My 2008 evaluation of chiropractic concluded that the concepts of chiropractic are not based on solid science and its therapeutic value has not been demonstrated beyond reasonable doubt. It also pointed out that the advice of chiropractors often is dangerous and not in the best interest of the patient: many chiropractors have a very disturbed attitude towards immunisation: anti-vaccination attitudes till abound within the chiropractic profession. Despite a growing body of evidence about the safety and efficacy of vaccination, many chiropractors do not believe in vaccination, will not recommend it to their patients, and place emphasis on risk rather than benefit.
In case you wonder where this odd behaviour comes from, you best look into the history of chiropractic. D. D. Palmer, the magnetic healer who ‘invented’ chiropractic about 120 years ago, left no doubt about his profound disgust for immunisation: “It is the very height of absurdity to strive to ‘protect’ any person from smallpox and other malady by inoculating them with a filthy animal poison… No one will ever pollute the blood of any member of my family unless he cares to walk over my dead body… ” (D. D. Palmer, 1910)
D. D. Palmer’s son, B. J. Palmer (after literally walking [actually it was driving] over his father’s body) provided a much more detailed explanation for chiropractors’ rejection of immunisation: “Chiropractors have found in every disease that is supposed to be contagious, a cause in the spine. In the spinal column we will find a subluxation that corresponds to every type of disease… If we had one hundred cases of small-pox, I can prove to you, in one, you will find a subluxation and you will find the same condition in the other ninety-nine. I adjust one and return his function to normal… There is no contagious disease… There is no infection…The idea of poisoning healthy people with vaccine virus… is irrational. People make a great ado if exposed to a contagious disease, but they submit to being inoculated with rotten pus, which if it takes, is warranted to give them a disease” (B. J. Palmer, 1909)
Such sentiments and opinions are still prevalent in the chiropractic profession – but today they are expressed in a far less abrupt, more politically correct language: The International Chiropractors Association recognizes that the use of vaccines is not without risk. The ICA supports each individual’s right to select his or her own health care and to be made aware of the possible adverse effects of vaccines upon a human body. In accordance with such principles and based upon the individual’s right to freedom of choice, the ICA is opposed to compulsory programs which infringe upon such rights. The International Chiropractors Association is supportive of a conscience clause or waiver in compulsory vaccination laws, providing an elective course of action for all regarding immunization, thereby allowing patients freedom of choice in matters affecting their bodies and health.
Not all chiropractors share such opinions. The chiropractic profession is currently divided over the issue of immunisation. Some chiropractors now realise that immunisations have been one of the most successful interventions ever for public health. Many others, however, do still vehemently adhere to the gospel of the Palmers. Statements like the following abound:
Vaccines. What are we taught? That vaccines came on the scene just in time to save civilization from the ravages of infectious diseases. That vaccines are scientifically formulated to confer immunity to certain diseases; that they are safe and effective. That if we stop vaccinating, epidemics will return…And then one day you’ll be shocked to discover that … your “medical” point of view is unscientific, according to many of the world’s top researchers and scientists. That many state and national legislatures all over the world are now passing laws to exclude compulsory vaccines….
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?
Yes, I do agree: the position of far too many chiropractors is ‘crystal clear’ – unfortunately it is also dangerously wrong.
49 Responses to Why so many chiropractors advise against immunisation
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Professor Ernst
Thank you for pointing out that not all chiropractors share this opinion. I note that one of the main chiropractic teaching establishments the AECC states that they endorse the infant vaccination program in the UK (http://www.aecc.ac.uk/clinic/whatischiro.aspx). The chiropractors that I have worked with in the UK have never had an anti-vax stance although I am aware that there may be a small number of chiropractors, particularly outside of Europe, who still do.
Andy wrote: “I note that one of the main chiropractic teaching establishments the AECC states that they endorse the infant vaccination program in the UK (http://www.aecc.ac.uk/clinic/whatischiro.aspx).”
Whilst the AECC’s vaccination stance is commendable, it’s a matter for concern that the following, lifted from that link, doesn’t seem to agree with the outcome (with regard to evidence) of the British Chiropractic Association v. Simon Singh libel case:
QUOTE
“Our clinic and chiropractic in general have experienced an increasing number of referrals from midwives, health visitors and parents seeking care for their newborn children. We see a multifaceted role for chiropractors in healthcare that primarily affects the musculoskeletal system. We also provide a careful health assessment of babies and offer gentle treatment.”
I’d like to know what evidence the college is using to support its “gentle treatment” of babies and children. Let’s not forget that the editor of the British Medical Journal, Fiona Godlee, speaking of a BMJ article by Professor Ernst in 2009 on the British Chiropractic Association’s “plethora of evidence” for the chiropractic treatment of childhood ailments, said:
QUOTE
“His demolition of the 18 references is, to my mind, complete”.
Link: http://www.bmj.com/content/339/bmj.b2783.full
As far as I know, there’s been no robust new data to counter Professor Ernst’s findings from five years ago – something which would suggest that chiropractors shouldn’t be treating children.
AHPRA clamped down on anti-vaccination chiro’s here. COCA has had a position statement in support for years as has the CAA. AHPRA is also taking disciplinary action as it is totally outside our scope of practice. Besides, if you are into health and PREVENTION then nothing in medicine encapsulates this more than Vaccination. The evidence in favour is overwhelming! Definite No Brainer! If patients ask me any questions on what I think on the subject I tell them that my whole family is up to date on our vaccination and I am a supporter but offering advice is outside my scope of practice so talk to your doctor!
