmeasurable entity.

Reliance on anecdotal claims rather than controlled studies

Promotional material filled with scientifically dubious statements

Remains isolated from the sciences. The concept of subluxations has not led to any advances in scientific knowledge.

No coherent theory of chiropractic has been developed which is modified to incorporate new findings in neurophysiology, endocrinology, and other areas. Rather, the original nonscientific "theory" is left intact, and a variety of scientific concepts are invoked as possible explanations even though the relationships of these to subluxations are dubious.

Flawed logic:

• If medicine has deficiencies (doesn't know everything; some doctors engage in quackery; some doctors are not well trained in dealing with back problems; drugs, especially NSAIDs, have side effects) then an alternative (chiropractic) is valid.

• Effects of known lesions and abnormalities of the spinal cord cited as evidence that subluxations could produce similar effects.

Several studies found that chiropractors gave a variety of inconsistent diagnoses (including frequent "short legs") for the same healthy subjects, and some used bizarre diagnostic techniques. Among invalid systems of diagnosis and treatment are: applied kinesiology, based on the concept that specific muscle weaknesses correspond to specific organic problems; and Activator Methods, in which corrections to spinal problems are made by small blows to the spine or elsewhere using a hand-held, spring-loaded hammer.

Use of other dubious treatments by some chiropractors

Some chiropractors attempt to undermine vaccinations, drug therapy and other aspects of scientific medicine.

Campbell et al.(Pediatrics 105(4), e43 (2000)) reviewed chiropractic attitudes toward vaccinations: “...a vocal element of the chiropractic profession maintains a strongly antivaccination bias.”

Lee et al. (Arch. Pediatr. Adolesc. Med. 154, 401-407 (2000)) surveyed chiropractors in the Boston area, and found that “Seventy percent of the respondents recommended herbs and dietary supplements. For pediatric care, 30% reported actively recommending childhood immunizations; presented with a hypothetical 2-week-old neonate with a fever, 17% would treat the patient themselves rather than immediately refer the patient to a doctor of medicine, doctor of osteopathy, or an emergency facility...Pediatric chiropractic care is often inconsistent with recommended medical guidelines.”

Other aspects

Chiropractors have been adept at using political power to achieve favorable legislation.

Successful lawsuit against American Medical Association (AMA) for restraint of trade, 1987 (Wilk et al v. AMA et al). AMA was found guilty of anti-trust laws by its ethical prohibition against professional association with nonscientific health care providers. However, the ruling does not mean that the AMA or individual physicians cannot speak out against chiropractic. It also did not rule that chiropractic was scientifically valid. It agreed that the AMA was motivated by concern for patients, not for monetary gain.

Aggressive marketing, including (in some cases) deceptive and fraudulent practices. Faced with paying off student loans and intense competition, new chiropractic graduates may need to be aggressive in building business. The chiropractic profession has expanded much faster than the demand, and faces increased competition from acupuncture and massage.

S. Homola, writing on the Healthfraud e-mail discussion list, noted that some chiropractors do not treat on the first visit. Rather, they do testing in order to reveal supposed dangerous subluxations, which the patient is then persuaded to have corrected in a series of later visits.

Referring to a 2007 Gallup poll, Murphy et al. (Chiropr. Osteopat. 16, 10 (2008)) noted: "The profession still finds itself in a situation in which it is rated dead last among healthcare professionals with regard to ethics and honesty."

Legislation in 1999 and 2000 increased access to chiropractic in the Veterans’ Administration system, and directed that chiropractic care be made available to all U.S. military personnel on active duty.

Mainous et al. (Arch. Fam. Med. 9, 446-450 (2000)), reporting on a national survey of chiropractors and family physicians, noted that “care is fragmented between chiropractors and the general medical sector, with little information communicated between health care providers on issues with critical importance to quality of care.”

In 2005 R25 education grants were awarded by NCCAM to four chiropractic universities "to strengthen their research/evidence-based practice curricula. The grants required that complementary and alternative medicine institutions pair with a research-intensive medical institution with a goal of improving complementary and alternative medicine students' evidence-based practice skills." (LeFebvre et al. (2012), J. Evid. Based Complement. Altern. Med. 18, 75-79)

Some chiropractic colleges "are now called a 'University of Health Sciences,' retreating somewhat from the subluxation theory and incorporating such procedures as acupuncture, homeopathy, oriental medicine, massage therapy, and health and wellness subjects." (Homola (2006) Clin. Orthop. Relat. Res. 444, 236-242)

SUMMARY

Chiropractic appears to be useful for dealing with some types of back pain, but it is not clear whether it is superior to other forms of treatment. It has not been shown to be useful for other conditions. The concept that subluxations are involved in a wide variety of diseases is inconsistent with medical knowledge. To a much greater extent than medical doctors, chiropractors are associated with pseudoscientific techniques and scientifically unsupported methods of treatment.

