MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Amidst the current controversy of chiropractic spinal manipulation for new-born babies, the previous director of Chiropractor’s Association of Australia NSW, Alex Fielding, published an interesting article. In it, he declared:

  1. I do not condone the chiropractic treatment of children for non-musculoskeletal conditions it is simply not our place. There is little to no evidence for it and it should not be done. If a chiro is report them to AHPRA.
  2. There is no evidence for “subluxation” it simply has not been shown to exist by any credible source.
  3. Chiropractic does not equal spinal manipulative therapy (SMT) or adjustment. We are trained to assess and treat musculoskeletal conditions, use exercise rehab, various forms of manual therapy including SMT, give sound evidence based advice and refer to better suited health professionals in the appropriate circumstance. To say there is no evidence for chiropractic is an ill informed politically charged statement, if you mean SMT, say SMT.

Here I only want to comment on his last point. I think it is important, not least because we hear it ad nauseam. As soon as there emerges new evidence to show that SMT does little for back or neck pain or is ineffective for non-spinal conditions, chiropractors insist that they do so much more than just SMT, and therefore any such findings do not ever lend themselves to a verdict about chiropractic care.

In my view, this argument is a bit like ‘wanting the cake and eat it’ (chiros want to be different from physios by adhering to SMT, but they don’t want to be judged by the uselessness of SMT). It begs the following questions:

  1. What other modalities do chiros use?
  2. For which conditions do they use them?
  3. What is the evidence for or against them?
  4. In what percentage of patients do chiros use SMT?

The last question may be the most important one. I am not aware of data from ‘down under’ but, in the UK, the percentage is close to 100%. This is why I often call SMT the ‘hallmark therapy of chiropractors’. No other profession employ it more frequently. It is the treatment that defines the chiropractic profession.

If the evidence for SMT is flimsy or negative or non-existent, it seems not unreasonable to voice doubts about the profession that uses it most. The fact that chiropractors also administer other modalities – most of which, by the way, have a shaky evidence-base too – is simply a smoke-screen used to mislead us.

An example might make this a bit clearer. Imagine a surgeon who takes out the tonsils of every patient he sees, regardless of any tonsillitis or other tonsil-related condition (historically, this fad once existed; tonsillectomy was even used to treat depression). This surgeon also does all sorts of other things: he prescribes pain-killers, gives antibiotics, orders bed-rest, gives life-style advice etc. etc. Yet he is a charlatan because his hallmark intervention is not effective and even puts patients at unnecessary risks.

I know, the analogy is not perfect, but it makes the point: chiropractors refuse to be judged by the uselessness of SMT. Yet it is what defines them and they continue using SMT pretty much regardless of the evidence. Fielding pleads: To say there is no evidence for chiropractic is an ill informed politically charged statement, if you mean SMT, say SMT. I’d say there is no good evidence for SMT nor for chiropractic care that includes SMT.

My advice for chiropractors therefore is: abandon SMT and become physiotherapists. This will make you a bit better grounded in evidence, but at least you would have rid yourself of the Palmer-cult with all the BS that comes with it.

36 Responses to Chiropractors, is it not time to abandon SMT?

  • Quote. ” We are trained to assess and treat musculoskeletal conditions, use exercise rehab, various forms of manual therapy including SMT, give sound evidence based advice and refer to better suited health professionals in the appropriate circumstance.”

    There is already a profession doing all this with a solid training. It is called PHYSIOTERAPIST.

    • If only you could spell it though!

    • Chiropractors were practicing physiotherapy long before it became a separate profession. Physiotherapists are excellent at what they do but have little to no training in physical diagnosis, radiology, laboratory diagnosis and differential diagnosis.

  • And I have personal experience of working with a fine surgeon who first qualified as a physiotherapist.
    It can be done.

    A practitioner who “asseses and treats …conditions” is, or should be, a medically qualified doctor.
    The medical profession became regulated in the UK (1858) precisely to protect patients from practitioners who made claims to be able to ‘assess and treat’ without being qualified in medicine.

    Until a patient is ‘assessed’ how does any practitioner know the disease, injury of affliction is attributable to “musculo-skeletal conditions”?

    Of course this creates an elite. That is how standards were raised, and continue to be maintained.
    Patients should look askance at those who claim otherwise.

    It would be very helpful if Mr Fielding would explain why he was attracted to chiropractic and why he studied, trained and qualified in chiropractic rather than physiotherapy. Or medicine.

