MD, PhD, FMedSci, FSB, FRCP, FRCPEd

chiropractic

1 2 3 7

Few subjects make chiropractors more uneasy than a discussion of the safety of their spinal manipulations. Many chiropractors flatly deny that there are any risks at all. However, the evidence seems to tell a different story.

The purpose of a new review was to summarise the literature for cases of adverse events in infants and children treated by chiropractors or other manual therapists, identifying treatment type and if a preexisting pathology was present. English language, peer-reviewed journals and non-peer-reviewed case reports discussing adverse events (ranging from minor to serious) were systematically searched from inception of the relevant searchable bibliographic databases through March 2014. Articles not referring to infants or children were excluded.

Thirty-one articles met the selection criteria. A total of 12 articles reporting 15 serious adverse events were found. Three deaths occurred under the care of various providers (1 physical therapist, 1 unknown practitioner, and 1 craniosacral therapist) and 12 serious injuries were reported (7 chiropractors/doctors of chiropractic, 1 medical practitioner, 1 osteopath, 2 physical therapists, and 1 unknown practitioner). High-velocity, extension, and rotational spinal manipulation was reported in most cases, with 1 case involving forcibly applied craniosacral dural tension and another involving use of an adjusting instrument. Underlying preexisting pathology was identified in a majority of the cases.

The authors concluded that published cases of serious adverse events in infants and children receiving chiropractic, osteopathic, physiotherapy, or manual medical therapy are rare. The 3 deaths that have been reported were associated with various manual therapists; however, no deaths associated with chiropractic care were found in the literature to date. Because underlying preexisting pathology was associated in a majority of reported cases, performing a thorough history and examination to exclude anatomical or neurologic anomalies before applying any manual therapy may further reduce adverse events across all manual therapy professions.

This review is a valuable addition to our knowledge about the risks of spinal manipulations. My own review summarised 26 deaths after chiropractic manipulations. In several of these instances, the age of the patient had not been reported. Therefore the above conclusion (no deaths associated with chiropractic) seems a little odd.

The following text is a shortened version of the discussion of my review which, I think, addresses most of the pertinent issues.

 numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death. Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely. Even if it were merely a remote possibility, the precautionary principle in healthcare would mean that neck manipulations should be considered unsafe until proven otherwise. Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition. Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive.

Reliable estimates of the frequency of vascular accidents are prevented by the fact that underreporting is known to be substantial. In a survey of UK neurologists, for instance, under-reporting of serious complications was 100%. Those cases which are published often turn out to be incomplete. Of 40 case reports of serious adverse effects associated with spinal manipulation, nine failed to provide any information about the clinical outcome. Incomplete reporting of outcomes might therefore further increase the true number of fatalities.

This review is focussed on deaths after chiropractic, yet neck manipulations are, of course, used by other healthcare professionals as well. The reason for this focus is simple: chiropractors are more frequently associated with serious manipulation-related adverse effects than osteopaths, physiotherapists, doctors or other professionals. Of the 40 cases of serious adverse effects mentioned above, 28 can be traced back to a chiropractor and none to a osteopath. A review of complications after spinal manipulations by any type of healthcare professional included three deaths related to osteopaths, nine to medical practitioners, none to a physiotherapist, one to a naturopath and 17 to chiropractors. This article also summarised a total of 265 vascular accidents of which 142 were linked to chiropractors. Another review of complications after neck manipulations published by 1997 included 177 vascular accidents, 32 of which were fatal. The vast majority of these cases were associated with chiropractic and none with physiotherapy. The most obvious explanation for the dominance of chiropractic is that chiropractors routinely employ high-velocity, short-lever thrusts on the upper spine with a rotational element, while the other healthcare professionals use them much more sparingly.

[REFERENCES FOR THE ABOVE STATEMENTS CAN BE FOUND IN MY REVIEW]

How many times have we heard from practitioners of alternative medicine, particularly chiropractors, that their patients are more severely ill than those of conventional clinicians. The claim is usually that they have tried all that conventional medicine can offer and eventually, as a last resort, they turn to the alternatives.

But is this true? If so, it would explain why these patients do no better or even worse than those treated conventionally.

Here is a new article that goes some way in addressing these issues.