Hey, TC, that’s fine. No one wants to stop you.
Here’s a movie for you:
http://www.youtube.com/watch?v=Df2IDbNY8cI
Yes, linking to a Gary Null YT video must be the answer. He speaks the Troof ™.
LOL! SMH…
Well, EE, you tell others to roll up their sleeves and their kids sleeves and take 60+ jabs, and you won’t even line up for a simple flu shot! So why should anyone else? What does that say? Are YOU up-to-date on your immunisations? The elderly are supposed get all immunised up, you know.
Yes, I know, EE. You just don’t “get round to it”. Translation: It’s not that important.
http://edzardernst.com/2014/06/how-prince-charles-disrespects-his-constitutional-role/#comment-60132
correct! a flu jab for a healthy person at my age is not as important as to immunise children against potentially life-threatening infections.
if I don’t take a flue jab, I might be endangering my own health at worst; if chiros advise against childhood immunisations they endanger public health.
EE wrote: “if I don’t take a flue jab, I might be endangering my own health at worst”
No exercise, spreads the flu by not lining up and rolling up the sleeve for the betterment of society. I guess allopaths aren’t keen on these things either. Likely other medicos on this “blog” don’t keep up with their vaccinations either.
you are writing so much nonsense that I am beginning to fear that YOU ARE ON THE PAYROLL OF BIG PHARMA TO GIVE POOR CHIRO A BAD NAME!
Yes, that’s it, EE! Right as usual.
Maybe these are some reasons that you and your allopathic friends aren’t keen to line up for your multiple jabs. It certainly has to do with parents reluctance to do the same:
http://www.hrsa.gov/vaccinecompensation/vaccinetable.html
@SkeptdocProf,
the only time my GP has seen me in the last decades was when I was there to fresh up my vaccinations (I’m up to date with all my recommended jabs). If my insurance pays it, I get it – most people I know are the same. It’s not that I wouldn’t take multiple jabs, it’s just that for most vaccines, once you’ve had your primary vaccination you’ll only need boosters every now and then.
Why do you focus so much on the flu vaccination? It’s the one vaccination that hasn’t proven its benefits for the general population (and because of that isn’t recommended for everyone)?
@Edzard Ernst:
I’m pretty sure I know the answer is a resounding NO, but just to make sure SkepdocProf can sleep at night: are you an anti-vaccinationist/”vaccine critic”?
I am pro-immunisation – not because of some dogma or belief, but because the evidence is very clear.
the pot between you and the other guy is confusing, pumping flu shots the stating exercise? But exercise caught my eye, think about this real hard, why do people not get the flu or flu shot from April til September? Why is the flu so prevalent in the winter months? EXERCISE!!!!!!! DING DING DING WE HAVE A WINNER!!!!! HARDLY NO ONE HAS THE FLU IN THE SUMMER WHY? BECAUSE THEY ARE EXERCISING, HAVE A HEALTHY IMMUNE SYSTEM, ABSORBING SUNLIGHT MAKING VITAMIN D, AND FLOURISHING. DO YOU REALLY THINK THE FLU JUST GOES AWAY AND COMES BACK IN THE FALL AND WINTER? NO HUMANS BECOME DORMANT, STAY INSIDE, WEAKEN AND COMPROMISE THEIR IMMUNE SYSTEMS AND BAM THEY ARE SICK!!!!! AND WITH OR WITHOUT A FLU SHOT YOU WILL GET SICK, THE FLU SHOT IS FOR THE MOST COMMON STRAIN OF FLU PREVALENT THAT SEASON, LAST I KNEW THERE WHERE OVER 100 STRAINS OF KNOWN FLU VIRUSES, VACCINATE AND POLLUTE YOU BODY WITH HARSH CHEMICALS AND THIMEROSAL WHICH IS BASICALLY MERCURY. OH BUT IT’S SAFE SPILL SOME ON THE FLOOR AT THE HOSPITAL AND SEE WHAT HAPPENS, THEY WILL QUARANTINE THE WHOLE FLOOR AND HAVE HAZMAT THERE CLEANING IT UP IN SPACE AGED CHEMICAL SUITS, BUT IT IS OK TO PUT IN YOUR BODY!!! HA SAME HOLDS TRUE FOR CHEMO THERAPY!!!!!
Thiomersal in vaccines is not dangerous, unfortunately. You are exposed to higher amounts of mercury by eating big fish such as tuna, than by a couple of vaccines every other decade or so. Uninterestingly, it is the same typical story. People were concerned with safety, some governments banned the substance because of the pressure, so people believed it was toxic and responsible for everything and that’s why it was banned. It’s the same with homeopathy.. it’s available because it’s popular, not because it works (it doesn’t).
Exercise does not prevent the flu, unfortunately. It does improve things a slight bit in terms of the immune response, but nothing prevents the flu, because it does not depend on the organism, it depends on carriers and barriers. The soap prevents the flu, a handkerchief too. And taking protective measures when near people with the flu.
Does this make sense?
This does not make sense, because people do exercise in the winter. Further, vitamin D is fat soluble, it lingers throughout the year rather than experiencing an abrupt drop. And if it were as simple as diet or vitamin D levels, this would be easy to demonstrate (vitamin D in particularly has consistently failed to show results in clinical trials).
