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Chiropractic

The world of Chiropractic has had a parallel existence with mainstream medicine for more than a century. It is a difficult topic to summarize in one essay. Indeed, the subject has come to mean different things to different people, even within the culture of chiropractic.

Some of the practices that have emerged in the modern world of chiropractic overlap considerably with mainstream practices, yet others keep chiropractic out of the Venn circle of scientific medicine.

Due to this long and complex history, this section is unusually long. Hopefully it is worth the read.


History

The time was 1886.

The world of medicine was just beginning to think of the biologic world scientifically. Louis Pasteur had experimentally confirmed germ theory in the 1860’s. Charles Darwin’s On the Origin of Species was changing the way we thought of biologic organisms. Science was coming into fashion.

Many practices that seemed scientific were popular. “Heroic Medicine” was practiced by mainstream doctors.  This was based on the idea that dangerous diseases should be treated with noxious agents, bleeding, purging, blistering and other toxic “remedies.” Mainstream medicine most definitely was doing more harm than good.


Many practitioners of other “healing” arts rightly rejected heroic medicine and pursued other methods. Their patients often did better than those treated with ‘heroic” medicine, for at least little harm was being done. Such practitioners called themselves “Doctor”. One such man was D.D. Palmer.

Chiropractic History: a Primer states:

Dr. Palmer was a man of strong convictions and irrepressibly sharp tongue, and he broadcast his views on the horrors and abominations of mainstream medicine by means of a newspaper-sized advertiser (successively known as The Educator, The Magnetic Cure, and The Chiropractic) which reached thousands in Davenport and surrounding communities. D.D. Palmer was a lightning rod for controversy.

Daniel David Palmer went into the practice of “magnetic healing” in Burlington, Iowa. Magnetic healing was essentially a form of vitalism. It sprung from the concept of 'animal magnetism' in which it was believed that living beings possessed a form of magnetism that could be influenced by the healer to treat disease. D.D. Palmer felt that he possessed the magnetic healing touch.

After ten years of practice in magnetic healing, D.D. Palmer made what he thought was an astonishing discovery. The custodian of the building was allegedly a deaf man named Harvey Lillard. Apparently, Lillard told Palmer that, years prior, he was working in a cramped space and hurt his upper back. He claimed to be at least partially deaf ever since. Palmer manipulated this area and apparently restored Lillard’s hearing. Following this miracle, Palmer then claimed to have cured a patient of heart trouble by manipulating the spine to improve the innervation of the heart.

In his book, The Science, Art and Philosophy of Chiropractic, D.D. states:

Then I began to reason if two diseases, so dissimilar as deafness and heart trouble, came from impingement, a pressure on nerves, were not other disease due to a similar cause? Thus the science (knowledge) and art (adjusting) of Chiropractic were formed at that time."

D.D. Palmer felt that he had found the cause (and cure) of all disease.

He fancied himself a “magnetic manipulator”. He coined the term “chiropractic” with the help of his patient Rev. Samuel Weed, combining 2 Greek works to mean “done by hand”. In 1896, he began teaching this method to others. Thus, the Palmer School of Chiropractic was born in 1897.

Palmer was jailed and fined in 1906 in Iowa for practicing medicine without a license. This was around the time of the drive for reform in the American medical education system, leading to the Flexner Report in 1908. Palmer sold his school to his son, B.J. Palmer, and moved out West to establish other chiropractic schools.

B.J. Palmer expanded the teaching of chiropractic. New schools opened across many states to teach the manipulative techniques of his father. Father and son differed on their approach and philosophy of how chiropractic should be taught. In particular, B.J. emphasized the use of spinal x-rays in the diagnosis and treatment of disease.


Chiropractic emphasised the concepts of “Innate Intelligence” and “Subluxation Theory”. Such principles were thought to explain the apparent healing attributed to chiropractors. However, the scientific evidence for such concepts was (and continues to be) dubious.

As chiropractors focused on their ideas of subluxation and spinal adjustments, “heroic medicine” began its transformation into scientific medicine. The twentieth century saw advances in antibiotics, surgical techniques, nutrition, fluid management, diagnostic tools, diabetes management and many, many other areas. Vaccines were developed and proven to save countless lives. Other sectarian “healing” practices began falling by the wayside. In the U.S.A., homeopathic hospitals were shut down. Osteopathic medicine transformed itself by embracing scientific medicine, while still maintaining manipulation practices.

It should be noted that in certain circumstances, spinal manipulation might be helpful and has a small, if not questionable evidence base. However, spinal ‘adjustments’ to alleviate the chiropractic ‘subluxation’ for the facilitation of ‘innate intelligence’ have not achieved scientific validation (see below). Evidence for the former should not be misconstrued as evidence for the latter.

Chiropractors in America have had some sort of political body since 1906, when the Palmer School formed the Universal Chiropractic Association (UCA). As an organization, chiropractors united in an attempt to protect themselves against prosecution by the mainstream. The UCA advocated “straight” chiropractic (faithfully maintaining the Palmers’ original ideas and rejecting the influence of “mainstream medicine”).

Other chiropractors in America at the time were less enamored with the quasi-metaphysics of the Palmers. They “mixed” philosophies of chiropractic, other alternative sectarian practices and “mainstream” medicine. These “mixers” formed the American Association of Chiropractors.  

The American Chiropractic Association merged with the UCA in 1922 to form the National Chiropractic Association (NCA). B.J. Palmer continued the fight to keep Chiropractic “straight”. In 1938 he formed the International Chiropractor’s Association (ICA). The ICA continues to this day to advocate practices based on the metaphysical idea of innate intelligence and subluxation “theory”. In keeping with its name, the ICA does have international membership, but is not affiliated with the World Health Organization.

Chiropractors continued to be prosecuted for practicing medicine without a license. According to the ACA, by 1931, there were reportedly 15,000 such prosecutions among only 12,000 chiropractors. Despite such efforts, chiropractic continued without scientific validation, even as mainstream medicine was becoming more scientifically minded.

In 1963, the NCA reorganized to be called (again) the American Chiropractic Association. That same year, the American Medical Association’s Board of Regents created the “Committee on Quackery” with an emphasis on eliminating chiropractic. In 1966, the AMA issued a statement containing the following:

“It is the position of the medical profession that chiropractic is an unscientific cult whose practitioners lack the necessary training and background to treat human disease. Chiropractic constitutes a hazard to rational health care in the United States because of the substandard and unscientific education”

Mirtz et.al., in the Journal of Controversial Medical Claims, writes:

This antagonism reached its height in the 1980s when four chiropractors brought an antitrust suit against the American Medical Association (AMA). When the AMA was found guilty of an illegal boycott of chiropractic in the 1986 Sherman antitrust lawsuit, chiropractors presented this decision as proof of the court's endorsement of chiropractic. It was not. The transcripts stated:

  All of the parties to the case, including the plaintiff chiropractors and
  the AMA, agreed that chiropractic treatment of diseases such as diabetes,
  high blood pressure, cancer, heart disease, and infectious disease is not
  proper, and that the historic theory of chiropractic that there is a single
  cause and cure of disease was wrong and that there was evidence that
  chiropractic theory of subluxations was unscientific, and evidence that
  some chiropractors engaged in unscientific practices.