For this study, Danish chiropractors and general practitioners recruited adult patients seeking care for low back pain (LBP). Extensive baseline questionnaires were obtained and descriptive analyses were performed to define the differences between the two populations.

Questionnaires were returned from 934 patients in chiropractic practice and 319 patients from general practice. Four out of five patients had previous episodes, one-fourth were on sick leave, and the LBP considerably limited daily activities. The general practice patients were slightly older and less educated, more often female, and generally worse on all disease-related parameters than chiropractic patients. All the disease specific parameters showed a statistically significant difference between general and chiropractic practice. Patients in general practice were generally more severely affected. They had higher pain intensity (mainly for leg pain), longer pain duration, more previous episodes, more sick leave, more activity limitation on the disability scale, slightly higher level of depression, slightly more fear-avoidance beliefs, and a poorer self-reported general health. All these differences were statistically significant.

The authors concluded that LBP in primary care was recurrent, causing sick leave and activity limitations. There were clear differences between the chiropractic and general practice populations in this study.

I know, I know: these findings are from Denmark and therefore they cannot be generalised to other countries. However, the authors point out that similar findings have been reported from the US. Furthermore the observations relate to chiropractors and must not be applied to other alternative practitioners. Nevertheless they do show that, in this specific scenario, patients opting for the alternative are not more but less severely ill.

The next time an alternative practitioner claims ‘my patients have worse outcomes because they are sicker’, I will insist on seeing the evidence before I believe it.

Adverse events have been reported extensively following chiropractic.  About 50% of patients suffer side-effects after seeing a chiropractor. The majority of these events are mild, transitory and self-limiting. However, chiropractic spinal manipulations, particularly those of the upper spine, have also been associated with very serious complications; several hundred such cases have been reported in the medical literature and, as there is no monitoring system to record these instances, this figure is almost certainly just the tip of a much larger iceberg.

Despite these facts, little is known about patient filed compensation claims related to the chiropractic consultation process. The aim of a new study was to describe claims reported to the Danish Patient Compensation Association and the Norwegian System of Compensation to Patients related to chiropractic from 2004 to 2012.

All finalized compensation claims involving chiropractors reported to one of the two associations between 2004 and 2012 were assessed for age, gender, type of complaint, decisions and appeals. Descriptive statistics were used to describe the study population.

338 claims were registered in Denmark and Norway between 2004 and 2012 of which 300 were included in the analysis. 41 (13.7%) were approved for financial compensation. The most frequent complaints were worsening of symptoms following treatment (n = 91, 30.3%), alleged disk herniations (n = 57, 19%) and cases with delayed referral (n = 46, 15.3%). A total financial payment of €2,305,757 (median payment €7,730) were distributed among the forty-one cases with complaints relating to a few cases of cervical artery dissection (n = 11, 5.7%) accounting for 88.7% of the total amount.

The authors concluded that chiropractors in Denmark and Norway received approximately one compensation claim per 100.000 consultations. The approval rate was low across the majority of complaint categories and lower than the approval rates for general practitioners and physiotherapists. Many claims can probably be prevented if chiropractors would prioritize informing patients about the normal course of their complaint and normal benign reactions to treatment.

Despite its somewhat odd conclusion (it is not truly based on the data), this is a unique article; I am not aware that other studies of chiropractic compensation  claims exist in an European context. The authors should be applauded for their work. Clearly we need more of the same from other countries and from all professions doing manipulative therapies.

In the discussion section of their article, the authors point out that Norwegian  and Danish chiropractors both deliver approximately two million consultations annually. They receive on average 42 claims combined suggesting roughly one claim per 100.000 consultations. By comparison, Danish statistics show that in the period 2007–2012 chiropractors, GPs and physiotherapists (+ occupational therapists) received 1.76, 1.32 and 0.52 claims per 100.000 consultations, respectively with approval rates of 13%, 25% and 21%, respectively. During this period these three groups were reimbursed on average €58,000, €29,000 and €18,000 per approved claim, respectively.

These data are preliminary and their interpretation might be a matter of debate. However, one thing seems clear enough: contrary to what we frequently hear from apologists, chiropractors do receive a considerable amount of compensation claims which means many patients do get harmed.