There are several reasons why influenza is thought to be more prevalent in winter months, the one I am most intrigued by is idea that higher humidity in the summer actually weighs down the viral particles, causing them to drop to ground level more quickly and easily, reducing spread.
Also, your concerns about mercury are not warranted; for one thing, there is a difference between elemental mercury (very dangerous, which is why you need to take precautions against inhaling it if it is aerosolized) and a mercury atom bound into a molecule (which is the form found in thimerosal). For another thing, thimerosal is now only found in multi-dose vials (at least in the US) which are much less common; you can easily receive a thimerosal-free version of the vaccine if you want to.
Consider how dangerous elemental sodium and chlorine are when you are exposed to them, consider how delicious they are when bound together as table salt. That is why doctors don’t worry about the mercury found in vaccines.
Chiropractors like to tout their education, saying it is comparable to what medical students receive, yet, by the nonsense shown here, they seem to lack even a basic understanding of science and biology.
In reply to Rob:
Education isn’t the issue, its lack of critical thinking amongst some chiropractors! We don’t all adhere to an outdated dogma and call it philosophy! Saw this recent definition of philosophy:
“An ‘evidence-based’ methodology involves critical reflection on the methods of acquiring and interpreting evidence – that is, philosophy.”
Says it All!
. You sir are an imbicile to put all alternative medicine in one basket — just as it would be equally bad to put all medicine in one basket or all doctors in one basket. I go to doctors that put the best in medicine and the best of alternative medicine together which makes them far superior to the typical MD.
When you are in enough pain and medicine tells you there is nothing more they can do, maybe then you will consider what alternative medicine has to offer.
LOL!
Perhaps you could give some specific details about this ‘best of alternative medicine’ and ‘what alternative medicine has to offer’ instead of trying to insult Prof Ernst?
What do you mean put them all in ‘one basket’? EE considers each one separately. Read his blogs. And his books.
Btw, the word is spelt ‘imbecile’. Pots and kettles spring to mind.
After there is nothing left that medicine can do, there usually is still money, relief from which is certainly something alternative medicine has to offer, and does offer, usually very successfully!
Can’t speak for all but I graduated from the Macquarie University Chiropractic program relatively recently. We were taught to promote all public health programs. There was no doubt over whether vaccines should be advised or not.
The times are changing for the chiropractic profession. The move is towards full integration into the healthcare world and a renouncement of the crazy chiropractors you see at home shows, placing full page ads, and promoting free exams, x-rays, etc. A fast growing group of influential chiropractors are promoting evidenced based, ethical, integrative care and they have a rich undergraduate education in the sciences. They fully understand the benefits of vaccinations and are embarrassed by their philosophically based, financially motivated unscientific “non” peers. The “crazies” make up anywhere from 18-25% of the profession but they are the highest visibility chiropractors. Chiropractors do have a lot to offer concerning conservative musculoskeletal care as long as they understand their place in the bigger healthcare picture and embrace the scientific method.
How long do you think it’ll take to convert or get rid of the ‘crazies’ (as you describe them), particularly considering your figures work out that there are some 12,000 to 18,000 of them in the US alone? And what do they uniquely have to offer that is science and evidence-based?
… and what will you call them? The reasonable term would be ‘Physiotherapists’.
There would be no reason any more to affiliate them with the fantastical nonsense concocted a long time ago by a megalomaniac magnetic healer named D.D. Palmer.
@Chiroleader
Why not train as a physiotherapist (goodness knows physiotherapy itself is already way behind in terms of evidence-based practice) instead of using the title of an obsolete, disproven, ridiculous philosophy? Or is it that a “chiropractor” can charge higher fees than a mere physiotherapist?
And what’s your answer to Alan’s question: what do you uniquely have to offer that is science and evidence based?
Evidenced based chiropractors understand their place and that place is primarily dealing with pain related to the spine and associated structures. In a typical outpatient setting a PT will excel in treating post surgical musculoskeletal conditions and the occasional extremity injury. PT training is not as extensive as that of a DC concerning spinal conditions. And the average DC training is not as strong in post surgical treatment but current DC training by credible schools are strong in the treatment of extremity problems. Many of us have actually discussed the possibility of physical therapists, now that most programs are requiring a DPT, and evidence-based chiropractors combining in some way but there appears to be more than enough expertise required for the physical therapist continue with a focus on postsurgical treatment and rehabilitation and chiropractors focusing on spinal related health.
The niche for the DC is in non-surgical treatment of spinal related conditions. Similar to an optometrist in that they can treat a large majority of the less complicated eye issues and leave the more serious conditions to the ophthalmologist. This will require DC’s to add limited prescriptive authority, which has happened in New Mexico and a spattering in other states. All chiropractic schools require at least one semester, and some require more, of pharmacology and toxicology. In some of the evidence-based chiropractic schools the pharmacology and biochemistry coursework is on par with dentists and optometrists. Even though dentists and optometrists are generally not required to complete a residency the chiropractic profession, through a few of their progressive schools, are affiliating with hospitals and the Veterans Administration and providing residencies for its graduates.
