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

Most chiropractors claim they can effectively treat a wide range of conditions. I have looked far and wide but I fail to see sound evidence to show that this assumption is true. On a good day, I might agree that chiropractic works for back pain (but this would need to be a very good day and I would need to close at least one eye) – and that’s basically it! Unsurprisingly, chiropractors vehemently disagree with me. Yet, they have an all too obvious conflict of interest in that question and, therefore, they are unlikely to be objective.

One regular commentator of this blog recently reminded me that the UK ‘ADVERTISING STANDARDS AUTHORITY’ (ASA) state on their website that based on all evidence submitted and reviewed to date, the ASA and CAP accept that chiropractors may claim to treat the following conditions:

  • Ankle sprain (short term management)
  • Cramp
  • Elbow pain and tennis elbow (lateral epicondylitis) arising from associated musculoskeletal conditions of the back and neck, but not isolated occurrences
  • Headache arising from the neck (cervicogenic
  • Joint pains
  • Joint pains including hip and knee pain from osteoarthritis as an adjunct to core OA treatments and exercise
  • General, acute & chronic backache, back pain (not arising from injury or accident)
  • Generalised aches and pains
  • Lumbago
  • Mechanical neck pain (as opposed to neck pain following injury i.e. whiplash)
  • Migraine prevention
  • Minor sports injuries
  • Muscle spasms
  • Plantar fasciitis (short term management)
  • Rotator cuff injuries, disease or disorders
  • Sciatica
  • Shoulder complaints (dysfunction, disorders and pain)
  • Soft tissue disorders of the shoulder
  • Tension and inability to relax

This is an impressive yet very odd list:

  • Why is ‘joint pain’ listed twice?
  • Can lateral epicondylitis arise from musculoskeletal conditions of the back and neck?
  • What exactly are ‘generalised aches and pains’?
  • Isn’t lumbago and backache the same?
  • Are ‘minor sports injuries’ (including a cut, bruise or haematoma?) a category that is well-defined?
  • What is a ‘soft tissue disorders of the shoulder’

But let’s not be pedantic. Let’s assume these are all defined conditions that need to be treated. The problem still remains that there is hardly any good evidence that they can be effectively treated by chiropractic spinal manipulation (in case you disagree, please post the evidence in the comments section).

And here we come to the crux of the matter, I think.

Chiropractors would say that they use so much more than spinal manipulations.

  • For a sport injury, they might apply an ice-pack.
  • For the inability to relax, they might give a massage.
  • For rotator cuff problems, they might administer exercises.
  • For tennis elbow, they might recommend immobilizing the joint.
  • Etc., etc.

But that’s not chiropractic!

Yes, it is what we do, insist the chiropractors.

I do not doubt it, but survey after survey shows that chiropractors treat almost all their patients with spinal manipulation. And the history of chiropractic is purely based on spinal manipulation. Yes, today they also use treatments borrowed from other disciplines, yet spinal manipulation is the treatment that defines them.

Let me try an example to make my point clear. Imagine a surgeon who specialises in an obsolete type of operation (e.g. ligation of the mammary artery as a treatment of coronary artery disease). Following the chiro-logic, he could claim that:

  • my approach is not ineffective because I do so much more than just operate,
  • I also prescribe medications,
  • I give dietary advice,
  • I give nutritional advice,
  • I recommend relaxation,
  • I suggest regular exercise.

And the results would, of course, show that many of his patients benefit from all this.

Does that mean our surgeon provides effective care for his patients?

Similarly, crystal healing could be seen as being effective, because some crystal healers tell their obese patients to eat less and exercise more?

So, the above-cited list of claims that the ASA now allows UK chiropractors to make is either way too long or much too short – in any case, it is nonsense. If we base it on the proven effectiveness of spinal manipulation, it must be very short indeed. If we base it on everything chiropractors might do in addition, it is far too short; in this case, it should include everything in the medical textbooks from AIDS to ZOSTER (I cannot imagine many conditions for which life-style advice, exercise or cryotherapy [for pain-control] etc. would not be helpful).

My conclusions from all this are as follows:

  • Chiropractors have tried to reinvent themselves by borrowing some treatments from other healthcare professions.
  • They have done this, I suspect, to avoid being judged by their largely ineffective hallmark intervention, spinal manipulation. The move may be commercially clever, but it is nevertheless transparently nonsensical and wholly unconvincing.
  • Chiropractors must be judged not by the treatments they borrowed and might use occasionally, but by the only therapy that is inherent to chiropractic: spinal manipulation.
  • And spinal manipulation is certainly not effective for a wide range of conditions.