This investigation was aimed at examining the messages utilised by the chiropractic profession around issues of scope and efficacy through website communication with the public. For this purpose, the authors submitted the website content of 11 major Canadian chiropractic associations and colleges, and of 80 commercial clinics to a mixed-methods analysis. Content was reviewed to quantify specific health conditions described as treatable by chiropractic care. A qualitative textual analysis identified the primary messages related to evidence and efficacy utilised by the websites.

The results show that chiropractic was claimed to be capable of addressing a wide range of health issues. Quantitative analysis revealed that association and college websites identified a total of 41 unique conditions treatable by chiropractic, while private clinic websites named 159 distinct conditions. The most commonly cited conditions included back pain, headaches/migraines and neck pain. Qualitative analysis revealed three prominent themes drawn upon in discussions of efficacy and evidence: grounded in science, the conflation of safety and efficacy and “natural” healing.

The authors concluded that the chiropractic profession claims the capacity to treat health conditions that exceed those more traditionally associated with chiropractic. Website content persistently declared that such claims are supported by research and scientific evidence, and at times blurred the lines between safety and efficacy. The chiropractic profession may be struggling to define themselves both within the paradigm of conventional science as well as an alternative paradigm that embraces natural approaches.

These findings strike me as being similar to the ones we published 4 years ago. At this stage, we had conducted a review of 200 chiropractor websites and 9 chiropractic associations’ World Wide Web claims in Australia, Canada, New Zealand, the United Kingdom, and the United States. The outcome measures were claims (either direct or indirect) regarding the eight reviewed conditions, made in the context of chiropractic treatment: asthma, headache/migraine, infant colic, colic, ear infection/earache/otitis media, neck pain, whiplash (not supported by sound evidence), and lower back pain (supported by some evidence).

We found evidence that 190 (95%) chiropractor websites made unsubstantiated claims regarding at least one of the conditions. When colic and infant colic data were collapsed into one heading, there was evidence that 76 (38%) chiropractor websites made unsubstantiated claims about all the conditions not supported by sound evidence. Fifty-six (28%) websites and 4 of the 9 (44%) associations made claims about lower back pain, whereas 179 (90%) websites and all 9 associations made unsubstantiated claims about headache/migraine. Unsubstantiated claims were made about asthma, ear infection/earache/otitis media, neck pain.

At the time, we concluded that the majority of chiropractors and their associations in the English-speaking world seem to make therapeutic claims that are not supported by sound evidence, whilst only 28% of chiropractor websites promote lower back pain, which is supported by some evidence. We suggest the ubiquity of the unsubstantiated claims constitutes an ethical and public health issue.

Comparing the two studies, what should we conclude? Of course, the new investigation was confined to Canada; we therefore cannot generalise its results to other countries. Nevertheless it provides a fascinating insight into the (lack of) development of chiropractic in this part of the world. My conclusion is that, at least in Canada, there is very little evidence that chiropractic is about to become an ethical and evidence-based profession.

The purpose of this paper was to compare the characteristics of the chiropractic technique systems that have utilised radiography for subluxation detection with the characteristics of religion, and to discover potential historical links that may have facilitated the development of those characteristics.

The authors found 23 technique systems requiring radiography for subluxation analysis. Evidence of religiosity from the early founders’ writings was compared with textbooks, published papers, and websites of subsequently developed systems. Six criteria denoting religious thinking were developed: supernatural concepts, claims of supremacy, rules and rituals, sacred artefacts, sacred stories, and special language. All of these were found to a greater or lesser degree in the publicly available documents of all the subluxation-based chiropractic x-ray systems.

The authors concluded that the founders and early pioneers of chiropractic did not benefit from the current understanding of science and research, and therefore substituted deductive and inductive reasoning to arrive at conclusions about health and disease in the human body. Some of this thinking and rationalisation demonstrably followed a religion-like pattern, including BJ Palmer’s use of radiography. Although access to scientific methods and research education became much advanced and more accessible during the past few decades, the publicly available documents of technique systems that used radiography for chiropractic subluxation detection examined in this paper employed a historically derived paradigm for radiography that displayed characteristics in common with religion.