OSTEOPATHY

Background

Invented by Andrew Taylor Still, a bonesetter, in the 1880's. Based in part on his own self-healing of headaches, etc., through neck manipulation. Established American School of Osteopathy in 1892.

In 2013 there were about 82,000 U.S. practitioners, with the number expected to reach 100,000 by 2020 (American Osteopathic Association 2013 "Osteopathic Medical Profession Report"). There 30 osteopathic medical colleges with about 21,000 students. Practitioners obtain D.O. degree; in general they have the same privileges as M.D.'s in prescriptions, surgery, etc.

Unlike chiropractic, osteopathy has advanced with advances in medical science. "While retaining a separate identity - in part because it used manipulative therapy and emphasized the muscles and skeletal system - osteopathy gradually adopted the concepts and practices of orthodox medical science as well." (Barrett, Health Schemes, Scams, and Frauds, p. 160) Preclinical training is same as medical students except for additional courses on manipulation and other subjects. For residency, many train in conventional medical programs. These programs are increasingly turning to osteopathic graduates to fill positions in primary care residencies.

Principles of osteopathy

Emphasis on importance of vascular system, particularly arteries, in enhancing the body's functions and natural healing power. Seek to use manipulation to restore homeostasis. (However, Still's original theory was abandoned in 1948.)

"Rule of the artery" - manipulation improves circulation by reducing muscle spasms.

"The osteopathic goal is to prevent disease by identifying structural problems before they become chronically disabling." (Waldron (1997) Discover, Jan., 91-93)

While osteopathy takes a largely scientific approach, there does persist among some osteopaths a body of pseudoscientific concepts, such as craniosacral therapy (discussed in the handout on holistic methods).

"According to osteopathic teaching, structural misalignment in the cranium may lead to somatic symptoms throughout the body...Osteopathic physicians are taught to identify structural misalignments of the skull by assessment of the frequency of the cranial rhythmic impulse (CRI)." (Kotzampaltiris et al. (2009) J. Altern. Complement. Med. 15, 341-345)

Techniques

Use of palpation to assess musculoskeletal system and other aspects of physical condition.

In contrast to the "short lever high velocity" manipulations of chiropractors, osteopaths generally use "long lever low velocity" manipulations (using the femur, shoulder, head or pelvis to manipulate the spine) or more nonspecific manipulations.

"...we frequently use techniques of manipulation and stretching to help retrain muscles, joints, and connective tissue that have been stressed or damaged." (Waldron, op. cit.)

Research

Jäkel and von Hauenschild (J. Am. Osteopath. Assoc. 111, 685-693 (2011)) reviewed the efficacy of osteopathic manipulation for a variety of conditions. They found that the evidence was "insufficient to draw definitive conclusions."

Andersson et al. (New Engl. J. Med. 341, 1426-1431 (1999)) compared osteopathic spinal manipulation with standard medical care for low back pain. “Osteopathic manual care and standard medical care have similar clinical results in patients with subacute low back pain. However, the use of medication is greater with standard care.”

Licciardone et al. (Spine 28, 1355-1362 (2003)), in a study of chronic low back pain, concluded that “There were no significant benefits with osteopathic manipulative treatment, as compared with sham manipulations.” A later study (Licciardone et al. (2013) Ann. Fam. Med. 11, 122-129) found that the treatment provided "a medium effect size in relieving chronic low back pain," but not "improvements in back-specific functioning, general health, or work disability."

A study by Mills et al. (Arch. Pediatr. Adolesc. Med. 157, 861-866 (2003)) indicated a benefit of osteopathic manipulative treatment as an adjuvant therapy in children with recurrent acute otitis media. However, the parents were not blinded as to the treatment.

Posadzki et al. (Pediatrics 132, 140-152 (2013)) concluded that "The evidence of the effectiveness of OMT for pediatric conditions remains unproven due to the paucity and low methodological quality of the primary studies."

Other aspects

Because of their emphasis on the whole body, in contrast to increasing specialization within the medical profession, osteopaths may be more likely than M.D.'s to choose more general areas such as family practice.

“Back door phenomenon” - many applicants to osteopathic schools may be ones not accepted to conventional medical schools, rather than being inclined toward the osteopathic approach.