77 Responses to Is chiropractic of proven effectiveness for a long list of conditions? No, I really don’t think so

  • This list is indeed nonsense. As you say, it depends on what you call chiropractic. I suggest you ask the ASA why their list is so much longer than that of the NHS:

    https://www.nhs.uk/conditions/chiropractic/

  • EE…”But that’s not chiropractic!”

    Who decides what is and what is not chiropractic? After all, BJ Palmer had a rehab clinic in the 1940s.

    https://www.slideshare.net/mobile/drhambrick/bj-palmer-private-clinic-davenport-ia-c-1946

  • As usual, this post really has it clearly and succinctly cornered. You honed in on the ruse in a way only a chiroquacker could take umbrage to i.e. used truth, facts and reason. The hearty DC readers will likely post one of a litany of logical fallacies and off-point piffel as a defense.
    It’s always important to point out that NO chiroquacker now or 120 years ago knows or knew exactly what the are doing. Sure they claim to (with precision and bravado) but common sense tells us they are following invalid precepts of a primordial cast of other entrepreneurs simply masquerading as healthcare practitioners (irrespective of whether or not “other-professions” do it too). They sell expensive tricks, trinkets and theatrics, none needing administration by a pseudo-doctor who’s never delivered a baby, stitched a wound, counseled the dying or effectively triaged a real injured person….they hook the gullible and lobby the governments that they are ultimately important to healthcare and social welfare. Like an astrologer or Scientology auditor…or a catholic priest. And charge accordingly.

  • Or, one can go back further. By 1908 DD Palmer was teaching minor surgery in his Oregon college. So if I’m not doing minor surgery am I not practicing chiropractic?

  • @ Edzard

    I do agree with DC – you are not answering the question (Who decides what is and what is not chiropractic?)

    • we clearly need a referendum!
      joking apart, I guess public opinion might be important: the public know that a surgeon uses surgery, a crystal healer employs crystals, and a chiro crack bones. but who decides? I am not sure I have a good answer.

    • dictionary:
      chiropractic
      [ˌkʌɪrə(ʊ)ˈpraktɪk]

      NOUN
      a system of complementary medicine based on the diagnosis and manipulative treatment of misalignments of the joints, especially those of the spinal column, which are believed to cause other disorders by affecting the nerves, muscles, and organs.

    • another dictionary:
      chiropractic noun
      chi·​ro·​prac·​tic | \ ˈkī-rə-ˌprak-tik,

      ˌkī-rə-ˈprak-\
      Definition of chiropractic
      : a system of noninvasive therapy which holds that certain musculoskeletal disorders result from nervous system dysfunction arising from misalignment of the spine and joints and that focuses treatment especially on the manual adjustment or manipulation of the spinal vertebrae

    • World Federation of Chiropractic: A health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. There is an emphasis on manual treatments including spinal adjustment and other joint and soft-tissue manipulation.

      • @ DC

        World Federation of Chiropractic on spinal manipulation for low back pain (the only evidence for chiropractic):

        “People with low back pain often turn to medical consultations and drug therapies, but they also use a variety of alternative approaches. Regardless of the treatment, most cases of acute back pain improve. At the time, people in such cases may credit the improvement to the interventions some of which clearly are more popular and even seemingly more effective than others (e.g. chiropractic and other manipulative treatments in which the laying on of hands and the person-to-person interaction during the treatment may account for some of the salutary results).”

        -snip-

        “The spread of chiropractic and other manipulative treatments worldwide has won many adherents to this treatment, who perceive that it works better than others. This hypothesis was recently put to the test (25) and, although the respondents still favoured such approaches (chiropractic adjustment, osteopathic manipulation, and physical therapy) perhaps because of the time spent and the laying on of hands meta-analysis cannot confirm the superiority of manipulative treatments (or, for that matter, of acupuncture and massage (26)) over other forms of therapy, or even time as a healer (25), which substantiates the contentions of WHO’s document (1). In most instances, manipulative treatments are more expensive than others (apart from surgery) and not more helpful to outcome (26).”

        Ref: https://tinyurl.com/ydalku7s

        • The topic was definition. So what’s your point?

          • the topic was my post and that is about chiros trying to re-vamp themselves

          • That “re-vamp” started in 1906 with the chiropractor John Fitz Allen Howard.

          • yes, and Hippocrates invented chiropractic

          • DC wrote on Thursday 17 January 2019 at 12:36: The topic was definition. So what’s your point?