As I was pondering these amazing statements, a friend alerted me to the promotional material by a chiropractic college in the US. The website of this institution refers to subluxation – have we not been told that this term now belongs to the realm of chiropractic history? –  in many places, e. g. :

Dr. Brian Kelly talks about the subluxation debate, and introduces to a comprehensive resource on the subluxation. Visit LifeWestPress to order your own copy of the “Atlas of Common Subluxations of the Human Spine and Pelvis.”

… an introduction to the literature concerning the scientific examination of the subluxation and its physiological and anatomical basis. The physiology, neurology, and biomechanics of subluxation and adjustment are surveyed.

The focus of Knee Chest Upper Cervical Chiropractic Care is to address the Upper Cervical Subluxation. This includes detecting the Subluxation, designing a customized correction with the assistance of imaging, and patient management.

Atlas of Common Subluxations By William J Ruch, D.C. “One of the most significant chiropractic clinical text of the decade” -Dr. Deed Harrison D.C. The serious results of subluxations of the spine can now been seen in color. by studying the dramatic consequences of chronic

Gonstead B provides an emphasis on patients who present with subluxations of the cervical and thoracic areas of the spine. Some case management protocols are also discussed. This course includes instruction in static and motion visualization, inspection, and palpation; skin temperature…

The president of this college tells us that “….We believe chiropractic is a vital part of health care and that the chiropractic lifestyle is something that the public is placing in high demand right now…” (Dr. Brian Kelly President). Inspired by such big words, I study more of the promotional material furthermore which informs us that:

We must study and understand the reason why chiropractic holds an impactful and necessary place in the future of our entire planet’s health. We must truly understand and own the principles of safe and eective healthcare for all.  Philosophy is not just “for fun”. Philosophy is the glue that holds all of the elements of our educational process together.

At this stage I begin to wonder whether they have more to offer than ‘philosophy’ – how about some evidence? I looked and looked hard, but my efforts were in vain. Evidence does not seem to be a focus of this college. Instead we are offered obsolete concepts like vitalism:

Vitalism is the understanding that there is more to the basic function of the human body than just a bunch of parts and mechanisms. There is something more to us than just many parts of a machine. Vitalism is the study of the underlying elements of the organization of intelligence in the human body (and in any living system) and how that intelligence runs the system. From a vitalistic viewpoint, the care provided by a chiropractor takes on a unique and critical role in supporting the human body’s natural inclination to heal itself and to remain healthy over the course of a lifetime.

Now I am acutely reminded of the well-documented fact that DD Palmer, the man who invented chiropractic, had toyed with the idea of founding a religion. Perhaps he has done exactly that and we have not yet noticed? More importantly perhaps, I get the feeling that all this talk (on this blog and elsewhere) that chiropractors are working ever so hard to leave their bizarre past behind and join the rest of us in the 21st century is little more that wishful thinking.

The chiropractic profession have been reminded time and times again that their claim to be able to effectively treat paediatric conditions is bogus. Many experts have asked them to produce some compelling evidence or stop this dangerous nonsense. Yet most of them seem to remain in denial, famously documented by the British Chiropractic Association suing Simon Singh for libel after he disclosed that they happily promote bogus treatments.

Some chiropractors now say that things have changed and that chiropractors are finally getting their act together. If that is true, progress must be painfully slow – so slow, in fact, that it is hard to see it at all. There are still far too many chiropractors who carry on just as before. There are hundreds, if not thousands of articles promoting chiropractic for childhood conditions; a very basic Google search for ‘chiropractic for children’ returns more than 7 million hits many of which advertise this sort of approach. Take this website, for instance; it makes its bogus claims entirely unabashed:

Even as an infant your child may have spinal nerve stress, known as subluxations. Although subluxations may not be painful, they can pose serious threats to your child’s development. If your baby was in a difficult position in the womb, or experienced a traumatic birth they may have developed subluxations. A common condition attributed to subluxations in children is known as Blocked Atlantal Nerve Syndrome. This condition may be the primary cause of ear and upper respiratory infections, and chronic tonsillitis.

Even regular childhood activities such as tumbles taken while learning to walk and run, bike riding, and participation in sports can also cause stress on your child’s body. Emotional stress and trauma may also be a cause of subluxations. Unless they are corrected they can affect future nerve function and the development of your child’s nervous system. They can also cause problems as your child grows and develops into adulthood.

