CHIROPRACTIC, OSTEOPATHY, AND MASSAGE

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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 2024

This material was originally developed as the second in a series of handouts for an elective course given to medical students at the University of Louisville. An updated version was published in 2014.

Copyright 2024. 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.

CONTENTS

Chiropractic

         Background                           

         Principles                               

         Practice and scope                

         Arguments in favor              

         Arguments against               

         Other aspects                      

         Reviews: back pain             

         Reviews: headache             

         Reviews: other conditions    

         Review: multiple conditions  

         Summary                             

Osteopathy                                      

         Background                         

         Principles                             

         Techniques                          

         Reviews                               

         Other points                         

Massage                                          

         Practice and scope              

         Reviews and commentary  

         Adverse effects                   

         Other points                         

References                                       

CHIROPRACTIC

Background

1. History

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(5):544-562). Chiropractic was further developed by D.D. Palmer's son, B.J. Palmer.

2. Usage

There are an estimated 70,000 American chiropractors. Chiropractors are licensed in all states. According to the 2017 National Health Interview Survey, about 10% of American adults and about 3% of children aged 4-17 visited a chiropractor in the previous year. Most of these visits are for neuromusculo-skeletal problems; 30-45% are for low back pain (an estimated 25% of the population suffers from low back pain in a given year).

Peng et al. (2021. J Manipulative Physiol Ther. 44(8):591-600) reported that "The number of children visiting a chiropractor and percent utilization showed a statistically significant, increasing trend from 2007 to 2016; however, total expenditure and the number of chiropractic visits did not significantly differ during this period...The mean annual number of visits was 6.4 visits, with a mean expenditure of $71.49 US dollars (USD) per visit...Children and adolescent chiropractic users in the United States were primarily 14 to 17 years old...Chiropractic visits in this population primarily involved low back conditions (52.4%), spinal curvature (14.0%), and head and neck complaints (12.8%)."

"While it is true that most chiropractic visits for older children likely involve problems like neck and back pain, [those for] virtually all infants and very young children do not. Infants in particular are often seen for complaints such as fussiness, reflux, feeding problems, sleep problems, or for a desire to boost a babies’ immune system. Toddlers and school aged children are also commonly seen for non-musculoskeletal complaints, such as bedwetting, ear infections, or concerns about overall health and development" (Jones 2022 Jul 8. Science-Based Medicine blog).

Chiropractic is especially prominent in its country of origin, the United States, but is also a recognized health profession in Canada, Australia, and many European countries. Hartvigsen and French (2020. Chiropr Man Therap. 28(1):4) reported that "chiropractors are present in 90 of 193 United Nations member nations with the highest prevalence in high-income countries. Although chiropractors are legally recognized in 75% of those countries, and chiropractic treatment is fully or partially subsidized by national healthcare systems in around 50%, in some countries chiropractic does not fall under any law or may even be illegal." Hall (2020 Sep 22. Science-Based Medicine blog) noted that "Chiropractic is said to be hugely popular, but the evidence shows that its popularity is variable and usually modest."

3. Chiropractic education

Chiropractors are trained in 4-year schools, which vary greatly in quality, where they obtain the D.C. degree. Enrollment in U.S. chiropractic colleges decreased 40% from 1996 to 2002, to about 10,000, and was about 11,000 in 2022-3.

"In 1973 the U.S. Office of Education approved the Council on Chiropractic Education (CCE) to accredit chiropractic schools. In 2018, the requirements for admission to a CCE-accredited school included 90 credit hours (about 3 years) of prechiropractic college education with at least a 3.0 (out of 4.0) grade-point average. To receive the doctor of chiropractic (D.C.) degree, students must complete at least 4,200 hours of study over a 4-year period. Courses include anatomy, biochemistry, microbiology, pathology, public health, diagnosis and x-ray examination, related health sciences, and chiropractic principles and practice. Seventeen chiropractic programs in the United States have CCE accreditation" (Barrett 2022. A close look at chiropractic wrongdoing. Quackwatch).

"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 2012. Chiropractic. Institute for Science in Medicine). Elsewhere (2017 Jul 6. Science-Based Medicine blog) Bellamy noted that "a chiropractor, who has no legal limitation on the age of the patients he sees and few on the conditions he can claim he treats, can go into practice having seen only uncomplicated MSK [musculoskeletal] conditions in his entire clinical training and not a single pediatric patient."

"Some chiropractors try to downplay their lack of clinical experience by claiming that they spend more hours than medical students do in one subject or another. These claims are misleading because nearly all medical doctors undergo at least 3 additional years of full-time clinical training before going into practice, whereas nearly all chiropractors enter practice directly after graduation from their 4-year program. Moreover, in chiropractic colleges, instruction in many subjects, including pediatrics, obstetrics, and gynecology, is confined to the classroom, with little or no actual patient contact and no experience with hospitalized patients" (Barrett 2022. Op. cit.).

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. 444:236-42).

4. Insurance

"Chiropractic insurance coverage is generally considered an ancillary benefit. This means that a health plan may cover this benefit as an optional 'rider' added onto a major medical plan, or there may be certain restrictions to this benefit...Under the Affordable Care Act, Marketplace plans are required to cover 10 essential health benefits...However, chiropractic care isn’t included as an 'essential health benefit.' ...In some states, chiropractic insurance coverage may be a state-mandated benefit, meaning any plans sold in that state are required to cover chiropractic services...Original Medicare (Part B) covers medically necessary chiropractic care when provided by a Medicare-approved chiropractor. Coverage typically includes spinal adjustments to correct subluxations...Medicaid coverage for chiropractic care varies by state" (Plemons 2024 Feb 1. eHealth).

"Congress authorized VA [Veterans Affairs] to begin providing chiropractic care in 1999. Since 2004 VA provides these services to all eligible Veterans either on-station or through community care at all medical centers. One study demonstrated that from fiscal year 2005 through 2015 the number of on-station VA chiropractic clinics increased from 27 to 65, and the number of Veterans receiving care in these clinics increased from just over 4,000 to over 37,000" (U.S. Department of Veterans Affairs. Rehabilitation and prosthetic services).

Chiropractors promoted the "Chiropractic Medicare Modernization Act of 2019" (H.R. 3654), "which would expand government-funded Medicare coverage of chiropractors’ services beyond 'manual manipulation of the spine.' According to the ACA [American Chiropractic Association], which had a heavy hand in its drafting, the bill would mean Medicare coverage for chiropractic’s 'broad-based, non-drug approach to pain management' including spinal and extremity manipulation, evaluation and management services, diagnostic imaging and 'utilization of other non-drug approaches' to prevent opioid abuse. The bill accomplishes this, per the ACA, by 'appropriately defining' a Doctor of Chiropractic as a 'physician' in the Medicare program and providing patients 'access to all Medicare-covered benefits allowable under a chiropractor’s state license'." (Bellamy 2019 Aug 15. Science-Based Medicine blog). The bill died in committee.

“A medical retainer agreement is the perfect vehicle to promote the thoroughly discredited notion that everyone, including infants and children, would benefit from regular ‘spinal checkups’ and spinal ‘adjustment’ to promote health and prevent disease, or ‘wellness care.’ It has the added benefit to the chiropractor’s bottom line of avoiding insurance company limits on number of treatments and out-and-out refusal to cover quackery like the Webster technique, neuroemotional technique, cranial manipulation, and numerous other bogus diagnostic methods and treatments chiropractors offer and insurers reject for lack of evidence, not to mention basic biological plausibility” (Bellamy 2018 Mar 29. Science-Based Medicine blog).

5. Organizations:

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

• American Chiropractic Association (the largest organization) ("mixers" - utilize other modes of treatment in addition to manipulation. There are about four 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. 2007. J Hum Hypertens. 21(5):347-52).

Principles of chiropractic

1. Subluxations

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, the immune system, and visceral organs. The Meric system relates vertebrae with organs that are supposedly affected. 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.)

According to subluxation "theory," 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(5):544-62).

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." Similarly, "A 2015 publication of the National Board of Chiropractic Examiners (NBCE), Practice Analysis of Chiropractic 2015, states that 'The specific focus of chiropractic practice is known as the chiropractic subluxation or joint dysfunction. A subluxation is a health concern that manifests in the skeletal joints, and, through complex anatomical and physiologic relationships, affects the nervous system and may lead to reduced function, disability, or illness'" (Homola 2017 Jul 7. Science-Based Medicine blog).

"A new definition of the chiropractic subluxation, formulated by The Rubicon Group, an international consortium of seven chiropractic colleges which includes three subluxation-based chiropractic colleges in the United States...describes a 'neurologically-centered model of subluxation': 'We currently define a chiropractic subluxation as a self-perpetuating, central segmental motor control problem that involves a joint, such as a vertebral motion segment, that is not moving appropriately, resulting in ongoing maladaptive neural plastic changes that interfere with the central nervous system’s ability to self-regulate, self-organize, adapt, repair and heal'" (Ibid.).

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.”

Hall (2019. Skeptical Inquirer. 43(6):24-6) noted that “The World Health Organization (WHO) defines the chiropractic vertebral subluxation as ‘a lesion of dysfunction in a joint or motion segment in which alignment, movement integrity, and/or physiological function are altered, although contact between joint surfaces remains intact. It is essentially a functional entity, which may influence biomechanical and neural integrity’.”

"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(5):551-5).

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. 444:243-9).

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

Some chiropractors claim that nearly all infants have subluxations that must be treated, and that children need regular adjustments to prevent childhood disease. "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. 15:214-22). The genuine traumatic injuries often seen during birth make it easy for chiropractors to convince parents that the infant spines may need adjustment. But even routine infant care is alleged to cause subluxations. "Treatment is often continued for over three months, even in the absence of clinical improvement" (Ernst 2008. J Pain Symptom Manage. 35(5):544-62).

"Research aimed at categorising the chiropractic profession identity into exclusive subtypes found that at least 20% of chiropractors have an exclusive vertebral subluxation focus. However, deeper exploration of the literature shows that vertebral subluxation is an important practice consideration for up to 70% of chiropractors" (Glucina et al. 2020. Complement Ther Clin Pract. 39:101105).

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

"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 2003. Does the vertebral subluxation exist? https://chiro.org/LINKS/ABSTRACTS/Does_VS_Exist.shtml).

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

 2. Spinal manipulation in general

Some chiropractors do not accept the idea of subluxations, but nevertheless feel that spinal manipulation is beneficial.

Meeker and Haldeman (2002. Ann Intern Med. 136(3):216-27) listed five proposed mechanisms for spinal manipulation:

• "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"

"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(5):544-62).

Practice and scope

1. Spinal manipulation and mobilization

The major technique employed by chiropractors is manipulation of vertebrae, usually by hand. The chiropractic manipulation is also known as an adjustment.

LeFebvre et al. (2012. J Evid Based Complementary Altern Med. 18(1):75-9): "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, © 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."

Curtis and Bove (1992. J Fam Pract. 35(5):551-5): "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: "Spinal manipulation is a technique where practitioners use their hands or a device to apply a controlled thrust to a joint of your spine. The amount of force can vary, but the thrust moves the joint more than it would on its own. Spinal manipulation is different from spinal mobilization, which doesn’t involve a thrust, is performed within a joint’s natural range of motion, and can be controlled by the patient" (National Center for Complementary and Integrative Health 2024. Spinal manipulation: what you need to know). Homola (1999. What a rational chiropractor can do for you. Quackwatch) wrote: "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."

Herzog et al. (2001. Spine 26(19):2105-11) 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.”

2. Varieties of manipulation and other spine-directed methods

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

"Some techniques rely on sustained pressure by gravity alone, some employ a thrust, some apply sustained post-thrust pressure, some a recoil, some are applied as an assisted and some as a resisted force, some use mechanical instruments, others are done by hand, and so on. Although this, on the face of it, provides a richness of approach, we contend that it has potentially trapped the profession in an eternal and fruitless search for the correct way to identify the lesion and the best technique to fix it" (O'Neill et al. 2024. Chiropr Man Therap. 32(1):11).

"Spinal manipulation is normally a hands-on procedure, used as an option in the treatment of a musculoskeletal problem. Chiropractors who subscribe to subluxation theory, however, might use a spring-loaded or electrically powered mallet to tap alleged vertebral subluxations into alignment as treatment for any ailment the patient might have" (Homola 2018 Jun 22. Science-Based Medicine blog).

"The overwhelming majority of chiropractors who treat babies employ very gentle adjustment techniques, often using handheld spring loaded devices called Activators that impart barely enough force to briefly indent the skin let alone break a skull or spinal bone. Chiropractors who see kids frequently work the gentle nature of the treatments into their sales pitch, usually comparing the amount of force used to checking a tomato for ripeness" (Jones 2016 Dec 30. Science-Based Medicine blog).

The Graston technique "is an instrument-assisted soft-tissue therapy involving the use of hand-held stainless steel instruments. The promoters of the GT claim that the instruments resonate in the clinician's hands allowing the clinician to isolate soft-tissue 'adhesions and restrictions,' and treat them precisely" (Crothers et al. 2016. Chiropr Man Therap. 24:16). The authors found that neither GT nor spinal manipulation therapy performed better than placebo for thoracic spine pain.

"In the early 1930s, after nearly three decades of teaching that subluxations anywhere in the spine can cause disease, B.J. Palmer, the developer of chiropractic, announced that he had found the one and only cause of disease: subluxation of the atlas, the vertebra at the top of the spine (C1)...Members of the National Upper Cervical Chiropractic Association [NUCCA] specialize in adjustment of the atlas vertebra, using the procedure as a primary treatment for a great variety of ailments...In an effort to locate 'minor pain-free atlas subluxations' that allegedly cause brainstem ischemia and compromise brainstem neural pathways, NUCCA practitioners commonly use these procedures:

• A supine leg-length check that reveals disparities in leg length when the head is turned left or right.

• Use of thermography or infrared thermocouple devices to measure skin temperature over the cervical spine.

• A postural analysis using the 'NUCCA Anatometer' that requires standing on a platform apparatus that measures postural imbalance, pelvic distortion, head tilt, and unequal right and left leg weight bearing.

• Three x-ray views of the atlas-axis area.

• Use of a protractor to measure atlas alignment.

The patient is then placed in a side-posture position (lying down) so that the heel of the hand (pisiform bone) or a machine stylus can be used to adjust the 'misaligned' atlas" (Homola 2019 Nov 22. Science-Based Medicine blog).

Functional Neurology "is based on the theory that lesions in the nervous system, including the brain, consisting of groups of dysfunctional neurons, explain many health conditions and that these lesions can be successfully improved by various types of stimulation, including spinal manipulation...We found no acceptable evidence in favour of effect/benefit of the FN approach. We therefore do not recommend its promotion as an evidence-based method" (Demortier and Leboeuf-Yde 2020. Chiropr Man Therap. 28(1):9).