            Sorry, I mixed up the World Federation of Chiropractic (WFC) with the World Health Organisation (WHO), but it’s still interesting to see that the WHO’s Guidelines on Basic Training and Safety in Chiropractic say the following in Section 1.2:

            QUOTE
            “The concepts and principles that distinguish and differentiate the philosophy of chiropractic from other health care professions are of major significance to most chiropractors and strongly influence their attitude and approach towards health care. A majority of practitioners within the profession would maintain that the philosophy of chiropractic includes, but is not limited to, concepts of holism, vitalism, naturalism…”

            Ref: http://www.registerchiropractor.nl/Chiro-Guidelines.pdf

            IMO, there is a stark difference between that description/definition and the WFC’s “A health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. There is an emphasis on manual treatments including spinal adjustment and other joint and soft-tissue manipulation.”

          • Shoot, most chiropractors don’t even know what vitalism actually means.

  • EE…Can lateral epicondylitis arise from musculoskeletal conditions of the back and neck?

    Maybe it’s better to look at, an address as needed, the kinetic chain rather than to be so reductionalistic?

    Analysis of posture and movement within the whole kinetic chain is recommended3 to identify potential risk factors that may be modifiable through rehabilitation.

    Neck pain is more common in patients with LET than in an age-matched healthy population.8 Physical impairments have also been demonstrated on manual ex- amination of C4-C7 segmental levels in patients with relatively localized symp- toms of LET.24 Moreover, self-report of shoulder or neck pain in patients with LET presenting to general practice was indicative of poorer short- or long-term prognosis, respectively.102

    journal of orthopaedic & sports physical therapy | volume 45 | number 11 | november 2015 | 939

    • this is roughly what I remember learning in med school:
      Tennis Elbow – Lateral Epicondylitis

      DESCRIPTION

      Lateral epicondylitis, commonly known as “tennis elbow,” is a painful condition involving the tendons that attach to the bone on the outside (lateral) part of the elbow. Tendons transmit a muscle’s force to the bone. The muscle involved in this condition, the extensor carpi radialis brevis, helps to straighten and stabilize the wrist (Figure 1).

      With lateral epicondylitis, there is degeneration of the tendon’s attachment, weakening the anchor site and placing greater stress on the area. This can lead to pain associated with activities in which this muscle is active, such as lifting, gripping and/or grasping. Sports such as tennis are commonly associated with this, but the problem can occur with many different activities.
      CAUSES
      This condition most commonly affects individuals between 30 and 50 years old, but it can occur in all ages and in both men and women.

      Here are some potential causes of this condition:
      Overuse: This can be both non-work and work-related. Overuse can happen from “repetitive” gripping and grasping activities such as meat cutting, plumbing, painting, auto-mechanic work, etc.
      Trauma: Although less common, a direct blow to the elbow may result in swelling of the tendon that can lead to degeneration. This can make the elbow more susceptible to an overuse injury.

  • Edzard you seem to be catching on (slowly) that chiropractic is not a single treatment but indeed a profession. Chiropractors are trained in a range of treatments that may include manual therapy, exercise, rehabilitation, massage, modalities, shockwave therapy etc. To keep going back to the Palmers (who also used exercise rehabilitation!) is ridiculous. Chiropractic (the profession) is defined by the training that chiropractors receive and in the UK the training is validated by the regulator as defined by an Act of Parliament.

    • yes, that’s how you want to re-brand it, I know. good for business, no doubt!

    • Chiropractic is the correct term for the set of theatrical parlour tricks, invented (not discovered, mind you) by DD Palmer and commercialised by his son, along with a fatuous fairy tale about non-existent subluxations. Later disciples have added several similarly stupid acts such as the activator or various vibrators. These can be called whatever you like.
      Additions to the script, later appropriated by various disciples of DD, from disciplines e.g. nutritionists or physiotherapists, have no relation to chiropractic even if many chiropractors say so.

  • An excellent post that describes the situation very well.

    The chiropractic profession has something of a problem. The results of many trials of their primary treatment (spinal manipulation) are pretty disappointing and it is no longer the treatment of choice for most (all?) conditions. Their solution seems to be to focus on providing a “package of care” as you described above. However, that leads to the problem that chiropractic no longer has an identity. They are effectively just copying physiotherapy. That being the case, why would anyone train as a chiropractor rather than a physio and why would anyone visit a chiropractor for treatment instead of a physio?

    • Or, why would one go to a PT when one can go to an evidence based chiropractor, considering that a chiropractor has a broader scope of practice?