Osteopaths have suffered from public misconceptions that their practice is limited to bone and muscle disorders, and that their training is inferior to that of M.D.'s. "They were physicians and surgeons, yet many confused them with chiropractors." (Gevitz, in Other Healers, p. 146)

Johnson et al. (Acad. Med. 76, 821-828 (2001)) surveyed osteopaths, and found that over 50% used osteopathic manipulative treatment (OMT) on less than 5% of their patients, and about one fourth did not use it at all. They concluded that “The evidence supports the assertion that OMT is becoming a lost art among osteopathic practitioners.”

MASSAGE

Various types of massage therapy range from standard treatments of conventional medicine and physical therapy, to bizarre and pseudoscientific approaches. Massage will also be discussed in handouts on other areas, such as mind-body medicine (relaxation, stress relief) and holistic approaches (bodywork, reflexology).

A survey found that 16% of American adults had received a massage within the previous year. 43% of the treatments were for medical or health reasons. (American Massage Therapy Association, "2014 Massage Therapy Industry Fact Sheet")

"There are more than 360 accredited massage therapy schools and programs in the United States" and an estimated 300,000 massage therapists and massage school students (Fact Sheet). Instruction and certification exams may require “knowledge” of pseudoscientific concepts (such as from traditional Chinese medicine).

In a review of chiropractic, Cooper and McKee (Milbank Quart. 81, 107-138 (2003)) noted that the form of manual treatment “that is most similar to chiropractic SMT in terms of both symptom control and cost is that provided by massage therapists..., who currently outnumber chiropractors by more than three to one and who are growing in both numbers and market share at more than five times their rate...” (references in text deleted). (In turn, more chiropractors are offering massage, either performing it themselves or including a massage therapist in their practice.)

Not covered by most health insurance plans. Some coverage if prescribed as part of physical therapy.

As of 2014, 44 states plus the District of Columbia had massage practice laws. Standards for education vary greatly from state to state.

Practice and scope

In general, massage is suggested to produce relaxation, reduce stress, improve circulation, and help eliminate "toxins." Claims range from fairly reasonable (relief of muscle spasms, improved healing of injuries) to scientifically unlikely (improvement in organ function, fat reduction, better eyesight, reversal of balding).

"At the most general level, four principal goals of treatment can be elucidated: 1) to promote relaxation and wellness (relaxation massage), 2) to address clinical concerns (clinical massage), 3) to enhance posture, movement and body awareness (movement re-education), and 4) to balance and 'move' subtle energy (energy work). Each of these goals can be accomplished using a number of different styles of massage, some of which are trademarked (e.g., Rolfing®)." (Sherman et al. (2006) BMC Complement. Altern. Med. 6, 24)

Examples (from National Center for Complementary and Alternative Medicine, "Massage Therapy as CAM"):

• In Swedish massage, the therapist uses long strokes, kneading, and friction on the muscles and moves the joints to aid flexibility.

• A therapist giving a deep tissue massage uses patterns of strokes and deep finger pressure on parts of the body where muscles are tight or knotted, focusing on layers of muscle deep under the skin.

• In trigger point massage (also called pressure point massage), the therapist uses a variety of strokes but applies deeper, more focused pressure on myofascial trigger points - "knots" that can form in the muscles, are painful when pressed, and cause symptoms elsewhere in the body as well.

• In shiatsu massage, the therapist applies varying, rhythmic pressure from the fingers on parts of the body that are believed to be important for the flow of a vital energy called qi.

"Myotherapy was developed by American Bonnie Prudden in the 1970s as a system of treating painful and dysfunctional muscles and soft tissue. The term is also used more generally to describe a suite of soft tissue and massage techniques." (Vagg (2012) "Myotherapy: Panacea or Placebo?" http://theconversation.com/myotherapy-panacea-or-placebo-9183)

"Myofascial release is a style of manual therapy that Barnes defines as a 'whole body, hands-on approach for the evaluation and treatment of the human structure. Its focus is to optimize the function of the fascial system.' Component techniques of myofascial release include three techniques used in craniosacral therapy (compression - static, listening to and following the craniosacral rhythm, still point), in addition to cross-fiber friction, deep gliding, holding, J-stroke, manual stretching, traction, skin rolling, rocking, jostling, shaking and vibration." (Sherman et al. (2006) BMC Complement. Altern. Med. 6, 24)

Tui na is a form of massage used in traditional Chinese medicine. It will be discussed in the handout on Eastern approaches.

Research

A trial by Cherkin et al. (Arch. Intern. Med. 161, 1081-1088 (2001)) concluded that “Therapeutic massage was effective for low back pain, apparently providing long-lasting benefits.”

A review that included three clinical trials also concluded that massage was useful for back pain (Cherkin et al. (2003) Ann. Intern. Med. 138, 871-881).