Chiropractic seemed to be changing. Some chiropractors wished to pursue scientific validation of their craft. In the 1980’s, the Journal of Manipulative and Physiological Therapeutics was launched, and is the only chiropractic journal listed in the Index Medicus. The Journal of the American Chiropractic Association (JACA) is also widely distributed to further the agenda. Thus, chiropractic was given a scientific and political appearance. The chiropractic world has achieved political influence. If its scientific evidence of progress is lacking, chiropractic’s evidence of international popularity is touted in testimonials and political headlines. Its evidence of political strength is displayed in the list of chiropractic organizations.

In 1984, a group of chiropractors openly rebelled against the pseudoscience and quasi-philosophy of their profession. They are known as “reform chiropractors” They embraced scientific medicine and rejected most of the traditional dogma of the Palmers. They formed a new group called the National Association for Chiropractic Medicine (NACM).

It would have been possible for the average consumer (and mainstream medical professional) to utilize the a chiropractor’s membership in NACM to identify evidence-based chiropractors for back pain treatment when usual care failed.  However, for whatever reason, NCAM dissolved sometime between 2008 and 2010.

Today, chiropractors remain divided between the “straights” and the “mixers”, as we shall see below. They range from those who are reasonable with respect to their knowledge of back pain and the limited ability to treat it, to those who advocate multiple unscientific ideas about human health and “treatments”.

It is the latter that keeps the field of chiropractic in the realm of pseudoscience. The average consumer has no good way of knowing on what part of the pseudoscience spectrum their chiropractor lies.


Subluxation "Theory"

The word “subluxation” causes confusion for doctors when they hear it used in discussions about chiropractic.

In medical schools, the word is used as defined in medical dictionaries:

sub·lux·a·tion : (medical definition) - Incomplete or partial dislocation, as of a bone in a joint.
(Note: a complete dislocation is called a “luxation”)

A subluxation, by this definition, is demonstrable on x-rays.

In chiropractic circles, the word “subluxation” implies “any mechanical impediment to nerve function”.

The chiropractic subluxation is generally defined as a functional impairment of proper nerve conduction to the spinal cord. These are not detectable by radiologists when looking at spine films, although modern chiropractors claim to infer their existence through copious use of x-rays and other techniques. The implication in classic chiropractic teaching is that these impediments to nerve function lead to impaired organ function and disease. Various chiropractic organizations have gone back and forth with the word’s definition. Some reject it altogether.

The International Chiropractors Association has adopted the following definition of subluxation :

"Any alteration of the biomechanical and physiological dynamics of the contiguous spinal structures which can cause neuronal disturbances."

The American Chiropractic Association definition goes even further: "An aberrant relationship between two adjacent structures that may have functional or pathological sequelae, causing an alteration in the biomechanical and/or neurophysiological reflections of these articular structures, their proximal structures, and/or other body systems that may be directly or indirectly affected by them.

The International Chiropractors Association states, “Subluxation is a responsible and credible diagnosis for the doctor of chiropractic and this condition should be recognized and reimbursed as a primary diagnosis by all third‑party payment organizations, both public and private. The analytical/diagnostic determination of a subluxation indicates the need for chiropractic care.

According to the above ICA statement, it is because of the nebulous chiropractic “subluxation” that people need spinal 'adjustments' (usually on a frequent basis) to restore proper health. While medical subluxations are simple anatomic facts that can be seen on x-rays, the evidence for the chiropractic subluxation is lacking. According to the ICA, its presence is determined by chiropractors and therefore we need chiropractic care (and reimbursement).

But, do we have evidence for such entities independent of chiropractors' determinations?

A 2009 review article in Chiropractic and Osteopathy used Hill’s criteria to look for a causal relationship between the chiropractic subluxation and disease. They concluded:

There is a significant lack of evidence to fulfill the basic criteria of causation. This lack of crucial supportive epidemiologic evidence prohibits the accurate promulgation of the chiropractic subluxation.

A 2010 article in the Journal of Chiropractic Humanities, the authors conclude:

“The “subluxation concept” currently faces challenges, which are briefly reviewed in this article. The only way forward is to strengthen our efforts to investigate the “subluxation concept” with high-quality scientific studies including animal models and human clinical studies.”

Unfortunately, the chiropractic subluxation concept has been protected with enough self-sealing fallacies that it is pretty much unfalsifiable, and therefore not scientific. “High-quality scientific studies” will not be fruitful. How does one logically observe the unobservable?

The concept of the chiropractic subluxation has been heavily challenged, from outside and within the field. Retired chiropractor Sam Homola, author of Bonesetting, Chiropractic & Cultism": confessions of a chiropractic heretic, explains in his Science Based Medicine article that some have tried to move away from the term, but not the idea.

“There are now some chiropractors who do not subscribe to the theory that some kind of segmental dysfunction in the spine can cause organic disease, but they are overshadowed by subluxation-based chiropractors who publish their own journals, using scientific-sounding jargon to defend implausible theories and dubious treatment methods. Some of these chiropractors do not use the “subluxation” word, instead substituting some other vague description of a spinal lesion, such as “joint dysfunction,” alleged to have the same effect on the nervous system and general health as a “vertebral subluxation.

It is worth noting again that when we talk about the “chiropractic subluxation”, we are not talking about the medical subluxation (partial dislocation of a joint). We are not talking about real nerve impingements from spine arthritis, trauma or disc herniations. We are talking about otherwise undetectable blockages of nerve impulses due to unobservable defects in otherwise normal spines. Despite numerous scientific-sounding devices and techniques which are claimed to detect the elusive chiropractic subluxation, it has yet to be demonstrated.

Because the word is a homophone with an actual scientific term, the word “subluxation” hijacks legitimacy.

X-rays, special devices and a lot of faith do not make them real.


Innate Intelligence

The vitalistic energy that is purported to flow through the nerves to preserve health and wellness was named "innate intelligence", or sometimes just "innate". Many think of innate in teleological terms as the body’s healing power. The term was coined by D.D. Palmer.  It may be analogous to "qi" and other energies of vitalism.  

According to classic chiropractic teachings, the flow of innate intelligence is blocked by subluxations. By adjusting the subluxations of the spine, the chiropractor restores health by restoring the flow of innate.