Also, the “crazy” DC % I quoted is in the US. The % is much smaller in Europe but that may change if Life University, the school that graduates the majority of the subluxation-based chiropractors is successful in entering Italy. Most of the chiropractic colleges in Europe are affiliated with universities and that will need to happen throughout the world if the profession truly wants to attain cultural authority.
By the way, a recent communiqué was released by six or seven of the chiropractic colleges in Europe renouncing the subluxation complex, “wellness” treatment (which is nothing more than trying to convince people they need multiple visits for the rest of their life or they will die a miserable death), and calling for all chiropractic programs to affiliate with universities. You will see four or five of the 16 or so schools in the United States sign onto that, in my opinion.
EB chiropractors do much more than spinal manipulation and I can’t think of anything that I personally do in my office that isn’t backed by research. Spinal manipulation for back pain is supported by the research, exercise instruction, stretching, some physical therapy modalities, soft tissue work, etc. I can’t think of anything that is done in an EB chiropractors office that isn’t done by a physiatrist, orthopedist, physical therapist, and athletic trainer. And again, there is research to support everything but the evidence-based chiropractor has all of these tools in one location. Where there is no research for some in our profession is the subluxation complex and the way certain chiropractors diagnose and treat this unsupported diagnosis. And for the evidence-based chiropractor the vaccination issue is no issue at all and should be left to the medical profession and scientific community.
If if I didn’t answer some of your questions to your satisfaction please add more.
please tell us what you do in daily routine that is backed by sound evidence.
Good question. I had a new patient this morning with lower back pain. I performed a history and examination that is, or should be, standard procedure, i.e. ROS, Vitals, Family history, history of injury, ortho and neuro tests, etc. Then I formed a working diagnosis. In this patient’s case she worked at a work station with a computer monitor too high and chair too high and she sleeps on her stomach. Research addresses modifications in these areas. She appears to have possibly caused the issue from performing a new exercise routine that included lunges. She also bends and twists throughout her day and research also leads to modifications in this area. There was not adequate movement in the right L5 facet and muscles spasms were present from L4 to the sacrum. After some deep tissue work in the right lumbar area I performed spinal manipulation. Evaluation after the procedure resulted in increased motion and decreased pain. Again, research clearly supports this intervention. But it doesn’t end there for the EB chiropractor. Evaluating any aggravating factors in this patient’s daily life and giving advice for that is normal procedure as well as appropriate stretches/exercises. I stressed to her how important my advice is and advised her to return to the office next week if her pain level hasn’t decreased by 50%. This pretty much, without all the details, is generally how an ethical, evidence-based chiropractor practices.
and which research, for instance, you consider backs up SMT for acute [or was it chronic?] back pain?
Dr. Ernst, I am a bit surprised by this question as I am familiar with your work concerning chiropractic and I would have thought you had researched the research. I don’t believe I’ve heard anyone in the past several years in the scientific community question research concerning spinal manipulation (SMT) when treating acute lower back pain. They question, rightly so, the use of spinal manipulation for many systemic/localized non-musculoskeletal issues. A simple Google search revealed many articles from peer reviewed journals concerning the effectiveness of SMT. But again, SMT is only a tool for EB DC’s and may not be indicated for the patient and the EB DC is trained to provide other treatments or refer to someone else.
I was sent a link tonight to a new chiropractic organization in Australia. Pretty much outlines the movement within the profession mentioned in my previous posts. Here is the link to their website and you will see policy statements concerning vaccination, subluxation, etc.
http://chiropracticaustralia.org.au/practice-policies/
Here is one statement:
Policy statement by Chiropractic Australia regarding Chiropractic
Education
Chiropractic Australia advocates quality, safe, and ethical chiropractic practice. As
such, it is essential that modern courses in the training of chiropractors be evidence
based and be underpinned by research. The curriculum should teach the history and
philosophy of science and chiropractic. The content must be scientifically current, it
should reinforce the value of clinical experience, and patient-centred care should be
the focus of its practical training.
Research plays a fundamental and pivotal role in the embodiment of these principles.
Accordingly, the primary and ongoing education of chiropractors in Australia must be
delivered by higher learning institutions within the university system.
please tell us what you do in daily routine that is backed by sound evidence.
Chiroleader.
Don’t bother answering Prof. EE’s questions. He is just goading you and being obtuse. Nothing you write could satisfy his style of questioning, so give up.
This may interest the both of you.
Physical therapists’ treatment choices for non-specific low back pain in Florida: an electronic survey. – PubMed – NCBI
http://www.ncbi.nlm.nih.gov/m/pubmed/26109832/
Here are a few items that relate to what an EB DC does in their office. To be clear, I’m not the person to debate research but this is what I found with a cursory search. Dr. Ernst, I know you have taken a lot of criticism from many in the chiropractic profession but know that many agree with some of your work. I hope you will have an open mind as many of us are trying to transform the profession into an integral part of the healthcare system and let the science take us where we need to go. It was my understanding the topic for this thread concerns immunizations and DC’s embracing the scientific method. If research leads to the conclusion in the future that manipulation is not indicated for spinal conditions then EB DC’s will follow the research. Except for the dogmatic chiropractors out there who believe SMT is the be all, end all, the overwhelming majority of DC’s treat SMT as one of many interventions they consider when treating patients and many want more options. Spinal manipulation doesn’t define the EB DC’s. Spinal manipulation is not a profession, just a technique. There are many instances where SMT is not indicated but through soft tissue work, stretching, exercises at the proper time, short term antiinflammatories and changes in AODL the patient will most likely improve. And, as we all know, many LBP patients get better without touching them but my experience is that if we delve deeply into their lifestyles/history we will usually find the cause of their back pain and with the proper advice keep them from having as many exacerbations in the future.