    • I had really positive experience with a good chiro when I was about 17 when I had chronic low back pain. Always had an interest in anything human body. I got into chiro so I played along. After this I got to the interview stage of applying for medicine but pulled out t and decided to go for physio instead because I really enjoy the exercise rehab and hands on injury management of physios and chiros. It’s annoying that I’m doing physio where so far the MSK training has been almost identical. But you know, these things happen

      • How did you know what you wanted to do?
        I only decided on surgery after studying all the other options.
        Had you not pulled out of medicine at the interview stage you could stll have gone on and studied/practiced chiropractic or physio (though I confess I do not know any doctors who practice as physiotherapists).

        You style yourself as ‘Alex, Chiro’ but seem to be a physiotherapist (who pulled out of medicine).
        Are you in the right profession?
        Depends I suppose on whether you believe ‘innate’ can be released by mainpulation and if so, that it affects physiology and pathology.

  • I’m famous! I made an Ernst blog! I just do what I’m trained to do. SMT was just one of many things I was taught to do. In regards to physio, yep I’m in the middle of doing that degree at the moment

  • You mention that chiropractors are the only profession using SMT, however you fail to recognise that osteopaths and even physiotherapists are also using SMT. And just like these other professions, it is not the only treatment modality offered by chiropractors. It is true that some chiros only use SMT as a treatment modality, just as there are some physios that use only ultrasound (or ultrabulls#@t) or some GPs offering only NSAIDS despite what research says.
    Other forms of treatment offered at a typical chiropractic practice include dry needling, exercise prescription, lifestyle modification, soft tissue techniques, nutritional support and the list goes on.
    So before you go and pigeon hole the whole profession maybe do some research, even speak to a few chiros rather than labelling the entire profession useless just because there are some individuals that do not make the standard. In case you didn’t realise, there are many of these in every profession.

    • “You mention that chiropractors are the only profession using SMT” – NO I DID NOT; READ IT AGAIN!

      • I apologise, however you do make associations between chiropractic and SMT.
        “This is why I often call SMT the ‘hallmark therapy of chiropractors’. No other profession employ it more frequently. It is the treatment that defines the chiropractic profession”.
        So i beg to differ with your comment, and you have again failed to recognise that other healthcare professionals such as GPs, physiotherapists and osteopaths also use SMT.
        Your other comment “The fact that chiropractors also administer other modalities – most of which, by the way, have a shaky evidence-base too – is simply a smoke-screen used to mislead us.” Seems to be a smoke screen in itself. What other modalities can you name? Dry needling, soft tissue techniques, exercise prescription, nutritional support, lifestyle modification are therapies typically found in chiropractic practices.

        • can’t you read?
          “No other profession employ it more frequently.”
          this means that other professionals use it albeit less often.

  • Your points above Edzard match conversations I have with evidence based chiropractors, educators and researchers on a regular basis. The professional suicide being loudly advocated by the hard core guru’s/high priests of the subluxation church and how to marginalize and ultimately eliminate them or at least reduce their numbers to the lowest % possible is an ongoing challenge!

    Here they have been forced out of the universities so out of desperation they have approached an American practice management guru to help them set up a private subluxation based college in Adelaide. CAA put a proposal for this college to a vote by members around 2012 and it was voted down by the members which seriously rattled the vitalists in the executive who thought that they called the shots and dictated policy. So some executives went ahead on their own, yet are still on CAA’s executive (national and South Australia). This seroiusly undermines the credibility of CAA!

    If you look at the high church of subluxation there are around 12-20 high priests who peddle their BS at all the usual love fests like CalJam, Edinburgh Lectures, Dynamic Growth, ChiroEurope, Mile High and the latest in you neck of the woods Rubicon. Targeting these key players instead of their mindless, uncritical camp followers would help those of us pushing hard for reform.

    @Richard Rawlings
    We have chiro – Dr – specialists here. The patron and one of the prime movers of COCA here is David De La Harpe who is a chiro and orthopod. We sadly lost Lindsay Rowe recently who was a chiro – Dr – Radiologist who passed away earlier this year. He co-wrote the core text “Essentials of Skeletal Radiology” while still a chiro and was acknowledged as a world authority on skeletal radiology even before becoming a radiologist. He was a strong supporter of chiropractic and reform. I have two chiro friends currently studying medicine and another in the middle of specialist training. There are also researchers and educators like Bruce Walker who also helped found COCA and actively pushes for communication and collaboration with doctors. All these individuals and association have raised standards and continue to do so. They also need your support!