The Webster Technique "is a method of adjusting alleged sacral subluxations in order to prevent breech birth and to assure a normal delivery by facilitating 'neuro-biomechanical function in the pelvis.' Whatever effect sacral manipulation might have on the body, there is no reason to believe that a sacral adjustment will improve nerve flow to the uterus or affect sacral nerves which pass through solid bony openings....Use of the Webster Technique to realign the sacrum in order to facilitate childbirth by reversing a breech presentation can endanger both the mother and the fetus by delaying appropriate care" (Homola 2020 Feb 11. Science-Based Medicine blog).

"The drop table chiropractic technique is claimed by chiropractors to involve lesser brute force for spinal manipulation than traditional chiropractic care. It involves low-velocity movement and less spinal manoeuvring on the specific area of injury. It is said to be particularly beneficial for adjusting the pelvis or sacroiliac joints...chiropractic manipulative therapy involving the commonly used drop-table can cause severe injury" (Ernst 2023 Dec 5. Edzard Ernst blog).

"Spinal decompression is a type of traction therapy applied to the spine in an attempt to bring about several theoretical benefits including:

• Create a negative intradiscal pressure to promote retraction or repositioning of the herniated or bulging disc material.

• Create a lower pressure in the disc that will cause an influx of healing nutrients and other substances into the disc.

While the fundamental theory of spinal decompression is widely accepted as valid, there is a lack of evidence supporting decompression therapy as being efficacious. Additionally there are some potential risks" (Gay 2013. All about spinal decompression therapy. Spine-Health.com). Many chiropractors use the VAX-D or similar motorized traction devices. A Cochrane Review (Wegner et al. 2013. Cochrane Database Syst Rev. CD003010) concluded that "traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP [low-back pain]."

Homola (2018 Sep 14. Science-Based Medicine blog) discussed some other approaches:

• "Combining two extremes, the Sacro-Occipital Technique, 'based on the provable fact that every human who is sick or in pain has a distortion and a subluxation responsible for that sickness or pain,' required manipulation of both the occiput and the sacrum to restore nerve function by removing interference with the circulation of cerebrospinal fluid."

• "The Parker System, developed by a practice-building expert, taught full-spine adjusting based on a full-spine x-ray exam in order to increase the income of chiropractors. Displacement of vertebrae was measured in millimeters which were added up to determine the number of adjustments that would be needed to cure the patient’s condition."

• "Surface electromyography (sEMG), paraspinal scanning with a hand-held device to detect electrical activity in muscles allegedly affected by vertebral subluxations, is a popular method of locating chiropractic subluxations."

• "Thermography used to record skin temperature up and down the spine is often used along with sEMG to produce colorful printouts indicating the presence of vertebral subluxations. Extraneous factors that influence the flow of blood to the skin, or a little more pressure applied with a hand-held scanning tool, will produce indications of an abundance of subluxations in areas of the spine where a particular chiropractor might prefer to work."

• "Many subluxation-based chiropractic techniques include use of a Derifield leg-length check to determine the need for an adjustment to correct a subluxation or to evaluate the results of an adjustment. Supposedly, a functional leg-length discrepancy is a temporary non-structural imbalance caused by the effect a vertebral subluxation has on musculoskeletal structures. Leg lengths, determined by bringing the feet together for visual inspection, return to normal when the subluxation has been corrected."

3. Other approaches

A 2003 survey by the National Board of Chiropractic Examiners revealed that 70% of chiropractors 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” (Sandefur and Coulter. Licensure and legal scope of practice. https://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. Op. cit.).

“A series of articles in an American Chiropractic Association publication...recommends that chiropractors employ diagnostic methods like fasting metabolic panels, lipid profiles, high sensitivity CRP to assess the level of endothelial inflammation and the risk of a cardiovascular event, hemoglobin A1c (HbA1c) profile, auscultation, thyroid palpation, assessment of bowel sounds, palpation of the abdomen, prostate exams, and rectal exams. This same series suggests that chiropractors can ‘co-manage’ metabolic syndrome, diabetes, hypertension, hyperlipidemia, obesity, arthritis, osteomalacia, osteopenia, osteoporosis, malnourishment, and depression” (Bellamy 2018 Mar 29. Science-Based Medicine blog).

Bellamy (2021 Jun 17. Science-Based Medicine blog) reported that the American Chiropractic Association "has gone so far as to establish the ersatz specialty of 'chiropractic internist,' billing it as 'the only natural primary care doctors that are licensed in all 50 states.' One can become a 'chiropractic internist' after a series of weekend classes in hotel conference rooms, taught by other chiropractors and containing little to no clinical training, and taking a test that, as far as I can tell, no one but chiropractors has evaluated or even seen." It was claimed that a chiropractic internist would be qualified to treat a wide range of diseases. In another post, she discussed the seminars in more detail: "...each 12-hour weekend covers a topic (or topics) that would ordinarily consume weeks of education and training in a real internal medicine residency. For example, 'Infectious Diseases and Emergency Disorders' is covered one weekend, as is 'Geriatrics and Mental Health.' Cardiovascular Disease? 12 hours. Pulmonary Disease and Lung Function? 12 hours. Dermatology? 12 hours. And so on" (Bellamy 2017 Jan 5. Science-Based Medicine blog).

Some states allow chiropractors to set up direct primary care agreements with their patients, providing most primary care services for a regular fee.

A survey of chiropractors by Gliedt et al. (2021. BMC Health Serv Res. 21(1):1049) found that "Respondents self-identified into three distinct subgroups based on the perceived role of the chiropractic profession in the greater healthcare system: 56.8% were spine/neuromusculoskeletal focused; 22.0% were primary care focused; and 21.2% were vertebral subluxation focused."

Another survey, of chiropractic students, found that "A majority agreed (35.6%) or strongly agreed (25.8%) the emphasis of chiropractic intervention is to eliminate vertebral subluxations/vertebral subluxation complexes. A large number of respondents (55.2%) were not in favor of expanding the scope of the chiropractic profession to include prescribing medications with appropriate advanced training" (Gliedt et al. 2015. Chiropr Man Therap. 23(1):4).

4. Other aspects

Chiropractors recommend frequent checkups and maintenance treatments. The use of X-rays for diagnosis appears to be declining, and "routine use of x-ray is not in accordance with current evidence and practice guidelines" (Hartvigsen and French 2020. Chiropr Man Therap. 28(1):4).

"Modern maintenance care aims to keep patients healthy regardless of their symptoms or history, alleviating and preventing pain through regular, prolonged care. This approach is largely preventive, serving as both secondary and tertiary care. Studies show chiropractic maintenance care often includes diverse treatments such as manual therapy, stress management, nutrition advice and more, with flexible intervals typically around three months...In the last several years, chiropractic maintenance care has changed; no longer does it only involve pain prevention and management for those with chronic conditions. It now encompasses all sorts of patients; no matter their history, symptoms or reasons for seeking a DC" (Anon. 2024 Jun 14. Chiropractic Economics).

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).

There is 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.

Arguments in favor of chiropractic

Many studies and reviews indicate some value of spinal manipulation for back pain (see reviews below).

"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).

Chiropractic has a large number of satisfied patients. Chiropractors may be seen as more caring than medical doctors. “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 Q. 81(1):107-38).

Hertzman-Miller et al. 2002 (Am J Public Health. 92(10):1628-33), 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.

Chiropractic is 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. Op. cit.).

Arguments against chiropractic

1. Subluxations - general

Homola (2019 May 27. Science-Based Medicine blog) wrote: "Simple or slight misalignment of a vertebra, often referred to by chiropractors as a 'subluxation,' can be caused by disc degeneration, curvatures, and structural abnormalities. Such a subluxation is common and cannot be corrected; it may or may not be mechanically symptomatic and can be seen on a plain x-ray image. In the absence of pathology such as disc herniation or osteophyte formation, vertebral subluxations or misalignments rarely affect spinal nerves and have never been associated with organic disease, even when a spinal nerve has been severely compressed. The reason for this is that spinal nerves supply skin and musculoskeletal structures while the body’s organs are supplied by autonomic ganglia and nerve plexuses located outside the spinal column and by autonomic cranial and sacral nerves that pass through solid bony openings. The involuntary function of organs can be sustained by hormones and other factors supplied by the flow of blood when nerve supply has been severed, as shown in the case of a transplanted organ. The body’s organs continue to function (supplied by blood flow and autonomic nerves) when a spinal cord injury in the neck paralyzes musculoskeletal structures from the neck down by shutting off brain impulses to spinal nerves.

"An orthopedic vertebral subluxation that causes pain and loss of mobility in the spine (often as a result of injury) or a compressed spinal nerve that causes pain and other symptoms in musculoskeletal structures cannot be equated with a chiropractic subluxation or an asymptomatic 'vertebral subluxation complex' that is alleged to cause disease by interfering with nerve supply to organs. Such a subluxation, with or without nerve root compression, has never been proven to exist. There is no plausible theory and no credible evidence to support the contention that 'nerve interference' originating in a single spinal segment can cause an organic disease. There is no reason to believe that the temporary physiological effects of spinal manipulation can affect the cause of an organic disease."

"...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).

Hall (2019. Skeptical Inquirer. 43(6):24-6) wrote, “Real medical illnesses are usually much better defined [than chiropractic subluxations]. Anyone can diagnose diabetes on the basis of blood sugar measurements or anemia on the basis of hemoglobin levels in the blood. But you would have to be a chiropractor to use these definitions of subluxation to diagnose a subluxation. They amount to gobbledygook designed to provide an excuse for chiropractors to ‘adjust’ the spine of any patient they want to treat.”

Continuing progress in scientific medicine has led to more detailed explanations for the causes of disease, often at the molecular level, but no information has emerged 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. Op. cit.).

"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).

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?

2. Critiques of subluxation concept from within the profession

"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).

"A 2015 Position Statement on Clinical and Professional Chiropractic Education, representing seven European chiropractic colleges, does not support chiropractic subluxation theory: 'The teaching of vertebral subluxation complex as a vitalistic construct that claims that it is the cause of disease is unsupported by evidence. Its inclusion in a modern chiropractic curriculum in anything other than an historical context is therefore inappropriate and unnecessary'" (Homola 2017 Jul 7. Science-Based Medicine blog).

"...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 2012. Chiropractic. Institute for Science in Medicine White Paper).

3. Subluxations and the nervous system

Chiropractic is based on a scientifically invalid view of the role of nervous system in all organ function. Chiropractors cannot define what aspect of nerve impulse is affected by subluxation.

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?

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. "Spinal nerves are commonly compressed by bony spurs and herniated discs. Even the most severe compression of a spinal nerve, which may cripple the supplied musculoskeletal structures, does not cause organic disease. In the absence of fracture or pathology such as disc herniation or osteophyte formation, vertebral misalignments rarely affect spinal nerves" (Homola 2023 Feb 21. Science-Based Medicine blog).

Nansel and Szlazak  (1995. J Manipulative Physiol Ther. 18(6):379-97) wrote "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 (2001. Scientific Rev. Alternative Med. 5(1):45-53): “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.”

4. Diagnostic issues

“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” (Ramey and Rollin 2004. Complementary and Alternative Veterinary Medicine Considered).

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

"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 May 3. Science-Based Medicine blog).

Ingraham (2022. Does spinal manipulation work? PainScience.com) wrote: "There are many ideas about how manipulation helps if it helps, but this is the main one: the mechanical action and/or sensory stimulation supposedly normalizes spinal joint movement. This is a less simplistic version of supposedly putting them 'back in place,' but it’s still quite simplistic...The unstate premise is that spinal joints can become some kind of stuck in the first place, moving inadequately or abnormally - one definition of a 'subluxation' - and presumably this state of affairs is annoying, like a grain of sand in your mouth, not necessarily serious, but obvious and irritating, and probably progressively aggravating over time. It’s unclear whether or not this actually happens to spinal joints in the first place. And, if it does, it’s probably difficult to reliably identify which joints it has happened to. The art of identifying stuck spinal joints is 'motion palpation,' and in a 2015 test, two expert motion palpators could not agree on the location of joint stiffness or pain in a couple dozen patients...And...does SMT change spinal joint movement? A 2016 review says 'no.' There are individual trials that show otherwise...but Aguirrebeña et al conclude that the trial data isn’t compelling: 'Evidence does not support an effect on segmental vertebral movement'. If there’s any movement dysfunction in the first place, this paper concludes that it’s unlikely that it can be put right. But it’s more likely that the premise is just bogus, and joints just aren’t 'stuck' or 'out' in any kind of important way in the first place...or only so rarely, and/or in such specific types of patients, that it’s just an undetectable phenomenon without much more statistically powerful studies."

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 review by Corso et al. (2020. Chiropr Man Therap. 28(1):33) found "no evidence that the use of routine or repeat radiographs to assess the function or structure of the spine, in the absence of red flags, improves clinical outcomes and benefits patients."

"Spinal X-rays can lead to the detection of radiographic findings that can be used as an overdiagnosis for the patient, even though they may be asymptomatic. These include spinal anomalies, osteophytes, reduced disc heights, low-grade spondylolisthesis, transitional segments, and spina bifida occulta. The chiropractor can use all radiographic findings as 'scare tactics' or 'fear-mongering' to retain a patient under a specific frequency of care, thus creating unnecessary concern for the patient. Multiple studies have concluded that radiographic findings do not always correlate with a patient’s symptomatology" (Williams et al. 2024. J Clin Imaging Sci. 14:18. Note: this paper has been retracted for reasons unrelated to this quote).

A review by Nolet et al. (2021. Chiropr Man Therap. 29(1):33) concluded that "Reliability of manual palpation tests in the assessment of LBP patients varies greatly. This is problematic because these tests are commonly used by manual therapists and clinicians. Little is known about the validity of these tests; therefore, their clinical utility is uncertain."

A review by Nim et al. (2021. Sci Rep. 11(1):23415) concluded that "The current evidence does not support that SMT [spinal manipulation therapy] applied at a supposedly 'clinically relevant' candidate site is superior to SMT applied at a supposedly 'not clinically relevant' site for individuals with spinal pain."

5. Alleged benefits

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(6):379-97).

"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" (ibid.).

Nelson et al. (2005. Chiropr Osteopat. 13:9): "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."

6. Comparison to other treatments

Hall (2019. Skeptical Inquirer. 43(6):24-6) wrote, “Chiropractic’s main claim to fame is spinal manipulation therapy (SMT). But SMT is not uniquely chiropractic; it is also used by physical therapists, doctors of osteopathic medicine (DOs), and some medical doctors (physiatrists, physical medicine and rehabilitation specialists). SMT is somewhat effective for low back pain, but it is not more effective than other standard treatments, such as analgesics, physical therapy care, exercises, and back school (practical training in proper lifting and other ways to minimize stress on the back). So it is a reasonable choice but can’t be recommended as the superior treatment of choice...Claims that SMT benefits conditions other than low back pain and neck pain are not supported by scientific evidence. It is not effective for asthma, infant colic, ear infections, sleep and feeding problems, health maintenance, or indeed for any non-musculoskeletal condition...There is no accepted indication for offering chiropractic treatments to young children, and many experts consider it a form of child abuse.”

