MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

The question whether chiropractic is a truly valuable option for people suffering from back pain has been addressed repeatedly on this blog. My answer was usually negative, but proponents of chiropractic tended to argue that I am biased. Therefore I find it constructive to see what an organisation that hardly can be accused of bias says on this topic. An article by ‘SHOW ME THE EVIDENCE’ has recently provided a comprehensive overview of treatments for back pain. This is what they wrote about chiropractic:

START OF QUOTE

Spinal manipulation, the cranking and tweaking on offer when you visit a traditional chiropractor, is among the most popular approaches to back pain. Practitioners lay their hands on the patient and move their joints to or beyond their range of motion — a technique that’s often accompanied by a pop or crack.

There is some evidence the approach can help people with chronic back pain — but not any more than over-the-counter painkillers or exercise, and you need to take precautions when seeking out a chiropractor.

First, a quick look at the evidence. There are two recent Cochrane reviews on spinal manipulation for low back pain: one focused on people with acute (again, episodic/short duration) pain and the other on chronic pain. The 2011 review on chronic low back pain found that spinal manipulation had small, short-term effects on reducing pain and improving the patient’s functional status — but this effect was about the same as other common therapies for chronic low back pain, such as exercise. That review was published in 2011; UpToDate reviewed the randomized trials that have come out since — and also found that spinal manipulation delivered modest, short-term benefits for chronic back pain sufferers.

The Cochrane review on acute pain found that spinal manipulation worked no better than placebo. So people with a short episode of back pain should probably not bother seeing a chiropractor.

“Based on the evidence,” University of Amsterdam assistant professor Sidney Rubinstein, who is the lead author on the Cochrane reviews, told me, “it would appear [spinal manipulation] works as well as other accepted conservative therapies for chronic low back pain, such as non-prescription medication or exercise, but less well for patients with acute low back pain.”

As a chiropractor himself, he had some advice for patients: They should avoid chiropractors who routinely make X-rays or do advanced diagnostics for low back pain because this adds nothing to the clinical picture, particularly in the case of nonspecific low back pain. Patients should also beware chiropractors who put them on extended programs of care.

“Patients who respond to chiropractic care traditionally respond rather quickly,” he said. “My advice is those patients who have not responded to a short course of chiropractic care or manipulation should consider another type of therapy.”

While the risks of serious side effects from spinal manipulation for back pain are rare — about one in 10 million — the risks associated with chiropractic therapy for neck pain tend to be slightly higher: 1.46 strokes for every million neck adjustments.

The issue is the vertebral artery, which travels from the neck down through the vertebrae. Manipulating the neck can put patients at a higher risk of arterial problems, including stroke or vertebral artery dissection, or the tearing of the vertebral artery (though Rubinstein noted that people in the initial stages of stroke or dissection may also seek out care for their symptoms, such as neck pain, which makes it difficult to untangle how many of health emergencies are brought on by the adjustments).

END OF QUOTE

This all seems fairly reasonable to me – except for the following not entirely unimportant points:

  • I am not sure where the evidence about risks of spinal manipulation comes from. In my view, it is not entirely correct: as there is no effective post-marketing surveillance, we cannot possibly name the incidence figures.
  • Neck manipulations are clearly more risky than manipulations lower down. But this does not necessarily mean that back patients are safer than those with neck pain. Chiropractors view the spine as a whole organ and will regularly manipulate the neck (if they sense ‘subluxations’ in this area), even if the patient comes with low back pain.
  • There are also indirect risks with consulting a chiropractor; for instance, they often give incompetent advice about healthcare. This can include discouraging immunisations or treating serious diseases, such as asthma, colic etc., with chiropractic.
  • I think the article should point out that exercise is not just as effective (or as ineffective) as chiropractic, but it is much safer and less expensive.
  • What Rubinstein says about responders is debatable, in my view. In particular, most chiropractors will convince their patients to continue treatment, even if they do not ‘respond’. And ‘responding’ might be simply the natural history of the condition and therefore totally unrelated to the therapy.

The bottom line: Chiropractic is not the best treatment for back pain!

45 Responses to Chiropractic is not the best treatment for back pain !!!

  • But it is the best treatment for folks who believe it is!
    In other words – chiropractic is a variety of faith healing, and another theatrical placebo.

    Part of the family of condimentary medicine modalities – might be nice and adds flavour, but has no substantial effect on the condition.

