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

Many experts have pointed out that the subluxation myth (which is at the core of chiropractic history, theory and practice) lacks sufficient evidence to even reach the level of a theoretical construct. In fact, it is no more than pseudoscientific dogma. I have discussed the issue repeatedly, for instance here, here and here.

The myth continues to generate fierce debate within and outside the chiropractic profession. This survey sought to determine how many chiropractic institutions worldwide still use the term in their curricula.

Forty-six chiropractic programs (18 from US and 28 non-US) were identified from the World Federation of Chiropractic Educational Institutions list. Websites were searched for curricular information September 2016– September 2017. Some data were not available on line, so email requests were made for additional information. Two institutions provided additional information. The total number of mentions of subluxation in course titles, technique course (Tech) descriptions, principles and practice (PP) descriptions, and other course descriptions were reported separately for US and non-US institutions. Means for each category were calculated. The number of course titles and descriptions using subluxation was divided by the total number of courses for each institution and reported as percentages.

Means for use of subluxation by US institutions were: total course titles = .44; Tech = 3.83; PP = 1.50; other = 1.16. For non-US institutions, means were: total course titles = .07; Tech = .27; PP = .44; other = 0. The mean total number of mentions was 6.94 in US vs. 0.83 in non-US institutions. Similarly, the mean course descriptions was 6.50 in US vs. 0.72 in non-US intuitions. The term subluxation was found in all but two US course catalogues. The use of subluxation in US courses rose from a mean of 5.53 in 2011 to 6.50 in 2017. US institutions use the term significantly more frequently than non-US.

The authors comment that unscientific terms and concepts should have no place in modern education, except perhaps in historical context. Unless these outdated concepts are rejected, the chiropractic profession and individual chiropractors will likely continue to face difficulties integrating with established health care systems and attaining cultural authority as experts in conservative neuro-musculoskeletal health care.

This paper prompted a comment in ‘The Chronicle of Chiropractic‘. It is full with ad hominem attacks against the authors. In the comments section of this blog, we have ample evidence that this is one thing in which chiropractors often excel. Here are a few quotes:

While one should be aware of Fake News these days, chiropractors should be aware of Fake Research by the likes of Mirtz and Perle and anything published by this journal tool of the subluxation deniers club…

Among other things, Perle believes the subluxation construct is “scientifically unsubstantiated” and that those focusing on subluxation are practicing a “pseudo-religion”…

It is another great case study in the use of logical fallacies – particularly the straw man fallacy, and the liberal use of unreferenced opinions presented as facts…

END OF QUOTES

For once, I do sympathise with chiropractors; they clearly are in a pickle:

  • Abandoning subluxation is scientifically necessary, as otherwise chiropractors will become the laughing stock of the healthcare community (to a degree, this has already happened; so, there is not much time!).
  • Abandoning subluxation would quickly lead to the end of chiropractic, as it would ‘degrade’ chiropractors to some sort of inferior physiotherapist and thus threaten their right to exist.

Dammed if they do, and dammed if they don’t!

 

 

32 Responses to Chiropractors: dammed if they do, and dammed if they don’t (abandon the subluxation myth)

  • I agree that the term Subluxation used in the context of chiropractic creates confusion with its medical radiological usage. As such, I am more inclined to use the term spinal displacements or deformity as they can be strongly supported using evidence-based chiropractic practices and procedures. I refer the interested reader to the recent publication in the journal of Dose Response discussing the use of X-ray imaging for the documentation of spinal displacements and deformities essential for the chiropractic developed rehabilitation management of non-surgical spinal conditions. Physiotherapy is learning a lot from chiropractors and I take it as a compliment that strategies are in process to take ownership of the science of chiropractic non-surgical correction of spinal displacements, also known historically known as Spinal Subluxations
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024283/

    • the article you cite is not what guidelines about diagnosing low back pain state; in fact, it seems totally bonkers.

      • May I recommend you write a letter to the editor and state your opinion regarding the validity of the article. I dare you to do that!

        • Having read that paper, which is basically a reprint from an article he submitted to JVSR, and trying to discuss these views in the past with several CBP practioneers, it appears to be a waste of time. As a general observation they don’t take critique very well.

          Heck, just the other day i simply pointed out one of the authors stated limitations of a surgical study, studies which CBPers like to use to try and validate their approach, and i was accused of trolling.