An editorial by Ernst (BMJ 326, 562-563 (2003)) noted that “the evidence for massage as a symptomatic relief of back pain is encouraging but not compelling.”

Tsao (Evid. Based Complement. Altern. Med. 4, 165-179 (2007)): "Existing research provides fairly robust support for the analgesic effects of massage for non-specific low back pain, but only moderate support for such effects on shoulder pain and headache pain."

Cherkin et al. (Ann. Intern. Med. 155, 1-9 (2011)) concluded that "Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months. No clinically meaningful difference between relaxation and structural massage was observed in terms of relieving disability or symptoms."

Kumar et al. (Int. J. Gen. Med. 6, 733-741 (2013)) concluded that there is some evidence for effectiveness in short-term treatment of low back pain, compared to placebo. It is not clear if it is effective when compared to other therapies.

Shoemaker et al. (Med. Sci. Sports Exerc. 29, 610-614 (1997)): massage does not increase blood flow to muscles. In another study, Hinds et al. (Med. Sci. Sports Exerc. 36, 1308-1313 (2004)) found no increase in arterial blood flow, and concluded that without such an increase, “any increase in SKBF [skin blood flow] is potentially diverting flow away from recovering muscle. Such a response would question the efficacy of massage as an aid to recovery in postexercise settings.”

Corbin (Cancer Control 12, 158-163 (2005)) wrote, “...the strongest evidence for the ability of massage therapy to decrease anxiety and distress is found in trials involving cancer patients. The ability of massage to decrease pain is likely, but the number of patients studied is small. The efficacy of massage on other symptoms associated with cancer as well as on the number of medications used for symptom control also warrants more study.” A study by Cassileth and Vickers (J. Pain Symptom Manage. 28, 244-249 (2004)) found that “massage therapy is associated with substantive improvement in cancer patients’ symptom scores.”

A study of massage for chronic tension headaches (Quinn et al. (2002) Am. J. Public Health 92, 1657-1661) was supportive.

A Cochrane review (2012) concluded that massage appears to reduce pain in labor, but more research is needed.

A study of massage and stress (Hanley et al. (2003) Br. J. Gen. Pract. 53, 20-25) found no benefit compared to relaxation tapes.

Side effects

Ernst (BMJ 326, 562-563 (2003)) discussed the risks of massage: “Too much force can cause fractures of osteoporotic bones; and even rupture of the liver and damage to nerves have been associated with massage. These events are rarities and massage is relatively safe, provided that well trained therapists observe the contraindications: phlebitis, deep vein thrombosis, burns, skin infections, eczema, open wounds, bone fractures, and advanced osteoporosis.”

According to Corbin (Cancer Control 12, 158-163 (2005)), “There has been no evidence that massage therapy can spread cancer, although direct pressure over a tumor is usually discouraged.”

Yin et al. (Evid. Based Complement. Alternat. Med. 2014, 480956 (2014)) concluded that "Clearly, massage therapies are not totally devoid of risks. But the incidence of such events is low."

Other points

A therapist writing on the Healthfraud e-mail discussion list noted that ordinary massage is physically demanding, and a therapist can only perform a limited number per work day. However, addition of techniques such as reiki, which require little physical effort, allows a therapist to increase his or her income greatly.

READING

Chiropractic - overview

National Center for Complementary and Alternative Medicine (2012) “Chiropractic: An Introduction”

Meeker, W.C. and Haldeman, S. (2002) “Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine” Ann. Intern. Med. 136, 216-227 [abstract]

Homola, S. (2001) “Chiropractic: Does the Bad Outweigh the Good?”

Kaptchuk, T.J. and Eisenberg, D.M. (1998) “Chiropractic: Origins, Controversies, and Contributions” Arch. Intern. Med. 158, 2215-2224

Homola, S. (1999) “What a Rational Chiropractor Can Do for You”

Barrett, S. (2000) "Tips on Choosing a Chiropractor"

Barrett, S. (2009) “Glossary of Chiropractic Terms”

Barrett, S. (2004) Chiropractic Techniques [links to promotional sites describing various techniques]

Mainous, A.G., Gill, J.M., Zoller, J.S., and Wolman, M.G. (2000) “Fragmentation of Patient Care Between Chiropractors and Family Physicians” Arch. Fam. Med. 9, 446-450

Cooper, R.A. and McKee, H.J. (2003) “Chiropractic in the United States: Trends and Issues” Milbank Quart. 81, 107-138

LeFebvre, R., Peterson, D., and Haas, M. (2012) "Evidence-Based Practice and Chiropractic Care" J. Evid. Based Complement. Altern. Med. 18, 75-79

