MD, PhD, FMedSci, FSB, FRCP, FRCPEd

In many countries, consumers seem to be fond of consulting chiropractors – mostly for back pain, but also for other conditions. I therefore think it is might be a good and productive idea to give anyone who is tempted to see a chiropractor some simple, easy to follow advice. Here we go:

  1. Ask your chiropractor what he/she thinks about the chiropractic concept of subluxation. This is the chiropractors’ term (real doctors use the word too but understand something entirely different by it) for an imagined problem with your spine. Once they have diagnosed you to suffer from subluxation, they will persuade you that it needs correcting which is done by spinal manipulation which they tend to call ‘adjustments’. There are several important issues here: firstly subluxations do not exist outside the fantasy world of chiropractic; secondly chiropractors who believe in subluxation would diagnose subluxation in about 100% of the population – also in individuals who are completely healthy. My advice is to return straight back home as soon as the chiropractor admits he believes in the mystical concept of subluxation.
  2. Ask your chiropractor what he/she thinks of ‘maintenance care’. This is the term many chiropractors use for indefinite treatments which do little more than transfer lots of cash from your account to that of your chiropractor. There is no good evidence to show that maintenance care does, as chiropractors claim, prevent healthy individuals from falling ill. So, unless you have the irresistible urge to burn money, don’t fall for this nonsense. You should ask your chiropractor how long and frequent your treatment will be, what it will cost, and then ask yourself whether it is worth it.
  3. Run a mile, if the chiropractor wants to manipulate your neck (which most will do regardless of whether you have neck-pain, some even without informed consent). Neck manipulation is associated with very serious complications; they are usually caused by an injury to an artery that supplies parts of your brain. This can cause a stroke and even death. Several hundred such cases have been documented in the medical literature – but the true figure is almost certainly much larger (there is still no system in place to monitor such events).
  4. Run even faster, if the chiropractor wants to treat your children for common paediatric conditions. Many chiropractors believe that their manipulations are effective for a wide range of health problems that kids frequently suffer from. However, there is not a jot of evidence that these claims are true.
  5. Be aware that about 50% of all patients having chiropractic treatments will suffer from side effects like pain and stiffness. These symptoms usually last for 2-3 days and can be severe enough to impede your quality of life. Ask yourself whether the risk is outweighed by the benefit of chiropractic.
  6. Remember that there is no good evidence that chiropractors can treat any condition effectively other than lower back pain (and even for that condition the evidence is far from strong). Many chiropractors claim to be able to treat a plethora of non-spinal conditions like asthma, ear infection, gastrointestinal complaints, autism etc. etc. There is no good evidence that these claims are correct.
  7. Distrust the advice given by many chiropractors regarding prescribed medications, vaccinations or surgery. Chiropractic has a long history of warning their patients against all sorts of conventional treatments. Depending on the clinical situation, following such advice can cause very serious harm.

I am minded to write similar posts for all major alternative therapies (this will not make me more popular with alternative therapists, but I don’t mind all that much) – provided, of course, that my readers find this sort of article useful. So, please do give me some feedback.

27 Responses to Seven things to remember when you next consult a chiropractor

  • If you could do this in the form of leaflets I could give out to my patients, with references, I would be very interested.

    • If it could be in the former of leaflets I could give out in my surgery, I would be quite interested. I would certainly buy the book.

  • I’m reminded of the advice on chiropractic offered by Martin Gardner (Fads and Fallacies in the Name of Science, 1957), “Call on a practitioner, name a few symptoms, memorize carefully the exact spots where he finds subluxations, then leave on some pretext before he gives you treatment. Go and see a second chiropractor, name a different set of symptoms, and see if he finds the same spinal spots in need of adjustment. If he doesn’t, try a third chiropractor, and continue until you obtain duplicate diagnoses. This may be an expensive experiment, but it should prove illuminating.”

    The point was that different textbooks of chiropractic often suggested subluxations in different vertebrae as the cause of the same diagnoses.