Reviewing Edzard Ernst's book on chiropractic, Hall (2020 Sep 22. Science-Based Medicine blog) noted that "For acute low back pain, the average patient can expect a 50/50 chance of up to a 20% improvement in pain and function, but more than 50% will report harms such as increased pain and muscle stiffness. A new drug with that risk/benefit ratio would not be approved for marketing. For chronic low back pain, the evidence shows that the treatment of choice is exercise and continued normal activity. For neck pain, the evidence is too weak to recommend SMT for routine use. One analysis showed that 31-66% of patients using chiropractic for back or neck pain also took opioids, a sad commentary on the effectiveness of chiropractic."

Citing a review of spinal manipulation therapy for chronic low back pain, Ernst (2021 Aug 25. Edzard Ernst blog) wrote, "This means that SMT has effects that are very similar to placebo (the uncertain effects on function could be interpreted as the result of residual de-blinding due to a lack of an optimal placebo or sham intervention). In turn, this means that the effects patients experience are largely or completely due to a placebo response and that SMT has no or only a negligibly small specific effect on back pain. Considering the facts that SMT is by no means risk-free and that less risky treatments exist, the inescapable conclusion is that SMT cannot be recommended as a treatment of chronic back pain."

7. Adverse effects

Spinal manipulations have resulted in fractures, disk ruptures, strokes, and even fatalities (though such complications are rare considering the enormous number of treatments). The degree of safety is difficult to assess because there is no surveillance system for adverse effects, and research studies have been deficient in their reporting. A review by Gorrell et al. (2023. BMJ Open. 13(5):e067526) concluded that "While the current level of reporting of adverse events associated with spinal manipulation in RCTs [randomized controlled trials] has increased since our 2016 publication on the same topic, the level remains low and inconsistent with established standards."

a. Vertebrobasilar artery dissection and stroke

Chiropractic treatment involving rotation of the head presents a risk to the cervical arteries, leading to stroke. "Neck manipulation should not be done except in the case of a carefully selected mechanical-type neck problem in which use of manipulation, like mobilization, does not involve rotating the head to force rotation of upper cervical structures beyond normal ranges of movement (into the paraphysiologic joint space), stretching vertebral arteries in the atlanto-axial area. Risk certainly outweighs benefit when any neck manipulation is based on correction of a putative chiropractic subluxation" (Homola 2023 Feb 21. Science-Based Medicine blog).

Among estimates of the incidence of stroke following chiropractic cervical manipulation are 1.3 per 100,000 visits (Rothwell et al. 2001. Stroke. 32(5):1054-60) and 1 in 6 million visits (Haldeman et al. 2001. Can Med Assoc J. 165:907-8). 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. (2003. Neurology. 60(9):1424-8) concluded that “SMT is independently associated with vertebral arterial dissection, even after controlling for neck pain.” More recently, an incidence of 1 stroke in 20,000 cervical manipulations has been cited (e.g., Britt et al. 2023. Vertebral artery dissection. StatPearls).

Cassidy (2008. Eur Spine J. 17(Suppl 1):176–83) 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 (2010. Perfusion 23:73-74; 2010. Int J Clin Pract. 64(6):673-7) 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.

Ernst (2023 Feb 20. Edzard Ernst blog) wrote, "I am impressed by the number of cases that go to court where a settlement of some sort is reached and further reporting of the incident is prevented. As a consequence, these cases are not published in the medical literature. In turn, this means that chiropractors can continue to claim that these complications do not exist or are exceedingly rare."

b. Other

A review by Ernst (2001. J Pain Symptom Manage. 21(3):238-42) concluded that “about half of all patients will experience adverse events after chiropractic SM [spinal manipulation]. 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 an update, Ernst (2008.  J Pain Symptom Manage. 35(5):544-62) wrote: "Since then, two further prospective studies (n=465 and 336, respectively) reported that such adverse effects occur in 61% and 30% of patients."

In addition to stroke, "Serious complications associated with chiropractic adjustment are overall rare, but may include:

• A herniated disk or a worsening of an existing disk herniation

• Compression of nerves in the lower spinal column"

(Mayo Clinic 2022. Chiropractic adjustment).

"Some physicians say the proliferation of infant chiropractic care on social media is concerning because the treatments, particularly in the wrong hands, could be risky. Those physicians say one worry is that a baby’s bones are softer, making them more malleable under pressure, and joints are looser, making them prone to overstretching" (Amenabar 2022 Sep 15. Washington Post).

Homola (2017 Jul 7. Science-Based Medicine blog) wrote, "I do not know of any medically acceptable diagnosis that would warrant manipulating the spine of a pre-adolescent child. The cartilaginous, immature spine of an infant or a small child should never be manipulated, as some chiropractors are doing to correct alleged 'subluxations'."

In another article (2016. Bioethics. 30(2):63-8) he wrote: "The cartilaginous vertebral growth centers of pre-adolescent children under the age of 8 to 10 years are most vulnerable to injury caused by spinal manipulation. Such injury may not be detectable. 'The incidence of subtle growth plate fractures following high-velocity [manipulation] techniques is surely unappreciated because of the occult nature of these injuries' [O'Neal et al. 2003. Compr Ther. 29(2):124-9]. Spinal manipulation clearly has the potential to injure the spine of a child. A systematic review of 13 studies published up to June 2004 uncovered 14 significant manipulation-related injuries in children up to 18 years of age, 9 of which were serious...and 2 of which were fatal..."

Hurwitz et al. (2005. Spine. 30(13):1477-84)) 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.”

"Reports of serious adverse events from spinal manipulation during pregnancy are very rare, but there has not been much rigorous research on this topic" (NCCIH 2024. Spinal manipulation: what you need to know).

Patients may be delayed in or prevented from obtaining necessary medical care. Butler (1992. A Consumer's Guide to "Alternative Medicine," pp. 83-4) noted that given symptoms of ulcer and heart conditions, chiropractors recommended manipulation rather than referring to physician.

There is a 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 (2003. Br J Sports Med. 37(3):195-6): “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 can result in radiation exposure.

"Diagnosis and treatment of chiropractic subluxations adds a substantial burden to health care costs with no return in terms of benefit" (Bellamy 2012. Chiropractic. Institute for Science in Medicine White Paper White Paper).

An adverse psychological effect is the dependence on "maintenance" treatments for continued health. Another psychological aspect was discussed by Ingraham (2022. Does spinal manipulation work? PainScience.com): "SMT can badly frighten patients, which is a serious risk factor for chronic neck and back pain. This is certainly not a life-threatening risk, but it’s not trivial either. The nervous patient has much to lose with SMT. Patients may be nervous because:

• they believe their spine is more fragile and vulnerable than it really is (and talk of 'subluxations' usually aggravates this anxiety), and/or because

• the idea of spinal adjustment bothers them in any case (many people are 'freaked out' by the idea of spinal joint cracking).

Combining these factors - acute pain, minor potential therapeutic benefits, a high rate of harm, fear of your spine’s fragility, fear of the treatment - is all just a recipe for disaster. And so, although many clients have reported being 'cured' by chiropractic treatment...many also have reported being 'ruined' by a chiropractic treatment they found to be intense and terrifying and painful. This unfortunate situation may then be more deeply aggravated by the therapist’s response: using the bad reaction as evidence of profound structural instability in the spine, and as a justification for (much) more treatment."

c. Refutation of chiropractic arguments

Ernst (2024 Jan 2. Edzard Ernst blog) listed 17 chiropractic arguments about safety, along with his responses. Here are four of them:

• "There are hundreds of clinical trials that demonstrate the safety of CSMs [chiropractic spinal manipulations]. This argument is utterly unconvincing for at least two reasons: firstly clinical trials are far too small for identifying rare (but serious) complications; secondly, we know that clinical trials of CSM very often fail to report adverse events."

• "Case reports of adverse effects are mere anecdotes and thus not reliable evidence. As there is no post-marketing surveillance system of adverse events after CSMs, case reports are, in fact, the most important and informative source of information we currently have on this subject."

• "Case reports cannot establish cause and effect. True, but they do provide important signals which then should be investigated further. It would be up to chiropractors to do this; sadly, this is not what is happening."

• "Patients who experience harm had pre-existing issues. Again, this notion is mostly based on wishful thinking and not based on sound evidence...it is irresponsible to administer CSM if there is the possibility that pre-existing issues are present."

8. Vaccinations

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

Campbell et al.(2000. Pediatrics. 105(4):E43) reviewed chiropractic attitudes toward vaccinations: “...a vocal element of the chiropractic profession maintains a strongly antivaccination bias.”

"The ICA Policy on Immunization and Vaccination has remained unchanged for almost 50 years and clearly states: 'The International Chiropractors Association recognizes that the use of vaccines is not without risk and questions the wisdom of mass vaccination programs.  Chiropractic principles favor the enhancement of natural immunity over artificial immunization...'" (Clay 2021 Oct 12. International Chiropractors Association affirms policy on health freedom).

“In the past several years, as more states have considered tightening their vaccination policies, chiropractors have quietly emerged as sources of fundraising and support for the movements fighting to defend religious exemptions” (Schulson 2020 Apr 11. Undark).

9. Pediatric chiropractic (see also "adverse effects" and "vaccinations" above)

Lee et al. (2000. Arch Pediatr Adolesc Med. 154(4):401-7) 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.”

Jones (2016 Feb 27. Science-Based Medicine blog) wrote, "There is a lot of cold reading that goes on during these visits which can give the impression that the chiropractor’s examination uncovered problems like constipation or colic. Most of the time the parent has told the chiropractor what the problem is and naturally the cause, a subluxation, is discovered at just the right spot to explain it. Some do a better job than others. Often the chiropractor reacts to random non-purposeful movements, yawns, crying, etc. by working it into the narrative. If a baby begins to cry during palpation, they found a bothersome area. If the baby happens to stop crying, the adjustment did the trick."

"When I see a chiropractor palpate the fat-padded, cartilaginous spine of a baby and then proceed to adjust a subluxation, I suspect that the chiropractor is pretending to have found a subluxation and then pretends to manipulate the spine. If the chiropractor is convinced that a subluxation has been found in the baby’s spine, use of a thrust-type manipulative technique dictated by subluxation theory may result in injury that is not detectable, such as a fracture in a radiolucent ossification center. Pediatric chiropractors who simply use finger-tip pressure or a spring-loaded stylus in a misguided attempt to tap a vertebra into alignment may not injure the baby, but such pretentious care can certainly delay appropriate treatment by misinforming the parents of the child" (Homola 2016 Feb 26. Science-Based Medicine blog).

10. Pseudoscientific aspects

The "theory" behind chiropractic was originated by a layman who engaged in quackery.

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

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

There is reliance on anecdotal claims rather than controlled studies

Chiropractic promotional material is filled with scientifically dubious statements

The concept of subluxations is isolated from other sciences, and 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 are 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. Applied kinesiology is discussed in the article "Chelation Therapy; Allergy and Arthritis Treatments; Other Miscellaneous Topics."

Some chiropractors use a "nervoscope" "to detect uneven heat distribution across spinal bones with subluxations. They claim that this represents inflammation or nerve pressure. In reality, it represents how hard the device is pressed against the skin and allows for a subluxation to always be found" (Jones 2021 Aug 6. Science-Based Medicine blog).

Chiropractors may employ other unscientific treatments, "including homeopathy, acupuncture, cupping, applied kinesiology, electrodermal testing machines like Vega Test, energy healing, detox, chelation, and untested dietary supplements" (Hall 2020 Sep 22. Science-Based Medicine blog).

Novella (2017 Mar 22. Science-Based Medicine blog) wrote, "There are two schools of thought within the science-based medicine community, and it is an interesting dilemma. There are those who think that the chiropractic profession needs to be brought within the sphere of science and evidence. They should purge themselves of pseudoscience, limit their practice to evidence-based interventions, and meaningful engage in research and with mainstream medical practice. If they did there is a role for them as health professionals with expertise in certain musculoskeletal conditions. The other school of thought is that the chiropractic profession is hopelessly and inherently pseudoscientific. It cannot be reformed, and should only be opposed. It is fundamentally based on philosophy, rather than science, and culturally is anti-science and anti-mainstream medicine. The few exceptions are a tiny minority with no political power within the profession. I could go either way in this debate, as both sides have legitimate points. What is clear is that currently we are stuck in the middle, with a chiropractic profession that has legal and cultural legitimacy it has not earned and does not deserve. Far from moving toward being more science-based, chiropractors (as a profession) continue to embrace pseudoscience, or at least do not oppose it within their own profession."

11. Other criticisms

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. 15:284-7).

Some criticisms of specific techniques are included in the section "Varieties of manipulation and other spine-directed methods" above.

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.

Simpson and Innes (2020. Chiropr Man Therap. 28(1):60) asked, "Can a patient ever provide informed consent for the removal of an entity (VS) [vertebral subluxation] without credible evidence / reasonable grounds? Can VS care ever meet the code of conduct standards when it lacks an evidence base and is practitioner-centered?"

Chiropractic - other aspects

1. Political and legal issues

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

Chiropractors won a lawsuit against the American Medical Association (AMA) for restraint of trade in 1987 (Wilk et al v. AMA et al). The 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.

2. Marketing and practice issues

Chiropractic is associated with 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.

"Many chiropractors offer contracts under which patients pay in advance or agree to pay for many visits at a 'discount' price. I have seen contracts for as many as 100 visits. Chiropractors who offer them typically tell all patients that long-term care is needed to prevent recurrence, spinal degeneration, or various serious diseases. Some chiropractors display a chart of 'subluxation degeneration' or 'spinal decay' that they say is inevitable without intensive and/or long-term care. Some tell nearly all of their patients that the curvature of their neck needs to be changed. All such advice represents overselling. 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. In addition to excessive visits, contracts often contain provisions intended to discourage quitting." (Barrett 2021. Don't pay or contract in advance for chiropractic visits at a "discount" price. Quackwatch).

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.

"A sharp escalation of 'multidisciplinary' clinics illicitly owned by chiropractors has arisen in recent years. These clinics might offer massage therapy, physical therapy and other treatments, in addition to chiropractic care. This greatly multiplies opportunities for false billing...These clinics position themselves to insurers as group medical practices. Assistants or nurse practitioners provide invasive treatments such as trigger-point and knee-point injections. Chiropractic manipulation services may not be reported - or billed as something else - in order to cloak the illegal chiropractic owners in states where chiropractors cannot own true medical clinics" (Bowerman 2018 Feb. Journal of Insurance Fraud in America).