With regular chiropractic care your child may be at less risk for common childhood disease such as colds and fevers. Some children show a marked improvement in asthma symptoms with regular chiropractic care and nutritional counselling. While chiropractors do no treat disease or sickness, they can identify and remove subluxations which interfere with your child’s natural ability to heal. By removing this stress from your child’s spinal system their immune system may function more efficiently and your child may have a better defense to disease. Their overall health may improve as their natural healing power is released. Children who receive regular chiropractic care may also be able to handle emotional and physical stress better and this care may contribute to their natural development.

Your child is never too young to start chiropractic care. Well-child care starts are early as the first month of life. Doctors use a very gentle pressure to treat children (no more pressure than picking up a tomato in the grocery store) and their treatments are very soothing to your child. After their first visit it is recommended that they receive treatments every three months up to age three, and then every six to 12 month after that. You may also want to visit your chiropractor after major milestones in your child’s life such as learning to sit up, crawl, and walk. They should also be seen if they experience any falls or trauma, and if you notice any balance issues they may be experiencing. These may include head tilting and limping.

Pediatric chiropractic care has many benefits. Children as young as infants may see an improvement in their development and overall health with regular care. Doctors of chiropractic take a proactive approach to health by striving to return and maintain your body’s natural balance. If you are looking for an alternative or supplement to traditional medical care, look into chiropractic care for your entire family.

Just a few rotten apples!… the apologists would probably say. But this is clearly not true. I find it even hard to locate the non-rotten apples in this decomposing and disgusting mess. More importantly, if it were true that things were now changing, one would expect that the progressive sections of the chiropractic profession protest regularly, sharply and effectively to shame the many charlatans amongst their midst. Crucially, one would expect the chiropractic professional organisations  to oust their bogus members systematically and swiftly.

The sad truth, however, is that none of this is really happening – certainly not in the US or the UK. On the contrary, organisations like THE INTERNATIONAL PEDIATRIC ASSOCIATION, books entitled CHIROPRACTIC PEDIATRICS, and periodicals like the JOURNAL OF PEDIATRIC, MATERNAL AND FAMILY CHIROPRACTIC remain popular and respected within the chiropractic profession. A few lip-services here and there, yes. But truly effective action? No!

The tolerance of quackery, I would argue, must be one of the most important hallmarks of a quack profession.

Some people are their worst enemies, and it seems as though chiropractors are no strangers to this strange phenomenon.

On this blog, I frequently criticise chiropractic; my main concerns are that

  1. chiropractors make far too many bogus claims far too often,
  2. there is precious little evidence that their hallmark treatment, spinal manipulation, generates more good than harm.

I repeatedly voice those concerns because I feel strongly that consumers have the right to unbiased information for making evidence-based therapeutic decisions. When I do this, I get invariably attacked by some chiropractors who disagree with me. Frequently, these chiropractors are not interested to discuss the issues I raised with me; instead they insult me in the most primitive way imaginable.

This happens far too often to write about each time, but occasionally things are so extraordinary that I do blog about them. A case in point is the email I recently received out of the blue from “Dr” Brian Moravec, a chiropractor who believes in subluxation and claims that new-born babies should have spinal adjustments. My last post quotes his astonishing views in full; he believes I am a self proclaimed “expert” on alternative medicine, promoting so much misinformation with regard to chiropractic care.  Unfortunately he failed to tell me which of my statements he considers to be misleading and he continued: fortunately you look old.  and soon will be gone. 

Rejoicing at the (hopefully not so) imminent demise of a fellow human being is perhaps not what one might expect from a health care professional. Yet it does fit into the behaviour of chiropractors which tends to turn outright self-destructive when challenged. The comments by chiropractors that followed my post seem to confirm this tendency. They show that the demolition of chiropractic’s reputation by chiropractors is relentless.

One chiropractor claimed Moravec’s opinion could “have been better put”… and “come over as a somewhat personal attack” while quickly changing the subject by starting a discussion on the evidence-base of chiropractic. This ended abruptly in him agreeing with me to disagree. Other chiropractors seemed to concur.