For Acute and Chronic Pain
“Many treatments are available for low back pain. Often exercises and physical therapy can help. Some people benefit from chiropractic therapy or acupuncture.”
–Goodman et al. (2013), Journal of the American Medical Association
“[Chiropractic Manipulative Therapy] in conjunction with [standard medical care] offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute low back pain.”
–Goertz et al. (2013), Spine
In a Randomized controlled trial, 183 patients with neck pain were randomly allocated to manual therapy (spinal mobilization), physiotherapy (mainly exercise) or general practitioner care (counseling, education and drugs) in a 52-week study. The clinical outcomes measures showed that manual therapy resulted in faster recovery than physiotherapy and general practitioner care. Moreover, total costs of the manual therapy-treated patients were about one-third of the costs of physiotherapy or general practitioner care.
— Korthals-de Bos et al (2003), British Medical Journal
“Patients with chronic low-back pain treated by chiropractors showed greater improvement and satisfaction at one month than patients treated by family physicians. Satisfaction scores were higher for chiropractic patients. A higher proportion of chiropractic patients (56 percent vs. 13 percent) reported that their low-back pain was better or much better, whereas nearly one-third of medical patients reported their low-back pain was worse or much worse.”
– Nyiendo et al (2000), Journal of Manipulative and Physiological Therapeutics
In Comparison to Other Treatment Alternatives:
“Manual-thrust manipulation provides greater short-term reductions in self-reported disability and pain compared with usual medical care. 94% of the manual-thrust manipulation group achieved greater than 30% reduction in pain compared with 69% of usual medical care.”
– Schneider et al (2015), Spine
“Reduced odds of surgery were observed for…those whose first provider was a chiropractor. 42.7% of workers [with back injuries] who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor.”
– Keeney et al (2012), Spine
“Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction; clinically important differences in pain and disability improvement were found for chronic patients.”
– Haas et al (2005), Journal of Manipulative and Physiological Therapeutics
“In our randomized, controlled trial, we compared the effectiveness of manual therapy, physical therapy, and continued care by a general practitioner in patients with nonspecific neck pain. The success rate at seven weeks was twice as high for the manual therapy group (68.3 percent) as for the continued care group (general practitioner). Manual therapy scored better than physical therapy on all outcome measures. Patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care, and manual therapy and physical therapy each resulted in statistically significant less analgesic use than continued care.”
– Hoving et al (2002), Annals of Internal Medicine
Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: the results of a pragmatic randomized comparative effectiveness study.
Goertz, Christine M; Long, Cynthia R; Hondras, Maria a; Petri, Richard; Delgado, Roxana; Lawrence, Dana J; Owens, Edward F & Meeker, William C
Spine
2012
ABSTRACT: Study Design: Randomized controlled trial.Objective: To assess changes in pain levels and physical functioning in response to standard medical care (SMC) vs. SMC plus chiropractic manipulative therapy (CMT) for the treatment of low back pain among 18 to 35-year-old active duty military personnel.Summary of Background Data: Low back pain is common, costly and a significant cause of long-term sick leave and work loss. Many different interventions are available, but there exists no consensus on the best approach. One intervention often used is manipulative therapy. Current evidence from randomized controlled trials demonstrates that manipulative therapy may be as effective as other conservative treatments for LBP, but its appropriate role in the health care delivery system has not been established.Methods: Prospective, 2-arm RCT pilot study comparing SMC plus CMT to SMC alone. The primary outcome measures were changes in back-related pain on the Numerical Rating Scale (NRS) and physical functioning at 4 weeks on the Roland Morris Disability Questionnaire (RMQ) and Back Pain Functional Scale (BPFS).Results: Mean RMQ scores decreased in both groups over the course of the study, but adjusted mean scores were significantly better in the SMC plus CMT group than in the SMC group at both week 2 (p<0.001) and week 4 (p=0.004). Mean NRS was also significantly better in the group that received CMT. Adjusted mean BPFS scores were significantly higher (improved) in the SMC plus CMT group than in the SMC group at both week 2 (p<0.001) and week 4 (p=0.004).Conclusion: The results of this trial suggest that CMT in conjunction with standard medical care offers a significant advantage for decreasing pain and improving physical functioning when compared to standard care alone, for men and women between the ages of 18-35 with acute low back pain.
Meta-analysis: exercise therapy for nonspecific low back pain.