Homola, S. (2006) "Chiropractic: History and Overview of Theories and Methods" Clin. Orthop. Rel. Res. 444, 236-242 [abstract]

Ndetan, H., Evans, M.W., Hawk, C., and Walker, C. (2012) "Chiropractic or Osteopathic Manipulation for Children in the United States: An Analysis of Data from the 2007 National Health Interview Survey" J. Altern. Complement. Med. 18, 347-353 [abstract]

Alcantara, J., Ohm, J., and Kunz, D. (2010) "The Chiropractic Care of Children"J. Altern. Complement. Med. 16, 621-626

Koren, T. (2003) "Does the Vertebral Subluxation Exist?"

Nelson, C.F., Lawrence, D.J., Triano, J.J. et al. (2005) "Chiropractic as Spine Care: a Model for the Profession" Chiropr. Osteopat. 13, 9

DeVocht, J.W. (2006) "History and Overview of Theories and Methods of Chiropractic" Clin. Orthop. Rel. Res. 444, 243-249 [abstract]

Chiropractic - critiques (see also “risks” below)

Chirobase (“Your Skeptical Guide to Chiropractic History, Theories, and Practices”)

Jarvis, W.T. (2000) “Chiropractic: A Skeptical View”

Nelson, C.F. et al. (2005) “Chiropractic as Spine Care: a Model for the Profession” Chiropractic & Osteopathy 13, 9

Anonymous “An Inside View of a Chiropractic Office”

Barrett, S. (2006) “Subluxation: Chiropractic's Elusive Buzzword’”

Barrett, S. (2003) “The Selling of the Spine”

Barrett, S. (2013) “Chiropractors and Immunization”

Lattanze, W. (1999) “A Warning for Pre-Chiropractic Students”

Lee, A.C.C., Li, D.H., and Kemper, K.J. (2000) “Chiropractic Care for Children” Arch. Pediatr. Adolesc. Med. 154, 401-407

Campbell, J.B., Busse, J.W. and Injeyan, H.S. (2000) “Chiropractors and Vaccinations: A Historical Perspective” Pediatrics 105(4), e43

Crelin, E.S. (1973) "A Scientific Test of the Chiropractic Theory" American Scientist 61, 574-580 [measures how much displacement of vertebrae must occur before spinal nerves are impinged or encroached upon]

Ernst, E. (2008) "Chiropractic: A Critical Evaluation" J. Pain Symptom Manage. 35, 544-562

Ernst, E. (2009) "Chiropractic Maintenance Treatment, a Useful Preventive Approach?" Prev. Med. 49, 99-100

Murphy, D.R., Schneider, M.J., Seaman, D.R., Perle, S.M. and Nelson, C.F. (2008) "How Can Chiropractic Become a Respected Mainstream Profession? The Example of Podiatry" Chiropr. Osteopat. 16, 10

Keating, J.C., Jr., Charlton, K.H., Grod, J.P. et al. (2005) "Subluxation: Dogma or Science?" Chiropr. Osteopat. 13, 17

Bellamy, J.J. (2012) "White Paper: Chiropractic" Institute for Science in Medicine [link for pdf file]

Homola, S. (2010) "Real Orthopaedic Subluxations Versus Imaginary Chiropractic Subluxations" Focus Altern. Complement. Med. 15, 284-287 [abstract]

Bellamy, J.J. (2010) "Legislative Alchemy: the US State Chiropractic Practice Acts" Focus Altern. Complement. Med. 15, 214-222 [abstract]

Homola, S. (2011) "Subluxation Theory: A Belief System That Continues to Define the Practice of Chiropractic" Science-Based Medicine, Dec. 30

Homola, S. (2010) "Should Chiropractors Treat Children?" Skeptical Inquirer 34(5), 50-53

Homola, S. (2013) "Pseudoscience in the Use of Manipulation by Chiropractors" Focus Altern. Complement. Ther. 18, 89-94 [abstract]

Homola, S. (2008) "Chiropractic: A Profession Seeking Identity" Skeptical Inquirer 32(1), 19-22

Thyer, B. and Whittenberger, G. (2008) "A Skeptical Consumer's Look at Chiropractic Claims: Flimflam in Florida?" Skeptical Inquirer 32(1), 23-25

Chirotalk: The Skeptical Chiropractic Discussion Forum

Barrett, S. (2009) "A Skeptical Look at Chiropractic BioPhysics (CBP)"

Barrett, S. (2012) "The Toftness Radiation Detector Is a Bogus Device"