  • I do find the listing of claims and the lack of proof helpful. I do not have somatic problems and thus do not need a chiropractor or a real therapist either. I do have friends who insist on going regularly. Unfortunately they have little interest in learning the problems with their treatment. They have been convinced of the “truth”. They are convinced that I know nothing because I have not given chiropractic a try. I find this attitude to be very common among the patients of alternative practitioners.

  • Many good points above! All should be covered in in the informed consent, which is a common law requirement here:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051308/?tool=pmcentrez&report=abstract
    That includes mild adverse events which match similar findings found by the physio’s. I have been doing it since 1995 and I am on my 6th revision. It is checked every year by the registration board and my professional indemnity insurer.

    The most important thing is distrust and be skeptical with all advise from all health professionals as we are all biased towards what we do! As for chiropractors advising on medication and vaccination, that is outside of our scope of practice. I don’t even advise on OTC medication as its not permitted here and the board has clamped down on the antivaccination fringe! As for surgery, which being a chiropractor means spinal surgery, I know all the Neuro’s and Orthopods in Sydney and I know who are over enthusiastic in utilising the scalpel and who are cautious. I have an excellent referral relationship with several cautious ones and I refer my patients to them for a second opinion if I am at all concerned. I work within the system with the doctors who are very aware of the cowboys within their speciality!

    I have consistently said to the paediatric chiro’s, do the research, show me the evidence and I will take it onboard. Unfortunately, when you look at the ICPA websites research it is solid case studies and the pleural of anecdote is not evidence! Until the evidence and resulting best practice guidelines are there, I don’t touch paediatrics!

    Chiropractors need to be skeptical and critical of everything that we do and I find this lacking in the subbies!

  • So if you have a chiro that:
    1) Is anti subbie
    2) Thinks maintainance care is bogus
    3) Doesn’t see Cervical manipulation as a useful procedure
    4) Doesn’t do paeds
    5) Issues informed consent and advises on side effects of all modalities
    6) Uses a multi modal evidence based approach for MSK conditions only
    7) Only offers evidence based advice within their scope of practice and refers off accordingly

    You’ll do just fine… A lot of us out there Ernst… like with any health profession if unsure get a second opinion or ask what’s the evidence on that? 🙂

  • This layperson finds your post very helpful and enlightening, and I would love to see additional posts on those topics you feel appropriate. “Off label” uses of medications and substances (e.g., silver, chelation agents, urine[!]) are especially of interest to me.

  • I’m an evidence based massage therapist and I have to say I LOVE this post given the disproportionate number of chiropractors I know who follow dogma rather than trusting in science and following evidence based practice.
    I’d love for you to do something like this for Massage therapy addressing things like “flushing toxins”, “drinking more water”, “breaking up adhesions/scar tissue”, “emotional centers”, etc… The list is practically endless.

  • 1. Agree
    2. Depends what you mean by maintenance. Up front payment , indefinite treatment, agree.
    3.incorrect. No causative link proven. As likely to experience a stroke after visiting your GP.
    4. Up to the parents. Some evidence but weak. But then 75% of the effect of antidepressants is placebo. Would you advise running a mile from SSRI use?
    5. Mostly extremely mild. Serious ones vanishingly rare and much rarer than side effects caused by aspirin. Would you advise not taking aspirin ?
    6. Incorrect. Consistent evidence that manipulation is as good a treatment for non specific low back pain as ANYTHING else on offer and that it is safe and patients are nearly 100% satisfied
    7.The vast majority of chiropractors give sound and evidence based advice centred on exercise , movement and lifting techniques along with a host of other sound public health messages. Those that advise against vaccination, wholesale I personally think should be avoided. Those that engage in sensible discussion about the risk/ benefits of vaccination in the same way a GP might engage with concerned parents are to be seen as normal health care professionals along with everyone else.

    • As a ‘Director of Research at the Anglo-European College of Chiropractic’ you would say that, wouldn’t you?