"A shocking 82 percent of the chiropractic services billed to Medicare is unallowable, according to a recent audit by the Office of Inspector General" (Ernst 2023 Nov 5. Edzard Ernst blog).

Barrett (2020. Some notes on the Pastoral Medical Association and other "private membership associations." Credential Watch) wrote: "Hundreds of practitioners are using the credentials 'PSc.D.,' 'D.PSc.,' and/or 'Doctor of Pastoral Medicine' to promote their services. These titles come from the Texas-based Pastoral Medical Association (PMA), which 'licenses' practitioners and registers prospective patients as 'members' who wish to receive care from these providers. The PMA...describes itself as 'a private ecclesiastical membership association with a mission to promote scripture-based health and wellness concepts.' Its practitioner members typically offer medical services that require a government-issued license to provide, but the PMA asserts that 'regulation of the Almighty’s health care concepts is outside the jurisdiction of...secular regulatory boards'...I found that most of the licensed members are chiropractors...People who wish to receive treatment from the Pastoral Medical Association’s 'licensed' members are required to join its 'Member Share Program' by signing its Member Share Agreement...In simple terms, the agreement calls for patients assume all of the risks of a provider-patient relationship without any government protection."

3. Use of subluxation concept

Funk et al. (2018. Chiropr Man Therap. 26:24) examined chiropractic curricula for the use of the term “subluxation.” It was mentioned in almost all U.S. chiropractic colleges, and much more frequently than in foreign college curricula, suggesting that “professional identity in non-US countries is not as dependent upon adherence to the subluxation construct as in the US.” One possible reason for retaining the concept in the U.S. is that it is used in professional practice acts, as well as in accreditation standards.

"Making an effort to separate themselves from the stigma associated with chiropractic subluxation theory, some subluxation believers no longer use the 'subluxation' word, instead substituting vague descriptions of a spinal problem, such as a 'joint dysfunction' or a 'neuro-biomechanical lesion.' Some of these descriptions do not involve displacement of a vertebra, but all are alleged to have an adverse effect on the nervous system and general health. You cannot rely upon the care of a chiropractor who claims to have abandoned the vertebral subluxation theory but who continues to manipulate the spine in an attempt to restore and maintain health by removing nerve interference – care that is no different from that of a subluxation believer" (Homola 2017 Jul 7. Science-Based Medicine blog).

4. Psychological effects of manipulation

"Aside from physical effects, spinal manipulation has powerful placebo and nocebo effects that perpetuate such treatment beyond reasonable use. Manipulation can produce popping sounds (cavitation) in normal joints. Such popping is not considered to be significant, but it can have a powerful placebo effect among those who believe that the popping sound signals correction of a dangerous subluxation. Unfortunately, some chiropractors allow their patients to believe that a popping sound means that vertebral subluxations are always present, producing a nocebo effect that lures fearful chiropractic patients and their families into a program of regular spinal adjustments in order to maintain health by keeping their vertebrae aligned" (Homola 2023 Feb 21. Science-Based Medicine blog).

"The main skeptical take on cracking/SMT is that it’s a blast of novel sensory input that has a transient, minor effect analogous to finally getting to stretch your legs after getting off a long flight, or scratching an itch. When you really want to move, when you feel stiff, even a teensy bit of extra joint movement can feel very welcome" (Ingraham 2022. Does spinal manipulation work? PainScience.com).

Reviews and meta-analyses of spinal manipulation therapy (SMT): back pain (2000-present only)

• Ferreira at al. 2002. Aust J Physiother. 48(4):277-84: "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. 2003. Ann Intern Med. 138(11):871-81: “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 2003. Milbank Q. 81(1):107-38: “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 2003. Physical Ther. Rev. 8:85-91: "The effectiveness of chiropractic spinal manipulation is not supported by compelling evidence from the majority of randomised clinical trials."

• Bronfort et al. 2004. Spine J. 4(3):335-56: "Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP [neck pain]."

• Ernst 2008. J Pain Symptom Manage. 35(5):544-62: "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."

• Rubinstein et al. 2011. Cochrane Database Syst Rev. CD008112: "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..."

• Rubinstein et al. 2012. Cochrane Database Syst Rev. CD008880: "SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies."

• Merepeza 2014. J Can Chiropr Assoc. 58(4):456-66: "Based on the findings of this systematic review there is no conclusive evidence that clearly favours spinal manipulation or exercise as more effective in treatment of CLBP [chronic low back pain]."

• Blanchette et al. 2016. PLoS One. 11(8):e0160037: "Moderate evidence suggests that chiropractic care for LBP [low back pain] appears to be equally effective as physical therapy. Limited evidence suggests the same conclusion when chiropractic care is compared to exercise therapy and medical care although no firm conclusion can be reached at this time."

• Paige et al. 2017. JAMA. 317(14):1451-60: "Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms."

• Rubinstein et al. 2019. BMJ. 364:l689: "SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term."

• Skelly et al. 2020. Agency for Healthcare Research and Quality (US) Report No.: 20-EHC009 [chronic low back pain]: “Spinal manipulation was associated with small improvements compared with sham manipulation, usual care, an attention control, or a placebo intervention in short-term (3 trials) and intermediate-term (3 trials) function (SOE [strength of evidence]: low). There was no difference between spinal manipulation versus sham manipulation, usual care, an attention control, or a placebo intervention in short-term pain (3 trials), but manipulation was associated with a small improvement compared with controls on intermediate-term pain (3 trials) (SOE: low for short term, moderate for intermediate term).”

• de Zoete et al. 2021. Physiotherapy. 112:121-34: "Sufficient evidence suggest that SMT provides similar outcomes to recommended interventions, for pain relief and improvement of functional status. SMT would appear to be a good option for the treatment of chronic LBP." Edzard Ernst (2021 Aug 23. Edzard Ernst blog) commented: "Can any reasonable person seriously assume that SMT would do better than exercise when accounting for costs and risks? I very much doubt it!"

• Lavazza et al. 2021. BMJ Open. 11(5):e045106: "MT [manual therapy, including physiotherapy, chiropractic, osteopathy, massage, kinesiology and reflexology] does not seem to have clinically relevant effect compared with ST [hand contact sham therapy]. Similar effects were found with no treatment."

• Jenks et al. 2022. Eur Spine J. 31(7):1821-45: "SMT provides similar outcomes to recommended interventions for pain and functional status in the older adult with chronic LBP. SMT should be considered a treatment for this patient population." However, Ernst (2022 Jun 6. Edzard Ernst blog) wrote, "Its results confirm what I have been saying ad nauseam: we do not currently have a truly effective therapy for back pain, and most options are as good or as bad as the rest."

Other reports on back pain

• American College of Physicians guidelines (2017. Qaseem et al. Ann Intern Med. 166(7):514-530): Acute or subacute low back pain: "Low-quality evidence showed that spinal manipulation was associated with a small effect on function compared with sham manipulation; evidence was insufficient to determine the effect on pain." Chronic low back pain: "Low-quality evidence showed no difference in pain with spinal manipulation versus sham manipulation at 1 month. Low-quality evidence showed that spinal manipulation slightly improved pain compared with an inert treatment. Moderate-quality evidence showed no clear differences in pain or function compared with another active intervention."

• National Center for Complementary and Integrative Health (2022. Spinal manipulation: what you need to know ): "Spinal manipulation is one of several nondrug approaches that may be used to treat acute and chronic low-back pain. It may lead to small improvements in both pain and function."

Reviews and meta-analyses of spinal manipulation therapy: headache (2000-present only)

• Bronfort et al. 2001. J Manipulative Physiol Ther. 24(7):457-66: "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 2002. Cephalalgia. 22(8):617-23: “Despite claims that spinal manipulation is an effective treatment for headache, the data available to date do not support such definitive conclusions.

• Brønfort et al. 2004. Cochrane Database Syst Rev. CD001878: 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. 2004. Pain. 112(3):381-8: insufficient evidence to support effectiveness of spinal manipulation for tension-type headache.

• Posadzki and Ernst 2012. Complement Ther Med. 20(4):232-9: "The evidence that spinal manipulation alleviates tension-type headaches is encouraging but inconclusive."

• Rist et al. 2019. Headache. 59(4):532-42: "Spinal manipulation may be an effective therapeutic technique to reduce migraine days and pain/intensity. However, given the limitations to studies included in this meta-analysis, we consider these results to be preliminary."

• Fernandez et al. 2020. Eur J Pain. 24(9):1687-1702 [cervicogenic headache]: “For CGHA, SMT provides small, superior short-term benefits for pain intensity, frequency and disability, but not pain duration, however, high-quality evidence in this field is lacking. The long-term impact is not significant.” However, Ernst (2020 Jul 24. Edzard Ernst blog) wrote, “The new paper was published by chiropractors. Its positive result is not clinically relevant, almost certainly due to residual bias and confounding in the primary studies, and thus most likely false-positive.”

• Skelly et al. 2020. Agency for Healthcare Research and Quality (US) Report No.: 20-EHC009 [chronic tension headache]: “Spinal manipulation therapy was associated with small improvements in function and moderate improvements in pain compared with usual care over the short term in one trial (SOE [strength of evidence]: low).”

• Kamonseki et al. 2022. Disabil Rehabil. 44(10):1780-9 [tension-type headache]: "High velocity and low amplitude techniques were not superior to no treatment on reducing pain intensity (SMD = 0.01, low evidence) and frequency (SMD = -0.27, moderate evidence)."

Reviews and meta-analyses of spinal manipulation therapy: other conditions (2000-present only)

• Balon and Mior 2004. Ann Allergy Asthma Immunol. 93(2 Suppl 1):S55-60: “There is currently no evidence to support the use of chiropractic SMT as a primary treatment for asthma or allergy.”

• Hondras et al. 2005. Cochrane Database Syst Rev. CD001002: “there is insufficient evidence to support or refute the use of manual therapy for patients with asthma.”

• Corso et al. 2019. Chiropr Man Therap. 27:25 (athletic performance): "The preponderance of evidence suggests that SMT in comparison to sham or other interventions does not enhance performance-based outcomes in asymptomatic adult population."

• Meyer et al. 2019. Chiropr Man Therap. 27:60: “The available evidence suggests that changes occur in 'brain function' in response to spinal manipulation but are inconsistent across and - sometimes - within studies. The clinical relevance of these changes is unknown. It is therefore premature to promote the use of spinal manipulation as a treatment to improve 'brain function'.”

• O'Connor et al. 2003. Cochrane Database Syst Rev. CD003219 (carpal tunnel syndrome): “Trials of magnet therapy, laser acupuncture, exercise, or chiropractic care did not demonstrate symptom benefit when compared to placebo or control.”

• Hunt et al. 2012. Hand Ther. 14:89-94: "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.”

• Carnes et al. 2018. BMJ Open. 8(1):e019040 (colic): "Some small benefits were found, but whether these are meaningful to parents remains unclear as does the mechanisms of action." However, Ernst (2018 Jan 30. Edzard Ernst blog) noted an "overt lack of critical input" and potential bias.

• Perry et al. 2019. Syst Rev. 8(1):271: “Probiotics, fennel extract and spinal manipulation show promise to alleviate symptoms of colic, although some concerns remain.” However, Ernst (2019 Nov 22) wrote: “How the review authors could come to the verdict that spinal manipulation shows promise is...more than a little mysterious.”

• Cabanillas-Barea et al. 2023. Acta Paediatr. 112(7):1378-88: "Osteopathy and chiropractic treatment failed to reduce the crying time and increase sleeping time in babies with infantile colic, compared with no additional intervention."

• Reid and Rivett 2005. Man Ther. 10(1):4-13: studies of manual therapy for cervicogenic dizziness were positive but of low methodological quality.

• Proctor et al. 2006. Cochrane Database Syst Rev. CD002119: "Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea."

• Chow et al. 2021. JAMA Netw Open. 4(4):e215493: "In this systematic review of 13 studies, no clinical evidence was found to support or refute claims that SMT was efficacious or effective in changing immune system outcomes."

• Pauli 2007. J Vertebral Subluxation 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 2009. Prev Med. 49(2-3):99-100: "No compelling evidence was found to indicate that chiropractic maintenance therapy effectively prevents symptoms or diseases."

• Gross et al. 2004. Cochrane Database Syst Rev. CD004249 (mechanical neck disorders): manipulation and/or mobilization plus exercise was of value.

• Coulter et al. 2019. Pain Physician. 22(2):E55-E70: "Studies published since January 2000 provide low-moderate quality evidence that various types of manipulation and/or mobilization will reduce pain and improve function for chronic nonspecific neck pain compared to other interventions."

• Chaibi et al. 2021. J Clin Med. 10(21):5011: "SMT alone or in combination with other modalities was effective for patients with acute neck pain. However, limited quantity and quality, pragmatic design, and high heterogeneity limit our findings."

• Makin et al. 2024. BMC Sports Sci Med Rehabil. 16(1):86: "MT [manual therapy] may be more effective for people with neck pain in both short and long-term with a better safety profile regarding adverse events when compared to patients receiving oral pain medications. However, we advise caution when interpreting our safety results due to the different level of reporting strategies in place for MT and medication-induced adverse events." Ernst (2024 Apr 23. Edzard Ernst blog) noted: " The small differences in favor of MT that (some of) the trials report have little to do with the effectiveness of MT itself. They are almost certainly due to the fact that none of these studies were placebo-controlled and double blind (even though this would clearly be possible). In contrast to popping a pill, MT involves extra attention, physical touch, empathy, etc. These factors easily suffice to bring about the small differences that some studies report."

• Posadzki and Ernst 2012. Focus Altern Complement Ther. 17(1):22-6 (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."

• Driehuis et al. 2019. PLoS One. 14(6):e0218940: "Based on GRADE methodology, we found the evidence was of very low quality; this prevented us from drawing conclusions about the effectiveness of specific SMT techniques in infants, children and adolescents."

• Parnell Prevost et al. 2019. BMC Complement Altern Med. 19(1):60: “Fifty studies investigated the clinical effects of manual therapies for a wide variety of pediatric conditions. Moderate-positive overall assessment was found for 3 conditions: low back pain, pulled elbow, and premature infants. Inconclusive unfavorable outcomes were found for 2 conditions: scoliosis (OMT [osteopathic manual therapy]) and torticollis (MT [manual therapy]). All other condition's overall assessments were either inconclusive favorable or unclear.” Ernst (2019 Mar 18. Edzard Ernst blog) provided a critical assessment of this review, and concluded that “there is no good evidence for chiropractic, osteopathic or other manual treatments for children suffering from any condition.”

• Milne et al. 2022. BMC Pediatr. 22(1):721: "Whilst some individual high-quality studies demonstrate positive results for some conditions, our descriptive synthesis of the collective findings does not provide support for spinal manipulation or mobilisation in paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks."