Barrett, S. (2011) "Be Wary of Spinal Decompression Therapy with VAX-D or Similar Devices"

Tiller, M.J., Bruening, W., Tregear, S., et al. (2007) "Decompression Therapy for the Treatment of Lumbosacral Pain." Agency for Healthcare Research and Quality Technology Assessment Program Link to 91-page pdf file

Daniel, D.M. (2007) "Non-Surgical Spinal Decompression Therapy: Does the Scientific Literature Support Efficacy Claims Made in the Advertising Media?" Chiropr. Osteopat. 15, 7

Chiropractic - research on back pain (reviews only)

Ferreira, M.L., Ferreira, P.H., Latimer, J. Herbert, R., and Maher, C.G. (2002) "Does Spinal Manipulative Therapy Help People with Chronic Low Back Pain?" Aust. J. Physiother. 48, 277-284 [abstract with link to free pdf file]

Assendelft, W.J.J., Morton, S.C., Yu, E.I. et al. (2003) “Spinal Manipulative Therapy for Low Back Pain. A Meta-Analysis of Effectiveness Related to Other Therapies” Ann. Intern. Med. 138, 871-881 [abstract with link to free pdf file]

Cherkin, D.C., Sherman, K.J., Deyo, R.A. and Shekelle, P.G. (2003) “A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage Therapy, and Spinal Manipulation for Back Pain” Ann. Intern. Med. 138, 898-906 [abstract with link to free pdf file]

Ernst, E. and Canter, P.H. (2003) "Chiropractic Spinal Manipulation Treatment for Back Pain? A Systematic Review of Randomised Clinical Trials" Phys. Ther. Rev. 8, 85-94 [abstract]

Rubinstein, S.M., van Middlekoop, M., Assendelft, W.J.J., de Boer, M.R., and van Tulder, M.W. (2011) "Spinal Manipulative Therapy for Chronic Low-Back Pain" Cochrane Database System. Rev., CD008112

National Center for Complementary and Alternative Medicine (2013) "Spinal Manipulation for Low-Back Pain"

Rubinstein, S.M., Terwee, C.B., Assendelft, WJJ, de Boer, M.R., and van Tulder, M.W. (2013) "Spinal Manipulative Therapy for Acute Low Back Pain: An Update of the Cochrane Review" Spine 38, E158-E177 [abstract]

Chiropractic - research on other conditions

Ernst, E. (2000) “Does Spinal Manipulation Have Specific Treatment Effects?” Family Practice 17, 554-556

Ernst, E. and Canter, P.H. (2006) "A Systematic Review of Systematic Reviews of Spinal Manipulation" J. R. Soc. Med. 99, 192-196 [see also next item]

Bronfort, G., Haas, M., Moher, D. et al. (2006) "Review Conclusions by Ernst and Canter Regarding Spinal Manipulation Refuted" Chiropr. Osteopat. 14, 14

Ernst, E. (2003) "Chiropractic Manipulation for Non-Spinal Pain - A Systematic Review" N. Z. Med. J. 116(1179), U539 [link to pdf file of entire issue]

Balon, J.W. and Mior, S.A. (2004) “Chiropractic Care in Asthma and Allergy” Ann. Allergy Asthma Immunol. 93(Suppl 1), S55-60 [abstract]

Hondras, M.A., Linde, K. and Jones, A.P. (2005) "Manual therapy for asthma" Cochrane Database Syst. Rev., CD001002

Hunt, K.J., Hung, S.K., Boddy, K. and Ernst, E. (2009) "Chiropractic Manipulation for Carpal Tunnel Syndrome: A Systematic Review" Hand Therapy 14, 89-94 [abstract]

Reid, S.A. and Rivett, D.A. (2005) "Manual Therapy for Treatment of Cervicogenic Dizziness: A Systematic Review" Man. Ther. 10, 4-13 [abstract]

Bronfort, G., Assendelft, W.J.J., Evans, R., Haas, M., and Bouter, L. (2001) "Efficacy of Spinal Manipulation for Chronic Headache: A Systematic Review" J. Manipulative Physiol. Ther. 24, 457-466 [abstract]

Lessinck, M-L.B., Damen, L., Verhagen, A.P. et al. (2004) "The Effectiveness of Physiotherapy and Manipulation in Patients With Tension-Type Headache: A Systematic Review" Pain 112, 381-388 [abstract]

Posadkzi, P. and Ernst, E. (2012) "Spinal Manipulations for Tension-Type Headaches: A Systematic Review of Randomized Controlled Trials" Complement. Ther. Med. 20, 232-239