    • 1) glad you agree
      2) sorry that you do not seem to know the term used by fellow chiros to make money [http://www.chiro.org/research/ABSTRACTS/Maintenance_Care.shtml]
      3) even if you think the evidence is not compelling that upper spinal manipulation can cause a stroke [apart from chiros, few people do], one should consider the precautionary principle. the Cassidy study, by the way has been debunked several times and is only one of several case-control studies on the subject [do not cherry-pick your evidence]]
      4) I do not advise on conventional medicine, as my expertise is in alt med.
      5) not mild enough to impede QoL for several days. Aspirin has proven benefits, thus its risk/benefit balance is positive [contrary to chiro]
      6) I did say there is evidence for LBP; the point is that most of the other chiro claims are bogus – and you know it [even the libel court must have told you that]
      7) were you already in Bournemouth when I gave a lecture to your students and asked for a show of hands who was against vaccination?

      • @ Dave Newell

        Re your condemnation of chiropractic beliefs in mystical subluxations. The UK General Chiropractic Council’s stance on subluxations is very confusing. In August 2010 it changed its guidance on the Vertebral Subluxation Complex to allow chiropractors to treat ‘health concerns’ caused by ‘subluxations’. See here:
        http://skepticbarista.files.wordpress.com/2010/08/subluxrevltr1.jpg

        The new guidance is here: http://skepticbarista.files.wordpress.com/2010/08/subluxrevguidance.jpg

        Do you know what evidence the General Chiropractic Council applied in order to arrive at its revision, and would you agree that the new guidance is wholly unhelpful to patients?

        Re ‘maintenance’ chiropractic care (which you agree shouldn’t encompass up front payment and indefinite treatment), this review concludes that the prevalence with which maintenance care is used has not been established, and that the efficacy and cost-effectiveness of maintenance care for various types of conditions are unknown: http://www.chiromt.com/content/16/1/3 Can you cite any robust studies from the last half dozen years on the effectiveness of chiropractic maintenance treatment apart from this dubious one http://www.bodyinmind.org/maintenance-spinal-manipulation-the-cherry-pickers-quandary/ ?

        Re your claim that patients are as likely to experience a stroke after visiting their GP, I hope you’ve read the many valid criticisms of the Cassidy study: http://tinyurl.com/bp7dkn3 Incredibly, on the sole basis of the findings of the study, Cassidy retracted an admission that he had previously caused a stroke in a patient (watch his admission and retraction here: http://www.youtube.com/watch?v=xkZQlrQMJ-k ), yet, in his study, he didn’t rule out neck manipulation as a potential cause of some vertebrobasilar artery strokes: http://tinyurl.com/nzar5ta

        Re chiropractic treatment for children being “up to the parents”. I hope chiropractors tell parents the following:

        QUOTE
        “A 1993 risk–benefit analysis of spinal manipulative therapy (SMT) for relief of lumbar or cervical pain, published in Online Neurosurgery, advised neurosurgeons that “potential complications and unknown benefits indicate that SMT should not be used in the pediatric population” (Powell 1993)…Although spinal manipulation is often recommended as a treatment for back pain, this recommendation does not often apply to children. When the U.S. Department of Health and Human Services published guidelines suggesting that spinal manipulation might be helpful in treating low back pain without radiculopathy (sciatic pain) when used within the first month of symptoms, its recommendations did not apply to children younger than eighteen* years of age “since diagnostic and treatment considerations for this group are often different than for adults” (Bigos 1994)…All things considered, it’s an understatement to say that “pediatric chiropractic care is often inconsistent with recommended medical guidelines” (Lee 2000). Recommendation of any complementary alternative medicine (CAM) therapy that has a risk–benefit ratio that is not acceptable and is not supported in medical literature may make a referring physician liable for negligence if the referral causes harm by delaying necessary conventional treatment (Cohen 2005). For this reason, and with the best interest of children in mind, few physicians would consider referring a child to a chiropractor.”
        Ref: http://www.csicop.org/si/show/should_chiropractors_treat_children/
        [* Generally, pediatricians classify a child as being under eighteen years of age—before vertebral end plate growth is complete. In a child under the age of eight to ten years, the cartilaginous growth centers are too immature and too vulnerable to injury to be subjected to spinal manipulation. There is some speculation that injury to growth plates might result in spinal deformity (such as scoliosis or Scheuermann’s kyphosis) as growth progresses (O’Neal 2003). Such injury might not be detectable. “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” (O’Neal 2003).]