At that stage, one chiropractor noted that Moeavec’s email is doing no favours to the reputation of chiropractic, a ray of light which quickly was instantly overshadowed by a further chiropractor’s comments. This man – or perhaps woman (hiding behind a pseudonym) – is a regular commentator on my blog. He felt that Moravec’s comments were rather polite an opinion which he justified as follows: Dr. Moravec thinks you are old because of your unflattering (IMO) photo. The shiny, bald look adds years to a person’s looks, especially in photos. It is the old glass half-empty or half-full debate. IOW, have you lost hair or have you gained face? The mustache is so fifties, too. The perpetual scowl, however, does suit you rather well. Just sayin’.  

At this point, I cannot help but laugh out loud. Someone asked how I can bear those vicious attacks. The answer is that I merely cringe at the stupidity on display.  Are these guys really so limited as to not realise what they are doing to their own reputation? Do they not notice that this amounts to a relentless and general demolition of chiropractic’s reputation?

All of this would, of course, be rather trivial fun, if it were a single occurrence – but it is most definitely not!

As I already pointed out, such things happen to me all the time. More remarkably, chiropractors have repeatedly tried to get me fired. Much more importantly, chiropractors have behaved in this way when they decided to sue Simon Singh for libel. Each time, they ended up with plenty of egg on their faces.

Isn’t it time that they learn a lesson? Isn’t it time that they learn to consider criticism seriously? Isn’t it time the more rational one amongst them do something about the many cranks in their midst? Isn’t it time they got their act together?

“Dr” Brian Moravec is a chiropractor from the US; he has a website where he describes himself and his skills as follows: I attended Chiropractic College and I am a graduate of Palmer College of Chiropractic in Davenport Iowa. I earned a Bachelor of Science degree as well as my Doctor of Chiropractic degree from Palmer College, which is the first chiropractic college in the world and the origin of our profession. I also attend continuing education seminars designed to keep doctors current with regard to clinical chiropractic, technique and nutrition.

The key to overall health and wellness is to have a healthy nervous system and that is what I do as a chiropractor – I make sure that your spine is functioning at its best so that your nervous system functions at its best. When the nervous system is functioning at 100%, you are a healthier individual that experiences a higher quality of life and health. I know this to be true in myself, my family and my patients.

I go to great lengths to provide my patients with the best chiropractic care I can give. I work with my patients to design a treatment plan that will be effective for their particular condition and specific to their needs. We utilize manual and low force techniques (safe and effective for newborns to seniors), to correct sublaxations in the spine. Chiropractic adjustments remove nerve interference, which allows the body to perform at its best again. I also am available for consultations on nutrition and diet, dietary supplementation and how to minimize the wear and tear on your spine.

[Emphases are mine]

What he does not state is the fact that he also is a nifty e-mail writer!

To my great surprise, I received an e-mail from him which is far too good to be kept for myself. So I decided to share it with my readers; here it is in its full and unabbreviated beauty:

its interesting to see someone with your education, and is a self proclaimed “expert” on alternative medicine, promote so much misinformation with regard to chiropractic care.   fortunately you look old.  and soon will be gone.  I always refer to the few of you anti chiropractic fools left here as “dinosaurs”.   the proof is in the pudding my “friend”.  chiropractic works and will continue to be here for centuries more.   you and others with much much more power than you (the AMA for example) have tried to perpetuate lies and squash chiropractic.  you fail, and they failed, because whatever better serves mankind will stand the test of time.   you’re a dying breed edzard.  thank God.
yours in health,

brian moravec d.c.

I am encouraged to see that he recognises my education but do wonder why his upbringing obviously failed so dismally teach him even a minimum of politeness, tact, or critical thinking. It is disappointing, I think, that he does not even mention what he perceives as my lies about his beloved chiropractic. So sad, I am sure it would have been fun to debate with him.

One of the problems regularly encountered when evaluating the effectiveness of chiropractic spinal manipulation is that there are numerous chiropractic spinal manipulative techniques and clinical trials rarely provide an exact means of differentiating between them. Faced with a negative studies, chiropractors might therefore argue that the result was negative because the wrong techniques were used; therefore they might insist that it does not reflect chiropractic in a wider sense. Others claim that even a substantial body of negative evidence does not apply to chiropractic as a whole because there is a multitude of techniques that have not yet been properly tested. It seems as though the chiropractic profession wants the cake and eat it.