  • No ‘g’ in my name – but never mind.
    For the record, and I apologise for not knowing, but where is ‘here’ and what does COCA stand for?
    I am delighted chiropractors are studying medicine. Their experience as manipulators will be very valuable – but they will be expected to comply with the stringencies of medical practice, base their practice on best available evidence and obtain fully informed consent from patients –

    “I must tell you there is no plausible evidence for ‘innate’ and nor for ‘subluxations’, which is why I have abandoned ‘chiropractic’ – but I have learnt some manipulative techniques which might help you…”

    If only more chiropractors adopted this approach they would have my full support.

    • There is a growing percentage of chiropractors who don’t hold onto the traditional concepts and definitions of “subluxation” and “innate”. Our research is focusing more on responders vs nonresponders with regards to SMT. Many of us utilize many tools with our patients and focus on being evidence informed in our approaches.

      But yes, as someone mentioned, the quenching of the vocal minority who hold onto outdated concepts is an ongoing battle.

      Blogs, like what Ernst posts above, well, they are what they are…ones persons simple view on a multifaceted issue.

      • But if you don’t ‘hold onto traditional concepts and definitions of ‘subluxations’ and ‘innate’, why do you claim to be a chiropractor?
        Are you not making false claims and/or practising medicine without a medical licence.

        The medical profession became regulated to protect the public from quacks.
        How does anyone judge whether you are a quack, and/or a fraud?

        If you wanted to practice in a regulated profession, why not qualify as a doctor as so many others have done?

        • “But if you don’t ‘hold onto traditional concepts and definitions of ‘subluxations’ and ‘innate’, why do you claim to be a chiropractor?”

          Because chiropractic as a profession is evolving (for many of us anyway).

          “Are you not making false claims and/or practising medicine without a medical license.”

          One would have to evaluate the claims to determine if they are false. One would have to define “medicine” to answer that question.

          “How does anyone judge whether you are a quack, and/or a fraud?”

          Look at the claims and the evidence. (A agreed upon definition of “quack” helps as well)

          “If you wanted to practice in a regulated profession, why not qualify as a doctor as so many others have done?”

          I did. Chiropractic in the USA is a regulated profession and we can use the title “Doctor”.

          • In the UK, anyone can use the title ‘doctor’, but they must not claim to be a registered medical practitioner unless they are.
            In the US I guess the title Dr might induce some to believe you are medically qualified and no doubt this helps marketing, But is that not inherently dishonest?
            And is this not the problem the medical profession has had with ‘chiropractic’ ever since D D Palmer came up with a way to market his practice as a ‘magnetic practitioner’?

            Sorry Doc, but you have yet to explain why you did not study and practice medicine, by which I mean, (in US terms), to be a MD? In UK – a registered medical practitioner?
            What was (is) so attractive about chiropractic?

          • “In the US I guess the title Dr might induce some to believe you are medically qualified and no doubt this helps marketing, But is that not inherently dishonest?”

            That was a decision made by the Deptarment of Education. In all states that I’m aware of, when advertising and marketing, we must identify ourselves as a chiropractor.

            “And is this not the problem the medical profession has had with ‘chiropractic’ ever since D D Palmer came up with a way to market his practice as a ‘magnetic practitioner’?”

            I’m sure there are several reasons for the historical conflicts between the two professions. Fortunately, these walls are slowly being torn down.

            “Sorry Doc, but you have yet to explain why you did not study and practice medicine, by which I mean, (in US terms), to be a MD? In UK – a registered medical practitioner?
            What was (is) so attractive about chiropractic?”

            I liked the global systems-based thinking.

          • @ Doc Dale on Sunday 01 May 2016 at 16:41

            “Because chiropractic as a profession is evolving (for many of us anyway).”

            From what to what? The fundamental premise was “innate intelligence” and the “subluxation”; how does chiro “evolve” from nonsense?

            “One would have to evaluate the claims to determine if they are false. One would have to define “medicine” to answer that question.”

            A little too cute. Are you being purposefully abstruse to make such statements? Medicine is what Richard practices, not what you do; however, are you claiming to offer similar services?

            “I did. Chiropractic in the USA is a regulated profession and we can use the title “Doctor”.”