        It’s also worth mentioning this: “Although 14% of chiropractic patients are children, chiropractors have done almost no robust research in this area” http://www.chiromt.com/content/18/1/16 ; and this: “With this review, we have detected a paradox within the chiropractic profession: Although the major reason for pediatric patients to attend a chiropractor is spinal pain, no adequate studies have been performed in this area. It is time for the chiropractic profession to take responsibility and systematically investigate the efficiency of joint manipulation of problems relating to the developing musculoskeletal system” http://www.chiromt.com/content/18/1/15 ; and this, too: Statement on chiropractic for children from the chiefs of the departments of pediatrics and pediatric hospitals in Canada (Haslam RHA and others,1994) http://tinyurl.com/q2turpf

        Re there being “consistent evidence that manipulation is as good a treatment for non specific low back pain as ANYTHING else on offer and that it is safe and patients are nearly 100% satisfied.”

        When it comes to spinal manipulation administered by chiropractors, you cannot say conclusively that it is safe. IOW, due to the ongoing pseudoscientific beliefs of many chiropractors, it cannot be recommended for low back pain:

        QUOTE
        “Chiropractors view the spine as an entity. Where they diagnose ‘subluxations’, they will normally manipulate and ‘adjust’ them (11). And ‘subluxations’ will be diagnosed in the upper spine, even if the patient suffers from back pain. Thus many, if not most back pain patients receive upper spinal manipulations. It follows that the risks of this treatment should be included in any adequate risk assessment.”
        Ref: Spinal manipulation for the early management of persistent non-specific low back pain — a critique of the recent NICE guidelines, Edzard Ernst, Int J Clin Pract (18th August 2009). Reference (11) is Ernst E. Chiropractic: a critical evaluation. J Pain Sympt Man 2008; 35: 544–62. Page 6 of the paper mentions a report that indicates that only 11% of all cervical manipulations are “appropriate” and gives the reference Coulter I, Hurwitz E, Adams A, et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica, CA: RAND, 1996:18e43.

        Re “The vast majority of chiropractors give sound and evidence based advice centred on exercise, movement and lifting techniques along with a host of other sound public health messages.”

        That’s not true. The majority of them stray from evidence based practice: 89.8% of (US) chiropractors feel that spinal manipulation should not be limited to musculoskeletal conditions. [Ref: McDonald W, Durkin K, Iseman S, et al. How Chiropractors Think and Practice. Ada: Institute for Social Research, Ohio University, 2003.] The World Federation of Chiropractic (an association of chiropractic organisations in 85 countries) adopted an ‘identity statement’ based on a survey in which thousands of chiropractors were asked how the public should perceive them. [Ref. Carey PF and others. Final report of the Identity Consultation Task Force, April 30, 2005] The survey report states that 65% of respondents said that the phrase “management of vertebral subluxation and its impact on general health” fits chiropractic “perfectly” or almost perfectly. [Ref. Consultation on Identity. Quantitative research findings. (Slide #30) World Federation of Chiropractic, Dec 2004] Those figures are supported by a 2007 survey of UK chiropractors which revealed that traditional chiropractic beliefs (chiropractic philosophy) were deemed important by 76% of respondents, with 63% considering the subluxation to be central to chiropractic intervention:
        http://www.ebm-first.com/chiropractic/uk-chiropractic-issues/1188-the-scope-of-chiropractic-practice-a-survey-of-chiropractors-in-the-uk.html

        Here’s a question that’s been raised before on this blog and remains unanswered: *How would a member of the public distinguish between a reputable registered chiropractor and a disreputable registered chiropractor when consulting the UK General Chiropractic Council’s register?*

        Re “Those that advise against vaccination, wholesale I personally think should be avoided.”