  • The lead author on the cochrane reviews was Rubinstein who is himself a chiropractor (and he has an active chiropractic practice). This is a clear source of potential bias.

    This article also conflicts with the NICE guidelines for low back pain which recommends exercise as THE first-line treatment and also says “massage and manipulation should only be used with exercise because there is not enough evidence to show they are of benefit when used alone”. https://www.nice.org.uk/news/article/nice-publishes-updated-advice-on-treating-low-back-pain

  • Correction: SMT alone is not the best treatment for back pain

  • Entrepreneurial-theatrics is more accurate than ‘placebo’ I’d say.
    Chiropractic should be a 3-Treatment-and-out ($25-40) modality as anything further is pointless (as perhaps the first 3 are as well) and always bait-and-switch.
    Though it’s $200,000 “education” would be a really tough sell. It’s also a wonder as to where their “alternative-to-manipulation” entrepreneurial-theatrics come from if not taught at the clown-colleges. I’m sure the research on “drop-tables”, Muscle-tests and Decompression is ongoing daily at these institutions? Research, research, research has always been the shibboleth of Chiropractors and Scientologists.
    Spinal “manipulation” is increasingly less the lead-in theatric-of-choice, at least in the US, as drops, AK, Activators, Decompression, curve-corrections, Lasers and all form of muscle-release gizmos are easier to do and less traumatic. Fear of bone-cracking limits many patients so “non-crack Techniques” afford a marketing angle to get the gullible affixed to ‘nerve-interference’ correction. Funny how when you’re a DC EVERYTHING and anything you do corrects “nerve interference” and improves “real health” at its source.
    And of course the utter non-sensical “tests” used to determine which of these pointless toys will be most compelling to gain excess sessions is where the shtick really shines and ethics are stretched to their breaking point. But the defenders will be at the ready with numerous defensive logical fallacies and “you do it too” retorts.
    It is a criminal venture when 125 years of hyperbolic religious piffel and thievery from Andrew Still results in “no better than over the counter meds”. Outstanding work!

    • Andrew Still is the Founder of Osteopathy not Chiropractic. Osteopaths are virtually indistinguishable from Medical Doctors in the U.S.

    • @ Michael

      I remember reading that you are a physio. I was wondering if you could explain a treatment plan you would give for a person with non specific low back pain (no radicular symptoms, no yellow flags).

      • surely that needs to be decided on the individual case based on much fuller information

      • @AN: I would follow evidence-based methods just like a highly trained DC does, of course.
        First I spend several minutes in discussion regarding the “big idea” and “look well to the spine for the cause of disease” and “as the twig is bent so grows the tree” and “your immune function is dependent on proper nerve transmission”.
        Then I do several minutes of motion-palpation tests to determine the mis-alignments and altered segmental motion I will un-fixate & realign (over the next several weeks, 3xs a week…or until the insurance runs out).
        Then on to the Leg-length discrepancy checks to help reveal a PI/AS pelvis, then use my Activator “challenges” to reveal other subluxated segments up the spine….and whether Atlas has slipped out left or right. If too far out I may opt for a Toggle-recoil or Gonstead chair adjustment (depending on the ‘energy’ I feel).
        Then AK muscle-checks to reveal other nerve-interference issues and to validate which homeopathic remedy may facilitate the fullest recovery.
        And of course I also use AK to scientifically validate the orthotic, pillow and supplements necessary to help “support the adjustment”.
        IF covered by insurance, I take a bunch of x-rays to really prove misalignments and to see if that neck-curve is “off”. Then I check that pesky Psoas and see if it needs to be “released”.
        Then of course I start-a-whackin’, rubbin’ and stretchin’ with my drop-table, Activator, Pro-adjuster, Arthro-stim, percussive-massager, distraction-table and Diversified flying-seven manipulations.
        All the while directing the customer as to “what” is happening, how adept and well-trained I am and how important this care really is for proper nerve transmission and wellness…..and that its going to take A LOT of treatments…perhaps a lifetime.
        And that stroke or other serious side-effects are just conspiracies perpetuated by avarice MDs.
        Of course I validate all I did with post-treatment motion-palpation and leg-length RE-checks….I AM evidenced-based after all!
        And then I say: “Voila’ YOU are now realigned AND free of deadly nerve-interference”…(at least for the next 18mins).
        What else would you expect I do??
        I, like a DC am both cutting-edge and ultimately scientific.