Innate intelligence is a nebulous property, the concept of which is developed in the 33 Principles of Chiropractic, as listed by the ICA. Excerpts from these principles include:

The mission of Innate Intelligence is to maintain the material of the body of a "living thing" in  active organization.”
“The function of Innate Intelligence is to adapt universal forces and matter for use in the body, so that all parts of the body will have co-ordinated action for mutual benefit.”
“In order to carry on the universal cycle of life, Universal forces are destructive, and Innate forces constructive, as regards structural matter.”
“The forces of Innate Intelligence operate through or over the nervous system in animal bodies.”
“Interference with transmission in the body is always directly or indirectly due to subluxations in the spinal column.”

Such an energy has no scientific correlate. Indeed, it has no defined properties that can be directly measured beyond saying that it is simply the normal self-healing abilities of the body. Biologic organisms are able to repair themselves from a large varieties of insults. However, these abilities are biologic and have extreme limitations. Blockage of neural flow from subluxations is not one of those limitations. Healing from injury or disease can occur even with complete transection of the spinal cord.

Remember, science is grounded in observation (and inferences based on those observations). In principle, ideas should be falsifiable in order to be considered scientific. To date, we have no way to falsify the claim of “innate intelligence”.

We do, however, have a strong understanding of how nerves actually work and their pathways.  Given this growing body of knowledge, the concept of an undiscovered, unobservable energy has a very low plausibility (or in Bayesian terms, a low "prior probability"). The low prior, combined with our inability to experimentally observe such an energy, gives innate intelligence a vanishingly small probability overall.

Remember, Occam's Razor holds that we should reject hypotheses that require unnecessary or unknown assumptions in favor or hypotheses that are plausible through known mechanisms. The concept of innate intelligence and other unfalsifiable vitalistic energies require extraordinary assumptions which are not warranted.

Many chiropractors have moved away from the idea of innate intelligence, although “straight” chiropractors hold on to the concept. The definition morphs from one school of thought to the next and is difficult to pin down.

Those who practice on the basis of unfalsifiable, implausible claims keep chiropractic in the realm of pseudoscience.


The Cure for All Disease?

A hallmark of medical pseudoscience is the appeal to simplicity and certainty. The pseudoscientist often claims to have found both the cause and cure for all disease. Chiropractic is a prime example.

D.D. Palmer, in The Science, Art and Philosophy of Chiropractic, stated:

"A subluxated vertebra ... is the cause of 95 percent of all diseases ... The other five percent is caused by displaced joints other than those of the vertebral column."

In 1909 B.J. Palmer explained the one cause and cure of all (apparent) infectious disease in terms of subluxation in The Philosophy of Chiropractic :

"Chiropractors have found in every disease that is supposed to be contagious, a cause in the spine. In the spinal column we will find a subluxation that corresponds to every type of disease. If we had one hundred cases of smallpox, I can prove to you where, in one, you will find a subluxation and you will find the same conditions in the other ninety-nine. I adjust one and return his functions to normal... . There is no contagious disease... . There is no infection... . There is a cause internal to man that makes of his body in a certain spot, more or less a breeding ground [for microbes]. It is a place where they can multiply, propagate, and then because they become so many they are classed as a cause."


The ICA seems certain that they know the cause (and hence the cure) for disordered health:

All bodily function is controlled by the nervous system, consequently a central theme of chiropractic theories on health is the premise that abnormal bodily function may be caused by interference with nerve transmission and expression due to pressure, strain or tension upon the spinal cord, spinal nerves, or peripheral nerves as a result of a displacement of spinal segments or other skeletal structures (subluxation).”

When you are faced with claims about the cause and cure for all disease, you might just be dealing with a pseudoscience.


Straights and Mixers

Are you a “straight” or a “mixer”?

As we learned above, chiropractors have been divided over over the fundamental quasi-philosophical ideas of innate intelligence and subluxation “theory”. Those that continue to hold the belief that all disease is caused by disruption of innate intelligence by subluxations have been dubbed “straights”. Those who acknowledge chiropractic’s metaphysical roots, but expand their practice to include a variety of other types of treatment (alternative or otherwise) are dubbed “mixers”.

The straights hold firmly to their beliefs. They “know” the cause and cure for all disease. They focus on the subluxation and maintenance of innate intelligence. They are staunchly against any scientific medicine. Straights are more likely to reject Germ Theory and vaccines. They are more likely to advocate against proven treatments for asthma, diabetes and cardiovascular disease.

To the average paying customer (who has no reason to know better), “straight” chiropractors are a dangerous group.

Today, the majority of chiropractors likely fall into the “mixers” camp. Of course, there is a spectrum of beliefs within this group. On one end, we have chiropractors who mix manipulative techniques with other various pseudoscientific beliefs and practices. They may advocate homeopathy, applied kinesiology, acupuncture, etc.

Mixers may also advocate nutrition, exercise and other healthy practices. Although, even among these uncontroversial subjects, there is a spectrum of science to pseudoscience.

At the other end of the “mixer” spectrum, some “reform chiropractors” embrace science and evidence based medicine. They encourage their patients to see medical doctors for medical problems and focus their attention solely on back pain. As we shall see below, there is some limited, scientific evidence to support manual therapy for the treatment of low back pain. Most reasonable mainstream doctors and medical societies would likely have little problem accepting chiropractors at this end of the spectrum.

A 2011 Australian article in the chiropractic journal, Chiropractic and Manual Therapies concludes:

The future of chiropractic in Australia is at a crossroads. For the profession to move forward it must base its future on science and not ideological dogma. The push by some for it to become a unique and all-encompassing alternative system of healthcare is both misguided and irrational.”

Unfortunately, most do not advertise their position on the spectrum. The general public does not know the differences between “straights”, “mixers” and “reformed” chiropractors. NACM apparently is no longer in existence.

Until the field as a whole embraces science, chiropractic will maintain its status as a pseudoscience.


Back and Neck Pain

Above, we discussed the pseudoscience of chiropractic that continues to plague serious attempts to legitimize the practice. But what about the scientific evidence for the practice of manipulative therapy for back and neck pain? It seems plausible that manipulation (as opposed to “adjustment” -- see above) could have a therapeutic effect on mechanical back pain.

Let’s take a look at various summaries of the evidence.

Note - we will deal with the issue of manipulative therapy of the neck for neck pain in the What’s the Harm? section.

Back pain can be divided into categories. “Acute” back pain usually indicates a recent onset of back pain, typically less than a month or so. “Chronic” back pain typically means a duration of six months or more. For our purposes, we will use the term “common” back pain to represent back pain without a systemic or structural cause that can be observed. It is likely from mechanical strain and perhaps inflammation in the muscles and supportive tissues. We also use the term “pathologic” back pain to represent back pain from a disease state or anatomic derangement.