Hayden, Jill A; van Tulder, Maurits W; Malmivaara, Antti V & Koes, Bart W
Annals of internal medicine
2005
BACKGROUND: Exercise therapy is widely used as an intervention in low back pain. OBJECTIVE: To evaluate the effectiveness of exercise therapy in adult nonspecific acute, subacute, and chronic low back pain versus no treatment and other conservative treatments. DATA SOURCES: MEDLINE, EMBASE, PsychInfo, CINAHL, and Cochrane Library databases to October 2004; citation searches and bibliographic reviews of previous systematic reviews. STUDY SELECTION: Randomized, controlled trials evaluating exercise therapy for adult nonspecific low back pain and measuring pain, function, return to work or absenteeism, and global improvement outcomes. DATA EXTRACTION: Two reviewers independently selected studies and extracted data on study characteristics, quality, and outcomes at short-, intermediate-, and long-term follow-up. DATA SYNTHESIS: 61 randomized, controlled trials (6390 participants) met inclusion criteria: acute (11 trials), subacute (6 trials), and chronic (43 trials) low back pain (1 trial was unclear). Evidence suggests that exercise therapy is effective in chronic back pain relative to comparisons at all follow-up periods. Pooled mean improvement (of 100 points) was 7.3 points (95\% CI, 3.7 to 10.9 points) for pain and 2.5 points (CI, 1.0 to 3.9 points) for function at earliest follow-up. In studies investigating patients (people seeking care for back pain), mean improvement was 13.3 points (CI, 5.5 to 21.1 points) for pain and 6.9 points (CI, 2.2 to 11.7 points) for function, compared with studies where some participants had been recruited from a general population (for example, with advertisements). Some evidence suggests effectiveness of a graded-activity exercise program in subacute low back pain in occupational settings, although the evidence for other types of exercise therapy in other populations is inconsistent. In acute low back pain, exercise therapy and other programs were equally effective (pain, 0.03 point [CI, -1.3 to 1.4 points]). LIMITATIONS: Limitations of the literature, including low-quality studies with heterogeneous outcome measures inconsistent and poor reporting, and possibility of publication bias. CONCLUSIONS: Exercise therapy seems to be slightly effective at decreasing pain and improving function in adults with chronic low back pain, particularly in health care populations. In subacute low back pain populations, some evidence suggests that a graded-activity program improves absenteeism outcomes, although evidence for other types of exercise is unclear. In acute low back pain populations, exercise therapy is as effective as either no treatment or other conservative treatments.
Spinal Manipulation for Low-Back Pain
Paul G. Shekelle, MD, MPH; Alan H. Adams, DC; Mark R. Chassin, MD, MPH, MPP; Eric L. Hurwitz, DC, MS; and Robert H. Brook, MD, ScD
[+] Article, Author, and Disclosure Information
Ann Intern Med. 1992;117(7):590-598. doi:10.7326/0003-4819-117-7-590 Text Size: A A A
Grant Support: In part by the California Chiropractic Foundation and the Foundation for Chiropractic Education and Research (grant 89-038).
Requests for Reprints: Paul G. Shekelle, MD, MPH, RAND, 1700 Main Street, P.O. Box 2138, Santa Monica, CA 90406-2138.
Current Author Addresses: Drs. Shekelle and Brook: RAND, 1700 Main Street, P.O. Box 2138, Santa Monica, CA 90406-2138.
Dr. Adams: Los Angeles College of Chiropractic, 16200 East Amber Valley Drive, P.O. Box 1166, Whittier, CA 90609-1166.
Dr. Chassin: New York State Department of Health, Empire State Plaza, Corning Tower Building, Albany, NY 12237.
Dr. Hurwitz: Department of Epidemiology, School of Public Health, University of California, Los Angeles, CA 90024.
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▪ Purpose: To review the use, complications, and efficacy of spinal manipulation as a treatment for low-back pain.
▪ Data Identification: Articles were identified through a MEDLINE search, review of articles' bibliographies, and advice from expert orthopedists and chiropractors.
▪ Study Selection: All studies reporting use and complications of spinal manipulation and all controlled trials of the efficacy of spinal manipulation were analyzed. Fifty-eight articles, including 25 controlled trials, were retrieved.
▪ Data Analysis: Data on the use and complications of spinal manipulation were summarized. Controlled trials of efficacy were critically appraised for study quality. Data from nine studies were combined using the confidence profile method of meta-analysis to estimate the effect of spinal manipulation on patients' pain and functional outcomes.
▪ Results of Data Synthesis: Chiropractors provide most of the manipulative therapy used in the United States for patients with low-back pain. Serious complications of lumbar manipulation, including paraplegia and death, have been reported. Although the occurrence rate of these complications is unknown, it is probably low. For patients with uncomplicated, acute low-back pain, the difference in probability of recovery at 3 weeks favoring treatment with spinal manipulation is 0.17 (for example, increase in recovery from 50% to 67%; 95% probability limits of estimate, 0.07 to 0.28). For patients with low-back pain and sciatic nerve irritation, the difference in probabilities of recovery at 4 weeks is 0.098 (probability limits, — 0.016 to 0.209).
▪ Conclusions: Spinal manipulation is of short-term benefit in some patients, particularly those with uncomplicated, acute low-back pain. Data are insufficient concerning the efficacy of spinal manipulation for chronic low-back pain.8
@chiroleader
Looks like the subluxation is alive and kicking in the UK. This Tweet today from the United Chiropractic Association:
Alan and FrankO–The subluxation is alive and kicking all over the world but please don’t infer the majority of chiropractors agree. There are several, often overlapping in membership, groups promoting unethical, subluxation based practice (practice isn’t really the word I’m looking for but a more descriptive word escapes me now). This UK group is one I haven’t heard of before.