          BTW, the editors of Dose Response seem to be proponents of hormesis. Which may have some value within the medical arena, but i have not seen any evidence to support it use with full spine radiography.

          Regarding M&D papers, well, a critical evaluation of their papers reveals the internal and external issues.

    • did you see this:
      The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: P.A.O. was paid by CBP NonProfit, Inc, for writing the manuscript; D.E.H. teaches spine rehabilitation methods and sells products to physicians for patient care that require radiography for biomechanical analysis.

      Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by funds from CBP NonProfit, Inc.

      ——————————————
      a bunch of chiros who call themselves ‘doctor’ without disclosing they are DCs who promote the weirdest things I have seen for a while!

      • Yes, I am very much aware that they admit teaching and producing products that require radiography for biomechanical analysis and fund the research from a non-profit organization. From my understanding that is called transparency.

    • have you looked at the reference list?
      the authors cite almost exclusively themselves!

  • Even more reason for Principals of Chiro Colleges to be honest with their intending students and make sure they understand all this.
    For sure, many students will then not apply, and seek to train as doctors, physiotherapists, osteopaths or something else.
    But there will always be some who want to train to be charlatans – just as there were in Palmer’s day.

    Integrity demands colleges act with honesty. It is because they do not and so many students are then caught up in the sunk cost fallacy, that this problem is taking so long to resolve.
    But it will be resolved eventually as the colleges die out.

  • Dr Michael Epstein wrote: “I agree that the term Subluxation used in the context of chiropractic creates confusion”

    @ Dr Michael Epstein

    Indeed it does. There are 329 terms that either relate to, are synonyms for, or have been used or cited in connection with describing a subluxation or aspects of a VSC. Therefore it follows that the chiropractic subluxation can be anything a chiropractor needs it to be. For example, the following terms are lifted from Rome P.L., Usage of chiropractic terminology in the literature — 296 ways to say “subluxation.” Chiropractic Technique 1996;8:1-12.

    https://edzardernst.com/2017/01/educating-chiros/#comment-85340

  • In my experience a profession tends to be accurately portrayed in its largest circulation magazines. The most read DC magazine: The American Chiropractor (which finds its way via an ex-wife to my mailbox each month) gives any investigator all the ammunition necessary to brand the profession a money-laundering scheme…entrepreneurial theatrics masquerading as healthcare for 123 years. Some examples: “are you ready to grow? Practice accelerator with orthotics, a proven patient generator”….and “help your adjustments HOLD with orthotics”.
    Cortisol reduction pills, personal-injury-“systems” to teach how to reach the med-pay maximum with each patient. A full page ad for Formula 303 “a proven homeopathic muscle relaxant (buy 12 bottles get 6 free!)”. A 4 page cover story by 2 DCs called: Chiropractic vertebral subluxation (and it’s not a treatise for its abandonment). Infrared mineral lamps, homeopathic-based 500 calorie-a-day diet schemes that can “generate an additional $150,000 cash!”.
    International academy of “medical” acupuncture taught by a DC with a bad hairpiece, since 1973! Ultra Slim non-invasive “Laser” body contouring (you can scam the gullible into paying $3000.00 to lose 1/4 cm of fat).
    A dozen “detox” systems, disc-Decompression units “as low as $999.00 a month”!
    “How to generate more pediatric patients”, and “how to become certified in functional medicine”, and “why DCs must become primary care physicians”.
    Fortunately for the pariah selling to DCs thieves all tend to stick together.
    There is no defense for the indefensible.

    • in their defence: they don’t know any better, having been exposed to this sort of thing from day one at chiro college, they think all healthcare is like that.

  • Nah, the majority of patients come to chiropractors for neck and back issues. Only 3% for nonmusculoskeletal complaints (the Palmer subluxation model). Utilization continues to climb in most countries…. interestingly enough, the fastest growing regions are those who are pushing the EB model and suppressing the Palmer model.

    The EB chiros are doing just fine without the Palmer “subluxation” model.

    In fact, the latest review found that “Eleven
    guidelines provided recommendations for spinal manipulation, and nine guidelines recommended its use.”

    Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview.
    Review article
    Oliveira CB, et al. Eur Spine J. 2018.

    So the ones who have concerns are those like you mentioned…McCoy and the little herd of TICs.