First, we should consider the fact that spinal manipulative therapy (SMT) is rarely the only means used in a chiropractor’s office for the patient with common back pain.

In the 2011 Cochrane review entitled Combined chiropractic interventions for low-back pain, chiropractic was defined as encompassing a combination of therapies such as spinal manipulation, massage, heat and cold therapies, electrotherapies, the use of mechanical devices, exercise programs, nutritional advice, orthotics, lifestyle modification and patient education.

This review found most of the studies had significant bias problems. The better studies lead the review authors to conclude,The review shows that while combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute and subacute low-back pain, there is currently no evidence to support or refute that combined chiropractic interventions provide a clinically meaningful advantage over other treatments for pain or disability in people with low-back pain.

So, the combination of treatments usually offered seemed to help people with back pain, but it was unclear if the actual “chiropractic” therapy (SMT) part was the part that made the results significant. It could have been the other modalities, such as massage, heat, exercise or “lifestyle modification” that made the difference. Or, maybe not.

In the 2012 Cochrane review Spinal manipulative therapy for acute low-back pain concluded, "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."



Other reviews have looked at studies that tried to isolate the effects of SMT for common back pain.

One such review is the 2008 Cochrane review entitled Spinal manipulative therapy for low-back pain. This review of 39 trials found that spinal manipulation was more effective in reducing pain and improving the ability to perform everyday activities than sham (fake) therapy and therapies already known to be unhelpful. However, it was no more or less effective than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner.

So, SMT may be more effective for back pain than doing nothing (even “sham” manipulation), but not more effective than the usual care one would receive through a primary care physician. This is not a dismissal of SMT. It appears to be just as legitimate for back pain as physical therapy, back exercises or NSAIDS.

But what about chronic back pain? This is usually defined as back pain that has persisted for over six months. As such, these patients have commonly sought “usual” care and failed.

An update to a Cochrane review was published in 2011 entitled, Spinal Manipulative Therapy for Chronic Low-Back Pain. This looked at 26 RCTs with over 6000 patients total. The authors concluded, “(h)igh-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain.

So, sufferers of chronic low back pain did benefit somewhat from manipulative therapy, but not more than other methods. This does not bode well for patients with chronic low back pain,  because “other methods” do not fare so well either.

Radiculopathy associated back pain is different than common low back pain. This is a pathologic problem that is associated with a real impingement of the radicular nerves that leave the spine to form the spinal nerves (as opposed to the unobservable chiropractic “subluxations” -- see above). Treatment for such pain is notoriously difficult.

A 2010 systematic review in Physical Medicine and Rehabilitation Clinics of North America entitled Spinal manipulation or mobilization for radiculopathy: a systematic review concluded, There is moderate quality evidence that spinal manipulation is effective for the treatment of acute lumbar radiculopathy. The quality of evidence for chronic lumbar spine-related extremity symptoms and cervical spine-related extremity symptoms of any duration is low or very low. At present, no evidence exists for the treatment of thoracic radiculopathy.

So, people with acute radiculopathy-associated back pain may benefit from SMT. People with chronic radicular symptoms of the neck and low back did not seem to do so well. People with chronic mid-back radicular pain received no demonstrable benefit.

Some trials compare interventions with simple patient education in the form of a booklet on back pain. Before we consider such trials, we should ask how effective is the “booklet” method?

A review entitled Individual Patient Education for low-back pain revealed People with low-back pain who received an in-person patient education session lasting at least two hours in addition to their usual care had better outcomes than people who only received usual care. Shorter education sessions, or providing written information by itself without an in-person education session, did not seem to be effective.

So, the more contact patients have with the provider, the better the outcomes. Written information, by itself, had no effect.

The same review also noted “Patient education was no more effective than other interventions such as cognitive behavioural group therapy, work-site visits, x-rays, acupuncture, chiropractic, physiotherapy, massage, manual therapy, heat-wrap therapy, interferential therapy, spinal stabilisation, yoga, or Swedish back school. One study found that patient education was more effective than exercises alone for some measures of function.

It would appear that the common element in all of the useful approaches in the above paragraph is the contact time with a provider. This is not pseudoscience per se as long as no unwarranted claims are being made beyond the unspoken premise of “I care about you and I am going to try to help you feel better”.

An oft-cited 1998 study in The New England Journal of Medicine entitled A Comparison of Physical Therapy, Chiropractic Manipulation, and Provision of an Educational Booklet for the Treatment of Patients with Low Back Pain pitted physical therapy, chiropractic and written education for common low back pain. For all outcomes, there were no significant differences between the physical-therapy and chiropractic groups and no significant differences among the groups in the numbers of days of reduced activity or missed work or in recurrences of back pain.

This article also measured satisfaction and cost. About 75 percent of the subjects in the therapy groups rated their care as very good or excellent, as compared with about 30 percent of the subjects in the booklet group (P<0.001). Over a two-year period, the mean costs of care were $437 for the physical-therapy group, $429 for the chiropractic group, and $153 for the booklet group.

Back pain, acute and chronic, is a frequent and difficult problem to treat. There is some evidence for spinal manipulative therapy (SMT). The evidence is on par with other treatments commonly prescribed by mainstream doctors and performed by physical therapists. Edzard Ernst summarizes, "In view of the cost of chiropractic spinal manipulation and the uncertainty about its safety, I would probably not rate this approach as the treatment of choice but would consider the current Cochrane review which concludes that “high quality evidence suggests that there is no clinically relevant difference between spinal manipulation and other interventions for reducing pain and improving function in patients with chronic low-back pain“ Personally, I think it is more prudent to recommend exercise, back school, massage or perhaps even yoga to chronic low-back pain sufferers."


As such, SMT for back pain does not meet our definition of “alternative medicine” and should not be included in reviews for the “efficacy” of alternative medicine.


No Benefit for Other Medical Problems

As we have seen above, there is a weak evidence base for manipulative therapy (by a chiropractor or other practitioners) for back pain. However, claims of benefit for non-musculoskeletal medical problems drag the field into the sphere of pseudoscience. Here we examine some of these claims and the scientific evidence for them.

Asthma

The RCT from 1998 entitled A Comparison of Active and Simulated Chiropractic Manipulation as Adjunctive Treatment for Childhood Asthma states In children with mild or moderate asthma, the addition of chiropractic spinal manipulation to usual medical care provided no benefit.

Hypertension

In 2002, the study called Treatment of Hypertension with Alternative Therapies (THAT) Study: a randomized clinical trial concluded: chiropractic spinal manipulation in conjunction with a dietary modification program offered no advantage in lowering either diastolic or systolic blood pressure compared to diet alone.