Ernst, E. (2003) "Chiropractic Spinal Manipulation for Neck Pain: A Systematic Review" J. Pain 4, 417-421 [abstract]

Hoving, J.L., de Vet, H.C.W., Koes, B.W. et al. (2006) "Manual Therapy, Physical Therapy, or Continued Care by the General Practitioner for Patients With Neck Pain: Long-Term Results From a Pragmatic Randomized Clinical Trial" Clin. J. Pain 22, 370-377 [abstract]

Bronfort, G., Evans, R., Anderson, A.V. et al. (2012) "Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain" Ann. Intern. Med. 156, 1-10; Editorial, Walker, B.F. and French, S.D. (2012), "Pain in the Neck: Many (Marginally Different) Treatment Choices" Ann. Intern. Med. 156, 52-53

Plastaras, C., Schran, S., Kim, N., Darr, D. and Chen, M.S. (2013) "Manipulative Therapy (Feldenkrais, Massage, Chiropractic Manipulation) for Neck Pain" Curr. Rheum. Rep. 15, 339 [abstract]

Posadzki, P. and Ernst, E. (2012) "Is Spinal Manipulation Effective for Paediatric Conditions? An Overview of Systematic Reviews" Focus Altern. Complement. Ther. 17, 22-26 [abstract]

Ernst, E. and Posadzki, P. (2012) "Chiropractic for the Prevention and/or Treatment of Sports Injuries: A Systemic Review of Controlled Clinical Trials" Focus Altern. Complement. Ther. 17, 9-14 [abstract]

Côte, P., Hogg-Johnson, S., Cassidy, J.D. et al. (2005) "Initial Patterns of Clinical Care and Recovery From Whiplash Injury" Arch. Intern. Med. 165, 2257-2263

Chiropractic - risks

Barrett, S. (2013) “Chiropractic’s Dirty Secret: Neck Manipulation and Stroke”

Rothwell, D.M., Bondy, S.J., and Williams, J.I. (2001) “Chiropractic Manipulation and Stroke: A Population-Based Case-Control Study” Stroke 32, 1054-1060

Reuter, U., Hämling, M., Kavuk, I., Einhäupl, K.M., and Schielke, E. (2006) "Vertebral Artery Dissections After Chiropractic Neck Manipulation in Germany Over Three Years" J. Neurol. 253, 724-730 [abstract]

Cassidy, J.D., Boyle, E., Côté, P. et al. (2008) "Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-Based Case-Control and Case-Crossover Study" Spine 33, S176-S183 [abstract]

Ernst, E. (2010) "Vascular Accidents After Neck Manipulation: Cause or Coincidence?" Int. J. Clin. Pract. 64, 673-677 [abstract]

Biller, J., Sacco, R.L., Albuquerque, F.C. et al. (2014) "Cervical Arterial Dissections and Association With Cervical Manipulative Therapy: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association" Stroke 45, 3155-3174

Ernst, E. (2001) “Prospective Investigations into the Safety of Spinal Manipulation” J. Pain Symptom Manage. 21, 238-242

Hurwitz, E.L. et al. (2005) “Frequency and Clinical Predictors of Adverse Reactions to Chiropractic Care in the UCLA Neck Pain Study” Spine 30, 1477-1484 [abstract]

Ernst, E. (2007) "Adverse Effects of Spinal Manipulation: A Systematic Review" J. R. Soc. Med. 100, 330-338

Ernst, E. (2010) "Deaths After Chiropractic: A Review of Published Cases" Int. J. Clin. Pract. 64, 1162-1165 [abstract]

Homola, S. (2009) "Chiropractic Neck Manipulation and Informed Consent" Skeptical Inquirer 33(4), 53-56

Cassidy, J.D., Bronfort, G., and Hartvigsen, J. (2012) "Should We Abandon Cervical Spine Manipulation for Mechanical Neck Pain? No" BMJ 344, e3680 [1st paragraph]

Vohra, S., Johnston, B.C., Cramer, K., and Humphreys, K. (2007) "Adverse Events Associated With Pediatric Spinal Manipulations: A Systematic Review" Pediatrics 119, e275-e283 [abstract]; Errata, Pediatrics 119, 867

Humphreys, B.K. (2010) "Possible Adverse Events in Children Treated by Manual Therapy: a Review" Chiropr. Osteopat. 18, 12

Chiropractic - promotional

Web sites for chiropractic organizations:

• American Chiropractic Association

• International Chiropractors Association

• World Chiropractic Alliance

• International Chiropractic Pediatric Association

• Palmer College of Chiropractic

Osteopathy

Barrett, S. (2003) “Dubious Aspects of Osteopathy”