    • HERE IS THE CORRECT QUOTE:
      “For treatment of patients with chronic low back pain, the guidelines recommend the use of NSAIDs and antidepressants, exercise therapy, and psychosocial interventions. In addition, referral to a specialist is recommended in case of suspicion of specific pathologies or radiculopathy or if there is no improvement after 4 weeks. While there were a few discrepancies across the current clinical practice guidelines, a substantial proportion of recommendations was consistently endorsed. In the current review, we identified some differences compared to the previous overview regarding the recommendations for assessment of psychosocial factors, the use of some medications (e.g., paracetamol) as well as an increasing amount of information regarding the types of exercise, mode of delivery, acupuncture, herbal medicines, and invasive treatments.”

      • It’s just a different quote.

        • it’s all they state in the abstract about treatment.
          here is the full abstract:
          OBJECTIVE:
          The aim of this study was to provide an overview of the recommendations regarding the diagnosis and treatment contained in current clinical practice guidelines for patients with non-specific low back pain in primary care. We also aimed to examine how recommendations have changed since our last overview in 2010.
          METHOD:
          The searches for clinical practice guidelines were performed for the period from 2008 to 2017 in electronic databases. Guidelines including information regarding either the diagnosis or treatment of non-specific low back pain, and targeted at a multidisciplinary audience in the primary care setting, were considered eligible. We extracted data regarding recommendations for diagnosis and treatment, and methods for development of guidelines.
          RESULTS:
          We identified 15 clinical practice guidelines for the management of low back pain in primary care. For diagnosis of patients with non-specific low back pain, the clinical practice guidelines recommend history taking and physical examination to identify red flags, neurological testing to identify radicular syndrome, use of imaging if serious pathology is suspected (but discourage routine use), and assessment of psychosocial factors. For treatment of patients with acute low back pain, the guidelines recommend reassurance on the favourable prognosis and advice on returning to normal activities, avoiding bed rest, the use of nonsteroidal anti-inflammatory drugs (NSAIDs) and weak opioids for short periods. For treatment of patients with chronic low back pain, the guidelines recommend the use of NSAIDs and antidepressants, exercise therapy, and psychosocial interventions. In addition, referral to a specialist is recommended in case of suspicion of specific pathologies or radiculopathy or if there is no improvement after 4 weeks. While there were a few discrepancies across the current clinical practice guidelines, a substantial proportion of recommendations was consistently endorsed. In the current review, we identified some differences compared to the previous overview regarding the recommendations for assessment of psychosocial factors, the use of some medications (e.g., paracetamol) as well as an increasing amount of information regarding the types of exercise, mode of delivery, acupuncture, herbal medicines, and invasive treatments.

          • I quoted from the paper.

          • I know; but you were a bit economical with the truth. the full paragraph reads as follows:
            “The recommendations for spinal manipulation and acupuncture vary across clinical practice guidelines. Eleven guidelines provided recommendations for spinal manipulation, and nine guidelines recommended its use. Most guidelines (6 out of 9; 66%) recommend spinal manipulation for acute LBP, but there are some discrepancies on the indications. The guidelines recommend spinal manipulation in addition to usual care [30], if there is no improvement after other treatments [7, 31], or in any circumstance [10, 28]. Three guidelines [15, 24, 32] (33%) recommend spinal manipulation as a component of a multimodal or active treatment program for patients with any symptom duration. Three guidelines (33%) recommend spinal manipulation as a component of a multimodal treatment program [10] or in any circumstance for chronic LBP [28]. In contrast, two guidelines recommend against spinal manipulation for acute LBP [9] or chronic LBP [31].”
            DO YOU AGREE THAT THIS IS VERY DIFFERENT?

          • I am fine with either qoute as overall both support what many chiropractors (particularly those who align with EB practices) are doing in clinical practice.

            Its the minority, those clinging onto Palmers model, who are at risk of becoming, shall i say, a page in history books.

          • I know – but I am not happy with getting quotes that are economical with the truth.
            and, ITS NOT A MINORITY!!!

          • My qoute was the truth.

            Evidence they are the majority?

  • “Science works in part because we have to have faith that what people write in their papers is, in fact, the truth. It is not truthful to say 9 people died when only 4 did. Thus can we trust the rest of what Ernst tells us?”

    https://edzardernst.com/2018/08/chiropractors-dammed-if-they-do-and-dammed-if-they-dont-abandon-the-subluxation-myth/#comments

    LOL!