      • Which aspects of this “broader scope of practice” would be beneficial and why?
        (Scope of practice varies depending on geographical location so it would help if you could specify the geographical location you are referring to)

        • Indeed. There is no scope of practice for chiros in the UK, so the ‘regulator’ has allowed them to get away with making a wide range of bogus claims with impunity.

        • In the USA, most states don’t allow a PT to order x rays (last I saw two states allowed a DPT to do it). I don’t think any state allows a DPT to read x rays or other imaging but I understand they are working to change this.

          I haven’t checked but I don’t think any state allows a PT to order lab work.

          Most states don’t allow a PT to extend a treatment plan without a MD approval (some states allow walk in access but that has strict criteria).

          The benefit of seeing a chiropractor over a PT….one doesn’t always have to see a MD, which usually cuts down on time and cost.

          • you are joking!
            seeing a chiro tends to INCREASE cost because they have a vested interest in doing needlessly long series of treatment or even advocate maintenance therapy.

          • DC wrote: “In the USA, most states don’t allow a PT to order x rays (last I saw two states allowed a DPT to do it). I don’t think any state allows a DPT to read x rays or other imaging but I understand they are working to change this.”

            @ DC

            That’s true:

            QUOTE
            “Of the 209 physical therapy programs in the US, 111 now offer Doctor of Physical Therapy (DPT) degrees [28]. Some of these programs have been opened to qualified chiropractors. According to the American Physical Therapy Association [34] Physical therapy, by 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists. Consumers will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services. Physical therapists will be practitioners of choice in patients’/clients’ health networks and will hold all privileges of autonomous practice…”

            Ref: http://jmmtonline.com/documents/HomolaV14N2E.pdf

            DC wrote: “The benefit of seeing a chiropractor over a PT….one doesn’t always have to see a MD, which usually cuts down on time and cost.”

            Why don’t you mention that it leaves clients very vulnerable to being ensnared by quackery?

          • ensnared by quackery
            paying over the odds endlessly
            at the receiving end of dangerous advice [e. g. immunisations]

          • What do surveys show on the average number of visits for a condition?

          • BW. “Why don’t you mention that it leaves clients very vulnerable to being ensnared by quackery?”

            Because the question was about benefits.

          • Thanks for your reply. I disagree with your suggestion that these things are a benefit and let me explain why. The most common complaint that chiropractors treat is low back pain. Guidelines for low back pain recommend against the routine use of imaging. I don’t believe that lab work is normally recommended either. In the case where there is a suspected serious underlying condition that warrants imaging and / or lab work then I believe it would make much more sense for a chiropractor or physio to refer on to a doctor (MD in the US). For a chiropractor to continue to treat a patient in these circumstances would present a risk rather than a benefit. I actually think that a better pathway would be for patients to visit a doctor / MD first in all cases and then for the doctor to refer on to a chiropractor or physio as they deem appropriate. This is what commonly happens in the NHS in the UK (where the referral would normally be to physio, although some patients choose to pay privately to see a physio, chiro or osteopath outside of the NHS without referral). That allows the doctor to rule out any serious underlying conditions before referring on for more conservative management.

          • A chiropractor, after obtaining results, can usually refer to the appropriate specialist as needed.

            But if you want to go the MD route first, thats your choice.

          • @DC
            “A chiropractor, after obtaining results, can usually refer to the appropriate specialist as needed. ”

            I’m aware that chiropractors can do this. The question is whether it is benefit that they can carry out these tests in the first place. Carrying out and interpreting these tests would normally fall under the remit of a doctor. For a chiropractor to be doing this instead of a doctor actually introduces a risk not a benefit.

      • a chiropractor has a broader scope of practice?
        This may be true but in most cases I would prefer to go to the expert who may have a narrower scope of practice but a lot more knowledge of the subject. For example, if I needed dietary advice I would prefer a dietician.

        For that matter if I needed dietary advice I would prefer a dietician over my family physician as the source.

    • When they haven’t got the results they hoped for from a physio?

      • In that case, why not go to another physio? If you go to a doctor and don’t get the results you were hoping for, would you go to another doctor or got to a homeopath instead?

        • @compandalt There will be multiple factors involved for any individual. Do they feel they’ve given physio a good try, or did they feel the original physio simply didn’t understand their condition well? What are the patient’s personal beliefs about health and medicine? Is there evidence (scientific or anecdotal) that leads them to believe a different modality may be worth a try? What are the relative costs of treatment, and what can they afford? Etc. etc.

          • I agree that there are a range of factors involved and this applies to any healthcare decision. That wasn’t really my question though so let me try re-wording: If chiropractors change the types of treatments they offer to align with those of a physiotherapy, does chiropractic then have anything to give it a unique selling point or is it really just physio by another name? If the latter then as physio is more accepted / mainstream what specific reasons would there be for someone going to a chiro instead of physio?