Barrett, S. (2005) “Misleading Claims by the American Osteopathic Association”

Andersson, G.B.J., Lucente, T., Davis, A.M., Kappler, R.E., Lipton, J.A. and Leurgans, S. (1999) “A Comparison of Osteopathic Spinal Manipulation with Standard Care for Patients with Low Back Pain” New Engl. J. Med. 341, 1426-1431

Johnson, S.M. and Kurtz, M.E. (2001) “Diminished Use of Osteopathic Manipulative Treatment and Its Impact on the Uniqueness of the Osteopathic Profession” Acad. Med. 76, 821-828

Cummings, M. and Dobbs, K.J. (2005) “The Irony of Osteopathic Medicine and Primary Care” Acad. Med. 80, 702-705

Jäkel, A. and von Hauenschild, P. (2011) "Therapeutic Effects of Cranial Osteopathic Manipulative Medicine: A Systematic Review" J. Am. Osteopath. Assoc. 111, 685-693

Posadzki, P., Lee, M.S., and Ernst, E. (2013) "Osteopathic Manipulative Treatment for Pediatric Conditions: A Systematic Review" Pediatrics 132, 140-152

Licciardone, J.C., Minotti, D.E., Gatchel, R.J., Kearns, C.M. and Singh, K.P. (2013) "Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: A Randomized Controlled Trial" Ann. Fam.Med. 11, 122-129

Massage - overview

American Massage Therapy Association

Barrett, S. (2006) “Massage Therapy: Riddled with Quackery”

Sherman, K.J., Dixon, M.W., Thompson, D., and Cherkin, D.C. (2006) "Development of a Taxonomy to Describe Massage Treatments for Muscoloskeletal Pain" BMC Complement. Altern. Med. 6, 24

National Center for Complementary and Alternative Medicine (2014) "Massage Therapy for Health Purposes: What You Need To Know"

Vagg, M. (2012) "Myotherapy: Panacea or Placebo"

Massage - research

Cherkin, D., Eisenberg, D., Sherman, K.J. et al. (2001) “Randomized Trial Comparing Traditional Chinese Medical Acupuncture, Therapeutic Massage, and Self-care Education for Chronic Low Back Pain” Arch. Intern. Med. 161, 1081-1088

Cherkin, D.C., Sherman, K.J., Deyo, R.A. an Shekelle, P.G. (2003) “A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage Therapy, and Spinal Manipulation for Back Pain” Ann. Intern. Med. 138, 898-906 [abstract with link to free pdf file]

Cherkin, D.C., Sherman, K.J., Kahn, J. et al. (2011) "A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain: A Randomized, Controlled Trial" Ann. Intern. Med. 155, 1-9

Kumar, S. Beaton, K., and Hughes, T. (2013) "The Effectiveness of Massage Therapy for the Treatment of Nonspecific Low Back Pain: A Systematic Review of Systematic Reviews" Int. J. Gen. Med. 6, 733-741

Corbin, L. (2005) “Safety and Efficacy of Massage Therapy for Patients with Cancer” Cancer Control 12, 158-163 [contents page with link to pdf file]

Cassileth, B.R. and Vickers, A.J. (2004) “Massage Therapy for Symptom Control: Outcome Study at a Major Cancer Center” J. Pain Symptom Manage. 28, 244-249

Smith, C.A., Levett, K.M., Collins, C.T., and Jones, L. (2012) "Massage, Reflexology and Other Manual Methods for Managing Pain in Labour" Cochrane Database System. Rev., CD009290

Tsao, J. (2007) "Effectiveness of Massage Therapy for Chronic, Non-Malignant Pain: A Review" Evid. Based Complement. Altern. Med. 4, 165-179

Hanley, J., Stirling, P. and Brown, C. (2003) “Randomised Controlled Trial of Therapeutic Massage in the Management of Stress” Br. J. Gen. Pract. 53, 20-25 [abstract with link to pdf file]

Shoemaker, J.K., Tiidus, P.M., and Mader, R. (1997) “Failure of Manual Massage to Alter Limb Blood Flow: Measures by Doppler Ultrasound” Med. Sci. Sports Exerc. 29, 610-614 [abstract]

Hinds, T. et al. (2004) “Effects of Massage on Limb and Skin Blood Flow after Quadriceps Exercise” Med. Sci. Sports Exerc. 36, 1308-1313 [abstract]

Massage - risks

Yin, P., Gao, N. Wu, J., Litscher, G., and Xu, S. (2014) "Adverse Events of Massage Therapy in Pain-Related Conditions: A Systematic Review" Evid. Based Complement. Alternat. Med. 2014, 480956