        • @ Michael

          I would love to hear what you really do?

        • Satire is an art, like chiropractics and other alt. health practices. However, this brilliant display of satire by MK is based on poking fun at true charlatans, which is a far cry from the “artistic” con games of the alt cults who take advantage of the truly gullible.

        • @ Michael Kenny

          I feel obliged to point out a serious flaw in your therapeutic strategy! After the leg-length test (which you should always perform in the supine position you should NOT use the activator until you have done a thorough nano-alignment with the modified disk-sander as demonstrated by one of the worlds best chiropractors, Houston Chiropractor Dr Gregory Johnson at Advanced Chiropractic Relief:

          https://youtu.be/Fm9wmDJ-QCE?t=5m40s

          Another good opton is of course the modified electric jig saw, which fixes even the worst cases of hiatal hernia:

          https://youtu.be/DNdIaVyXHKw?t=9m44s

          • @ Bjorn: Many thanks! I have been to Home Depot to update my treatment equipment after realizing I was clearly short-changing my patients (as well as finally finishing that bookcase). Dear God it’s practically malpractice to not have a sander in the office.
            Additionally I have retrieved all the authors @GibletGiblet suggested I read and was pleasantly surprised that they too recommend the ‘supine leg check and Activator’ AFTER the sander. Whew, lucky he posted those authors so we tyros can be learned real good by an ex-spert. Haldemans’ extensive work on AK and drop table techniques was a real eye opener as well…I’m glad to see both he and Bogduk get most of their insights channelling Edgar Cayce.during a seance.
            Though he spelled their names correctly I doubt he’s ever really understood anything they’ve written….or recognized that NONE of them are in Chiropractic practice (odd, since Giblet seems to suggest they are all supreme Chiropractic proponents?) and I’m going to guess….just a guess mind you, but NONE of them have suggested their children pursue a “career” in Chiropractic? Perhaps after they get a medical degree, MS or PhD….THEN comes Chiropractic (clown) college? Clearly that’s where the real scientists are…

      • Physio plan for low back (or most) conditions is “Bake, shake and fake”.

        • what an intelligent comment!

        • @gg: with such wit, perspicacity and research-driven “clinicians” it’s no wonder Chiropractic is the worlds leading non-scientific health care delivery system!
          And by the way Dr.smarty pants; It’s fake, bake THEN shake.

          • Michael, no matter how you write it:

            zero times zero times zero equals zero.

            Physio: shake, bake and fake is still the “hands on homeopathy” of physical medicine.

          • @gg: as is typical you can have no real response. Pointing to bad behavior to explain away other bad behavior is a logical fallacy. But as a DC logic is of no interest or consequence to you.
            I was married to a DC for several years…I KNOW the nonsense first hand.
            I used to say to the staff: “Chiropractic: pretending to get sick people well since 1895” (perhaps why the marriage failed? My experience is that the most “successful” DCs are those with blinders and who simply dismiss any criticism of their religion.
            Being a DC you are in a long tradition of denying the obvious and always filling a discussion with obfuscatory language and deflection. What else could you do??
            As Upton Sinclair said:
            “It’s diffcult to get a man to understand something when his income depends on not understanding it”. As I pointed out before a huge difference between PT and Chiropractic is that PT, with its many inequities is still the primary source of its own critique and evolving remediation.
            Chiropractics’ entrepreneurial-theatrics, adoption of gypsy tricks and useless trappings of pseudoscience assures that the profession will ALWAYS remain on the fringe.

  • What a joke article. Bunch of disgruntled MDs who profession with a hundred year head start has not cured 1 disease, based on the JAMA is the 3rd leading cause of death for Americans, lead the US to being ranked 47/48 of the sickest countries in the modern world. Reason for the opioid epidemic. Big pharma Slaves and professional drug dealers and butcher’s. Without BIG Pharma and the Rockefellers, MDs would be like the modern chiropractor now. Instead they are slaves to a dieing healthcare system that drains the life blood and money from the nation.

    • interesting comment ‘doctor’ Barrett!

    • did they not teach you in chiro school that you need arguments for a meaningful discussion, rather that insults?
      did they not teach you at PE that you ought to play the ball, and not the player?