FrankO–I have seen just about everything on Dr. Ernst’s website and have seen his work for years. As I said in a previous post, debating research is not my expertise. And the reason I included a cite about exercise is to make the point spinal manipulation is only a tool (doesn’t define the profession for EB DC’s) and, in my clinical experience, long term relief is achieved by proper rehabilitation which almost always includes exercise instruction as well as changes in activities of daily living. And we all know spinal manipulation is not an easy treatment to research. It isn’t like most other medical procedures where double-blind studies often rule. But research must continue (and due to so many governmental and other biases it is extremely difficult to obtain funding to do research in this area).
I guess we can continue to explore the past of the chiropractic profession and the lack of clear and definitive research (I think we all know many medical procedures lack definitive research as well) but I hope we can all agree there is a large movement to change, accept research that may be more clear and definitive concerning other treatment options and embrace the medical model so our patients are exposed to the best treatments possible. When and if there is definitive research that SMT is not helpful or indicated the EB DC will change gears and follow the research. Maybe calling chiropractors something else would help in the long run if so many equate SMT as the only therapy DC’s offer. And the subluxation based DC’s can continue to use the term.
I have seen other “anti chiropractic” blogs/websites before and the dialog was not very respectful and I chose not to engage. I do appreciate the professional responses I’ve received.
@Chiroleader
Astronomy began serious life when some astrology practitioners realized the basic tenets of astrology were bunk. Yet astrologers had extensive knowledge of the movements of stars and planets. I’d suggest something similar applies to chiropractic, yet few of it practitioners appear willing to start a new movement. How about “spinoflexism” (Latin for spinal manipulation is spinalis flexibus or something similar). If you break away you’ll be well placed to conduct one or more really fine studies, perhaps in collaboration with physios, and you’ll carry none of the baggage of the obsolete, unfounded notions of chiropractic.
Chiroleader said:
I made no such inference. However, subluxationists would seem to be a very significant minority – and, I suspect – some are reluctant to admit they are.
Stephen Perle likes quoting one survey that put the subluxationists at 18% in the US. This could well be an underestimate, but that means there some 14,250 of them in the US. If they are all treating customers as if subluxations were real and the source of all ills, then the chiro industry has a very real and serious problem.
So, they are out there and proudly advertising their vitalistic nonsense. The chiro trainers in the UK are all allegedly only teaching the subluxation as an ‘historical concept’, but who knows of that really is the case and, of course, that still leaves many chiro who will be subluxation believers till they retire, exposing the public to their nonsense.
The UCA is one of the UK trade bodies, the others being the British Chiropractic Association, the McTimoney Chiropractic Association, Scottish Chiropractic Association. I strongly suspect they will all have a subluxation-believing wing.
@Chiroleader
Many thanks for your responses on this thread. I appreciate the insights you give us into the way you think, and the detail you give us of the way you work. I’m sure I’m not alone in appreciating the time you’ve taken to respond to the questions raised.
The reason Prof. Ernst keeps asking you about evidence is because he knows all too well how little evidence there is to support spinal manipulation for the treatment of acute lower back pain. You have shown us you can dig out papers from the literature, but looking down your list I see the following.
Goodman et al. (2013), Goertz et al. (2013), Hoving et al (2002): all examples of trials of A+B vs. A. You don’t have to go very far on this blog before you’ll find a post decrying this type of clinical research as valueless. Adding chiropractic to another treatment in one group without adding some kind of placebo to the other, in a double-blind design, proves nothing at all.
You are quoting all the trials at their face value, accepting the authors’ conclusions as stated. But you need to appreciate that not all trials are of scientifically high quality. (The best type for clinical research is the prospective, randomized, double-blind approach — this allows objective separation of the effects of a treatment from all the other factors that can confound outcomes.) There are plenty of published pieces of science (medical and non-medical) that are just plain lousy. Cherry-picking papers with favourable conclusions without paying attention to their quality is poor scholarship.
Because clinical trials vary in quality, the concept of the systematic review was born and has been with us for quite a few years now. You cite one such: the meta-analysis by Hayden et al. Unfortunately, that’s concerned with exercise therapy, not chiropractic! The short and simple way to find good systematic reviews and meta-analyses of clinical trials is to look in the Cochrane Database (www.cochrane.org) which exists solely to compile the best clinical systematic reviews and provide the evidence base for present-day scientific medicine.
For chiropractic (spinal manipulative therapy; SMT) interventions in acute lower-back pain the most recent Cochrane evidence is here: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008880.pub2/abstract;jsessionid=EF443DF05B09B1022F2F5048C3547299.f03t04. Do take a look at the detail. The summary conclusion reads: “Overall, we found generally low to very low quality evidence suggesting that SMT is no more effective in the treatment of patients with acute low-back pain than inert interventions, sham (or fake) SMT, or when added to another treatment such as standard medical care. SMT also appears to be no more effective than other recommended therapies. SMT appears to be safe when compared to other treatment options but other considerations include costs of care.” That is not a ringing endorsement for what you do.
Prof. Ernst will keep nagging you about evidence, because you haven’t shown you understand his point. He has devoted very many years to clinical trialling and systematically reviewing evidence for complementary and alternative medicine. He is also possibly offended that you seem not to have looked at any of the many other posts about chiropractic on this blog, which deal with evidence for efficacy, safety and the attitudes of chiropractors to what they do. You can search these specifically with the link on the right of each page.
Forgot to answer the question about how long it will take to get rid of the “crazies”. In my opinion when Life University and Sherman College lose their accreditation, go out of business because a light is shined on them by the ethical DC organizations, boards of chiropractic examiners hold the unethical practitioners’ feet to the fire, and the ones’ in practice die off.