Ear Infections

In 1996, the chiropractic Journal of Physiologic and Manipulative Therapy published Ear infection: a retrospective study examining improvement from chiropractic care and analyzing for influencing factors that tried to find evidence for a benefit in ear infections.

“Although there were several limitations to this study (mostly because of its retrospection but also, significantly, because very little data was found regarding the natural course of ear infections), this study's data indicate that limitation of medical intervention and the addition of chiropractic care may decrease the symptoms of ear infection in young children.“

So, retrospective study seemed to correlate with improvement of symptoms of ear infections, however, the authors stated that they were not aware of the “natural course of ear infections”. Today, much is known about the “natural course of ear infections”.

In the 2003 article Natural history of untreated otitis media, we learned that acute ear infections usually resolve spontaneously with good outcomes. This includes groups on and not on antibiotics! It turns out that most treatments for ear infections are not superior to the “natural history”.

Headache

The 2005 review article, Physical treatments for headache: a structured review states, Chiropractic manipulation demonstrated a trend toward benefit in the treatment of tension-type headache (TTH), but evidence is weak. Chiropractic manipulation is probably more effective in the treatment of TTH than it is in the treatment of migraine. Evidence is lacking regarding the efficacy of these treatments in reducing headache frequency, intensity, duration, and disability in many commonly encountered clinical situations. Many of the published case series and controlled studies are of low quality.

Not really reassuring.

Hearing Loss

This was D.D. Palmer’s initial claim for the wonders of chiropractic (see above). He claimed to restore the hearing of a deaf man by manipulating his spine. Is there evidence for this? Is it even plausible? In her article, Chiropractic and Deafness: Back to 1895, Dr. Harriet Hall takes apart this claim piece by piece. The answer to these questions is ‘no’; it is not plausible.

In 2002, The Medical Letter had this to say: For treatment of other conditions such as asthma, dysmenorrhea and enuresis, a recent review of placebo-controlled studies found no statistically significant evidence that spinal manipulation differed from a sham intervention.




What's the Harm?

A major concern for harm invokes the possibility of an association between rapid neck manipulation and a form of stroke from injury to the vertebral-basilar artery system in the neck.


The vertebral arteries run through the bones of the cervical spine in the neck. The spine does not carry similar arteries below the level of the neck. The vertebral arteries join above the neck to form the basilar artery, which supplies blood to the back of the brain. Shear forces on the vertebrobasilar system may lead to a dissection of the arteries (a tear of the layers of the arterial lining) which, in turn, cuts off blood flow to the back of the brain. In other words, injury to this system leads to a serious form of stroke involving the visual and coordination systems of the brain.

Collectively, problems associated with these kinds of strokes are called vertebrobasilar circulatory disorders. Symptoms include loss of coordination of movement and speech, difficulty swallowing, loss of control of bowel and bladder function, vision disturbances and more. Tears in the vertebrobasilar system are often associated with escalating neck pain which may precede the other symptoms by a day or more. This delay lies at the heart of controversy between the chiropractic community and skeptics over the risks of rapid neck manipulation (cervical spine manipulative therapy -- CSMT or just CMT for short).

Although the published chiropractic literature is of the opinion that manipulation of the cervical spine is extremely safe, the data on this subject is lacking and likely under-reported.

A commonly quoted paper from the chiropractic literature claims to have studied the risk of vertebral stroke and SMT. Its conclusions seemed to exonerate chiropractic. This case control study concluded, The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.

However, case control studies are not designed to determine cause. Also, results reported in the body of the study suggest a different conclusion.


Dr. Mark Crislip reviewed the same data and pointed out that, Table 3 has the smoking gun. The highest odds ratio (14) for a stroke is 12, 4 times any other, in the age less than 45 in the first 24 hours after a visit to a chiropractor. And, to give credit where credit is due, they mention this as a key point in the discussion and, in the introduction, note two other studies that show an association between visiting a chiropractor and having a stroke. The risk of stroke is 5 to 6 times in these studies.

A review of the literature in Spine looked at reporting of injuries from 1966 through 2007. It states:

Despite the increasing popularity of chiropractic, there are few properly designed prospective controlled trials, and there is a disproportionate lack of evaluation of its safety profile. The literature reports multiple neurologic complications of spinal manipulation, some of which are clinically relevant and even life threatening.”

“The frequency of adverse events varied between 33% and 60.9%, and the frequency of serious adverse events varied between 5 strokes/100,000 manipulations to 1.46 serious adverse events/10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations.”

“There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue.”

A review of the literature since 2001 raises more concerns. “The most common serious adverse effects were due to vertebral artery dissections. The two prospective reports suggested that relatively mild adverse effects occur in 30% to 61% of all patients. The case-control studies suggested a causal relationship between spinal manipulation and the adverse effect. The survey data indicated that even serious adverse effects are rarely reported in the medical literature.

A 2007 Southern Medical Journal case report and review of the literature points out the inadequacy of reporting of serious complications. The most common risk factors are migraine, hypertension, oral contraceptive pills and smoking. Stroke following CSMT is more common than the literature reports. The best values derive from retrospective surveys. The lack of identifiable risk factors place those who undergo CSMT at risk of neurologic damage.”

The Medical Letter made it very clear that the risks of neck manipulation should not be ignored.
Spinal manipulation can cause life-threatening complications. Manipulation of the cervical spine, which has been associated with dissection of the vertebral artery, appears to be especially dangerous.”

Tim Farley has collected a series of anecdotes that demonstrate “What’s the Harm”.


WHO Guidelines and Contraindications

The following are excerpts from the World Health Organization’s guidelines and contraindications for the use of chiropractic manipulations. It was written by chiropractors. Curiously, it seems to contradict the Palmers’ claims about chiropractic subluxations and manipulation for the cure of disease (other than symptomatically treating back and neck pain). It also seems to recognize the medical / anatomic definition of “subluxation” paradoxically as a contraindication to manipulation.


“Manipulations can be classified as either nonspecific, long‐lever techniques or specific,
short‐lever, high‐velocity, low‐amplitude techniques (the most common forms of
chiropractic adjustment) which move a joint through its active and passive ranges of
movement to the paraphysiological space.

Mobilization is where the joint remains within a passive range of movement and no
sudden thrust or force is applied.

Contraindications to spinal manipulative therapy range from a non-indication for such
an intervention, where manipulation or mobilization may do no good, but should
cause no harm, to an absolute contraindication, where manipulation or mobilization
could be life‐threatening.

Clearly, in relative contraindications, low‐force and soft‐tissue techniques are the treatments of choice, as both may be performed safely in most situations where a relative contraindication is present.  