• Lewis et al. 2015. Spine J. 15(6):1461-77 [sciatica]: "For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture."

• Sun et al. 2023. Biomed Res Int. 2023:7928429 (adolescent idiopathic scoliosis): "There is insufficient data to determine the effectiveness of spinal manipulation limited by the very low quality of included studies."

• Minkalis et al. 2017. Chiropr Man Therap. 25:1: "No clinical trials of thrust manipulation for non-surgical shoulder conditions other than subacromial impingement syndrome were found. There is limited evidence to support or refute thrust manipulation as a solitary treatment for this condition." However, Ernst (2017 Feb 13. Edzard Ernst blog) wrote, "This is yet another very odd conclusion from an otherwise almost acceptable analysis...If pain reductions are found within groups but not between real and sham manipulation, the evidence is as clear as it can be: manipulations have no specific effects. In other words, they are a pure placebo therapy...we don’t need such weasel words, all we need is to stress loud and clear that there is no good positive evidence."

• Ernst and Posadzki 2012. Focus Altern Complement Ther. 17(1):9-14: "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."

Reviews of spinal manipulation for multiple conditions

• Ernst 2000. Fam Pract. 17(6):554-6 (meta-analysis 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.”

• Ernst 2003. N Z Med J. 116(1179):U539: value of chiropractic for non-spinal conditions is not supported by data from rigorous clinical trials.

• Ernst and Canter 2006. J R Soc Med. 99(4):192-6: "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. 2007. J Altern Complement Med. 13(5):491-512: "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."

• Goncalves et al. 2018. Chiropr Man Therap. 26:10: "We found no evidence in the literature of an effect of chiropractic treatment in the scope of PP [primary prevention] or early secondary prevention for disease in general."

• Côté et al 2021. Chiropr Man Therap. 29(1):8: "We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function."

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. Menke (2022. Skeptic. 27(3):50-7) noted that "My meta-analysis showed 97 percent of acute back pain resolves with the passage of time, some attention, and regular exercise."

"Historically, spinal manipulative therapy for acute low back pain has been touted as the best example of evidence-based care routinely offered by the chiropractic profession, and they are not going to stop just because the actual evidence contradicts that profitable belief. Even many fierce critics of chiropractic continue to echo it - or at least leave it alone while focusing on more glaring issues with that profession. But others have pointed out that even this 'best' use of SMT has such disappointingly small benefits that it can hardly be considered effective" (Ingraham 2022. Does spinal manipulation work? PainScience.com).

Ernst (2019 Jan 16. Edzard Ernst blog) wrote, "Chiropractors have tried to reinvent themselves by borrowing some treatments from other healthcare professions. They have done this, I suspect, to avoid being judged by their largely ineffective hallmark intervention, spinal manipulation...Chiropractors must be judged not by the treatments they borrowed and might use occasionally, but by the only therapy that is inherent to chiropractic: spinal manipulation."

Chiropractic has not been shown to be useful for conditions other than back pain. 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.

O'Neill and others (2024. Chiropr Man Therap. 32(1):11) wrote, "...a narrow focus on a single modality combined with controversial theories and unrealistic expectations of its clinical efficacy have contributed to the precarious position we believe the profession now finds itself in...the unlimited scope of practice, which is still advocated by some chiropractors, and which has not been met with unequivocal political rejection, an over-reliance on SMT in the management of MSK [musculoskeletal] disorders, and an over-emphasis on the technical intricacies of SMT represent weaknesses within chiropractic. We argue that these are obstacles to professional development and the major causes of professional stagnation both intellectually and in the market place."

Hall (2019. Skeptical Inquirer. 43(6):24-6) commented, “I see no reason to prefer a reformed chiropractor to a good physical therapist who offers SMT. So why do we need chiropractors? They are often very skilled in SMT, so perhaps they could be retrained with a new title, becoming physical therapists for the spine.”

"If you are looking for a chiropractor who treats back pain or a musculoskeletal problem, look for one who does not subscribe to subluxation theory and who combines use of generic spinal manipulation with physical therapy modalities. A good science-based chiropractor is always willing to exchange office notes with your family physician. Remember that acute low-back pain, when it is mechanical in nature and not accompanied by fever or radiation down one leg, is often a self-limiting condition that will resolve in four to six weeks, with or without treatment. Appropriate treatment, however, can relieve symptoms, which may provide temporary but welcome relief that may reduce need for medication" (Homola 2023 Feb 21. Science-Based Medicine blog).

OSTEOPATHY

Background

Osteopathy was invented by Andrew Taylor Still, a physician, in the 1880's. “The core idea on which he founded OM [osteopathic medicine] was the notion that the bones and their connections (ligaments, tendons, fascia) represent a continuous energy that can heal the whole body. This was not an unusual idea at the time, a manifestation of the ‘life force’ (or vitalism), and all you have to do is free or support this force and the body will heal itself. This is also the essence of chiropractic” (Novella 2020 Oct 7. Science-Based Medicine blog). It was based in part on his own self-healing of headaches, etc., through neck manipulation. He established the American School of Osteopathy in 1892.

Practitioners obtain the D.O. degree; they have the same privileges as M.D.'s in prescriptions, surgery, etc. In the U.S. they refer to themselves as osteopathic physicians and their profession as osteopathic medicine.

“In 2023, the total number of osteopathic physicians in the U.S. reached almost 149,000 - a 30% increase over the past five years. Over the past three decades, the total number of DOs and osteopathic medical students has more than quadrupled to reach 186,871 in 2023. Currently representing more than 11% of all physicians and 25% of all medical students in the U.S., the osteopathic medical profession is positioned to continue growing exponentially...The osteopathic medical profession added more than 7,300 DOs to the physician workforce in 2022. Moreover, the pipeline of future DOs poised to enter the profession reached an all-time high, with approximately 36,500 osteopathic medical students expected to matriculate during the 2022-23 academic year. Over the last decade, the number of students attending osteopathic medical school has grown by 77%, helping lead to an overall 81% increase in the total number of DOs and osteopathic medical students in the U.S...In 2023, more than half of the nation’s DOs practice in the primary care specialties of family medicine, internal medicine and pediatrics...Women currently represent 44% of all DOs in active practice...During the 2023-24 academic year, the AOA’s Commission on Osteopathic College Accreditation (COCA) will accredit 40 colleges of osteopathic medicine offering instruction at 65 locations to more than 38,000 medical students” (American Osteopathic Association 2024. 2023 OMP [Osteopathic Medical Profession] Report tracks growth & expansion of osteopathic medicine).

Unlike chiropractic, osteopathy (at least in the United States) has advanced with progress in medical science. Jarry (2022 Oct 14. McGill Office for Science and Society) noted that “Osteopathic physicians in America are of a very different breed than the osteopaths that practice in much of the rest of the world. They receive a training that is comparable to medical doctors and is complemented by a few hundreds of hours of osteopathic manual therapy training." For residency, most train in conventional medical programs (these programs have increasingly turned to osteopathic graduates to fill positions in primary care residencies).

The situation differs elsewhere in the world. Ernst (2020 Dec 30. Edzard Ernst blog) wrote, “There are of course 2 types of osteopaths: the US osteopaths who are very close to real doctors, and the osteopaths from all other countries who are practitioners of so-called alternative medicine.” MacBeth (2020 Feb 21. Science-Based Medicine blog) noted that in other countries, “osteopaths are not physicians and are basically the same as chiropractors.”

Principles of osteopathy

There is an emphasis on the importance of the vascular system, particularly arteries, in enhancing the body's functions and natural healing power. Osteopaths seek to use manipulation to restore homeostasis. However, Still's original theory was abandoned in 1948.

Jarry (Op. cit.) wrote, “To try to define what osteopathy is is akin to grabbing a wet fish. Definitions tend to be vague, even those coming out of official bodies. Like so many alternatives to medicine, osteopathy focuses on an imagined boogeyman. Diseases and their symptoms are thought to originate from the impaired movement of muscles, bones, tendons, or ligaments. These blockages can allegedly be felt by the osteopath by touching their client’s body and treated by manipulating muscles, limbs, joints, and especially the fascia, the web of connective tissue that envelops our muscles and organs. This manual intervention is said to ‘help the body heal itself’...”

"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:91-3).

While osteopathy takes a largely scientific approach, there does persist among some osteopaths a pseudoscientific method known as cranial osteopathy (when practiced by osteopaths) or craniosacral therapy. This is discussed in more depth in the article on holistic methods (section on bodywork). "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(4):341-5).

MacBeth (op. cit.) discussed another unscientific concept: “A major topic in OMM [osteopathic manipulative medicine] education is Chapman’s points or Chapman reflexes, which aren’t any different from meridians, or chiropractic subluxations. They’re total nonsense...According to the Atlas [of Osteopathic Techniques]: ‘The current definition used by the osteopathic profession defines CRs as “a system of reflex points that present as predictable anterior and posterior fascial tissue texture abnormalities (plaque-like changes or stringiness of the involved tissues) assumed to be reflections of visceral dysfunction or pathology” (ECOP, 2006). This definition encompasses the lymphatic, neuroendocrine, and autonomic response to injury, illness, and disease as palpable and predictable viscerosomatic tissue reflexes found on the anterior and posterior body surface.’...What they’re proposing is that when you get sick, bumps called Chapman’s points or Chapman’s reflexes will appear on your body in specific locations based on what’s wrong with you...The Foundations [of Osteopathic Medicine] textbook doesn’t really cite any credible evidence showing that they actually exist and that the presence of these points correspond to a dysfunction in the part of the body...The entire theory is so convoluted; the presence of Chapman points supposed to be used as a diagnostic tool, but later in chapter there’s a guide to treat them as if they’re a medical problem in and of themselves. On top of all of that, the book suggests that stimulating these Chapman points can somehow treat serious medical conditions...The theory of Chapman reflex points is ridiculous and it’s obvious Chapman points don’t exist, but every year medical students at DO schools are required to memorize the locations of these magical points and regurgitate them on their school and board exams.”

Techniques

Osteopaths use 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 1997. Op. cit.)

Osteopathic visceral manipulation (or visceral osteopathy) "was invented by the French osteopath, Jean-Pierre Barral. In the 1980s, he stated that through his clinical work with thousands of patients, he discovered that many health issues were caused by our inner organs being entrapped and immobile. According to its proponents, OVM is based on the specific placement of soft manual forces that encourage the normal mobility, tone and function of our inner organs and their surrounding tissues. In this way, the structural integrity of the entire body is allegedly restored. I am not aware of good evidence to show that OVM is effective" (Ernst 2023 Nov 26. Edzard Ernst blog).

Reviews

• Jäkel and von Hauenschild 2011. J Am Osteopath Assoc. 111(12):685-93: "The currently available evidence on the clinical efficacy of cranial OMM [osteopathic manipulative medicine] is heterogeneous and insufficient to draw definitive conclusions.

• Posadzki and Ernst 2011. Clin Rheumatol. 30(2):285-91: "Collectively, these data fail to produce compelling evidence for the effectiveness of osteopathy as a treatment of musculoskeletal pain." 

• Ruffini et al. 2016. Complement Ther Med. 26:72-8 (gynecology and obstetrics): "Although positive effects were found, the heterogeneity of study designs, the low number of studies and the high risk of bias of included trials prevented any indication on the effect of osteopathic care." 

• Bagagiolo et al. 2016. Am J Perinatol. 33(11):1050-4: “Most published studies favor OMT [osteopathic manipulative treatment], but the generally small sample sizes in these studies cannot support ultimate conclusions about the efficacy of osteopathic therapy in pediatric age.” 

• Guillaud et al. 2018. BMC Complement Altern Med. 18(1):65: “The results of the systematic review lead us to conclude that well-conducted and sound evidence on the reliability and the efficacy of techniques in visceral osteopathy is absent.” 

• Verhaeghe et al. 2018. PLoS One. 13(11):e0206284: “In conclusion, the findings of the current literature review suggested that osteopathic care may improve pain and functional status in patients suffering from spinal complaints...Today, no clear conclusions of the impact of osteopathic care for spinal complaints can be drawn.” Ernst (2019 Mar 12) added, “Considering that the evidence for osteopathy is even far worse for non-spinal conditions (numerous trials exist for all sorts of other conditions, but they tend to be flimsy and usually lack independent replications), it is fair to conclude that osteopathy is NOT an evidence-based therapy.” 

• Ernst (2019 Sep 4. Edzard Ernst blog) summarized the evidence for visceral osteopathy: “Several studies have assessed the diagnostic reliability of the techniques involved. The totality of this evidence fails to show that they are sufficiently reliable to be of practical use. Other studies have tested whether the therapeutic techniques used in visceral osteopathy are effective in curing disease or alleviating symptoms. The totality of this evidence fails to show that visceral osteopathy works for any condition. The treatment itself is probably safe, yet the risks of visceral osteopathy are nevertheless considerable: if a patient suffers from symptoms related to her inner organs, a visceral osteopath is likely to misdiagnose them and subsequently mistreat them. If the symptoms are due to a serious disease, this would amount to medical neglect and could, in extreme cases, cost the patient’s life.” 

• Rehman et al. 2020 J Am Osteopath Assoc. 120(12):888-906: "Moderate quality evidence suggests that OMTh [osteopathic manual therapy] is effective for CNCP [chronic non-cancer pain] patients. There was a significant association between visceral OMTh and reduced pain severity and disability." 

• Dal Farra et al. 2021. Complement Ther Med. 56:102616: "Results strengthen evidence that osteopathy is effective in pain levels and functional status improvements in NS-CLBP [non-specific chronic low back pain] patients. MFR [myofascial release] reported better level of evidence for pain reduction if compared to other interventions."

• Bagagiolo et al. 2022. BMJ Open. 12(4):e053468: "Based on the currently available SRs [systematic reviews] and MAs [meta-analyses], promising evidence suggests the possible effectiveness of OMT [osteopathic manipulative treatment] for musculoskeletal disorders. Limited and inconclusive evidence occurs for paediatric conditions, primary headache and IBS [irritable bowel syndrome]. Further well-conducted SRs and MAs are needed to confirm and extend the efficacy and safety of OMT." 

• Posadzki et al. 2022. J Clin Med. 2022 Jul 30;11(15):4455: "The quality of the primary trials of OMT [osteopathic manipulative treatment] has improved during recent years. However, the quality of the totality of the evidence remains low or very low. Therefore, the effectiveness of OMT for selected pediatric populations remains unproven." 