One major problem is the president of Life University has money, power and political connections. He is nothing more than a slick evangelist who could sell you the Brooklyn Bridge. Life U. fly prospective students to their campus, show them a great time and convince them they are in the right place. What credible professional educational institution does that? 90% of the 18-25% of the “crazies” come from this one school. They are the biggest. Another way to marginalize this group is for legislative change to allow the EB DC’s to expand their scope (with proper post graduate education). This has happened in a few states and it is having a negative effect on the dogmatic DC’s. These “new” DC’s will have a competitive advantage and could put the others out of business. The internet is already having a negative impact on the subluxation based DC’s. For every one patient they scam for $3000 there are 10 others that left the office with a bad taste in their mouth and they post their reviews for others to see.
During my Soviet childhood I was taught that untreated acute bronchitis would lead to chronic one.
Since then diagnostics have improved and it has turned out that chronic bronchitis in non-smokers is much less common than asthma and acid reflux. But even medical statistics speaks about increasing number of asthma patients, although nobody knew how many there were e.g. hundred years ago. And, what is more important: how long they survived, especially women.
But those trying to persuade that people did well even without vaccines do even more lousy job, because data about longevity and causes of death can be found, bat anti-vac people either are to lazy themselves or hope nobody will look for these data.
I feel that every practitioner in any field of medicine has a grave responsibility to respect the lives of those he or she is treating. Scientific studies that are twisted to support the interests of corrupt corporations should not be accepted as “science” by medical practitioners in ANY field who practice with integrity. We have a man named William Thompson who openly admitted that he (along with several other researchers) lied about the results of a CDC study that supposedly proved that the MMR vaccine was not linked to autism. Mr. Thompson stated and I quote, “We lied,” …”I cannot believe that we did what we did, but we did.” As you demonize the positions of chiropractors just make sure Mr mouthpiece of Big Pharma that you know just what kind of an evil you are supporting.. Why don’t you watch a movie called Vaxxed by Gary Null. If you can watch that and still attack folks who are against immunizations, then you are hopelessly brainwashed. I wonder also if people like you who love vaccines so much could stand to live for one day with a severely autistic child and deal with the living nightmare that so many parents of these vaccine injured children are dealing with every day. You would not have the courage I am sure. You do not even have the courage to base your assertions on “real science”! You and others like you just regurgitate the same crap that the pharmaceutical companies have been selling you since the day you entered college. You also are no doubt very aware that these companies are ultimately responsible for your paycheck. You do not have the courage that Andrew Wakefield has displayed. I am sure you think he is full of it even though he was once one of yours…How long will you continue to keep your head in the sand?
@Leslie
No, vaccines have been proven not to cause autism.
No, William Thompson did not blow the whistle on a cover up. There was nothing to cover up.
Yes, I have seen the film Vaxxed and was not impressed by that bizarre propaganda film disguised as a documentary, produced to cover up Andrew Wakefield’s frauds and attempt to monetize on anti-vaccine hysteria .
Yes I am pro-vax and proud of it. Seeing Vaxxed only strengthened that sentiment.
Yes, my children and everyone in my family are fully immunised and they are all healthy, extremely intelligent and pursuing brilliant scholarly careers.
Yes, I and my whole family take the flu shot every year and we never get more than mild reactions.
No, I am not paid by Big Pharma.
Yes, I read the package insert and I also read reliable information on the safety and effects of minute additives in vaccines.
Yes I recommend vaccinations, warmly. They are an important public health measure and it is important they provide enough cover for heard immunity.
Yes I criticise chiropractors for selling useless theatrical manipulations invented (not discovered) by a charlatan swindler named DD Palmer.
Yes I criticise many chiropractors for spreading lies and deceptions about vaccines and other health related subjects.
No Andrew Wakefield did not show courage, he committed cowardly fraud so serious his license to practice medicine was taken from him. He has indirectly caused more deaths and harm than anyone can ever imagine by starting the wave of anti-vaccination hysteria that has led to many outbreaks of preventable diseases like measles, mumps and whooping cough.
Yes, you should stop reading junk science sites and seek help for apparent paranoid delusions.
Oh… I forgot:
No, “Vaxxed” is not by Gary Null. Even if he is also seriously delusional in many ways, not the least vaccine paranoid, the film Vaxxed was made by Andrew Wakefield and a bloke named Dell Bigtree
https://en.wikipedia.org/wiki/Vaxxed
https://en.wikipedia.org/wiki/Gary_Null
Here is my take on this, Are you a chiropractor? “CHIROPRACTIC” The SCIENCE ART and PHILOSOPHY OF ADJUSTING SEGMENTS OF THE SPINE,TO REMOVE THE CAUSE OF DIS-EASE! Nowhere does it say Pills, Potions, medicines, and shots, If you as a CHIROPRACTOR learned anything from your education, it is that the human body is amazing and needs no outside chemical interference to survive and or function!!! “Above Below Inside Out”
“SUBLUXATION” THE CONDITION OF A VERTEBRA THAT HAS LOST ITS’ PROPER JUXTA POSITION WITH THE ONE ABOVE OR BELOW OR BOTH TO ANY EXTENT LESS THAN LUXATION!!!!
Brilliant… Who would have known…