It should be understood that the purpose of chiropractic spinal manipulative therapy is
to correct a joint restriction or dysfunction, not necessarily to influence the disorders
identified, which may be coincidentally present in a patient undergoing treatment for a
different reason.*  Most patients with these conditions will require referral for medical
care and/or co-management.
                              (* Note the contradiction of the Palmers’ original claims for chiropractic)

Absolute Contraindications
1. anomalies such as dens hypoplasia, unstable os odontoideum, etc.
2. acute fracture
3. spinal cord tumour
4. acute infection such as osteomyelitis, septic discitis, and tuberculosis of
the spine
5. meningeal tumour
6. haematomas, whether spinal cord or intracanalicular
7. malignancy of the spine
8. frank disc herniation with accompanying signs of progressive
neurological deficit
9. basilar invagination of the upper cervical spine
10. Arnold‐Chiari malformation of the upper cervical spine
11. dislocation of a vertebra
12. aggressive types of benign tumours, such as an aneurysmal bone cyst,
giant cell tumour, osteoblastoma or osteoid osteoma
13. internal fixation/stabilization devices  
14. neoplastic disease of muscle or other soft tissue
15. positive Kernig’s or Lhermitte’s signs
16. congenital, generalized hypermobility  
17. signs or patterns of instability
18. syringomyelia
19. hydrocephalus of unknown aetiology
20. diastematomyelia
21. cauda equina syndrome

NOTE:  In cases of internal fixation/stabilization devices, no osseous manipulation may be
performed, although soft-tissue manipulation can be safely used. Spinal manipulative
therapy may also only be absolutely contraindicated in the spinal region in which the
pathology, abnormality or device is located, or the immediate vicinity.

Inflammatory conditions, such as rheumatoid arthritis, seronegative spondyloarthropies, demineralization or ligamentous laxity with anatomical subluxation * or dislocation, represent an absolute contraindication to joint manipulation in anatomical regions of involvement.
                                                (* note the distinction with Palmer’s definition of subluxation)

Clinical manifestations of vertebrobasilar insufficiency syndrome warrant particular caution and represent a relative‐to‐absolute contraindication to cervical joint manipulation at the area of pathology. This would include patients with a previous history of stroke.

Signs and symptoms of acute myelopathy, intracranial hypertension, signs and symptoms of meningitis or acute cauda equina syndrome represent absolute contraindications to joint manipulation.

While it is understood that the actual incidence of cerebral vascular injury could be higher than the number of reported incidents, estimates from recognized authorities in research in this area have varied from as little as one fatality in several tens of millions of manipulations (59), one in 10 million (60) and one in one million (61) to the slightly more significant “one important complication in 400, 000 cervical manipulations.”


Is Chiropractic Worth Any Risk?

Dr. Harriet Hall wonders if chiropractic manipulation, especially of the neck, can be justified.

The only thing neck manipulations have been shown to help with is mechanical neck pain, and a recent Cochrane review did not find that manipulation was any better than simple mobilization treatments. If there is no benefit, isn’t any degree of risk too much?

A review of the published literature from 2000 through 2005 poses this question too.
The conclusions of these reviews were largely negative, except for back pain where spinal manipulation was considered superior to sham manipulation but not better than conventional treatments.”
“Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.

Dr. Stephen Barrett wrote this in his summary of the literature:
“...since stroke is such a devastating event, every effort should be made to stop chiropractors from manipulating necks without adequate reason. Many believe that all types of headaches might be amenable to spinal manipulation even though no scientific evidence supports such a belief. Many include neck manipulation as part of "preventative maintenance" that involves unnecessarily treating people who have no symptoms. Even worse, some chiropractors—often referred to as "upper cervical specialists"—claim that most human ailments are the result of misalignment of the topmost vertebrae (atlas and axis) and that every patient they see needs neck manipulation. Neck manipulation of children under age 12 should be outlawed ."



How About Other Manual Therapies?

If there is any risk at all, why not turn to less risky modalities? Other therapies, including physical therapy, are demonstrably as effective for treating neck and back pain as chiropractic manipulation. Why not just do these?

A review of the literature from 1925 through 1997 revealed the following risks about manipulation of the cervical spine (MCS) as performed by different types of providers:

One hundred seventy-seven published cases of injury reported in 116 articles were reviewed. The cases were published between 1925 and 1997. The most frequently reported injuries involved arterial dissection or spasm, and lesions of the brain stem. Death occurred in 32 (18%) of the cases.

Physical therapists were involved in less than 2% of the cases, and no deaths have been attributed to MCS provided by physical therapists.

Although the risk of injury associated with MCS appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (nonthrust passive movements). The literature does not demonstrate that the benefits of MCS outweigh the risks.

The evidence summarized in this systematic review indicates that specific exercises may be effective for the treatment of acute and chronic mechanical neck pain, with or without headache. No manipulation required.

Physical therapy (PT) seems comparable to SMT for common back pain in terms of outcome and cost. So, why not pursue PT over chiropractic? Are some chiropractors actually doing physical therapy? “Physical Therapist” is a legally protected term implying that the therapist has been licensed by an accredited organization. Only physical therapists can do physical therapy (and charge for it). However, physical therapists also have training in SMT if appropriate.

Doctor of Physical Therapy, Derek Dalton, writes on his blog, More and more, it looks like Physical Therapists are able to combine quality therapeutic exercise with manual techniques such as manipulation to provide the BEST care for many musculoskeletal problems.  Remember, only licensed PT’s provide Physical Therapy and chiropractors aren’t the only providers skilled and trained to perform spinal manipulation.

Studies published in journals such as the Journal of Manipulative Therapy demonstrate numerous biases in their assessment of the risks of spinal manipulation in chiropractic. Nearly all medical treatments come with risks, but they must be lower than their benefits to be considered worth it.

A diabetes drug that may have a remote association with bladder cancer should not be used if a drug with equivalent or better therapeutic value --without the risk-- is available (no matter how much the doctor is attached to it). In the world of medicine, this is a ‘no-brainer’.

Again, when it comes to treating neck pain, is any risk worth it when there are safer alternatives?


Other Risks

Other risks are of concern. The risks involved with manipulating the spines of babies and children are addressed in the Pediatrics section below.

A very broad concern, particularly for skeptics, is the infiltration of pseudoscience (and frankly anti-scientific thinking) into popular culture. The subset of chiropractors (namely the “straights”, but also many “mixers”) that hold to the Palmers’ pseudoscientific notions (eg. “subluxations” and “innate intelligence”) blur the lines between reality and fantasy.

Such practitioners also tend to promote other pseudosciences such as acupuncture and homeopathy. This is explored below in the Gateway to Other Pseudoscience and Denialism section.


Pediatrics

Increasingly, children are being manipulated by chiropractors.

A 1998 survey in Boston revealed that 11% of visits to chiropractors were for children. That’s about 420,000 children in one city in one year. Is there legitimate scientific evidence to support this? The authors of this survey note that, (p)ediatric chiropractic care is often inconsistent with recommended medical guidelines.