• Jarry (2022 Oct 14. McGill Office for Science and Society): “When osteopathy’s musculoskeletal interventions have been investigated in systematic reviews and meta-analyses, the conclusions are almost always the same. The benefits are either non-existent, inconclusive, or very carefully enunciated as being preliminary, while the studies that are examined in these reviews are diagnosed as being of low or very low quality and at high risk of bias. This is often because blinding in these clinical trials, meaning the inability of a participant to figure out if they are getting the real treatment or a sham, is absent or not reported...Even back pain, which sounds like it might be the remit of osteopathy, does not emerge as a clear indication for osteopathic manipulations...As Professor Edzard Ernst...has pointed out, the benefits of osteopathy for low back pain seem to rely heavily on a single researcher who works at ‘the flag-ship of research into osteopathy.’ When the same researcher keeps reporting positive findings that the rest of the world can’t replicate, we have reasons to be skeptical.” 

• Ceballos-Laita et al. 2023. Explore (NY). 19(2):195-202: "This systematic review and meta-analysis showed a lack of high-quality studies showing the effectiveness of visceral osteopathy in pain, disability, and physical function in patients with LBP [low-back pain]." 

• Ceballos-Laita et al. 2024. Int J Osteo Med (Jul 18, in proof) (visceral osteopathy): "For musculoskeletal disorders, the qualitative and quantitative synthesis suggested that VO produces no statistically significant changes in any outcome variable for patients with low back pain, neck pain or urinary incontinence. For non-musculoskeletal conditions, the qualitative synthesis showed that VO was not effective for the treatment of irritable bowel syndrome, breast cancer, and very low weight preterm infants." 

Other points

“Back door phenomenon” - some applicants to osteopathic schools may be ones not accepted by their preferred 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 1988. Other healers: unorthodox medicine in America).

Johnson and Kurtz (2001. Acad Med. 76(8):821-8) 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.” In a 2018 survey (Healy et al. 2021. J Osteopath Med. 121(1):57-61), 78% used OMT on less than 5% of their patients, and 57% did not use it at all (though this survey had only a 17% response rate).

Ernst (2021 Jul 26. Edzard Ernst blog), in commenting on an analysis of osteopathic publications from 1966 to 2018, wrote: "What the authors fail to state is that their analysis discloses osteopathy to be an area of utter unimportance. Less than 400 studies in 52 years is a dismal result. The fact that they were mostly published in journals of no impact makes it even worse."

A British osteopath wrote: “Spinal alignment, muscular and postural imbalances are seemingly not predisposing or maintaining factors for many musculoskeletal conditions, despite what continues to be taught in osteopathic colleges. It is hugely underappreciated that most of the factors deemed by osteopaths to be significant to a patient’s symptoms are prevalent in asymptomatic people” (Anonymous 2018 Nov 7. Edzard Ernst blog).

MASSAGE

Various types of massage therapy range from standard treatments of conventional medicine and physical therapy to bizarre and pseudoscientific approaches. Massage is also discussed in articles on mind-body medicine (relaxation, stress relief) and holistic approaches (bodywork, reflexology).

“In the United States, there are over 360,000 massage therapists practicing in various settings...Approximately 47.5 million American adults had a massage at least once in 2020...Over 62% of American adults have had a massage for medical or health reasons” (Worldmetrics.org Report 2024. Over $24.7 billion: massage industry statistics & market trends).

“There are currently 245+ accredited massage therapy institutions in the United States. Many institutions have multiple campuses...Training programs in massage therapy generally require a high school diploma, though post-secondary education is useful” (American Massage Therapy Association 2024. Starting your massage career). Instruction and certification exams may require “knowledge” of pseudoscientific concepts (such as from traditional Chinese medicine).

“In states that regulate massage therapy (45 states and the District of Columbia), therapists must get a license or certification before practicing massage. State regulations typically require graduation from an approved program and passing an examination. Some massage therapists obtain certification from the National Certification Board for Therapeutic Massage & Bodywork. To do this, they must meet specific educational requirements, undergo a background check, and pass an examination” (National Center for Complementary and Integrative Health 2019. Massage therapy: what you need to know).

Massage is not covered by most health insurance plans. There is some coverage if it is prescribed as part of physical therapy.

In a review of chiropractic, Cooper and McKee (2003. Milbank Q. 81(1):107-38) noted that the form of manual treatment “that is most similar to chiropractic SMT [spinal manipulative therapy] 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...” In turn, some chiropractors offer massage, either performing it themselves or including a massage therapist in their practice.

Practice and scope

“The term ‘massage therapy’ includes many techniques. The most common form of massage therapy in Western countries is called Swedish or classical massage; it is the core of most massage training programs. Other styles include sports massage, clinical massage to accomplish specific goals such as releasing muscle spasms, and massage traditions derived from Eastern cultures, such as Shiatsu and Tuina” (NCCIH 2019. Op. cit.).

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."

Lymph drainage: “It is a gentle massage technique applied along the lymph vessels and nodes to stimulate lymph flow. All sorts of extraordinary claims are made for this treatment. In  particular, lymphoedema after surgery for breast cancer, which can be a debilitating complication, is claimed to be preventable with this approach” (Ernst 2018 Jul 16. Edzard Ernst blog).

"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. Complement Altern Med. 6:24).

"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 Oct 3. The Conversation).

Naprapathy is a system of massage focusing on connective tissue. It is described in the article "Homeopathy, naturopathy, energy medicine, and other 'holistic' approaches."

Structural Energetic Therapy, according to its practitioners, “is the only therapy that releases the spiral twist, found in everyone, into a weight-bearing support, which then relieves the stresses on joints, spine, and discs that lead to pain and body dysfunction. This is achieved using unique cranial/structural techniques and myofascial protocols, found nowhere else, to release patterns that maintain painful conditions in the body” (Structural Energetic Therapy 2024. Welcome to Structural Energetic Therapy®). “A search on PubMed turned up no studies supporting any benefits for SET, or the existence of the spiral twist. General searches online also did not turn up any scientific studies” (Novella 2023 Aug 2. Science-Based Medicine blog).

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

Reviews and commentary

• Davis et al. 2020. BMJ Open Sport Exerc Med. 6(1):e000614 [athletic performance]: “Although our study finds no evidence that sports massage improves performance directly, it may somewhat improve flexibility and DOMS [delayed onset muscle soreness].” 

• Dakic et al. 2023. Sports (Basel). 11(6):110 [athletic performance]: “The direct usage of massages just for gaining results in sport and exercise performance seems questionable. However, it is indirectly connected to performance as an important tool when an athlete should stay focused and relaxed during competition or training and recover after them.” 

• Ernst 2003. BMJ. 326(7389):562-3 (editorial): “the evidence for massage as a symptomatic relief of back pain is encouraging but not compelling.” 

• Tsao 2007. Evid Based Complement Alternat Med. 4(2):165-79: "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." 

• Kumar et al. 2013. Int J Gen Med. 6:733-41: 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. 

• NCCIH 2019. Massage therapy: what you need to know: “Several evaluations of massage for low-back pain have found only weak evidence that it may be helpful.” 

• Corbin 2005. Cancer Control. 12(3):158-64): “...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.” 

• Ernst 2009. Support Care Cancer. 17(4):333-7 [cancer patients]: “...Massage can alleviate a wide range of symptoms: pain, nausea, anxiety, depression, anger, stress and fatigue. However, the methodological quality of the included studies was poor, a fact that prevents definitive conclusions.” 

• NCCIH 2019. Massage therapy: what you need to know: “With appropriate precautions, massage therapy can be part of supportive care for cancer patients who would like to try it; however, the evidence that it can relieve pain and anxiety is not strong.” 

• Ibid.: “Massage therapy may be helpful for some fibromyalgia symptoms if it’s continued for long enough.” 

• Ibid.: “Only a small number of studies of massage for headache have been completed. These studies looked at different types of massage and different types of headache, and their results are not consistent.” 

• Ibid.: “There’s some evidence that massage therapy may have benefits for anxiety, depression, and quality of life in people with HIV/AIDS, but the amount of research and number of people studied are small.” 

• Vijayakumar et al. 2024. J Bodyw Mov Ther. 37:109-14: “The findings demonstrated that massage therapy resulted in a minimal reduction in blood pressure among patients with hypertension.” 

• Jones et al. 2012. Cochrane Database Syst Rev. CD009234: concluded that massage appears to reduce pain in labor, but more research is needed. 

• Heidari et al. 2022. Disabil Rehabil. 44(20):5758-69: “Different massage approaches effectively improved MS [multiple sclerosis] symptoms such as fatigue, pain, anxiety, depression, and spasticity.” Ernst (2021 Aug 19. Edzard Ernst blog) noted, “Clinical trials of massage therapy face formidable obstacles [such as in blinding]...Thus, the evidence is often less convincing than one would hope. This, however, does not mean that massage therapy does not have considerable potential for a range of indications.” 

• NCCIH 2019. Massage therapy: what you need to know: “Massage therapy may be helpful for neck or shoulder pain, but the benefits may only last for a short time.” 

• Ibid.: “The small amount of research that’s been done on massage therapy for osteoarthritis of the knee suggests that it may have short-term benefits in relieving knee pain.” 

• Miake-Lye et al. 2016. Massage for pain: an evidence map. Department of Veterans Affairs: “Findings from high-quality systematic reviews describe potential benefits of massage for pain indications including labor, shoulder, neck, back, cancer, fibromyalgia, and temporomandibular disorder. However, no findings were rated as moderate- or high-strength.” 

• Mak et al. 2024. JAMA Netw Open. 7(7):e2422259: "This study found that despite a large number of randomized clinical trials, systematic reviews of massage therapy for painful adult health conditions rated a minority of conclusions as moderate-certainty evidence and that conclusions with moderate- or high-certainty evidence that massage therapy was superior to other active therapies were rare." 

• Liu et al. 2022. Complement Ther Med. 71:102892: “Our systematic review showed that MT [massage therapy] may be effective for postoperative pain relief. We also found a high level of heterogeneity among existing studies, most of which were compromised in the methodological quality.” Ernst (2023 Jan 5. Edzard Ernst blog) noted, “In the end, we have to realize that, with clinical trials of certain treatments, scientific rigor can reach its limits. It is not possible to conduct double-blind, placebo-controlled studies of MT. Thus we can only conclude that, for some indications, massage seems to be helpful (and almost free of adverse effects).” 

• NCCIH 2019. Massage therapy: what you need to know: “There’s evidence that premature babies who are massaged may have improved weight gain. No benefits of massage for normal full-term infants have been clearly demonstrated.”

Adverse effects

Ernst (2003. BMJ. 326(7389):562-3) 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 (2005. Cancer Control. 12(3):158-64), “There has been no evidence that massage therapy can spread cancer, although direct pressure over a tumor is usually discouraged.”

Yin et al. (2014. Evid Based Complement Alternat Med. 2014:480956) 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.

In an essay entitled “Why I quit my massage therapy career” (2019 Feb 1. Science-Based Medicine blog), Ingraham wrote: “The massage world is still rotten with faith-based treatments and flaky magical thinking, and what little interest in science you find is often shallow. Vitalism is rampant and many therapists indulge in overt quackery like Reiki and reflexology, but that’s only the most obvious nonsense, the tip of a far larger iceberg of health care amateurism and hair-raising ignorance, incompetence, and overconfidence. Practitioners earnestly keen on science and evidence-based practice are a depressingly small minority, and they are inevitably sneered at by many of their colleagues. Massage therapy has a deeply pseudoscientific character overall, defining itself mostly in opposition to science-based or ‘mainstream’ health care, where rejection of science is actually celebrated by many practitioners, probably a majority.”

REFERENCES

See also references for review articles in the text.

Chiropractic

         Overview

         Techniques

         General critiques

         Critiques - research and reviews of effectiveness

         Critiques - pediatric chiropractic

         Adverse effects 

         Promotional

Osteopathy

         Overview

         Critiques

Massage

         Overview

         Critiques

                Adverse effects

Chiropractic - overview

Chirobase. Your skeptical guide to chiropractic history, theories, and practices. Quackwatch

National Center for Complementary and Integrative Health. 2024. Chiropractic: in depth

National Center for Complementary and Integrative Health. 2024. Spinal manipulation: what you need to know

Kaptchuk TJ, Eisenberg DM. 1998. Chiropractic: origins, controversies, and contributions. Arch Intern Med. 158(20):2215-24

Homola S. 1999. What a rational chiropractor can do for you. Quackwatch

Barrett S. 2000. Tips on choosing a chiropractor. Quackwatch

Lee AC, Li DH, Kemper KJ. 2000. Chiropractic care for children. Arch Pediatr Adolesc Med. 154(4):401-7

Homola S. 2001. Chiropractic: does the bad outweigh the good? Quackwatch

Meeker WC, Haldeman S. 2002. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med. 136(3):216-27 [abstract]

Koren T. 2003. Does the vertebral subluxation exist? Chiro.org

Cooper RA, McKee HJ. 2003. Chiropractic in the United States: trends and issues. Milbank Q, 81(1):107-38

Nelson CF, Lawrence DJ, Triano JJ, Bronfort G, Perle SM, et al. 2005. Chiropractic as spine care: a model for the profession. Chiropr Osteopat. 13:9

Alcantara J, Ohm J, Kunz D. 2010. The chiropractic care of children. J Altern Complement Med. 16(6):621-6

Lefebvre R, Peterson D, Haas M. 2012. Evidence-based practice and chiropractic care. J Evid Based Complementary Altern Med. 18(1):75-9

Gliedt JA, Hawk C, Anderson M, Ahmad K, Bunn D, et al. 2015. Chiropractic identity, role and future: a survey of North American chiropractic students. Chiropr Man Therap. 23(1):4

Lisi AJ, Brandt CA. 2016. Trends in the use and characteristics of chiropractic services in the Department of Veterans Affairs. J Manipulative Physiol Ther. 39(5):381-6

Puhl AA, Reinhart CJ, Injeyan HS, Tibbles A. 2017. Description of the case mix experienced by chiropractic students during a clinical internship. J Chiropr Educ. 31(2):132-9

Funk MF, Frisina-Deyo AJ, Mirtz TA, Perle SM. 2018. The prevalence of the term subluxation in chiropractic degree program curricula throughout the world. Chiropr Man Therap. 26:24

Bellamy J. 2019 Aug 15. The DC wants to play PCP on your dime: H.R. 3654 forces Medicare to cover full chiropractic scope of practice. Science-Based Medicine

Hartvigsen J, French SD. 2020. So, what is chiropractic? Summary and reflections on a series of papers in Chiropractic and Manual Therapies. Chiropr Man Therap. 28(1):4

Bellamy J. 2020 Jan 30. Legislative Alchemy 2019: Chiropractors seek scope of practice expansion, including authority to prescribe drugs. Science-Based Medicine

Ernst E. 2021 Oct 8. Beliefs and behaviors of US chiropractors. Edzard Ernst

Ernst E. 2022 Jul 6. Pediatric chiropractic seems to be on the rise. Edzard Ernst [see next two items]

Jones C. 2022 Jul 8. Recent trends in pediatric chiropractic use: the good, the bad, and the unhelpful. Science-Based Medicine [see next item]