    • Dr. Erudite:
      And what diseases have you and your colleagues cured? What new, effective interventions are you/they taking credit for?? AK? Motion-palpation? Leg-checks? Dental-impactors?
      Resurrecting 1000 year old gypsy tricks is not a real solution Einstein. You “treat” back pain as your specialty but amidst 60,000 in the US and thousands throughout the world nothing disables more people than back pain. The ‘medical profession’ isn’t suggesting they have a “cure”…..yours however does, and in no uncertain terms. Congratulations! You’re a liar as well as a fraud!
      Whenever a fake-doctor or their family gets a real illness or injury off to the crazy MD they go…fair-weather critics the whole lot of you.
      I’m sure you also recognize that chemistry causes a lot of problems and alchemy is the ideal way rational people
      Help keep it in check.
      Too bad your lofty, $200,000 clown-college degree didn’t include critical thinking and logic.

  • If you will die from a chiropractic manipulation you would have died anyway .. sooner or later .. such arguments are part of chiropractor’s brainwashing
    http://www.forumgesund.ch/immagini-upload/Manipulationsrisiko.pdf

  • ‘spinal manipulation worked no better than placebo. So people with a short episode of back pain should probably not bother seeing a chiropractor.’
    But a placebo is something, will give short duration relief. Surely that is better than nothing?
    Or have I missed something?

    • @Alan Byron

      But a placebo is something, will give short duration relief. Surely that is better than nothing?
      Or have I missed something?

      I speak both from personal, from studies of chiropractic history, “theory” and practice and from professional medical experience:
      A brisk walk, preferably in terrain and some simple exercises will do at least as good as bringing yourself to the chiropractor and having it twist your back and do the theatrical thumping trick. And it costs you no money.
      A visit to a chiropractic is rather expensive and there is one thing chiropractors excel at, to seduce their customers into thinking they should come for endless costly repeat manipulations. Mine did, and I went with it for a while. The experience was instrumental in lighting my interest in health fraud and deception.

      On top of that, chiropractic manipulation is not without hazards, especially manipulation of the neck.
      If you add some well chosen analgesics and even a couple of nights with a sedative, you will get over most cases of simple lumbago in far less time than if you rely on the entertainment a chiropractor has to offer.
      A short course of such medications is practically without risk.

      Placebo effects are severely overrated and almost never better than good advice from a knowledgable doctor and then “wait and see”. Placebo, by definition entails deception which is unethical.
      The studies that supposedly show its effects forget to subtract the effect of doing nothing, that is to say a placebo only makes you think you feel better.
      Now…
      If you believe you can prove me wrong, by all means submit your arguments.

      • So true, but nuance seems to be an unknown understanding by most writers on this blog. This trait unfortunately seems to be a requirement in order to make a point.
        True: chiropractors have a good education, but often overestimate their ability to ‘cure’
        True: chiropractors are well equipped to examine and treat mechanical disorders. These changes in the proprioceptive system are often accompanied by changes in the autonomic system, accounting for ‘weird and wonderfull’ systemic changes.
        True: chiropractors do use placebo in a very effective way. If it helps the patient why not?
        Chiropractors effect the nerveus system effectively via biomechanisch, through SMT, muscle techniques, excersise, activator, traction techniques etc…. it actually is very simple. Chiropractic is not solely synonymous with SMT.
        Fact: the profession (like any other profession) partly consists of extremists. They do not represent the vast majority (like IS does not represent Islam).
        Fact: excersize is the most important prerequisite for musculoskeletal health. Chiropractic facilitates and helps to maintain and maximise this ability to excersize.

        • @JG: Fact: Absolutely nothing you said represents anything but your personal opinion(s), nothing remotely resembling a fact.
          Fact: Chiropractors do not effect the nervous system any more than a slap on the back, a trip off a curb or getting in or out of bed. Your dogma don’t make it so…
          Fact: Chiropractors are not well equipped to examine and treat mechanical problems since their education is replete in nonsensical dogma regarding palpation, leg checks, AK and reduction of subluxations (or the equally spurious fixations or “facilitated segments).
          Fact: many if not most painful intervertebral segments are hyper-mobile…a feature likely demonstrating valid and reliable tests (something unavailable regarding hypo-mobile subluxations).
          Fact: non-specific back pain is ALL they could ever treat…by it’s very definition it has no particular diagnosable features…..excepting the ones each pseudoscientist assigns it.
          Fact: exercise has never been proven to be a pre-requisite to MSK health.
          Perhaps you may want to examine your nuisance and critical thinking skills?