It seems that many, if not a majority, of pediatric visits are directed at issues other than neck and back pain. Indeed, neck and back pain is relatively rare in children and should be considered pathologic until proven otherwise.
The rationale for pediatric spinal manipulation therefore falls back on the Palmers’ pseudoscience of subluxations and innate intelligence. We have already read above about the lack of evidence for SMT in infantile colic and ear infections. Are there any benefits of SMT for children? Are there risks?

A 2010 review in Chiropractic and Osteopathy states:

A great deal has been published in the chiropractic literature regarding the response, or lack thereof, of various common pediatric conditions to chiropractic care. The majority of that literature is of low scientific value (that is, case reports or case series).

The more scientifically rigorous studies show conflicting results for colic and the crying infant, and there is little data to suggest improvement of otitis media, asthma, nocturnal enuresis or attention deficit hyperactivity disorder.”

The efficacy of chiropractic care in the treatment of non-musculoskeletal disorders has yet to be definitely proven or disproven, with the burden of proof still resting upon the chiropractic profession.”

Indeed, the burden of proof is always on those making the extraordinary claim, for extraordinary claims require extraordinary evidence.

What about adverse events?

A 2007 review in Pediatrics, entitled Adverse Events Associated With Pediatric Spinal Manipulation: A Systematic Review looked at 13 studies.

It reports, (w)e identified 14 cases of direct adverse events involving neurologic or musculoskeletal events. Nine cases involved serious adverse events (eg, subarachnoidal hemorrhage, paraplegia), two involved moderately adverse events that required medical attention (eg, severe headache), and three involved minor adverse events (eg, midback soreness). Another 20 cases of indirect adverse events involved delayed diagnosis (eg, diabetes, neuroblastoma) and/or inappropriate provision of spinal manipulation for serious medical conditions (ie, meningitis, rhabdomyosarcoma).

Again, these events appear relatively rare. Observational studies cannot prove causation, only association. The authors called for prospective, controlled trials to assess causation. We do not know if these injuries are being caused by manipulating children, but the pretest probability seems significant.

The above study also raises the serious question of delayed diagnosis due to the mistaken belief that SMT can cure disease, and chiropractor’s lack of knowledge/ training in scientific pediatric medicine.

Here is an eye-opening example of such pseudoscience:

“Nerve interference can result from spinal misalignments or abnormal motion in the spine called vertebral subluxations and because the nervous system affects immune function it is important to reduce or correct any vertebral subluxations if found” advised Dr. Christopher Kent, chiropractic researcher and President of the Foundation for Vertebral Subluxation.

In his article, Be Wary of Chiropractic Pediatrics, retired chiropractor and author Samuel Homola, D.C., details the lack of evidence to support manipulative therapy in kids. Again, the practice is driven by the dangerous pseudoscience that is still adhered to by many (not all) chiropractors. Homola argues from the knowledge that the pediatric spine is still developing.

In children under the age of 8 to 10 years, the cartilaginous growth centers are too immature and too vulnerable to injury to be subjected to spinal manipulation. There is even speculation that injury to growth plates might result in spinal deformity (such as scoliosis or Scheuermann's kyphosis) as growth progresses. Such injury may not be detectable.
As noted by one observer: "The incidence of subtle growth plate fractures following high-velocity [manipulation] techniques in children is surely under-appreciated because of the occult nature of these injuries." (link added)

Here is another excerpt from Homola’s article:

Considering the implausibility of chiropractic's vertebral subluxation theory and their lack of training, there is good reason to doubt the ability of chiropractors to diagnose and treat childhood ailments. Even if they can diagnose conditions accurately, there is no evidence to support the belief that manipulating the spine of a child to correct "vertebral subluxations" would be appropriate treatment for anything. A 1993 risk/benefit analysis of spinal manipulative therapy for relief of lumbar or cervical pain, published in Online Neurosurgery, advised neurosurgeons that "Potential complications and unknown benefits indicate that SMT [spinal manipulative therapy] should not be used in the pediatric population."  (link added)

The ICA Council on Chiropractic Pediatrics states, "Chiropractic care can never start too early."

The ICA also states, Chiropractors have been providing safe and effective care for children for more than 103 years. Without efficacy, parents would have long ceased to seek out a doctor of chiropractic for their children. A 1992 survey showed that the most common conditions for which children visit a chiropractor are: earaches, neck pain, check-up, headache, upper respiratory, low back pain, allergies, asthma, enuresis, and thoracic pain. Other reasons are ADD and ADHD, colic, torticollis, insomnia, growing pains, and persistent crying in infants.”

What are the key logical fallacies in the above statement?

There are two in the first sentence. First there’s begging the question by unstated major premise (“Chiropractors have been providing safe and effective care for children for more than 103 years.” -- Have they been doing this? This has not been established.) Then there is the argument from antiquity. Just because chiropractors have been manipulating children “for more than 103 years” does not mean that it has ever been a good idea. The second sentence commits begging the question by circular reasoning and equivocates the word “efficacy” (“Without efficacy, parents would have long ceased to seek out a doctor of chiropractic for their children.”). This redefines efficacy as people not ceasing to seek out care from chiropractic. It also appeals to popularity. The litany of conditions listed for which children visit a chiropractor represents an argument from artifice and, also, begs the question from unstated major premise. It assumes that chiropractors actually can treat these conditions beyond the placebo effect.

In short, there is no scientifically valid reason to manipulate the spines of children. There is a potential for harm.

What on Earth are we doing?


Gateway to Denialism and Other Pseudoscience?

An overlooked and potentially damaging adverse effect of embracing a pseudoscience is the introduction to other realms of pseudoscience.

It stands to reason that those who ignore evidence and science in one area, would be credulous about the extraordinary claims in others. Likewise, one may predict that a purveyor of pseudoscience may also deny legitimate science.

Certainly, not all chiropractors promote other pseudosciences in their practice. Samuel Homola, D.C. is one of them. Indeed, “reform” chiropractors who claim only to help people with the symptoms of back pain are rarities and should be embraced, for such chiropractors understand the limits of the evidence for manipulative therapy.

However, those who embrace subluxation and innate intelligence are not interested in simply helping back pain. Their view of biology incorporates magical thinking and views their role as restoring health by promoting the flow of vitalistic energy by adjusting unseen subluxations. Why not throw in some other magical thinking?

The following are examples of other pseudosciences that are promoted at many chiropractic offices.