        Has the Anglo European College of Chiropractic (AECC) revised its stance on vaccination in the last few months? It appears that it’s stepped away from evidence-based public health policy – i.e. back in July of this year, its website declared:

        QUOTE
        “we endorse and recommend the NHS vaccination programme”
        http://web.archive.org/web/20140410173038/http://www.aecc.ac.uk/clinic/whatischiro.aspx

        However, that URL now appears to be devoid of any mention of its former support for the NHS vaccination programme:
        http://www.aecc.ac.uk/clinic/whatischiro.aspx

        I’ve searched the AECC’s website to see if its position on vaccinations has been moved to another page, but can’t find anything about it. I hope it’s just an oversight.

  • I am indeed director of research at the Anglo Europesn College of Chiropractic and am mightely proud to be so. In that position I strive to know and understand the evidence pertaining to the impact of chiropractic care and spinal manipulation. You might have thought given that this is my full time job I might very well know this literature very well. Not being a chiropractor and having a background in molecular biology to PhD level I think I also have at least a little claim to understanding the scientific method and the strengths and limitations of clinical research methodology and interpretation of the research. I believe I do that in a balanced and informed manner pointing out where and where there is not evidence for claims in service of the profession and the students I have the privilege to teach and have taught over nearly 30 years. I also work hard to give our students the tools to understand what is defensible and what is not and along with my colleagues here at the AECC spend much time and effort to provide extensive knowledge, education and skills in the hope our students will go on to provide care to their patients at the highest ethical, professional and evidence based level.

    I must admit the rather dismissive and belittling tone of your point by point answer seems uncalled for Edzard. I have strived to always be scrupulously polite in my exchanges with you as I feel all scientific debate should be.

    I can only reiterate my original point by point comments to which I adhere to and feel you have not really added much to in your subsequent reply.

    Kindest regards Professor Ernst.

    Dr Dave Newell. Director of Resarch at the Anglo European College of Chiropractic

  • As a student, I find this debate fascinating. I have in the past received treatment for injury from sports masseurs, physiotherapists and osteopaths. All of which I had adverse reactions of sore muscles and stiffness for 24-48 hours afterwards. The masseur told me they were increasing blood flow to sore areas to allow ‘healing agents’ to work faster to heal my muscles. The private physio wanted me in 3 times a week for a 10 week programme, the oestopath quite frankly just confused me and I came out thinking I had blow flow problems. I then went to see a chiropractor and walked out pain free for the first time in months, without any soreness or stiffness. They also only saw me once more before giving me an exercise/stretch sheet and recommended I find a local Personal trainer to work on muscle strength and to call if I had any problems. My point to this is that every profession has its good and bad – I tried several others and chiropractic worked for me. I may have been lucky, the chiropractors that I have been around and inspired me to want to be one are very bio mechanical based. They adjust if needed, but aren’t phased if it is tissue work that is needed. Subluxation is a swear word and they have good working relationship with local GPs and other professions. It saddens me that a group of ‘bad Eggs’ are causing so many problems, but then MP’s wouldn’t exist if we wiped out professions because of a few idiots!

  • I agree to an extent but also disagree on statements mentioned above. I am currently a student of chiropractic and to be bold I think the word and meaning of subluxation used by chiropractors is pathetic. First let me say that although I am a student of chiropractic I do my own research and am skeptical on many levels. I believe as a doctor you should be. Evidence based care is the best way to go and it’s a shame that many working chiropractors do not abide by this, but not all.

    As far as cervical manipulation you either didn’t research enough or you twisted your words around. There is research that shows cervical manipulation and mobilization to be affective. As for the stroke you MDs believe to be caused by cervical manipulation is false. There is no causation. Truthfully you MDs have as much or more causation, if any, than a chiropractor. Chiropractors have more correlation due to the nature of their work. As an example chiropractors will receive more patients than MDs with headaches. And as you should know a headache is a symptom of the vertebral artery stroke. So correlation not causation, a drastic difference then you discussed above.

    For maintenance care I believe manipulative therapy is useful. Does that mean that it is needed, no. But if a patient prefers it then why not? But you didn’t specify manipulative care for maintenance you said chiropractic care. Chiropractic care can involve soft tissue work not just manipulative therapy. But I must say maintenance care at this point should be up to the patient because they feel better not the chiropractor trying to break the patients bank.