Peng T, Chen B, Brown HS, Douphrate D, Janak J, Gabriel KP. 2021. National trends in the expenditure and utilization of chiropractic care in U.S. children and adolescents from the 2007-2016 Medical Expenditure Panel Survey: a cross sectional study.  J Manipulative Physiol Ther. 44(8):591-600

Menke M. 2022. Cracking history: chiropractic's secret origin. Skeptic. 27(3):50-7

Ernst E. 2024 Apr 1. The threats to chiropractic: science, the impact of EBM [evidence-based medicine], accountability to authorities and third party-payers. Edzard Ernst [see next item]

O'Neill SFD, Nim C, Newell D, Leboeuf-Yde C. 2024. A new role for spinal manual therapy and for chiropractic? Part I: weaknesses and threats. Chiropr Man Therap. 32(1):11. Part II: strengths and opportunities. Chiropr Man Therap. 32(1):12

Chiropractic - techniques

Barrett S. 2004. Chiropractic techniques. Quackwatch [links to promotional sites describing various techniques]

Homola S. 2006. Chiropractic: history and overview of theories and methods. Clin Orthop Relat Res. 444:236-42 [abstract]

Barrett S. 2009. Glossary of chiropractic terms. Quackwatch

Barrett S. 2015. A skeptical look at Chiropractic BioPhysics (CBP). Quackwatch

Barrett S. 2016. Be wary of spinal decompression with VAX-D or similar devices. Quackwatch

Barrett S. 2017. The Toftness Radiation Detector is a bogus device. Quackwatch

Homola S. 2018 Jun 22. Certification in chiropractic techniques: legitimate care or tomfoolery? Science-Based Medicine

Homola S. 2018 Sep 4. The chiropractic technique parade. Science-Based Medicine

Homola S. 2019 Nov 22. Upper cervical chiropractic: NUCCA - the legacy of HIO. Science-Based Medicine

Demortier M, Leboeuf-Yde C. 2020. Unraveling Functional Neurology: an overview of all published documents by FR Carrick, including a critical review of research articles on its effect or benefit. Chiropr Man Therap. 28(1):9

Homola S. 2020 Feb 11. Chiropractic Webster Technique: nonsense based on nonsense. Science-Based Medicine

Ernst E. 2020 Mar 7. Functional neurology - more chiro-quackery? Edzard Ernst

Ernst E. 2020 Jul 21. The clinical utility of routine spinal radiographs by chiropractors. Edzard Ernst

Hall H. 2020. Applied kinesiology and other chiropractic delusions. Skeptical Inquirer. 44(3):21-3

Ernst E. 2020 Nov 23. "DRX9000" for back pain: a nice little earner for chiropractors and other back pain quacks. Edzard Ernst

Ernst E. 2021 Mar 21. Strong support for routine use of radiological imaging in chiropractic? Edzard Ernst

Ernst E. 2021 Sep 15. Diagnostic tests regularly used by chiropractors and osteopaths are of dubious value. Edzard Ernst

Ernst E. 2021 Dec 8. Does diagnostic imaging affect the clinical outcome in patients with low back pain presenting for chiropractic care? Edzard Ernst

Ernst E. 2022 Jul 8. The over-use of full-length spinal radiographs by chiropractors. Edzard Ernst

Chiropractic - general critiques

(see also "research and reviews of effectiveness," "pediatric chiropractic," and “adverse effects” below)

Crelin ES. 1973. A scientific test of the chiropractic theory. Am Scientist. 61:574-80 [measures how much displacement of vertebrae must occur before spinal nerves are impinged or encroached upon] [revised 2010 for Quackwatch]

Lattanze W. 1999. A warning to pre-chiropractic students. Quackwatch

Jarvis WT. 2000. Chiropractic: a skeptical view. Quackwatch

Barrett S. 2003. Chiropractic: the selling of the spine. Quackwatch

Keating JC Jr, Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF. 2005. Subluxation: dogma or science? Chiropr Osteopat. 13:17

Ernst E. 2008. Chiropractic: a critical evaluation. J Pain Symptom Manage. 35(5):544-62

Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF. 2008. How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropr Osteopat. 16:10

Homola S. 2008. Chiropractic: a profession seeking identity. Skeptical Inquirer. 32(1):19-22

Thyer B, Whittenberger G. 2008. A skeptical consumer's look at chiropractic claims: flimflam in Florida? Skeptical Inquirer. 32(1):23-25

Homola S. 2011 Dec 30. Subluxation theory: a belief system that continues to define the practice of chiropractic. Science-Based Medicine

Bellamy JJ. 2012. White Paper: Chiropractic. Institute for Science in Medicine [link for pdf file]

Jones C. 2015 Oct 23. The time a Pulitzer Prize winning journalist got manipulated by a chiropractor. Science-Based Medicine

Homola S. 2016 Apr 12. Cervicogenic headache and cervical spinal manipulation. Science-Based Medicine

Ernst E. 2016 Oct 25. Only 50% of chiropractors are aware of current radiographic guidelines. Edzard Ernst

Bellamy J. 2017 Jan 5. Chiropractic internist: a "specialty" to avoid. Science-Based Medicine

Novella S. 2017 Mar 22. Cracking down on chiropractic pseudoscience. Science-Based Medicine

Homola S. 2017 Jul 7. Chiropractic and spinal manipulation red flags: a comprehensive review. Science-Based Medicine

Barrett S. 2018. Chiropractic's elusive subluxations. Quackwatch

Homola S. 2018. Inside chiropractic: past and present problems. Quackwatch

Bellamy J. 2018 Mar 29. Direct primary care agreements and chiropractors: a bad deal for patients. Science-Based Medicine

Barrett S. 2019. Why doesn't the FTC attack false chiropractic claims? Quackwatch

Ernst E. 2019 Jan 16. Is chiropractic of proven effectiveness for a long list of conditions? No, I really don’t think so. Edzard Ernst

Homola S. 2019 May 27. The yoke of chiropractic: vertebral subluxation doctrine. Science-Based Medicine

Anonymous. 2019. An inside view of a chiropractic office. Quackwatch

Ernst E. 2019 Sep 17. Journals of chiropractic are not a reliable source of information. Edzard Ernst

Ernst E. 2019 Dec 26. Surprise, surprise! Chiropractors recommend chiropractic management of neck pain. Edzard Ernst

Barrett S. 2020. Some notes on the Pastoral Medical Association and other “private membership associations.” Credential Watch

Schulson M. 2020 Apr 11. With legislation looming, chiropractors get political on vaccines. Undark

Barrett S. 2020. Chiropractors sparring over immune-boosting claims. Quackwatch

Côté P, Bussières A, Cassidy JD, Hartvigsen J, Kawchuk GN et al. 2020. A united statement of the global chiropractic research community against the pseudoscientific claim that chiropractic care boosts immunity. Chiropr Man Therap. 28(1):21

Hall H. 2020 Sep 22. Edzard Ernst tackles chiropractic. Science-Based Medicine

Ernst E. 2020 Nov 19. Chiropractic misinformation during the COVID-19 pandemic. Edzard Ernst

Simpson JK, Innes S. 2020. Informed consent, duty of disclosure and chiropractic: where are we? Chiropr Man Therap. 28(1):60

Barrett S. 2021. Don’t pay or contract in advance for chiropractic visits at a “discount” price. Quackwatch

Ernst E. 2021 Aug 9. Chiropractic "subluxation" is by no means a notion of the past. Edzard Ernst

Bellamy J. 2021 Oct 7. Anti-vaccination ideology and COVID misinformation in chiropractic continuing education courses: “Plandemic” edition. Science-Based Medicine

Ernst E. 2022 Aug 13. Literally 99% of chiropractic is a scam. Edzard Ernst

Ingraham P. 2022 Aug. 13. Does spinal manipulation work? PainScience.com

Barrett S. 2022. A close look at chiropractic wrongdoing. Quackwatch

Ernst E. 2022 Sep 28. Chiropractic manipulations after car accidents: best avoided, if you ask me. Edzard Ernst

Ernst E. 2023 Feb 5. Veterinary chiropractic revisited. Edzard Ernst

Homola S. 2023 Feb 21. Spinal manipulation, chiropractic, and subluxation theory. Science-Based Medicine 

Ernst E. 2023 Mar 3. Chiropractic subluxation: the myth must be kept alive. Edzard Ernst

Ernst E. 2023 Jul 27. Chiropractic and public health. Edzard Ernst

Suleta K. 2023 Oct 9. Chiropractors aren't the solution to the primary care shortage. American Council on Science and Health

Ernst E. 2023 Nov 1. The cult of chiropractic. Edzard Ernst

Ernst E. 2023 Nov 5. Medicare fraud by chiropractors costs taxpayers millions. Edzard Ernst

Ernst E. 2024 Mar 19. No one should see a chiropractor thinking they are seeing a doctor. Edzard Ernst

Homola S. 2024 Jan 23. Chiropractic subluxation theory: science or gobbledegook? Science-Based Medicine

Ernst E. 2024 Jun 7. Chiropractors’ profitable over-use of X-ray diagnostics: “scare tactics” and “fear-mongering.” Edzard Ernst

Ernst E. 2024 Jun 21. "Maintenance care" is very good for chiropractic economics … but not for anything else! Edzard Ernst

Ernst E. 2024 Jun 24. Chiropractic maintenance care: sly scare mongering of greedy chiropractors to fleece vulnerable individuals. Edzard Ernst

Ernst E. 2024 Jul 6. Chiropractic: a view from inside of the cult. Edzard Ernst

Chiropractic - critiques - research and reviews of effectiveness

Daniel DM. 2007. Non-surgical spinal decompression therapy: does the scientific literature support efficacy claims made in the advertising media? Chiropr Osteopat. 15:7

Ernst E. 2009. Chiropractic maintenance treatment, a useful preventative approach? Prev Med. 49(2-3):99-100 [abstract]

Ernst E. 2015 Jan 15. Chronic low back pain: exercise is better than spinal manipulation. Edzard Ernst

Hall H. 2016 Apr 12. When headaches are a pain in the neck: spinal manipulation vs. mobilization for cervicogenic headache. Science-Based Medicine

Ernst E. 2016 May 21. Chiropractic treatments are placebos. Edzard Ernst

Ernst E. 2016 Sep 14. A new systematic review of chiropractic for low back pain: far less encouraging than chiros make us believe. Edzard Ernst

Ernst E. 2016 Oct 11. Chiropractic manipulation for migraine is a placebo therapy. Edzard Ernst

Ernst E. 2017 Feb 13. Shoulder problems? Don’t see a chiro! Edzard Ernst

Crislip M. 2017 Feb 17. Spinal manipulation for back and neck pain: does it work? Annotated. Science-Based Medicine

Ernst E. 2017 Apr 25. Spinal manipulation for acute low back pain, a new meta-analysis is “damning it with faint praise.” Edzard Ernst

Crislip M. 2017 Apr 28. Spinal Manipulation and the JAMA meta-analysis: an analysis of fuel. Science-Based Medicine

Ernst E. 2018 Jan 5. Chiropractic is not the best treatment for back pain !!! Edzard Ernst

Ernst E. 2018 Apr 19. Chiropractic: a truly remarkable and excellent review by chiropractors. Edzard Ernst

Ernst E. 2018 Dec 20. Chiropractic manipulation and primary prevention. It’s time that chiropractors stop misleading the public in order to fill their pockets. Edzard Ernst

Ernst E. 2019 Jan 28. The AHRQ review of spinal manipulation for chronic back pain: more bad news for chiropractors. Edzard Ernst

Ernst E. 2019 Mar 16. Update on spinal manipulation for back pain confirms: it is not the treatment of choice. Edzard Ernst

Ernst E. 2019 May 16. Chiropractic manipulation is not the best therapy for back pain of seniors. Edzard Ernst

Ernst E. 2019 Apr 29. Chiropractic spinal manipulation for migraine – torture the data until they confess! Edzard Ernst

Ernst E. 2019 Oct. 7. Is spinal manipulation a placebo therapy? Edzard Ernst

Ernst E. 2019 Dec 4. Chiropractic maintenance care: boosting chiropractic cash flow in perpetuity. Edzard Ernst

Ernst E. 2019 Dec 6. Suffering from persistent low back pain? Forget about chiropractic or other SCAMs. Edzard Ernst

Ernst E. 2020 Feb 18. Manipulation-induced hypoalgesia: another chiro-myth busted. Edzard Ernst

Ernst E. 2020 May 21. Spinal manipulation for chronic pain: an important update. Edzard Ernst

Ernst E. 2020 Jul 24. Spinal manipulation for the management of cervicogenic headache: a new review of the evidence. Edzard Ernst

Ernst E. 2020 Aug 1. Spinal manipulation is not the best therapy for non-specific chronic neck pain: a randomized controlled trial. Edzard Ernst

Ernst E. 2021 Apr 15. No evidence that spinal manipulation improves immune function. Edzard Ernst

Ernst E. 2021 Jul 25. No evidence that spinal manipulations work for non-musculoskeletal conditions. Edzard Ernst

Ernst E. 2021 Aug 20. Manual therapy (mainly chiropractic and osteopathy) does not have clinically relevant effects on back pain compared with sham treatment. Edzard Ernst

Ernst E. 2021 Aug 23. Spinal manipulation therapy is as good (or bad) for chronic back pain as other options … and should therefore NOT be recommended. Edzard Ernst

Ernst E. 2021 Aug 25. Spinal manipulative therapy (SMT) for chronic back pain is a mere placebo therapy. Edzard Ernst

Ernst E. 2021 Nov 21. Manipulation versus mobilization for the management of cervicogenic headache. Edzard Ernst

Ernst E. 2021 Nov 22. No effect from adding chiropractic manipulations to exercises for neck pain. Edzard Ernst

Ernst E. 2022 Jun 6. Spinal manipulative therapy for older adults with chronic low back pain fails to generate convincing results. Edzard Ernst

Ernst E. 2022 Nov 1.High velocity, low amplitude techniques are not superior to no treatment in the management of tension-type headache. Edzard Ernst

Ernst E. 2022 Nov 19. Manual therapy for shoulder pain? Edzard Ernst

Ernst E. 2022 Nov 26. More evidence to suggest that spinal mobilizations for low back pain are ineffective. Edzard Ernst

Ernst E. 2023 May 27. More evidence to suggest that chiropractic is useless. Edzard Ernst

Ernst E. 2023 Jun 8. Spinal manipulations for lumbar radicular syndrome? Edzard Ernst

Ernst E. 2023 Dec 27. The new WHO guideline for the management of chronic low back pain. Focus: spinal manipulation. Edzard Ernst

Ernst E. 2024 Apr 23. Effectiveness and safety of manual therapy compared with oral pain medications in patients with neck pain. Edzard Ernst