Applied Kinesiology
Detoxification  (Google “chiropractic detoxification”)
Herbal Medicine
Acupuncture
Nutrition Pseudoscience
Many Advocate "Thermography" (see A Critical Look at Thermography)

Many are denialists of proven medical therapies and science. Consider the following:

Vaccine Denialism  (The ICA’s possition statement promotes “choice” and the “dangers” of vaccines.
Fluoridation Denialism

Many discourage treatment for hypertension, asthma and others. A few clicks on Google are revealing:

Google “Chiropractic do not take high blood pressure medication”)
Google “Chiropractic no asthma medication
Google “chiropractic no diabetes medications
Google “chiropractic no thyroid medication

You get the idea.

Our patients, family members and fellow human beings are subjected to factually wrong and dangerous ideas such as these at chiropractic offices around the world. We currently lack a controlling body to stop them from making these pseudoscience and denialist claims.


The BCA vs. Simon Singh

One would expect that those who cannot defend their claims on the basis of facts, evidence and reason would turn to litigation to silence their critics. Such was the case of the British Chiropractic Association’s libel suit against writer and skeptic Simon Singh.

Singh co-authored the excellent book, Trick or Treatment: The Undeniable Facts about Alternative Medicine with Edzard Ernst. Following this book in 2008, Singh authored an article in The Guardian in the U.K. entitled Beware the Spinal Trap. In this article, Singh made the following statement about the BCA:

“The British Chiropractic Association claims that their members can help treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying, even though there is not a jot of evidence. This organisation is the respectable face of the chiropractic profession and yet it happily promotes bogus treatments.” (emphasis added)

The BCA sued Singh for libel in England over the use of the word “bogus”, implying that Singh used the word to claim that the BCA willfully deceives people. Simon Singh however maintained that “bogus treatments” meant that chiropractic treatments for medical ailments are not supported by evidence, not that chiropractors willfully deceive people.

The U.K.’s libel laws at the time heavily favored the plaintiff, shifting the burden of proof on the defendant. With the help of skeptical activists around the world, Singh fought and won the case, although suffering a personal financial cost.

The case, however, sparked a campaign (led by Singh and supported by the skeptical movement) to reform Britain’s libel laws.


Conclusion

Critical analysis of chiropractic is difficult. The term has come to mean different things to different people, even within the chiropractic culture. It started with a pre-scientific idea about the workings of the human body and romanticized by the notion of a vitalistic life force.

Today, there seems to be two distinct camps of chiropractors.

On one hand, there is the group that rejects the pseudoscience of subluxation and innate intelligence (for example, see the Appendix for the General Chiropracic Counsel's statement on the matter). This group focuses on treating mechanical back pain with manipulative techniques, a practice that is modestly supported by evidence. The evidence shows that such practice is about as effective as other means of treating back pain, and that some patients prefer it. Many science-based doctors would have no problem with an expansion of this type of chiropractor. It would represent one more option for our patients with back pain. They would have considerable overlap with physical therapists, and indeed could work together, as do podiatrists and orthopedists, cardiologists and heart surgeons, and psychiatrists and psychologists. Granted there are always some “turf” attitudes, but overall, these various groups work together. The problem is...this group of chiropractors are not distinctly separate from the other group.

The other group (and this appears to be the larger of the two camps) view themselves as healers with the ability to alter disease by adjusting mysterious, unobservable subluxations to restore the healing power of vitalistic innate intelligence (or something like that). This group keeps chiropractic in the sphere of pseudoscience. This group makes unscientific health claims that have been demonstrated to be false, yet the claims continue to flourish. When critical thinking is left out and the standards for ‘evidence’ are ignored, the door to other pseudosciences swings wide open.

Of even more concern, chiropractors in the second group reject science-based medicine altogether, leading people away from demonstrably valuable treatments such as vaccinations and medical treatments for conditions such as asthma, hypertension, diabetes, thyroid disease and others.

The risk of serious injury, such as vertebrobasilar stroke, is probably relatively rare. However there is little good reporting to determine the real risk. Those chiropractors in the evidence-based group would likely be more mindful of this risk and, it would seem, be more mindful of the proposed guidelines concerning manipulation of the neck. Those who tend to reject established science, would likely be more apt to reject the notion that there is any risk at all.

When your standards for evidence depend on personal and anecdotal experience, confirmation and myside biases, there is very little drive to question your own practices critically.

Most patients are not equipped with the knowledge and critical thinking skills to tell the two groups apart. Most patients do not have a pre-existing bias toward science or pseudoscience. Most patients just want to feel better when they hurt and when they are sick. Skeptical doctors are concerned about steering their patients with the best available knowledge.

Mainstream doctors are not perfect. Many do not carry the tools of skepticism written about on this site. Many doctors promote pseudoscience too. However, as a whole, the culture of mainstream medicine is governed by established, evidence-based standards. Science is not perfect, but scientific knowledge is still the best that we can know (by definition). Medicine is progressing more toward evidence based care and guidelines. Some doctors are upset about this, shouting publicly about impingement of freedom. However, the system as a whole is demanding evidential standards. Science is messy. Medical science is even messier. But it slowly makes progress by phasing out unsupported ideas and promoting the supported ones. This is happening even despite the rise in trendy departments of “integrative medicine”.

Many chiropractors (from the second group) point to the failures of mainstream medicine somehow as evidence for their mixed bags of pseudoscience. Skeptics recognize this as the tu quoque fallacy. It should be pointed out that we discover our failures through the process of science. Without science, we would continue on with our false practices as we did with bloodletting for centuries.To use knowledge obtained by science as evidence against science is logically invalid. You can’t have it both ways.

Until the culture of chiropractic as a whole embraces scientific thinking, or until those who practice only evidence-based services splinter off into a distinct and recognized group, skeptical doctors will likely view the chiropractic with an extremely critical eye. Reality actually matters.

Many of us would welcome another science-based partner in patient care. That day is not here yet.

We are waiting.


John Byrne, MD


Appendix

Claims of Subluxation Causing Disease Prohibited in Great Britain Published on May 25, 2010
The General Chiropractic Council (GCC), a UK-wide statutory body with regulatory powers, has published a new position related to subluxation and the claims made by Doctors of Chiropractic.  The GCC was established by the British Parliament to “regulate and develop the chiropractic profession”.

The chiropractic vertebral subluxation complex is an historical concept but it remains a theoretical model. It is not supported by any clinical research evidence that would allow claims to be made that it is the cause of disease or health concerns.

Chiropractors are reminded that:

  • they must make sure their own beliefs and values do not prejudice the patients’ care (GCC Code of Practice section A3)

  • they must provide evidence based care, which is clinical practice that incorporates the best available evidence from research, the preferences of the patient and the expertise of practitioners, including the individual chiropractor her/himself (GCC Standard of Proficiency section A2.3 and the glossary)

  • any advertised claims for chiropractic care must be based only on best research of the highest standard (GCC Guidance on Advertising issued March 2010)




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