    Now let’s touch on the subject of side effects. This truly makes me laugh. I’m not sure where your information comes from but 50% of patients do not walk away from treatment with increased pain or stiffness. Even if that were true it doesn’t compare to the side effects of the medication that you MDs prescribe. What I took from that statement was that in your eyes pain/stiffness is more dramatic than increased BP, syncope, dysphasia, nausea, diarrhea, and even death. And many times other medications are prescribed by you MDs to deal with the side effects of the previously prescribed medication. And you call this optimum care for your patient!?

    It’s a shame that you MDs need to pick apart other professions. I don’t believe one healthcare profession to be the best. Everyone has its flaws, weaknesses, and strengths. I believe medication does help in certain situations and hurt in others. I believe chiropractice care to be strong and useful in some cases and weak in others. The care should be based on what is best for the patient. And you know what kind of care that is? Integrated care! Not just you and not just me, but both of us together. This is most optimal for the patient.

  • Kill yourself

  • I had a colleague who consulted a chiropractor for back pain. As expected, the chiropractor didn’t resolve the issue or identify its cause – which was spinal TB. Fortunately the chiropractor’s ineffectiveness prompted her to visit a conventional doctor, who identified spinal TB as the cause. Now, if the colleague had opted for a homeopathic cure or continued chiropractic visits, she would now be 6 feet under.

    • NO chiropractor should claim that they can resolve a problem, we don’t cure we do not fix anything. But we do help to improve your body to point of optimally functioning with minimum pain. Keep in mind not everyone will take care of their spine when necessary and sometimes what the person brings to the chiropractor to work with takes months and months of treatments to improve. If you want a quick fix then get a surgery or medicaitons. but those will have their own side effects. Would you rather take pain medication or have surgery than getting adjusted regularly ?

  • It is definitely interesting to see and read all these comments. There are many articles that even conclude that the cervical adjustments do not cause stroke. Do you really think we live in a world were the board of chiropractic will lie to you and find chiropractic safe? If cervical adjustments causes stroke then how come people who Don’t see a chiropractor get strokes ? It sounds like whoever you are, have not done unbiased research. Of course because a lot of insurance does not cover the chiropractic then most people assume it is not necessary . Have you even been around people that are getting regular adjustments versus people who have not ? I am a chiropractor and I don’t even use the word “subluxation” , that term simply put is part of the philosophy some doctors believe but the best doctors shy away from that term anyways. It is a shame to see ( if you are a real MD) how little knowledge you do have about chiropractic. If you had spent four years studying chiropractic along with sciences then maybe we could have a fair debate. I would be more than happy to answer any questions !

    • @Elmira
       
      “Do you really think we live in a world were [sic] the board of chiropractic will lie to you and find chiropractic safe?” Do you really think we live in a world where a huge car manufacturer will lie to you and tell you their exhaust emissions are within limits? Do you really think we live in a world where governments will lie to you and kill their own citizens? Do you really think we live in a world where a giant corporation will lie to you about its finances when it’s actually bankrupt. Alright, I know these are more extreme cases, but the answer to your question is “yes”: chiropractic entirely safe (your implication); never.
       
      “If cervical adjustments causes [sic] stroke then how come people who Don’t see a chiropractor get strokes ?” Facepalm! This is like a creationist saying “If man evolved from apes, how come there are still apes?”
       
      “If you had spent four years studying chiropractic along with sciences then maybe we could have a fair debate. I would be more than happy to answer any questions !” Is it too much to ask that you read someone’s biography before you make a stupid comment like this? Click on the About>Edzard Ernst button at the top of any page of this blog and you’ll see that Professor Ernst has been involved with the study of all kinds of alternative medicine for decades. Your comments demonstrate the absence of critical thinking skills and blinkered loyalty to an evidence-free pseudo-medicine that we have come to expect from chiropractors.

Leave a Reply

Your email address will not be published. Required fields are marked *

Please answer the following: *

Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted.


Click here for a comprehensive list of recent comments.

Categories