    • Another possible reason…

      CONCLUSIONS: Chiropractic care alone or DC with MD care incurred appreciably fewer charges for ULBP than MD care with or without PT care. This finding was reversed for CLBP. Adjusted charges for both ULBP and CLBP patients were significantly lower for DC patients.

      https://www.jmptonline.org/article/S0161-4754(16)00053-1/fulltext

    • It is for a ‘chiropractor’ to explain why they studied, trained and ‘qualified’ as a chiropractor and not as a physiotherapist, nurse, osteopath or doctor (MD).

      IMHO students thinking of studying chiropractic should be able to answer easily, or should move on to a more respected profession – avoiding the pernicious sunk cost fallacy.

  • @DC
    “If it’s not subluxation it’s not chiropractic”.
    “Any evidence must have been stolen from physiotherapy”.
    “All chiropractors do is crack joints”.
    “Copying Physiotherapy”.
    The regular cynics here have devoted years to these tenets and are unwilling to change.
    The irony that the subluxation based chiropractors use the same arguments seems to escape them.

    @Michael Kenny
    “NO chiroquacker now or 120 years ago knows or knew exactly what the are doing”.
    Such certainty. 🙂
    I envy you.

  • DC on Wednesday 16 January 2019 at 23:17 wrote: “Any evidence that his [BJ Palmer’s] rehab clinic was just a business venture?”

    @ DC

    There’s plenty of evidence that BJ Palmer was a very astute businessman. See page 51 here:
    https://tinyurl.com/yb2hcxwn

  • From above paper…scope of practice. How many of these can a PT perform or order?

    Full-spine radiographs (n = 46) can be performed in all jurisdictions without additional education, except in Delaware and Rhode Island, where they can only be ordered. It is legal for doctors of chiropractic (DCs) to order or perform the following services in all jurisdictions that responded: computed tomography (CT; n = 43) and magnetic resonance imaging (MRI; n = 45).

    Doctors of chiropractic are able to order or perform surface EMG (n = 43) in all jurisdictions that responded.

    Blood analysis (n = 44) can be ordered or performed in all jurisdictions that responded.

    Doctors of chiropractic may order or perform impairment ratings (n = 42) in all jurisdictions that responded.

    Vitamin supplementation (n = 44), diet formulation (n = 43), and botanical therapy (n = 41) could be performed in all jurisdictions.

    Etc.

    • are you deaf?
      physios work in several areas of healthcare that chiros have not even a clue about.
      the end

    • And of course one must not forget all the Palmarian platitudes, axioms, mantras and miracle-testimonials from the late ‘20s to 1960 were based entirely on the wonderfully science-based concoction that only the axis and atlas (HIO) can “subluxate”…and only realign with a head-torqued, knee chest “toggle-adjustment”. Not unexpectedly after BJs earlier-than-expected demise all his earth-shattering research and treatment protocols disappeared like a proverbial fart in the wind.
      Of course the hyper-modern DC surrounds themselves in full-spine flying-7 adjusting, kinesio-tape, motion-palpation, AK, short-leg analysis and Woody Woodpecker-like adjusting “guns”.
      All would agree; monumental, science-based progress!

  • DC wrote on Thursday 17 January 2019: 15:01 “BW. ‘Why don’t you mention that it leaves clients very vulnerable to being ensnared by quackery?’ Because the question was about benefits.”

    @ DC

    Benefits need to be discussed in relation to risk.

    • As the National Council of States Boards of Nursing put it…

      “Overlap among professions is necessary. No one profession actually owns a skill or activity in and
      of itself. One activity does not define a profession, but it is the entire scope of activities within the
      practice that makes any particular profession unique. Simply because a skill or activity is within one
      profession’s skill set does not mean another profession cannot and should not include it in its own
      scope of practice.”

      Outside of the quackiness of some chiropractors, are there some things that make chiropractors unique? I think so. Can we loose that uniqueness, yes. Will we? Time will tell.

      I need to focus on other stuff for awhile. Thanks for being civil BW. Later.

Leave a Reply to Tom Kennedy Cancel reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

If you want to be able to edit your comment for five minutes after you first submit it, you will need to tick the box: “Save my name, email, and website in this browser for the next time I comment.”
Recent Comments

Note that comments can be edited for up to five minutes after they are first submitted but you must tick the box: “Save my name, email, and website in this browser for the next time I comment.”

The most recent comments from all posts can be seen here.

Archives
Categories