Amongst the most commonly used is the ‘DIVERSIFIED TECHNIQUE’ (DT) which has been described as follows: Like many chiropractic and osteopathic manipulative techniques, Diversified is characterized by a high velocity low amplitude thrust. Diversified is considered the most generic chiropractic manipulative technique and is differentiated from other techniques in that its objective is to restore proper movement and alignment of spine and joint dysfunction.

Also widely used is a technique called ‘FLEXION DISTRACTION’ (FD) which involves the use of a specialized table that gently distracts or stretches the spine and which allows the chiropractor to isolate the area of disc involvement while slightly flexing the spine in a pumping rhythm.

The ‘ACTIVATOR TECHNIQUE’ (AT) seems a little less popular; it involves having the patient lie in a prone position and comparing the functional leg lengths. Often one leg will seem to be shorter than the other. The chiropractor then carries out a series of muscle tests such as having the patient move their arms in a certain position in order to activate the muscles attached to specific vertebrae. If the leg lengths are not the same, that is taken as a sign that the problem is located at that vertebra. The chiropractor treats problems found in this way moving progressively along the spine in the direction from the feet towards the head. The activator is a small handheld spring-loaded instrument which delivers a small impulse to the spine. It was found to give off no more than 0.3 J of kinetic energy in a 3-millisecond pulse. The aim is to produce enough force to move the vertebrae but not enough to cause injury.

There is limited research comparing the effectiveness of these and the many other techniques used by chiropractors, and the few studies that are available are usually less than rigorous and their findings are thus unreliable. A first step in researching this rather messy area would be to determine which techniques are most frequently employed.

The aim of this new investigation was to do just that, namely to provide insight into which treatment approaches are used most frequently by Australian chiropractors to treat spinal musculoskeletal conditions.

A questionnaire was sent online to the members of the two main Australian chiropractic associations in 2013. The participants were asked to provide information on treatment choices for specific spinal musculoskeletal conditions.

A total of 280 responses were received. DT was the first choice of treatment for most of the included conditions. DT was used significantly less in 4 conditions: cervical disc syndrome with radiculopathy and cervical central stenosis were more likely to be treated with AT. FD was used almost as much as DT in the treatment of lumbar disc syndrome with radiculopathy and lumbar central stenosis. More experienced Australian chiropractors use more AT and soft tissue therapy and less DT compared to their less experienced chiropractors. The majority of the responding chiropractors also used ancillary procedures such as soft tissue techniques and exercise prescription in the treatment of spinal musculoskeletal conditions.

The authors concluded that this survey provides information on commonly used treatment choices to the chiropractic profession. Treatment choices changed based on the region of disorder and whether neurological symptoms were present rather than with specific diagnoses. Diversified technique was the most commonly used spinal manipulative therapy, however, ancillary procedures such as soft tissue techniques and exercise prescription were also commonly utilised. This information may help direct future studies into the efficacy of chiropractic treatment for spinal musculoskeletal disorders.

I am a little less optimistic that this information will help to direct future research. Critical readers might have noticed that the above definitions of two commonly used techniques are rather vague, particularly that of DT.

Why is that so? The answer seems to be that even chiropractors are at a loss coming up with a good definition of their most-used therapeutic techniques. I looked hard for a more precise definition but the best I could find was this: Diversified is characterized by the manual delivery of a high velocity low amplitude thrust to restricted joints of the spine and the extremities. This is known as an adjustment and is performed by hand. Virtually all joints of the body can be adjusted to help restore proper range of motion and function. Initially a functional and manual assessment of each joint’s range and quality of motion will establish the location and degree of joint dysfunction. The patient will then be positioned depending on the region being adjusted when a specific, quick impulse will be delivered through the line of the joint in question. The direction, speed, depth and angles that are used are the product of years of experience, practice and a thorough understanding of spinal mechanics. Often a characteristic ‘crack’ or ‘pop’ may be heard during the process. This is perfectly normal and is nothing to worry about. It is also not a guide as to the value or effectiveness of the adjustment.

This means that the DT is not a single method but a hotchpotch of techniques; this assumption is also confirmed by the following quote: The diversified technique is a technique used by chiropractors that is composed of all other techniques. It is the most commonly used technique and primarily focuses on spinal adjustments to restore function to vertebral and spinal problems.