            As ridiculous as it is, you are allowed to use the title, despite doing a half-arsed degree without any of the rigour of real medicine. It is an absolute disgrace. What’s more, the title “doctor” attracts so many boneheads who wouldn’t ever get into medicine, and don’t they love to flaunt it. The peanut chiro who used to live across from me didn’t refer to himself as “doctor” but he was representative of the few I’ve come across, and avoid.

            As for this;
            “Blogs, like what Ernst posts above, well, they are what they are…ones persons simple view on a multifaceted issue.”

            The prof has spent many years on such research, so to label it as you have makes one of you look simple.

            “I liked the global systems-based thinking.”

            LOL, please enlighten where chiro does this? I thought it was a joke when I read this, but I think you might meant it.

          • @frank…”From what to what? The fundamental premise was “innate intelligence” and the “subluxation”; how does chiro “evolve” from nonsense?”

            This appears to be the direction some of the profession is heading. Granted, this article is outdated regarding current research and thus incomplete in that aspect.

            “Postural reflexes can be subcategorized as the following: visual righting reflexes, labyrinthine righting reflexes, neck righting reflexes, body on head righting reflexes, and body on body righting reflexes [28]. Although some of the reflexes and neuroanatomy have been defined and illustrated separately, these collective reflexes and their interactions have not been examined from a chiropractic perspective. Since conservative postural treatment is becoming increasingly investigated, knowledge of the postural reflexes will only aid the practitioner in providing treatment consistent with foundational postural neurophysiology.”

            http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1198239/#!po=8.08824

      • But if you have given up on subluxations and ‘innate’ – why are you still practicing chiropractic?
        Are you not a (unqualified) physical therapist, or an unlicensed doctor?

        • “But if you have given up on subluxations and ‘innate’ – why are you still practicing chiropractic?”

          We are not bound to antiquated views and definitions.

          “Are you not a (unqualified) physical therapist, or an unlicensed doctor?”

          I am licensed and allowed to use the title doctor…this was covered earlier.

    • @Richard Rawlins
      Apologies Richard Rawlins!
      Here is Australia.
      COCA stands for Chiropractic and Osteopathic College of Australasia, now renamed and expanding to Chiropractic Australia (CA).
      Informed consent is a common law requirement here. It has been mandatory for all professions here since 2000 and I have employed it as standard since 1995. See here:
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2051308/?tool=pmcentrez
      All support for the reformers appreciated!

      • Critical_Chiro said:COCA stands for Chiropractic and Osteopathic College of Australasia, now renamed and expanding to Chiropractic Australia (CA).

        Expanding by dropping osteopathy? But you do have to wonder about the separate classes for osteo and chiro.

        • @Alan Henness
          Expanding by becoming more vocal both in the public and political arena, advocating for reform and not leaving it to The Chiropractic Association of Australia (CAA) to be the sole voice of the profession for the sake of peace and quiet. CAA is pissed off to put it mildly!

          • why do chiros so often create new meaning to common terms? EXPANDING IS NOT THE SAME AS ‘BECOMING MORE VOCAL’.

  • EE wrote, “I’d say there is no good evidence for SMT nor for chiropractic care that includes SMT.”

    An interesting position in light of this finding…

    METHODS:
    Faculty from 205 accredited physical therapy programs were invited to participate in an anonymous 35-item electronic survey during the summer of 2012.
    RESULTS:
    Seventy-two percent of programs responded to the survey, with 99% of programs teaching TJM

    http://www.ncbi.nlm.nih.gov/pubmed/25899212

  • Oh good heavens!
    Doc Dale became a chiropractor because he “liked the global systems-based thinking.”
    What, on earth does that mean? In what way is that different from ‘medicine’ (by any definition)?

    “The walls between the professions are slowly being torn down.”

    Any walls there are, are the result of chiropractors failure to qualify as doctors (MD). It is they who have devised an original ‘profession’ as an alternative to ‘medicine’.
    Palmer himself said “chiropractic is founded on different principles from medicine.”

    So be it. Get over it. Carry on marketing! But be honest, and properly inform your patients what you are up to. Please.

    Good luck and may the Wu be with you.

    • Apparently, you have an unwillingness to accept that some chiropractors have moved past Palmerian thinking. Sobeit.

      • I accept some chiropractors ‘have moved past Palmerian thinking.’
        Excellent.
        They are no longer chiropractors in any meaningful sense of the word, because chiropractic is a system which was devised and defined by Palmer.
        Welcome to the real world.

        • we hear the same thing from the fundamental and traditional chiropractors…which makes your view somewhat ironic, but not foreign.

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