Chiropractic - critiques - pediatric chiropractic (see also adverse effects)

Campbell JB, Busse JW, Injeyan HS. 2000. Chiropractors and vaccination: a historical perspective. Pediatrics 105(4):E43 [abstract]

Homola S. 2010. Should chiropractors treat children? Skeptical Inquirer. 34(5):50-3

Barrett S. 2016. Chiropractors and immunization. Quackwatch

Homola S. 2016. Pediatric chiropractic care: the subluxation question and referral risk.  Bioethics. 30(2):63-8 [abstract]

Homola S. 2016 Feb 26. Subluxation correction: a chiropractic treatment for babies. Science-Based Medicine

Jones C. 2016 Feb 27. Chiropractic and the newborn baby. Science-Based Medicine

Jones C. 2016 Dec 30. Newborn chiropractic, false balance, and The Doctors. Science-Based Medicine

Bellamy J. 2017 Jul 6. Chiropractic clinical training with pediatric patients or complicated cases: slim to none. Science-Based Medicine

Jones C. 2017 Sep 22. Maximized Living: "5 essentials" of chiropractic marketing propaganda. Science-Based Medicine

Ernst E. 2018 Jan 30. Manual therapies for infant colic? A very sore point in the history of chiropractic. Edzard Ernst

Jones C. 2018 May 18. A Canadian journalist calls out pediatric chiropractic again, and the Canadian Chiropractic Association responds…again. Science-Based Medicine

Bellamy J. 2018 Jun 7. Chiropractic Pediatrics: “delayed referral, misdiagnosis, adverse events and ineffective treatments.” Science-Based Medicine

Ernst E. 2019 Mar 18. No good evidence for chiropractic, osteopathic or other manual treatments for children suffering from any condition. Edzard Ernst

Ernst E. 2019 Jun 13. More chiropractic delusions about infantile colic. Edzard Ernst

Jones C. 2019 Jun 28. No. “Big data” does not support chiropractic care for infants. Science-Based Medicine

Ernst E. 2019 Jul 1. Towards the prohibition of chiropractic spinal manipulation for children. Edzard Ernst

Bellamy J. 2019 Aug 1. Anti-vaccination ideology in chiropractic continuing education and conference (again!). Science-Based Medicine

Ernst E. 2019 Oct 2. The effectiveness of chiropractic spinal manipulations/mobilisation for children is unproven. TIME TO STOP TREATING KIDS! Edzard Ernst

Ernst E. 2019 Nov 21. Chiropractic spinal care for children is dangerous, unwarranted and must cease immediately. Edzard Ernst

Ernst E. 2019 Nov 22. Chiropractic spinal manipulation shows promise to alleviate symptoms of infant colic? Surely not! Edzard Ernst

Ernst E. 2019 Dec 3. Chiropractic spinal manipulation of children: an independent review. Edzard Ernst

Ernst E. 2020 Jan 16. Chiropractic spinal manipulation for a newborn. Edzard Ernst

Jones C. 2021 Jul 23. A new study finds no benefit from chiropractic for infant colic, but they’ll keep doing it anyway. Science-Based Medicine

Ernst E. 2021 Oct 14. The International Chiropractors Association's statement on vaccination. Edzard Ernst

Ernst E. 2022 Nov 3. The most common conditions that chiropractors (cannot) help kids with. Edzard Ernst

Jones C. 2022 Dec 9. The Washington Post takes on baby chiropractic. Science-Based Medicine

Ernst E. 2022 Dec 22. Spinal manipulation or mobilisation for kids? No, stay away from both! Edzard Ernst

Ernst E. 2023 Apr 26. Informed consent for chiropractors who treat children. Edzard Ernst

Ernst E. 2023 May 5. Chiropractic or osteopathy for infant colic? … No, thanks! Edzard Ernst

Ernst E. 2023 Nov 2. Clinical practice guidelines for best practice management of pediatric patients by chiropractors. Edzard Ernst

Ernst E. 2024 Mar 25. Spinal manipulation and mobilisation among infants, children, and adolescents: an international Delphi survey of expert physiotherapists. Edzard Ernst

Ernst E. 2024 Jun 13. Australian chiropractors are “irresponsible” trying to put their financial interests before the health of babies. Edzard Ernst

Chiropractic - adverse effects

Ernst E. 2001. Prospective investigations into the safety of spinal manipulation. J Pain Symptom Manage. 21(3):238-42

Rothwell DM, Bondy SJ, Williams JI. 2001. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. 32(5):1054-60

Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM. 2005. Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study. Spine. 30(13):1477-484 [abstract]

Reuter U, Hämling M, Kavuk I, Einhäupl KM, Schielke E. 2006. Vertebral artery dissections after chiropractic neck manipulation in Germany over three years. J Neurol. 253(6):724-30 [abstract]

Ernst E. 2007. Adverse effects of spinal manipulation: a systematic review. J R Soc Med. 100(7):330-8

Vohra S, Johnston BC, Cramer K, Humphreys K. 2007. Adverse events associated with pediatric spinal manipulation: a systematic review. Pediatrics. 119(1):e275-83 [abstract]

Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S et al. 2008. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 33(4 Supp):S176-83

Ernst E. 2010. Vascular accidents after neck manipulation: cause or coincidence? Int J Clin Pract. 64(6):673-7 [abstract]

Ernst E. 2010. Deaths after chiropractic: a review of published cases. Int J Clin Pract. 64(8):1162-5 [abstract]

Humphreys BK. 2010. Possible adverse events in children treated by manual therapy: a review.  Chiropr Osteopat. 18:12

Biller J, Sacco RL, Albuquerque FC, Demaerschalk BM, Fayad P 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(10):3155-74

Puentedura EJ, O'Grady WH. 2015. Safety of thrust joint manipulation in the thoracic spine: a systematic review.  J Man Manip Ther. 23(3):154-61

Ernst E. 2015 Sep 3. The risk of (chiropractic) spinal manipulations: a new article. Edzard Ernst [see previous item]

Gorski D. 2016 Feb 8. Did chiropractic neck manipulation kill Katie May? Science-Based Medicine

Hall H. 2016 Apr 5. Chiropractic and stroke: no evidence for causation but still reason for concern. Science-Based Medicine

Crislip M. 2016 Apr 15. Chiropractic - ignoring the precautionary principle since 1895. Science-Based Medicine

Nielsen SM, Tarp S, Christensen R, Bliddal H, Klokker L, Henriksen M. 2017. The risk associated with spinal manipulation: an overview of reviews. Syst Rev. 6(1):64

Ernst E. 2017 Feb 16. Upper neck manipulations (by chiropractors) regularly cause serious harm. Why are they still used? Edzard Ernst

Ernst E. 2017 Apr 3. The risks associated with spinal manipulation are likely to be real and serious. Edzard Ernst

Ernst E. 2017 Sep 4. Cervical artery dissection and stroke related to chiropractic manipulation. Edzard Ernst

Bellamy J. 2017 Sep 14. Study: patients should be warned of stroke risk before chiropractic neck manipulation. Science-Based Medicine

Swait G, Finch R. 2017. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Therap. 25:37

Ernst E. 2018 Jun 7. Ophthalmic adverse effects after chiropractic neck manipulation. Edzard Ernst

Ernst E. 2018 Aug 29. Chiropractic neck manipulations can damage your eyes. Edzard Ernst

Ernst E. 2018 Dec 3. The benefits of chiropractic X-rays do not outweigh the risks. Edzard Ernst

Ernst E. 2019 Jan 14. Severe adverse effects of chiropractic in children. Edzard Ernst

Ernst E. 2019 Jan 21. Are cervical manipulations for neck pain truly "much safer than the use of NSAIDs"? Edzard Ernst

Ernst E. 2019 Apr 3. Cervical spine manipulation: a rapid literature review. Edzard Ernst

Ernst E. 2019 Apr 22. A risk-benefit assessment of (chiropractic) neck manipulation. Edzard Ernst

Ernst E. 2019 Jun 19. The majority of patients having manual therapy for back or neck pain report adverse events. Edzard Ernst

Ernst E. 2020 Feb 27. The risks of (chiropractic) spinal manipulative therapy in children under 10 years. Edzard Ernst

Ernst E. 2020 Sep 9. Beliefs, perceptions and practices of chiropractors and patients about adverse events after spinal manipulation. Edzard Ernst

Ernst E. 2020 Nov 11. An outstanding article on the subject of harms of chiropractic. Edzard Ernst

Ernst E. 2021 May 24. Chiropractic manipulations are a risk factor for vertebral artery dissections. Edzard Ernst

Ernst E. 2021 Jul 29. Spinal epidural hematoma after spinal manipulations: Report of three cases and a review of the literature. Edzard Ernst

Barrett S. 2022. Chiropractic's dirty secret: neck manipulation and strokes. Quackwatch

Ernst E. 2022 Apr 2. Malpractice litigation involving chiropractic spinal manipulation. Edzard Ernst

Ernst E. 2022 Apr 4. Chiropractic: "a safe form of treatment"? Edzard Ernst

Ernst E. 2023 Feb 20. More about the dangers of chiropractic. Edzard Ernst

Ernst E. 2023 May 10.  Scientific misconduct by chiropractors or osteopaths should no longer get published. Edzard Ernst

Crislip M. 2023 May 16. The good. The bad. The ugly. Science-Based Medicine

Ernst E. 2023 Jun 6. Adverse events associated with spinal manipulation. Edzard Ernst

Ernst E. 2023 Aug 2. The ‘GLOBAL PATIENT SAFETY TASK FORCE’ of the World Federation of Chiropractic. Edzard Ernst

Ernst E. 2023 Aug 17. Cervical manipulation for neck pain: DON'T DO IT! Edzard Ernst

Ernst E. 2023 Nov 10. Chiropractic adjustments are causing more and more strokes in younger adults. Edzard Ernst

Ernst E. 2023 Nov 13. Chiropractic has been shown to be a dangerous placebo therapy. My conclusion: do not consult chiropractors! Edzard Ernst

Ernst E. 2024 Jan 2.Chiropractic spinal manipulations are safe!!! …Or aren’t they? Edzard Ernst

Ernst E. 2024 Jun 28. Cervical spine manipulation and cervical artery dissection: an embarrassingly daft attempt of a white-wash. Edzard Ernst

Chiropractic - promotional

Web sites for chiropractic organizations:

• American Chiropractic Association

• International Chiropractors Association

• World Chiropractic Alliance

• International Chiropractic Pediatric Association

Palmer College of Chiropractic

Life University

Osteopathy - overview

Johnson SM, Kurtz ME. 2001. Diminished use of osteopathic manipulative treatment and its impact on the uniqueness of the osteopathic profession. Acad Med. 76(8):821-8 [abstract]

Cummings M, Dobbs KJ. 2005. The irony of osteopathic medicine and primary care. Acad Med. 80(7):702-5 [abstract]

Novella S. 2020 Oct 7. Osteopathic medicine - what is it? Science-Based Medicine

Ernst E. 2021 Mar 3. Do US osteopaths still use manipulation? Edzard Ernst

Jarry J. 2022 Oct 14. Osteopathy needs science to lend a hand. McGill Office for Science and Society

Osteopathy - critiques

Barrett S. 2005. Misleading claims by the American Osteopathic Association. Quackwatch

Barrett S. 2018. Dubious aspects of osteopathy. Quackwatch

Ernst E. 2018 Feb 28. Visceral osteopathy is implausible and does not work … SO, LET’S FORGET ABOUT IT ONCE AND FOR ALL. Edzard Ernst

Ernst E. 2018 Dec 28. What is osteopathy? Edzard Ernst

Anonymous. 2018 Nov 7. Osteopathy - not all it’s cracked up to be. Edzard Ernst

Ernst E. 2019 Mar 12. New review confirms: osteopathy is NOT evidence-based. Edzard Ernst

Ernst E. 2019 Sep 4. Osteopathic hubris. Edzard Ernst

MacBeth B. 2020 Feb 21. Quackery in medical school: Chapman points. Science-Based Medicine

Ernst E. 2021 Jul 26. Osteopathy: a bibliometric analysis (1966 – 2018) suggests that its impact is minimal. Edzard Ernst

Ernst E. 2021 Sep 9. Osteopathy = a much-hyped placebo therapy. Edzard Ernst

Ernst E. 2022 Apr 13. Osteopathic manipulative treatment: an overview of the evidence. Edzard Ernst

Ernst E. 2022 Aug 20. Osteopathic manipulative treatment for pediatric conditions: a systematic review lays bare the unethical behavior of osteopaths. Edzard Ernst

Ernst E. 2022 Sep 6. Cranial osteopathy is based on absurd concepts and does not merit further research. Edzard Ernst

Ernst E. 2022 Oct 6. Cranial osteopathy revisited. Edzard Ernst

Ernst E. 2022 Oct 17. Osteopathy: an absence of good-quality evidence. Edzard Ernst

Ernst E. 2023 Aug 13. Visceral osteopathy for low-back pain? No thanks! Edzard Ernst

Ernst E. 2023 Nov 26. Osteopathic visceral manipulation for chronic mechanical low back pain? Edzard Ernst

Ernst E. 2024 Jan 12. Craniosacral therapy is ineffective nonsense. Edzard Ernst

Ernst E. 2024 Jul 27. Is visceral osteopathy therapy effective? Our systematic review and meta-analysis. Edzard Ernst

Massage - overview

American Massage Therapy Association

Sherman KJ, Dixon MW, Thompson D, Cherkin DC. 2006. Development of a taxonomy to describe massage treatments for musculoskeletal pain. BMC Complement Altern Med. 6:24

National Center for Complementary and Integrative Health. 2019. Massage therapy: what you need to know

Vagg M. 2012 Oct 3. Myotherapy: panacea or placebo. The Conversation

Massage - critiques

Barrett S. 2006. Massage therapy: riddled with quackery. Quackwatch

Ernst E. 2018 Jul 16. Lymph-drainage: we need more and better research. Edzard Ernst

Ernst E. 2019 Jan 11. Massage: one of the few alternative treatments that is supported by fairly sound evidence. Edzard Ernst

Ingraham P. 2019 Feb 1. Why I quit my massage therapy career. Science-Based Medicine

Ernst E. 2021 19 Aug. Massage therapy for multiple sclerosis? Edzard Ernst

Ernst E. 2023 Jan 5. Massage therapy for postoperative pain? Edzard Ernst

Novella S. 2023 Aug 2. Structural Energetic Therapy. Science-Based Medicine

Ernst E. 2023 Aug 5. Massage for athletic performance? Edzard Ernst

Massage - adverse effects

Yin P, Gao N, Wu J, Litscher G, Xu S. 2014. Adverse events of massage therapy in pain-related conditions: a systematic review. Evid Based Complement Alternat Med. 2014:480956

A PDF file of this document (49 pages) is available for download at this site: CHIRO