          • Michael Kenny, your unreferenced diatribe shows that you have no understanding of the Neurodynamics of vertebral dysfunction. Good authors for you to start reading would include Haldeman, Beck, Jull, Bogduk, Stoddard, Terrett, Haavik, just to name a few. Until you become more familiar with the whole concept and theories behind the neurophysiology of spinal dysfunction and appropriate methods of treatment, you will remain blind in your ignorance. No one has shown a more appropriate method of management of low back pain than spinal manual therapy, do you know of something better?
            How many physiotherapist does it take to change a light bulb?
            None, because physiotherapists cannot change anything.

      • @ Bjorn

        Are placebo effects the same as contextual effects i.e. empathy, attentive listening etc.

      • Bjorn Geir. This is anecdotal and unreferenced rubbish. Please do better next time.

  • Physicians and others, It demonstrates a significant lack of intellectual honesty and integrity assassinating the messenger because you happen to disagree with the message. Resorting to adolescent bullying and name calling demonstrates even less. Dr. Patrick

    From; Death by Medicine By Gary Null, PhD; Carolyn Dean MD, ND; Martin Feldman, MD; Debora Rasio, MD; and Dorothy Smith, PhD March 2004

    Something is wrong when regulatory agencies pretend that vitamins are dangerous, yet ignore published statistics showing that government-sanctioned medicine is the real hazard.
    This group of researchers meticulously reviewed statistical evidence, their findings are absolutely shocking, presenting evidence that the medical system frequently causes more harm than good. Every “count” in this “indictment” of US medicine is validated by published, peer-reviewed scientific studies.

    This fully referenced report shows:
    • Over 700,000 Americans die each year at the hands of government-sanctioned medicine.
    • Conventional medicine is “the leading cause of death” in the United States.
    • Adverse reactions to prescribed drugs are 2.2 million per year.
    • Unnecessary antibiotics prescribed annually for viral infections are 20 million.
    • Unnecessary medical and surgical procedures annually are 7.5 million.
    • Unnecessary hospitalization annually is 8.9 million.
    • More than half of US population receives unneeded medical treatment in a decade.

    Simply entering a hospital could result in the following:
    1. In 16.4 million people, 186,000 will have a serious adverse drug reaction.
    2. In 16.4 million people, 489,500 acquire a nosocomial infection.
    3. In16.4 million people, 1.78 million have a medical error or adverse drug reactions
    4. In 16.4 million people, 1.3 million have a procedure error.

    American medical system is the leading cause of death and injury.
    Total deaths caused by western medicine is an astounding 783,936 per year.
    By contrast:
    1. number of deaths attributable to heart disease in 2001 was 699,697,
    2. number of deaths attributable to cancer was 553,251.5
    3. number of deaths attributable to chiropractic adjustments in 2005 was 0

    • “Something is wrong when regulatory agencies pretend that vitamins are dangerous, yet ignore published statistics showing that government-sanctioned medicine is the real hazard.”
      no, I’d say something is wrong in the education of chiros if they fail to understand that interventions must be judged by their ris/benefit balance.

      • @ Dr. Patrick

        Medicine’s answers to its critics:

        Part 1
        http://www.sciencebasedmedicine.org/answering-our-critics-part-1-of-2/

        Part 2
        http://www.sciencebasedmedicine.org/answering-our-critics-part-2-of-2-whats-the-harm/

        And here’s a snippet from Death by Medicine:

        QUOTE
        “Doctor-bashers use their numbers to argue that alternative medicine is safer. Maybe it is. I suppose not treating at all would be safer still. It depends on how you define ‘safe’. To my mind, a treatment is not very ‘safe’ if it causes no side effects but lets you die. Most of us don’t just want ‘safe’: we want ‘effective’. What we really want to know is the risk/benefit ratio of any treatment.

        The ironic thing is that all the statistics these doctor-bashers have accumulated come from the medical literature that those bashed doctors have written themselves. Scientific medicine constantly criticizes itself and publishes the critiques for all to see. There is NOTHING comparable in the world of alternative medicine.”

        Ref: http://www.sciencebasedmedicine.org/death-by-medicine/

        ______________________________________________________________________

        “Chiropractic is the correct term for the collection of deceptions DD Palmer invented.”

        Björn Geir Leifsson, MD

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