What does that mean for research into chiropractic spinal manipulation? It means, I think, that even if we manage to define that a study was to test the effectiveness of one named chiropractic technique, such as DT, the chiropractors doing the treatments would most likely do what they believe is required for each individual patient.

There is, of course, nothing wrong with that approach; it is used in many other area of health care as well. In such cases, we need to view the treatment as something like a ‘black box'; we test the effectiveness of the black box without attempting to define its exact contents, and we trust that the clinicians in the trial are well-trained to use the optimal mix of techniques as needed for each individual patient.

I would assume that, in most studies available to date, this is precisely what already has been implemented. It is simply not reasonable to assume that a trial the trialists regularly instructed the chiropractors not to use the optimal treatments.

What does that mean for the interpretation of the existing trial evidence? It means, I think, that we should interpret it on face value. The clinical evidence for chiropractic treatment of most conditions fails to be convincingly positive. Chiropractors often counter that such negative findings fail to take into account that chiropractors use numerous different techniques. This argument is not valid because we must assume that in each trial the optimal techniques were administered.

In other words, the chiropractic attempt to have the cake and eat it has failed.

Influenza kills thousands of people every year. Immunisation could prevent many of these deaths. Those at particularly high risk, e.g. young children, individuals aged 65 and older and people with severe diseases in their medical history, are therefore encouraged to get immunised. Nova Scotia health officials have just started their annual flu shot campaign. Now they are warning about some anti-flu vaccine literature being distributed by a chiropractor.

The leaflets from local chiropractic clinics suggest that flu shots increase the risk of a child ending up in hospital and link Alzheimer’s disease to flu shots. When questioned about this, the chair of the Nova Scotia College of Chiropractors defended this misinformation and claimed the author of the pamphlet did his homework. “Chiropractic is really pro information. Look at the positive, look at the negative, look at both sides, get your information and make the appropriate decision that’s right for you,” he said.

However, Dr. Robert Strang, Nova Scotia’s chief public health officer, said the message is wrong and added that the pamphlet is not based on medicine and is confusing to the public. “It’s discouraging, but unfortunately there are a range of what I call alternative-medicine practitioners who espouse a whole bunch of views which aren’t evidence based,” he said.

The stance of many chiropractors against immunisations is well known and has long historical roots. Campbell and colleagues expressed this clearly: Although there is overwhelming evidence to show that vaccination is a highly effective method of controlling infectious diseases, a vocal element of the chiropractic profession maintains a strongly antivaccination bias… The basis seems to lie in early chiropractic philosophy, which, eschewing both the germ theory of infectious disease and vaccination, considered disease the result of spinal nerve dysfunction caused by misplaced (subluxated) vertebrae. Although rejected by medical science, this concept is still accepted by a minority of chiropractors. Although more progressive, evidence-based chiropractors have embraced the concept of vaccination, the rejection of it by conservative chiropractors continues to have a negative influence on both public acceptance of vaccination and acceptance of the chiropractic profession by orthodox medicine.

No doubt, there will be comments following this post claiming that many chiropractors have now learnt their lesson and have considerably revised their stance on vaccination. This may well be true. But far too many chiropractors still post hair-raising nonsense about vaccination. Take this guy, for instance, who concludes his article (just one example of many) on the subject with this revealing paragraph: Our original blood was good enough. What a thing to say about one of the most sublime substances in the universe. Our original professional philosophy was also good enough. What a thing to say about the most evolved healing concept since we crawled out of the ocean. Perhaps we can arrive at a position of profound gratitude if we could finally appreciate the identity, the oneness, the nobility of an uncontaminated unrestricted nervous system and an inviolate bloodstream. In such a place, is not the chiropractic position on vaccines self-evident, crystal clear, and as plain as the sun in the sky? 

As long as dangerous cranks are tolerated by the vast majority of chiropractors and their professional organisations to mislead the public, I have to agree with Dr Strang: “It’s discouraging, but unfortunately there are a range of what I call alternative-medicine practitioners who espouse a whole bunch of views which aren’t evidence based.”

1 2 3 7
Recent Comments
Click here for a comprehensive list of recent comments.
Categories