  • This notion of an evidenced based “chiropractic” remains oxymoronic until those chiropractors who promote “EB practice” can name anything that chiropractors think, say, and do that is UNIQUE to the profession that is also supported BY evidence. So far, after more than 100 years of Chiropractic Dalmatians, chiropractors’ unique contribution has been collection of arbitrary diagnostic and therapeutic Chirodigms grounded in Chiropractic Subluxationism. No argument chiropractors own and operate The Chiropractic Subluxation. But, none of this Empty Chiropractism has been substantiated… even a little bit.

    In short, “chiropractic” remains an unsubstantiated assertion made BY chiropractors with each office visit made to a chiropractor still another faith-based experiment.

    ~TEO.

    • That is circular because what makes them unique is their desire to follow evidence based care and put Palmerian thinking into the history section.

      • I’m sorry you’re going in chiropractic circles trying to resolve an oxymoronic evidence-based “chiropractic.”

        I repeat for the hard of chiropractic hearing, “The notion of an evidenced based ‘chiropractic’ remains oxymoronic until those chiropractors who promote ‘EB practice’ can name anything that chiropractors think, say, and do that is UNIQUE to the profession that is also supported BY evidence.” That’s not complicated, actually, never mind “circular.”

        You need only describe any diagnosis and treatment that’s specifically and uniquely “chiropractic” that IS evidence-based. If you can’t, then whatever it is that you’ve described is either NOT “chiropractic” or NOT evidence-based. Can’t have it both ways and that, doctor, is the etiology of your chiropractic headache and nausea … going-on the chiropractic gas and EB brake at the same time.

        Are you somehow imagining that whatever you consider to be “Palmerian” has been replaced by evidence-based diagnoses and therapies now that all that old-time “chiropractic” has been found to be diagnostic and therapeutic bunk and bunco? If so, what ARE these replacement chiropractic diagnoses and chiropractic treatments that ARE evidence-based?

        DO you practice EB “chiropractic?” Can you even tell me what “chiropractic” is? Probably not.

        ~TEO.

        • “…name anything that (EB) chiropractors think, say, and do that is UNIQUE to the profession that is also supported BY evidence.”

          Why does it have to be unique to the profession?

          How about we provide a service that has a need within healthcare?

        • @John Badanes: 👍👍👍👍👍👍👍

  • Chirodigm? Is that a technical term in chiropractic? Its Greek roots suggest that it means some kind of hand display – a show of gestures, perhaps, maybe like the conductor of an orchestra.

    • This has to be a parallelism to “paradigm”. It probably portrays a certain “methodological style” or “approach” in chiropractic. As chiropractic is based on the scientific equivalent of quicksand, I expect that different “chirodigms” abound…

  • @Michael Epstein
    Deed Harrisons research is all about promoting Deed and CBP.
    That paper is a joke.
    BTW drop the title Dr.
    I would love to see the title “Dr” go back to the good old days of state registration where abuse of the title was banned and enforced with fines. 🙂 The national registration board permitting the title “Dr of Chiropractic” is a total stuff up IMHO.
    @Edzard Ernst
    “Dammed if they do, and dammed if they don’t!”
    “Abandoning subluxation” works.
    This has already been demonstrated in the rapidly expanding utilization rates of chiropractic in jurisdictions that have actively abandoned subluxation like Denmark, Sweden and Ontario. (Now at 22 -25% and they are struggling to keep up with demand).
    So more accurate would be:
    “Just get on with it and the subluxationists either change or go the way of the Dodo”.

  • Why does EB chiropractic have to have a “…diagnosis and treatment that’s specifically and uniquely “chiropractic””?

    Why not just be in a position to fill a need?

    • @D(umb) C(confused): of course You’re going to think that because you need to defend and perpetuate your income and business. Try taking your DC out of your ass and see the view from the outside. We nay-sayers are absolutely correct in our judgement…you however are unable and unwilling to recognize the onerous and well-adjudged reality and thus hurt your income. You instead toss around nonsensical non sequiturs. I’m sure there are quackeries out there that really gall YOU as well but you and your ilk are unable to engage in THAT conversation so as to avoid the obvious domino-effect. Perhaps you could give your pseudoscience education a run at homeopathic-vaccinations, Scientology auditing, colonics, aura-balancing, and faith-healing and let this audience in on how YOU process information and make critical judgement. Would be fun for all!

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